Intrauterine insemination: simultaneous with or 36 h after HCG? A randomized clinical trial

RESEARCH QUESTION

Does intrauterine insemination (IUI) carried out simultaneously with HCG triggering ('simultaneous IUI') increase the ongoing pregnancy rate compared with IUI 32-36 h after HCG triggering ('regular IUI')?

STUDY DESIGN

An open-label randomized clinical trial was conducted in seven Dutch fertility clinics. One hundred and sixty-six couples were randomized to receive simultaneous IUI and 208 couples to receive regular IUI. Treatment was allocated using a computer-based randomization algorithm using sealed opaque envelopes. Data were analysed according to the intention-to-treat principle. Couples with unexplained or mild-to-moderate male factor subfertility were eligible. Exclusion criteria were female age 42 years or older, female body mass index 35 kg/m² or over, double-sided tubal pathology or severe male factor subfertility. Mild ovarian stimulation was carried out by subcutaneous FSH self-administration. 'Simultaneous IUI' was carried out at the point of HCG triggering for ovulation. 'Regular IUI' was carried out 32-36 h after HCG triggering.

RESULTS

The cumulative ongoing pregnancy rate after a maximum of four cycles was 26.2% for simultaneous IUI (43 ongoing pregnancies) and 33.7% for regular IUI (70 ongoing pregnancies) (RR 0.78 95% CI 0.57 to 1.07). Ongoing pregnancy rates per cycle in the simultaneous IUI group were 6.8%, 10.5%, 9.5% and 7.4% for the first, second, third and fourth IUI cycle. In the regular IUI group, ongoing pregnancy rates were 8.3%, 16.4%, 13.5% and 9.0% for the first, second, third and fourth IUI cycle.

CONCLUSIONS

This multicentre randomized controlled trial did not demonstrate that IUI carried out at the point of HCG triggering increases pregnancy rates compared with IUI carried out around the time of ovulation.

[Assisted reproductive technologies in HIV patients: Which results and which strategy in France in 2019?]

With the use of antiretroviral therapy, HIV transmission from mother to fetus and between sexual partners has been significantly reduced, successively allowing pregnancy, then assisted reproductive technologies, and targeted unprotected sex among couples living with HIV. Since first French Morlat report in 2013, natural procreation is now possible under certain conditions for these couples living with HIV and the use of assisted reproductive technologies is increasingly limited to the treatment of infertility. While the results of intrauterine insemination seem satisfactory for serodiscordant couples living with HIV, in vitro fertilization results appear to be unfavorable when the woman is infected with HIV. In vitro fertilization results appear to be comparable to those in general population when only the man is infected with HIV. It can be assumed that ovaries are impacted by the treatment and/or the HIV in infected women.

Growing body of evidence supports intrauterine insemination as first line treatment and rejects unfounded concerns about its efficacy, risks and cost effectiveness

IUI has been practiced for five decades but only three unconvincing trials attempted to demonstrate the superiority of IUI over sexual intercourse (SI). In the absence of evidence of its effectiveness, the National Institute for Clinical Excellence (NICE) recommended IVF over IUI after 2 years of unprotected SI. High-quality recent data in well-constructed studies suggest that biases against IUI procedures and in favour of IVF are invalid. It is unethical to continue to misinform patients and stakeholders. The well-constructed randomised controlled trials (RCT) show IUI procedure to be efficient, with minimal risk, and above all improved cost-effectiveness when compared to IVF for live birth. IUI as first-line treatment should be offered to most patients, while funding agencies and stakeholders need to be urgently informed of the cost-benefit in offering IUI. Fertility clinics, IVF interest groups, and regulatory bodies should amend their patient information and guidance to state that IUI should be the first line treatment and that IVF should be offered only when essential. Reappraising and promoting IUI based on evidence enhances patient autonomy, choices, and trust, while allowing the fertility industry to operate within an ethical and acceptable framework not seen as exploitative toward vulnerable patients.

Can anti-Müllerian hormone predict success outcomes in donor sperm inseminations?

Anti-Müllerian hormone (AMH) is a useful biomarker to predict the ovarian response to controlled ovarian stimulation (COS) for IVF. However, currently there is a lack of evidence for the role of ovarian reserve markers when there is no need of COS. The aim of this study was to evaluate the usefulness of AMH to predict the outcomes of donor sperm insemination cycles in non-infertile women. A retrospective study including 139 healthy women, who underwent 348 intrauterine insemination (IUI) cycles with donor sperms under the stimulated or natural cycles, was conducted. All patients had an AMH evaluation performed before starting the first IUI attempt. AMH levels were similar in both, women who conceived and those who did not (2.00 ± 1.52 vs. 1.88 ± 1.64 ng/ml; p = .45). The area under the ROC curve in predicting pregnancy for AMH was 0.53. After adjusting for other confounding variables, the multivariate analysis revealed that AMH was not associated with pregnancy (aOR 0.89; 95% CI 0.57-1.37). We conclude that AMH is not predictive of pregnancy in healthy non-infertile women who perform IUI with donor sperm. These findings suggest the low capability of AMH to predict fertility when no COS is needed.

Small-sized follicles could contribute to high-order multiple pregnancies: outcomes of 6552 intrauterine insemination cycles

RESEARCH QUESTION

Can predictors of twin and high-order multiple pregnancy among women with multiple cycles of ovarian stimulation intrauterine insemination (IUI) be identified?

DESIGN

Retrospective cohort study of IUI cycles carried out between January 2014 and December 2015 in a private clinic in Spain. The 4879 women and 6552 cycles analysed in this study include single IUI with ovarian stimulation using recombinant FSH.

RESULTS

Number of follicles and follicle size were the only factors with a significant effect (P < 0.001) on the likelihood of achieving a twin or multifetal pregnancy. Follicles 12 mm or wider greatly increase the chances of achieving a twin or multifetal pregnancy. A total of 73 out of 127 (57.5%) twin pregnancies occurred in cycles with at least one additional follicle measuring 12 mm or wider, and 102 out of 127 twin pregnancies (80.3%) occurred in cycles with at least one additional follicle measuring 14 mm or wider. Cancellation criteria should consider the presence of follicles 12 mm or wider.

CONCLUSION

Follicles measuring 12 mm or wider increase the risk of having a twin or a high-order multiple pregnancy rate. These data may help clinicians balance decision-making between cancelling and performing the cycle within an IUI procedure.

Molecular mechanisms of embryonic implantation in mammals: Lessons from the gene manipulation of mice

BACKGROUND

Human infertility has become a serious and social issue all over the world, especially in developed countries. Numerous types of assisted reproductive technology have been developed and are widely used to treat infertility. However, pregnancy outcomes require further improvement. It is essential to understand the cross-talk between the uterus (mother) and the embryo (fetus) in pregnancy, which is a very complicated event.

METHODS

The mammalian uterus requires many physiological and morphological changes for pregnancy-associated events, including implantation, decidualization, placentation, and parturition, to occur. Here is discussed recent advances in the knowledge of the molecular mechanisms underlying these reproductive events - in particular, embryonic implantation and decidualization - based on original and review articles.

MAIN FINDINGS RESULTS

In mice, embryonic implantation and decidualization are regulated by two steroid hormones: estrogen and progesterone. Along with these hormones, cytokines, cell-cycle regulators, growth factors, and transcription factors have essential roles in implantation and decidualization in mice.

CONCLUSION

Recent studies using the gene manipulation of mice have given considerable insight into the molecular mechanisms underlying embryonic implantation and decidualization. However, as most of the findings are based on mice, comparative research using different mammalian species will be useful for a better understanding of the species-dependent differences that are associated with reproductive events, including embryonic implantation.

Are we choosing the correct FSH starting dose during controlled ovarian stimulation for intrauterine insemination cycles? Potential application of a nomogram based on woman's age and markers of ovarian reserve

PURPOSE

To evaluate the potential application of a nomogram based on woman's age and ovarian reserve markers as a tool to optimize the follicle-stimulating hormone (FSH) starting dose in intrauterine insemination (IUI) cycles.

METHODS

We conducted a retrospective analysis enrolling 179 infertile women undergoing controlled ovarian stimulation (COS), followed by IUI. Each woman received an FSH starting dose according to clinical decision. After collecting data about COS and IUI procedures, we calculated the FSH starting dose according to the nomogram. The main outcomes measured were women's baseline characteristics, COS, and clinical outcomes.

RESULTS

The FSH starting dose calculated by the nomogram was significantly lower than the one actually prescribed (p < 0.001), in only 14.8% of the cycles nomogram calculated a higher starting dose. When gonadotropin dose was decreased during COS, and similarly in case of hyper-response (more than two follicles ≥ 16 mm retrieved), the FSH starting dose calculated by the nomogram would have been lower in most of the cases (81.8% and 48.8%, respectively). Conversely, when gonadotropin dose was increased during COS and in case of low ovarian response (no follicle ≥ 16 mm retrieved), the FSH starting dose calculated by the nomogram would have been lower in most of the cases (64.7% and 100%, respectively); in these groups median anti-Müllerian hormone (AMH) level was 5.62 ng/mL.

CONCLUSIONS

The application of this nomogram in IUI cycles would lead to a more tailored FSH starting dose and improved cost-effectiveness, although in PCOS women, particularly the ones with high AMH, it does not seem adequate.

Effect of time intervals from the end of sperm collection to intrauterine insemination on the pregnancy rates in controlled ovarian hyperstimulation-intrauterine insemination cycles

OBJECTIVE

To analyze the effect of time intervals from the end of sperm collection to IUI on the pregnancy rates in couples who treated by COH-IUI cycles with gonadotropin due to unexplained infertility.

METHODS

556 couples who underwent the first COH-IUI treatment with gonadotopin due to unexplained infertility were included. Semen samples were obtained by masturbation in a private room near the laboratory on the day of insemination. For each semen samples, time between the delivery time to the laboratory and starting time of sperm washing procedure was noted as semen collection to sperm washing (SC-SW) interval, the time between the starting time of sperm washing procedure and insemination time was noted as sperm washing to insemination (SW-IUI) interval and the time between the delivery time to the laboratory and insemination was noted as semen collection to insemination (SC-IUI) interval. Clinical pregnancy was defined as positive pregnancy test followed by the presence of an intrauterine gestational sac with fetal cardiac activity by transvaginal ultrasonography at least 4 weeks after IUI.

RESULTS

Among 556 couples, there were 84 cases of succesful clinical pregnancy and pregnancy rate was calculated as 15.1%. Intervals from SW to IUI and SC to IUI were significantly shorter in pregnant women than in non-pregnant (p<0.001 and p=0.007, respectively). SW performed ≤40min after SC resulted in higher clinical pregnancy rates than did SW performed >40min after SC (19.1% vs. 6.3%, respectively) (p<0.001). IUI performed ≤60min after the end of SW had higher pregnancy rates (16.9%) compared to IUI performed >60min after the end of SW (4.0%) (p=0.017). Likewise, IUI performed ≤90min after SC resulted in higher pregnancy rates than did IUI performed >90min after SC (18.9% vs. 12.0%, respectively) (p=0.029).

CONCLUSION

IUI outcome is enhanced by shorter intervals from SC to SW, from SW to IUI, and from SC to IUI in gonadotropin-IUI cycles for unexplained infertile couples.

The impact of ovarian stimulation on the outcome of intrauterine insemination treatment: an analysis of 8893 cycles

OBJECTIVE

To evaluate the impact of ovarian stimulation on the outcome of intrauterine insemination (IUI).

DESIGN

Retrospective analysis.

SETTING

A single university-based centre.

POPULATION

A total of 5109 couples with 8893 cycles.

METHODS

The outcome of IUI with different protocols for ovarian stimulation was examined.

MAIN OUTCOME MEASURES

The live birth rate (LBR), twin pregnancy rate and ovarian hyperstimulation syndrome (OHSS).

RESULTS

In ovulatory women without ovarian stimulation, the LBR was 7.6%. Stimulation with clomifene citrate (CC), letrozole (LE), human menopausal gonadotrophin (HMG), CC or LE combined with HMG achieved LBRs of 6.1, 5, 7.9, 8 and 12.2%, respectively. LE combined with HMG achieved a significantly improved LBR compared with no stimulation. HMG stimulation was associated with a higher rate of twins (7.4%) than no stimulation (0%, P < 0.01). In ovulatory women, the LBR appeared lower in CC and LE compared with no stimulation (P > 0.05). In anovulatory women, ovarian stimulation with CC, LE, HMG, CC or LE combined with HMG achieved LBRs of 11.3, 5.1, 11.8, 12.6 and 13.6%, respectively. No significant difference was observed. There were no triplet pregnancies or OHSS in stimulated cycles.

CONCLUSIONS

In ovulatory women, ovarian stimulation with LE combined with HMG achieved a significantly improved live birth rate. HMG stimulation resulted in a high risk for twins.

TWEETABLE ABSTRACT

In ovulatory women, ovarian stimulation with letrozole and HMG resulted in a significantly improved LBR.

Intrauterine Insemination: Current Place in Infertility Management

Infertility has become a significant problem worldwide. Multiple management options are available nowadays, which include intrauterine insemination (IUI), in vitro fertilisation (IVF), and intracytoplasmic sperm injection. IUI is one of the oldest and most popular methods. After >50 years since it was first used, IUI has evolved through various innovations but still struggles to find its place in infertility management. After the introduction of revised guidelines from the National Institute for Health and Care Excellence (NICE) in 2013, there has been a surge in the use of IVF as a primary treatment modality. The aim of this evidence-based review is to highlight the factors associated with success of IUI and to find out whether IUI can be offered as a first-line treatment option for infertile couples.

Expression of cystatin C in the female reproductive tract and its effect on human sperm capacitation

BACKGROUND

Cystatin C (CST3), a cysteine protease inhibitor in seminal plasma, is expressed in animal uteri. However, its expression in the human female reproductive tract and its effect on human sperm capacitation are unclear.

METHODS

The cellular localization of CST3 was observed using immunohistochemistry. The binding of CST3 to sperm was examined using immunocytochemistry. Sperm motility parameters were analyzed using computer-assisted sperm analysis. Sperm capacitation was evaluated by analyzing cholesterol content, protein tyrosine phosphorylation levels, and the acrosome reaction.

RESULTS

Immunohistochemical staining demonstrated that CST3 is prominently expressed in the female reproductive tract, including the epithelial lining and cervix and endometrium fluids, particularly at times near ovulation. It can bind to human sperm on the post-acrosomal head region and the mid and principal piece of the tail. CST3 enhances sperm motility and inhibits the signal initiating sperm capacitation, i.e., efflux of cholesterol from the sperm plasma membrane and a late sperm capacitation event, i.e., the increase in the sperm protein tyrosine phosphorylation. The suppressive trend on sperm acrosome reaction further supports CST3's ability to inhibit sperm capacitation.

CONCLUSIONS

These findings suggest that cervical CST3 may prevent precocious capacitation and acrosome reaction, thus preserving sperm fertilizing ability before it reaches the fallopian tube. Additionally, CST3 may help sperm enter the upper reproductive tract by enhancing sperm motility.

Tamoxifen is Better than Low-Dose Clomiphene or Gonadotropins in Women with Thin Endometrium (<7 mm) after Clomiphene in Intrauterine Insemination Cycles: A Prospective Study

Aim:

Gonadotropin stimulation is used as the second line of treatment in patients with thin endometrium following clomiphene citrate (CC) administration, which is associated with higher cost, multiple births, and ovarian hyperstimulation syndrome. Tamoxifen (TMX), a selective estrogen receptor modulator, acts as an agonist on the endometrium. The objective of the present study was to compare the efficacy of low-dose CC, TMX, and gonadotropins in women with thin endometrium (<7 mm) following Clomiphene in intrauterine insemination (IUI) cycles.

Settings and Design:

A prospective observational study between December 2011 and June 2013 was carried out in a tertiary infertility center.

Methods:

Women (n = 502) undergoing IUI with endometrium <7 mm after 100 mg CC were included in the study and divided into three treatment groups. Women in Group A (n = 182, cycles = 364) received clomiphene (50 mg/day from day 3 to 7), Group B (n = 179, cycles = 342) received TMX (40 mg/day from day 3 to 7), and Group C (n = 141, cycles = 226) received continuous urine-derived follicle-stimulating hormone 75–150 IU from day 3 onward until human chorionic gonadotropin injection. Endometrial thickness (ET), pregnancy rate, and live birth rate were considered as main outcome measures.

Statistical Analysis:

Multiple comparisons using one-way ANOVA and Schiff's test were performed.

Results:

Pregnancy and live birth rate were significantly higher (P < 0.004) in TMX and gonadotropin groups compared to clomiphene. A number of follicles in the TMX group were found to be lower (P < 0.001) compared to other two groups. In polycystic ovary syndrome patients, ovulation induction with TMX resulted in inadequate response in more than half of the cycles.

Conclusions:

TMX can improve ET and live birth rate in patients with thin endometrium after clomiphene.

Therapeutic Efficacy of Endometrial Scratching in Repeated Controlled Ovarian Stimulation (COS) Failure Cycles

Objective:

The objective of the study was (1) “to evaluate the therapeutic efficacy of endometrial scratching in repeated controlled ovarian stimulation (COS) failure cycles.” And (2) “to compare differences in pregnancy outcome by endometrial scratching in early (D2–D4) and late follicular phases (D7–D9) of the same stimulation cycle.”

Materials and Methods:

Women attending infertility clinic in a tertiary care center and who have two or more repeated COS failure cycles and planned for COS with intrauterine insemination (IUI) were included in the study which is a prospective parallel, interventional, single-blinded, randomized control study, in 1:1 allocation ratio. A total of 165 patients were recruited and randomly allocated into three groups: Group A (n = 55) underwent endometrial scratching on D2–D4 of the same COS cycle, Group B (n = 55) on D7–D9, and Group C (n = 55) no intervention done. All the patients underwent COS according to standard protocol followed by IUI.

Results:

Clinical pregnancy rate was 12.73% (odds ratio [OR] =0.87 95% confidence interval [CI] =0.288–2.55, P = 1), 16.36% (OR = 1.15; 95% CI = 0.40–3.23, P = 1), and 14.54%, respectively, in Group A, B, and C, respectively (P = 0.86), as per intention to treat analysis. Using Chi-square test, P value between Group A and B was 0.787, between Group A and C was 1.000, and between Group B and C was 1.000. As per protocol analysis, clinical pregnancy rate was 13.46% (OR = 0.83; 95% CI = 0.27–2.5, P = 0.74), 19.57% (OR = 1.3 95%; CI = 0.45–3.73, P = 0.41), and 15.69%. Using Chi-square test, Pvalue between Group A and B was 0.588, between Group A and C was 0.967, and between Group B and C was 0.815. No abortions and multiple pregnancies occurred in either of the groups.

Conclusion:

The effect found was of good quantum in Group B as per protocol analysis which could be of clinical relevance if larger sample size would have been taken. Endometrial scratching is a cost-effective and easy technique which may improve clinical pregnancy rates in previous COS failure cycles, but more trials are needed to be conducted using larger sample size to achieve the improved and significant outcome.

Effect of Gonadotropin Types and Indications on Homologous Intrauterine Insemination Success: A Study from 1251 Cycles and a Review of the Literature

Objective

To evaluate the IUI success factors relative to controlled ovarian stimulation (COS) and infertility type, this retrospective cohort study included 1251 couples undergoing homologous IUI.

Results

We achieved 13% clinical pregnancies and 11% live births. COS and infertility type do not have significant effect on IUI clinical outcomes with unstable intervention of various couples' parameters, including the female age, the IUI attempt rank, and the sperm quality.

Conclusion

Further, the COS used seemed a weak predictor for IUI success; therefore, the indications need more discussion, especially in unexplained infertility cases involving various factors. Indeed, the fourth IUI attempt, the female age over 40 years, and the total motile sperm count <5 × 10⁶ were critical in decreasing the positive clinical outcomes of IUI. Those parameter cut-offs necessitate a larger analysis to give infertile couples more chances through IUI before carrying out other ART techniques.

Intrauterine Insemination: Fundamentals Revisited

Intrauterine insemination (IUI) is an assisted conception technique that involves the deposition of a processed semen sample in the upper uterine cavity, overcoming natural barriers to sperm ascent in the female reproductive tract. It is a cost-effective, noninvasive first-line therapy for selected patients with functionally normal tubes, and infertility due to a cervical factor, anovulation, moderate male factor, unexplained factors, immunological factor, and ejaculatory disorders with clinical pregnancy rates per cycle ranging from 10 to 20%. It, however, has limited use in patients with endometriosis, severe male factor infertility, tubal factor infertility, and advanced maternal age ≥ 35 years. IUI may be performed with or without ovarian stimulation. Controlled ovarian stimulation, particularly with low-dose gonadotropins, with IUI offers significant benefit in terms of pregnancy outcomes compared with natural cycle or timed intercourse, while reducing associated COH complications such as multiple pregnancies and ovarian hyperstimulation syndrome. Important prognostic indicators of success with IUI include age of patient, duration of infertility, stimulation protocol, infertility etiology, number of cycles, timing of insemination, number of preovulatory follicles on the day of hCG, processed total motile sperm > 10 million, and insemination count > 1 × 106 with > 4% normal spermatozoa. Alternative insemination techniques, such as Fallopian tube sperm perfusion, intracervical insemination, and intratubal insemination, provide no additional benefit compared to IUI. A complete couple workup that includes patient history, physical examination, and clinical and laboratory investigations is mandatory to justify the choice in favor of IUI and guide alternative patient management, while individualizing the treatment protocol according to the patient characteristics with a strict cancelation policy to limit multi-follicular development may help optimize IUI pregnancy outcomes.

Ovarian stimulated cycle: not a better alternative for women without ovulation disorder in intrauterine insemination

To explore the related factors on the clinical pregnancy outcome in intrauterine insemination, a retrospective study was conducted on the clinical data of 580 cycles for 301 infertile couples who were treated with intrauterine insemination. The female age, male age, duration of infertility, treatment protocols, endometrial thickness and sperm parameters were compared between pregnant group and non-pregnant group. The results showed that there were statistical differences in female age, duration of infertility and endometrial thickness between the two groups. The pregnancy rate was 19.34% in Group A (female age ≤ 30 y) compared with 10.91% in Group B (female age > 30 y). The pregnancy rate was 18.44% when the duration of infertility ≤ 2 years, which was higher than another group 10.73% when the duration of infertility > 2 years. Group analysis according to endometrial thickness (Group1: < 8 mm; Group 2: ≥ 8 mm and ≤ 12 mm; Group 3: > 12 mm) demonstrated significant differences in clinical pregnancy rate (7.41%, 18.00% and 11.48% respectively). For those infertile female without ovulation failure, the higher clinical pregnancy rates were observed in patients undergoing intrauterine insemination in natural cycle 16.12% when compared with the patients in ovarian stimulated cycles 10.48%. Thus, we demonstrate that the pregnancy rate is related with female age, duration of infertility and endometrial thickness. The ovarian stimulated cycle couldn’t improve the pregnancy outcome for those women without ovulation disorder in intrauterine insemination.

Longer time interval between semen processing and intrauterine insemination does not affect pregnancy outcome

OBJECTIVE

To study whether the pregnancy outcome of intrauterine insemination (IUI) is affected by a longer time interval between semen processing and insemination.

DESIGN

Retrospective cohort.

SETTING

Teaching hospital.

PATIENT(S)

Couples with subfertility and an indication for IUI over a 10-year period.

INTERVENTION (S)

Insemination performed the day after but within 24 hours of semen collection and processing (delayed insemination) compared with insemination performed immediately after sperm collection and processing (immediate insemination).

MAIN OUTCOME MEASURE(S)

Ongoing pregnancy rate, defined as a pregnancy confirmed by ultrasound at 10 to 12 weeks of gestation.

RESULT(S)

In total, 1,136 cycles were analyzed. In 77 of 547 couples (14%) an ongoing pregnancy occurred after delayed insemination, and in 77 of 589 couples (13%) an ongoing pregnancy occurred after immediate insemination. Both groups had similar baseline characteristics. After adjustment for confounders, there was no difference in the ongoing pregnancy rate between delayed as compared with immediate insemination (odds ratio 0.89; 95% confidence interval, 0.63-1.25).

CONCLUSION(S)

There is no negative effect on pregnancy rate when IUI of processed sperm is delayed until the next day. This approach allows additional flexibility for couples when the male partner is not available on the day of ovulation, and it allows for a spread of workload in the laboratory.

[Intra-uterine insemination at either 24 or 48hours after ovulation induction: Pregnancy and birth rates]

OBJECTIVE

Comparing rates of pregnancy and childbirth between IUI at either 24 or 48hours after injection of HCG.

METHODS

This is a single-center retrospective study of couples who underwent intrauterine insemination between January 2013 and December 2014 at Medical-Surgical Obstetrical Centre of Schiltigheim. Stimulation of ovulation was done by FSH or HMG, and ovulation induction by 250μg of recombinant HCG. The insemination was performed after 2 days (group D2) or the day after (group D1).

RESULTS

Among the 1092 intrauterine insemination cycles included in our study, 62 were done the day after ovulation induction by HCG (D1), and 1030 the day after (D2). Our study showed no significant difference in the rate of biological pregnancy, defined by a rate of BHCG>15IU/L, between the group D1 (19.35%) and the group D2 (18.12%), P=0.94, and no difference in live birth rate: respectively 14,50% and 11.75%, P=0.18.

CONCLUSION

Our study reported similar rates of pregnancy and childbirth in the group who underwent IUI at D1 and D2 of ovulation induction, suggesting the possibility of IUI on day 1 when the organization of the service needs it, without loss of opportunity for pregnancy.

Nitric oxide donors increase the pregnancy rate in patients with unexplained infertility undergoing clomiphene citrate stimulation and intrauterine insemination: a randomized controlled pilot study

This study evaluated the effects of nitric oxide donor's treatment on the pregnancy rate and uterine blood flow in patients with unexplained infertility undergoing clomiphene citrate stimulation and intrauterine insemination. A total of 120 patients were randomly allocated to a control group who received 100 mg clomiphene citrate daily from day 5 to 9 of cycle plus placebo vaginal tablets, and a study group received clomiphene citrate plus isosorbide mononitrate 10 mg vaginal tablets. Vaginal ultrasound was done before treatment and every other day starting from day 12 of cycle to count mature follicles and ovulation was triggered by IM injection of 10 000 IU hCG when one follicle measured 18 ≥ mm followed by intrauterine insemination after 36 h. The endometrial thickness, uterine arteries resistance and pulsation indices, and endometrial vascular flow and vascular flow indices were measured before treatment and at day of hCG injection. Results were analyzed after one cycle treatment using the Mean ± SD, the Student t test and the Fisher Exact test. Significant result was considered at p values <0.05. The study group had significant higher pregnancy rate/cycle, higher endometrial and lower uterine artery blood flow indices (p < 0.05).

Outcomes of anastrozole in oligozoospermic hypoandrogenic subfertile men

OBJECTIVE

To determine whether the change in sperm parameters in subfertile hypoandrogenic men treated with anastrozole is correlated to the magnitude of increase in testosterone (T) to estrogen ratio in men responding to treatment.

DESIGN

Retrospective study.

SETTING

Male fertility clinic.

PATIENT(S)

The study group consisted of 86 subfertile hypoandrogenic men with low T/estradiol (E₂) ratio (n = 78) or a prior aversive reaction to clomiphene citrate (n = 8).

INTERVENTION(S)

All patients were treated with 1 mg anastrozole daily, administered orally.

MAIN OUTCOME MEASURE(S)

Hormone analysis and semen analysis before and after treatment were performed. Hormone analysis included measurements of total T, E₂, sex-hormone binding globulin, albumin, FSH, and LH, and bioavailable T was calculated. Total motile sperm count was calculated from the semen analysis.

RESULT(S)

In all, 95.3% of patients had an increased serum T and decreased serum E₂ after treatment with anastrozole. Sperm concentration and total motile counts improved in 18 of 21 subfertile hypoandrogenic oligozoospermic men treated with anastrozole. In these men the magnitude of total motile count increase was significantly correlated with the change in the T/E₂ ratio. No improvement was seen in semen parameters of men with azoospermia, cryptozoospermia, or normozoospermia at presentation.

CONCLUSION(S)

Approximately 95% of men with hypoandrogenism responded with improved endocrine parameters, and a subset of oligozoospermic men (approximately 25% of all patients) displayed significantly improved sperm parameters. In that subset, increase in sperm parameters was correlated with the change in the T/E₂ ratio, which argues for a physiologic effect of treatment.

Natural conception: repeated predictions over time

STUDY QUESTION

How can we predict chances of natural conception at various time points in couples diagnosed with unexplained subfertility?

SUMMARY ANSWER

We developed a dynamic prediction model that can make repeated predictions over time for couples with unexplained subfertility that underwent a fertility workup at a fertility clinic.

WHAT IS KNOWN ALREADY

The most frequently used prediction model for natural conception (the 'Hunault model') estimates the probability of natural conception only once per couple, that is, after completion of the fertility workup. This model cannot be used for a second or third time for couples who wish to know their renewed chances after a certain period of expectant management.

STUDY DESIGN, SIZE, DURATION

A prospective cohort studying the long-term follow-up of subfertile couples included in 38 centres in the Netherlands between January 2002 and February 2004. Couples with bilateral tubal occlusion, anovulation or a total motile sperm count <1 × 10⁶ were excluded.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The primary endpoint was time to natural conception, leading to an ongoing pregnancy. Follow-up time was censored at the start of treatment or at the last date of contact. In developing the new dynamic prediction model, we used the same predictors as the Hunault model, i.e. female age, duration of subfertility, female subfertility being primary or secondary, sperm motility and referral status. The performance of the model was evaluated in terms of calibration and discrimination. Additionally, we assessed the utility of the model in terms of the variability of the calculated predictions.

MAIN RESULTS AND THE ROLE OF CHANCE

Of the 4999 couples in the cohort, 1053 (21%) women reached a natural conception leading to an ongoing pregnancy within a mean follow-up of 8 months (5th and 95th percentile: 1-21). Our newly developed dynamic prediction model estimated the median probability of conceiving in the first year after the completion of the fertility workup at 27%. For couples not yet pregnant after half a year, after one year and after one and a half years of expectant management, the median probability of conceiving over the next year was estimated at 20, 15 and 13%, respectively. The model performed fair in an internal validation. The prediction ranges were sufficiently broad to aid in counselling couples for at least two years after their fertility workup.

LIMITATIONS, REASONS FOR CAUTION

The dynamic prediction model needs to be validated in an external population.

WIDER IMPLICATIONS OF THE FINDINGS

This dynamic prediction model allows reassessment of natural conception chances after various periods of unsuccessful expectant management. This gives valuable information to counsel couples with unexplained subfertility that are seen for a fertility workup.

STUDY FUNDING/COMPETING INTERESTS

This study was facilitated by grant 945/12/002 from ZonMW, The Netherlands Organization for Health Research and Development, The Hague, The Netherlands. No competing interests.

Low levels of PRSS37 protein in sperm are associated with many cases of unexplained male infertility

PRSS37, a putative trypsin-like serine protease, is highly conserved during mammalian evolution as revealed by multiple sequence alignment. Mice deficient for Prss37 gene exhibit male infertility, but their mating behavior, spermatogenesis, sperm morphology, and motility remain unaffected, similar to a situation called unexplained male infertility (UMI) in men (human being). Here, we demonstrated that PRSS37 is restrictively expressed in human testis, where it is mainly located in the elongating and elongated spermatids during spermiogenesis as shown by immunohistochemical analysis of normal human testicular sections. In mature sperm, PRSS37 appears in the acrosome region and diminishes during acrosome reaction. Further examination reveals that PRSS37 contents in sperm from patients with UMI are dramatically lower than those in sperm from men with proven fertility or from sperm donors. Sperm with low PRSS37 contents exhibit abnormal activation of the proacrosin/acrosin system and premature proteolysis of ADAM2, which may impair the functional competence of human sperm in vivo However, the in vitro fertilization outcomes of sperm with low PRSS37 contents are not affected. Together, these data implicate an important role of PRSS37 for male fertility. PRSS37 can be used as a potential molecular biomarker for evaluating sperm fertilization capability in vivo but not in vitro.

Factors affecting clinical pregnancy rates after IUI for the treatment of unexplained infertility and mild male subfertility

OBJECTIVE

The aim of the present retrospective study was to evaluate intrauterine insemination (IUI) clinical experiences and to define the variables for predicting success.

MATERIAL AND METHODS

The present study was an observational trial performed in a private IVF center on subfertile couples who had applied for treatment between 2002 and 2012, in which the data of 503 IUI cases were retrospectively reviewed. Couples who had been diagnosed with unexplained and mild male subfertility were included. The primary outcome measure was the clinical pregnancy rate in an attempt to form a predictive model for the odds of a clinical pregnancy. Recorded parameters were used to determine the prediction model.

RESULTS

Utilizing univariate logistic regression analysis, clinical pregnancy was positively associated with the duration of infertility (OR=1.09, p=0.089), secondary infertility (OR=1.77, p=0.050), and +4 sperm motility after preparation (OR=1.03, p=0.091). Following an adjustment analysis involving a multivariate logistic regression, clinical pregnancy was still found to positively associate with secondary infertility (OR=2.51, p=0.008).

CONCLUSION

IUI success in secondary infertile couples who were in the unexplained infertility and mild male subfertility groups was higher than that in primary infertile couples, and the chances of pregnancy increased as sperm numbers with +4 motility increased. It is difficult to concomitantly evaluate all these parameters and to determine a predictive parameter in IUI independent from other factors.

A New Dawn for Intrauterine Insemination: Efficient and Prudent Practice will Benefit Patients, the Fertility Industry and the Healthcare Bodies

This review addresses the misplaced facts about the IUI procedure within a lucrative fertility industry. Evidence suggests IUI must be a first-line treatment option for most couples except in cases of bilateral tubal blockage and severe oligozoospermia. We introduce the concept of using 'consecutive ejaculation' in men with subfertility and one which can radically alter the male infertility definition, thereby providing a new approach to examining and managing male factor infertility. The review also explores various aspects affecting the IUI procedure, its determinants of success, risks and areas for future improvements. Areas such as choice of patients, clinical management of patients, the type of stimulation regime, timing and the management of sperm usage have significant bearing to whether IUI will succeed. The paper asserts that IUI should be the first choice of fertility treatment.

Evidence for obtaining a second successive semen sample for intrauterine insemination in selected patients: results from 32 consecutive cases

Objective

The goal of this study was to compare the semen parameters of two successive samples obtained within an interval of less than 60 minutes from patients planning to undergo intrauterine insemination (IUI) whose first samples exhibited low semen quality.

Methods

Thirty-two consecutive patients were enrolled in the study. On the day of IUI, the semen analysis of the samples initially presented by all patients met at least two of the following criteria: sperm concentration <5×10⁶/mL, total sperm count <10×10⁶, progressive sperm motility (a+b) in the native sample <30%, and total motile sperm count (TMSC) <4×10⁶. A successive semen sample was obtained no more than 60 minutes after the first sample.

Results

Compared to the first sample, the second exhibited significantly (p<0.05) improved sperm concentration, TMSC, progressive motility, and vitality. Regarding TMSC, the most critical parameter on the day of IUI, 23 patients (71.8%) improved it, while nine (28.2%) displayed poorer outcomes.

Conclusion

In defined cases, requesting a second successive ejaculate on the day of insemination may result in a high percentage of cases in an improvement of the quality of the sample.

Luteal phase support in intrauterine insemination cycles

Intrauterine insemination (IUI) treatment aims to increase the rate of conception by increasing the chances that the maximum number of healthy sperm reach the site of fertilization. IUI with controlled ovarian stimulation is frequently used in assisted reproduction practice. Although widely used, the efficacy of luteal support in IUI remains controversial. In this article, we aimed to review what we know regarding luteal support in IUI cycles and to adjudicate about the clinical use and benefits of this treatment. Based on the study results available in the literature, it appears to be beneficial to supplement the luteal phase in gonadotropin-stimulated IUI cycles that yield more than one follicle.

Luteal phase support in intrauterine insemination cycles: a prospective randomized study of 300 mg versus 600 mg intravaginal progesterone tablet

Vaginal progesterone (P) has been suggested to be used for luteal phase support (LPS) in controlled ovarian stimulation (COH)-intrauterine insemination (IUI) cycles, however, no concensus exists about the best P dose. Therefore, considering the fecundability rate as the primary end point, our main objective was to find the optimal dose of P in COH-IUI cycles, comparing the two groups of women, each of which comprised of 100 women either on 300 mg or 600 mg of intravaginal P tablets, in a prospective randomized study design. The mean age of the women, duration of infertility, basal and day of hCG injection hormone levels in the female and sperm parameters were similar in the two study groups. Also, duration and dose of gonadotropin given, number of follicles, endometrial thickness, the total, ongoing and multiple pregnancy rates were comparable in both groups. We, therefore, claim that 300 mg of intravaginal micronized P should be the maximum dose of LPS in IUI cycles.

Ovarian reserve markers in unexplained infertility patients treated with clomiphene citrate during intrauterine insemination

INTRODUCTION

The aim of this retrospective case control study was to identify predictors of ovarian response and pregnancy outcomes in intrauterine insemination (IUI).

MATERIAL AND METHODS

One hundred women undergoing IUI cycles with clomiphene citrate were enrolled. The number of antral follicles and the total ovarian volume by ultrasound, and the basal levels of follicle-stimulating hormone (FSH), estradiol, and inhibin B on cycle day 3 were measured in groups that were divided according to ovarian response. The tests were also evaluated according to ovarian response and pregnancy outcomes. All analyses were performed using the Statistical Package for the Social Sciences, version 15.0 (SPSS, Chicago, IL, USA).

RESULTS

The antral follicle count (AFC) was the best single predictor for ovarian response and pregnancy outcomes. The sensitivity and specificity for prediction of ovarian response were 81% and 78% for AFC at an optimum cutoff value of ≤ 13.1. Age was negatively correlated with ovarian volume (r = -0.280, p = 0.021) and AFC (r = -0.358, p = 0.003). Increasing FSH was associated with a reduction in AFC (r = -0.273, p = 0.025). The AFC was significantly correlated with ovarian volume (r = 0.660, p < 0.0001) and FSH (r = -0.273, p = 0.03).

CONCLUSIONS

Our data demonstrate that the AFC provides better prognostic information on the occurrence of ovarian response during clomiphene citrate stimulation for IUI.

Is mandating elective single embryo transfer ethically justifiable in young women?

Compared with natural conception, IVF is an effective form of fertility treatment associated with higher rates of obstetric complications and poorer neonatal outcomes. While some increased risk is intrinsic to the infertile population requiring treatment, the practice of multiple embryo transfer contributes to these complications and outcomes, especially concerning its role in higher order pregnancies. As a result, several jurisdictions (e.g. Sweden, Belgium, Turkey, and Quebec) have legally mandated elective single-embryo transfer (eSET) for young women. We accept that in very high-risk scenarios (e.g. past history of preterm delivery and poor maternal health), double-embryo transfer (DET) should be prohibited due to unacceptably high risks. However, we argue that mandating eSET for all young women can be considered an unacceptable breach of patient autonomy, especially since DET offers certain women financial and social advantages. We also show that mandated eSET is inconsistent with other practices (e.g. ovulation induction and intrauterine insemination-ovulation induction) that can expose women and their offspring to risks associated with multiple pregnancies. While defending the option of DET for certain women, some recommendations are offered regarding IVF practice (e.g. preimplantation genetic screening and better support of IVF and maternity leave) to incentivise patients to choose eSET.

RETRACTED: Comparing the effect of office hysteroscopy with endometrial scratch versus office hysteroscopy on intrauterine insemination outcome: a randomized controlled trial

This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been retracted at the request of the Editor-in-Chief. The editors were alerted to the possibility of data fabrication in this study by a systematic reviewer who had noticed discrepancies between the trial registry and the published version, and an implausible interval between the date of last recruit and paper submission, given the duration of follow-up. The editors wrote to Dr El-Khayat, who did not give a clear explanation, but kindly supplied a copy of the trial dataset. An independent statistical review of that dataset suggested a high probability that at least some of the data had been fabricated. We shared the comments of our statistical reviewer's analysis with Dr El-Kayat who again failed to give a satisfactory explanation. As suggested by the Committee on Publication Ethics (COPE), the editor-in-chief wrote to the authorities at Cairo University requesting that they investigate. We have not heard back from them. We have therefore decided to retract.

The safety of treatments for angioedema with hereditary C1 inhibitor deficiency

INTRODUCTION

Angioedema is a localized and self-limiting edema of the subcutaneous and submucosal tissue. Hereditary angioedema with C1 inhibitor deficiency (C1-INH-HAE) is the best characterized form of hereditary angioedema. In C1-INH-HAE, the reduced plasma levels of C1-INH cause instability of the contact system with release of bradykinin, the key mediator of angioedema. C1-INH-HAE is characterized by recurrent skin swelling, abdominal pain, and potentially life-threatening upper airways obstruction. Knowledge of the molecular mechanisms leading from C1-INH deficiency to angioedema allowed the development of several therapies.

AREAS COVERED

The aim of this review article is to discuss the safety of currently available treatments of C1-INH-HAE. The authors give an insight on the mechanism of action and safety profile of drugs for treatment of acute attacks and for short- and long-term prophylaxis. Evidence from systematic reviews, clinical trials, retrospective studies, and case reports is summarized in this review.

EXPERT OPINION

C1-INH-HAE is a disabling, life-threatening condition that lasts life-long. Different therapeutic approaches with different drugs provide significant benefit to patients. Safety profiles of these therapies are critical for optimal therapeutic decision and need to be known by C1-INH-HAE treating physicians for appropriate risk/benefit evaluation.

The ultrasonographic detection of follicular rupture at the time of intrauterine insemination: is it really decisive?

Our aim is to assess the impact of the ultrasonographic detection of follicular rupture on the intrauterine insemination success. A total of 313 women undergoing ovarian stimulation for intrauterine insemination were enrolled. Transvaginal ultrasonography was performed to check whether the dominant follicle had ruptured and according to that the patients were divided into two groups. The ultrasound detection of follicular rupture was observed in 156 patients (54%). The independent variables favoring follicular rupture were: Age (t: 7.646, p < 0.0005), FSH value (t: -5.637, p < 0.0005), duration of infertility (t: -4.265, p < 0.0005), menstrual cycle length (t: -4.927, p < 0.0005). Moreover, the logistic regression analysis demonstrated that the predictive variables for follicular rupture were: FSH value (OR 1.7, CI 95% 1.3-2.3, p < 0.0005), duration of infertility (OR 2.6, CI 95% 1.6-4.2, p < 0.0005) and menstrual cycle length (OR 2.4, CI 95% 1.7-3.4, p < 0.0005). Pregnancy occurred in 23 patients of the group A (14.7%) and in 22 patients of the group B (16.5%) without a significant difference (p = 0.6). The logistic regression analysis confirmed that neither the evidence of follicular rupture nor any other variables influenced the pregnancy rate.

Successful pregnancy by vitrified-warmed embryo transfer for a woman with Kallmann syndrome

Purpose

Kallmann syndrome is a genetic disorder characterized by hypogonadotropic hypogonadism and anosmia. We report the case of a 31-year-old woman with Kallmann syndrome who successfully gave birth after intracytoplasmic sperm injection (ICSI) and vitrified-warmed embryo transfer, despite relatively ineffective ovarian stimulation.

Method

A 30 year-old woman with primary amenorrhea wished to achieve pregnancy. Diagnostic testing results were consistent with Kallmann syndrome. Follicular stimulation was started with human menopausal gonadotropin (hMG; 150 IU/day). After 28 days of treatment, 4 follicles were observed (total hMG; 4200 IU), with a dominant follicle diameter of 23 mm. Ovum pick-up was performed and 2 oocytes, one at metaphase II (MII) and one at the germinal vesicle stage, were obtained. Piezo-ICSI was performed on the MII oocyte and an 8-cell stage embryo was cryopreserved on day 3. Subsequently, embryo transfer was performed after endometrial preparation.

Result

A gestational sac and embryo heart activity were confirmed by ultrasonographic monitoring, and a healthy male infant weighing 3246 g was delivered by Caesarean section after 41 weeks 3 days of gestation.

Conclusion

This is the first report of a healthy delivery after vitrified-warmed embryo transfer for a woman with Kallmann syndrome. Our experience suggests that ICSI and vitrified-warmed embryo transfer are effective for women with Kallmann syndrome.

Minimal stimulation using gonadotropin combined with clomiphene citrate or letrozole for intrauterine insemination

PURPOSE

To evaluate the efficacy of minimal stimulation using discretely administered gonadotropin combined with clomiphene citrate (CC) or letrozole (LTZ) for intrauterine insemination (IUI) cycles.

MATERIALS AND METHODS

Total 257 IUI cycles from 158 infertile couples were assessed. A CC dose of 100 mg/day (n=126 cycles) or a LTZ dose of 5 mg/day (n=131 cycles) was administered on days 3-5 of the menstrual cycle for 5 days. Each group received human menopausal gonadotropin at a dose of 150 IU by two or three alternative day: CC combined with alternate-day regimen for 2 or 3 days (CC+300, n=37; CC+450, n=89) and LTZ combined with alternate-day regimen for 2 or 3 days (LTZ+300, n=36; LTZ+450, n=95).

RESULTS

The clinical pregnancy rate was comparable between the CC and LTZ groups (18.3% vs. 13.0%, p=0.243). The clinical pregnancy rate also showed no significant difference among the 4 groups (21.6% vs. 16.9% vs. 11.1% vs. 12.6%, p=0.507). The multiple pregnancy rate was significantly higher in LTZ compared to CC group (37.5% vs. 8.7%, p=0.028) and in the LTZ+450 compared to CC+450 group (50% vs. 13.3%, p=0.038). Overall, there were 15 cases of ovarian hyperstimulation syndrome (OHSS), with the prevalence being significantly lower in the LTZ compared to CC group (1.5% vs. 10.3%, p=0.003). OHSS was more prevalent in the CC+450 compared to the LTZ+450 group (12.4% vs. 1.1%, p=0.002).

CONCLUSION

Our findings suggest that minimal stimulation using two alternate-day gonadotropin with LTZ decreases the development of OHSS and multiple pregnancies, while maintaining comparable pregnancy rates in IUI cycles.

Evaluation of human chaperonin 10 and high-sensitivity C-reactive protein levels of infertile women who underwent ovulation induction and intra-uterine insemination

INTRODUCTION

The implantation of embryo is one of the crucial steps of a successful pregnancy. The foetus should be protected from maternal immune system, for the appropriate implantation and modification in maternal immunity is crucial. We investigated high-sensitivity C-reactive protein (hs CRP), which is an indicator of low-grade inflammation and Cp10 that has immunosuppressant and growth-promoting capabilities at embryo levels in ovulation induction and intra-uterine insemination (IUI)applied in infertile women. The ovulation induction was maintained by clomiphene citrate or gonadotropins for 42 infertile patients. After successful ovulation induction, IUI was carried out. The blood samples were taken 2 and 8 days after IUI to evaluate Cp10 and hs CRP levels. The pregnant and non-pregnant groups' results were analyzed. The Cp10 levels 8 days after IUI were higher in pregnant group, whereas there was no difference for the 2 days after levels between pregnant and non-pregnant group. The hs CRP levels were similar for both 2nd and 8th days when we compared pregnant and non-pregnant groups. The Cp10 levels increased from day 2 to day 8 in pregnant group. In contrast, the Cp10 levels decreased in non-pregnant group. The change in hs CRP levels from day 2 to day 8 was not significant in pregnant and non-pregnant groups. The Cp10 levels were higher in early phases of fertilisation and elevated through the preceding days of conception in pregnant patients, while it decreased in non-pregnant patients with failed cycles.

The effectiveness of flow cytometric sorting of human sperm (MicroSort®) for influencing a child's sex

BACKGROUND

Flow cytometric sorting can be used to separate sperm based on sex chromosome content. Differential fluorescence emitted by stained X- vs. Y-chromosome-bearing sperm enables sorting and collection of samples enriched in either X- or Y-bearing sperm for use to influence the likelihood that the offspring will be a particular sex. Herein we report the effectiveness of flow cytometric sorting of human sperm and its use in human ART procedures.

METHODS

This prospective, observational cohort study of the series of subjects treated with flow cytometrically sorted human sperm was conducted at investigational sites at two private reproductive centers. After meeting inclusion criteria, married couples (n = 4993) enrolled to reduce the likelihood of sex-linked or sex-limited disease in future children (n = 383) or to balance the sex ratio of their children (n = 4610). Fresh or frozen-thawed semen was processed and recovered sperm were stained with Hoechst 33342 and sorted by flow cytometry (n = 7718) to increase the percentage of X-bearing sperm (n = 5635) or Y-bearing sperm (n = 2083) in the sorted specimen. Sorted sperm were used for IUI (n = 4448) and IVF/ICSI (n = 2957). Measures of effectiveness were the percentage of X- and Y-bearing sperm in sorted samples, determined by fluorescence in situ hybridization, sex of babies born, IVF/ICSI fertilization- and cleavage rates, and IUI, IVF/ICSI, FET pregnancy rates and miscarriage rates.

RESULTS

Sorted specimens averaged 87.7 ± 5.0% X-bearing sperm after sorting for X and 74.3 ± 7.0% Y-bearing sperm after sorting for Y. Seventy-three percent of sorts were for girls. For babies born, 93.5% were females and 85.3% were males after sorting for X- and Y-bearing sperm, respectively. IUI, IVF/ICSI, and FET clinical pregnancy rates were 14.7%, 30.8%, and 32.1%, respectively; clinical miscarriage rates were 15.5%, 10.2%, and 12.7%.

CONCLUSIONS

Flow cytometric sorting of human sperm shifted the X:Y sperm ratio. IUI, IVF/ICSI and FET outcomes were consistent with unimpaired sperm function. Results provide evidence supporting the effectiveness of flow cytometric sorting of human sperm for use as a preconception method of influencing a baby's sex.

TRIAL REGISTRATION

NCT00865735 (ClinicalTrials.gov).