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Li J, Yu J, Huang Y, Xie B, Hu Q, Ma N, Qin R, Luo J, Wu H, Liao M, Qin A. The impact of thyroid autoimmunity on pregnancy outcomes in women with unexplained infertility undergoing intrauterine insemination: a retrospective single-center cohort study and meta-analysis. Front Endocrinol (Lausanne) 2024; 15:1359210. [PMID: 38596217 PMCID: PMC11003302 DOI: 10.3389/fendo.2024.1359210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 03/05/2024] [Indexed: 04/11/2024] Open
Abstract
Introduction Infertility affects 8-12% of couples worldwide, with 15-30% classified as unexplained infertility (UI). Thyroid autoimmunity (TAI), the most common autoimmune disorder in women of reproductive age, may impact fertility and pregnancy outcomes. However, the underlying mechanism is unclear. This study focuses on intrauterine insemination (IUI) and its potential association with TAI in UI patients. It is the first meta-analysis following a comprehensive literature review to improve result accuracy and reliability. Methods Retrospective cohort study analyzing 225 women with unexplained infertility, encompassing 542 cycles of IUI treatment. Participants were categorized into TAI+ group (N=47, N= 120 cycles) and TAI- group (N=178, N= 422 cycles). Additionally, a systematic review and meta-analyses following PRISMA guidelines were conducted, incorporating this study and two others up to June 2023, totaling 3428 IUI cycles. Results Analysis revealed no significant difference in independent variables affecting reproductive outcomes. However, comparison based on TAI status showed significantly lower clinical pregnancy rates (OR: 0.43, P= 0.028, 95%CI: 0.20-0.93) and live birth rate (OR: 0.20, P= 0.014, 95%CI: 0.05 ~ 0.71) were significantly lower than TAI- group. There was no significant difference in pregnancy rate between the two groups (OR: 0.61, P= 0.135, 95%CI: 0.32-1.17). However, the meta-analysis combining these findings across studies did not show statistically significant differences in clinical pregnancy rates (OR:0.77, P=0.18, 95%CI: 0.53-1.13) or live birth rates (OR: 0.68, P=0.64, 95%CI: 0.13-3.47) between the TAI+ and TAI- groups. Discussion Our retrospective cohort study found an association between TAI and reduced reproductive outcomes in women undergoing IUI for unexplained infertility. However, the meta-analysis incorporating other studies did not yield statistically significant associations. Caution is required in interpreting the relationship between thyroid autoimmunity and reproductive outcomes. Future studies should consider a broader population and a more rigorous study design to validate these findings. Clinicians dealing with women with unexplained infertility and TAI should be aware of the complexity of this field and the limitations of available evidence.
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Affiliation(s)
- Jiaxu Li
- Reproductive Medicine Research Center, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Jiaxin Yu
- Reproductive Medicine Research Center, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Yingqin Huang
- Reproductive Medicine Center, Maternity and Child Health Care of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Baoli Xie
- Reproductive Medicine Research Center, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Qianwen Hu
- Reproductive Medicine Research Center, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Nana Ma
- Gynecology Department, Shenzhen Luohu Hospital Group Luohu People’s Hospital, Shenzhen, Guangdong, China
| | - Rongyan Qin
- Reproductive Medicine Research Center, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Jianxin Luo
- Reproductive Medicine Research Center, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Hao Wu
- Reproductive Medicine Research Center, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Ming Liao
- Reproductive Medicine Research Center, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Aiping Qin
- Reproductive Medicine Research Center, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
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Man JKY, Parker AE, Broughton S, Ikhlaq H, Das M. Should IUI replace IVF as first-line treatment for unexplained infertility? A literature review. BMC Womens Health 2023; 23:557. [PMID: 37891606 PMCID: PMC10612289 DOI: 10.1186/s12905-023-02717-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 10/17/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Unexplained infertility accounts for 25% of infertility causes in the UK. Active intervention methods, such as intrauterine insemination (IUI) or in vitro fertilisation (IVF), are often sought. Despite the National Institute for Health and Care Excellence (NICE) recommending IVF for unexplained infertility, this recommendation has generated an ongoing debate, with few fertility clinics discontinuing the use of IUI as the first-line management of choice. In contrast to NICE, recent guidance released from the European Society for Human Reproduction and Embryology (ESHRE) in August 2023 supports the use of IUI as first-line. High-quality evidence behind such interventions is lacking, with current literature providing conflicting results. AIMS This review aims to provide a literature overview exploring whether IUI or IVF should be used as first-line treatment for couples with unexplained infertility, in the context of current guidelines. METHODS The primary outcome used to assess efficacy of both treatment methods is live birth (LB) rates. Secondary outcomes used are clinical pregnancy (CP) and ongoing pregnancy (OP) rates. A comprehensive literature search of 4 databases: Ovid MEDLINE, EMBASE, Maternity & Infant Care and the Cochrane Library were searched in January 2022. Upon removal of duplications, abstract screening, and full-text screening, a total of 34 papers were selected. DISCUSSION/CONCLUSION This review highlights a large discrepancy in the literature when examining pregnancy outcomes of IUI and IVF treatments. Evidence shows IUI increases LB and CP rates 3-fold compared to expectant management. Literature comparing IUI to IVF is less certain. The review finds the literature implies IVF should be used for first-line management but the paucity of high-quality randomised controlled trials (RCTs), coupled with heterogeneity of the identified studies and a lack of research amongst women > 40 years warrants the need for further large RCTs. The decision to offer IUI with ovarian stimulation (IUI-OS) or IVF should be based upon patient prognostic factors. We suggest that IUI-OS could be offered as first-line treatment for unexplained infertility for women < 38 years, with good prognosis, and IVF could be offered first to those > 38 years. Patients should be appropriately counselled to enable informed decision making.
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Affiliation(s)
- Jessica Ka-Yan Man
- Faculty of Medicine, Imperial College London (Hammersmith Campus), Du Cane Road, London, W12 0NN, UK.
| | - Anne Elizabeth Parker
- Faculty of Medicine, Imperial College London (Hammersmith Campus), Du Cane Road, London, W12 0NN, UK
| | - Sophie Broughton
- Faculty of Medicine, Imperial College London (Hammersmith Campus), Du Cane Road, London, W12 0NN, UK
- Medical School, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Hamza Ikhlaq
- Faculty of Medicine, Imperial College London (Hammersmith Campus), Du Cane Road, London, W12 0NN, UK
| | - Mausumi Das
- Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London, W12 0HS, UK
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Turner KA, Achinger L, Kong D, Kluczynski DF, Fishman EL, Phillips A, Saltzman B, Loncarek J, Harstine BR, Avidor-Reiss T. Abnormal centriolar biomarker ratios correlate with unexplained bull artificial insemination subfertility: a pilot study. Sci Rep 2023; 13:18338. [PMID: 37884598 PMCID: PMC10603076 DOI: 10.1038/s41598-023-45162-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/17/2023] [Indexed: 10/28/2023] Open
Abstract
The mechanisms underlying male infertility are poorly understood. Most mammalian spermatozoa have two centrioles: the typical barrel-shaped proximal centriole (PC) and the atypical fan-like distal centriole (DC) connected to the axoneme (Ax). These structures are essential for fertility. However, the relationship between centriole quality and subfertility (reduced fertility) is not well established. Here, we tested the hypothesis that assessing sperm centriole quality can identify cattle subfertility. By comparing sperm from 25 fertile and 6 subfertile bulls, all with normal semen analyses, we found that unexplained subfertility and lower sire conception rates (pregnancy rate from artificial insemination in cattle) correlate with abnormal centriolar biomarker distribution. Fluorescence-based Ratiometric Analysis of Sperm Centrioles (FRAC) found only four fertile bulls (4/25, 16%) had positive FRAC tests (having one or more mean FRAC ratios outside of the distribution range in a group's high-quality sperm population), whereas all of the subfertile bulls (6/6, 100%) had positive FRAC tests (P = 0.00008). The most sensitive biomarker was acetylated tubulin, which had a novel labeling pattern between the DC and Ax. These data suggest that FRAC and acetylated tubulin labeling can identify bull subfertility that remains undetected by current methods and may provide insight into a novel mechanism of subfertility.
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Affiliation(s)
- Katerina A Turner
- Department of Biological Sciences, College of Natural Sciences and Mathematics, University of Toledo, 3050 W. Towerview Blvd, Toledo, OH, 43606, USA
| | - Luke Achinger
- Department of Biological Sciences, College of Natural Sciences and Mathematics, University of Toledo, 3050 W. Towerview Blvd, Toledo, OH, 43606, USA
| | - Dong Kong
- Laboratory of Protein Dynamics and Signaling, Center for Cancer Research, National Institutes of Health, National Cancer Institute, Frederick, MD, USA
| | - Derek F Kluczynski
- Department of Biological Sciences, College of Natural Sciences and Mathematics, University of Toledo, 3050 W. Towerview Blvd, Toledo, OH, 43606, USA
| | - Emily Lillian Fishman
- Department of Biological Sciences, College of Natural Sciences and Mathematics, University of Toledo, 3050 W. Towerview Blvd, Toledo, OH, 43606, USA
| | - Audrey Phillips
- Department of Biological Sciences, College of Natural Sciences and Mathematics, University of Toledo, 3050 W. Towerview Blvd, Toledo, OH, 43606, USA
| | - Barbara Saltzman
- Department of Population Health, College of Health and Human Services, University of Toledo, Toledo, OH, USA
| | - Jadranka Loncarek
- Laboratory of Protein Dynamics and Signaling, Center for Cancer Research, National Institutes of Health, National Cancer Institute, Frederick, MD, USA
| | | | - Tomer Avidor-Reiss
- Department of Biological Sciences, College of Natural Sciences and Mathematics, University of Toledo, 3050 W. Towerview Blvd, Toledo, OH, 43606, USA.
- Department of Urology, College of Medicine and Life Sciences, University of Toledo, Toledo, OH, USA.
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Sunkara SK, Kamath MS, Pandian Z, Gibreel A, Bhattacharya S. In vitro fertilisation for unexplained subfertility. Cochrane Database Syst Rev 2023; 9:CD003357. [PMID: 37753821 PMCID: PMC10523437 DOI: 10.1002/14651858.cd003357.pub5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
BACKGROUND In vitro fertilisation (IVF) is a treatment for unexplained subfertility but is invasive, expensive, and associated with risks. OBJECTIVES To evaluate the effectiveness and safety of IVF versus expectant management, unstimulated intrauterine insemination (IUI), and IUI with ovarian stimulation using gonadotropins, clomiphene citrate (CC), or letrozole in improving pregnancy outcomes. SEARCH METHODS We searched following databases from inception to November 2021, with no language restriction: Cochrane Gynaecology and Fertility Register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL. We searched reference lists of articles and conference abstracts. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing effectiveness of IVF for unexplained subfertility with expectant management, unstimulated IUI, and stimulated IUI. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methods. MAIN RESULTS IVF versus expectant management (two RCTs) We are uncertain whether IVF improves live birth rate (LBR) and clinical pregnancy rate (CPR) compared to expectant management (odds ratio (OR) 22.0, 95% confidence interval (CI) 2.56 to 189.37; 1 RCT; 51 women; very low-quality evidence; OR 3.24, 95% CI 1.07 to 9.8; 2 RCTs; 86 women; I2 = 80%; very low-quality evidence). Adverse effects were not reported. Assuming 4% LBR and 12% CPR with expectant management, these would be 8.8% to 9% and 13% to 58% with IVF. IVF versus unstimulated IUI (two RCTs) IVF may improve LBR compared to unstimulated IUI (OR 2.47, 95% CI 1.19 to 5.12; 2 RCTs; 156 women; I2 = 60%; low-quality evidence). We are uncertain whether there is a difference between IVF and IUI for multiple pregnancy rate (MPR) (OR 1.03, 95% CI 0.04 to 27.29; 1 RCT; 43 women; very low-quality evidence) and miscarriage rate (OR 1.72, 95% CI 0.14 to 21.25; 1 RCT; 43 women; very low-quality evidence). No study reported ovarian hyperstimulation syndrome (OHSS). Assuming 16% LBR, 3% MPR, and 6% miscarriage rate with unstimulated IUI, these outcomes would be 18.5% to 49%, 0.1% to 46%, and 0.9% to 58% with IVF. IVF versus IUI + ovarian stimulation with gonadotropins (6 RCTs), CC (1 RCT), or letrozole (no RCTs) Stratified analysis was based on pretreatment status. Treatment-naive women There may be little or no difference in LBR between IVF and IUI + gonadotropins (1 IVF to 2 to 3 IUI cycles: OR 1.19, 95% CI 0.87 to 1.61; 3 RCTs; 731 women; I2 = 0%; low-quality evidence; 1 IVF to 1 IUI cycle: OR 1.63, 95% CI 0.91 to 2.92; 2 RCTs; 221 women; I2 = 54%; low-quality evidence); or between IVF and IUI + CC (OR 2.51, 95% CI 0.96 to 6.55; 1 RCT; 103 women; low-quality evidence). Assuming 42% LBR with IUI + gonadotropins (1 IVF to 2 to 3 IUI cycles) and 26% LBR with IUI + gonadotropins (1 IVF to 1 IUI cycle), LBR would be 39% to 54% and 24% to 51% with IVF. Assuming 15% LBR with IUI + CC, LBR would be 15% to 54% with IVF. There may be little or no difference in CPR between IVF and IUI + gonadotropins (1 IVF to 2 to 3 IUI cycles: OR 1.17, 95% CI 0.85 to 1.59; 3 RCTs; 731 women; I2 = 0%; low-quality evidence; 1 IVF to 1 IUI cycle: OR 4.59, 95% CI 1.86 to 11.35; 1 RCT; 103 women; low-quality evidence); or between IVF and IUI + CC (OR 3.58, 95% CI 1.51 to 8.49; 1 RCT; 103 women; low-quality evidence). Assuming 48% CPR with IUI + gonadotropins (1 IVF to 2 to 3 IUI cycles) and 17% with IUI + gonadotropins (1 IVF to 1 IUI cycle), CPR would be 44% to 60% and 28% to 70% with IVF. Assuming 21% CPR with IUI + CC, CPR would be 29% to 69% with IVF. There may be little or no difference in multiple pregnancy rate (MPR) between IVF and IUI + gonadotropins (1 IVF to 2 to 3 IUI cycles: OR 0.82, 95% CI 0.38 to 1.77; 3 RCTs; 731 women; I2 = 0%; low-quality evidence; 1 IVF to 1 IUI cycle: OR 0.76, 95% CI 0.36 to 1.58; 2 RCTs; 221 women; I2 = 0%; low-quality evidence); or between IVF and IUI + CC (OR 0.64, 95% CI 0.17 to 2.41; 1 RCT; 102 women; low-quality evidence). We are uncertain if there is a difference in OHSS between IVF and IUI + gonadotropins with 1 IVF to 2 to 3 IUI cycles (OR 6.86, 95% CI 0.35 to 134.59; 1 RCT; 207 women; very low-quality evidence); and there may be little or no difference in OHSS with 1 IVF to 1 IUI cycle (OR 1.22, 95% CI 0.36 to 4.16; 2 RCTs; 221 women; I2 = 0%; low-quality evidence). There may be little or no difference between IVF and IUI + CC (OR 1.53, 95% CI 0.24 to 9.57; 1 RCT; 102 women; low-quality evidence). We are uncertain if there is a difference in miscarriage rate between IVF and IUI + gonadotropins with 1 IVF to 2 to 3 IUI cycles (OR 0.31, 95% CI 0.03 to 3.04; 1 RCT; 207 women; very low-quality evidence); and there may be little or no difference with 1 IVF to 1 IUI cycle (OR 1.16, 95% CI 0.44 to 3.02; 1 RCT; 103 women; low-quality evidence). There may be little or no difference between IVF and IUI + CC (OR 1.48, 95% CI 0.54 to 4.05; 1 RCT; 102 women; low-quality evidence). In women pretreated with IUI + CC IVF may improve LBR compared with IUI + gonadotropins (OR 3.90, 95% CI 2.32 to 6.57; 1 RCT; 280 women; low-quality evidence). Assuming 22% LBR with IUI + gonadotropins, LBR would be 39% to 65% with IVF. IVF may improve CPR compared with IUI + gonadotropins (OR 14.13, 95% CI 7.57 to 26.38; 1 RCT; 280 women; low-quality evidence). Assuming 30% CPR with IUI + gonadotropins, CPR would be 76% to 92% with IVF. AUTHORS' CONCLUSIONS IVF may improve LBR over unstimulated IUI. Data should be interpreted with caution as overall evidence quality was low.
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Affiliation(s)
- Sesh Kamal Sunkara
- Division of Women's Health, Faculty of Life Sciences & Medicine, King's College London, London, UK
- Kings Fertility, London, UK
| | - Mohan S Kamath
- Department of Reproductive Medicine and Surgery, Christian Medical College, Vellore, India
| | | | - Ahmed Gibreel
- Obstetrics & Gynaecology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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Abdullah AA, Ahmed M, Oladokun A. Characterization and risk factors for unexplained female infertility in Sudan: A case-control study. World J Methodol 2023; 13:98-117. [PMID: 37456975 PMCID: PMC10348085 DOI: 10.5662/wjm.v13.i3.98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 02/08/2023] [Accepted: 03/15/2023] [Indexed: 06/20/2023] Open
Abstract
BACKGROUND Female infertility with unknown causes (unexplained) remains one of the mysteries in the reproductive health field, where the diagnostic evidence is still weak and the proposed treatments still work with unknown methods. However, several studies have proposed some possible causes and risk factors for unexplained female infertility.
AIM To characterize and identify factors associated with unexplained infertility in Sudanese women.
METHODS A matched (age and body mass index) case-control study was conducted from March 2021 to February 2022. The study samples were 210 women with unexplained infertility (UI) and 190 fertile women of reproductive age who were attending the maternity hospitals and fertility clinics in Khartoum, Sudan. The risk factors of unexplained infertility were identified using a structured, pre-tested questionnaire containing information on socio-demographic variables, anthropometrics, clinical diagnosis of infertility, behavioral factors, physical activity assessment, diversity, and consumption of different food groups by the study participants.
RESULTS The results showed a higher proportion of women diagnosed with UI were residents of rural areas than controls (21.4% vs 11.1%, P < 0.05), and previous miscarriages and/or abortions were more common in fertile women compared with infertile women (13.16% vs 5.71%, P < 0.05). Additionally, infertile women had a significantly (P < 0.05) higher proportion of family history of infertility (explained and unexplained) compared with controls. Finally, after controlling for the effects of potentially confounding variables using multivariable logistic regression analysis, only marital status, family history of infertility, use of modern contraceptives, smoking, caffeine consumption, physical activity level, meals consumed, other vitamin-A-rich fruits and vegetables, and other vegetables were found to be significant (P < 0.05) factors associated with unexplained infertility among Sudanese women.
CONCLUSION Married women with a family history of infertility who smoke and consume a high amount of caffeine, who live a sedentary lifestyle, and who consume more than two meals free of vitamin-A-rich fruits and/or vegetables and/or other vegetables per day are at the highest risk of developing unexplained infertility.
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Affiliation(s)
- Abdullah Abdulslam Abdullah
- Reproductive Health Sciences Program, Pan African University Life and Earth Sciences Institute, University of Ibadan, Ibadan 119, Oyo state, Nigeria
- Department of Obstetrics and Gynecology, College of Medicine, University of Ibadan, Ibadan 119, Oyo state, Nigeria
- Department of Biomedical Sciences, Faculty of Veterinary Sciences, University of Gadarif, Al-Gadarif 32211, Sudan
| | - Musa Ahmed
- Reproductive Health Sciences Program, Pan African University Life and Earth Sciences Institute, University of Ibadan, Ibadan 119, Oyo state, Nigeria
- Department of Obstetrics and Gynecology, College of Medicine, University of Ibadan, Ibadan 119, Oyo state, Nigeria
- Department of Veterinary Surgery, Faculty of Veterinary Medicine, AL-Salam University, Al-fula 120, West Kordofan, Sudan
| | - Adesina Oladokun
- Department of Obstetrics and Gynecology, College of Medicine, University of Ibadan, Ibadan 119, Oyo state, Nigeria
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Wessel JA, Mochtar MH, Besselink DE, Betjes H, de Bruin JP, Cantineau AEP, Groenewoud ER, Hooker AB, Lambalk CB, Kwee J, Kaaijk EM, Louwé LA, Maas JWM, Mol BWJ, van Rumste MME, Traas MAF, Goddijn M, van Wely M, Mol F. Expectant management versus IUI in unexplained subfertility and a poor pregnancy prognosis (EXIUI study): a randomized controlled trial. Hum Reprod 2022; 37:2808-2816. [PMID: 36331493 PMCID: PMC9712943 DOI: 10.1093/humrep/deac236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/31/2022] [Indexed: 11/06/2022] Open
Abstract
STUDY QUESTION For couples with unexplained subfertility and a poor prognosis for natural conception, is 6 months expectant management (EM) inferior to IUI with ovarian stimulation (IUI-OS), in terms of live births? SUMMARY ANSWER In couples with unexplained subfertility and a poor prognosis for natural conception, 6 months of EM is inferior compared to IUI-OS in terms of live births. WHAT IS KNOWN ALREADY Couples with unexplained subfertility and a poor prognosis are often treated with IUI-OS. In couples with unexplained subfertility and a relatively good prognosis for natural conception (>30% in 12 months), IUI-OS does not increase the live birth rate as compared to 6 months of EM. However, in couples with a poor prognosis for natural conception (<30% in 12 months), the effectiveness of IUI-OS is uncertain. STUDY DESIGN, SIZE, DURATION We performed a non-inferiority multicentre randomized controlled trial within the infrastructure of the Dutch Consortium for Healthcare Evaluation and Research in Obstetrics and Gynaecology. We intended to include 1091 couples within 3 years. The couples were allocated in a 1:1 ratio to 6 months EM or 6 months IUI-OS with either clomiphene citrate or gonadotrophins. PARTICIPANTS/MATERIALS, SETTING, METHODS We studied heterosexual couples with unexplained subfertility and a poor prognosis for natural conception (<30% in 12 months). The primary outcome was ongoing pregnancy leading to a live birth. Non-inferiority would be shown if the lower limit of the one-sided 90% risk difference (RD) CI was less than minus 7% compared to an expected live birth rate of 30% following IUI-OS. We calculated RD, relative risks (RRs) with 90% CI and a corresponding hazard rate for live birth over time based on intention-to-treat and per-protocol (PP) analysis. MAIN RESULTS AND THE ROLE OF CHANCE Between October 2016 and September 2020, we allocated 92 couples to EM and 86 to IUI-OS. The trial was halted pre-maturely owing to slow inclusion. Mean female age was 34 years, median duration of subfertility was 21 months. Couples allocated to EM had a lower live birth rate than couples allocated to IUI-OS (12/92 (13%) in the EM group versus 28/86 (33%) in the IUI-OS group; RR 0.40 90% CI 0.24 to 0.67). This corresponds to an absolute RD of minus 20%; 90% CI: -30% to -9%. The hazard ratio for live birth over time was 0.36 (95% CI 0.18 to 0.70). In the PP analysis, live births rates were 8 of 70 women (11%) in the EM group versus 26 of 73 women (36%) in the IUI-OS group (RR 0.32, 90% CI 0.18 to 0.59; RD -24%, 90% CI -36% to -13%) in line with inferiority of EM. LIMITATIONS, REASONS FOR CAUTION Our trial did not reach the planned sample size, therefore the results are limited by the number of participants. WIDER IMPLICATIONS OF THE FINDINGS This study confirms the results of a previous trial that in couples with unexplained subfertility and a poor prognosis for natural conception, EM is inferior to IUI-OS. STUDY FUNDING/COMPETING INTEREST(S) The trial was supported by a grant of the SEENEZ healthcare initiative. The subsidizing parties were The Dutch Organisation for Health Research and Development (ZonMW 837004023, www.zonmw.nl) and the umbrella organization of 10 health insurers in The Netherlands. E.R.G. receives personal fees from Titus Health care outside the submitted work. M.G. declares unrestricted research and educational grants from Guerbet, Merck and Ferring not related to the presented work, paid to their institution VU medical centre. A.B.H. reports receiving travel and speakers fees from Nordic Pharma and Merck and he is member of the Nordic Pharma ANGEL group and of the Safety Monitoring Board of Womed. C.B.L. reports speakers fee from Inmed and Yingming, and his department receives research grants from Ferring, Merck and Guerbet paid to VU medical centre. B.W.J.M. is supported by a NHMRC Investigator grant (GNT1176437) and reports consultancy for ObsEva and Merck. M.v.W. received a grant from the Netherlands Organisation for Health Research and Development ZonMW (80-8520098-91072). F.M. received two grants from the Netherlands Organisation for Health Research and Development ZonMW (NTR 5599 and NTR 6590). The other authors report no competing interest. TRIAL REGISTRATION NUMBER Dutch Trial register NL5455 (NTR5599). TRIAL REGISTRATION DATE 18 December 2015. DATE OF FIRST PATIENT’S ENROLMENT 26 January 2017.
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Affiliation(s)
- J A Wessel
- Department of Obstetrics and Gynaecology, Centre for Reproductive Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands,Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - M H Mochtar
- Department of Obstetrics and Gynaecology, Centre for Reproductive Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands,Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - D E Besselink
- Department of Obstetrics & Gynaecology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - H Betjes
- Department Obstetrics and Gynaecology, Flevo Hospital, Almere, The Netherlands
| | - J P de Bruin
- Department of Gynaecology & Obstetrics, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - A E P Cantineau
- Department of Obstetrics and Gynaecology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - E R Groenewoud
- Department of Obstetrics, Gynaecology & Reproductive Medicine, Noordwest Ziekenhuisgroep, Den Helder, The Netherlands
| | - A B Hooker
- Department of Obstetrics and Gynaecology, Zaans Medical Center, Zaandam, The Netherlands
| | - C B Lambalk
- Department of Reproductive Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - J Kwee
- Department of Obstetrics and Gynaecology, OLVG West, Amsterdam, The Netherlands
| | - E M Kaaijk
- Department of Obstetrics and Gynaecology, OLVG Oost, Amsterdam, The Netherlands
| | - L A Louwé
- Department of Gynaecology, Leiden University Medical Center, Leiden, The Netherlands
| | - J W M Maas
- Department of Obstetrics and Gynaecology MUMC+ and Grow-school of Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands
| | - B W J Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia,Aberdeen Centre for Women’s Health Research, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - M M E van Rumste
- Department of Gynaecology, Catharina Hospital, Eindhoven, The Netherlands
| | - M A F Traas
- Department of Gynaecology, Gelre Hospital, Apeldoorn, The Netherlands
| | - M Goddijn
- Department of Obstetrics and Gynaecology, Centre for Reproductive Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands,Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - M van Wely
- Department of Obstetrics and Gynaecology, Centre for Reproductive Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands,Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - F Mol
- Correspondence address. Department of Obstetrics and Gynaecology, Centre for Reproductive Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands. E-mail:
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7
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Luna-García LA, Meza-Herrera CA, Pérez-Marín CC, Corona R, Luna-Orozco JR, Véliz-Deras FG, Delgado-Gonzalez R, Rodriguez-Venegas R, Rosales-Nieto CA, Bustamante-Andrade JA, Gutierrez-Guzman UN. Goats as Valuable Animal Model to Test the Targeted Glutamate Supplementation upon Antral Follicle Number, Ovulation Rate, and LH-Pulsatility. BIOLOGY 2022; 11:biology11071015. [PMID: 36101396 PMCID: PMC9311901 DOI: 10.3390/biology11071015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 06/28/2022] [Accepted: 07/02/2022] [Indexed: 11/16/2022]
Abstract
The potential effect of intravenous administration of glutamate on the ovarian activity and the LH secretion pattern, considering the anestrous yearling goat as an animal model, were assessed. In late April, yearling goats (n = 20) were randomly assigned to either (1) Glutamate supplemented (GLUT; n = 10, Live Weight (LW) = 29.6 ± 1.02 kg, Body Condition (BCS) = 3.4 ± 0.2 units; i.v. supplemented with 7 mg GLUT kg−1 LW) or (2) Non-supplemented (CONT; n = 10; LW = 29.2 ± 1.07 kg, BCS = 3.5 ± 0.2 units; i.v. saline). The oats were estrus-synchronized; blood sampling (6 h × 15 min) was carried out for LH quantification. Response variables included pulsatility (PULSE), time to first pulse (TTFP), amplitude (AMPL), nadir (NAD), and area under the curve (AUC) of LH. Ovaries were ultra-sonographically scanned to assess ovulation rate (OR), number of antral follicles (AF), and total ovarian activity (TOA = OR + AF). LH-PULSE was quantified with the Munro algorithm; significant treatment x time interactions were evaluated across time. The variables LW and BCS did not differ (p > 0.05) between the experimental groups. Nevertheless, OR (1.77 vs. 0.87 ± 0.20 units), TOA (4.11 vs. 1.87 ± 0.47 units) and LH-PULSE (5.0 vs. 2.2 pulses 6 h-1) favored (p < 0.05) to the GLUT group. Our results reveal that targeted glutamate supplementation, the main central nervous system neurotransmitter, arose as an interesting strategy to enhance the hypothalamic−hypophyseal−ovarian response considering the anestrous-yearling goat as an animal model, with thought-provoking while promising translational applications.
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Affiliation(s)
- Luis A. Luna-García
- Universidad Autónoma Chapingo, Unidad Regional Universitaria de Zonas Áridas, Bermejillo 35230, Durango, Mexico;
- Departamento de Medicina y Cirugía Animal, Campus Rabanales, Universidad de Córdoba, 14014 Córdoba, Spain;
| | - César A. Meza-Herrera
- Universidad Autónoma Chapingo, Unidad Regional Universitaria de Zonas Áridas, Bermejillo 35230, Durango, Mexico;
- Correspondence: or
| | - Carlos C. Pérez-Marín
- Departamento de Medicina y Cirugía Animal, Campus Rabanales, Universidad de Córdoba, 14014 Córdoba, Spain;
| | - Rebeca Corona
- Departamento de Neurobiología Celular y Molecular, Laboratorio de Neuroanatomía Funcional y Neuroendocrinología, Instituto de Neurobiología, UNAM, Querétaro 76230, Mexico;
| | - Juan R. Luna-Orozco
- Centro de Bachillerato Tecnológico Agropecuario No. 1, Torreón 27000, Coahuila, Mexico;
| | - Francisco G. Véliz-Deras
- Universidad Autónoma Agraria Antonio Narro, Unidad Laguna, Torreón 27054, Coahuila, Mexico; (F.G.V.-D.); (R.D.-G.); (R.R.-V.)
| | - Ramón Delgado-Gonzalez
- Universidad Autónoma Agraria Antonio Narro, Unidad Laguna, Torreón 27054, Coahuila, Mexico; (F.G.V.-D.); (R.D.-G.); (R.R.-V.)
| | - Rafael Rodriguez-Venegas
- Universidad Autónoma Agraria Antonio Narro, Unidad Laguna, Torreón 27054, Coahuila, Mexico; (F.G.V.-D.); (R.D.-G.); (R.R.-V.)
| | - Cesar A. Rosales-Nieto
- Facultad de Agronomía y Veterinaria, Universidad Autónoma de San Luis Potosí, San Luis Potosí 78321, Mexico;
| | - Jorge A. Bustamante-Andrade
- Facultad de Agricultura y Zootecnia, Universidad Juárez del Estado de Durango, Venecia Durango 35111, Mexico; (J.A.B.-A.); (U.N.G.-G.)
| | - Ulises N. Gutierrez-Guzman
- Facultad de Agricultura y Zootecnia, Universidad Juárez del Estado de Durango, Venecia Durango 35111, Mexico; (J.A.B.-A.); (U.N.G.-G.)
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8
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Merviel P, Labarre M, James P, Bouée S, Chabaud JJ, Roche S, Cabry R, Scheffler F, Lourdel E, Benkhalifa M, Copin H, Drapier H, Beauvillard D. Should intrauterine inseminations still be proposed in cases of unexplained infertility? Retrospective study and literature review. Arch Gynecol Obstet 2022; 305:1241-1254. [PMID: 34981203 DOI: 10.1007/s00404-021-06351-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 11/24/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Unexplained infertility is defined by the absence of identifiable causes of infertility. The results of randomized studies and meta-analysis regarding the treatment of unexplained infertility are discordant due to methodological problems. DESIGN The aim of this study is to compare the clinical pregnancy rate per cycle (CPR/c) in IUI and IVF/ICSI in cases of unexplained infertility, according to the woman's age group and to identify the factors which predict success. INTERVENTIONS We performed a retrospective study in two ART centers, comparing overall clinical pregnancy, ongoing pregnancy and live birth rates in IVF/ICSI and IUI. We also compared pregnancy and birth rates according to different female age groups. RESULTS 855 IVF/ICSI and 804 IUI cycles were compared. We found a significant difference (p < 0.001) in the pregnancy and live birth rates per cycle between IUI and IVF/ICSI, overall and in the different female age groups, except in women aged 40 and over. The greatest chances of pregnancy with IUI are found in women with secondary unexplained infertility, during the first two cycles and with a bi-follicular response to stimulation. In IVF/ICSI, pregnancy rates are higher in women with secondary unexplained infertility, in the first two cycles, in IVF and in women receiving a transfer of two embryos regardless of the embryonic stage. CONCLUSION We recommend IVF/ICSI treatment rather than IUI for unexplained infertility (OR CPR/c 4.20 with 95% CI [3.72-4.68]). This is in accordance with NICE, which advises the use of IVF after 2 years.
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Affiliation(s)
- Philippe Merviel
- ART Center, Brest University Hospital, 2 Avenue Foch, 29200, Brest, France.
| | - Marion Labarre
- ART Center, Brest University Hospital, 2 Avenue Foch, 29200, Brest, France
| | - Pandora James
- ART Center, Brest University Hospital, 2 Avenue Foch, 29200, Brest, France
| | - Sarah Bouée
- ART Center, Brest University Hospital, 2 Avenue Foch, 29200, Brest, France
| | | | - Sylvie Roche
- ART Center, Brest University Hospital, 2 Avenue Foch, 29200, Brest, France
| | - Rosalie Cabry
- ART Center, Amiens University Hospital, Rue du Professeur Christian Cabrol, 80000, Amiens, France
| | - Florence Scheffler
- ART Center, Amiens University Hospital, Rue du Professeur Christian Cabrol, 80000, Amiens, France
| | - Emmanuelle Lourdel
- ART Center, Amiens University Hospital, Rue du Professeur Christian Cabrol, 80000, Amiens, France
| | - Moncef Benkhalifa
- ART Center, Amiens University Hospital, Rue du Professeur Christian Cabrol, 80000, Amiens, France
| | - Henri Copin
- ART Center, Amiens University Hospital, Rue du Professeur Christian Cabrol, 80000, Amiens, France
| | - Hortense Drapier
- ART Center, Brest University Hospital, 2 Avenue Foch, 29200, Brest, France
| | - Damien Beauvillard
- ART Center, Brest University Hospital, 2 Avenue Foch, 29200, Brest, France
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9
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Helmer A, Magaton I, Stalder O, Stute P, Surbek D, von Wolff M. Optimal Timing of Ovulation Triggering to Achieve Highest Success Rates in Natural Cycles-An Analysis Based on Follicle Size and Oestradiol Concentration in Natural Cycle IVF. Front Endocrinol (Lausanne) 2022; 13:855131. [PMID: 35692395 PMCID: PMC9178246 DOI: 10.3389/fendo.2022.855131] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 03/31/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Timing of ovulation triggering is essential in infertility treatments including treatments based on natural menstrual cycles. However, data on follicle size and oestradiol (E2) concentration are limited. Therefore, the model of natural cycle IVF (NC-IVF) was applied to provide more detailed information on these parameters to better schedule the optimal time for triggering ovulation. MATERIALS AND METHODS A retrospective cross-sectional analysis of 606 monofollicular NC-IVF cycles was performed at a university-based IVF centre from 2016 to 2019. Follicle size and E2 and LH serum concentrations were evaluated on day -5 to 0 (day 0 = day of oocyte retrieval). Ovulation was triggered if follicle size was 14-22 mm. Patients with irregular cycles, endometriosis >II°, cycles with azoospermia or cryptozoospermia and cycles with inconsistent data were excluded. All parameters were analysed inter- and intraindividually, and associations of the parameters were evaluated. Associations were adjusted for age, cause of infertility and number of previous transfers. RESULTS The mean age of women undergoing NC-IVF was 35.8 ± 4.0 years. Follicle size increased by 1.04 ± 0.03 mm, and E2 concentration by 167 ± 11.0 pmol/l per day.Based on a multivariate adjusted mixed model with follicle size, E2 and their interaction, the number of retrieved oocytes was associated with E2 concentration (aOR 1.91, 95% CI: 1.03-3.56; p = 0.040). Maturity of oocytes was associated not only with E2 concentration (aOR 2.01, 95% CI: 1.17-3.45; p = 0.011) but also with follicle size (aOR 1.27, 95% CI: 1.01-1.60; p = 0.039), as was the interaction of both parameters (aOR 0.96, 95% CI: 0.93-0.99; p = 0.017).LH surge was calculated to start in 25% of cases at an E2 level of 637 pmol/l, in 50% of cases at 911 pmol/l and in 75% of cases at an E2 level of 1,480 pmol/l.The live birth rate per follicle aspiration cycle was (non-significantly) higher in cycles with follicles sizes at the time of oocyte retrieval of 18-22 mm (7.7%-12.5%) versus in cycles with follicles sizes of 14-17 mm (1.6%-4.3%). CONCLUSION The study contributes to an optimization of infertility treatments involving natural cycles. The study gives guidance about the number of days required after follicle monitoring to schedule the optimal time for triggering ovulation.
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Affiliation(s)
- Anja Helmer
- University Women’s Hospital, Division of Gynaecological Endocrinology and Reproductive Medicine, Inselspital, Bern, Switzerland
| | - Isotta Magaton
- University Women’s Hospital, Division of Gynaecological Endocrinology and Reproductive Medicine, Inselspital, Bern, Switzerland
| | - Odile Stalder
- Clinical Trial Unit (CTU) Bern, University of Bern, Bern, Switzerland
| | - Petra Stute
- University Women’s Hospital, Division of Gynaecological Endocrinology and Reproductive Medicine, Inselspital, Bern, Switzerland
| | - Daniel Surbek
- University Women’s Hospital, Department of Obstetrics and Feto-Maternal Medicine, Inselspital, Bern, Switzerland
| | - Michael von Wolff
- University Women’s Hospital, Division of Gynaecological Endocrinology and Reproductive Medicine, Inselspital, Bern, Switzerland
- *Correspondence: Michael von Wolff,
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10
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Amooee S, Shomali Z, Namazi N, Jannati F. Is There any Role for Granulocyte Colony Stimulating Factor in Improvement of Implantation in Intrauterine Insemination? A Prospective Double-Blind Randomized Control Trial. INTERNATIONAL JOURNAL OF FERTILITY & STERILITY 2022; 16:281-285. [PMID: 36273314 PMCID: PMC9627008 DOI: 10.22074/ijfs.2021.537125.1171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Granulocyte colony stimulating factor (GCSF) has been introduced as an immunomodulatory agent by increasing implantation rate in vitro fertilization (IVF) patients but it has not been studied in intrauterine insemination (IUI) patients. The aim of this study is to answer the role of GCSF in implantation rate of IUI. MATERIALS AND METHODS In this prospective double-blind randomized control trial, 320 eligible patients were enrolled, who were referred to the referral infertility clinic of Shiraz University of Medical Sciences from February 2018 till the end of 2019. They were divided into two groups randomly. After collecting the demographic data, all patients received clomiphene citrate from the 5th day of the menstruation cycle for 5 days. 50-150 units of recombinant purified follicle-stimulating factor (FSH) were started from the 8th day of the cycle. Follicle monitoring was done by transvaginal sonography till a mature follicle of 18 mm or more was developed. Human chorionic gonadotropin (HCG) injection was done in both groups with intrauterine administration of 300 μg GCSF in the case group and normal saline in the control group simultaneously. After 36 hours, IUI was performed. The clinical pregnancy, miscarriage, and ongoing pregnancy rates of both groups were calculated by SPSS software. RESULTS The results showed improvement of clinical pregnancy rate [15.38% vs. 13.81% OR=1.17 (0.62-2.21)], miscarriage rate [3.84% vs. 5.26% OR=0.74 (0.25-2.20)] and ongoing pregnancy rate [11.53% vs. 8.55% OR=1.37 (0.65-2.92)] in the GCSF group compared to the control. However, the results revealed no statistically significance (P>0.05). CONCLUSION Although it was not statistically significant, 300 μg Intrauterine GCSF administration simultaneously with hCG injection in standard IUI procedure might increase the pregnancy outcomes. Further studies are warranted (registration number: IRCT201212079281N2).
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Affiliation(s)
- Sedigheh Amooee
- Department of Obstetrics and Gynecology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran,Infertility Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zahra Shomali
- Department of Obstetrics and Gynecology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran,Infertility Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Niloofar Namazi
- Department of Obstetrics and Gynecology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran,Infertility Research Center, Shiraz University of Medical Sciences, Shiraz, Iran,P.O.Box: 7134846114Department of Obstetrics and GynecologySchool of MedicineShiraz University of Medical SciencesShirazIran
| | - Fatemeh Jannati
- Infertility Research Center, Shiraz University of Medical Sciences, Shiraz, Iran,Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
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11
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Use of uterine artery Doppler velocimetry values to predict pregnancy in intrauterine insemination cycles in couples with unexplained infertility. JOURNAL OF SURGERY AND MEDICINE 2022. [DOI: 10.28982/josam.1036208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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12
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Rolland L, Amar-Hoffet A, Lubin V, Préaubert L, Miquel L, Courbiere B. Unexplained infertility: A French national survey of clinical practices. J Gynecol Obstet Hum Reprod 2021; 51:102301. [PMID: 34971768 DOI: 10.1016/j.jogoh.2021.102301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 12/10/2021] [Accepted: 12/23/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The aim of our study was to carry out a national survey of French practitioners to evaluate (i) their diagnostic criteria for making a diagnosis of unexplained infertility (UEI) and (ii) their management strategy when facing UEI. MATERIALS AND METHOD An online questionnaire comprising ten multiple-choice questions was sent by mail to French reproductive practitioners in 80 fertility centres. RESULTS The response rate was 59.6% (195/327). Post coital testing was always or often prescribed by 14.8% of respondents (n=36). Chlamydia trachomatis testing was never prescribed by 31.7% (n=59) of them, 30.2% prescribed a pelvic MRI in cases of UEI and 18.4% (n=33) always or often performed laparoscopy. For 87.6% (n=169), advanced maternal age was always or often an indication of first-line IVF, with an average threshold of 37.4 years. For 68.6% (n=129), diminished AMH was an indication for first-line IVF, with an average AMH threshold of 1.2 ng/ml. With respect to the management of UEI, we did not observe a consensus between the strategies of 2 to 6 intrauterine insemination cycles before IVF or IVF as the first-line treatment. CONCLUSION There is no consensus in France on what tests should or should not be carried out to conclude UEI, and there is also no consensus on the management of UEI. UEI is one of the top 10 priorities for future infertility research. The diagnostic criteria must be standardized to enable the comparison of studies on this topic as well as to improve the translation of research into clinical practice.
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Affiliation(s)
- Lucie Rolland
- Service of Medicine and Reproductive Biology, Hôpital Saint-joseph, 26, boulevard de Louvain, 13008 Marseille, France.
| | - Aurelie Amar-Hoffet
- Service of Medicine and Reproductive Biology, Hôpital Saint-joseph, 26, boulevard de Louvain, 13008 Marseille, France.
| | - Vanessa Lubin
- Service of Medicine and Reproductive Biology, Hôpital Saint-joseph, 26, boulevard de Louvain, 13008 Marseille, France.
| | - Lise Préaubert
- Department of Gynecology, Obstetric and Reproductive Medicine, Gynepôle, AP-HM La Conception, 147 bd Baille, 13005 Marseille, France.
| | - Laura Miquel
- Department of Gynecology, Obstetric and Reproductive Medicine, Gynepôle, AP-HM La Conception, 147 bd Baille, 13005 Marseille, France.
| | - Blandine Courbiere
- Department of Gynecology, Obstetric and Reproductive Medicine, Gynepôle, AP-HM La Conception, 147 bd Baille, 13005 Marseille, France; Aix Marseille Université, CNRS, IRD, Avignon Université, IMBE UMR 7263, 13397, Marseille, France.
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13
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Cantineau AE, Rutten AG, Cohlen BJ. Agents for ovarian stimulation for intrauterine insemination (IUI) in ovulatory women with infertility. Cochrane Database Syst Rev 2021; 11:CD005356. [PMID: 34739136 PMCID: PMC8570324 DOI: 10.1002/14651858.cd005356.pub3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Intrauterine insemination (IUI), combined with ovarian stimulation (OS), has been demonstrated to be an effective treatment for infertile couples. Several agents for ovarian stimulation, combined with IUI, have been proposed, but it is still not clear which agents for stimulation are the most effective. This is an update of the review, first published in 2007. OBJECTIVES To assess the effects of agents for ovarian stimulation for intrauterine insemination in infertile ovulatory women. SEARCH METHODS We searched the Cochrane Gynaecology and Fertility Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL and two trial registers from their inception to November 2020. We performed reference checking and contacted study authors and experts in the field to identify additional studies. SELECTION CRITERIA We included truly randomised controlled trials (RCTs) that compared different agents for ovarian stimulation combined with IUI for infertile ovulatory women concerning couples with unexplained infertility. mild male factor infertility and minimal to mild endometriosis. DATA COLLECTION AND ANALYSIS We used standard methodological procedures recommended by Cochrane. MAIN RESULTS In this updated review, we have included a total of 82 studies, involving 12,614 women. Due to the multitude of comparisons between different agents for ovarian stimulation, we highlight the seven most often reported here. Gonadotropins versus anti-oestrogens (13 studies) For live birth, the results of five studies were pooled and showed a probable improvement in the cumulative live birth rate for gonadotropins compared to anti-oestrogens (odds ratio (OR) 1.37, 95% confidence interval (CI) 1.05 to 1.79; I2 = 30%; 5 studies, 1924 participants; moderate-certainty evidence). This suggests that if the chance of live birth following anti-oestrogens is assumed to be 22.8%, the chance following gonadotropins would be between 23.7% and 34.6%. The pooled effect of seven studies revealed that we are uncertain whether gonadotropins lead to a higher multiple pregnancy rate compared with anti-oestrogens (OR 1.58, 95% CI 0.60 to 4.17; I2 = 58%; 7 studies, 2139 participants; low-certainty evidence). Aromatase inhibitors versus anti-oestrogens (8 studies) One study reported live birth rates for this comparison. We are uncertain whether aromatase inhibitors improve live birth rate compared with anti-oestrogens (OR 0.75, CI 95% 0.51 to 1.11; 1 study, 599 participants; low-certainty evidence). This suggests that if the chance of live birth following anti-oestrogens is 23.4%, the chance following aromatase inhibitors would be between 13.5% and 25.3%. The results of pooling four studies revealed that we are uncertain whether aromatase inhibitors compared with anti-oestrogens lead to a higher multiple pregnancy rate (OR 1.28, CI 95% 0.61 to 2.68; I2 = 0%; 4 studies, 1000 participants; low-certainty evidence). Gonadotropins with GnRH (gonadotropin-releasing hormone) agonist versus gonadotropins alone (4 studies) No data were available for live birth. The pooled effect of two studies revealed that we are uncertain whether gonadotropins with GnRH agonist lead to a higher multiple pregnancy rate compared to gonadotropins alone (OR 2.53, 95% CI 0.82 to 7.86; I2 = 0; 2 studies, 264 participants; very low-certainty evidence). Gonadotropins with GnRH antagonist versus gonadotropins alone (14 studies) Three studies reported live birth rate per couple, and we are uncertain whether gonadotropins with GnRH antagonist improve live birth rate compared to gonadotropins (OR 1.5, 95% CI 0.52 to 4.39; I2 = 81%; 3 studies, 419 participants; very low-certainty evidence). This suggests that if the chance of a live birth following gonadotropins alone is 25.7%, the chance following gonadotropins combined with GnRH antagonist would be between 15.2% and 60.3%. We are also uncertain whether gonadotropins combined with GnRH antagonist lead to a higher multiple pregnancy rate compared with gonadotropins alone (OR 1.30, 95% CI 0.74 to 2.28; I2 = 0%; 10 studies, 2095 participants; moderate-certainty evidence). Gonadotropins with anti-oestrogens versus gonadotropins alone (2 studies) Neither of the studies reported data for live birth rate. We are uncertain whether gonadotropins combined with anti-oestrogens lead to a higher multiple pregnancy rate compared with gonadotropins alone, based on one study (OR 3.03, 95% CI 0.12 to 75.1; 1 study, 230 participants; low-certainty evidence). Aromatase inhibitors versus gonadotropins (6 studies) Two studies revealed that aromatase inhibitors may decrease live birth rate compared with gonadotropins (OR 0.49, 95% CI 0.34 to 0.71; I2=0%; 2 studies, 651 participants; low-certainty evidence). This suggests that if the chance of a live birth following gonadotropins alone is 31.9%, the chance of live birth following aromatase inhibitors would be between 13.7% and 25%. We are uncertain whether aromatase inhibitors compared with gonadotropins lead to a higher multiple pregnancy rate (OR 0.69, 95% CI 0.06 to 8.17; I2=77%; 3 studies, 731 participants; very low-certainty evidence). Aromatase inhibitors with gonadotropins versus anti-oestrogens with gonadotropins (8 studies) We are uncertain whether aromatase inhibitors combined with gonadotropins improve live birth rate compared with anti-oestrogens plus gonadotropins (OR 0.99, 95% CI 0.3 8 to 2.54; I2 = 69%; 3 studies, 708 participants; very low-certainty evidence). This suggests that if the chance of a live birth following anti-oestrogens plus gonadotropins is 13.8%, the chance following aromatase inhibitors plus gonadotropins would be between 5.7% and 28.9%. We are uncertain of the effect of aromatase inhibitors combined with gonadotropins compared to anti-oestrogens combined with gonadotropins on multiple pregnancy rate (OR 1.31, 95% CI 0.39 to 4.37; I2 = 0%; 5 studies, 901 participants; low-certainty evidence). AUTHORS' CONCLUSIONS Based on the available results, gonadotropins probably improve cumulative live birth rate compared with anti-oestrogens (moderate-certainty evidence). Gonadotropins may also improve cumulative live birth rate when compared with aromatase inhibitors (low-certainty evidence). From the available data, there is no convincing evidence that aromatase inhibitors lead to higher live birth rates compared to anti-oestrogens. None of the agents compared lead to significantly higher multiple pregnancy rates. Based on low-certainty evidence, there does not seem to be a role for different combined therapies, nor for adding GnRH agonists or GnRH antagonists in IUI programs.
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Affiliation(s)
- Astrid Ep Cantineau
- Department of Obstetrics and Gynaecology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | | | - Ben J Cohlen
- Department of Obstetrics and Gynaecology, Isala Clinics, Zwolle, Netherlands
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Expectant Management Before In vitro Fertilization in Women Aged 39 or Above and Unexplained Infertility Does Not Decrease Live Birth Rates Compared to Immediate Treatment. Reprod Sci 2021; 29:1232-1240. [PMID: 34724170 PMCID: PMC8559689 DOI: 10.1007/s43032-021-00767-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 10/05/2021] [Indexed: 11/04/2022]
Abstract
Unexplained infertile couples can have further expectant management before starting assisted reproductive treatments. However, ovarian reserve and in vitro fertilization (IVF) outcomes rapidly decline after 39 years or more. It is thus important to clarify whether a waiting policy is also appropriate for women of advanced age. Couples who had access to a waiting list for approximately 1 year before receiving reimbursed public IVF were compared with those paying for access to immediate treatment. To allow for comparisons between these two strategies, we followed up couples who opted to pay for 1 year after the last embryo transfer from their first cycle. We calculated the proportion of live births in both groups and compared these using logistic regression models and a two-sample Z test for equality of proportions. Six hundred thirty-five couples were evaluated. Out of 359 couples in the immediate group, 70 (19.5%) had a live birth of which 11 after natural conception and 59 after IVF. Out of 276 couples in the waiting group, 57 (20.7%) had a live birth of which 37 after natural conception and 20 after IVF. There was no statistically significant difference between the two strategies in terms of the crude cumulative live birth rate (cLBR). The adjusted odds ratio of 0.69 (95%CI:0.39–1.22) did not change this conclusion as our sensitivity analyses. The cLBR for the ‘waiting before IVF’ and the ‘immediate’ strategies were similar. Further studies are needed to better characterize couples affected by unexplained infertility in order to individualize treatment strategies.
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Nandi A, Raja G, White D, Tarek ET. Intrauterine insemination + controlled ovarian hyperstimulation versus in vitro fertilisation in unexplained infertility: a systematic review and meta-analysis. Arch Gynecol Obstet 2021; 305:805-824. [PMID: 34636983 DOI: 10.1007/s00404-021-06277-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 10/01/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND IUI + COH is widely used in cases of unexplained infertility before resorting to IVF. Debate continues about what should be the first-line treatment for couples with unexplained infertility. OBJECTIVES This systematic review assessed the relative efficacy of IUI + COH compared with IVF in couples with unexplained infertility. SEARCH STRATEGY We searched Medline, Embase, CIHNL, Pscy Info, and Cochrane Library from 1980 to November 2019. SELECTION CRITERIA Only RCTs published articles in full text with female patients aged 18-43 years and diagnosed with unexplained infertility were included. DATA COLLECTION AND ANALYSIS Two authors reviewed citations from primary search independently and any disagreement was resolved by mutual discussion and consultation with a third author. MAIN RESULT In total, eight RCTs were included. The quality of evidence was moderate to low due to inconsistency across the trials and imprecision. The pooled result showed that IVF was associated with a statistically significant higher live birth rate (RR 1.53, 95% CI 1.01-2.32, P < 0.00001 I2 = 86%) with no significant difference in multiple pregnancy rate or OHSS rate. Sensitivity analysis based on women's age and a history of previous IUI or IVF treatment showed no significant difference in the live birth rates (RR 1.01, 95% CI 0.88-1.15, I2 = 0%, 3 RCTs) in treatment-naïve women younger than 38 years. In women over 38 years, the live birth rates were significantly higher in the IVF group (RR 2.15, 95% CI 1.16-4.0, I2 = 42%, 1 RCT). CONCLUSION Further research using a standardised treatment protocol and taking into account important prognostic variables and cumulative live birth rates from fresh IVF and all sibling frozen embryos is required to further guide clinical practice.
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Affiliation(s)
- Anupa Nandi
- Assisted Conception Unit, Great Maze Pond, Guy's and St Thomas' Hospital NHS Trust, London, SE1 9RT, UK.
| | - Gangopadhyay Raja
- Department of Obstetrics and Gynaecology, Watford General Hospital, Hertfordshire, UK
| | - Davinia White
- Assisted Conception Unit, Great Maze Pond, Guy's and St Thomas' Hospital NHS Trust, London, SE1 9RT, UK
| | - El-Toukhy Tarek
- Assisted Conception Unit, Great Maze Pond, Guy's and St Thomas' Hospital NHS Trust, London, SE1 9RT, UK
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Shahid MN, Khan TM, Neoh CF, Lean QY, Bukhsh A, Karuppannan M. Effectiveness of Pharmacological Intervention Among Men with Infertility: A Systematic Review and Network Meta-Analysis. Front Pharmacol 2021; 12:638628. [PMID: 34483894 PMCID: PMC8415454 DOI: 10.3389/fphar.2021.638628] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 07/09/2021] [Indexed: 01/18/2023] Open
Abstract
Background. Infertility is an emerging health issue for men. Comparative efficacy of different pharmacological interventions on male infertility is not clear. The aim of this review is to investigate the efficacy of various pharmacological interventions among men with idiopathic male infertility. All randomized control trials evaluating the effectuality of interventions on male infertility were included for network meta-analysis (NMA) from inception to 31 April 2020, systematically performed using STATA through the random effect model. The protocol was registered at PROSPERO (CRD42020152891). Results. The outcomes of interest were semen and hormonal parameters. Treatment effects (p < 0.05) were estimated through WMD at the confidence interval of 95%. Upon applying exclusion criteria, n=28 RCTs were found eligible for NMA. Results from NMA indicated that consumption of supplements increases sperm concentration levels [6.26, 95% CI 3.32, 9.21] in comparison to SERMs [4.97, 95% CI 1.61, 8.32], hormones [4.14, 95% CI 1.83, 6.46], and vitamins [0.15, 95% CI -20.86, 21.15)] with placebo, whereas the use of SERMs increased percentage sperm motility [6.69, 95% CI 2.38, 10.99] in comparison to supplements [6.46, 95% CI 2.57, 10.06], hormones [3.47, 95% CI 0.40, 6.54], and vitamins [-1.24, 95% CI -11.84, 9.43] with placebo. Consumption of hormones increased the sperm morphology [3.71, 95% CI, 1.34, 6.07] in contrast to supplements [2.22, 95% CI 0.12, 4.55], SERMs [2.21, 95% CI -0.78, 5.20], and vitamins [0.51, 95% CI -3.60, 4.62] with placebo. Supplements boosted the total testosterone levels [2.70, 95% CI 1.34, 4.07] in comparison to SERMs [1.83, 95% CI 1.16, 2.50], hormones [0.40, 95% CI -0.49, 1.29], and vitamins [-0.70, 95% CI -6.71, 5.31] with placebo. SERMs increase the serum FSH levels [3.63, 95% CI 1.48, 5.79] better than hormones [1.29, 95% CI -0.79, 3.36], vitamins [0.03, 95% CI -2.69, 2.76], and supplements [-4.45, 95% CI -7.15, -1.76] in comparison with placebo. Conclusion. This review establishes that all interventions had a significantly positive effect on male infertility. Statistically significant increased sperm parameters were noted in combinations of zinc sulfate (220 mg BID), clomiphene citrate (50 mg BID), and testosterone undecanoate and CoQ10; tamoxifen citrate and FSH were shown to improve the hormonal profile in infertile males.
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Affiliation(s)
- Muhammad Nabeel Shahid
- Department of Pharmacy Practice, Faculty of Pharmacy, Universiti Teknologi MARA (UiTM), Bandar Puncak Alam, Malaysia
- Department of Pharmacy Practice, Institute of Pharmaceutical Sciences, University of Veterinary and Animal Sciences, Lahore, Pakistan
| | - Tahir Mehmood Khan
- Department of Pharmacy Practice, Institute of Pharmaceutical Sciences, University of Veterinary and Animal Sciences, Lahore, Pakistan
- School of Pharmacy, Monash University, Subang Jaya, Malaysia
| | - Chin Fen Neoh
- Department of Pharmacy Practice, Faculty of Pharmacy, Universiti Teknologi MARA (UiTM), Bandar Puncak Alam, Malaysia
| | - Qi Ying Lean
- Faculty of Pharmacy, Universiti Teknologi MARA (UiTM), Pulau Pinang, Malaysia
- Vector-Borne Diseases Research Group (VERDI), Pharmaceutical and Life Sciences CoRe, Universiti Teknologi MARA (UiTM), Shah Alam, Malaysia
| | - Allah Bukhsh
- Department of Pharmacy Practice, Institute of Pharmaceutical Sciences, University of Veterinary and Animal Sciences, Lahore, Pakistan
- School of Pharmacy, Monash University, Subang Jaya, Malaysia
| | - Mahmathi Karuppannan
- Department of Pharmacy Practice, Faculty of Pharmacy, Universiti Teknologi MARA (UiTM), Bandar Puncak Alam, Malaysia
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17
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Wessel JA, Mol F, Danhof NA, Bensdorp AJ, Tjon-Kon Fat RI, Broekmans FJM, Hoek A, Mol BWJ, Mochtar MH, van Wely M. Birthweight and other perinatal outcomes of singletons conceived after assisted reproduction compared to natural conceived singletons in couples with unexplained subfertility: follow-up of two randomized clinical trials. Hum Reprod 2021; 36:817-825. [PMID: 33347597 PMCID: PMC7891811 DOI: 10.1093/humrep/deaa298] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 10/05/2020] [Indexed: 11/14/2022] Open
Abstract
STUDY QUESTION Does assisted reproduction, such as ovarian stimulation and/or laboratory procedures, have impact on perinatal outcomes of singleton live births compared to natural conception in couples with unexplained subfertility? SUMMARY ANSWER Compared to natural conception, singletons born after intrauterine insemination with ovarian stimulation (IUI-OS) had a lower birthweight, while singletons born after IVF had comparable birthweights, in couples with unexplained subfertility. WHAT IS KNOWN ALREADY Singletons conceived by assisted reproduction have different perinatal outcomes such as low birthweight and a higher risk of premature birth than naturally conceived singletons. This might be due to the assisted reproduction, such as laboratory procedures or the ovarian stimulation, or to an intrinsic factor in couples with subfertility. STUDY DESIGN, SIZE, DURATION We performed a prospective cohort study using the follow-up data of two randomized clinical trials performed in couples with unexplained subfertility. We evaluated perinatal outcomes of 472 live birth singletons conceived after assisted reproduction or after natural conception within the time horizon of the studies. PARTICIPANTS/MATERIALS, SETTING, METHODS To assess the possible impact of ovarian stimulation we compared the singletons conceived after IUI with FSH or clomiphene citrate (CC) and IVF in a modified natural cycle (IVF-MNC) or standard IVF with single embryo transfer (IVF-SET) to naturally conceived singletons in the same cohorts. To further look into the possible effect of the laboratory procedures, we put both IUI and IVF groups together into IUI-OS and IVF and compared both to singletons born after natural conception. We only included singletons conceived after fresh embryo transfers. The main outcome was birthweight presented as absolute weight in grams and gestational age- and gender-adjusted percentiles. We calculated differences in birthweight using regression analyses adjusted for maternal age, BMI, smoking, parity, duration of subfertility and child gender. MAIN RESULTS AND THE ROLE OF CHANCE In total, there were 472 live birth singletons. Of the 472 singleton pregnancies, 209 were conceived after IUI-OS (136 with FSH and 73 with CC as ovarian stimulation), 138 after IVF (50 after IVF-MNC and 88 after IVF-SET) and 125 were conceived naturally.Singletons conceived following IUI-FSH and IUI-CC both had lower birthweights compared to naturally conceived singletons (adjusted difference IUI-FSH -156.3 g, 95% CI -287.9 to -24.7; IUI-CC -160.3 g, 95% CI -316.7 to -3.8). When we compared IVF-MNC and IVF-SET to naturally conceived singletons, no significant difference was found (adjusted difference IVF-MNC 75.8 g, 95% CI -102.0 to 253.7; IVF-SET -10.6 g, 95% CI -159.2 to 138.1). The mean birthweight percentile was only significantly lower in the IUI-FSH group (-7.0 percentile, 95% CI -13.9 to -0.2). The IUI-CC and IVF-SET group had a lower mean percentile and the IVF-MNC group a higher mean percentile, but these groups were not significant different compared to the naturally conceived group (IUI-CC -5.1 percentile, 95% CI -13.3 to 3.0; IVF-MNC 4.4 percentile, 95% CI -4.9 to 13.6; IVF-SET -1.3 percentile, 95% CI -9.1 to 6.4).Looking at the laboratory process that took place, singletons conceived following IUI-OS had lower birthweights than naturally conceived singletons (adjusted difference -157.7 g, 95% CI -277.4 to -38.0). The IVF group had comparable birthweights with the naturally conceived group (adjusted difference 20.9 g, 95% CI -110.8 to 152.6). The mean birthweight percentile was significantly lower in the IUI-OS group compared to the natural group (-6.4 percentile, 95% CI -12.6 to -0.1). The IVF group was comparable (0.7 percentile, 95% CI -6.1 to 7.6). LIMITATIONS, REASONS FOR CAUTION The results are limited by the number of cases. The data were collected prospectively alongside the randomized controlled trials, but analyzed as treated. WIDER IMPLICATIONS OF THE FINDINGS Our data suggest IUI in a stimulated cycle may have a negative impact on the birthweight of the child and possibly on pre-eclampsia. Further research should look into the effect of different methods of ovarian stimulation on placenta pathology and pre-eclampsia in couples with unexplained subfertility using naturally conceived singletons in the unexplained population as a reference. STUDY FUNDING/COMPETING INTEREST(S) Both initial trials were supported by a grant from ZonMW, the Dutch Organization for Health Research and Development (INeS 120620027, SUPER 80-83600-98-10192). The INeS study also had a grant from Zorgverzekeraars Nederland, the Dutch association of healthcare insurers (09-003). B.W.J.M. is supported by an NHMRC investigator Grant (GNT1176437) and reports consultancy for ObsEva, Merck Merck KGaA, Guerbet and iGenomix, outside the submitted work. A.H. reports grants from Ferring Pharmaceutical company (the Netherlands), outside the submitted work. F.J.M.B. receives monetary compensation as a member of the external advisory board for Merck Serono (the Netherlands), Ferring Pharmaceutics BV (the Netherlands) and Gedeon Richter (Belgium), he receives personal fees from educational activities for Ferring BV (the Netherlands) and for advisory and consultancy work for Roche and he receives research support grants from Merck Serono and Ferring Pharmaceutics BV, outside the submitted work. The remaining authors have nothing to disclose. TRIAL REGISTRATION NUMBER INeS study Trial NL915 (NTR939); SUPER Trial NL3895 (NTR4057).
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Affiliation(s)
- J A Wessel
- Centre for Reproductive Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam 1105 AZ, the Netherlands
| | - F Mol
- Centre for Reproductive Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam 1105 AZ, the Netherlands
| | - N A Danhof
- Centre for Reproductive Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam 1105 AZ, the Netherlands
| | - A J Bensdorp
- Centre for Reproductive Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam 1105 AZ, the Netherlands
| | - R I Tjon-Kon Fat
- Centre for Reproductive Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam 1105 AZ, the Netherlands
| | - F J M Broekmans
- Centre for Reproductive Medicine, University Medical Centre Utrecht, Utrecht 3508 GA, the Netherlands
| | - A Hoek
- Department of Obstetrics and Gyneacology, University of Groningen, University Medical Centre Groningen, Groningen 9713 GZ, the Netherlands
| | - B W J Mol
- Department of Obstetrics and Gynaecology, Monash University, Monash Medical Centre, Clayton, VIC 3168, Australia
| | - M H Mochtar
- Centre for Reproductive Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam 1105 AZ, the Netherlands
| | - M van Wely
- Centre for Reproductive Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam 1105 AZ, the Netherlands
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18
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Huang S, Wang R, Yan H, Li N, Wang H, Luo L, Wang L, Norman RJ, Li R, Qiao J, Mol BWJ. Intrauterine insemination (IUI) with or without letrozole for unexplained or mild male factor infertility: A randomized pilot study. Eur J Obstet Gynecol Reprod Biol 2021; 262:216-220. [PMID: 34062308 DOI: 10.1016/j.ejogrb.2021.05.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 05/12/2021] [Accepted: 05/13/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To study the feasibility of a randomized controlled trial (RCT) comparing intrauterine insemination (IUI) with and without letrozole in couples with unexplained or mild male factor infertility STUDY DESIGN: We performed a randomized pilot study including 100 couples with unexplained or mild male factor infertility in the Reproductive Medicine Centre of Peking University Third Hospital in China. The couples scheduled for IUI were randomized to IUI with or without ovarian stimulation (letrozole) for up to 3 cycles within a time horizon of 4 months. Women in the letrozole group received 5 mg oral letrozole daily starting from cycle day 3-5 for 5 days. Women in the natural cycle IUI group did not receive any ovarian stimulation before IUI. The primary outcome is ongoing pregnancy leading to live birth. The study was registered under trial number NCT03455426 RESULTS: Between March 2018 and January 2019, 158 couples were eligible to participate after initial screening and 100 (63.3 %) couples agreed to participate. Of the 100 recruited couples, 50 were randomly allocated to IUI with letrozole and 50 to natural cycle IUI. Live birth occurred in 12 women (24.0 %) in the letrozole group and 10 women (20.0 %) in the natural cycle group (RR 1.20 (95 % CI 0.57-2.52)). Clinical pregnancy rates were 28 % and 26 % in the letrozole group and natural cycle group respectively (RR 1.08 (95 % CI 0.56-2.05). There were no multiple pregnancies in both groups. Patients were willing to be randomized and useful information was gained to plan a definitive trial. CONCLUSIONS We showed that an RCT comparing IUI with letrozole versus natural cycle IUI in couples with unexplained or mild male factor infertility is feasible and acceptable.
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Affiliation(s)
- Shuo Huang
- Centre of Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Rui Wang
- Department of Obstetrics and Gynaecology, School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia
| | - Hongmei Yan
- Centre of Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Nannan Li
- Centre of Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Haiyan Wang
- Centre of Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Li Luo
- Centre of Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Lina Wang
- Centre of Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Robert J Norman
- Robinson Research Institute, University of Adelaide, Australia
| | - Rong Li
- Centre of Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China.
| | - Jie Qiao
- Centre of Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China.
| | - Ben Willem J Mol
- Department of Obstetrics and Gynaecology, School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia
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19
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Sunkara SK, Zheng W, D'Hooghe T, Longobardi S, Boivin J. Time as an outcome measure in fertility-related clinical studies: long-awaited. Hum Reprod 2021; 35:1732-1739. [PMID: 32644107 PMCID: PMC7398622 DOI: 10.1093/humrep/deaa138] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 04/27/2020] [Indexed: 01/11/2023] Open
Abstract
Time taken to achieve a live birth is an important consideration that is central to managing patient expectations during infertility treatment. However, time-related endpoints are not reported as standard in the majority of fertility-related clinical studies and there is no internationally recognized consensus definition for such endpoints. There is, therefore, a need for meaningful discussions around the selection of appropriate time-related treatment outcome measures for studies evaluating fertility treatments that will be relevant to diverse stakeholders (e.g. patients, healthcare professionals, clinical scientists, authorities and industry). Here, we provide a proposal for the evaluation of time-related outcome measures in fertility-related clinical studies, alongside associated definitions.
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Affiliation(s)
- Sesh K Sunkara
- Division of Women's Health, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Wenjing Zheng
- Global Medical Affairs Fertility, Research and Development, Merck KGaA, Darmstadt, Germany
| | - Thomas D'Hooghe
- Global Medical Affairs Fertility, Research and Development, Merck KGaA, Darmstadt, Germany.,Research Group Reproductive Medicine, Department of Development and Regeneration, Organ Systems, Group Biomedical Sciences, KU Leuven (University of Leuven), Leuven, Belgium.,Department of Obstetrics and Gynecology, Yale University, New Haven, CT, USA
| | - Salvatore Longobardi
- Global Clinical Development, Merck Serono S.p.A, Rome, Italy, an affiliate of Merck KGaA, Darmstadt, Germany
| | - Jacky Boivin
- School of Psychology, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
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20
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Garolla A, Pizzol D, Carosso AR, Borini A, Ubaldi FM, Calogero AE, Ferlin A, Lanzone A, Tomei F, Engl B, Rienzi L, De Santis L, Coticchio G, Smith L, Cannarella R, Anastasi A, Menegazzo M, Stuppia L, Corsini C, Foresta C. Practical Clinical and Diagnostic Pathway for the Investigation of the Infertile Couple. Front Endocrinol (Lausanne) 2021; 11:591837. [PMID: 33542705 PMCID: PMC7851076 DOI: 10.3389/fendo.2020.591837] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 11/25/2020] [Indexed: 01/23/2023] Open
Abstract
Capsule This expert opinion summarizes current knowledge on risk factors for infertility and identifies a practical clinical and diagnostic approach for the male and female partners of an infertile couple aimed to improve the investigation and management of fertility problems. Background Infertility represents an important and growing health problem affecting up to 16% of couples worldwide. In most cases, male, female, or combined factor can be identified, and different causes or risk factors have been related to this condition. However, there are no standardized guidelines on the clinical-diagnostic approach of infertile couples and the recommendations concerning infertility are sometimes lacking, incomplete, or problematic to apply. Objective The aim of this work is to provide an appropriate clinical and diagnostic pathway for infertile couples designed by a multidisciplinary-team of experts. The rationale is based on the history and physical examination and then oriented on the basis of initial investigations. This approach could be applied in order to reduce variation in practice and to improve the investigation and management of fertility problems. Methods Prominent Italian experts of the main specialties committed in the ART procedures, including gynecologists, andrologists, embryologists, biologists, geneticists, oncologists, and microbiologists, called "InfertilItaly group", used available evidence to develop this expert position. Outcomes Starting from the individuation of the principal risk factors that may influence the fertility of females and males and both genders, the work group identified most appropriate procedures using a gradual approach to both partners aimed to obtain a precise diagnosis and the most effective therapeutic option, reducing invasive and occasionally redundant procedures. Conclusions This expert position provides current knowledge on risk factors and suggests a diagnostic workflow of infertile couples. By using this step-by-step approach, health care workers involved in ART, may individuate a practical clinical management of infertile couples shared by experts.
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Affiliation(s)
- Andrea Garolla
- Section of Andrology and Reproductive Medicine & Centre for Male Gamete Cryopreservation, Department of Medicine, University of Padova, Padova, Italy
| | - Damiano Pizzol
- Section of Andrology and Reproductive Medicine & Centre for Male Gamete Cryopreservation, Department of Medicine, University of Padova, Padova, Italy
- Italian Agency for Development Cooperation, Public Health, Jerusalem, Israel
| | - Andrea Roberto Carosso
- Department of Surgical Sciences, Gynecology and Obstetrics 1, Physiopathology of Reproduction and IVF Unit, S. Anna Hospital, University of Torino, Torino, Italy
| | - Andrea Borini
- 9.baby, Family and Fertility Center, Tecnobios Procreazione, Bologna, Italy
| | | | - Aldo Eugenio Calogero
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Alberto Ferlin
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Antonio Lanzone
- Department of Woman’s Health Sciences of the Child and Public Health, Unit of Obstetrics Pathology, University Clinic Foundation “A Gemelli” IRCCS, Rome, Italy
- Clinic of Obstetrics and Gynecology, Catholic University Sacro Cuore, Rome, Italy
| | - Francesco Tomei
- Assisted Reproductive Unit, Santa Maria degli Angeli Hospital, Pordenone, Italy
| | - Bruno Engl
- Donna Salus, Center for Women’s Health and Fertility, Bolzano, Italy
| | - Laura Rienzi
- GENERA Centre for Reproductive Medicine, Clinica Valle Giulia, Rome, Italy
| | - Lucia De Santis
- IVF Unit, Gynaecological-Obstetric Department, IRCCS San Raffaele Hospital, Vita-Salute University, Milan, Italy
- Italian Society of Embryology, Reproduction and Research (SIERR), Giarre, Italy
| | - Giovanni Coticchio
- 9.baby, Family and Fertility Center, Tecnobios Procreazione, Bologna, Italy
| | - Lee Smith
- The Cambridge Centre for Sport & Exercise Sciences, Anglia Ruskin University, Cambridge, United Kingdom
| | - Rossella Cannarella
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Attilio Anastasi
- Center for Physiopathology of Human Reproduction, Delta Hospital, Lagosanto, Italy
| | - Massimo Menegazzo
- Section of Andrology and Reproductive Medicine & Centre for Male Gamete Cryopreservation, Department of Medicine, University of Padova, Padova, Italy
| | - Liborio Stuppia
- Department of Psychological, Health and Territorial Sciences, School of Medicine and Health Sciences, “G. d’Annunzio” University, Chieti, Italy
- Center for Advanced Studies and Technology (CAST), “G. d’Annunzio” University of Chieti-Pescara, Chieti, Italy
| | - Christian Corsini
- Section of Andrology and Reproductive Medicine & Centre for Male Gamete Cryopreservation, Department of Medicine, University of Padova, Padova, Italy
| | - Carlo Foresta
- Section of Andrology and Reproductive Medicine & Centre for Male Gamete Cryopreservation, Department of Medicine, University of Padova, Padova, Italy
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21
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van Eekelen R, Rosielle K, van Welie N, Dreyer K, van Wely M, Mol BW, Eijkemans MJ, Mijatovic V, van Geloven N. Does the effectiveness of IUI in couples with unexplained subfertility depend on their prognosis of natural conception? A replication of the H2Oil study. Hum Reprod Open 2020; 2020:hoaa047. [PMID: 33598567 PMCID: PMC7875174 DOI: 10.1093/hropen/hoaa047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 08/04/2020] [Indexed: 01/09/2023] Open
Abstract
STUDY QUESTION Can we replicate the finding that the benefit of IUI-ovarian stimulation (IUI-OS) compared to expectant management for couples with unexplained subfertility depends on the prognosis of natural conception? SUMMARY ANSWER The estimated benefit of IUI-OS did not depend on the prognosis of natural conception but did depend on when treatment was started after diagnosis, with starting IUI-OS later yielding a larger absolute and relative benefit of treatment. WHAT IS KNOWN ALREADY IUI-OS is often the first-line treatment for couples with unexplained subfertility. Two randomized controlled trials (RCTs) compared IUI-OS to expectant management using different thresholds for the prognosis of natural conception as inclusion criteria and found different results. In a previous study (a Dutch national cohort), it was found that the benefit of IUI-OS compared to expectant management seemed dependent on the prognosis of natural conception, but this finding warrants replication. STUDY DESIGN SIZE DURATION We conducted a secondary analysis of the H2Oil study (n = 1119), a multicentre RCT that evaluated the effect of oil-based contrast versus water-based contrast during hysterosalpingography (HSG). Couples were randomized before HSG and followed up for 3-5 years. We selected couples with unexplained subfertility who received HSG and had follow-up or pregnancy data available. Follow-up was censored at the start of IVF, after the last IUI cycle or at last contact and was truncated at a maximum of 18 months after the fertility workup. PARTICIPANTS/MATERIALS SETTING METHODS The endpoint was time to conception leading to an ongoing pregnancy. We used the sequential Cox approach comparing in each month the ongoing pregnancy rates over the next 6 months of couples who started IUI-OS to couples who did not. We calculated the prognosis of natural conception for individual couples, updated this over consecutive failed cycles and evaluated whether prognosis modified the effect of starting IUI-OS. We corrected for known predictors of conception using inverse probability weighting. MAIN RESULTS AND THE ROLE OF CHANCE Data from 975 couples were available. There were 587 couples who received at least one IUI-OS cycle within 18 months after HSG of whom 221 conceived leading to an ongoing pregnancy (rate: 0.74 per couple per year over a median follow-up for IUI of 5 months). The median period between HSG and starting IUI-OS was 4 months. Out of 388 untreated couples, 299 conceived naturally (rate: 0.56 per couple per year over a median follow-up of 4 months). After creating our mimicked trial datasets, starting IUI-OS was associated with a higher chance of ongoing pregnancy by a pooled, overall hazard ratio of 1.50 (95% CI: 1.19-1.89) compared to expectant management. We did not find strong evidence that the effect of treatment was modified by a couple's prognosis of achieving natural conception (Akaike's Information Criterion (AIC) decreased by 1 point). The effect of treatment was dependent on when couples started IUI-OS (AIC decreased by more than 2 points). The patterns of estimated absolute chances over time for couples with increasingly better prognoses were different from the previous study but the finding that starting later yields a larger benefit of treatment was similar. We found IUI-OS increased the absolute chance of pregnancy by at least 5% compared to expectant management. The absolute chance of pregnancy after IUI-OS seems less variable between couples and starting times of treatment than the absolute chance after expectant management. LIMITATIONS REASONS FOR CAUTION This is a secondary analysis, as the H2Oil trial was not designed with this research question in mind. Owing to sample size restrictions, it remained difficult to distinguish between the ranges of prognoses in which true benefit was found. WIDER IMPLICATIONS OF THE FINDINGS We replicated the finding that starting IUI-OS later after diagnosis yields a larger absolute and relative benefit of treatment. We did not replicate the dependency of the effect of IUI-OS on the prognosis of natural conception and could not identify clear thresholds for the prognosis of natural conception when IUI-OS was and/or was not effective. Because many of these couples still have good chances of natural conception at the time of diagnosis, we suggest clinicians should advise couples to delay the start of IUI-OS for several months to avoid unnecessary treatment. STUDY FUNDING/COMPETING INTERESTS The H2Oil study (NTR 3270) was an investigator-initiated study that was funded by the two academic institutions (AMC and VUmc) of the Amsterdam UMC. The follow-up study (NTR 6577) was also an investigator-initiated study with funding by Guerbet, France. The funders had no role in study design, collection, analysis and interpretation of the data. B.W.M. is supported by an Investigator grant (GNT1176437) from the Australian National Health and Medical Research Council (NHMRC). K.D. reports receiving travel and speaker fees from Guerbet. B.W.M. reports consultancy for ObsEva, Merck, Merck KGaA, iGenomix and Guerbet. V.M. reports receiving travel- and speaker fees as well as research grants from Guerbet.
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Affiliation(s)
- R van Eekelen
- Amsterdam UMC, Academic Medical Centre, Centre for Reproductive Medicine, Amsterdam, the Netherlands
| | - K Rosielle
- Department of Reproductive Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - N van Welie
- Department of Reproductive Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - K Dreyer
- Department of Reproductive Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - M van Wely
- Amsterdam UMC, Academic Medical Centre, Centre for Reproductive Medicine, Amsterdam, the Netherlands
| | - B W Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC, Australia
| | - M J Eijkemans
- Department of Biostatistics and Research Support, Julius Centre, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - V Mijatovic
- Department of Reproductive Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - N van Geloven
- Medical Statistics, Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, the Netherlands
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Prentice L, Sadler L, Lensen S, Vercoe M, Wilkinson J, Edlin R, Chambers GM, Farquhar CM. IVF and IUI in couples with unexplained infertility (FIIX study): study protocol of a non-inferiority randomized controlled trial. Hum Reprod Open 2020; 2020:hoaa037. [PMID: 32995562 PMCID: PMC7508023 DOI: 10.1093/hropen/hoaa037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/28/2020] [Indexed: 11/16/2022] Open
Abstract
STUDY QUESTIONS In couples with unexplained infertility and a poor prognosis of natural conception, are four cycles of IUI with ovarian stimulation (IUI-OS) non-inferior to one completed cycle of IVF for the outcome of cumulative live birth? Are four cycles of IUI-OS associated with a lower cost per live birth compared to one completed cycle of IVF? Will four cycles of IUI-OS followed by one complete cycle of IVF result in as many live births at lower cost per live birth, than two complete cycles of IVF? Will four cycles of IUI-OS followed by two complete cycles of IVF result in more live births at lower cost per live birth, than two complete cycles of IVF alone? WHAT IS KNOWN ALREADY IUI is widely used in the USA, the UK and Europe as a low cost, less invasive alternative to IVF for couples with unexplained infertility. Although three to six cycles of IUI were comparable to IVF in the three major studies carried out to date, gonadotrophin ovarian stimulation was used in the majority of cases, and this also resulted in a high multiple pregnancy rate in some studies. Ovarian stimulation with clomiphene citrate is known to have lower multiple pregnancy rates. STUDY DESIGN, SIZE, DURATION The FIIX study is a multicentre, open label, parallel, pragmatic non-inferiority randomized controlled trial of 580 couples with unexplained infertility comparing four cycles of IUI-OS with clomiphene citrate and one completed cycle of IVF. Variable block randomization stratified by age and clinic with electronic allocation will be used. PARTICIPANTS/MATERIALS, SETTING, METHODS Couples with poor prognosis for natural conception and who are eligible for publicly funded fertility treatment in six fertility clinics in New Zealand. STUDY FUNDING/COMPETING INTEREST(S) Auckland Medical Research Fund (3718892/1119003), A+ Trust, Auckland District Health Board (A + 8479), Maurice and Phyllis Paykel Trust (3718514). No competing interests. TRIAL REGISTRATION NUMBER ACTRN12619001003167. TRIAL REGISTRATION DATE 15 July 2019 DATE OF FIRST PATIENT’S ENROLMENT 02/08/2019
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Affiliation(s)
- Lucy Prentice
- Fertility Plus, National Women's, Auckland District Health Board, Auckland, New Zealand.,Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| | - Lynn Sadler
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand.,Women's Health, National Women's, Auckland District Health Board, Auckland, New Zealand
| | - Sarah Lensen
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia
| | - Melissa Vercoe
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| | - Jack Wilkinson
- Centre for Biostatistics, University of Manchester, Manchester, UK
| | - Richard Edlin
- School of Population Health, University of Auckland, Auckland, New Zealand
| | - Georgina M Chambers
- Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, NSW, Australia
| | - Cynthia M Farquhar
- Fertility Plus, National Women's, Auckland District Health Board, Auckland, New Zealand.,Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
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van Eekelen R, Eijkemans MJ, Mochtar M, Mol F, Mol BW, Groen H, van Wely M. Cost-effectiveness of medically assisted reproduction or expectant management for unexplained subfertility: when to start treatment? Hum Reprod 2020; 35:deaa158. [PMID: 32876323 PMCID: PMC7550266 DOI: 10.1093/humrep/deaa158] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 06/04/2020] [Indexed: 12/18/2022] Open
Abstract
STUDY QUESTION Over a time period of 3 years, which order of expectant management (EM), IUI with ovarian stimulation (IUI-OS) and IVF is the most cost-effective for couples with unexplained subfertility with the female age below 38 years? SUMMARY ANSWER If a live birth is considered worth €32 000 or less, 2 years of EM followed by IVF was the most cost-effective, whereas above €32 000 this was 1 year of EM, 1 year of IUI-OS and then 1 year of IVF. WHAT IS KNOWN ALREADY IUI-OS and IVF are commonly used fertility treatments for unexplained subfertility although many couples can conceive naturally, as no identifiable barrier to conception could be found by definition. Few countries have guidelines on when to proceed with medically assisted reproduction (MAR), mostly based on the expected probability of live birth after treatment, but there is a lack of evidence to support the strategies proposed by these guidelines. The increased uptake of IUI-OS and IVF over the past decades and costs related to reimbursement of these treatments are pressing concerns to health service providers. For MAR to remain affordable, sustainable and a responsible use of public funds, guidance is needed on the cost-effectiveness of treatment strategies for unexplained subfertility, including EM. STUDY DESIGN, SIZE, DURATION We developed a decision analytic Markov model that follows couples with unexplained subfertility of which the woman is under 38 years of age for a time period of 3 years from completion of the fertility workup onwards. We divided the time axis of 3 years into three separate periods, each comprising 1 year. The model was based on contemporary evidence, most notably the dynamic prediction model for natural conception, which was combined with MAR treatment effects from a network meta-analysis on randomized controlled trials. We changed the order of options for managing unexplained subfertility for the 1 year periods to yield five different treatment policies in total: IVF-EM-EM (immediate IVF), EM-IVF-EM (delayed IVF), EM-EM-IVF (postponed IVF), IUIOS-IVF-EM (immediate IUI-OS) and EM-IUIOS-IVF (delayed IUI-OS). PARTICIPANTS/MATERIALS, SETTING, METHODS The main outcomes per policy over the 3-year period were the probability of live birth, the average treatment and delivery costs, the probability of multiple pregnancy, the incremental cost-effectiveness ratio (ICER) and finally, which policy yields the highest net benefit in which costs for a policy were deducted from the health effects, i.e. live births gained. We chose the Dutch societal perspective, but the model can be easily modified for other locations or other perspectives. The probability of live birth after EM was taken from the dynamic prediction model for natural conception and updated for Years 2 and 3. The relative effects of IUI-OS and IVF in terms of odds ratios, taken from the network meta-analysis, were applied to the probability of live birth after EM. We applied standard discounting procedures for economic analyses for Years 2 and 3. The uncertainty around effectiveness, costs and other parameters was assessed by probabilistic sensitivity analysis in which we drew values from distributions and repeated this procedure 20 000 times. In addition, we changed model assumptions to assess their influence on our results. MAIN RESULTS AND THE ROLE OF CHANCE From IVF-EM-EM to EM-IUIOS-IVF, the probability of live birth varied from approximately 54-64% and the average costs from approximately €4000 to €9000. The policies IVF-EM-EM and EM-IVF-EM were dominated by EM-EM-IVF as the latter yielded a higher cumulative probability of live birth at a lower cost. The policy IUIOS-IVF-EM was dominated by EM-IUIOS-IVF as the latter yielded a higher cumulative probability of live birth at a lower cost. After removal of policies that were dominated, the ICER for EM-IUIOS-IVF was approximately €31 000 compared to EM-EM-IVF. The range of ICER values between the lowest 25% and highest 75% of simulation replications was broad. The net benefit curve showed that when we assume a live birth to be worth approximately €20 000 or less, the policy EM-EM-IVF had the highest probability to achieve the highest net benefit. Between €20 000 and €50 000 monetary value per live birth, it was uncertain whether EM-EM-IVF was better than EM-IUIOS-IVF, with the turning point of €32 000. When we assume a monetary value per live birth over €50 000, the policy with the highest probability to achieve the highest net benefit was EM-IUIOS-IVF. Results for subgroups with different baseline prognoses showed the same policies dominated and the same two policies that were the most likely to achieve the highest net benefit but at different threshold values for the assumed monetary value per live birth. LIMITATIONS, REASONS FOR CAUTION Our model focused on population level and was thus based on average costs for the average number of cycles conducted. We also based the model on a number of key assumptions. We changed model assumptions to assess the influence of these assumptions on our results. The change in relative effectiveness of IVF over time was found to be highly influential on results and their interpretation. WIDER IMPLICATIONS OF THE FINDINGS EM-EM-IVF and EM-IUIOS-IVF followed by IVF were the most cost-effective policies. The choice depends on the monetary value assigned to a live birth. The results of our study can be used in discussions between clinicians, couples and policy makers to decide on a sustainable treatment protocol based on the probability of live birth, the costs and the limitations of MAR treatment. STUDY FUNDING/COMPETING INTEREST(S) This work was supported by the ZonMw Doelmatigheidsonderzoek (80-85200-98-91072). The funder had no role in the design, conduct or reporting of this work. B.W.M. is supported by a NHMRC Practitioner Fellowship (GNT1082548). B.W.M. reports consultancy for ObsEva, Merck KGaA and Guerbet and travel and research support from ObsEva, Merck and Guerbet. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- R van Eekelen
- Centre for Reproductive Medicine, Amsterdam UMC, location Academic Medical Centre, 1105 AZ Amsterdam, the Netherlands
| | - M J Eijkemans
- Department of Biostatistics and Research Support, Julius Centre, University Medical Centre Utrecht, 3584 CX Utrecht, the Netherlands
| | - M Mochtar
- Centre for Reproductive Medicine, Amsterdam UMC, location Academic Medical Centre, 1105 AZ Amsterdam, the Netherlands
| | - F Mol
- Centre for Reproductive Medicine, Amsterdam UMC, location Academic Medical Centre, 1105 AZ Amsterdam, the Netherlands
| | - B W Mol
- Department of Obstetrics and Gynaecology, Monash Medical Centre, VIC 3800 Clayton, Australia
| | - H Groen
- Department of Epidemiology, University of Groningen, University Medical Centre Groningen, 9713 GZ Groningen, the Netherlands
| | - M van Wely
- Centre for Reproductive Medicine, Amsterdam UMC, location Academic Medical Centre, 1105 AZ Amsterdam, the Netherlands
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24
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Siristatidis C, Pouliakis A, Sergentanis TN. Special characteristics, reproductive, and clinical profile of women with unexplained infertility versus other causes of infertility: a comparative study. J Assist Reprod Genet 2020; 37:1923-1930. [PMID: 32504303 DOI: 10.1007/s10815-020-01845-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 05/28/2020] [Indexed: 01/19/2023] Open
Abstract
PURPOSE To investigate whether women with unexplained infertility (UI) demonstrate different demographic and IVF characteristics compared to those with other causes of infertility. METHODS Data on 245 couples that underwent a total of 413 IVF/ICSI cycles were analyzed (UI 114 cycles, 73 women; anovulation (PCO/PCOS) 83 cycles, 51 women; tubal factor 85 cycles, 47 women; male factor 131 cycles, 74 women). Features of UI were compared versus other infertility groups, after adjustment for multiple comparisons. Generalized least squares (GLS) and random-effects logistic regression analysis were also performed. RESULTS Live birth rates, consisting of the primary outcome, were similar in all compared infertility groups. Compared to male infertility, UI was associated with woman's older age at cycle, lower body mass index (BMI), and higher follicle-stimulating hormone (FSH). Compared to tubal infertility, UI was linked to lower endometrial thickness at oocyte retrieval and lower BMI; compared to anovulatory infertility related to PCO/PCOS, UI was linked to woman's older age, more frequent smoking, and poorer ovarian reserve tests (FSH and antral follicle count). After adjustment for other types of infertility, woman's age, age at menarche, and FSH levels, anovulatory infertility presented with higher odds of clinical pregnancy compared to UI (adjusted OR = 2.13, 95% C: 1.01-4.52). CONCLUSIONS Infertile women with UI undergoing assisted reproduction demonstrate different demographic and clinical characteristics compared to those of other causes of infertility, albeit live birth rates are similar.
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Affiliation(s)
- Charalampos Siristatidis
- Assisted Reproduction Unit, Third Department of Obstetrics and Gynecology, Medical School, National and Kapodistrian University of Athens, "Attikon" University Hospital, 1 Rimini Street, Chaidari, 12642, Athens, Greece.
- Assisted Reproducton Unit, Second Department of Obstetrics and Gynecology, Aretaieion Hospital, National and Kapodistrian University of Athens, Athens, Greece.
| | - Abraham Pouliakis
- Second Department of Pathology, Medical School, National and Kapodistrian University of Athens, "Attikon" University Hospital, 1 Rimini Street, Chaidari, 12642, Athens, Greece
| | - Theodoros N Sergentanis
- Department of Clinical Therapeutics, Medical School, National and Kapodistrian University of Athens, "Alexandra" Hospital, 80 Vas. Sofias Ave, 11528, Athens, Greece
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25
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Li S, He Y, Cao M, Liu H, Liu J. Low-dose human menopausal gonadotrophin versus natural cycles in intrauterine insemination for subfertile couples with regular menstruation. J Ovarian Res 2020; 13:36. [PMID: 32247312 PMCID: PMC7129328 DOI: 10.1186/s13048-020-00638-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 03/23/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Women with irregular menstruation should be considered to benefit from the ovarian stimulation. However, most literature did not separate ovulatory disorders from normal menstrual cycles. Our purpose was to assess the superiority of ovarian mild stimulation compared with the natural cycle in IUI for subfertile couples when the women with regular menstruation. METHODS A retrospective study in a single medical center in which 2413 couples with 3573 IUI cycles were studied from 2013 to 2018. The results of IUI in natural cycles versus low-dose HMG induced cycles were analyzed. RESULTS For young women (age < 35 years) with normal menstrual cycle, HMG induced ovulation combined with IUI can improve clinical pregnancy outcome (13.55% in two follicular induced cycles vs. 7.23% in natural cycles, p < 0.01); even if only one follicle was induced, the clinical pregnancy rate was increased to 10.32% (p < 0.01). When two growth follicles were induced in HMG cycles, a remarkable improvement of the live birthrate (10.28% vs. 5.91% in natural cycles, p < 0.05) was noted. Simultaneously, twin pregnancy rates were increased to 20.69% (p < 0.01). Twin pregnancies showed significantly increased risk of both ectopic pregnancy and preterm birth (p = 0.00 for both). For advanced women (age ≥ 35 years) with regular menstrual cycle, ovulation induction didn't improve clinical pregnancy and live birthrates, while age was the only relevant factor. CONCLUSIONS Combining HMG induced ovulation and IUI can improve pregnancy outcome in young women with normal menstrual cycles. 1-2 follicles with diameter ≥ 14 mm served as the purpose of ovulation induction. Further, both twin and ectopic pregnancy rate in HMG cycles with two growth follicles were significantly higher than those in natural cycles were. Therefore, doctors must evaluate the risk before making choices and inform the patients to achieve the best results. For advanced women with normal menstrual cycles, natural IUI cycles were optional.
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Affiliation(s)
- Sichen Li
- Department of Reproductive Medicine, the Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Guangzhou, Guangdong, China
- Key Laboratory of Reproductive Medicine of Guangdong Province, Guangzhou, Guangdong, China
- Key Laboratory for Major Obstetric Diseases of Guangdong Province, Guangzhou, Guangdong, China
- Key Laboratory of Reproduction and Genetics of Guangdong Higher Education Institutes, Guangzhou, Guangdong, China
| | - Yuxia He
- Department of Reproductive Medicine, the Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Guangzhou, Guangdong, China
| | - Mingzhu Cao
- Department of Reproductive Medicine, the Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Guangzhou, Guangdong, China
| | - Hanyan Liu
- Department of Reproductive Medicine, the Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Guangzhou, Guangdong, China
| | - Jianqiao Liu
- Department of Reproductive Medicine, the Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Guangzhou, Guangdong, China.
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26
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Ayeleke RO, Asseler JD, Cohlen BJ, Veltman‐Verhulst SM. Intra-uterine insemination for unexplained subfertility. Cochrane Database Syst Rev 2020; 3:CD001838. [PMID: 32124980 PMCID: PMC7059962 DOI: 10.1002/14651858.cd001838.pub6] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Intra-uterine insemination (IUI) is a widely-used fertility treatment for couples with unexplained subfertility. Although IUI is less invasive and less expensive than in vitro fertilisation (IVF), the safety of IUI in combination with ovarian hyperstimulation (OH) is debated. The main concern about IUI treatment with OH is the increase in multiple pregnancy rates. OBJECTIVES To determine whether, for couples with unexplained subfertility, the live birth rate is improved following IUI treatment with or without OH compared to timed intercourse (TI) or expectant management with or without OH, or following IUI treatment with OH compared to IUI in a natural cycle. SEARCH METHODS We searched the Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL and two trials registers up to 17 October 2019, together with reference checking and contact with study authors for missing or unpublished data. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing IUI with TI or expectant management, both in stimulated or natural cycles, or IUI in stimulated cycles with IUI in natural cycles in couples with unexplained subfertility. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, quality assessment and data extraction. Primary review outcomes were live birth rate and multiple pregnancy rate. MAIN RESULTS We include 15 trials with 2068 women. The evidence was of very low to moderate quality. The main limitation was very serious imprecision. IUI in a natural cycle versus timed intercourse or expectant management in a natural cycle It is uncertain whether treatment with IUI in a natural cycle improves live birth rate compared to treatment with expectant management in a natural cycle (odds ratio (OR) 1.60, 95% confidence interval (CI) 0.92 to 2.78; 1 RCT, 334 women; low-quality evidence). If we assume the chance of a live birth with expectant management in a natural cycle to be 16%, that of IUI in a natural cycle would be between 15% and 34%. It is uncertain whether treatment with IUI in a natural cycle reduces multiple pregnancy rates compared to control (OR 0.50, 95% CI 0.04 to 5.53; 1 RCT, 334 women; low-quality evidence). IUI in a stimulated cycle versus timed intercourse or expectant management in a stimulated cycle It is uncertain whether treatment with IUI in a stimulated cycle improves live birth rates compared to treatment with TI in a stimulated cycle (OR 1.59, 95% CI 0.88 to 2.88; 2 RCTs, 208 women; I2 = 72%; low-quality evidence). If we assume the chance of achieving a live birth with TI in a stimulated cycle was 26%, the chance with IUI in a stimulated cycle would be between 23% and 50%. It is uncertain whether treatment with IUI in a stimulated cycle reduces multiple pregnancy rates compared to control (OR 1.46, 95% CI 0.55 to 3.87; 4 RCTs, 316 women; I2 = 0%; low-quality evidence). IUI in a stimulated cycle versus timed intercourse or expectant management in a natural cycle In couples with a low prediction score of natural conception, treatment with IUI combined with clomiphene citrate or letrozole probably results in a higher live birth rate compared to treatment with expectant management in a natural cycle (OR 4.48, 95% CI 2.00 to 10.01; 1 RCT; 201 women; moderate-quality evidence). If we assume the chance of a live birth with expectant management in a natural cycle was 9%, the chance of a live birth with IUI in a stimulated cycle would be between 17% and 50%. It is uncertain whether treatment with IUI in a stimulated cycle results in a lower multiple pregnancy rate compared to control (OR 3.01, 95% CI 0.47 to 19.28; 2 RCTs, 454 women; I2 = 0%; low-quality evidence). IUI in a natural cycle versus timed intercourse or expectant management in a stimulated cycle Treatment with IUI in a natural cycle probably results in a higher cumulative live birth rate compared to treatment with expectant management in a stimulated cycle (OR 1.95, 95% CI 1.10 to 3.44; 1 RCT, 342 women: moderate-quality evidence). If we assume the chance of a live birth with expectant management in a stimulated cycle was 13%, the chance of a live birth with IUI in a natural cycle would be between 14% and 34%. It is uncertain whether treatment with IUI in a natural cycle results in a lower multiple pregnancy rate compared to control (OR 1.05, 95% CI 0.07 to 16.90; 1 RCT, 342 women; low-quality evidence). IUI in a stimulated cycle versus IUI in a natural cycle Treatment with IUI in a stimulated cycle may result in a higher cumulative live birth rate compared to treatment with IUI in a natural cycle (OR 2.07, 95% CI 1.22 to 3.50; 4 RCTs, 396 women; I2 = 0%; low-quality evidence). If we assume the chance of a live birth with IUI in a natural cycle was 14%, the chance of a live birth with IUI in a stimulated cycle would be between 17% and 36%. It is uncertain whether treatment with IUI in a stimulated cycle results in a higher multiple pregnancy rate compared to control (OR 3.00, 95% CI 0.11 to 78.27; 2 RCTs, 65 women; low-quality evidence). AUTHORS' CONCLUSIONS Due to insufficient data, it is uncertain whether treatment with IUI with or without OH compared to timed intercourse or expectant management with or without OH improves cumulative live birth rates with acceptable multiple pregnancy rates in couples with unexplained subfertility. However, treatment with IUI with OH probably results in a higher cumulative live birth rate compared to expectant management without OH in couples with a low prediction score of natural conception. Similarly, treatment with IUI in a natural cycle probably results in a higher cumulative live birth rate compared to treatment with timed intercourse with OH. Treatment with IUI in a stimulated cycle may result in a higher cumulative live birth rate compared to treatment with IUI in a natural cycle.
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Affiliation(s)
- Reuben Olugbenga Ayeleke
- University of AucklandDepartment of Obstetrics and GynaecologyPrivate Bag 92019AucklandNew Zealand
| | - Joyce Danielle Asseler
- Academic Medical CenterDepartment of Obstetrics and GynaecologyMeibergdreef 9AmsterdamNetherlands1105AZ
| | - Ben J Cohlen
- Isala Clinics, Location SophiaDepartment of Obstetrics and GynaecologyDr van Heesweg 2Isala ZwolleNetherlands
| | - Susanne M Veltman‐Verhulst
- Department of Reproductive Medicine and GynecologyUniversity Medical Center UtrechtRoom F5.126, PO Box 85500,UtrechtNetherlands3508 GA
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27
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ZARINARA A, ZERAATI H, KAMALI K, MOHAMMAD K, RAHMATI M, AKHONDI MM. The Success Rate and Factors Affecting the Outcome of Assisted Reproductive Treatment in Subfertile Men. IRANIAN JOURNAL OF PUBLIC HEALTH 2020; 49:332-340. [PMID: 32461941 PMCID: PMC7231713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 06/19/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND This study was conducted to evaluate the success rate of male infertility treatment and the factors affecting its outcome. METHODS In a historical cohort study, from Mar 2013 to Mar 2014, 323 couples with male factor were investigated. Couples had treated with IUI or/and ICSI were included randomly. Assisted reproduction technology (ART) outcome (treatment success) was defined as a live birth. Age, duration of infertility, type of infertility, treatment history and clinical examination results were investigated. The logistic regression and survival analysis were applied. RESULTS The average of men age, duration of infertility and BMI were 33.5, 4.7 (yr) and 26.6 (kg/m2) respectively. 87.9% of men have primary infertility and average duration of treatment was 14.1(month). Previous treatment, type of infertility, treatment method, man's BMI, normality of sperm and sperm head were important variable that affecting outcome. The rate of live birth in the first attempt was 29.7%, and 44.9% of the couples succeeded to give live birth after several treatment cycles. Couples who had no previous history of treatment were 8.5 times more successful in live birth. The Cox analysis showed that "BMI of man" and percentage of "Sperm with normal head" are predictors that had a significant effect on live birth. CONCLUSION Live birth in the first treatment cycles was influenced by four variables but two other variable were affecting several treatment cycles outcome. The chances of successful treatment were higher with taking into account the length of time and having live birth was determined as 78% for five years of continuous treatment.
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Affiliation(s)
- Alireza ZARINARA
- Reproductive Biotechnology Research Center, Avicenna Research Institute, Tehran, Iran
| | - Hojjat ZERAATI
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Koorosh KAMALI
- Department of Public Health, School of Public Health, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Kazem MOHAMMAD
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam RAHMATI
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
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