Gamete intrafallopian transfer vs superovulation with intrauterine insemination for the treatment of infertility

Comparison of the sperm quality necessary for successful intrauterine insemination with World Health Organization threshold values for normal sperm

OBJECTIVE

To compare World Health Organization threshold values for normal sperm with the initial sperm quality necessary for successful IUI.

DESIGN

Retrospective study.

SETTING

Private fertility clinic.

PATIENT(S)

One thousand eight hundred forty-one couples undergoing 4,056 cycles of IUI.

INTERVENTION(S)

Intrauterine insemination.

MAIN OUTCOME MEASURE(S)

Relation of initial sperm quality to fecundity.

RESULT(S)

Progressive motility and total motile sperm count were the initial sperm characteristics most closely related to pregnancy on discriminant analysis. The per-cycle pregnancy rate averaged 11.1% during the first three IUI cycles. Pregnancy rates were > or = 8.2% per cycle when the initial sperm values were a concentration of > or = 5 X 10(6)/mL, a total count of > or = 10 X 10(6), progressive motility of > or = 30%, or a total motile sperm count of > or = 5 x 10(6). Minimal increases in fecundity occurred when initial values were greater than these threshold levels. The lowest initial values that resulted in pregnancy were a concentration of 2 x 10(6)/mL, a total count of 5 x 10(6). motility of 17%, and a total motile sperm count of 1.6 X 10(6). Pregnancy rates were <3.6% when initial values were between the threshold levels and the lowest levels.

CONCLUSION(S)

The sperm quality that is necessary for successful IUI is lower than World Health Organization threshold values for normal sperm. Intrauterine insemination is effective therapy for male factor infertility when initial sperm motility is > or = 30% and the total motile sperm count is > or = 5 X 10(6). When initial values are lower, IUI has little chance of success.

After superovulation-intrauterine insemination fails: the prognosis for treatment by gamete intrafallopian transfer/pronuclear stage transfer

OBJECTIVE

To determine the prognosis for gamete intrafallopian transfer (GIFT)/pronuclear stage transfer (PROST) treatment after prior superovulation-intrauterine insemination (IUI).

DESIGN

Matched, retrospective.

SETTING

Outpatient university endocrine-infertility program.

PATIENTS, PARTICIPANTS

One hundred forty-four women matched for infertility factors and age were studied according to the following three treatment groups: superovulation-IUI only, GIFT/PROST only, or GIFT/PROST after superovulation-IUI.

MAIN OUTCOME MEASURES

Per cycle and cumulative pregnancy rates (PRs) were compared utilizing life table analysis.

RESULTS

Cumulative PRs (0.408) for superovulation-IUI only were lower than initial (0.469) and cumulative (0.802) cycle fecundity of GIFT/PROST (P = 0.002). Per cycle and cumulative PRs did not differ between GIFT/PROST only versus GIFT/PROST after superovulation-IUI.

CONCLUSIONS

Gamete intrafallopian transfer/PROST may be cost-effective when compared with superovulation-IUI. The prognosis for GIFT/PROST success is not negatively affected by earlier superovulation-IUI treatment failure.

In vivo fertilization procedures in infertile women with patent fallopian tubes: a comparison of gamete intrafallopian transfer, combined intrauterine and intraperitoneal insemination, and controlled ovarian hyperstimulation alone

This prospective study was undertaken to evaluate the relative efficacy of three in vivo methods of assisted fertilization in 150 infertile women with patent fallopian tubes: gamete intrafallopian transfer (GIFT), combined intrauterine and direct intraperitoneal insemination (IUI+DIPI), and controlled hyperstimulation (COHS) alone. The clinical pregnancy rate was highest in the IUI/DIPI and GIFT groups: IUI/DIPI, 29.3%; GIFT, 28.6%; and COHS, 8.9%. We believe that controlled ovarian hyperstimulation combined with IUI and DIPI is a good alternative to GIFT.

The role of superovulation with menotropins in ovulatory infertility: a review

The risks of menotropin therapy (ovarian hyperstimulation syndrome, multiple gestation, adnexal torsion) are well known and have been previously described. Superovulation should not be considered for the indications described herein until more traditional therapies for infertility have been tried and found unsuccessful and sufficient time has elapsed for conception to occur. The cost of superovulation is high: the medications are expensive, frequent E2 monitoring and US studies are costly, and pregnancy complications relating to the higher rate of pregnancy loss and multiple gestation may add substantially to the overall cost. Yet, compared with IVF and GIFT, superovulation cycles combined with IUI cost between one third to one sixth that of an IVF cycle. Protocols involving combined CC/hMG/hCG, which reduce the total number of ampules of Pergonal needed per cycle and still provide multiple follicular development, may further reduce costs. There is a growing consensus that superovulation-IUI protocols should be attempted before GIFT and IVF in couples with normal pelvic viscera. There is little doubt that IVF and GIFT cycles are more costly, stressful, and complex. No comparative data have clearly shown IVF and GIFT to be superior to superovulation protocols in ovulatory women with normal pelvic anatomy. In the only study examining this issue published to date, Kaplan et al. retrospectively analyzed all GIFT and superovulation/IUI cycles at a single university center and found GIFT to be three times more efficient. However, the inherent limitations of a nonrandomized, nonprospective study of this kind are obvious as these authors have suggested. Therefore, it may be wise to consider the use of superovulation before assisted reproductive technologies until this issue is settled. It would be interesting to determine if the high PRs reported for couples with unexplained infertility or mild endometriosis in IVF and GIFT cycles in some centers not incorporating superovulation/IUI protocols would hold up if such an approach was routinely followed. Despite the increasing acceptance of superovulation protocols, we must be aware that many of the studies suggesting a role of hMG in treating ovulatory infertile women with normal pelvic anatomy suffer from deficiencies in experimental design. In a payor-driven system, such as in the United States, the difficulties in designing and carrying out scientifically sound clinical studies examining infertility therapies are obvious. The lack of federal or outside funding for the study of infertility issues contributes to the problem. It is our hope that better designed studies examining the role of superovulation in the treatment of ovulatory infertile women with normal pelvic anatomy will be forthcoming.