Factors responsible for multiple pregnancies after ovarian stimulation and intrauterine insemination with gonadotropins

Comparison of two cancellation strategies to lower the risk of multiple pregnancies in gonadotropin stimulated intrauterine insemination cycles

OBJECTIVE

To compare two cancellation policies in controlled ovarian stimulation-intrauterine insemination (COS-IUI) cycles to lower the risk of multiple pregnancies (MP).

DESIGN

We performed a bicentric retrospective cohort study in two academic medical centers: Angers (group A) and Besançon (group B) University Hospitals. We included 7056 COS-IUI cycles between 2011 and 2019. In group A, cancellation strategy was based on an algorithm taking into account the woman's age, the serum estradiol level, and the number of follicles of 14 mm or greater on ovulation trigger day. In group B, cancellation strategy was case-by-case and physician-dependent, based on the woman's age, number of follicles of 15 mm or greater, and the previous number of failed COS-IUI cycles, without any predefined cut-off. Our main outcome measures were the MP rate (MPR) and the live-birth rate (LBR).

RESULTS

We included 884 clinical pregnancies (790 singletons, 86 twins, and 8 triplets) obtained from 6582 COS-IUI cycles. MPR was significantly lower in group A compared with group B (8.1% vs 13.3%, P = 0.01), but LBR were comparable (10.8% vs 11.8%, P = 0.19). Multivariate logistic regression found the following to be risk factors for MP: the "cancellation strategy" effect (adjusted odds ratio [aOR] 1.63, 95% confidence interval [CI] 1.02-2.60) and the number of follicles of 14 mm or greater (aOR 1.39, 95% CI 1.16-1.66). Cycle cancellation rate for excessive response was significantly lower in group A compared with group B (1.3% vs 2.4%, P < 0.001).

CONCLUSIONS

The use of an algorithm based on the woman's age, serum estradiol level and number of follicles of at least 14 mm on trigger day allows the MPR to be reduced without impacting the LBR.

Effect of small follicles on clinical pregnancy and multiple pregnancy rates in intrauterine insemination: a cohort study

STUDY QUESTION

What is the effect of small follicles on clinical pregnancy and multiple pregnancy rates in women undergoing IUI with ovarian stimulation (IUI-OS)?

SUMMARY ANSWER

The presence of ≥2 small follicles with a diameter of 10-12 or 12-14 mm was associated with an increased chance of clinical pregnancy and the presence of any 12-14 mm or larger follicles, but not smaller follicles, was statistically significantly associated with an increased risk for multiple pregnancy.

WHAT IS KNOWN ALREADY

IUI-OS is widely used as the first-line treatment for unexplained or mild male factor infertility. However, IUI is associated with the risk of multiple pregnancy. While the positive association between the number of follicles ≥14 mm and the chance of pregnancy and the risk of multiple pregnancy is known, the impact of smaller follicles is uncertain.

STUDY DESIGN, SIZE, DURATION

This was a retrospective cohort study that included women undergoing IUI cycles from January 2007 to May 2021 in one assisted reproduction center.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We studied the impact of the number and size of follicles on trigger day on clinical pregnancy and multiple pregnancy rates. Generalized estimation equation regression models were used to compute unadjusted and adjusted odds ratios and 95% CI in all women and only women who achieved clinical pregnancy separately. The chance of clinical pregnancy and multiple pregnancy for different numbers of small follicles in cycles with one >18-mm follicle was calculated using marginal effects estimate.

MAIN RESULTS AND THE ROLE OF CHANCE

This cohort included 12 933 IUI cycles in 7504 women. The overall clinical pregnancy rate was 16.1% (2081/12 933), with a multiple pregnancy rate of 10.5% (218/2081). In the adjusted analysis, the chance of clinical pregnancy increased significantly with the increase in the number of follicles with the diameter of 14-16, 16-18, and 18-20 mm. As for 10-12 mm [adjusted odds ratio (aOR) 1.22, 95% CI 1.02-1.46] and 12-14 mm (aOR 1.29, 95% CI 1.07-1.56) follicles, only groups with ≥2 follicles of those sizes showed significantly increased chance of clinical pregnancy. In cycles that led to pregnancy, follicles with the diameter of 12-14 mm were associated with an increased risk of multiple pregnancy (aOR 1.73, 95% CI 1.19-2.53 for one such follicle; aOR 2.27, 95% CI 1.44-3.56 for ≥2 such follicles), while 10- to 12-mm follicles were not significantly associated with multiple pregnancy (aOR 1.18, 95% CI 0.72-1.95 for ≥2 such follicles). The associations of multiple pregnancy were similar when including all cycles.

LIMITATIONS, REASONS FOR CAUTION

This was a retrospective observational study from a single center. The records of follicle diameter in our center were of a 2-mm interval which limited our ability to analyze the size of follicle as a continuous variable. Also, the number of cycles with a high number of small follicles was still limited which impeded more detailed analysis on the ≥2 follicles subgroup. Similarly, the value of some parts of the marginal probability estimation for multiple pregnancy versus pregnancy according to size and number of follicles was also limited by the low sample size of certain combinations.

WIDER IMPLICATIONS OF THE FINDINGS

Follicles larger than 10 mm, especially those ≥12 mm, may need to be clearly recorded during transvaginal ultrasound surveillance and their potential effects on both pregnancy and multiple pregnancy can be discussed with couples undergoing IUI.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by the National Natural Science Foundation of China (Grant numbers 82201912, 82371651, and 82071615) and Shanghai Sailing Program (21YF1423200). B.W.M. is supported by an NHMRC Investigator grant (GNT1176437). B.W.M. reports consultancy for ObsEva and Merck and travel support from Merck. B.W.M. has received research funding from Ferring and Merck. The authors declare no other competing interests.

TRIAL REGISTRATION NUMBER

N/A.

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

RESEARCH QUESTION

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

DESIGN

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

RESULTS

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

CONCLUSION

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

Obstetric and perinatal outcomes in subfertile patients who conceived following low technology interventions for fertility enhancement: a comprehensive review

PURPOSE

Low technology interventions for fertility enhancement (LTIFE) are strategies that avoid retrieval, handling, and manipulation of female gametes. The definition of LTIFE is yet to be widely accepted and clarified, but they are commonly used in milder cases of infertility and subfertility. Based on these considerations, the aim of the present study was comprehensively to review and investigate the obstetric and perinatal outcomes in subfertile patients who underwent LTIFE.

METHODS

A literature search up to May 2017 was performed in IBSS, SocINDEX, Institute for Scientific Information, PubMed, Web of Science, and Google Scholar. An evidence-based hierarchy was used according to The Oxford Centre for Evidence-Based Medicine to determine which articles to include and analyze, and to provide a level of evidence of each association between intervention and outcome.

RESULTS

This analysis identified preliminary and low-grade evidence on the influence of LTIFE on obstetric and perinatal outcomes in subfertile women.

CONCLUSIONS

LTIFE women should deserve major consideration from Clinicians/Researchers of Reproductive Medicine, because these treatments could be potentially responsible for mothers' and babies' complications. So far, the lack of well-designed and unbiased studies makes further conclusions difficult to be drawn.

Racial Disparities in Seeking Care for Help Getting Pregnant

BACKGROUND

Fertility counselling and treatment can help women achieve their desired family size; however, disparities exist in the utilisation of this care.

METHODS

This study examines the persistence of a racial disparity in visiting a doctor for help getting pregnant by estimating the direct effect of this association using data from the Furthering Understanding of Cancer Health and Survivorship in Adult Women's Study, a population-based cohort study. This cohort included 1073 reproductive age women (22-45 years) with 28% reporting infertility. We fit log binomial models to quantify the magnitude of the racial difference in reported care seeking after adjustment for hypothesised mediators using inverse probability weighting.

RESULTS

Compared with white women, black women were less likely to visit a doctor in the total population [adjusted risk ratio (RR) 0.57, 95% confidence interval (CI) 0.41, 0.80] and in the subgroup of women with infertility [RR 0.75, 95% CI 0.56, 0.99]. In addition, black women waited twice as long, on average, before seeking help compared with white women.

CONCLUSIONS

There were notable racial differences in visiting a doctor for help getting pregnant in this study although reports of infertility were similar by race. These differences may be mitigated through improved communication about the range of counselling and treatment options available.

The efficacy of conversion from IUI to IVF-ET in infertility patients with hyper-response to ovulation induction: a retrospective study

BACKGROUND

The aim of the study was to determine the efficacy of in vitro fertilization and embryo transfer (IVF-ET) in patients with hyper-response to ovulation induction for intrauterine insemination (IUI).

METHODS

Patients with polycystic ovary syndrome (PCOS) who were initially treated with IUI in our centre between Jan 2007 and Oct 2010 were retrospectively analyzed. The ovarian hyper-stimulation syndrome (OHSS) found in 50 patients was then treated with IVF-ET following informed consent.

RESULTS

The fresh transfer had 42 cycles and a total of 87 embryos were transferred. Urine pregnancy tests were positive in 15 patients and fetal heart beat was detected in 12 patients by transvaginal ultrasound, from which 3 patients had two fetuses, 2 patients had three fetuses, and 7 patients had a single fetus. The overall clinical pregnancy rate was 28.5% (12/42) for the fresh embryo transfer. A total of 21 cycles of frozen embryo transfer with up to 55 embryos were conducted for patients who were not pregnant at the end of fresh embryo transfer cycles or who did not receive fresh embryo transfer in the first place. Urine pregnancy tests were positive in 10 patients and fetal heart beat was detected in 8 patients. The clinical pregnancy rate was 38.1% (8/21) for frozen embryo transfer.

CONCLUSION

We conclude that IVF-ET is an effective method for patients with hyper-response to ovulation induction in IUI.

Estimating rates of multiple gestation pregnancies: sample size calculation from the assessment of multiple intrauterine gestations from ovarian stimulation (AMIGOS) trial

Infertility afflicts 15% of couples who wish to conceive. Despite intensive evaluation of both male and female partners, the etiology may remain unknown leading to a diagnosis of unexplained infertility. For such couples, treatment often entails ovulation induction (OI) with fertility medications coupled with intrauterine insemination. Complications of this therapy include ovarian hyperstimulation syndrome and creation of multiple gestation pregnancies, which can be complicated by preterm labor and delivery, and the associated neonatal morbidity and expense of care for preterm infants. The Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation (AMIGOS) study is designed to assess whether OI in couples with unexplained infertility with an aromatase inhibitor produces mono-follicular development in most cycles, thereby reducing multiple gestations while maintaining a comparable pregnancy success rate to that achieved by OI with either gonadotropins or clomiphene citrate. These results will provide future guidance of therapy for couples with unexplained infertility, and if comparable pregnancy rates are achieved with a substantial reduction in multiple gestations, the public health benefit will be considerable.

[Predictive factors of success in ovulation induction with recombinant FSH: results of Indigo study]

INTRODUCTION

Although ovulation induction is commonly used to treat infertility, few data are available concerning this treatment. Therefore, the aim of this prospective observational study was to describe medical practices and to identify predictive outcome factors of ovarian stimulation by recombinant FSH (r-hFSH), administrated with a self-injector pen.

PATIENTS AND METHODS

At the time of the prescription of ovarian stimulation followed by sexual intercourse (SI) or artificial insemination (HAI) with a normal husband sperm, 370 gynaecologists consecutively sent from January to November 2005, for a maximum of six patients (1398 patients in total), a form dealing with the assessment of infertility factors prior to stimulation (n=1340), then a monitoring form of the treated cycle (n=1227) and when a pregnancy was obtained, a follow-up form at 12 weeks of amenorrhea (n=254). Each patient had to complete an autoquestionnaire about the use of the pen (n=1044).

RESULTS

Seventy percent of the contributing gynaecologists had only a private practice. The mean age of patients was 31.9+/-4.8 years. Dealing with infertility exploration prior to stimulation, 9% did not have tubal assessment. Although it was the first stimulation attempt for 52% of cases, 91% of patients found the pen easy to manipulate. The mean duration of r-hFSH administration was 8.8+/-3.7 days and the mean daily dose was 75.4+/-29.4 IU. Ultrasound and hormonal monitoring was performed for 88% of patients. The cycle cancellation rate was 11%. The hCG administration was performed on cycle day 13+/-3. An HAI was programmed in 60% of patients and SI in 40%. The pregnancy rates for positive betahCG, ongoing and multiple pregnancies were, respectively, 22.7, 18 and 16% (twins 14%; 2% of triplets or more 2%). Three prognosis factors were independently related to ongoing pregnancy rate: age<35 years, previous pregnancy obtained by treatment and presence of ovulatory disorders.

DISCUSSION AND CONCLUSION

This observatory of ovarian stimulation out of FIV allowed to describe medical practices of gynaecologists: infertility assessment prior to ovarian stimulation, used FSH doses, ultrasound and hormonal monitoring, and it outlined three predictive factors of outcome: age, previous pregnancy obtained by treatment and presence of ovulatory disorders.

Strategies to reduce multiple pregnancies due to ovulation stimulation

OBJECTIVE

To review factors associated with high-order multiple births (HOMB) due to ovulation induction (OI) and the efficacy of strategies to reduce their occurrence.

DESIGN

Retrospective analysis of published studies of OI with intrauterine insemination (IUI) where patient and cycle characteristics were fully documented.

RESULT(S)

High-order multiple pregnancies (HOMP) were positively related to use of high doses of gonadotropin, number of 7-10 mm preovulatory follicles, and E(2), and inversely related to age and number of treatment cycles. Strategies successful in reducing HOMP include: use of clomiphene (CC) before gonadotropins, minimal gonadotropin doses, cancellation for more than three follicles >10-15 mm, and aspiration of excess follicles. Depending on the strategy used, 5%-20% of cycles may be canceled but HOMP rates can be less than 2% and pregnancy rates can average 10%-20% per cycle. Pregnancy rates per patient need not be reduced if low doses are continued for 4-6 cycles.

CONCLUSION(S)

High-order multiple pregnancies due to OI can be reduced to 2% or less by less aggressive stimulation without reducing overall chances of pregnancy for most patients.

Relationship between follicle number and (multiple) live birth rate after controlled ovarian hyperstimulation and intrauterine insemination

OBJECTIVES

The goal of this study was to determine the relationship between the number of mature ovarian follicles and the (multiple) live birth rate after controlled ovarian hyperstimulation and intrauterine insemination.

STUDY DESIGN

A total of 2463 intrauterine insemination cycles performed during a natural cycle (n = 118), or after controlled ovarian hyperstimulation with either clomiphene citrate (n = 663) or with gonadotrophins (n = 1682) were reviewed to assess the impact of the type of stimulation and the number of follicles 14 mm or larger on the (multiple) live birth rate per cycle.

RESULTS

The live birth rate after intrauterine insemination was significantly higher (P = .02) after stimulation with gonadotrophins (13%) than after clomiphene cirate (8%) if only 1 follicle 14 mm or larger was present. If 2 or more follicles were present, there was no statistically significant difference between both stimulation methods.

CONCLUSION

Treatment of intrauterine insemination with gonadotrophin is effective with an acceptable (multiple) live birth rate when 1 or 2 follicles 14 mm or larger are present.

[Intrauterine insemination: against systematic ovarian stimulation]

Intrauterine insemination is a technique proposed of first intention in many situations of non-tubal infertilities. It is very frequently associated with a stimulation of ovulation, with the objective of precisely synchronizing the intra uterine stimulation and ovulation, and an increase in follicular recruitment. If intrauterine stimulation is often a determining factor in obtaining pregnancy, stimulation of ovulation does not always bring about an obvious benefit and its interest must be discussed according to the indications, knowing on the other hand that it is determining in the occurring of multiple pregnancies.

Is controlled ovarian stimulation in intrauterine insemination an acceptable therapy in couples with unexplained non-conception in the perspective of multiple pregnancies?

BACKGROUND

Controlled ovarian stimulation (COS) with intrauterine insemination (IUI) is a common treatment in couples with unexplained non-conception. Induction of multifollicular growth is considered to improve pregnancy outcome, but it contains an increased risk of multiple pregnancies and ovarian hyperstimulation syndrome. In this study the impact of the number of follicles (>14 mm) on the ongoing pregnancy rate (PR) and multiple PR was evaluated in the first four treatment cycles.

METHODS

A retrospective cohort study was performed in all couples with unexplained non-conception undergoing COS-IUI in the Academic Hospital of Maastricht. The main outcome measure was ongoing PR. Secondary outcomes were ongoing multiple PR, number of follicles of >or=14 mm, and order of treatment cycle.

RESULTS

Three hundred couples were included. No significant difference was found in ongoing PR between women with one, two, three or four follicles respectively (P=0.54), but in women with two or more follicles 12/73 pregnancies were multiples. Ongoing PR was highest in the first treatment cycle and declined significantly with increasing cycle order (P=0.006), while multiple PR did not change.

CONCLUSIONS

In COS-IUI for unexplained non-conception, induction of more than one follicle did not improve the ongoing PR, but increased the risk of multiple pregnancies. Multiple PR remained high in the first four cycles with multifollicular stimulation. Therefore, in order to reduce the number of multiple pregnancies, in all IUI cycles for unexplained non-conception monofollicular growth should be aimed at.

Risk factors for high-order multiple pregnancy and multiple birth after controlled ovarian hyperstimulation: Results of 4,062 intrauterine insemination cycles

OBJECTIVE

To determine factors responsible for high-order multiple pregnancy (HOMP) and high-order multiple births when multiple cycles of controlled ovarian hyperstimulation-IUI (COH-IUI) are performed.

DESIGN

Retrospective analysis.

SETTING

Private infertility clinic.

PATIENT(S)

Women (n = 2,272) who underwent 4,067 consecutive COH-IUI cycles.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

High-order multiple pregnancy rate, pregnancy rate (PR), and birth rate (PR) per cycle.

RESULT(S)

High-order multiple pregnancy was related to number of follicles of diameter > or = 10 mm, age, and treatment cycle. For age <32 years, HOMP was 6% for three to six follicles and 20% for seven or more follicles. For ages 32 to 37 years, HOMP was 5% for three to six follicles and 12% for seven or more follicles. In the first COH-IUI cycle, HOMP was 8% for three to six follicles and 15% for seven or more follicles. In the second cycle, HOMP did not occur unless there were more than six follicles. No HOMP occurred after the second cycle. Pregnancy rate did not increase significantly when there were more than four follicles. Continuing COH-IUI past the third cycle resulted in additional pregnancies in patients with one to eight follicles.

CONCLUSION(S)

High-order multiple pregnancy can be predicted by age and number of follicles of diameter > or = 10 mm. Controlled ovarian hyperstimulation is not necessary to achieve satisfactory overall pregnancy rates if ovulation induction is continued past the third cycle in low responders.

Conversion of high-response gonadotropin intrauterine insemination cycles to in vitro fertilization results in excellent ongoing pregnancy rates

OBJECTIVE

To determine whether conversion of gonadotropin/IUI cycles at high risk of high-order multiple pregnancies to IVF yields a pregnancy rate high enough to warrant the added intervention.

DESIGN

Case-control study.

SETTING

Brigham and Women's Hospital assisted reproductive technology program.

PATIENT(S)

Seventy-seven patients converted from gonadotropin/IUI to IVF, 77 consecutive age and attempt number-matched controls (sequential controls [SCs]), and 77 consecutive age-, attempt-, and E(2)-matched controls (E(2) controls [ECs]).

INTERVENTION(S)

Gonadotropin/IUI cycles with exuberant responses were converted to IVF (cases) to avoid cycle cancellation and high-order multiple pregnancies.

MAIN OUTCOME MEASURE(S)

Pregnancy rates, delivery rates, E(2) levels, follicle and oocyte number, and fertilization and implantation rates.

RESULT(S)

Compared with SCs and ECs, cases had more follicles (16.3 +/- 0.6 vs. 13.3 +/- 0.9 and 14.4 +/- 0.9) and higher E(2) at hCG administration (1,951 +/- 93 vs. 1,568 +/- 96 and 1,939 +/- 89 pg/mL). Delivery rates among the three groups (45.5% vs. 32.5% and 39.0%) did not differ significantly. Despite the transfer of fewer embryos in cases than in controls (2.5 +/- 0.1 vs. 3.1 +/- 0.1 and 2.9 +/- 0.1), three triplet pregnancies occurred in cases and three in controls.

CONCLUSION(S)

Conversion of high responder gonadotropin/IUI patients to IVF is an effective alternative to cycle cancellation and offers a delivery rate as high or higher per cycle than that of planned IVF. Sample size limited the statistical power of the study.

A computerized decision support system for ovarian stimulation by gonadotropins

OBJECTIVE

To evaluate the effectiveness of a computerized decision support system for ovarian stimulation with gonadotropins.

DESIGN

Retrospective and prospective randomized studies.

SETTING

Private and university teaching hospital.

PATIENT(S)

Women undergoing ovarian stimulation to treat infertility.

MAIN OUTCOME MEASURE(S)

Pregnancy rate.

RESULT(S)

In the retrospective study, computer-generated decisions were compared with clinicians' decisions in 118 stimulated cycles in 53 patients. In 90% of cases, the choice of FSH regimens and adjustments to dosages were identical. In the prospective study, the computer-generated decisions achieved a pregnancy rate per cycle of 18% (15 of 82 cycles), compared with 16% (13 of 82 cycles) achieved by clinicians.

CONCLUSION(S)

A computerized decision making system was as effective as skilled clinicians in achieving pregnancy by using ovarian stimulation with FSH.

Risk factors for high-order multiple implantation after ovarian stimulation with gonadotrophins: evidence from a large series of 1878 consecutive pregnancies in a single centre

BACKGROUND

High-order multiple pregnancies (triplets or more) have a large adverse impact on perinatal morbidity and mortality as well as important economic consequences. Most triplets and higher births are due to ovulation induction alone or in combination with intrauterine insemination (IUI) rather than to in-vitro fertilization (IVF). The present investigation was undertaken to determine whether there were specific variables that related to patient clinical characteristics (age of the woman, duration of infertility, type of infertility, body mass index, basal FSH and LH concentrations), treatment characteristics (initial dose of gonadotrophins, total dose of gonadotrophins administered, number of days of ovarian stimulation, insemination procedure, number of spermatozoa inseminated in patients undergoing IUI, type of luteal support), and ovarian response (oestradiol serum concentrations, number and size of follicles) that might be associated with the occurrence of high-order multiple implantation in order to develop a prediction model.

METHODS

This study employed univariate, multivariate and receiver-operating characteristic (ROC) analysis of a large series of 1878 consecutive pregnancies obtained in cycles stimulated with gonadotrophins. Of them, 1771 (94.3%) were low-order pregnancies (1477 singletons and 294 pairs of twins) and 107 (5.7%) were high-order pregnancies.

RESULTS

Predictive variables in the multivariate analysis were age of the woman, serum oestradiol concentrations and number of follicles >10 mm on the day of HCG injection. Stratification of the number of follicles into three categories (1 to 3, 4 to 5, and >5 follicles respectively), peak serum oestradiol and woman's age according to the ROC curves, showed that the risk of high-order multiple implantation correlated significantly with increasing total number of follicles and was significantly increased in women with a serum oestradiol >862 pg/ml and aged < or =32 years.

CONCLUSIONS

This three-variable model can help to identify patients at high-risk for high-order multiple pregnancy in ovulation induction cycles.

Relationship of follicle numbers and estradiol levels to multiple implantation in 3,608 intrauterine insemination cycles

OBJECTIVE

To determine the relationship of follicle numbers and estradiol (E(2)) levels to multiple implantations in human menopausal gonadotropin (hMG) and clomiphene citrate (CC) cycles.

DESIGN

Fifteen-year prospective study.

SETTING

Private infertility clinic.

PATIENT(S)

Women who underwent 3608 cycles of husband or donor intrauterine insemination (IUI).

INTERVENTION(S)

Ovulation induction (OI) with CC, hMG, or CC+hMG.

MAIN OUTCOME MEASURE(S)

Pregnancy and multiple implantations.

RESULT(S)

Triplet and higher-order implantations-but not twin implantations-were related to age, E(2) levels, and number of follicles > or = 12 mm and > or = 15 mm, but not number of follicles > or = 18 mm, in hMG and CC+hMG cycles. For patients less than 35 years old, three or more implantations tripled when six or more follicles were > or = 12 mm, in CC, hMG, and CC+hMG cycles, and when E(2) was > or = 1000 pg mL in hMG and CC+hMG cycles. For patients 35 or older, pregnancy rates in hMG and CC+hMG cycles doubled when six or more follicles were > or = 12 mm, or E(2) levels were >1000 pg mL, whereas 3 or more implantations were not significantly increased.

CONCLUSIONS

Withholding hCG or IUI in CC, hMG, and CC+hMG cycles when six or more follicles are > or = 12 mm may reduce triplet and higher-order implantations by 67% without significantly reducing pregnancy rates for patients under 35 years of age.

[Benefits and risks of ovarian stimulation before intrauterine insemination]

Performance of intra-uterine insemination (IIU) is generally advocated as a first line therapy for infertility related to cercical hostility, male factor, unexplained infertility or mild endometriosis. IIU are usually performed following stimulation of ovulation, even in absence of anovulation. However the rationale for such a systematic ovulation induction is still questionable. Indeed, while an overall assessment of ovarian stimulation tends to conclude to a beneficial effect of these treatments in unexplained or some male infertility, it is clear that no definitive conclusion can be drawn. Indeed, the methodology in many published series is mostly inadequate, data are usually not analysed according to the type of infertility or to the female hormonal features. Finally, adverse effects are imperfectly descripted. A more accurate analysis of these data in relation to the number of recruited follicles definitively shows that, if a bifollicular development is associated with a significant increase in the pregnancy rates, there is no advantage to stimulate further the ovary. Indeed, surpassing the recruitment of two follicles would lead to dramatically increase the risk of OHSS and multiple pregnancies. Thus, further investigations including prospective, randomized studies are needed to better define what should be the most adequate regimen of ovulation induction. Specifically, tailoring the rate of multifollicular development according to the duration, the type of infertility (etiology; primary or secondary; female age) would prove to be a safer approach for getting pregnancy as well as avoiding adverse effects. Such a policy remains to be determined in the light of further clinical studies conducted in the more appropriate manner.

Risk factors for multiple gestation in women undergoing intrauterine insemination with ovarian stimulation

OBJECTIVE

To identify whether sperm characteristics after washing and/or ovulation induction cycle characteristics can predict the occurrence of multiple conception in patients undergoing ovarian stimulation and IUI.

DESIGN

Retrospective study.

SETTING

A gynecology clinic and an andrology laboratory at a tertiary care facility.

PATIENT(S)

One hundred patients with single pregnancies and 22 patients with multiple pregnancies.

INTERVENTION(S)

Patients underwent ovarian stimulation and IUI with their partner's sperm.

MAIN OUTCOME MEASURE(S)

Relation of patient characteristics, ovarian stimulation, and sperm characteristics after washing to the occurrence of multiple pregnancy.

RESULT(S)

The mean serum E2 level on the day of hCG injection was significantly higher in the multiple conception group, but the number of follicles was not. The total sperm count, total motile sperm count, and sperm motility after washing did not differ between the groups. However, couples with multiple pregnancies had sperm with a significantly higher amplitude of lateral head movement than couples with single pregnancies. A peak E2 level of >583 pg/mL on the day of hCG injection and sperm with an ALH of >4 microm after washing predicted the occurrence of multiple pregnancy.

CONCLUSION(S)

Sperm with an amplitude of lateral head movement of >4 microm and a peak E2 level of >583 pg/mL are significant risk factors for multiple pregnancy in patients undergoing IUI.

Early resort to ovarian stimulation improves the cost-effectiveness of a donor insemination programme

Women undergoing donor insemination (DI) are usually regularly ovulating, therefore the role of ovulation induction in this modality of treatment has been controversial. Some recent studies reported higher pregnancy rates in stimulated cycles in comparison with natural cycles. We employed a sequential step-up protocol in which treatment was started in a natural cycle, continued with a clomiphene citrate-stimulated cycle, and finished with an ovulation induction cycle. The patients were allowed three attempts at each step before moving to the next if conception did not occur. The aim of this protocol was to enhance the cost-effectiveness of the DI programme by increasing the cycle fecundability. A total of 101 patients underwent 216 cycles of DI, including 44 patients in 80 natural cycles, 38 patients in 89 CC-stimulated cycles, and 19 patients in 47 ovulation induction cycles. The clinical pregnancy rate per started cycle (CPR/C) and per patient during this period was 14% and 30% respectively. The pregnancy rates per started cycle and per patient in the natural, CC-stimulated and ovulation induction cycles were: 13 and 32%, 10 and 18%, and 21 and 53% respectively. There was no significant difference in the CPR/C in the three groups; however, the CPR per patient in the induced ovulation cycles was significantly higher than in the CC-stimulated cycles (P = 0.005). Only one patient during this period had a multiple pregnancy in the ovulation induction group, giving an overall multiple pregnancy of 3%. By using this treatment strategy, we achieved a high clinical pregnancy rate, a low multiple pregnancy rate and a low cost of treatment per pregnancy.