A proportional hazards analysis of the clinical characteristics of infertile couples

Gender's Role in Responses to Infertility

Infertility is a major life stressor that affects approximately 10% of U.S. married couples. Infertile women and men have reported experiencing depression, helplessness, and marital strain. Given U.S. society's emphasis on women's role as mothers, it has been suggested that women's lives are more disrupted by infertility than those of men. This hypothesis was supported in a survey of 185 infertile couples and 90 presumed fertile couples. Infertile wives, as compared to their husbands, perceived their fertility problem as more stressful, felt more responsible for and in control of their infertility, and engaged in more problem-focused coping. Infertile husbands experienced more home life stress and lower home life performance than did their wives. These differences were not found for presumed fertile couples. Both infertile and presumed fertile wives experienced more depression, more sexual dissatisfaction, and lower self-esteem than did their husbands. Theoretical and counseling implications of these findings are discussed.

Use of laparoscopy in unexplained infertility

OBJECTIVE

The use of laparoscopy in unexplained infertility work-up is still a subject of debate, although laparoscopy remains the gold standard for diagnosis and treatment of several pelvic pathologies. The objective of this study was to assess the rates and types of pelvic pathologies observed during diagnostic laparoscopy, and the pregnancy rate in couples with unexplained infertility following laparoscopy.

STUDY DESIGN

Prospective study, from November 2003 to October 2009, including 114 infertile, spontaneously ovulating women with normal clinical examination, ovarian reserve assessment, pelvic ultrasound scan and patent tubes on hysterosalpingography. Semen analyses were normal according to the World Health Organization criteria. After three cycles of ovulation induction with or without intra-uterine insemination and no pregnancy, women were referred for diagnostic laparoscopy.

RESULTS

Laparoscopy revealed pelvic pathology in 95 patients. Endometriosis, pelvic adhesions and tubal disease were observed and treated in 72, 46 and 24 patients, respectively. Following laparoscopy, bilateral and unilateral tubal patencies were observed in 107 and five patients, respectively. Pregnancy was observed in 77 out of 102 patients who tried to conceive after surgery, 35 of whom conceived using their own tubes.

CONCLUSION

Diagnostic laparoscopy should be strongly considered in unexplained infertility work-up, and tubal efficiency should not be underestimated.

Laparoscopy should be strongly considered for women with unexplained infertility

AIM

Women with unexplained infertility frequently become pregnant after diagnostic laparoscopy. In this study the effect of laparoscopic surgery on such women was evaluated by the pregnancy rate after laparoscopic surgery.

METHODS

A total of 47 unexplained infertile women underwent laparoscopic evaluation during the period August 2002 to January 2005 in our center. The percentage of positive laparoscopic findings and the pregnancy rate after laparoscopy were calculated. The patients were divided into 5 subgroups according to maternal age, pregnancy rates were calculated for each group, and compared with the outcome of assisted reproductive technology (ART) treatment for the same age groups.

RESULTS

In 87.2% of the women, laparoscopy revealed abnormal findings; endometriosis lesions, peritubal adhesions and tubal obstructions were found in 21, 17 and 3 cases, respectively. After laparoscopy 23 achieved pregnancy (pregnancy rate: 48.9%). The pregnancy rates of the groups at the age of 25 years old or less, 26-30, 31-35, 36-40 and over 41 years old were 100%, 75.0%, 45.5%, 27.2% and 0%, respectively. In the case of the 26-30 years old group, the pregnancy rate after laparoscopy was significantly higher than that in the ART treatment group (33.3%, P < 0.05).

CONCLUSIONS

Laparoscopy should be strongly considered for examining women with unexplained infertility.

Impact of laparoscopic cystectomy on fecundity of infertility patients with ovarian endometrioma

AIM

To clarify the effect of laparoscopic cystectomy for ovarian endometrioma in infertility patients, the pregnancy outcome was evaluated.

METHODS

This was a retrospective study. From August 2002 to February 2006, 33 infertility patients with ovarian endometrioma underwent laparoscopic cystectomy at our center. According to the laparoscopic findings 33 were divided into two groups; 10 were evaluated as the patients who need assisted reproductive technologies (ART) treatment (IVF subgroup) and 23 were evaluated as the patients who do not need ART treatment but conventional infertility treatment (non-IVF subgroup). During the same period, 70 patients who were age-matched and received ART treatment without laparoscopy were defined as control (control group). Following up to 12 months after laparoscopy, the cumulative pregnancy rate in the non-IVF subgroup was calculated.

RESULTS

The patients age, duration of infertility and size of endometrioma were equal in the IVF and the non-IVF subgroups. The revised-American Society of Reproductive Medicine (r-ASRM) score in the IVF subgroup was significantly higher than that in the non-IVF group (P < 0.05). The pregnancy rates after laparoscopic cystectomy in IVF and non-IVF subgroups were 50.0% and 60.9%, respectively. These rates in the IVF and the non-IVF groups were slightly higher than that in control group (41.4%), but these differences were not significant. The cumulative pregnancy rate in the non-IVF group reached 52.2%, 12 months after laparoscopic surgery.

CONCLUSIONS

Laparoscopic surgery should be performed prior to ART treatment not only for making a decision about the treatment course but also for establishing a good pelvic condition to induce a pregnancy during ART treatment in infertility treatment with ovarian endometrioma.

Does gravidity influence the success of in vitro fertilization-embryo transfer cycles?

OBJECTIVE

To evaluate the influence of gravidity on the results of in vitro fertilization (IVF)-embryo transfer (ET) cycles.

PATIENTS AND METHODS

All consecutive women aged <35 years admitted to our IVF unit from January 2002 to December 2004 were enrolled in the study. Only patients undergoing one of their first three IVF cycle attempts were included. Gravidity, ovarian stimulation characteristics, number of oocytes retrieved, number of embryo transferred and clinical pregnancy rate were assessed.

RESULTS

Three hundred and forty-two consecutive IVF cycles were evaluated. One hundred and sixty-one cycles were from nulligravidas and 181 from women with a history of at least one previous clinical pregnancy. Forty-eight (29.8%) clinical pregnancies were observed in the nulligravida group and 56 (30.9%) in the gravida group. There were no differences between nulligravidas and gravidas in causes of infertility, length of ovarian stimulation, peak estradiol and progesterone levels, number of oocytes retrieved, fertilization rate and number of embryos transferred. Gravidas were significantly older (30.4 vs. 27.6 years, p < 0.001) and used more gonadotropin ampoules (36.1 vs. 31.8, p < 0.004) compared with the nulligravidas.

CONCLUSIONS

Patient gravidity has no influence on the likelihood of achieving pregnancy in IVF-ET cycles.

Follicular response and pregnancy among infertile women undergoing ovulation induction and intrauterine insemination

OBJECTIVE

To determine the relationship between ovarian follicular response (number and diameter of follicles) to ovulation induction agents and pregnancy.

DESIGN

Retrospective cohort study.Hospital-based center of reproductive medicine.

PATIENT(S)

Three hundred twenty-two clinically diagnosed infertile couples undergoing 1483 cycles of ovulation induction and IUI. Oral and injectable fertility drugs were administered for 2-10 cycles; ultrasound follicular measurements were recorded around time of ovulation; hCG was administered when follicles were 18-20 mm or more in diameter; IUI was performed 36-40 hours after administration of hCG.

MAIN OUTCOME MEASURE(S)

A first positive pregnancy test as indicative for conception. Women with follicular diameters >or=20 mm were less likely to become pregnant as compared to women with diameters between 15.00 and 19.99 mm (risk ratio [RR] = 0.58, 95% confidence interval [CI] = 0.35, 0.97). Women >or=30 years of age were half as likely to become pregnant as compared to women <30 years (RR = 0.51, 95% CI = 0.30, 0.85). Likelihood of pregnancy increased by 21% for each prior pregnancy (RR = 1.21, 95% CI = 1.00, 1.47).

CONCLUSION(S)

Maternal age, gravidity, and follicular diameters around the time of insemination are prognostic factors in the likelihood of pregnancy.

Relation between semen quality and fertility: a population-based study of 430 first-pregnancy planners

BACKGROUND

Semen analysis is part of the routine assessment of infertile couples. WHO defines a sperm concentration above 20x10(6) per mL seminal fluid as normal. We studied the association between semen quality and the probability of conception in a single menstrual cycle in Danish couples with no previous reproductive experience.

METHODS

In 1992-94, we invited 52,255 trades-union members aged 20-35 years, who lived with a partner and had no children to take part in the study; 430 couples agreed. The couples discontinued use of contraception, and were followed up for six menstrual cycles or until a pregnancy was verified within this period. Each man was asked to provide a semen sample at enrolment (which was analysed without freezing). Women kept a daily record of vaginal bleeding and sexual activity. The association between semen quality and likelihood of pregnancy was assessed by logistic regression, adjusted for sexual activity and female factors associated with low fertility.

RESULTS

There were 256 (59.5%) pregnancies among the 430 couples: 165 (65.0%) among those with a sperm concentration of 40x10(6)/mL or more and 84 (51.2%) among those with lower sperm concentrations. The probability of conception increased with increasing sperm concentration up to 40x10(6)/mL, but any higher sperm density was not associated with additional likelihood of pregnancy. The proportion of sperm with normal morphology was strongly related to likelihood of pregnancy independently of sperm concentration. Semen volume and motility were of limited value in pregnancy prediction.

INTERPRETATION

Our study suggests that the current WHO guidelines for normal semen quality should be used with caution. Some men with sperm counts above the lower limit of the normal range defined by WHO may in fact be subfertile.

Fecundity of infertile women with minimal or mild endometriosis and women with unexplained infertility. The Canadian Collaborative Group on Endometriosis

OBJECTIVE

To assess whether infertile women with minimal or mild endometriosis have lower fecundity than women with unexplained infertility.

DESIGN

Prospective cohort study.

SETTING

Twenty-three infertility clinics across Canada.

PATIENT(S)

Three hundred thirty-one infertile women aged 20-39 years.

INTERVENTION(S)

Diagnostic laparoscopy for infertility. Infertile women with minimal or mild endometriosis (n = 168) were compared with women with unexplained infertility (n = 263). Both groups were managed expectantly. The women were followed up for 36 weeks after the laparoscopy or, for those who became pregnant, for up to 20 weeks of the pregnancy.

MAIN OUTCOME MEASURE(S)

Fecundity refers to the probability of becoming pregnant in the first 36 weeks after laparoscopy and carrying the pregnancy for > or = 20 weeks. The fecundity rate is the number of pregnancies per 100 person-months.

RESULT(S)

Fecundity was 18.2% in infertile women with minimal or mild endometriosis and 23.7% in women without endometriosis (log-rank test). The fecundity rate was 2.52 per 100 person-months in women with endometriosis and 3.48 per 100 person-months in women with unexplained infertility. The crude and adjusted fecundity rate ratios were 0.72 and 0.83 (95% confidence interval = 0.53-1.32), respectively.

CONCLUSION(S)

The fecundity of infertile women with minimal or mild endometriosis is not significantly lower than that of women with unexplained infertility.

Time to conception after orchidopexy: evidence for subfertility?

OBJECTIVE

To determine whether time to conception is increased among men who were formerly bilaterally or unilaterally cryptorchid compared with a group of matched control men.

DESIGN

Retrospective cohort study.

SETTING

Human volunteers in an academic research environment.

PATIENT(S)

Men who underwent orchidopexy between 1955 and 1971 at the Children's Hospital of Pittsburgh (n = 547) and a group of matched control men (n = 463) were surveyed by questionnaire.

RESULT(S)

Of the men who attempted paternity, the mean time to conception for the bilateral cases, unilateral cases, and control men was 33.90, 11.11, and 8.78 months, respectively. Kaplan-Meier survival analysis showed a significantly longer time to conception among bilateral cases compared with unilateral cases and controls, but not between unilateral cases and control men. Adjustment for confounders and covariates using a Cox Proportional Hazards model showed that former bilaterally cryptorchid men were 68% (95% CI = 55% to 81%) less likely than former unilaterally cryptorchid men or controls to conceive per month of unprotected intercourse.

CONCLUSION(S)

Time to conception was increased among former bilaterally cryptorchid men compared with both former unilaterally cryptorchid and control men. However, there were no significant differences in time to conception between the unilateral cryptorchid men and the control men.

Fertility prognosis for infertile couples

OBJECTIVE

To develop a fertility prognosis model for infertile couples.

DESIGN

Prospective follow-up study.

PARTICIPANTS

In the period November 30, 1977 to June 1, 1985, 321 consecutive couples were investigated for infertility at Hvidovre University Hospital. Investigation of the female included detection of ovarian, cervical, and anatomic disorders, whereas in the male semen analysis and sperm penetration test (P-test) were performed. Altogether, 108 couples (34%) conceived, whereas 213 (66%) were observed for an average of 2.3 years without having achieved pregnancy.

MAIN OUTCOME MEASURE

The Cox regression model was used to predict the time required to conceive based on informations provided by fertility investigations.

RESULTS

Three of 16 prognostic variables (the period of infertility, the female infertility factor, and the P-test) possess significant prognostic information. The period of infertility and the P-test are best scored as continuous variables, whereas the female infertility factor are best categorized in four classes, i.e., normal, ovulation or cervical disorder, anatomic disorder, or a combination of disorders.

CONCLUSIONS

The three prognostic variables are combined to form a prognostic index that predicts the fecundability of the individual infertile couple.

Tests of human sperm function and fertilization in vitro

OBJECTIVE

To review recent studies on the development of new tests of human sperm function and evaluation of which sperm characteristics are most important for fertilization in vitro by logistic regression analysis.

STUDY SELECTION

Recent studies on the relationship between putative and new tests of human sperm function and fertility in vitro or in vivo are discussed in this review. Some physiological and technical aspects are included.

MAIN OUTCOME MEASURES

Fertilization rates in vitro and sperm tests including standard semen analysis, improved morphology assessment, objective assessment of sperm motility and movement characteristics, nuclear maturity, hypo-osmotic swelling, the acrosome and the acrosome reaction, acrosin activity, human sperm-hamster oocyte penetration assay, and sperm-zona pellucida (ZP) and sperm-oolemma binding.

RESULTS

The percentages of sperm with normal morphology and a normal intact acrosome, mean linearity, and the number of sperm binding to the ZP were highly significant related to fertilization rates in vitro. Other sperm tests evaluated usually provided no additional information about fertilization rates. The human ZP is highly selective for binding of morphologically normal sperm. Acrosome-reacted human sperm have little or no ability to bind to the ZP.

CONCLUSION

Results of in vitro fertilization can be used to evaluate tests of human sperm function. Logistic regression analysis is a powerful method for determining which groups of sperm characteristics are independently related to fertilization rates. Normal morphology, linearity, acrosome status, and sperm-ZP binding are the most important characteristics for fertilization in vitro.

Fertility prognosis for infertile men: results of follow-up study of semen analysis in infertile men from two different populations evaluated by the Cox regression model

Using the Cox proportional hazard regression model on one material (group I = 765, 1950 to 1951) we have identified four variables of semen analysis with significant prognostic information about fertility. The four variables were combined into a model for establishing the probability of the individual male to achieve pregnancy as a function of time. This model is tested first on another material (group II = 321, 1977 to 1985). A Goodness-of-fit test indicates excellent agreement between the expectations from the model and the observed number of pregnancies in group II. Second, the two groups are pooled (= 1,086). Then only three variables give significant prognostic information about the time until pregnancy: (1) the man's age at semen analysis (years); (2) the percentage of morphologically normal spermatozoa (ln %); and (3) the degree of motility (good/poor). These three important variables enter into a new and better prognostic model.

Do the results of semen analysis predict future fertility? A survival analysis study

The authors examined the results of the initial semen analysis from 1089 couples in an infertility clinic. The distributions of the values for various semen variables among couples who remained infertile were very similar to those among couples who later conceived. A cutoff point was selected in each pair of distributions to compare the cumulative probability of conception for couples with higher and lower results. The authors took into account the varying times to conception or loss to follow-up by using life table analysis. No statistically significant differences were found at the P = 0.05 level of significance. Cox's univariate and multiple regression models were then used to investigate the relationship between various semen characteristics and future fertility. Finding no significant influence of any semen characteristic on the cumulative probability of conception, the authors believe that using specific values of the semen analysis to estimate the potential for fertility of infertile couples is not useful.

The better prognosis in secondary infertility is associated with a higher proportion of ovulation disorders

To determine the reason for the higher pregnancy rate in couples with secondary infertility, the authors compared 237 infertile couples who had a previous pregnancy in the current partnership (secondary infertility) with 135 infertile couples in whom the woman had been pregnant only in a previous partnership and 925 couples with primary infertility. Couples with secondary infertility had the highest proportion of ovulation disorders (36%); these couples with secondary infertility and an ovulation disorder had the shortest duration of infertility (26 months). Cumulative pregnancy rates at 36 months were 56% in secondary fertility, 44% in primary infertility, and 42% in pregnancy in a previous partnership (P = 0.001). In this study, the better prognosis in secondary infertility may be related to the higher proportion of couples with ovulation disorders, who had a shorter duration of infertility. Abortion rates in the earlier pregnancies with current or previous partners were 37% and 30%, respectively; after the period of infertility, the abortion rates were 14% and 12%, respectively.