Life table analysis of intrauterine insemination pregnancy rates

Stimulated intrauterine insemination (SIUI) and donor insemination (DI) as first line management for a selected subfertile population: the Manchester experience

PURPOSE

The objective of our study is to investigate the optimum number of stimulated intrauterine insemination (SIUI) or donor insemination (DI) cycles that can be offered to the couples prior to in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) in a tertiary referral unit for assisted reproduction.

METHODS

This is a retrospective analysis of 408 SIUI and 704 DI cycles performed in a tertiary referral unit for assisted reproduction. SIUI's were performed by controlled ovarian hyperstimulation and ovulation induction followed by insemination 36 h later. DI's were performed in natural or stimulated cycles after thawing frozen donor sperm. The main outcome measured was cumulative live birth rate (CLBR) per couple.

RESULTS

A maximum CLBR of 26.1% was achieved after the fourth cycle of SIUI. The CLBR of DI increased to 60.1% in the sixth cycle.

CONCLUSIONS

This study, in line with a number of other studies, is unable to demonstrate unequivocally whether increasing numbers of IUI or DI cycles are justified clinically or financially. There is a need for larger datasets from multiple centres along with rigorous randomised trials to compare treatment pathways. Until then, the resources spent on the provision of extra SIUI cycles may be better utilized by early referral to IVF.

Management of male infertility by assisted reproductive technologies

Among the most popular techniques of assisted reproduction for the treatment of male subfertility and infertility are intrauterine insemination, in vitro fertilization and intracytoplasmic sperm injection. The objective of these techniques is to bring more functional spermatozoa closer to the oocyte in order to promote fertilization. These techniques are thus not a cure per se and are only indicated when no specific or effective treatment is available for the male partner, when this treatment has failed or when the improvement of the female fertility status has also failed. While for moderate oligoasthenozoospermia, intrauterine insemination has proved to be a valid treatment, the outcome after conventional in vitro fertilization is limited because of a high incidence of complete fertilization failure. Since the introduction of intracytoplasmic sperm injection, a reliable method has become available in order to achieve fertilization in vitro. Apart from well from ejaculated spermatozoa, epididymal or testicular spermatozoa too can be used successfully for intracytoplasmic sperm injection. The surgical retrieval of spermatozoa for intracytoplasmic sperm injection has therefore become a routine technique in clinical andrology. Although these techniques have been implemented in everyday infertility practice within a few years of their introduction, many concerns about safety continue to exist. Intracytoplasmic sperm injection must be applied with caution, only when no other treatment option is available and when an appropriate prospective follow-up of the offspring is available.

Evaluation of pregnancy rates after intrauterine insemination according to indication, age, and sperm parameters

PURPOSE

Our purpose was to evaluate intrauterine insemination results obtained in our clinic and identify prognostic factors for the chance of pregnancy.

METHODS

A retrospective study of data from 1989 to 1996 was undertaken. Only first attempts were included in this study, except for the part on the cumulative pregnancy rates. Couples with either one-sided tubapathology, hormonal dysfunction, idiopathic infertility, or andrological indication were selected. All women were stimulated with clomiphene citrate. Five hundred sixty-six couples who underwent 1763 cycles were included in the study.

RESULTS

The overall pregnancy rate for first pregnancies was 6.9% per cycle and 21.4% per patient. For first intrauterine insemination attempts this was 8.8% per cycle/patient, varying between 5.0% for andrological indication and 10.6% for tubapathology, 10.0% for idiopatic indication, and 10.3% for hormonal indication. These differences were not significant. Age did not have a significant effect either, although there were no pregnancies observed in women 40 years or older. The number of inseminated spermatozoa significantly affected the pregnancy rate: < 2 million, 4.6%; > or = 2 to < 10 million, 3.9%; and > or = 10 million, 11.3%.

CONCLUSIONS

Unless semen characteristics are insufficient, intrauterine insemination is a useful treatment for infertile couples.

The impact of the total motile sperm count on the success of intrauterine insemination with husband's spermatozoa

PURPOSE

The purpose of this study was to evaluate the relationship between the total motile sperm count and the success of IUI treatment cycles with postwashed husband spermatozoa in couples with infertility in a large patient population.

PATIENTS

When 939 couples underwent 1375 cycles of IUI with varying etiologies of infertility which included male factor, endometriosis, tubal factor, ovulatory dysfunction, uterine factor, cervical factor, and unexplained infertility, the results were 207 pregnancies.

RESULTS

The overall pregnancy rate per cycle was 15.1% (207/1375). The total motile sperm count were significantly increased in the pregnant group than the nonpregnant group (38.7 x 10(6) versus 28.6 x 10(6); P < 0.001). There was a trend toward an increased success rate with increased total motile sperm count. Significance was reached when the total motile sperm count exceeded 5 x 10(6). Life table analysis was performed and the curve representing a cumulative chance of pregnancy calculated from our data reached 72%.

CONCLUSIONS

Our findings suggest that a final postwashed total motile sperm count used for IUI may be considered predictive of the success for pregnancy and allow couples to be informed of the chances of success.

Comparison between a two-layer discontinuous Percoll gradient and swim-up for sperm preparation on normal and abnormal semen samples

PURPOSE

This work was to compare the effects of Percoll gradient and swim-up treatments for sperm preparation on the percentage of progressive motility, recovery of motile sperm, removal of debris, percentage of normal forms according to strict criteria, and movement characteristics of sperm using computer-assisted velocity analysis.

RESULTS

In total, 50 semen samples from 50 patients were tested and divided into two groups: a normal group (n = 27) with normal parameters and an abnormal group (n = 23) with abnormal parameters. The results in both the normal and abnormal groups revealed that the sperm concentration in the Percoll samples was significantly greater than that in the swim-up samples. Although the percentage of progressive motility was greater in the swim-up samples than in the Percoll samples, the number of motile sperm, reflecting the percentage of motile sperm recovery, was till greater in the Percoll samples. The debris of semen was equally removed by both methods and the percentage of normal forms was also similar in the samples treated according to these two procedures. Both curvilinear velocity (VCL) and straight-line velocity (VSL) of sperm were significantly greater in the swim-up samples than in the Percoll samples. Sperm from the swim-up procedure also showed a greater mean amplitude of lateral head displacement than that from the Percoll gradient procedure, but the distinction was insignificant.

CONCLUSION

The Percoll gradient technique, by recovering more motile sperm, may be applied to prepare oligospermic samples. The swim-up method may become the standard choice to prepare normal semen which could obtain sufficiently motile sperm, due to its simplicity and recovered sperm with superior motility.

Intrauterine insemination with frozen donor sperm: a prospective randomized trial comparing three different sperm preparation techniques

OBJECTIVE

To compare the pregnancy rates (PRs) after intrauterine insemination (IUI) with frozen-thawed donor sperm. Sperm were isolated after thawing using three different sperm preparation techniques: simple washing, Percoll density gradient, and Sephadex columns (SpermPrep Column; Fertility Technologies, Natick, MA).

DESIGN

Women (n = 98) were randomized upon entry into the program into one of three different sperm preparation methods. The same sperm preparation technique was used for the woman during subsequent cycles, if pregnancy did not occur. The study was stopped when > or = 75 treatment cycles for each group were completed for analysis of PRs per treatment cycle.

SETTING

All patients were treated at our private care center at the University of Texas Southwestern Medical Center.

PATIENTS

Patients entering this study were spontaneously ovulating women undergoing IUI with frozen donor sperm.

MAIN OUTCOME MEASURE

Pregnancy rate per cycle of timed IUI.

RESULTS

After 260 cycles of insemination, the PR per cycle was 19.1% with simple washing, 16.9% with Sephadex columns, and 11.4% with Percoll density gradient. Although these results were not statistically different, Percoll density gradient had a 40% lower PR per treatment cycle compared with simple washing. However, Percoll density gradient preparation of sperm resulted in a statistically significant increase in the motility, curvilinear velocity, straight line velocity, and the number of normal heads compared with the other two treatments.

CONCLUSION

Although Percoll density gradient separation of sperm results in a population of cells that is more motile and morphologically normal, this did not result in subsequent cycle fecundity. These data suggest that the reliance on the averaged values of motility, curvilinear velocity, straight line velocity and morphology may have little predictive value of the potential fertility of frozen-thawed sperm.

Intrauterine insemination with husband's sperm: comparison of pregnancy rates in couples with cervical factor, male factor, immunological factor and idiopathic infertility

Intrauterine insemination with husband's sperm (IUI) is offered to couples with infertility due to various causes although there is no general agreement on which of these causes should be so treated. In this report 77 couples were diagnosed as having either cervical factor, male factor, immunological factor or unexplained infertility. Insemination was performed 24-32 hours after a rapid rise in the serum LH level. Two of 16 pregnancies which resulted miscarried, 1 was ectopic and the remainder were full term. Eleven occurred in the cervical factor group, 3 in the immunological factor and only 1 in each of the male factor and unexplained infertility groups. The differences in the number of pregnancies between the cervical factor and male and unexplained infertility groups are significant but not between the groups with cervical and immunological factors. The majority of pregnancies (81%) were achieved in the first 4 cycles. Patients with the cervical factor as the cause of their subfertility are likely to benefit from the IUI with their husband's sperm. The small number of patients with the immunological factor in this study does not allow for a conclusion. In our experience the male factor and unexplained infertility patients are unlikely to benefit from intrauterine insemination with husband's sperm.

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.

Intrauterine insemination with semen of oligozoospermic men: effectiveness of the continuous-step density gradient centrifugation technique

There has been an argument as to whether the intrauterine insemination (IUI) substantially improves pregnancy rate in cases of oligoasthenozoospermia. The present study evaluates the efficiency of the IUI with the use of the life table analysis. The insemination was performed after washing and concentrating sperm using the continuous-step density gradient centrifugation reported in our previous papers. The number of IUI cycles studied was 222 (46 couples), in 13 cases of which pregnancy was established with a pregnancy rate of 28.3%. The cumulative probability of conception reached to 57% at the eleventh cycles of the IUI treatment. These results suggest that the potential efficiency of the IUI for the oligo-asthenozoospermic cases is high if the sperm is processed in a proper method.

A comparative analysis of the cycle fecundity rates associated with combined human menopausal gonadotropin (hMG) and intrauterine insemination (IUI) versus either hMG or IUI alone

Human menopausal gonadotropin (hMG) superovulation combined with washed intrauterine insemination (IUI) has been advocated for the treatment of various forms of infertility when more traditional therapy has failed. To assess the relative efficacy of combined treatment with hMG and IUI compared with either hMG or IUI alone, pregnancy outcomes of the three treatment groups were compared in couples having infertility because of male factor, cervical factor, endometriosis, or unexplained. A total of 751 cycles were analyzed from 322 couples. The mean cycle fecundity rate associated with hMG/IUI therapy was significantly higher than either hMG or IUI therapy alone for all patients (hMG/IUI = 19.6%, hMG = 6.3%, IUI = 3.4%). The improvement in cycle fecundity rates with hMG/IUI therapy was also observed when the couples were separated by infertility diagnostic groups: male factor (hMG/IUI = 15.3%, hMG = 4.4%, IUI = 3.0%), cervical factor (hMG/IUI = 26.3%, hMG = 7.9%, IUI = 5.1%), endometriosis (hMG/IUI = 12.85%, hMG = 6.6%), and unexplained infertility (hMG/IUI = 32.6%, hMG = 5.5%, IUI = 0%). Moreover, in patients who had failed to conceive with hMG or IUI alone, the cycle fecundity rate when they were switched to hMG/IUI therapy equaled that of patients who received combined therapy from the onset. We conclude that cycle fecundity rates and cumulative pregnancy rates are significantly greater using a combination of hMG and IUI compared with either modality alone in the treatment of male factor, cervical factor, endometriosis, or unexplained infertility. Indeed, in couples with nontubal related infertility, cycle fecundity rates with hMG/IUI approach the rates seen with in vitro fertilization and gamete intrafallopian tube transfer.

Home urinary luteinizing hormone immunoassays: clinical applications

Home ovulation prediction kits represent a valuable advance in monoclonal antibody technology and offer patients a quick, reliable, and relatively inexpensive means to predict the day of ovulation. These kits are used widely by patients trying to conceive and are commonly recommended by physicians involved in the care of infertile couples. They provide a more accurate and practical means to prospectively predict the time of ovulation than do BBT graphs or cervical mucus exams, and can be used as presumptive evidence of ovulation. Whereas ovulation prediction kits appear to be most useful for couples in timing sexual intercourse, other possible uses exist, including timing of AI, the PCT, and the endometrial biopsy for luteal phase evaluation. Despite multiple potential applications, clinical studies which support the use of urinary LH immunoassays in the evaluation and treatment of the infertile couple are quite limited. More well-designed studies to define the clinical value of ovulation prediction kits need to be undertaken.

Improved semen qualities after continuous-step density gradient centrifugation: application to artificial insemination and pregnancy outcome

For increasing sperm fertilizability in artificial insemination, it is effective to concentrate progressively motile sperm from whole ejaculate. We developed the continuous-step density gradient for the selective concentration of progressively motile sperm. The present procedure was applied to intrauterine artificial insemination. Infertile couples (n = 152) whose diagnoses involved oligoasthenospermia, cervical factor, and unexplained infertility were selected for artificial insemination with washed and concentrated sperm. Successful pregnancies (47) were obtained, with an overall pregnancy rate of 31% in the program. Sperm processing by this procedure improved pregnancy rates in couples with the sole diagnosis of oligoasthenospermia or cervical factor. In the patients in whom other fertility problems coexisted, however, it was essential to treat female fertility problems. Continuous-step density gradient centrifugation is effective in increasing the pregnancy rate in artificial insemination.

Therapeutic intrauterine insemination (TII)--controversial treatment for infertility

The literature on therapeutic intrauterine insemination (TII) is confused because of lack of homogeneity in case selection, differences in executing the procedural steps, and the manner of evaluating and reporting results. This review compares results from Norfolk with those in the English literature. Special emphasis has been placed on separately analyzing each step of the procedure and presenting results of different authors in a comparable fashion. Including all etiologic factors and types of cycles, the term pregnancy rate per cycle was 3% for Norfolk, 2.6% to 6.2% elsewhere. Patients receiving TII in stimulated cycles did significantly better than those receiving TII in natural cycles, in terms of total pregnancy rate per cycle (p = 0.002). In male factor infertility, term pregnancy rate per cycle was 1.1% in Norfolk, 4.7% to 6.2% elsewhere (perhaps because of stricter criteria in Norfolk). In cervical factor infertility, term pregnancy rate per cycle was 4.5% in Norfolk, 2.7% to 11% for others. For unexplained infertility, Norfolk had 5.8% term pregnancy rate per cycle for natural cycles, 8.3% for stimulated cycles. Best published prospective results were 23% for stimulated cycles. TII seems to have a very low efficiency rate judging from term pregnancy rates per cycle. There are clear data indicating the need for redefining the indications.

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

Superovulation with intrauterine insemination (SO-IUI) has been suggested as an alternative to gamete intrafallopian transfer (GIFT), despite the absence of controlled or comparative trials. We retrospectively analyzed all GIFT and SO-IUI cycles performed concurrently from January 1985 to August of 1987 at a single university center. Pregnancy rates were significantly better for GIFT than SO-IUI (P less than 0.001), with an odds ratio of 3.25 (P = 0.001). Stepwise multiple logistic regression identified factors that correlate with pregnancy: absence of endometriosis (P = 0.05), infertility less than 3 years' duration (P = 0.002), TMS greater than or equal to 30 X 10(6) (P = 0.005), and treatment with GIFT rather than SO-IUI (P = 0.001). These data give a first approximation of the increased efficacy of GIFT versus SO-IUI and provide valuable insight into significant confounding variables to be considered when planning a randomized, prospective trial to evaluate these techniques.