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Esposito G, Parazzini F, Viganò P, Cantarutti A, Franchi M, Corrao G, La Vecchia C, Somigliana E. Multiple births from medically assisted reproduction: contribution of different types of procedures and trends over time. Eur J Obstet Gynecol Reprod Biol 2024; 300:63-68. [PMID: 38996806 DOI: 10.1016/j.ejogrb.2024.07.004] [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: 04/04/2024] [Revised: 06/13/2024] [Accepted: 07/02/2024] [Indexed: 07/14/2024]
Abstract
OBJECTIVE To evaluate the relative impact of different strategies of medically assisted reproduction (MAR), i.e. first line treatment (ovarian stimulation with or without intrauterine insemination) and in vitro fertilization (IVF) procedures (conventional IVF or intracytoplasmic sperm injection), on the risk of multiple births. STUDY DESIGN We utilized the health care utilization databases of the Lombardy region to identify births resulting from MAR between 2007 and 2022. We gathered data on the total number of multiple births and calculated the prevalence rate by dividing the number of multiples by the total number of births. To examine the temporal trend in the proportion of multiple births after MAR over time, a linear regression model was employed separately for different types of techniques and in strata of maternal age. RESULTS A total of 30,900 births after MAR were included; 4485 (14.5 %) first line treatments and 26,415 (85.5 %) IVF techniques. Overall, 4823 (15.6 %) multiple births were identified. The frequency of multiple births over the study period decreased from 22.0 % in 2007 to 8.7 % in 2022 (p < 0.01). Multiple births from first line treatments were stable ranging from 13.5 % in 2007-2008 to 12.0 % in 2021-2022 (p = 0.29). Multiple births from IVF procedures decreased from 23.8 % in 2007-2008 to 8.4 % in 2021-2022 (p < 0.01). Stratifying for maternal age (i.e. < 35 and ≥ 35 years), the trends remained consistent. CONCLUSIONS The reduction in multiple births has been influenced by changes in IVF strategy and procedures. The decline has been gradual but steady since 2009, when a law restricting embryo freezing was repealed in Italy. In contrast, the proportion of multiple births resulting from first line treatments has remained constant over time. Despite declining, multiple births from MAR remained about one order of magnitude higher than those from spontaneous pregnancies.
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Affiliation(s)
- Giovanna Esposito
- Department of Clinical Sciences and Community Health, Dipartimento di Eccellenza 2023-2027, University of Milan, Milan, Italy.
| | - Fabio Parazzini
- Department of Clinical Sciences and Community Health, Dipartimento di Eccellenza 2023-2027, University of Milan, Milan, Italy
| | - Paola Viganò
- Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Anna Cantarutti
- Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy; National Centre for Healthcare Research and Pharmacoepidemiology, Milan, Italy
| | - Matteo Franchi
- Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy; National Centre for Healthcare Research and Pharmacoepidemiology, Milan, Italy
| | - Giovanni Corrao
- Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy; National Centre for Healthcare Research and Pharmacoepidemiology, Milan, Italy
| | - Carlo La Vecchia
- Department of Clinical Sciences and Community Health, Dipartimento di Eccellenza 2023-2027, University of Milan, Milan, Italy
| | - Edgardo Somigliana
- Department of Clinical Sciences and Community Health, Dipartimento di Eccellenza 2023-2027, University of Milan, Milan, Italy; Infertility Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Berdin A, Bellaïche K, El Hachem H, Vielle B, Legendre G, Descamps P, May-Panloup P, Prevost S, Bouet PE. Comparison of two cancellation strategies to lower the risk of multiple pregnancies in gonadotropin stimulated intrauterine insemination cycles. Int J Gynaecol Obstet 2024; 166:692-698. [PMID: 38425230 DOI: 10.1002/ijgo.15449] [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: 10/05/2023] [Revised: 01/09/2024] [Accepted: 02/12/2024] [Indexed: 03/02/2024]
Abstract
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.
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Affiliation(s)
- Aurélie Berdin
- Department of Reproductive Medicine, Besançon University Hospital, Besançon, France
| | - Kevin Bellaïche
- Department of Reproductive Medicine, Angers University Hospital, Angers, France
| | - Hady El Hachem
- Department of Obstetrics and Gynecology, Lebanese American University Medical Center, Beirut, Lebanon
| | - Bruno Vielle
- Clinical Research Center, Angers University Hospital, Angers, France
| | - Guillaume Legendre
- Department of Reproductive Medicine, Angers University Hospital, Angers, France
| | - Philippe Descamps
- Department of Reproductive Medicine, Angers University Hospital, Angers, France
| | - Pascale May-Panloup
- Department of Reproductive Medicine, Angers University Hospital, Angers, France
| | - Sarah Prevost
- Department of Reproductive Medicine, Besançon University Hospital, Besançon, France
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The role of peak serum estradiol level in the prevention of multiple pregnancies in gonadotropin stimulated intrauterine insemination cycles. Sci Rep 2022; 12:19554. [PMID: 36379965 PMCID: PMC9666543 DOI: 10.1038/s41598-022-23470-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 11/01/2022] [Indexed: 11/16/2022] Open
Abstract
The objective was to assess whether the measurement of serum estradiol (E2) level on trigger day in controlled ovarian stimulation with intrauterine insemination (COS-IUI) cycles helps lower the multiple pregnancy (MP) rate. We performed a unicentric observational study. We included all patients who underwent COS-IUI and had a subsequent clinical pregnancy (CP) between 2011 and 2019. Our main outcome measure was the area under Receiver-Operating Characteristic (ROC) curve. We included 455 clinical pregnancies (CP) obtained from 3387 COS-IUI cycles: 418 singletons, 35 twins, and 2 triplets. The CP, MP, and live birth rates were respectively 13.4%, 8.1% and 10.8%. The area under ROC curve for peak serum E2 was 0.60 (0.52-0.69). The mean E2 level was comparable between singletons and MP (260.1 ± 156.1 pg/mL vs. 293.0 ± 133.4 pg/mL, p = 0.21, respectively). Univariate and multivariate logistic regression analysis showed that E2 level was not predictive of MP rate (aOR: 1.13 (0.93-1.37) and 1.06 (0.85-1.32), respectively). Our study shows that, when strict cancelation criteria based on the woman's age and follicular response on ultrasound are applied, the measurement of peak serum E2 levels does not help reduce the risk of MP in COS-IUI cycles.
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Maternal, Perinatal and Neonatal Outcomes of Triplet Pregnancies According to Chorionicity: A Systematic Review of the Literature and Meta-Analysis. J Clin Med 2022; 11:jcm11071871. [PMID: 35407479 PMCID: PMC8999732 DOI: 10.3390/jcm11071871] [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: 03/07/2022] [Revised: 03/18/2022] [Accepted: 03/21/2022] [Indexed: 11/17/2022] Open
Abstract
Triplet pregnancies are rare events that affect approximately 93 in 100,000 deliveries in the world, especially due to the increased use of assisted reproductive techniques and older maternal age. Triplet pregnancies are associated with a higher risk of fetal and maternal morbidity and mortality compared to twins and singletons. Chorionicity has been proposed as a major determinant of perinatal and maternal outcomes in triplet pregnancies, although further evidence is needed to clarify the extent and real influence of this factor. Thus, the aim of this study was to conduct a systematic review of the literature and a meta-analysis of the maternal and perinatal outcomes of triplet pregnancies, evaluating how chorionicity may influence these results. A total of 46 studies with 43,653 triplet pregnancies and 128,145 live births were included. Among the main results of our study, we found a broad spectrum of fetal and maternal complications, especially in the group of monochorionic and dichorionic pregnancies. Risk of admission to NICU, respiratory distress, sepsis, necrotizing enterocolitis, perinatal and intrauterine mortality were all found to be higher in non-TCTA pregnancies than in TCTA pregnancies. To date, our meta-analysis includes the largest population sample and number of studies conducted in this field, evaluating a wide variety of outcome measures. The heterogeneity and retrospective design of the studies included in our research represent the main limitations of this review. More evidence is needed to fully assess outcome measures that could not be studied in this review due to scarcity of publications or insufficient sample size.
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Multiple gestation associated with infertility therapy: a committee opinion. Fertil Steril 2022; 117:498-511. [PMID: 35115166 DOI: 10.1016/j.fertnstert.2021.12.016] [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: 12/10/2021] [Accepted: 12/15/2021] [Indexed: 11/19/2022]
Abstract
This Committee Opinion provides practitioners with suggestions to reduce the likelihood of iatrogenic multiple gestation resulting from infertility treatment. This document replaces the document of the same name previously published in 2012 (Fertil Steril 2012;97:825-34 by the American Society for Reproductive Medicine).
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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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Lee J, Hwang S, Lee J, Yoo J, Jang D, Hwang K, Kim M. Effect of insemination timing on pregnancy outcome in association with female age, sperm motility, sperm morphology and sperm concentration in intrauterine insemination. J Obstet Gynaecol Res 2018; 44:1100-1106. [PMID: 29673000 DOI: 10.1111/jog.13625] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 02/05/2018] [Indexed: 12/01/2022]
Abstract
AIM We investigated the effect of insemination timing on pregnancy outcomes in intrauterine insemination (IUI) cycles. METHODS This is a retrospective study of 411 IUI cycles performed with a diagnosis of unexplained infertility and male factor infertility. The cycles were divided according to the interval between insemination and ovulation: ≤36 h, 36-37 h, 37-38 h and >38 h. The overall pregnancy rate, chemical pregnancy rate and clinical pregnancy rate were compared. We also analyzed the association between pregnancy outcomes and clinical characteristics, including age, duration of infertility, sperm concentration, body mass index (BMI), anti-Müllerian hormone (AMH) and number of mature follicles at ovulation. RESULTS There were no differences regarding age, duration of infertility, BMI, AMH, sperm concentration and number of mature follicles between different IUI timing groups. Sperm morphology was significantly lower in ≤36 h group (5.3 ± 1.4) compared to 36-37 h, 37-38 h and >38 h (6.3 ± 2.5 vs 6.5 ± 2.7 vs 6.5 ± 3.5, P = 0.004) groups. The ≤36 h group showed lowest total pregnancy rate (5.0%) compared to other IUI timings (21.8% vs 24.8% vs 20.0%, P = 0.05). Multivariate analysis showed that sperm morphology was associated with pregnancy in 36-37 h (odd ratio 1.42, 95% confidence interval 1.03-1.95, P = 0.02). CONCLUSION Insemination at least 36 h after ovulation is associated with increased pregnancy rate compared to IUIs performed ≤36 h following ovulation.
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Affiliation(s)
- Jisun Lee
- Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, Korea
| | - Suna Hwang
- Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, Korea
| | - Jaehun Lee
- Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, Korea
| | - Junghyun Yoo
- Department of Obstetrics and Gynecology, Bundang Jesaeng General Hospital, Bungdang-gu, Korea
| | - Dongmin Jang
- Department of Biological Science, Graduate School of Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Kyungjoo Hwang
- Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, Korea
| | - Miran Kim
- Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, Korea
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Veltman-Verhulst SM, Hughes E, Ayeleke RO, Cohlen BJ. Intra-uterine insemination for unexplained subfertility. Cochrane Database Syst Rev 2016; 2:CD001838. [PMID: 26892070 DOI: 10.1002/14651858.cd001838.pub5] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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 thAppendixan 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 rate. This is an update of a Cochrane review (Veltman-Verhulst 2012) originally published in 2006 and updated in 2012. OBJECTIVES To determine whether, for couples with unexplained subfertility, IUI improves the live birth rate compared with timed intercourse (TI), or expectant management, both with and without ovarian hyperstimulation (OH). SEARCH METHODS We searched the Cochrane Gynaecology and Fertility (formerly Cochrane Menstrual Disorders and Subfertility Group) Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, inception to Issue 11, 2015), Ovid MEDLINE, Ovid EMBASE, PsycINFO and trial registers, all from inception to December 2015 and reference lists of articles. Authors of identified studies were contacted for missing or unpublished data. The evidence is current to December 2015. SELECTION CRITERIA Truly randomised controlled trial (RCT) comparisons of IUI versus TI, in natural or stimulated cycles. Only couples with unexplained subfertility were included. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, quality assessment and data extraction. We extracted outcomes, and pooled data and, where possible, we carried out subgroup and sensitivity analyses. MAIN RESULTS We included 14 trials including 1867 women. IUI versus TI or expectant management both in natural cycleLive birth rate (all cycles)There was no evidence of a difference in cumulative live births between the two groups (Odds Ratio (OR) 1.60, 95% confidence interval (CI) 0.92 to 2.78; 1 RCT; n = 334; moderate quality evidence). The evidence suggested that if the chance of a live birth in TI was assumed to be 16%, that of IUI would be between 15% and 34%.Multiple pregnancy rateThere was no evidence of a difference in multiple pregnancy rate between the two treatment groups (OR 0.50, 95% CI 0.04 to 5.53; 1 RCT; n = 334; moderate quality evidence). IUI versus TI or expectant management both in stimulated cycleLive birth rate (all cycles)There was no evidence of a difference between the two treatment groups (OR 1.59, 95% CI 0.88 to 2.88; 2 RCTs; n = 208; I(2) = 72%; moderate quality evidence). The evidence suggested that if the chance of achieving a live birth in TI was assumed to be 26%, the chance of a live birth with IUI would be between 23% and 50%.Multiple pregnancy rateThere was no evidence of a difference in multiple pregnancy rates between the two treatment groups (OR 1.46, 95% CI 0.55 to 3.87; 4 RCTs, n = 316; I(2) = 0%; low quality evidence). IUI in a natural cycle versus IUI in a stimulated cycle Live birth rate (all cycles)An increase in live birth rate was found for women who were treated with IUI in a stimulated cycle compared with those who underwent IUI in natural cycle (OR 0.48, 95% CI 0.29 to 0.82; 4 RCTs, n = 396; I(2) = 0%; moderate quality evidence). The evidence suggested that if the chance of a live birth in IUI in a stimulated cycle was assumed to be 25%, the chance of a live birth in IUI in a natural cycle would be between 9% and 21%.Multiple pregnancy rateThere was no evidence of a difference in multiple pregnancy rate between the two treatment groups (OR 0.33, 95% CI 0.01 to 8.70; 2 RCTs; n = 65; low quality evidence). IUI in a stimulated cycle versus TI or expectant management in a natural cycleLive birth rate (all cycles)There was no evidence of a difference in live birth rate between the two treatment groups (OR 0.82, 95% CI 0.45 to 1.49; 1 RCT; n = 253; moderate quality evidence). The evidence suggested that if the chance of a live birth in TI or expectant management in a natural cycle was assumed to be 24%, the chance of a live birth in IUI in a stimulated cycle would be between 12% and 32%.Multiple pregnancy rateThere was no evidence of a difference in multiple pregnancy rate between the two treatment groups (OR 2.00, 95% CI 0.18 to 22.34; 2 RCTs; n = 304; moderate quality evidence). IUI in natural cycle versus TI or expectant management in stimulated cycle Live birth rate (all cycles)There was evidence of an increase in live births for IUI (OR 1.95, 95% CI 1.10 to 3.44; 1 RCT, n = 342; moderate quality evidence). The evidence suggested that if the chance of a live birth in TI in a stimulated cycle was assumed to be 13%, the chance of a live birth in IUI in a natural cycle would be between 14% and 34%.Multiple pregnancy rateThere was no evidence of a difference in multiple pregnancy rate between the groups (OR 1.05, 95% CI 0.07 to 16.90; 1 RCT; n = 342; moderate quality evidence).The quality of the evidence was assessed using GRADE methods. Quality ranged from low to moderate, the main limitation being imprecision in the findings for both live birth and multiple pregnancy.. AUTHORS' CONCLUSIONS This systematic review did not find conclusive evidence of a difference in live birth or multiple pregnancy in most of the comparisons for couples with unexplained subfertility treated with intra-uterine insemination (IUI) when compared with timed intercourse (TI), both with and without ovarian hyperstimulation (OH). There were insufficient studies to allow for pooling of data on the important outcome measures for each of the comparisons.
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Affiliation(s)
- Susanne M Veltman-Verhulst
- University Medical Center Utrecht, Department of Reproductive Medicine and Gynecology, Room F5.126, PO Box 85500,, Utrecht, Netherlands, 3508 GA
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Association between ovarian stimulators with or without intrauterine insemination, and assisted reproductive technologies on multiple births. Am J Obstet Gynecol 2015; 213:511.e1-511.e14. [PMID: 26079626 DOI: 10.1016/j.ajog.2015.06.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 05/10/2015] [Accepted: 06/10/2015] [Indexed: 11/21/2022]
Abstract
OBJECTIVE We sought to quantify the risk of multiple births associated with the use of different modalities of medically assisted reproduction. STUDY DESIGN We conducted a case-control study using a birth cohort from 2006 through 2009. This cohort was built with the linkage of data obtained by a self-administered questionnaire and medical, hospital, pharmaceutical, birth, and death databases in Quebec. Cases were pregnancies resulting in multiple live births (International Classification of Diseases, Ninth Revision/International Statistical Classification of Diseases, 10th Revision codes). Each case was matched, on maternal age and year of delivery, with 3 singleton pregnancies (controls) randomly selected among all Quebec singleton pregnancies. Data on the use of different fertility treatments were collected by a self-administered questionnaire. Multiple logistic regression models, adjusted for body mass index, number of previous live births, ethnicity, family income, place of residence, marital status, subfertility, reduction of embryos, diabetes, metformin treatment, folic acid supplementation, and lifestyle factors, were used to calculate the odds ratios (ORs) and confidence intervals (CIs). We evaluated the associations between each type of fertility treatment (ovarian stimulators used alone, intrauterine insemination [IUI] used with ovarian stimulation, and assisted reproductive technologies [ART]) and the risk of multiple births. RESULTS A total of 1407 cases of multiple births and 3580 controls were analyzed. More than half of multiple births following medically assisted reproduction (53.6%) occurred among women having used ovarian stimulation with or without IUI. The use of ovarian stimulators alone and IUI with ovarian stimulation increase the risk of multiple births (adjusted OR, 4.5; 95% CI, 3.2-6.4; and adjusted OR, 9.32; 95% CI, 5.60-15.50, respectively) compared to spontaneous conception. The use of invasive ART was associated with a greatly increased risk of multiple births. Among only the 465 women who used medically assisted reproduction for conception, the use of IUI with ovarian stimulation was associated with an increased risk of multiple births (adjusted OR, 1.98; 95% CI, 1.12-3.49) when compared to ovarian stimulators used alone. Invasive ART were associated with an increased risk of multiple births (adjusted OR, 6.81; 95% CI, 3.72-12.49) when compared to ovarian stimulators used alone. CONCLUSION Although the risk of multiple births associated with invasive ART can be decreased by elective implementing of single embryo transfer, special attention should be paid to the greatly increased risk associated with ovarian stimulation used alone or with IUI.
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Aydin Y, Hassa H, Oge T, Tokgoz VY. A randomized study of simultaneous hCG administration with intrauterine insemination in stimulated cycles. Eur J Obstet Gynecol Reprod Biol 2013; 170:444-8. [DOI: 10.1016/j.ejogrb.2013.07.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 06/14/2013] [Accepted: 07/10/2013] [Indexed: 12/01/2022]
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Veltman-Verhulst SM, Cohlen BJ, Hughes E, Heineman MJ. Intra-uterine insemination for unexplained subfertility. Cochrane Database Syst Rev 2012:CD001838. [PMID: 22972053 DOI: 10.1002/14651858.cd001838.pub4] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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 rate. OBJECTIVES To determine whether, for couples with unexplained subfertility, IUI improves the live birth rate compared with timed intercourse (TI), both with and without ovarian hyperstimulation (OH). SEARCH METHODS We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (searched July 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 7), MEDLINE (1966 to July 2011), EMBASE (1980 to July 2011), PsycINFO (1806 to July 2011), SCIsearch and reference lists of articles. Authors of identified studies were contacted for missing or unpublished data. SELECTION CRITERIA Truly randomised controlled trials (RCTs) with at least one of the following comparisons were included: IUI versus TI, both in a natural cycle; IUI versus TI, both in a stimulated cycle; IUI in a natural cycle versus IUI in a stimulated cycle; IUI with OH versus TI in a natural cycle; IUI in a natural cycle versus TI with OH. Only couples with unexplained subfertility were included. DATA COLLECTION AND ANALYSIS Quality assessment and data extraction were performed independently by two review authors. Outcomes were extracted and the data were pooled. Subgroup and sensitivity analyses were done where possible. MAIN RESULTS One trial compared IUI in a natural cycle with expectant management and showed no evidence of increased live births (334 women: odds ratio (OR) 1.60, 95% confidence interval (CI) 0.92 to 2.8). In the six trials where IUI was compared with TI, both in stimulated cycles, there was evidence of an increased chance of pregnancy after IUI (six RCTs, 517 women: OR 1.68, 95% CI 1.13 to 2.50). A significant increase in live birth rate was found for women where IUI with OH was compared with IUI in a natural cycle (four RCTs, 396 women: OR 2.07, 95% CI 1.22 to 3.50). However the trials provided insufficient data to investigate the impact of IUI with or without OH on several important outcomes including live births, multiple pregnancies, miscarriage and risk of ovarian hyperstimulation. There was no evidence of a difference in pregnancy rate for IUI with OH compared with TI in a natural cycle (two RCTs, total 304 women: data not pooled). The final comparison of IUI in natural cycle to TI with OH showed a marginal, significant increase in live births for IUI (one RCT, 342 women: OR 1.95, 95% CI 1.10 to 3.44). AUTHORS' CONCLUSIONS There is evidence that IUI with OH increases the live birth rate compared to IUI alone. The likelihood of pregnancy was also increased for treatment with IUI compared to TI in stimulated cycles. One adequately powered multicentre trial showed no evidence of effect of IUI in natural cycles compared with expectant management. There is insufficient data on multiple pregnancies and other adverse events for treatment with OH. Therefore couples should be fully informed about the risks of IUI and OH as well as alternative treatment options.
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Affiliation(s)
- Susanne M Veltman-Verhulst
- University Medical Center Utrecht, Department of Reproductive Medicine and Gynecology, Utrecht, Netherlands.
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12
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Multiple gestation associated with infertility therapy: an American Society for Reproductive Medicine Practice Committee opinion. Fertil Steril 2012; 97:825-34. [DOI: 10.1016/j.fertnstert.2011.11.048] [Citation(s) in RCA: 157] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Accepted: 11/29/2011] [Indexed: 11/23/2022]
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13
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Checa MA, Prat M, Carreras R. Antral follicle count as a predictor of hyperresponse in controlled ovarian hyperstimulation/intrauterine insemination in unexplained sterility. Fertil Steril 2010; 94:1105-7. [PMID: 20045519 DOI: 10.1016/j.fertnstert.2009.10.063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2009] [Revised: 09/24/2009] [Accepted: 10/28/2009] [Indexed: 10/20/2022]
Abstract
In this prospective study of women with unexplained infertility undergoing the first cycle of controlled ovarian hyperstimulation/intrauterine insemination, the presence of 16 or more antral follicles on day 3 of the cycle was a good predictor of cancellation due to hyperresponse.
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Affiliation(s)
- Miguel A Checa
- Department of Obstetrics and Gynecology, Hospital Universitari del Mar, Autonomous University of Barcelona, Barcelona, Spain.
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14
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Schieve LA, Devine O, Boyle CA, Petrini JR, Warner L. Estimation of the contribution of non-assisted reproductive technology ovulation stimulation fertility treatments to US singleton and multiple births. Am J Epidemiol 2009; 170:1396-407. [PMID: 19854803 DOI: 10.1093/aje/kwp281] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Infertility treatments that include ovulation stimulation, both assisted reproductive technologies (ARTs) and non-ART ovulation stimulation, are associated with increased risks of multiple birth and concomitant sequelae and adverse outcomes, even among singletons. While a US surveillance system for ART-induced births is ongoing, no population-based tracking system exists for births resulting from non-ART treatments. The authors developed a multistage model to estimate the uncertain proportion of US infants born in 2005 who were conceived by using non-ART ovulation treatments. Using published surveillance data, they estimated proportions of US multiple births conceived naturally and by ART and assumed that the remainder were conceived with non-ART treatments. They used Bayesian meta-analyses to summarize published clinical studies on the multiple-gestation risk associated with non-ART ovulation treatments, applied a fetal survival factor, and used this multiple-birth risk estimate and their own estimate of the proportion of US multiple births attributable to non-ART ovulation stimulation to estimate the total (and, through subtraction, singleton) proportion of infants conceived with such treatments. On the basis of the model, the authors estimate that 4.6% of US infants born in 2005 (95% uncertainty range: 2.8%-7.1%) resulted from non-ART ovulation treatments. Notably, this figure is 4 times greater than the ART contribution.
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Affiliation(s)
- Laura A Schieve
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, MS E-86, 1600 Clifton Road, Atlanta, GA 30333, USA.
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15
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Beyer D. Intrauterine Insemination (IUI). GYNAKOLOGISCHE ENDOKRINOLOGIE 2009. [DOI: 10.1007/s10304-009-0320-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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16
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17
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Dickey RP. Strategies to reduce multiple pregnancies due to ovulation stimulation. Fertil Steril 2008; 91:1-17. [PMID: 18973894 DOI: 10.1016/j.fertnstert.2008.08.008] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2008] [Accepted: 08/05/2008] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Richard Palmer Dickey
- Department of Obstetrics and Gynecology, Louisiana State University School of Medicine, The Fertility Institute of New Orleans, New Orleans, Louisiana, USA.
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18
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Abstract
Various predictors of fertility have been described, suggesting that none are ideal. The literature on tests of ovarian reserve is largely limited to women undergoing in vitro fertilization, and is reliant on the use of surrogate markers, such as cycle cancellation and number of oocytes retrieved, as reference standards. Currently available prediction models are far from ideal; most are applicable only to subfertile women seeking assisted reproduction, and lack external validation. Systematic reviews and meta-analyses of predictors of fertility are limited by their heterogeneity in terms of the population sampled, predictors tested and reference standards used. There is an urgent need for consensus in the design of these studies, definition of abnormal tests, and, above all, a need to use robust outcomes such as live birth as the reference standard. There are no reliable predictors of fertility that can guide women as to how long childbearing can be deferred.
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Affiliation(s)
- Abha Maheshwari
- Assisted Conception Unit, Department of Obstetrics & Gynaecology, University of Aberdeen, Aberdeen Maternity Hospital, Aberdeen, UK
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Arroyo G, Veiga A, Santaló J, Barri PN. Developmental prognosis for zygotes based on pronuclear pattern: usefulness of pronuclear scoring. J Assist Reprod Genet 2007; 24:173-81. [PMID: 17318392 PMCID: PMC3455056 DOI: 10.1007/s10815-006-9099-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2006] [Accepted: 12/06/2006] [Indexed: 10/23/2022] Open
Abstract
PURPOSE To relate pronuclear patterns (PN) and zygote cytoplasmic appearance and embryo morphology. METHODS The usefulness of PN classification described by Tesarik et al. 1999 (patterns p0-5) and Scott et al. 2000 (Z1-4), for embryo selection is assessed. RESULTS Sinchrony on polarization and number of nucleolar precursor bodies (NPB) were associated with good quality embryos (p0 60.9% and p3 67.3%, and Z1 62.5% and Z2 64.7%; p<0.01). Pattern 4 zygotes were associated with small number of NPB developed into multinucleated embryos (14.3%) and poor quality embryos (61.9%). No significant differences were found in the pregnancy rate between transfer of at least one good prognosis PN pattern and transfer of poor prognosis PN patterns, although 75% of the transfers included at least one embryo derived from a pattern 0 zygote, and 55% included embryos from categories Z1 or Z2. CONCLUSIONS Sequential assessment involving the evaluation of oocyte quality, the classification of PN patterns and embryo morphology allows a more accurate evaluation of embryos to be selected for transfer.
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Affiliation(s)
- Gemma Arroyo
- Servei Medecina de la Reproducció, Dpt Obstetrícia i Ginecologia, Institut Universitari Dexeus, Passeig Bonanova, Barcelona, Spain.
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20
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Crosignani PG, Somigliana E. Effect of GnRH antagonists in FSH mildly stimulated intrauterine insemination cycles: a multicentre randomized trial. Hum Reprod 2006; 22:500-5. [PMID: 17062582 DOI: 10.1093/humrep/del416] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The usefulness of GnRH antagonists in mild controlled ovarian hyperstimulation (COH) and intrauterine insemination (IUI) cycles is debated. METHODS Two-hundred and ninety-nine couples with unexplained or mild male factor infertility were enrolled in this international multicentre randomized controlled trial. Women allocated to the GnRH antagonist group (n=148) received 50 IU recombinant FSH starting on day 3 of the menstrual cycle and Ganirelix 0.25 mg daily starting from the day in which a follicle with a mean diameter of 13-14 mm was visualized at ultrasound. Women allocated to the control group (n=151) were administered only 50 IU recombinant FSH starting on day 3 of the menstrual cycle. Couples were recruited only for their first treatment cycle. The primary outcome was the clinical pregnancy rate per initiated cycle. RESULTS Baseline characteristics of the two treatment groups were similar. Clinical pregnancy rates per initiated cycle in women who did and did not receive GnRH antagonists were 12.2 and 12.6%, respectively (P=1.00). The relative risk of conception (95% confidence interval) for the use of GnRH antagonists was 1.0 (0.5-1.9). CONCLUSIONS In mild COH and IUI cycles, any benefit of the use of GnRH antagonists in improving pregnancy rates is <2-fold increase.
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Affiliation(s)
- P G Crosignani
- Department of Obstetrics and Gynecology II, Università degli Studi di Milano, Milano, Italy.
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21
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Verhulst SM, Cohlen BJ, Hughes E, Te Velde E, Heineman MJ. Intra-uterine insemination for unexplained subfertility. Cochrane Database Syst Rev 2006:CD001838. [PMID: 17054143 DOI: 10.1002/14651858.cd001838.pub3] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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 IUI improves the live birth rate compared with timed intercourse (TI), both with and without ovarian hyperstimulation. SEARCH STRATEGY We searched the Cochrane Menstrual Disorder and Subfertility Group Trials Register (searched March 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2005, Issue 4), MEDLINE (1966 to November 2005), EMBASE (1980 to November 2005), SCIsearch and reference lists of articles. Authors of identified studies were contacted for missing or unpublished data. SELECTION CRITERIA Truly randomised controlled trials (RCTs) with at least one of the following comparisons were included: --IUI versus TI, both in a natural cycle; --IUI versus TI, both in a stimulated cycle; --IUI in a natural cycle versus IUI in a stimulated cycle; --IUI with OH versus TI in natural cycle; --IUI in a natural cycle versus TI with OH. Only couples with unexplained subfertility were included. DATA COLLECTION AND ANALYSIS Quality assessment and data extraction were performed independently by two review authors. Outcomes were extracted and the data were pooled. Subgroup analyses and sensitivity analyses were done where possible. MAIN RESULTS In the six trials where IUI was compared with TI, both in stimulated cycles, there was evidence of an increased chance of pregnancy (six RCTs, 517 women: OR 1.68, 95% CI 1.13 to 2.50). A significant increase in pregnancy rate was also found for women where IUI with OH was compared with IUI in a natural cycle (three RCTs, 415 women: OR 2.33, 95% CI 1.46 to 3.71). However, the trials provided insufficient data to investigate the impact of IUI with or without OH on several important outcomes including live birth, multiple pregnancies, miscarriage and risk of ovarian hyperstimulation. There was no evidence of a difference in pregnancy rate for IUI with OH compared with TI in a natural cycle (one RCT, 51 women: OR 4.05, 95% CI 0.39 to 41.87). No RCTs were found for the other two comparisons. AUTHORS' CONCLUSIONS There is evidence that IUI with OH increases the live birth rate compared to IUI alone. The likelihood of pregnancy was also increased for treatment with IUI compared to TI both in stimulated cycles. There is insufficient data on multiple pregnancies and other adverse events for treatment with OH. Therefore, couples should be fully informed about the risks of IUI and OH as well as alternative treatment options.
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Affiliation(s)
- S M Verhulst
- Rijksuniversiteit Groningen, Vijverlaan 4, Rotterdam, Netherlands.
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22
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Ragni G, Anselmino M, Nicolosi AE, Brambilla ME, Calanna G, Somigliana E. Follicular vascularity is not predictive of pregnancy outcome in mild controlled ovarian stimulation and IUI cycles. Hum Reprod 2006; 22:210-4. [PMID: 16971382 DOI: 10.1093/humrep/del362] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Although follicular vascularity has been shown to be a good indicator of oocyte quality in IVF, scant evidence is currently available on the predictive value of this variable in terms of pregnancy rate during controlled ovarian stimulation (COS) and intrauterine insemination (IUI) cycles. METHODS Three-hundred and eighteen patients who had received mild COS underwent transvaginal ultrasound scan before performing the IUI. Using power Doppler imaging, vascularity of follicles with a mean diameter > or =16 mm was graded into a three grades according to the circumference of the follicle in which flow was identified. When more than one follicle was observed, grading was performed for all of them, and the highest vascularity grade was recorded. RESULTS Clinical pregnancy rate (number/total) in the low-, medium- and high-grade vascularity groups was 14.1% (14/99), 10.0% (10/100) and 11.8% (14/119), respectively (P = 0.66). Similar results were observed when only monofollicular cycles were considered. CONCLUSIONS Follicular vascularity does not predict the chance of pregnancy in women undergoing mild COS and IUI cycles.
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Affiliation(s)
- G Ragni
- Infertility Unit, Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milan, Italy
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23
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Aurell R, Tur R, Torelló MJ, Coroleu B, Barri PN. Clinical strategies to avoid multiple pregnancies in assisted reproduction. Gynecol Endocrinol 2006; 22:473-8. [PMID: 17071529 DOI: 10.1080/09513590600906805] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Multiple pregnancies following assisted reproductive techniques (ART) became an epidemic in the early nineties. Since then, most European countries have tried to apply restrictive policies to avoid multiples and high order multiples as far as possible. Those pregnancies may cause severe consequences to both the fetuses and mother. Economic, social and ethical dilemmas are also avoidable if caution is exercised when using ART to achieve those pregnancies. When restrictive policies are used in ovulation induction and in vitro fertilization, the results show a clear reduction in the number of MP maintaining satisfactory rates.
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Affiliation(s)
- Ramón Aurell
- Reproductive Medicine Service, Department of Obstetrics and Gynaecology, Institut Universitari Dexeus, Barcelona, Spain.
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24
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Ragni G, Caliari I, Nicolosi AE, Arnoldi M, Somigliana E, Crosignani PG. Preventing high-order multiple pregnancies during controlled ovarian hyperstimulation and intrauterine insemination: 3 years' experience using low-dose recombinant follicle-stimulating hormone and gonadotropin-releasing hormone antagonists. Fertil Steril 2006; 85:619-24. [PMID: 16500328 DOI: 10.1016/j.fertnstert.2005.09.021] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2005] [Revised: 09/06/2005] [Accepted: 09/06/2005] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To employ protocols of mild ovarian stimulation to prevent an excessively elevated rate of high-order multiple pregnancies. DESIGN Case series. SETTING University hospital. PATIENT(S) Six hundred and twenty one consecutive patients undergoing 1,259 controlled ovarian hyperstimulation and intrauterine insemination cycles. INTERVENTION(S) Patients received 50 IU per day of recombinant follicle-stimulating hormone (FSH) starting the third day of the cycle, then a gonadotropin-releasing hormone (GnRH) antagonist on the day in which a follicle > or =13 mm was visualized. Cycles were canceled if three or more follicles > or =16 mm and/or five or more follicles > or =11 mm were detected. MAIN OUTCOME MEASURE(S) Rate of high-order multiple pregnancies. RESULT(S) The clinical pregnancy rate per initiated cycle was 9.2% (95% confidence interval, 7.5-11.1%). The incidence of twins and high-order multiple pregnancies was 9.5% (95% CI, 5.3-16.2%) and 0 (0.0-3.2%), respectively. CONCLUSION(S) In controlled ovarian hyperstimulation and intrauterine insemination cycles, a protocol of 50 IU of recombinant FSH daily combined with the use of GnRH antagonists and a policy of strict cancellation based on echographic criteria are associated with a satisfactory pregnancy rate per initiated cycle and a low risk of high-order multiple pregnancies.
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Affiliation(s)
- Guido Ragni
- Department of Obstetrics-Gynecology, Ospedale Maggiore Policlinico, Mangiagalli and Regina Elena, Italy
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25
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Gleicher N. Prediction models for high-order multiple pregnancy. Fertil Steril 2005; 83:1888-9; author reply 1889. [PMID: 15950679 DOI: 10.1016/j.fertnstert.2005.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2005] [Indexed: 11/23/2022]
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26
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Tur R, Barri PN, Coroleu B. Reply of the Authors. Fertil Steril 2005. [DOI: 10.1016/j.fertnstert.2005.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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27
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Balasch J. Gonadotrophin ovarian stimulation and intrauterine insemination for unexplained infertility. Reprod Biomed Online 2004; 9:664-72. [PMID: 15670418 DOI: 10.1016/s1472-6483(10)61778-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Over the past 15 years, there has been a marked increase in the use of ovulation induction and intrauterine insemination (IUI) for the treatment of unexplained infertility. However, although ovulation induction and IUI have rapidly gained popularity, clinical use is based largely on practical experience rather than on well-designed scientific studies. This article summarizes the evidence in this area. Despite clinical heterogeneity and different methodological qualities of the trials, it can be concluded that ovulation induction significantly improves the probability of conception in couples with unexplained infertility, particularly when associated with IUI. It is remarkable, though, that there has been only one large-scale, randomized trial of ovulation induction plus IUI in the treatment of unexplained infertility in which one of the study arms is an untreated control group. For couples requiring treatment, the complication rate must be minimized, particularly the occurrence of high-order multiple pregnancy. Evaluation of the effectiveness and safety of low-dose gonadotrophin administration in patients with unexplained infertility is limited and further studies are warranted.
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Affiliation(s)
- Juan Balasch
- Institut Clínic of Gynecology, Obstetrics and Neonatology, Hospital Clínic-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Faculty of Medicine, University of Barcelona, Barcelona, Spain.
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