Endometrial thickness and pregnancy outcome after intrauterine insemination

Recombinant human luteinizing hormone increases endometrial thickness in women undergoing assisted fertility treatments: a systematic review and meta-analysis

Introduction

The optimal dosage of recombinant human luteinizing hormone (r-hLH) and its impact on endometrial thickness (EMT) when administered alongside recombinant human follicle-stimulating hormone (r-hFSH) during controlled ovarian stimulation (COS) for in vitro fertilization/intracytoplasmic sperm injection and embryo transfer are uncertain, which formed the aims of this systematic review and meta-analysis.

Method

A search was performed in PubMed, Cochrane Library, Web of Science, EMBASE, CNKI, and Wanfang from its inception to 10 July 2023. Twenty-seven Randomized controlled trials comparing r-hFSH/r-hLH co-treatment with r-hFSH alone during in vitro fertilization/intracytoplasmic sperm injection and embryo transfer (IVF/ICSI-ET) were included. Pooled odds ratios (OR) for dichotomous data and mean differences (MD) for continuous data, with their respective 95% confidence intervals (CI), were generated. Meta-analysis employed fixed-effect or random-effect models based on heterogeneity, using Q-test and I2-index calculations. The main outcomes included EMT on trigger day, clinical pregnancy rate (CPR) and live birth rate (LBR).

Results

r-hFSH/r-hLH significantly increased EMT on trigger day (MD = 0.27; 95% CI, 0.11-0.42; I2 = 13%), but reduced oocyte number (MD = -0.60; 95% CI, -1.07 to -0.14; I2 = 72%) and high-quality embryos (MD = -0.76; 95% CI, -1.41 to -0.10; I2 = 94%) than r-hFSH alone, more pronounced with the gonadotrophin-releasing hormone agonist long protocol. A subgroup analysis showed r-hLH at 75 IU/day increased CPR (OR = 1.23; 95% CI, 1.02-1.49; I2 = 16%) and EMT on trigger day (MD = 0.40; 95% CI, 0.19-0.61; I2 = 0%). Participants ≥35 years of age exhibited decreased retrieved oocytes (MD = -1.26; 95% CI, -1.78 to -0.74; I2 = 29%), but an increase in EMT on trigger day (MD = 0.26; 95% CI, 0.11-0.42; I2 = 29%).

Conclusion

r-hFSH/r-hLH during COS significantly improved EMT compared to r-hFSH alone. An r-hLH dose of 75 IU/day may be considered for optimal pregnancy outcomes, which still require further clinical studies to support this dosing regime.

Systematic Review Registration

[www.crd.york.ac.uk/PROSPERO], identifier [CRD42023454584].

Low Estradiol Level and Endometrial Thickness on the Day of Endometrial Transformation Influence Clinical Pregnancy After Intrauterine Insemination

Background

The causes of pregnancy failure after intrauterine insemination (IUI) are controversial. The purpose of this study was to investigate the influencing factors on clinical pregnancy after IUI.

Methods

This study retrospectively analyzed 1464 cycles of IUI performed at the Meizhou People's Hospital between March 2014 and June 2023. The χ2 test and logistic regression analysis was applied to assess the associations between the some factors (maternal age, paternal age, cycle type (natural cycle or ovulation induction cycle), hormone level on the day of endometrial transformation (estradiol (E2), luteinizing hormone (LH), and progesterone (P)), endometrial thickness on the day of endometrial transformation, and forward motile sperm concentration after treatment) and pregnancy failure.

Results

Among the 1464 IUI cycles in this study, 268 cycles of assisted reproduction resulted in clinical pregnancy, with a clinical pregnancy rate of 18.3%. During the cycles with clinical pregnancy, there were 25 (12.9%) preterm births and 169 (87.1%) full-term births. The E2 level on the day of endometrial transformation in clinical pregnancy group was higher than that in the pregnancy failure group (658.79±656.02 vs 561.21±558.83 pg/mL)(P=0.025). The clinical pregnancy group had a higher percentage of endometrial thickness between 8 and 13mm on the day of endometrial transformation than the pregnancy failure group (83.2% vs 75.0%)(P=0.002). The results of regressions analysis showed that low E2 level on the day of endometrial transformation (<238.3 pg/mL vs ≥238.3 pg/mL: OR 1.493, 95% CI: 1.086-2.052, P=0.014), and endometrial thickness <8mm on the day of endometrial transformation (<8mm vs 8-13mm: OR 1.886, 95% CI: 1.284-2.771, P=0.001) may increase risk of pregnancy failure performed IUI.

Conclusion

Low estradiol level, and endometrial thickness on the day of endometrial transformation may increase risk of pregnancy failure performed intrauterine insemination.

Intrauterine instillation of autologous platelet-rich plasma in infertile females with thin endometrium undergoing intrauterine insemination: an open-label randomized controlled trial

BACKGROUND

Thin endometrium in infertile female patients has always been a clinical challenge for the treating reproductive physicians.

OBJECTIVE

This study aimed to evaluate the effect of intrauterine instillation of autologous platelet-rich plasma on endometrial thickness and vascularity in infertile female patients with thin endometrium undergoing ovarian stimulation with intrauterine insemination.

STUDY DESIGN

This prospective randomized control study included 120 women undergoing ovarian stimulation with intrauterine insemination, aged between 21 and 37 years, with persistent thin endometrium (<7 mm) on ≥1 cycle in previous ovarian stimulation cycles, even after conventional treatment with estradiol valerate. The women were randomly assigned to study group A and control group B. Baseline endometrial thickness and endometrial vascularity were noted. Intrauterine instillation of autologous platelet-rich plasma was done on the day of trigger in group A, whereas estradiol valerate was given in group B. Another evaluation of endometrial parameters was done on the day of intrauterine insemination. The cycle was repeated for 3 cycles or until the pregnancy was achieved, whichever occurred earlier. Parameters were noted for both groups. Primary outcomes were the change in endometrial thickness and endometrial vascularity. Secondary outcomes were positive pregnancy rate and clinical pregnancy rate.

RESULTS

In group A, mean pre-platelet-rich plasma endometrial thickness was 4.66±0.79 mm, which significantly increased to 7.47±0.85 mm after platelet-rich plasma instillation (P<.05) after 3 cycles. This increase was significantly greater than that observed in group B. There was significant increase in endometrial vascularity in group A compared with group B (P<.05). The positive pregnancy rate and clinical pregnancy rate in group A were 23.73% and 18.64%, respectively, and significantly higher than those in group B.

CONCLUSION

Autologous platelet-rich plasma is a promising, easily procurable, and novel option for management of infertile females with thin endometrium not responding to conventional treatment. Using it in intrauterine insemination cycles can reduce costs and psychological burden of this subgroup of women by reducing the need for resorting to advanced options such as in vitro fertilization and surrogacy.

Magnetic resonance imaging thicknesses and apparent diffusion coefficient values of the endometrium and junction zone in women of reproductive age

BACKGROUND

The endometrium and uterine junction zone often change throughout the menstrual cycle. Some pathological conditions may appear normal in uterine imaging, which will lead to missed diagnosis and misdiagnosis.

PURPOSE

To evaluate the changes in the thickness and apparent diffusion coefficient (ADC) values of the endometrium and uterine junction zone throughout the menstrual cycle in magnetic resonance imaging (MRI) of women of reproductive age.

MATERIAL AND METHODS

Data were collected from 40 healthy women of reproductive age with regular menstrual cycles from January 2017 to April 2018. They underwent four total MRI sessions during the menstrual, proliferation, and early and late secretive phases. The main MRI sequences were T2-weighted (T2W) volume isotropic turbo spin echo acquisition (VISTA) spectral attenuated inversion recovery (SPAIR) and diffusion-weighted imaging (b = 0, 600, 800, 1000 s/mm²), which were used to measure the thicknesses and ADC values of endometrium and uterine junction zone.

RESULTS

First, the endometrium was thinnest during the menstrual phase and thickest in the late secretive phase. Second, the uterine junction zone was thinnest in the late secretive phase and thickest in the menstrual phase. Third, the ADC values of the endometrium were lowest in the menstrual phase and peaked in the early secretive phase. Finally, the ADC values of the uterine junction zone were lowest in the menstrual phase and peaked in the late secretive phase.

CONCLUSION

The endometrium and uterine junction zone showed cyclic changes. Radiologists should consider these changes in the thickness and ADC values when analyzing MRI images of the uterus.

Solving the Puzzle: What Is the Role of Progestogens in Neovascularization?

Ovarian sex steroids can modulate new vessel formation and development, and the clarification of the underlying mechanism will provide insight into neovascularization-related physiological changes and pathological conditions. Unlike estrogen, which mainly promotes neovascularization through activating classic post-receptor signaling pathways, progesterone (P4) regulates a variety of downstream factors with angiogenic or antiangiogenic effects, exerting various influences on neovascularization. Furthermore, diverse progestins, the synthetic progesterone receptor (PR) agonists structurally related to P4, have been used in numerous studies, which could contribute to unequal actions. As a result, there have been many conflicting observations in the past, making it difficult for researchers to define the exact role of progestogens (PR agonists including naturally occurring P4 and synthetic progestins). This review summarizes available evidence for progestogen-mediated neovascularization under physiological and pathological circumstances, and attempts to elaborate their functional characteristics and regulatory patterns from a comprehensive perspective.

Poor Endometrial Proliferation After Clomiphene is Associated With Altered Estrogen Action

CONTEXT

Suboptimal endometrial thickening is associated with lower pregnancy rates and occurs in some infertile women treated with clomiphene.

OBJECTIVE

To examine cellular and molecular differences in the endometrium of women with suboptimal vs optimal endometrial thickening following clomiphene.

METHODS

Translational prospective cohort study from 2018 to 2020 at a university-affiliated clinic. Reproductive age women with unexplained infertility treated with 100 mg of clomiphene on cycle days 3 to 7 who developed optimal (≥8mm; n = 6, controls) or suboptimal (<6mm; n = 7, subjects) endometrial thickness underwent preovulatory blood and endometrial sampling. The main outcome measures were endometrial tissue architecture, abundance and location of specific proteins, RNA expression, and estrogen receptor (ER) α binding.

RESULTS

The endometrium of suboptimal subjects compared with optimal controls was characterized by a reduced volume of glandular epithelium (16% vs 24%, P = .01), decreased immunostaining of markers of proliferation (PCNA, ki67) and angiogenesis (PECAM-1), increased immunostaining of pan-leukocyte marker CD45 and ERβ, but decreased ERα immunostaining (all P < .05). RNA-seq identified 398 differentially expressed genes between groups. Pathway analysis of differentially expressed genes indicated reduced proliferation (Z-score = -2.2, P < .01), decreased angiogenesis (Z-score = -2.87, P < .001), increased inflammation (Z-score = +2.2, P < .01), and ERβ activation (Z-score = +1.6, P < .001) in suboptimal subjects. ChIP-seq identified 6 genes bound by ERα that were differentially expressed between groups (P < .01), some of which may play a role in implantation.

CONCLUSION

Women with suboptimal endometrial thickness after clomiphene exhibit aberrant ER expression patterns, architectural changes, and altered gene and protein expression suggesting reduced proliferation and angiogenesis in the setting of increased inflammation.

Pregnancy outcomes following different protocols of controlled ovarian hyperstimulation in couples undergoing intrauterine insemination

Clomiphene citrate (CC), letrozole and cetrorelix acetate are frequently used agents in controlled ovarian hyperstimulation (COH). However, these three agents have not yet been compared to one another regarding their pregnancy outcomes. The present study was designed to retrospectively compare pregnancy outcomes among the three aforementioned agents. This study involved infertile couples with an infertility duration of at least 2 years, ages 18 to 42 years and who were referred to have their first intrauterine insemination (IUI) treatment cycle. All patients underwent COH with recombinant follicle-stimulating hormone (rFSH) plus CC (n = 118), letrozole (n = 81), or cetrorelix acetate (n = 62), followed by IUI. Using the one-way multivariate analysis of covariance to control female patients' ages, patients stimulated with cetrorelix acetate/rFSH or CC/rFSH had higher numbers of preovulatory follicles than women stimulated with letrozole/rFSH (P < .02), whereas women stimulated with cetrorelix acetate/rFSH had a thicker endometrium than women stimulated with CC/rFSH (P < .0005). Biochemical pregnancy rates were similar among the three protocols of COH. However, women stimulated with letrozole/rFSH showed clinical pregnancy rates higher than those stimulated with CC/rFSH (P = .003) or cetrorelix acetate/rFSH (P = .03) and subclinical abortion rates lower than those stimulated with CC/rFSH or cetrorelix acetate/rFSH (P = .009). Of the different protocols of COH, the odds of having a clinical pregnancy was 3.1 times greater for women stimulated with letrozole/rFSH than women stimulated with CC/rFSH (P = .004) and 2.8 times greater for women stimulated with letrozole/rFSH than women stimulated with cetrorelix acetate/rFSH (P = .03). Our observations show that increased numbers of preovulatory follicles or endometrium thickness do not necessarily improve pregnancy outcomes, because pregnancy outcomes are also subjected to the type of COH used agent. In this regard, letrozole produced fewer preovulatory follicles and did not significantly increase endometrium thickness, but significantly improved pregnancy outcomes in comparison to CC and cetrorelix acetate.

The strain rate of endometrium measured by real-time sonoelastography as a predictive marker for pregnancy in gonadotropin stimulated intrauterine insemination cycles

AIM

Sonoelastography is an imaging technique that measures tissue strain quantitatively. This study aims to investigate whether the strain rate of endometrium measured by elastography can predict pregnancy after intrauterine insemination (IUI).

METHODS

This study examined 197 gonadotropin-stimulated IUI cycles of 148 women diagnosed with unexplained infertility from February 2019 to November 2020. Endometrial thickness, pattern, and strain rate were measured by transvaginal ultrasonography immediately before the insemination. The endometrium and the parametrial tissue were selected for regions of interest, and the strain rate was calculated. The measurements were analyzed concerning the IUI outcome.

RESULTS

Of the 197 IUI cycles, the pregnancy rate was 15.20% (n = 30), and ongoing pregnancy rate was 12.2% (n = 24). The mean strain rates were not different between pregnant and nonpregnant groups (2.68 ± 1.28 vs. 2.81 ± 1.32, p = 0.651). Strain rate was not predictive for pregnancy, shown by receiver operating characteristic curve analysis; the area under the curve was 0.526 (95% CI 0.413-0.639; p = 0.649). Pregnancy rates were significantly affected by the women's age and the inseminated sperm count. In multiple logistic regression analysis, the other parameters, including body mass index, anti-Müllerian hormone, endometrial thickness, endometrial strain rate, and echogenic endometrial pattern, did not significantly change the odds ratio of pregnancy.

CONCLUSION

The endometrial strain rate does not significantly affect the pregnancy rates in gonadotropin stimulated IUI cycles. It appears that strain rate does not predict IUI outcome. More research is needed to evaluate the usefulness of sonoelastography in infertility treatments.

Effect of gonadotropins and endometrial thickness on pregnancy outcome in patients with unexplained infertility or polycystic ovarian syndrome undergoing intrauterine insemination

Objective

The purpose of this study was to investigate the effect of gonadotropin dose and endometrial thickness (EMT) on pregnancy outcome in patients undergoing intrauterine insemination (IUI).

Methods

We retrospectively analyzed data from 361 patients with unexplained infertility or polycystic ovarian syndrome (PCOS) who underwent 930 IUI cycles treated with gonadotropins. Then, we measured the effects of gonadotropins and EMT on the clinical pregnancy rate. Finally, we assessed the association of various doses of gonadotropins on EMT.

Results

The dose of gonadotropins given and thickness of the endometrium were higher in the pregnancy group than in the nonpregnancy group (636.0 vs. 600.0 IU for gonadotropin dose; 9.15 vs. 8.70 mm for EMT). Clinical pregnancy rates were significantly improved by increasing the dose of gonadotropins (9.1%, <450 IU; 16.2%, 450–599 IU; 18.6%, 600–749 IU, and 17.3%, ≥750 IU), or by increased EMT (0%, <5.0 mm; 12.2%, 5.0–6.9 mm; 15.5%, 7.0–14.0 mm; and 33.3%, >14.0 mm).

Conclusion

Increasing the dose of gonadotropins to stimulate one follicle to develop may benefit endometrial proliferation and improve IUI outcomes.

Relationship between sperm parameters and clinical outcomes of Intra Uterine Insemination (IUI)

Background:

Intrauterine insemination (IUI) is a widely utilized method for treating the infertile couples. The aim of the present study was to determine the pregnancy and abortion rates after IUI and to examine the relationship of sperm parameters with these rates.

Methods:

This retrospective study was performed on 911 infertile couples undergoing IUI treatment in Shahid Akbarabadi IVF Centre from May 2017 to May 2019. To evaluate the correlation of sperm parameters with the clinical pregnancy and abortion rates, odds ratio (OR) with 95% confidence intervals (CI) was calculated.

Results:

In this study, the pregnancy rate following IUI was 15.7% (143/911), and among women who achieved pregnancy, the abortion rate was 42.0% (60/143). According to the multiple logistic regression analysis, none of the sperm parameters was associated with the pregnancy rate. Couples with either male or female factor infertility etiologies were more likely to get pregnant than those with unexplained infertility. Regarding the abortion rate, multiple logistic regression analysis revealed that normal sperm count was related to a lower abortion rate (adjusted OR=0.25, 95% CI=0.07–0.91).

Conclusion:

The present study did not reveal a significant relationship between none of the sperm parameters and pregnancy rate after IUI treatment. However, among women who got pregnant, continuation of the pregnancy was associated with the normal sperm count. Furthermore, analysis of all semen parameters together in comparison to one parameter alone might be more accurate to predict pregnancy or abortion. Further prospective cohort studies with a large number of couples are required.

Endometrial thickness after ovarian stimulation with gonadotropin, clomiphene, or letrozole for unexplained infertility, and association with treatment outcomes

OBJECTIVE

To study the association of endometrial thickness (EMT) with live birth rates (LBR) in ovarian stimulation with intrauterine insemination (OS-IUI) treatments for unexplained infertility.

DESIGN

Prospective cohort analysis of the Reproductive Medicine Network's Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation (AMIGOS) randomized controlled trial.

SETTING

Multicenter randomized controlled trial.

PATIENTS

A total of 868 couples with unexplained infertility (n=2,459 cycles).

INTERVENTIONS

OS-IUI treatment cycles (n = 2,459) as part of the AMIGOS clinical trial.

MAIN OUTCOME MEASURES

Live birth rates; unadjusted and adjusted risk ratios (RR) for live birth by EMT category, calculated using generalized estimating equations.

RESULTS

The overall mean EMT on day of human chorionic gonadotropin administration in cycles with a live birth was significantly greater than in those without. Compared to the referent EMT group of 9 to 12 mm, the unadjusted RR for live birth for the EMT groups of ≤5 and 6-8 were 0.48 and 0.92, respectively. The test for trend indicated evidence of decreasing LBR with decreasing EMT. After adjustment for ovarian stimulation medication, a linear trend was no longer supported. Stratified analyses revealed no differences in associations by treatment group.

CONCLUSIONS

In OS-IUI for unexplained infertility, higher LBR are observed with increasing EMT; however, EMT is not significantly associated with LBR when adjusted for OS treatment type. Appreciable LBR are seen at all EMT, even those of ≤5 mm, suggesting that OS-IUI cycles should not be canceled for thin endometrium.

CLINICAL TRIAL REGISTRATION NUMBER

NCT01044862.

Impact of endometrial polyps detected during the follicular phase of intrauterine insemination treatments

RESEARCH QUESTION

Endometrial polyps are a frequent finding during fertility treatment. Although up to 27% of small polyps (<10 mm) regress spontaneously, there is clinical benefit to removing a polyp detected before intrauterine insemination (IUI), regardless of size. However, the clinical outcome of IUI following a new suspicion of a polyp during follicle tracking is unknown.

DESIGN

This retrospective cohort study included all patients with a normal baseline uterine ultrasound and/or hysteroscopy result who started an IUI cycle between May 2009 and March 2017. In 139 of 6606 patients (2.1%), encompassing 340 out of 15,147 cycles (2.3% of cycles), a polyp was diagnosed during the follicular phase. The 6467 controls had ultrasound results with no suspicion of a polyp. Each patient was included only once in the analysis during a maximum of three consecutive cycles of IUI.

RESULTS

Female age was significantly higher in the polyp group than the controls (35.4 ± 4.8 versus 33.0 ± 5.0, P < 0.01). The unadjusted cumulative live birth rate (CLBR) after three IUI cycles in women with and without a polyp was 24.1% versus 33.0% (P = 0.03), indicating a deleterious effect of polyp(s). However, after multivariate Cox regression analysis for body mass index, female age, number of follicles and sperm concentration, the presence of a polyp appeared not to influence the CLBR (adjusted hazard ratio 0.742, 95% confidence interval 0.477-1.156, P = 0.19).

CONCLUSIONS

These results may be reassuring, as ultrasound diagnosis of a polyp during the follicular phase of an IUI cycle does not seem to compromise clinical outcome when previous baseline examinations have been normal.

Conventional and modern markers of endometrial receptivity: a systematic review and meta-analysis

BACKGROUND

Early reproductive failure is the most common complication of pregnancy with only 30% of conceptions reaching live birth. Establishing a successful pregnancy depends upon implantation, a complex process involving interactions between the endometrium and the blastocyst. It is estimated that embryos account for one-third of implantation failures, while suboptimal endometrial receptivity and altered embryo-endometrial dialogue are responsible for the remaining two-thirds. Endometrial receptivity has been the focus of extensive research for over 80 years, leading to an indepth understanding of the processes associated with embryo-endometrial cross-talk and implantation. However, little progress has been achieved to translate this understanding into clinically meaningful prognostic tests and treatments for suboptimal endometrial receptivity.

OBJECTIVE AND RATIONALE

The objective of this systematic review was to examine the evidence from observational studies supporting the use of endometrial receptivity markers as prognostic factors for pregnancy outcome in women wishing to conceive, in order to aid clinicians in choosing the most useful marker in clinical practice and for informing further research.

SEARCH METHODS

The review protocol was registered with PROSPERO (CRD42017077891). MEDLINE and Embase were searched for observational studies published from inception until 26 February 2018. We included studies that measured potential markers of endometrial receptivity prior to pregnancy attempts and reported the subsequent pregnancy outcomes. We performed association and accuracy analyses using clinical pregnancy as an outcome to reflect the presence of receptive endometrium. The Newcastle-Ottawa scale for observational studies was employed to assess the quality of the included studies.

OUTCOMES

We included 163 studies (88 834 women) of moderate overall quality in the narrative synthesis, out of which 96 were included in the meta-analyses. Studies reported on various endometrial receptivity markers evaluated by ultrasound, endometrial biopsy, endometrial fluid aspirate and hysteroscopy in the context of natural conception, IUI and IVF. Associations were identified between clinical pregnancy and various endometrial receptivity markers (endometrial thickness, endometrial pattern, Doppler indices, endometrial wave-like activity and various molecules); however, their poor ability to predict clinical pregnancy prevents them from being used in clinical practice. Results from several modern molecular tests are promising and further data are awaited.

WIDER IMPLICATIONS

The post-test probabilities from our analyses may be used in clinical practice to manage couples' expectations during fertility treatments (IUI and IVF). Conventionally, endometrial receptivity is seen as a dichotomous outcome (present or absent), but we propose that various levels of endometrial receptivity exist within the window of implantation. For instance, different transcriptomic signatures could represent varying levels of endometrial receptivity, which can be linked to different pregnancy outcomes. Many studies reported the means of a particular biomarker in those who achieved a pregnancy compared with those who did not. However, extreme values of a biomarker (as opposite to the means) may have significant prognostic and diagnostic implications that are not captured in the means. Therefore, we suggest reporting the outcomes by categories of biomarker levels rather than reporting means of biomarker levels within clinical outcome groups.

The effect of endometrial thickness and endometrial blood flow on pregnancy outcome in intrauterine insemination cycles

Objective:

To investigate whether endometrial thickness and endometrial blood flow on the day of hCG administration is a predictor of intrauterine insemination (IUI) success.

Method:

A cross-sectional prospective clinical study with simple randomized sampling; Patient: 100 women experiencing the IUI cycle; Interventions: a comparison was made between pregnant and non-pregnant patients in terms of the endometrial thickness and pattern as well as the color Doppler flow on the day of hCG administration and also cycle parameters. Main outcome measures: endometrial thickness and patterns as well as the blood flow in color Doppler.

Results:

With the overall pregnancy rate being 38%, it was demonstrated that the endometrial blood flow was significantly greater in the cycle pregnancy obtained on the day of hCG administration, yet it was realized that the endometrial thickness and pattern of sonography did not have any predictive values for endometrial receptivity . In a multivariate analysis, the pregnancy rate was affected by the following variables: the duration of infertility, the women's age, the type number of IUI cycles, the number of injections to stimulate dominant follicles, and the sperm count. In the current study, the variability was realized to be of no predictive values for the IUI outcome, yet the endometrial flow in color Doppler was found to be positively connected with the pregnancy outcome.

Prognostic Factors to Achieve Higher Pregnancy and Live Birth Rate in Intrauterine Insemination Among Subfertile Women

Background: The purpose of this study was to evaluate the prognostic factors that could affect the clinical pregnancy rate (CPR) and live birth rate (LBR) among subfertile women undergoing intrauterine insemination (IUI).

Methods: A retrospective analysis study of a total of 2186 cycles of IUI among 1784 subfertile women between 2012 and 2017 at the infertility clinic in Taipei Medical University Hospital was conducted. Social demographics, CPR, and LBR were measured. Eleven prognostic factors were analysed with multivariable logistic regression.

Results: Of the 2186 cycles, 569 became pregnant (26.0%), resulting in 454 live births. The LBR per cycle and per patient were 20.8% and 24.6%, respectively. Eight factors were found to significantly predict the obstetric outcome among the women who underwent IUI (p [Formula: see text] 0.05). Age, [Formula: see text] 35.0 years old; serum anti-Müllerian hormone (AMH) level, [Formula: see text] 1.2 ng/mL; delayed sperm insemination, [Formula: see text] 36.0 hour following human chorionic gonadotropin (HCG) injection; serum estradiol level, [Formula: see text] 500 pg/mL; endometrial thickness, [Formula: see text] 7.0 mm on the day of HCG administration; and post-wash total motile sperm count (TMSC), [Formula: see text] 5 million/mL were found to be prognostic factors in determining the CPR and LBR (p [Formula: see text] 0.05). However, duration of subfertility and the presence of urine luteinizing hormone surge during the day of the HCG trigger inversely affected the LBR (p = 0.006 and p = 0.033, respectively) but not the CPR (p [Formula: see text] 0.05). The type of infertility, total antral follicle count, and pre-wash TMSC were not able to predict pregnancy outcome (p [Formula: see text] 0.05).

Conclusions: Six out of 11 factors were identified as strong prognostic factors for successful pregnancies and live births: age, serum AMH and serum estradiol levels, endometrial thickness, post-wash TMSC, and delayed sperm insemination after HCG injection.

The association between endometrial thickness and pregnancy outcome in gonadotropin-stimulated intrauterine insemination cycles

BACKGROUND

Intrauterine insemination (IUI) is the first-line treatment for non-tubal infertility. Injectable gonadotropins are often chosen as adjunctive stimulation to promote the growth of ovarian follicles in IUI cycles. The growing follicles produce estrogen, which induces endometrial proliferation and increased endometrial stripe thickness (EST). The association between EST and pregnancy outcome in gonadotropin stimulated IUI is not well studied. The objective of this study is to determine if EST can predict pregnancy outcome in gonadotropin-stimulated IUI cycles.

METHODS

A retrospective review was conducted of all exclusively gonadotropin-stimulated IUI cycles performed between 2012 and 2015 at an academic fertility clinic. Mean endometrial thickness was compared in positive versus negative cycles using Student T-test. Peak EST values were then divided into four groups of < 7 mm, 7.0-10.4 mm, 10.5-13.9 mm, and ≥ 14 mm. Multiple logistic regression analysis adjusted for potential confounders was conducted to assess the impact of peak EST on cycle outcome.

RESULTS

Our sample consisted of 1065 IUI cycles representing 548 patients with a 16.9% clinical pregnancy rate and 20.5% conception rate. No significant differences in mean peak EST were observed between cycles that achieved clinical pregnancy or conception and those that did not. Division of peak EST into four groups showed a non-linear relationship between peak EST and cycle outcome, with highest rates of positive outcomes between 10.5-13.9 mm. The odds of clinical pregnancy and conception increased by 38 and 44% respectively with each subsequent peak EST category up to 10.5-13.9 mm, following which they declined.

CONCLUSION

This is the largest study to date evaluating the effect of peak EST on gonadotropin-stimulated IUI cycles exclusively. The lack of significant difference in peak EST between positive and negative outcomes cycles may be due to the non-linear relationship between cycle outcomes and peak EST. Peak EST in the range of 10.5-13.9 mm was associated with significantly higher conception rates and a trend towards higher clinical pregnancy rates. This non-linearity is likely one of the reasons that EST in isolation was found to be a poor predictor of IUI outcomes, and therefore is not appropriate to be used as the sole indicator for cycle cancellation.

Optimizing the first-line fertility treatment

The objective of this study was to identify sperm score thresholds to achieve satisfactory intrauterine insemination (IUI) success rates according to the response to stimulation with clomiphene citrate (CC). To minimize the confounding effect of female age, we included only CC/IUI cycles of women ≤35 years old. A total of 1,194 CC/IUI cycles were included. Semen volume, concentration, and motility influenced the clinical pregnancy rate (CPR). Normal morphology (≥4%) was associated with a comparable CPR with 3%, 2%, and 1% normal forms (15.6%, 16.1%, 18.1%, and 13.1%, respectively). A combination of the total number of motile spermatozoa in the ejaculate before semen preparation (TM) at a threshold ≥20 × 10⁶ was associated with a CPR of 17.8% compared to 4.6% for a threshold <20 × 10⁶ (p < .001). Interestingly, the TM threshold to achieve satisfactory outcomes was lower (10 × 10⁶) in patients who had an optimal response to CC (≥2 dominant follicles with an endometrial thickness ≥7 mm) compared to 40 × 10⁶ for those who had a suboptimal response (one dominant follicle with an endometrial thickness <7 mm). In conclusion, the response to superovulation with CC determines each patient's TM threshold required for satisfactory outcomes. Couples whose TM is below the threshold may benefit from a superovulation with gonadotropins or in vitro fertilization.

Evaluation of Progesterone and Ovulation-stimulating Drugs on the Glandular Epithelium and Angiogenesis in Mice

Background:

Human endometrium is a dynamic tissue during the menstrual cycle can be influenced by ovarian hormones. The purpose of this study was to evaluate the endometrium angiogenesis under the influence of human menopausal gonadotropin and human chorionic gonadotropin (HMG and HCG) that stimulate ovulation and progesterone.

Materials and Methods:

In this study, thirty adult female mice were randomly divided into three groups as: control, gonadotropin and gonadotropin + progesterone. The mice in the other two groups except the control group received 7.5 IU HMG and later HCG. Subsequently, the mice were placed in a cage for mating. Gonadotropin + progesterone group was administered, 1 mg/mouse progesterone in 24, 48, and 72 h interval, after HMG injection. Ninety-six hours after HMG injection, animals were sacrificed, and their uterine specimens were prepared by immunohistochemistry technique for light microscopic studies, and statistical analysis was carried out.

Results:

Endometrium angiogenesis in control group showed that mean ± standard deviation was 24.15 ± 11.15, gonadotropin group was 62.50 ± 24.16, and gonadotropin + progesterone group was 41.85 ± 19.54. Significant difference between the control group and gonadotropin group and between the control group and gonadotropin + progesterone was observed. Statistically significant differences were observed in all groups in the endometrial angiogenesis (P < 0.05).

Conclusion:

Ovarian induction with gonadotropins and gonadotropins + progesterone could not change the morphometrically index of endometrial glandular epithelium in mice. Ovarian stimulation followed by progesterone injection could modify the angiogenesis of mice endometrium.

The effect of fertility stress on endometrial and subendometrial blood flow among infertile women

BACKGROUND

To investigate the effect of fertility stress on endometrial and subendometrial blood flow among infertile women.

METHODS

This case-control study was conducted in The First Affiliated Hospital of Zhengzhou University. The fertility problem inventory (FPI) was adopted to evaluate fertility stress. Three-dimensional power Doppler ultrasonography (3D PD-US) was performed during the proliferative phase of the menstrual cycle (days 5-11) to measure endometrial thickness, pattern, endometrial and subendometrial volume (V), the vascularization index (VI), the flow index (FI) and the vascularization-FI (VFI) index. Then, 300 infertile women were separated into two groups (high-score group and low-score group) based on total FPI scores and 80 healthy women were selected as controls.

RESULTS

No differences were found among all three groups with regard to general characteristics, endometrial thickness, pattern, endometrial and subendometrial V, VI and VFI. The endometrial and subendometrial FIs associated with different stress levels significantly differed among the three groups (F = 33.95, P < 0.001; F = 44.79, P < 0.001, respectively). The endometrial and subendometrial FIs in the control group were significantly higher than those in the high-score group and low-score groups. The endometrial and subendometrial FIs in the low-score group were significantly higher than those in the high-score group. The total FPI score was closely related to the endometrial and subendometrial FIs (r = -0.304, P < 0.001; r = -0.407, P < 0.001, respectively).

CONCLUSION

Fertility stress was associated with endometrial and subendometrial flow index. Whether fertility stress might affect pregnancy outcome by reducing endometrial and subendometrial blood flow requires further research.

Pregnancy Predictors after Intrauterine Insemination in Cases of Unexplained Infertility: A Prospective Study

Introduction. Aim of the study was to find the effect of various prognostic factors in cases of unexplained infertility undergoing controlled ovarian stimulation (COS) with intrauterine insemination (IUI). Methods. 146 cases of unexplained infertility were included. A maximum of 3 cycles of IUI were done with clomiphene citrate/HMG. Ovulation trigger was given when the largest follicle diameter was >18 mm, and IUI was planned 36 hours later. Luteal phase support was given for 15 days, urine pregnancy test was done on day 15, ultrasonography was done at 7 weeks, and pregnancy was followed up till delivery. Results. A total of 146 couples have undergone 239 cycles of IUI out of which 27 had UPT positive after 15 days. 14.8% had 1st-trimester abortion while 3.7% were ectopic. 86.3% were singleton pregnancies and 13.6% were twins. CPR was 11.29% per cycle and 18.4% per couple; LBR was 9.2% per cycle. Apart from duration of stimulation (p = 0.037) and number of treatment cycles (p = 0.045), no other factors had significant prognostic value. Conclusion. For unexplained infertility, IUI can be done to provide patients with the time that they need before moving on to IVF while providing a respectable chance of pregnancy.

Factors affecting pregnancy outcomes in young women treated with fertility-preserving therapy for well-differentiated endometrial cancer or atypical endometrial hyperplasia

BACKGROUND

Patients hoping to preserve their fertility receive conservative treatment with high-dose medroxyprogesterone acetate (MPA) for well-differentiated endometrioid adenocarcinoma (EC) or atypical endometrial hyperplasia (AEH) . Such treatment generally involves frequent intrauterine operations, including dilation and curettage (D&C) and endometrial biopsy (EMB), which could result in endometritis, endometrial thinning, or intrauterine adhesion. In turn, any of these outcomes could adversely affect implantation and pregnancy development. The current study thus aimed to identify factors that might affect pregnancy following conservative treatment by MPA.

METHODS

We compared a pregnancy group (45 patients) with a non-pregnancy group (53 patients) of MPA-treated patients to evaluate the factors affecting clinical pregnancy establishment. We undertook a multivariate logistic regression analysis based on factors shown by univariate analysis to be significantly different between the groups. Univariate analysis identified number of D&C, endometrial thickness, duration of MPA administration, age of pregnancy permission (the age at which a patient was first allowed to attempt pregnancy after disappearance of the lesion), period of disappearance of lesions, and recurrence as independent variables.

RESULTS

The odds ratios (95 % confidence interval) of multivariate analysis for disease recurrence, endometrial thickness during ovulation, and age of pregnancy permission were 0.283 (0.102-0.785), 1.677 (1.251-2.248), and 0.889 (0.792-0.998), respectively. There was no significant difference in the other independent variables between groups.

CONCLUSIONS

We identified three factors considered to affect pregnancy establishment following conservative treatment with MPA: recurrence, endometrial thickness during ovulation, and the age of the pregnancy permission. Introduction of infertility treatment including assisted reproductive technology (ART) soon after achieving tumor disappearance by MPA would therefore be beneficial for patients with disease recurrence, thin endometrium, or a higher age of pregnancy permission.

Clinical outcomes of three- or five-day treatment with clomiphene citrate combined with gonadotropins and a timed intercourse cycle in polycystic ovary syndrome patients

OBJECTIVE

This study aimed to investigate the effect of a new clomiphene citrate (CC) regimen on preventing thin endometrial lining in polycystic ovary syndrome (PCOS) patients receiving CC plus gonadotropin treatment with a timed intercourse cycle.

METHODS

A total of 114 women with PCOS were included in this trial. Patients were divided into two groups and treated in accordance with the controlled ovarian stimulation (COS) protocol. In group A, 104 COS cycles in 67 patients were included, and in each cycle 150 mg CC was given for three days, starting from day 3. In group B, 69 COS cycles in 47 patients were included, in which 100 mg CC was given for five days, starting from day 3. The thickness of the endometrium was measured on the day of human chorionic gonadotropin (hCG) injection. Timed intercourse was recommended at 24 and 48 hours after the hCG injection.

RESULTS

Additional doses of human menopausal gonadotropin and the number of days of hCG administration were not significantly different between the two groups. Endometrial thickness on the day of hCG administration was significantly larger in group A than group B (9.4±2.1 mm vs. 8.5±1.7 mm, p=0.004). The pregnancy rate was significantly higher in group A than in group B (38.4% vs. 21.7%, p=0.030).

CONCLUSION

Three-day CC treatment resulted in a significantly higher pregnancy rate than the standard five-day CC treatment in a timed intercourse cycle in PCOS patients. Facilitating adequate endometrial growth via the early discontinuation of CC might be a crucial factor in achieving a higher pregnancy rate.

Ovarian response is a better predictor of clinical pregnancy rate following embryo transfer than is thin endometrium or presence of an endometrioma

OBJECTIVES

To examine whether endometrial thickness and the presence of endometrioma are independent predictors of clinical pregnancy rate or simply associated with poor ovarian response (POR).

METHODS

This was a retrospective cohort study assessing the first cycle of all women undergoing in-vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) in a university hospital in Brazil between January 2011 and December 2012. Only the first cycle of each woman within the study period was considered. Women over 40 years of age and those who used clomiphene citrate during controlled ovarian stimulation (COS) or did not undergo embryo transfer were excluded from analysis. POR was defined as ≤ three oocytes retrieved and a thin endometrium was defined as endometrial thickness ≤ 7.0 mm on the day of human chorionic gonadotropin (hCG) administration. We performed a multiple regression analysis to identify which of the following parameters were independent predictors of clinical pregnancy: age, number of oocytes retrieved, endometrial thickness or the presence of endometrioma.

RESULTS

Within the study period, 787 women began COS, but 270 were excluded from analysis. Among the 517 women analyzed, those who achieved pregnancy were younger and yielded more oocytes. The proportion of POR was higher in women with a thin endometrium (17/57 (29.8%) vs 80/460 (17.4%); P = 0.03) and in women with endometrioma (15/39 (38.5%) vs 82/478 (17.2%); P = 0.002). The results of regression analysis showed that only age and the number of oocytes retrieved were independent predictors of pregnancy. Additionally, we observed higher clinical pregnancy rates in women with a thin endometrium from whom ≥ seven oocytes were retrieved (11/25 (44.0%)) compared to women with normal endometrial thickness (99/241 (41.1%)). Considering only women from whom ≥ four oocytes were retrieved, we observed reasonable pregnancy rates in those with a thin endometrium (14/40 (35.0%)) and in those with endometrioma (9/24 (37.5%)).

CONCLUSION

Both a thin endometrium and the presence of endometrioma are associated with POR but are not important independent predictors of clinical pregnancy. Good pregnancy rates can be observed when these conditions are present in women with a good ovarian response.

Do Endometrial Movements Affect The Achievement of Pregnancy during Intrauterine Insemination?

Background

This study was aimed to assess the effect of endometrial movements on pregnancy achievement in intrauterine insemination (IUI) cycles.

Materials and Methods

The population of this observational study was composed of unexplained infertility couples undergoing first-time IUI with clomiphene citrate between September 2010 and October 2011. Not only endometrial movements, but also thickness, volume, pattern, and echogenic change of endometrium were analyzed prospectively in prediction of pregnancy.

Results

The total number of 241 cycles of IUI with 49 intrauterine pregnancies (20.3%) was analyzed. Pregnancy was not related to endometrial thickness and endometrial volume, but significantly related to endometrial movements associated with the number of contraction, strong movement, cervicofundal direction, and hyperechoic change (p<0.05). Pregnant group showed higher cervicofundal movement rate (89.8 vs. 75.5%).

Conclusion

For IUI cycles stimulated by clomiphene citrate in unexplained infertility women, endometrial movements on the day of IUI could be a predictor of pregnancy.

Outcomes after intrauterine insemination are independent of provider type

OBJECTIVE

We sought to determine whether the success of intrauterine insemination (IUI) varies based on the type of health care provider performing the procedure.

STUDY DESIGN

This was a retrospective cohort study set at an infertility clinic at an academic institution. The patients who comprised this study were 1575 women who underwent 3475 IUI cycles from late 2003 through early 2012. Cycles were stratified into 3 groups according to the type of provider who performed the procedure: attending physician, fellow physician, or registered nurse (RN). The primary outcome was live birth. Additional outcomes of interest included positive pregnancy test and clinical pregnancy. Repeated measures log binomial regression was used to estimate the risk ratios (RR) and 95% confidence intervals (CI) for the outcomes and to evaluate the effect of potential confounders. All tests were 2-sided, and P values < .05 were considered statistically significant.

RESULTS

Of the 3475 IUI cycles, 2030 (58.4%) were gonadotropin stimulated, 929 (26.7%) were clomiphene citrate stimulated, and 516 (14.9%) were natural. The incidences of clinical pregnancy and live birth among all cycles were 11.8% and 8.8%, respectively. After adjusting for female age, male partner age, and cycle type, the incidence of live birth was similar for RNs compared with attending physicians (RR, 0.80; 95% CI, 0.58-1.1) and fellow physicians compared with attending physicians (RR, 0.84; 95% CI, 0.58-1.2). Similar results were seen for positive pregnancy test and clinical pregnancy.

CONCLUSION

There was no significant difference in live birth following IUI cycles in which the procedure was performed by a fellow physician or RN compared with an attending physician.

Prognosis factors of pregnancy after intrauterine insemination with the husband's sperm: conclusions of an analysis of 2,019 cycles

OBJECTIVE

To identify the prognostic factors for pregnancy after intrauterine insemination with the husband's sperm (IUI-H).

DESIGN

Retrospective study.

SETTING

A single university medical center.

PATIENT(S)

851 couples, for 2,019 IUI-H cycles.

INTERVENTION(S)

After controlled ovarian stimulation, IUI-H performed 36 hours after ovulation triggering or 24 hours after a spontaneous luteinizing hormone (LH) surge.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rate per cycle (PR) and delivery rate per cycle (DR).

RESULT(S)

The overall PR was 14.8% and DR 10.8%. Higher PR and DR were observed for patients presenting with ovulation disorders (particularly polycystic ovary syndrome) or with male infertility. Secondary infertility in the woman appeared to be a positive prognostic factor as did a basal follicle-stimulating hormone (FSH) level ≤ 7 IU/L and ovulation triggering over spontaneous LH rise. The other parameters influencing the results were the women's age, the number of mature follicles obtained (≥ 2), the endometrial thickness (10-11 mm), and the number of progressive motile spermatozoa inseminated (>1 million).

CONCLUSION(S)

In women aged ≤ 38 years, IUI-H should be considered as an option, particularly in cases of female infertility from ovulation disorders, in cases of a normal ovarian reserve, in cases of secondary infertility, or when ≥ 1 million progressive sperm are inseminated. Bifollicular stimulation is required. In other cases, in vitro fertilization should be discussed as the first-line treatment.

Vitamin D improves endometrial thickness in PCOS women who need intrauterine insemination: a randomized double-blind placebo-controlled trial

PURPOSE

To determine whether administration of vitamin D affects the success rates of intra uterine insemination (IUI) in infertile polycystic ovarian syndrome (PCOS) women and their endometrial thickness.

METHODS

This randomized, double-blind, placebo-controlled trial was conducted in an infertility clinic of Women's Hospital, and 110 infertile PCOS patients undergoing IUI were randomly divided to receive vitamin D or placebo. Endometrial thickness, IUI results, number of dominant follicles, duration of IUI cycle, and dose of HMG used in IUI were determined.

RESULTS

The endometrial thickness was significantly different in the group treated with vitamin D versus the placebo group (p = 0.003). There was no statistical difference in pregnancy out come between the two groups (RR = 1.167, CI 95 % 0.70-1.93). No statistical difference was found in number of dominant follicles (p = 0.96), duration of IUI cycles (p = 0.70) and dose of HMG used for IUI (p = 0.95).

CONCLUSIONS

It seems that administration of vitamin D induces endometrial proliferation in PCOS women during IUI cycle. The study was recorded in Iranian Registry of Clinical Trials(IRCT201104216246N1).

Influences on endometrial development during intrauterine insemination: clinical experience of 2,929 patients with unexplained infertility

OBJECTIVE

To characterize relationships associated with adverse endometrial development in patients undergoing IUI for unexplained infertility.

DESIGN

A retrospective review of 2,929 patients from 2004-2011.

SETTING

Large metropolitan infertility practice.

PATIENT(S)

Patients with unexplained infertility undergoing first IUI cycle at age less than 43 years, with a total motile sperm count ≥ 8 million.

INTERVENTION(S)

Clomiphene citrate (CC) with FSH stimulation followed by IUI.

MAIN OUTCOME MEASURE(S)

Endometrial thickness, serum E2 (in picograms per milliliter) levels on the day of hCG trigger administration, body mass index (BMI) (in kilograms per meter squared), total motile sperm, follicle number, and clinical pregnancy.

RESULT(S)

Of the 2,929 patients who met the inclusion criteria, 466 (15.9 %) achieved a clinical pregnancy. Pregnancy rates (PRs) increased significantly with increasing endometrial thickness on the day of hCG administration and with increasing serum E2 level, but were not significantly related to age, BMI, or follicle numbers according to multiple logistic regression modeling. Peak endometrial thickness declined with age and increasing E2 levels. The BMI was associated with thicker endometrium, but it was also associated with lower peak E2 levels.

CONCLUSION(S)

The impact of "endometrial factor" infertility may be underappreciated in IUI therapy. Targeted therapies to optimize the endometrium represent an important new area to improve in current fertility success rates.

The effect of administering vaginal estrogen to clomiphene citrate stimulated cycles on endometrial thickness and pregnancy rates in unexplained infertility

OBJECTIVE

Clomiphene citrate (CC) has some negative effects on the endometrium. We aimed to determine the effect of vaginally administered local estrogen (LE) on endometrial thickness (ET) and pregnancy rates in CC stimulated cycles.

MATERIAL AND METHODS

This was a prospective randomized crossover study that took place in a university hospital. The patients had received CC due to unexplained infertility (UI). Two different treatment protocols were given sequentially as, either CC+LE or CC alone. Each protocol was planned for two cycles and there was a one-month wash-out period between protocols. The effects of LE on the 3(rd) and 9(th) day, the ovulation day (OD) and 7(th) postovulation day (POD7) were investigated.

RESULTS

A total of 6 pregnancies were achieved with 3 patients from each protocol. The ET was 7.6±1.4 mm and 8.3±2.1 mm respectively and significantly different in the CC group and the CC+E2 groups on the OD (p=.039), while these values were 9.7±2.3 mm and 10.9±3.0 mm respectively and significantly different on the POD7 (p=.007). There was no significant difference between the groups for arterial PI values on the OD and POD7. The frequency of thin endometrium (<6 mm) was 15.2% and 12.2% respectively in the CC group and the CC+E2 group on the OD (p=.628) and 5.1% and 1.2% respectively on the POD7 (p=.182).

CONCLUSION

Adding vaginal LE to CC stimulated cycles led to a significant increase in ET on the OD and POD7. However, this difference in thickness was not reflected in the pregnancy rates in this study.

Does sperm morphology affect the outcome of intrauterine insemination in patients with normal sperm concentration and motility?

The aim of this study was to assess the correlation of sperm morphology with the intrauterine insemination (IUI) outcome in patients with normal sperm concentration and motility. About 412 couples who underwent 908 IUI cycles were involved in the present study. A total of 110 clinical pregnancies were achieved with a pregnancy rate of 12.11% per cycle. The pregnancy rates per cycle were 7.60%, 12.67%, 13.62% and 13.13% in patients with <5%, 5-9%, 10-14% and >14% normal forms, respectively. The lowest pregnancy rate (7.60%) was obtained in the group with normal forms below 5%. However, this rate was not significantly different from other subgroups. Moreover, no pregnancies occurred in women >35 years old with normal sperm forms below 5%, in comparison with that in other subgroups of the same age. For women younger than 35 years old, no significant difference in pregnancy rate was observed in terms of different level of morphologically normal sperm. Our results show that for patients with normal sperm concentration and motility, IUI is recommended for first-line treatment when the woman is younger than 35 years, or morphologically normal sperm is ≥ 5%. IVF/ICSI should be performed when the normal forms are <5% and female age is > 35 years.

Ultrasound for nurses in reproductive medicine

Nurses are in an ideal position to perform pelvic ultrasound evaluations, and appropriately trained nurses can perform limited ultrasound evaluations as part of the assessment and treatment of infertility. In this article, the author provides detailed descriptions and accompanying ultrasonic images illustrating the use of ultrasound in providing vital clinical information in reproductive medicine and in the assessment of the first trimester of pregnancy.

Decreased expression of c-kit and telomerase in a rat model of chronic endometrial ischemia

BACKGROUND

It was unclear whether chronic endometrial ischemia contributed to the pathogenesis of thin endometrium and was associated with decreased endometrial stem/progenitor cell. Thus, we explored the role of chronic endometrial ischemia in the pathogenesis of thin endometrium and its effect on endometrial stem/progenitor cells apoptosis.

MATERIAL/METHODS

In vitro, endometrial side population (ESP) cell apoptosis models were built, and apoptosis was quantified by fluorescence-activated cell sorter (FACS) analysis, pou5f1, and c-kit mRNA was detected by qPCR. In vivo, a rat model of chronic endometrial ischemia was induced by performing bilateral uterine artery ligation. TERT and caspase3 were detected by immunohistochemistry. Pou5f1and c-kit mRNA was examined by qPCR. C-kit, caspase3 and telomerase were detected by Western blot.

RESULTS

In the in vitro endometrial SP (ESP) cells apoptosis model, we found that the apoptotic rate was gradually increased with time, prolonging the expression of TERT, and c-kit mRNA was gradually decreased. In the in vivo endometrial SP (ESP) cells apoptosis model, we found that endometrial thickness, luminal epithelium thickness, gland epithelium thickness and the number of glands in the experiment group were significantly decreased compared with those in the control group (P<0.05). The expression levels of c-kit, pou5f1 and telomerase was significantly lower in the experimental group than those in the control group (P<0.05). The expression level of caspase3 was significantly higher in the experimental group compared with that in the control group (P<0.05).

CONCLUSIONS

The present work shows that chronic ischemia and chronic endometrial ischemia-associated stem/progenitor cells apoptosis may be responsible for the pathogenesis of thin endometrium.

Intrauterine insemination versus timed intercourse with clomiphene citrate in polycystic ovary syndrome: a randomized controlled trial

OBJECTIVE

To compare the efficacy of intrauterine insemination vs. timed intercourse with clomiphene citrate as a first-line treatment for anovulatory infertility associated with polycystic ovary syndrome.

DESIGN

A randomized controlled trial following the CONSORT criteria.

SETTING

A university hospital and a private practice setting.

PATIENTS

188 women (525 cycles) with polycystic ovary syndrome.

MAIN OUTCOME MEASURES

Women received three consecutive cycles of ovulation induction with clomiphene citrate and intrauterine insemination (n=93, 259 cycles) or three consecutive cycles of clomiphene citrate with timed intercourse (n=95, 266 cycles).

OUTCOME MEASURES

Clinical pregnancy rate per cycle, number of growing and mature follicles, serum estradiol, endometrial thickness at the hCG day, serum progesterone, ovulation, miscarriage and live birth rates.

RESULTS

There were no differences between the two groups regarding the clinical pregnancy rate per cycle or per woman (8.49 vs. 7.89% and 23.6 vs. 22.1%; p=0.26 and p=0.33, respectively). Two twin pregnancies occurred in each group. Miscarriage and live birth rates were comparable (18.1 vs. 19% and 19.35 vs. 17.89%; p=0.31 and p=0.33, respectively). No ectopic, higher-order pregnancies or cases of ovarian hyperstimulation syndrome occurred. No differences were found regarding the number of follicles, serum progesterone, ovulation rates, estradiol levels or endometrial thickness at the hCG day (7.7±0.4 vs. 7.5±0.6mm; p=0.54).

CONCLUSIONS

Ovulation induction with clomiphene citrate and timed intercourse is as effective as that with intrauterine insemination for achieving pregnancy in polycystic ovary syndrome and could represent the initial treatment option, being less invasive and less expensive than intrauterine insemination.

Significance of the serum CA-125 level in intrauterine insemination cycles

Objective

There are limited data regarding the significance of elevated serum CA-125 level during IUI cycles, even though it is used widely during the initial evaluation of infertile patients. The aim of this study was to investigate the prognostic value of serum CA-125 levels during IUI cycles.

Methods

Among the patients with controlled ovarian stimulation and IUI cycles at Seoul National University Hospital from Jan 2005 through Dec 2009, 92 cases with no identified endometriotic lesion, ovarian tumor, salpingeal lesion, or uterine myoma were selected. To compare the clinical characteristics between the pregnancy group and the non-pregnancy group, the Mann-Whitney U test and Fisher's exact test were used.

Results

The overall pregnancy rate was 18.5% (17/92). The pregnancy group showed a higher number of follicles 16 mm in diameter (p=0.036), endometrial thickness (p<0.001), ampules of gonadotropin (p=0.009), and higher body mass index (p=0.022) than the non-pregnancy group. No significant difference was observed in the serum CA-125 level or the proportion of patients with CA-125 exceeding 17 IU/mL between the two groups.

Conclusion

The prognostic value of serum CA-125 level among infertile patients with IUI cycles is considered limited.

Polycystic Ovary Syndrome: Update on Treatment Options and Treatment Considerations for the Future

Polycystic ovary syndrome is an endocrine disorder characterized by insulin resistance, hyperandrogenemia, obesity, and inflammation, and is the most common cause of infertility. Women with PCOS are at higher risk than non-PCOS women for diabetes, cardiovascular disease, endometrial cancer, and psychiatric disorders. Because many abnormalities present in PCOS and symptoms vary considerably among PCOS women, treatment is guided by presentation and does not consist of simply one modality. Often, however, one type of medication can ameliorate more than one abnormality in PCOS. This review summarizes current research on several treatment modalities for PCOS, including drugs that are fairly well-established as efficacious and other agents that may prove efficacious in the future, with particular emphasis on the benefits and barriers of lifestyle change.

Is it safe to prescribe clomiphene citrate without ultrasound monitoring facilities?

The majority of triplet and higher order multiple pregnancies now result from ovulation induction/superovulation rather than in vitro fertilisation. However, clomiphene citrate is still widely prescribed by gynaecologists and general practitioners who do not have access to ultrasound monitoring. The objective of our study was to determine the prevalence of multifollicular development with different doses of clomiphene citrate. A retrospective review of transvaginal ultrasound monitoring of 425 cycles in 182 women receiving clomiphene citrate from January 2002 to December 2003, was studied. Three or more follicles of >or= 14 mm were identified in 58 cycles (14%). Patients received 50 mg of clomiphene citrate in 52 of these 58 cycles and 25 mg in the remaining six. One patient was noted to have developed five follicles and 10 patients developed four follicles. One patient developed six follicles, despite receiving only 25 mg clomiphene citrate daily. It was concluded that a significant number of women (14%) developed three or more follicles, despite receiving low doses of clomiphene citrate.

Aromatase inhibitors for female infertility: a systematic review of the literature

Ovulation induction remains a milestone in the treatment of women with anovulatory infertility. Clomiphene citrate (CC) is considered the first line treatment for induction of ovulation in women with polycystic ovary syndrome (PCOS), while it may be used for ovulation induction in unexplained infertility. Aromatase inhibitors (AI) have been introduced as a new treatment option that could challenge CC for ovulation induction. A systematic review of the literature was conducted in order to highlight the efficacy and safety of AI in female infertility. Current data from randomized and non-randomized trials suggest that AI may have a role in ovulation induction regimens in PCOS patients, as well as for ovarian stimulation, since they achieve comparable clinical pregnancy rates to CC. Furthermore, when combined with gonadotrophins, AI improve the ovarian response of poor responders and reduce the gonadotrophin dose required. However, the current review is based on small trials with a limited number of patients. If solid data from future large adequately powered randomized trials support current evidence regarding efficacy and safety, AI might offer a new treatment choice for infertile women.

Sonographic study of the decidua basalis in the first trimester of pregnancy

OBJECTIVES

To describe the sonographic appearance of the decidua basalis and its changes in the first trimester of pregnancy.

METHODS

We reviewed images from 159 first-trimester ultrasound examinations in 105 women with uncomplicated pregnancies who later delivered at term. The appearance of the decidua basalis layer and the sonographic changes that it underwent, including in echogenicity and thickness, were analyzed with respect to gestational age.

RESULTS

A distinct decidual layer could be identified consistently at 5-6 weeks' gestation and its thickness peaked at 6-7 weeks. It was seen inconsistently at 8-9 weeks and was not identifiable by 10 weeks. Its appearance changed over time, from a uniformly echogenic layer at 5-6 weeks to a heterogeneous echogenic layer at 7 weeks, corresponding to the histological evidence of trophoblast penetration. The layer then became less echogenic with time until it became unidentifiable.

CONCLUSIONS

There is a window of opportunity in the first trimester for sonographic examination of the decidua. This may allow screening, at an early stage, for conditions that affect the decidua during pregnancy.

Characterization of endometrial growth in proliferative and early luteal phase in IVF cycles

Human endometrium has a definite role in implantation, although knowledge about its modifications in the course of IVF cycles is still limited. This study was performed to characterize endometrial growth throughout stimulation treatment in women undergoing IVF cycles, regardless of clinical outcomes. Endometrial growth was longitudinally evaluated by ultrasonography in the first induced ovarian stimulation cycle (717 patients). Acceleration and length of significant growth were used to assess the slope of the growth curve mathematically. Endometrial growth showed a parabolic trend and final thickness was significantly affected by age (P < 0.01). Endometria that tended to overgrowth had a more rapid and longer growth during the whole phase. A similar stimulation treatment was repeated within 6 months of the first one and a second evaluation was carried out to verify whether similar growth occurred. Similar growth was observed in 76% of the patients, with an absolute difference between the two cycles of <4 mm in 84% of cases. The endometrium seems to have an individual intrinsic potential that can be expressed regardless of the stimulation protocol. This supports the hypothesis that individual factors (intrinsic properties of the endometrium) significantly affect endometrial growth.