Relationship of follicle number and other factors to fecundability and multiple pregnancy in clomiphene citrate-induced intrauterine insemination cycles**Presented at The UCLA School of Medicine Third Annual In Vitro Fertilization and Embryo Transfer Comprehensive Update 1990, Santa Barbara, California, July 29 to August 1, 1990.††Reprint requests: Richard P. Dickey, M.D., Ph.D., Fertility Institute of New Orleans, 6020 Bullard Avenue, New Orleans, Louisiana 70128

Pregnancy Rates after Intrauterine Insemination in Moderate to Severe Endometriosis: A Systematic Review and Meta-analysis of Observational Studies

To evaluate the efficacy and safety of intrauterine insemination (IUI) in moderate to severe endometriosis patients, a systematic review and meta-analysis was conducted since the role of this treatment strategy in these patients is a matter of debate in the literature. Systematic searches were performed in PubMed, EMBASE, Cinahl, and The Cochrane Library from inception to September 1, 2016. Studies including moderate to severe endometriosis patients reporting pregnancy rates after IUI were selected. The primary outcome was live birth after IUI treatment compared to expectant management. Secondary noncomparative outcomes were live birth and clinical pregnancy, which were presented as weighed mean pregnancy rates. Nineteen articles (2 unclear design, 11 retrospective, 6 prospective) were included for the analysis. Our primary outcome measure was only addressed by one study, showing an odds ratio of 1.77 (95% confidence interval [CI], 0.86–3.63) on live birth favoring IUI versus no treatment. The calculated weighed mean live birth and clinical pregnancy rate per patient was 20.3% (95% CI, 11.2–29.4) and 32.7% (95% CI, 21.3– 44.0), respectively. This meta-analysis of observational data showed that IUI could be a feasible treatment in moderate to severe endometriosis. Whether this treatment should be structurally offered prior to in vitro fertilization needs to be investigated in a randomized, controlled trial, including time-to-pregnancy, safety, and cost-effectiveness.

Comparison of pregnancy rates in PCOS patients undergoing clomiphene citrate and IUI treatment with different leading follicular sizes

PURPOSE

The objective of the study was to compare the pregnancy rates in PCOS patients undergoing clomiphene citrate (CC) and intrauterine insemination (IUI) treatment with different leading follicular sizes.

METHODS

A total of 358 infertile women with PCOS who underwent 563 clomiphene citrate and IUI treatment cycles were included in this prospective study. Treatment cycles were divided into three groups according to leading follicular size on the day of hCG administration: Group I: follicular size 17-18 mm (n = 177), Group II: 19-22 mm (n = 321), and Group III : >22 mm (n = 65). Pregnancy rates were evaluated. Treatment outcomes of the groups were further analyzed related to endometrial thickness measurement on the day of hCG. For this purpose, cycles were placed into three subgroups as follows: endometrial thickness <7, 8-9, and >9 mm.

RESULTS

There was no statistically significant difference in clinical pregnancy rate per cycle between the groups (8.5, 10, and 9.2 % for Group I, II, and III, respectively, p = 0.86). In further analyses related to endometrial thickness, no significant difference was also found in pregnancy rate among the groups.

CONCLUSION

This results suggest that pregnancy rate is not related to leading follicle size on the day of hCG administration in PCOS patients treated with CC and IUI. In addition, pregnancy rate in women with different follicular sizes is not influenced by the endometrial thickness.

Patient satisfaction concerning assisted reproductive technology treatments in moderate to severe endometriosis

A prospective observational cohort study was performed to examine patient satisfaction after one Assisted Reproductive Technology (ART) treatment cycle in moderate to severe endometriosis patients. From May 2012 till September 2013, 25 patients with surgically proven endometriosis stage III-IV were included per group and received intrauterine insemination (IUI), in vitro fertilization (IVF) or IVF preceded by long-term pituitary down-regulation (IVF-ultralong). The median patient satisfaction scores were 8.3, 7.9 and 8.0 in patients receiving IUI (n = 22), IVF (n = 24) and IVF-ultralong (n = 23), respectively (p = 0.89). Both deterioration in pain and quality-of-life could not be identified as determinants of decreased patient satisfaction scores. Satisfaction was higher in women receiving their first ART treatment attempt (p = 0.002), after treatment accomplishment (p = 0.04) and after a positive pregnancy test (p = 0.04). A median satisfaction score concerning preceding long term pituitary down-regulation of 6.1 (IVF-ultralong n = 25, IUI n = 8) was reported. Only three patients would refrain from this preceding therapy in a next treatment attempt. We concluded that patient satisfaction scores were comparable between the three different ART treatments. Since patient satisfaction was in particular dependent on treatment outcomes, it is recommended to compare those three ART treatments in a randomized controlled trial investigating the efficacy, safety and cost-effectiveness.

Patient-specific predictions of outcome after gonadotropin ovulation induction/intrauterine insemination

OBJECTIVE

To use patient-specific and cycle-specific characteristics to predict clinical pregnancy, multiple pregnancy, and spontaneous abortion rates after gonadotropin ovulation induction (OI)/IUI.

DESIGN

Retrospective chart review.

SETTING

Academic fertility center.

PATIENT(S)

A total of 1,438 women who underwent 3,375 gonadotropin OI/IUI cycles.

INTERVENTION(S)

Individual and cycle-specific characteristics were evaluated to determine predictors of the rates of clinical pregnancy, multiple pregnancy, and spontaneous abortion. Logistic regression using individual parameters was used to create predictive models.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy (CPR), multiple pregnancy (MPR), and spontaneous abortion rates (SABR).

RESULT(S)

Multiple predictors were identified for CPR, MPR, and SABR. The presence of at least two follicles ≥ 13 mm at ovulation trigger significantly increased CPR (odds ratio [OR], 95% confidence interval [CI] = 1.45, 1.18-1.78) and MPR (OR, 95% CI = 5.17, 2.16-12.41). An E2 level >400 pg/mL significantly increased MPR (OR, 95% CI = 9.54, 2.31-39.42). Logistic regression models were developed for individualized predictions of outcome.

CONCLUSION(S)

Regression analysis reveals the patient and cycle-specific characteristics that are significant predictors of CPR, MPR, and SABR after OI/IUI. Logistic models using significant or nearly significant predictors for CPR, MPR, and SABR offer improved predictive power relative to simpler models, and allow for the development of a risk calculator for personalized patient counseling.

Intrauterine insemination with husband semen: an evaluation of pregnancy rate and factors affecting outcome

PURPOSE

The aim was to determine pregnancy rate following intrauterine insemination (IUI) and its associated factors in a university assisted reproductive technique center in Tehran, Iran.

METHODS

A retrospective analysis of 350 IUI cycles with ovarian stimulation by clomiphene citrate and/or gonadotropins was performed.

RESULTS

The overall pregnancy rate was 22% (77/350). Of the 77 pregnancies, 88.3% resulted in live birth, 7.8% in spontaneous abortion, 2.6% in blighted ovum and 1.3% were ectopic. Logistic regression analysis revealed three predictive variables as regards pregnancy: number of the treatment cycle (OR:3.5 CI:1.9 - 6.4 p:0.006), duration of infertility (OR:2.1 CI:1.2 - 3.7 p = 0.001) and age (OR:2.15 CI:1.1 - 4.4 p = 0.04). Pregnancy rate did not have any independent relation to sperm count, type of infertility, number and size of follicle and side of ovulatory ovary.

CONCLUSION

Our results indicate that clomiphene citrate and/or gonadotropins IUI is a convenient and useful treatment option in women with younger age ( <30 years) and fewer treatment cycles and fewer infertility duration (4 years).

Strategies to reduce multiple pregnancies due to ovulation stimulation

OBJECTIVE

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

DESIGN

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

RESULT(S)

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

CONCLUSION(S)

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

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

OBJECTIVES

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

Ovulatory status and follicular response predict success of clomiphene citrate-intrauterine insemination

OBJECTIVE

To test the hypothesis that anovulatory women would have good pregnancy rates (PRs), regardless of single or multiple follicular development, in response to clomiphene citrate (CC), whereas ovulatory women would have good PRs only when achieving multifollicular responses to CC.

DESIGN

Retrospective chart review.

SETTING

University-based infertility center.

PATIENT(S)

Two hundred and fifty-four women underwent 585 CC-IUI treatment cycles over a 3-year period.

INTERVENTION

Treatment with CC-IUI.

MAIN OUTCOME MEASURE(S)

Various factors were examined as predictors of clinical pregnancy rate (CPR) and live-birth rate (LBR) per cycle with the use of logistic regression.

RESULT(S)

Overall, the CPR was 11.1%, and the LBR was 8.7%. Of 65 clinical pregnancies, 81.5% resulted in live births (singletons, 67.7%; twins, 13.8%). There were no higher-order deliveries. In anovulatory women, the CPR and LBR were 15.7% and 13.6%, respectively. In ovulatory women, the CPR and LBR were 8.8% and 6.3%, respectively. As the number of large follicles increased from one to two, the LBR increased from 6.8% to 10.5%. Regarding the interaction of follicles with ovulatory status, anovulatory women had nearly double the CPR and LBR compared to those in ovulatory women, irrespective of the number of large follicles.

CONCLUSION(S)

Treatment with CC-IUI is more successful in anovulatory women than in ovulatory women. The multiple follicular response in both ovulatory and anovulatory women increases PRs.

No difference in cycle pregnancy rate and in cumulative live-birth rate between women with surgically treated minimal to mild endometriosis and women with unexplained infertility after controlled ovarian hyperstimulation and intrauterine insemination

OBJECTIVE

The association between infertility and minimal to mild endometriosis is controversial and poorly understood. The clinical pregnancy rate (PR) per cycle after controlled ovarian hyperstimulation (COH) with or without intrauterine insemination (IUI) is reportedly lower in women with surgically untreated minimal to mild endometriosis than in women with unexplained infertility. It is possible that prior laparoscopic removal of endometriosis has a positive effect on the clinical PR after COH and IUI. Therefore, we tested the hypothesis that after COH and IUI the PR per cycle and the cumulative live-birth rate (CLBR) are equal or higher in women with recently surgically treated minimal to mild endometriosis when compared with women with unexplained infertility.

DESIGN

A retrospective, controlled cohort study.

SETTING

Leuven University Fertility Centre, a tertiary academic referral center.

PATIENT(S)

One hundred seven women treated during 259 cycles with COH and IUI including patients with endometriosis (n = 58, 137 cycles) and unexplained infertility (n = 49, 122 cycles). All patients with endometriosis had minimal (n = 41, 100 cycles) or mild (n = 17, 37 cycles) disease that had been laparoscopically removed within 7 months before the onset of treatment with COH and IUI.

INTERVENTION(S)

Controlled ovarian hyperstimulation using clomiphene citrate (23 cycles) or gonadotrophins (236 cycles) in combination with IUI.

MAIN OUTCOME MEASURE(S)

Clinical PR per cycle and CLBR within four cycles of treatment with COH and IUI.

RESULT(S)

The clinical PR per cycle was comparable in women with minimal or mild endometriosis (21% or 18.9%, respectively) and in women with unexplained infertility (20.5%). The CLBR within four cycles of COH and IUI was also comparable in women with minimal endometriosis, mild endometriosis, and unexplained infertility (70.2%, 68.2 %, 66.5%, respectively).

CONCLUSION(S)

The data from our study suggest that COH and IUI shortly after laparoscopic excision of endometriosis is as effective as COH and IUI in patients with unexplained subfertility.

The role of laparoscopy in intrauterine insemination: a prospective randomized reallocation study

BACKGROUND

We questioned whether a laparoscopy should be performed after a normal hysterosalpingography before starting intrauterine inseminations (IUI) in order to detect further pelvic pathology and whether a postponed procedure after six unsuccessful cycles of IUI yields a higher number of abnormal findings.

METHODS

In a randomized controlled trial, the accuracy of a standard laparoscopy prior to IUI was compared with a laparoscopy performed after six unsuccessful cycles of IUI. The major end-point was the number of diagnostic laparoscopies revealing pelvic pathology with consequence for further treatment such as laparoscopic surgical intervention, IVF or secondary surgery. Patients were couples with medical grounds for IUI such as idiopathic subfertility, mild male infertility and cervical hostility.

RESULTS

Seventy-seven patients were randomized into the diagnostic laparoscopy first (DLSF) group and the same number was randomized into the IUI first (IUIF) group. The laparoscopy was performed on 64 patients in the DLSF group, 10 patients withdrew their consent from participation and three patients (3%) became pregnant prior to laparoscopy. In the IUIF group, 23 patients remained for laparoscopy because pregnancy did not occur after six cycles of IUI. From the original 77 randomized patients, 38 patients became pregnant and 16 patients dropped out. Abnormal findings during laparoscopy with therapeutic consequences were the same in both groups: in the DLSF group, 31 cases (48%) versus 13 cases (56%) in the IUIF group, P = 0.63; odds ratio (OR) = 1.4; 95% confidence interval (CI): 0.5-3.6. The ongoing pregnancy rate in the DLSF group was 34 out of 77 patients (44%) versus 38 out of 77 patients (49%) in the IUIF group (P = 0.63; OR = 1.2; 95% CI: 0.7-2.3).

CONCLUSIONS

Laparoscopy performed after six cycles of unsuccessful IUI did not detect more abnormalities with clinical consequences compared with those performed prior to IUI treatment. Our data suggest that the impact of the detection and the laparoscopic treatment of observed pelvic pathology prior to IUI seems negligible in terms of IUI outcome. Therefore, we seriously question the value of routinely performing a diagnostic and/or therapeutic laparoscopy prior to IUI treatment. Further prospective studies could be performed to determine the effect of laparoscopic interventions on the success rate of IUI treatment in order to rule out completely the laparoscopy from the diagnostic route prior to IUI.

Effect of diagnosis, age, sperm quality, and number of preovulatory follicles on the outcome of multiple cycles of clomiphene citrate-intrauterine insemination

OBJECTIVE

To determine how diagnosis, age, sperm quality, and number of preovulatory follicles affect pregnancy rates when multiple cycles of clomiphene citrate (CC)-IUI are performed.

DESIGN

Fifteen-year prospective observational study.

SETTING

Private infertility clinic.

PATIENT(S)

Three thousand, three hundred eighty-one cycles of husband or donor IUI.

INTERVENTION(S)

Ovulation induction with CC and IUI.

MAIN OUTCOME MEASURE(S)

Per-cycle pregnancy rate (PR), cumulative pregnancy rate (CPR).

RESULT(S)

Pregnancy rates remained constant through four cycles, then fell significantly for diagnoses other than ovulatory dysfunction. Mean PRs for cycles 1-4 were significantly lower for patients with the following characteristics: age >/=43 years, poor semen quality, single preovulatory follicles, and diagnoses other than ovulatory dysfunction. Additional cycles of CC-IUI compensated for low PRs because of age, semen quality, or number of follicles. After four cycles, CPRs were 46% for ovulatory dysfunction; 38% for cervical factor, male factor, and unexplained infertility; 34% for endometriosis; and 26% for tubal factor. After six cycles, CPRs were 65% for ovulation dysfunction, 35% for endometriosis, and unchanged for other diagnoses.

CONCLUSION(S)

Clomiphene citrate-intrauterine insemination should be performed for a minimum of four cycles. Additional cycles of CC-IUI can compensate for low pregnancy rates due to age, semen quality, or follicle number in patients with ovulation dysfunction.

Polycystic ovary syndrome and ovulation induction

Before initiating treatment to induce ovulation in cases of PCOS, an appropriate evaluation of the patient and her partner, based on individual considerations, is important to optimize outcome. For obese patients with PCOS, weight-loss measures should be pursued before pharmacologic treatment is initiated. For most patients, the pharmacologic agent of choice to induce ovulation is clomiphene citrate, alone or in combination with a glucocorticoid. Treatment with metformin, alone or in combination with clomiphene citrate, may also be beneficial. For patients not responsive to clomiphene citrate, injectable gonadotropin treatment is usually warranted, although, depending on individual circumstances, laparoscopic ovarian drilling may be appropriate.

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

OBJECTIVE

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

DESIGN

Fifteen-year prospective study.

SETTING

Private infertility clinic.

PATIENT(S)

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

INTERVENTION(S)

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

MAIN OUTCOME MEASURE(S)

Pregnancy and multiple implantations.

RESULT(S)

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

CONCLUSIONS

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

The management of unexplained infertility

Unexplained infertility is a diagnosis made by exclusion after all of the standard investigations have revealed no abnormality (1). The range of the prevalence is from 6 to 60 percent (23), depending on the diagnostic criteria. This article reviews the literature in the management of unexplained infertility; published data suggest no benefit of danazol or bromocriptine. The empirical use of clomiphene citrate suggests that ovarian stimulation using clomiphene citrate can double the spontaneous pregnancy rate (52, 58, 59). Induction of ovulation with human menopausal gonadotrophin (hMG) yields an overall pregnancy rate between 2 and 26 percent per cycle (68, 74). These results seem to be lower than those reported for in vitro fertilization (IVF) or gamete intrafallopian transfer (GIFT) procedures in similar patients (25-30 percent (92, 95)). Based on the literature, a rational treatment plan for treating infertility in couples with unexplained infertility includes up to four cycles of clomiphene citrate with or without intrauterine insemination (IUI). Superovulation with hMG and IUI or stimulated intrauterine insemination (SIUI) is the next step for three-cycle treatments and if unsuccessful, one of the variants of assisted reproductive techniques (ART) should be considered.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader will understand the appropriate tests and work up for unexplained infertility, the various treatment options for the unexplained infertility couple including which drugs are effective and not effective, and to be able to outline an appropriate treatment plan for such patients.

Comparison of intrauterine insemination with timed intercourse in superovulated cycles with gonadotropins: a meta-analysis

OBJECTIVE

To compare timed intercourse and IUI with the husband's sperm in patients with unexplained infertility who are undergoing superovulation with gonadotropins.

DESIGN

Meta-analysis. All published reports of randomized, prospective studies with an English-language abstract extracted from MEDLINE were analyzed. A crossover search was done from the papers obtained.

SETTING

Academic center.

PATIENT(S)

Couples with unexplained infertility.

INTERVENTION(S)

Meta-analysis of studies evaluating patients superovulated with gonadotropins and randomized for timed intercourse or IUI.

MAIN OUTCOME MEASURE(S)

Pregnancy rates (PRs) were obtained. The common odds ratio (OR) and 95% confidence intervals (95% CI) were calculated.

RESULT(S)

There were 49 pregnancies in 431 cycles of timed intercourse (11.37%), whereas there were 110 pregnancies in 549 cycles of IUI (20.04%). The PRs for IUI were significantly increased compared with those for timed intercourse in superovulation cycles (common OR = 1.84; 95% CI = 1.30-2.62).

CONCLUSION(S)

On the basis of the meta-analysis of 980 cycles in randomized and prospective studies, a patient's chances of becoming pregnant are greater with IUI with her husband's sperm than with timed intercourse in cycles superovulated with gonadotropins.

The effects of clomiphene citrate on normally ovulatory women

OBJECTIVE

To investigate the efficacy of clomiphene citrate (CC) on normally ovulatory women who complained of infertility.

DESIGN

A randomized study.

SETTING

University Hospital.

PATIENT(S)

Thirty-three normally ovulatory women with unexplained infertility.

INTERVENTION(S)

Eighteen women received CC at a 50-mg dosage. Fifteen women received no ovulation-induction drugs.

MAIN OUTCOME MEASURES

The pregnancy rate (PR) per patient, the PR per cycle, and the cumulative pregnancy rate.

RESULT(S)

Seven patients in the CC group stopped taking CC, and observations were terminated because of antiestrogenic effects. The pregnancy rate (PR) per patient and the PR per cycle were significantly decreased (P < 0.005) in the CC group (4 of 18 [22.2%] and 4 of 66 [6.1%], respectively) than in the spontaneous group (11 of 15 [73.3%] and 11 of 52 [21.2%], respectively). Kaplan-Meier tests showed that the cumulative pregnancy rate in the CC group was significantly lower than in the spontaneous group (P < 0.05). Five of seven patients who had stopped taking CC became pregnant in spontaneous cycles.

CONCLUSION(S)

Administration of CC to normally ovulatory women is not efficacious in terms of increasing the pregnancy rate.

Clomiphene citrate ovulation induction in combination with a timed intrauterine insemination: the value of urinary luteinizing hormone versus human chorionic gonadotropin timing

OBJECTIVE

To evaluate the clinical pregnancy rates (PRs) in anovulatory, male factor, and unexplained infertility using clomiphene citrate (CC) with an IUI and to evaluate the difference in PRs between urinary LH testing and hCG administration for timing of the IUI.

DESIGN

Retrospective clinical study.

SETTING

Academic, tertiary care fertility center.

PATIENT(S)

One hundred thirty-eight couples (432 cycles) undergoing IUI with CC ovulation induction as a treatment for unexplained, anovulatory, or male factor infertility were selected.

INTERVENTION(S)

All women with unexplained or male factor infertility received CC at a dose of 50 mg/d, and those with anovulation received CC at a dose ranging from 50 to 200 mg/d. All women in the study received a single IUI either the morning after a urinary LH surge or 36 to 38 hours after an evening hCG injection.

MAIN OUTCOME MEASURE(S)

Clinical PR.

RESULT(S)

There were no differences in the clinical PRs between LH testing or hCG administration in any of the three groups. Clinical PRs were extremely low in the male factor infertility group regardless of the timing used.

CONCLUSION(S)

These data suggest that the success of IUI with CC is not dependent on the method used to establish the timing for the IUI. In couples undergoing IUI with CC, the use of urinary LH testing may result in lower costs by reducing patient visits and the midcycle ultrasound.

Long gonadotrophin releasing hormone agonist/human menopausal gonadotrophin protocol for ovarian stimulation in intrauterine insemination treatment

OBJECTIVE

This prospective study was undertaken to examine the usefulness of a long gonadotrophin releasing hormone agonist (GnRH-a)/human menopausal gonadotrophin (hMG) protocol in intrauterine insemination (IUI) treatment. The results were compared to those of clomiphene citrate (CC)/hMG/IUI.

STUDY DESIGN

Seventy-five patients were recruited to a GnRH-a/hMG group (group 1) while 88 patients underwent CC/hMG stimulation and served as controls (group 2). The study subjects were stimulated with a long GnRH-a/hMG regimen. IUI was performed 36 h after the administration of human chorionic gonadotrophin.

RESULTS

The number of preovulatory follicles, the thickness of endometrium and sperm parameters were similar in both groups. The hMG requirements were significantly higher in group 1 than in group 2 (21.2 +/- 5.1 vs. 8.1 +/- 3.1 ampoules). The pregnancy rate was 20% in group 1 and 12.5% in group 2, the difference being not significant.

CONCLUSION

The pregnancy rates were not significantly different between the GnRH-a/hMG/ IUI and CC/hMG/IUI groups. In addition, GnRH-a/hMG stimulation is notably more expensive than CC/hMG, and for these reasons, GnRH-a/hMG stimulation is not cost-effective in routine IUI therapy.

Evolving patterns of iatrogenic multifetal pregnancy generation: implications for aggressiveness of infertility treatments

OBJECTIVE

Our purpose was to assess the changes in multifetal pregnancy generation as a function of utilization of ovulation stimulation and assisted reproductive techniques and to document the relative control of hyperstimulation between the methods.

STUDY DESIGN

The methods of infertility treatment, number of fetuses, and outcomes of 220 patients referred for multifetal pregnancy reduction were compared over three time periods (1986 to 1989, 1991 to 1992, and 1992 to 1993). Clomiphene, human menopausal gonadotropin, and ovulation stimulation with urofollitropin were compared against gamete intrafallopian transfer, zygote intrafallopian transfer, and in vitro fertilization (assisted reproductive techniques).

RESULTS

The proportion of multifetal pregnancies generated by assisted reproductive techniques has steadily risen from 26% in the first two time periods to nearly half in the last 2 years. However, the number and proportion of quintuplet and greater pregnancies from assisted reproductive techniques have steadily fallen while for ovulation stimulation the proportion has remained about one third.

CONCLUSION

Despite considerably increased use and proportionate generation of triplet and quadruplet pregnancies, the incidence of quintuplets has fallen for assisted reproductive techniques while there has been no improvement for ovulation stimulation. Continued, greater vigilance, particularly in the use of human menopausal gonadotropin and urofollitropin, must be emphasized.

Treatment by assisted conception of severe male factor infertility due to spinal cord injury or other neurologic impairment

PURPOSE

This retrospective study evaluated the pregnancy rates of 23 couples with male factor infertility due to traumatic spinal cord injury (N = 21), multiple sclerosis (N = 1) or transverse myelitis (N = 1).

METHODS

Ovulation induction by clomiphene citrate or gonadotropins was used in combination with intrauterine insemination as an initial approach for assisted conception in all but one couple.

RESULTS

Six pregnancies occurred in 60 cycles of intrauterine insemination (mean of 2.6 cycles). In this group, the cumulative pregnancy rate was 26%. Six couples who failed after a total of 33 intrauterine insemination cycles (mean of 5.5 cycles), and 1 couple with no previous intrauterine insemination cycles, initiated 10 cycles of in vitro fertilization (mean of 1.4 cycles). In this group, five pregnancies occurred. The pregnancy rate was 71%.

CONCLUSION

We conclude that ovulation induction in combination with intrauterine insemination offers an effective initial therapy of severe male factor infertility due to spinal cord injury.

Evaluation of clomiphene citrate and human chorionic gonadotropin treatment: a prospective, randomized, crossover study during intrauterine insemination cycles

OBJECTIVE

To test the hypothesis that in couples undergoing IUI, actively managed cycles using clomiphene citrate (CC) stimulation, ultrasound monitoring, and hCG timing will result in increased pregnancy rate (PR) per cycle compared with unstimulated urinary LH-timed cycles.

PATIENTS

Fifty-six couples with unexplained infertility (n = 26) or male factor infertility (n = 30) participated in the study.

SETTING

Tertiary academic medical center.

DESIGN

Prospective, randomized, crossover. Couples were randomized initially to one of the two study groups (treatment A: LH-timed IUI; treatment B: CC-stimulated, hCG-timed IUI). If no pregnancy occurred, each couple alternated between the two regimens during subsequent cycles, up to a total of four cycles.

RESULTS

Twenty-nine couples completed the study and the analysis of 95 cycles revealed that among the male factor infertility group, one pregnancy occurred during the 26 cycles of each treatment group (PR per cycle of 3.9% for both treatment groups). In contrast, among the unexplained infertility group, there was a marked difference in the effect of treatments. During treatment A only one pregnancy occurred in 20 cycles (PR of 5% per cycle) whereas during treatment B, six pregnancies occurred in 23 cycles (PR of 26.1% per cycle).

CONCLUSIONS

If IUI is chosen as the treatment modality in unexplained infertility, the addition of active ovulation management that includes CC stimulation, ultrasound monitoring of folliculogenesis, and hCG timing of ovulation increases the PR per cycle. In couples with male infertility, PR per cycle is low and is apparently not affected by the addition of active ovulation management.

Relationship of endometrial thickness and pattern to fecundity in ovulation induction cycles: effect of clomiphene citrate alone and with human menopausal gonadotropin

OBJECTIVE

To determine if preovulation endometrial thickness or pattern are related to fecundity and to use of clomiphene citrate (CC) or hMG in IUI.

DESIGN

Prospective ultrasound evaluation the day of hCG after CC alone (n = 197), hMG alone (n = 49), concurrent hMG or sequential CC and hMG (n = 205), and no medications (n = 23).

SETTING

Private fertility clinic.

PATIENTS

Two hundred seventy-one patients undergoing 474 cycles of IUI.

MAIN OUTCOME MEASURES

Endometrial thickness, pattern, per cycle fecundity, and continuing pregnancy.

RESULTS

Endometrial thickness was related to fecundity and continuing pregnancy. No pregnancies occurred when thickness was < 6 mm. The continuing pregnancy rate was 12.6% when thickness was > or = 9 mm, compared with 6.9% when thickness was 6 mm to 8 mm. Endometrial pattern was unrelated to pregnancy. Average endometrial thickness was decreased when hMG and CC were used in combination (7.9 mm) compared with hMG alone (9.4 mm). Endometrial thickness was negatively related to CC dose and positively related to the day of hCG administration by ANOVA.

CONCLUSIONS

Endometrial thickness the day of hCG administration is prognostic of fecundity and continuing pregnancy in cycles of ovulation induction.