Age of the female partner is a prognostic factor in prolonged unexplained infertility: a multicenter study

The Role of Total Oxidant and Antioxidant Levels in Follicular Fluid in Unexplained İnfertility

BACKGROUND

Unexplained infertility is defined as the absence of any pathology in the basic evaluation performed in couples who cannot achieve pregnancy after 1 year of unprotected sexual intercourse. The results of tests examining the causes of infertility show no identifiable cause in almost 15% of couples.

AIM

The aim of this study was to investigate the effects of reactive oxygen species (ROS) on pregnancy and embryos.

METHODS

This study included 200 patients, aged between 20-44 years, with unexplained infertility, who had recurrent intrauterine inseminations failures and hence started in vitro fertilization (IVF)/intracytoplasmic sperm injection treatment. Some amounts of waste follicular fluid samples were collected by embryologists from the oocytes of these patients during the ovum pick-up procedure. Next, total antioxidant status (TAS), total oxidant status (TOS), and oxidative stress index (OSI) values were calculated in the biochemistry laboratory.

RESULTS

In terms of pregnancy status, both follicular TOS and OSI values were not significantly different in patients with biochemical and clinical pregnancy, whereas TAS values were significantly higher in patients with pregnancy (P < 0.05). In terms of embryo quality, no significant difference was observed in TAS, TOS, and OSI values between grade 1 and 2 embryos, whereas pregnancy rates were significantly higher in patients who received grade 1 embryo transfer (P < 0.05). However, the follicular fluid TAS levels were significantly lower in smoking patients than in those who did not smoke; TOS and OSI levels were significantly higher.

CONCLUSION

This study showed that exposure to oxidative stress might be a causative factor for infertility. In addition, ROS decreased the level of TAS by increasing OSI in the follicular fluid; thus, antioxidant supplementation might be a necessity.

Long-term reproductive outcomes in patients with unexplained infertility: follow-up of the Fast Track and Standard Treatment Trial participants

OBJECTIVE

To evaluate long-term reproductive outcomes in couples who were enrolled in a large randomized controlled trial that studied optimal treatment for unexplained infertility.

DESIGN

Telephone survey, administered between March 2019 and February 2020.

SETTING

Large urban university-affiliated fertility center.

PATIENT(S)

Couples who enrolled in the Fast Track and Standard Treatment Trial (FASTT).

INTERVENTION(S)

None.

MAIN OUTCOMES MEASURE(S)

Number of live births, methods of conception, adoption, and satisfaction regarding family size.

RESULT(S)

Of the 503 couples enrolled in FASTT, 311 (61.8%) were contacted and 286 (56.9%) consented to participate. The mean age and follicle-stimulating hormone level at the time of enrollment in FASTT were 33.1 ± 3.2 years and 6.8 ± 2.2 mIU/mL, respectively, for those who participated in this study. The mean age at follow-up was 49.5 ± 3.4 years. Of the 286 women, 194 (67.8%) had a live birth during the trial and 225 (78.7%) continued to try to conceive after FASTT. Of those who tried to conceive without treatment, 101 of 157 (64.3%) had a successful live birth, whereas 12 (5.3%) women had a live birth via intrauterine insemination and 82 (36.4%) via autologous oocyte in vitro fertilization. Overall, 182 (80.9%) women achieved a live birth after FASTT.

CONCLUSION(S)

The majority of couples were able to achieve a live birth after FASTT. Only 19 (6.6%) never achieved a live birth during their reproductive years. Moving to treatment sooner allows the opportunity to achieve >1 live birth, which is associated with increased satisfaction regarding family size. This further supports access to care and insurance coverage for infertility treatment.

The stepwise development of an interactive web-based sex education programme for subfertile couples: the Pleasure & Pregnancy programme

STUDY QUESTION

Can we develop a web-based sex education programme (programme running in a web browser) that addresses the needs of subfertile couples who are advised expectant management for at least 6 months?

SUMMARY ANSWER

The 'Pleasure & Pregnancy' programme addresses couples' needs, is likely to improve couples' sexual functioning, and is subsequently hypothesised to improve the chance of natural pregnancy.

WHAT IS KNOWN ALREADY

According to professional guidelines (e.g. the Netherlands and UK) couples with unexplained subfertility and a good chance of natural pregnancy, should be advised at least 6 months of expectant management. Adherence to expectant management is challenging as couples and gynaecologist prefer a more active approach. Targeting sexuality may be useful as subfertility is a risk factor for decreased sexual functioning.

STUDY DESIGN, SIZE, DURATION

A novel programme was developed according to the three steps of the Medical Research Councils' (MRC) framework. First, relevant literature was explored. Second, an interdisciplinary expert panel developed a theory (based on a systematic literature review and patient interviews) on how the chance of natural conception can be improved. Third, the expected process and outcomes were modelled.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Two licenced clinical sexologists, two gynaecologists, a clinical embryologist and two midwife-researchers, all from Belgium and the Netherlands, proposed components for the sex education programme. PubMed was searched systematically for randomised controlled trials (RCTs) evaluating the proposed components in different patient populations. The needs of 12 heterosexual Dutch or Belgian couples who were advised expectant management were explored with in-depth interviews. The content and delivery characteristics of the novel programme were described in detail with the aid of 'Intervention Taxonomy'. To model the outcomes, a protocol for an RCT was designed, registered and submitted for publication.

MAIN RESULTS AND THE ROLE OF CHANCE

To help maintain or improve sexual functioning, mainly pleasure, and hence increase pregnancy rates, the web-based Pleasure & Pregnancy programme contains a combination of psychosexual education and couple communication, mindfulness and sensate focus exercises. Information on the biology of conception and interaction with fertility clinic staff and peers were added based on couples' needs to increase potential acceptability.

LIMITATIONS AND REASON FOR CAUTION

This paper outlines the development phase of a sex education programme according to the MRC-framework. Whether the Pleasure & Pregnancy programme actually is acceptable, improves sexual functioning, increases pregnancy rates and is cost-effective remains to be determined.

WIDER IMPLICATIONS OF THE FINDINGS

No previous interactive web-based sex education programme has aimed to increase the natural pregnancy rate of subfertile couples by targeting their sexual pleasure. The Pleasure & Pregnancy programme addresses couples' needs and its effect on sexual functioning and pregnancy rate is plausible but remains to be demonstrated by an RCT which is currently ongoing.

STUDY FUNDING/COMPETING INTEREST(S)

Funding was provided by The Netherlands Organisation for Health Research and Development (ZonMw), Flanders Research Foundation and the University of Amsterdam. C.B.L. is editor-in-chief of Human Reproductionbut was blinded to all parts of the peer review process. The remaining authors have no conflict of interest to report.

TRIAL REGISTRATION NUMBER

Not applicable.

A systemic review of intravenous immunoglobulin G treatment in women with recurrent implantation failures and recurrent pregnancy losses

Over the last few decades, the advancement in reproductive technologies and protocols to improve embryo quality through culture techniques and genetic testing to eliminate chromosomally abnormal embryos resulted in better pregnancy rates and outcomes after fertility treatments. Unfortunately, some patients still struggle with recurrent implantation failures (RIFs) and recurrent pregnancy losses (RPLs). Immune etiologies have been attributed to play an important role in some of those patients. Maintaining a pre-conceptional anti-inflammatory environment for implantation and pregnancy continuation yields superior results. Intravenous immunoglobulin G (IVIG) treatment has been reported to enhance reproductive outcome in patients with RIF and RPL with immune dysregulations. In this systemic review, we analyzed outcomes of IVIG trials for RIF and RPL, its mechanism of action, dosing, administration, side-effects, and evidence for its use in women with RIF and RPL.

Does Laparoscopy and Hysteroscopy Have a Place in the Diagnosis of Unexplained Infertility?

The standard fertility workup includes assessment of ovulation, semen analysis, and evaluation of tubal patency. If the fertility workup is found to be normal, a diagnosis of unexplained infertility is made. The role of laparoscopy in fertility workup has been a matter of debate. The current review presents the evidence for and against laparoscopy and hysteroscopy during fertility workup and subsequently prior to fertility treatment. After appraising the literature, we found the role of diagnostic laparoscopy in fertility workup is limited and is dependent on factors like prevalence of pelvic infection, setting, and availability of expertise. Moreover, whenever a laparoscopy is planned as a part of the fertility workup, the preparation should include ability to carry out simultaneous therapeutic intervention to maximize the benefit. Similarly, the routine use of hysteroscopy in women with unexplained infertility cannot be recommended. There is a need to investigate the impact of choice of tubal test on chances of spontaneous conception and treatment outcomes in women with unexplained infertility. Our future research agenda should also include high-quality multicenter randomized trials assessing the cost-effectiveness of screening and operative hysteroscopy prior to intrauterine insemination or in vitro fertilization.

Leptin as a Predictive Marker in Unexplained Infertility in North Indian Population

INTRODUCTION

According to WHO, the primary infertility in India is about 3.9% (age-standardized to 25-49 year) and 16.8% (age-standardized to 15-49 year), using the "age but no birth" definition. Several factors which affect fertility include low sperm production in men, poor egg quality and blocked fallopian tubes in women and also hormonal imbalances. Leptin plays a critical role in women's reproduction and neuroendocrine health. It is used for treating exercise-induced bone loss, eating disorders and infertility.

AIM

To evaluate the serum leptin levels in Indians and to ascertain the relationship between serum leptin levels, Unexplained Infertility (UI) and related variables [height, weight, Waist Hip Ratio (WHR), Body Mass Index (BMI)] between obese infertile, non-obese infertile and healthy subjects.

MATERIALS AND METHODS

The present case-control study was conducted at the Department of Obstetrics and Gynaecology, King George's Medical University (KGMU), Lucknow, India and funded by Department of Science and Technology, New Delhi, India. The study included 229 female participants in the age group of 18-40 years (120 cases and 109 controls) who were randomly selected. The blood samples were collected from the Infertility Clinic, Queen Mary's Hospital, KGMU, Lucknow, India. All the participants underwent complete physical examination. Initially, the participants were categorized into fertile and infertile groups, they were further divided on the basis of BMI, normal (BMI- 18.5-24.5) and overweight or obese (BMI≥25). Leptin level was measured by Active Human Leptin ELISA kit and BMI of all subjects was calculated in kg/m² (weight in kg and height in m).

RESULTS

A highly positive linear correlation (R=0.754, p<0.001) was found between BMI and serum leptin in unexplained infertile women, which indicates a strong relationship between BMI and serum leptin. The variation in serum leptin is explained by the independent variable, BMI. There was a partial positive linear correlation between BMI and serum leptin in the control group. Statistically there was no significant correlation (R=0.109, p=0.258) between BMI and serum leptin in the control group.

CONCLUSION

The present study clearly demonstrates that level of leptin is higher in unexplained infertile than in the fertile group, and also shows that a strong relationship exists between BMI and serum leptin in the obese group. Serum leptin level was significantly higher in obese than non-obese subjects. Thus, leptin is an important factor for normal reproductive function. Obesity, the main cause of infertility may be controlled by regulating the leptin concentration.

Regional Variation in Rates of IVF Treatment across Australia: A Population-based Study

Background: There is variation in uptake of in vitro fertilisation (IVF) between countries, and Australia has high incidence rates of IVF due to universal public funding. However, it remains unclear whether there is regional variation and, if present, what might cause this. Objectives: We sought to determine whether regional variations in treatment rates existed and what might influence these. Methods: The number of cycles of fresh IVF and intrauterine insemination (IUI) for women were obtained for the period 2011 until 2014 in two age groups (25 to 34 years and 35 to 44 years) to calculate incidence rates. Proxy indicators that might influence treatment affordability were: unemployment rates; average weekly total earnings; coverage of private health insurance; and, percentage of women in the highest socioeconomic quintile. Measures of accessibility considered were percentage of the population remote from urban areas and average state population density. Linear regressions were performed using log-transformed ratio of IVF and IUI incidence rates. Results: Variations were found in IVF uptake between states with greater differences in older women. There was no significant association between IVF procedures and population density or geographic isolation. Economic factors were not associated with IVF uptake. Conclusion: These findings suggest that factors such as physician preference, clinical practice guidelines, and cryopreservation protocols of ART units might explain the national variation in uptake of IVF.

Preovulatory uterine flushing with saline as a treatment for unexplained infertility: a randomised controlled trial protocol

INTRODUCTION

In vitro fertilisation (IVF) is the treatment of choice for unexplained infertility. Preovulatory uterine flushing could reduce intrauterine debris and inflammatory factors preventing pregnancy and constitute an alternative to IVF. Our objective is to assess the efficacy of preovulatory uterine flushing with physiological saline for the treatment of unexplained infertility.

METHODS AND ANALYSIS

We will perform a randomised controlled trial based on consecutive women aged between 18 and 37 years consulting for unexplained infertility for at least 1 year. On the day of their luteinising hormone surge, 192 participants will be randomised in two equal groups to either receive 20 mL of physiological saline by an intrauterine catheter or 10 mL of saline intravaginally. We will assess relative risk of live birth (primary outcome), as well as pregnancy (secondary outcome) over one cycle of treatment. We will report the side effects, complications and acceptability of the intervention.

ETHICS AND DISSEMINATION

This project was approved by the Ethics committee of the Centre Hospitatlier Universitaire de Quebec (no 2015-1146). Uterine flushing is usually well tolerated by women and would constitute a simple, affordable and minimally invasive treatment for unexplained infertility. We plan to communicate the results of the review by presenting research abstracts at conferences and by publishing the results in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT02539290; Pre-results.

Genetically induced oxidative stress in mice causes thrombocytosis, splenomegaly and placental angiodysplasia that leads to recurrent abortion

Historical data in the 1950s suggests that 7%, 11%, 33%, and 87% of couples were infertile by ages 30, 35, 40 and 45, respectively. Up to 22.3% of infertile couples have unexplained infertility. Oxidative stress is associated with male and female infertility. However, there is insufficient evidence relating to the influence of oxidative stress on the maintenance of a viable pregnancy, including pregnancy complications and fetal development. Recently, we have established Tet-mev-1 conditional transgenic mice, which can express the doxycycline-induced mutant SDHC^V69E transgene and experience mitochondrial respiratory chain dysfunction leading to intracellular oxidative stress. In this report, we demonstrate that this kind of abnormal mitochondrial respiratory chain-induced chronic oxidative stress affects fertility, pregnancy and delivery rates as well as causes recurrent abortions, occasionally resulting in maternal death. Despite this, spermatogenesis and early embryogenesis are completely normal, indicating the mutation's effects to be rather subtle. Female Tet-mev-1 mice exhibit thrombocytosis and splenomegaly in both non-pregnant and pregnant mice as well as placental angiodysplasia with reduced Flt-1 protein leading to hypoxic conditions, which could contribute to placental inflammation and fetal abnormal angiogenesis. Collectively these data strongly suggest that chronic oxidative stress caused by mitochondrial mutations provokes spontaneous abortions and recurrent miscarriage resulting in age-related female infertility.

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SDHC mutation induces oxidative stress in the female reproductive organs.

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Early development is completely normal in Tet-mev-1 mice.

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Non-pregnant and pregnant Tet-mev-1 mice exhibit thrombocytosis and splenomegaly.

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Pregnant mice have placental angiodysplasia with decreased Flt-1/ VEGFR-1.

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Habitual abortion is frequently caused with occasional maternal death in Tet-mev-1 mice.

The need for new methods of ovarian stimulation

It is easy to diagnose sterility but much harder to diagnose subfertility, because minor defects are not necessarily associated with consistent impairment of fertility. Correct evaluation of the background fertility can avoid needless treatment of couples. Ovarian stimulation is a powerful strategy frequently used to re-establish or improve fertility in infertile couples, but it is often the cause of twin pregnancy. The risks and costs of multiple gestation are important factors that must be taken into full account in the pro-fertility decision. To avoid twins, inseminations should preferably be done in unstimulated cycles or in association with induced mono-ovulatory cycles. For the same reason, it is probably time to follow the policy of favouring single embryo transfer in young women undergoing IVF and intracytoplasmic sperm injection programmes. In addition, there is an urgent need to avoid an invasive multiple transfer policy in women over 38 and to select new strategies to improve the well-known age-related lower implantation rate.

Management of the infertile couple: an evidence-based protocol

BACKGROUND

Infertility is defined as inability of a couple to conceive naturally after one year of regular unprotected sexual intercourse. It remains a major clinical and social problem, affecting perhaps one couple in six. Evaluation usually starts after 12 months; however it may be indicated earlier. The most common causes of infertility are: male factor such as sperm abnormalities, female factor such as ovulation dysfunction and tubal pathology, combined male and female factors and unexplained infertility.

OBJECTIVES

The aim of this study is to provide the healthcare professionals an evidence-based management protocol for infertile couples away from medical information overload.

METHODS

A comprehensive review where the literature was searched for "Management of infertility and/or infertile couples" at library website of University of Bristol (MetaLib) by using a cross-search of different medical databases besides the relevant printed medical journals and periodicals. Guidelines and recommendations were retrieved from the best evidence reviews such as that from the American College of Obstetricians and Gynaecologists (ACOG), American Society for Reproductive Medicine (ASRM), Canadian Fertility and Andrology Society (CFAS), and Royal College of Obstetricians and Gynaecologists (RCOG).

RESULTS

A simple guide for the clinicians to manage the infertile couples.

CONCLUSIONS

The study deploys a new strategy to translate the research findings and evidence-base recommendations into a simplified focused guide to be applied on routine daily practice. It is an approach to disseminate the recommended medical care for infertile couple to the practicing clinicians.

Public financing of IVF: a review of policy rationales

There is great diversity in in vitro fertilization (IVF) funding and reimbursement policies and practice throughout Europe and the rest of the world. While many existing reimbursement and regulatory frameworks address safety and legal concerns, economic factors also assume a central role. However, there are several problems with the evidence that is available on the economics of IVF. This suggests there is a need for more robust cost-effectiveness studies. It also indicates the need for alternative rationales to justify the reimbursement of IVF, which might more fully account for the social, political, ethical, and philosophical considerations embedded in notions of infertility and technology-driven reproductive treatments. The merits and limitations of five alternative rationales are discussed. The review suggests that while no existing single rationale provides a complete framework with which to support funding decisions, taken together they provide guideposts which signal important issues for consideration and highlight where further research, action, and debate are needed.

Comparison of single versus double intrauterine insemination

OBJECTIVE

To compare the outcomes of single versus double intrauterine insemination.

MATERIALS AND METHODS

This prospective randomized study was carried out in 100 infertile patients. One intrauterine insemination was applied 36 hours after human chorionic gonadotropin (hCG) injection to 50 patients in the first group. To 50 patients in the second group, two intrauterine inseminations were applied, of which the first was applied 24 hours after and the second 48 hours after the hCG injection.

RESULTS

In the first group, pregnancies were detected in eight patients (pregnancy rate per patient was 16%, pregnancy rate per cycle was 10.6%). In the second group, pregnancies were detected in five patients (pregnancy rate per patient was 10%, pregnancy rate per cycle was 6.4%). There was no statistically significant difference between the two groups ( p > 0.05).

CONCLUSION

Single intrauterine insemination can be considered to be more reasonable than double intrauterine insemination treatment, taking into consideration the economic cost and the psychologic trauma to the patients. However, further studies with larger sample sizes are needed in order to reveal any actual differences between the two methods.

Predictive value and clinical impact of Basal follicle-stimulating hormone in subfertile, ovulatory women

CONTEXT

Basal FSH is a marker for ovarian reserve.

OBJECTIVES

The objective of the study was to investigate the predictive value of basal FSH on spontaneous ongoing pregnancy in subfertile ovulatory women.

DESIGN

This was a prospective cohort study.

SETTING

The study was conducted in 19 fertility centers in The Netherlands.

PARTICIPANTS

Subfertile ovulatory women without two-sided tubal pathology and in whom the man had normal sperm parameters (total motile count > or = 3 x10(6)) participated in the study.

INTERVENTIONS

Interventions included a fertility work-up, including a basal FSH measurement on cycle d 3.

MAIN OUTCOME MEASURES

Spontaneous ongoing pregnancy was measured.

RESULTS

We included 3519 consecutive couples of which 562 (16%) had a spontaneous ongoing pregnancy within 1 yr. Basal FSH levels of 8 IU/liter or higher were associated with a decreased probability of spontaneous ongoing pregnancy [hazard ratio (HR) 0.93/IU.liter (95% confidence interval [CI] 0.87-0.98)]. In a multivariable analysis, female age (HR 0.97/yr, 95% CI 0.95-0.99), cycle length (HR 0.96/d, 95% CI 0.93-1.0), and FSH levels 8 IU/liter or greater (HR 0.93/IU.liter, 95% CI 0.87-0.99) were strong negative predictors for spontaneous ongoing pregnancy. Addition of FSH to a prediction model based on female age, duration of subfertility, previous pregnancy, referral status, and semen analysis changed the probability to conceive spontaneously from 30% or greater to less than 30% in 97 of 3219 couples (3.0%).

CONCLUSIONS

In ovulatory women, a basal FSH level of 8 IU/liter or higher is associated with decreasing fecundity, independent of female age and cycle length. Because the number of couples in whom the FSH level alters management decisions is low, we do not recommend routine testing of basal FSH in subfertile couples.

Association between age and epididymal and accessory sex gland function and their relation to sperm motility

Increased male age has been associated with significant reduction in pregnancy rates. This study investigated the association between age, the function of epididymal and accessory sex glands, and their relation to sperm motility. Ejaculates from 498 men assessed for infertility were analysed according to WHO [1999] guidelines. Seminal markers of epididymal (neutral alpha-glucosidase (NAG)), prostatic (prostate-specific antigen (PSA) and zinc), and seminal vesicle function (fructose) were measured. Four groups according to age were defined: G(21-30) (21-30 years), G(31-40) (31-40 years), G(41-50) (41-50 years), and G(>50) (51-66 years). Percentage progressive motility was significantly lower in G(>50) compared with G(21-30). NAG, PSA, zinc, and fructose were significantly lower in G(>50) compared with G(21-30). In a multiple regression analysis model, NAG and PSA showed positive significant association with percentage progressive motility. The opposite trend was found regarding zinc. No association between fructose and percentage progressive motility was shown. In this cross-sectional study, declined sperm motility observed in men over 50 years of age might be due to age-dependent changes in epididymal and accessory sex gland function.

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

OBJECTIVE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Use of ovarian reserve tests for the prediction of ongoing pregnancy in couples with unexplained or mild male infertility

The chance of infertile patients conceiving is related to factors like female age and duration of infertility. This prospective observational study evaluated whether the results of ovarian reserve tests, including the novel marker serum anti-Mullerian hormone (AMH), were of additional value in predicting ongoing pregnancy. Two hundred and twenty-two patients diagnosed with unexplained infertility or mild male factor (total motile count>10x10(6)) on the basis of the infertility work-up were prospectively included. Antral follicle count, AMH, inhibin B, FSH and oestradiol concentrations were determined during the early follicular phase. Outcome measures were treatment-dependent and treatment-independent ongoing pregnancy and time to ongoing pregnancy. There were 159 ongoing pregnancies, 52 of which occurred spontaneously. Pregnant patients were significantly younger than those who did not become pregnant (median age 32.4 versus 34.9 years, P<0.001) and FSH concentrations were higher in non-pregnant patients (median 6.8 versus 7.6 IU/l, P=0.04). Only age (hazard ratio 0.93, 95% CI 0.90-0.97) and whether or not the patient was undergoing treatment (hazard ratio 8.10, 95% CI 5.66-11.61) were significantly associated with time to ongoing pregnancy. Ovarian reserve tests, other than chronological age, seem of limited value in predicting (time to) ongoing pregnancy in patients with unexplained and mild male infertility.

Why do couples refuse or discontinue ART?

The first child born after in-vitro fertilisation, (IVF)-treatment, just passed its 26th birthday in July 2004. Since that birth-assisted reproduction techniques (ART) became a practicable technology, they had been used all over the world, and more than 2 million children were born after IVF-treatment. Despite all success in this field, ART is neither accepted nor used for all infertile couples, although this might be the only possibility of becoming pregnant. Two different kinds of ART refusal are distinguishable: the primary refusal being for financial, psychosocial, moral, ethical and medical reasons including the risk of severe ovarian hyperstimulation syndrome, the risk of multiple pregnancies and the risk of malformations. The secondary refusal includes dropouts after one or more unsuccessful IVF-treatments mainly influenced by the outcome of previous cycles (prognostic factors: oocyte and embryo count, embryo quality, females age) associated with psychological and emotional aspects. However, financial factors seem to be the most potent reasons for ART-refusal.

In vitro fertilisation for unexplained subfertility

BACKGROUND

In vitro fertilisation (IVF) is now a widely accepted treatment for unexplained infertility (RCOG 1998). However, with estimated live-birth rates per cycle varying between 13% and 28%, its effectiveness has not been rigorously evaluated in comparison with other treatments. With increasing awareness of the role of expectant management and less invasive procedures such as intrauterine insemination, concerns about multiple complications and costs associated with IVF, it is extremely important to evaluate the effectiveness of IVF against other treatment options in couples with unexplained infertility.

OBJECTIVES

The aim of this review is to determine, in the context of unexplained infertility, whether IVF improves the probability of live-birth compared with (1) expectant management, (2) clomiphene citrate (CC), (3) intrauterine insemination (IUI) alone, (4) IUI with controlled ovarian stimulation, and (5) gamete intrafallopian transfer (GIFT).

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (searched 23 March 2004), the Cochrane Central Register of Controlled Trials (Cochrane Library Issue 3, 2004), MEDLINE (1970 to August 2004), EMBASE (1985 to August 2004) and reference lists of articles. We also handsearched relevant conference proceedings and contacted researchers in the field.

SELECTION CRITERIA

Only randomised controlled trials were included. Live-birth rate per woman was the primary outcome of interest.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed eligibility and quality of trials.

MAIN RESULTS

Ten randomised controlled trials were identified. In two we could not extract data separately for unexplained infertility cases, two were non-randomised, one did not report valid rates (included in the review but not in the meta-analysis); leaving four trials for analysis. One trial compared two different interventions (IVF versus IUI with or without ovarian stimulation) and one study compared three interventions (IVF versus IUI with ovarian stimulation and GIFT). The numbers of trials assessing the effectiveness of IVF with the other treatments were as follows: IVF versus expectant management (two), IVF versus IUI (one), IVF versus IUI with ovarian stimulation (two) and IVF versus GIFT (three). Live-birth rate per woman was reported in three studies and three studies determined clinical pregnancy rate per woman. Multiple pregnancy rate was reported in three trials. Two studies reported ovarian hyperstimulation syndrome (OHSS) as an outcome measure. There were no comparative data for clomiphene citrate and no comparative data on live-birth rates for GIFT. There was no evidence of a difference in live-birth rates between IVF and IUI either without (OR 1.96; 95% CI 0.88 to 4.4) or with (OR 1.15; 95% CI 0.55 to 2.4) ovarian stimulation. There were significantly higher clinical pregnancy rates with IVF in comparison to expectant management (OR 3.24; 95% CI 1.07 to 9.80). There was no significant difference between IVF and GIFT for the one RCT that reported live-birth rates (OR 2.57; 95% CI 0.93 to 7.08). However, there was a significant difference in the clinical pregnancy rates between IVF and GIFT, with pregnancy rates greater for IVF (OR 2.14; 95% CI 1.08 to 4.2). There was no evidence of a difference in the multiple pregnancy rates between IVF and IUI with ovarian stimulation (OR 0.63; 95% CI 0.27 to 1.5), however, IVF had a higher rate than GIFT (OR 6.3; 95% CI 1.7 to 23). Clinical heterogeneity was present among the studies included. However, there was no evidence of statistical heterogeneity, which allowed the studies to be combined for statistical analysis.

AUTHORS' CONCLUSIONS

Any effect of IVF relative to expectant management, clomiphene citrate, IUI with or without ovarian stimulation and GIFT in terms of live-birth rates for couples with unexplained subfertility remains unknown. The studies included are limited by their small sample size so that even large differences might be hidden. Live-birth rates are seldom reported. Periods of follow up are inadequate and unequal. Adverse effects such as multiple pregnancies and ovarian hyperstimulation syndrome have also not been reported in most studies. Larger trials with adequate power are warranted to establish the effectiveness of IVF in these women. Future trials should not only report rates per woman/couple but also include adverse effects and costs of the treatments as outcomes. Factors that have a major effect on these outcomes such as fertility treatment, female partner's age, duration of infertility and previous pregnancy history should also be considered.

Present concept of unexplained infertility

Despite improvements in both diagnostic assessment and treatment of infertile couples, many couples still have no explanation for their infertility. Unexplained infertility (the failure to conceive of a couple in whom no definitive cause for infertility can be found) has an incidence of 10-20% in all infertile couples. The incidence varies with the population studied and with the criteria used. Unexplained infertility is not an absolute condition but rather a relative inability to conceive, and many of these couples may conceive without treatment. The treatment options for unexplained infertility are several and the treatment results are promising. Expectant management can be recommended if the woman is under 28-30 years of age and the infertility duration is less than 2-3 years. In vitro fertilization (IVF) has revolutionized the treatment of infertile couples, as well as profoundly increasing the basic understanding of human reproduction. IVF can be used as both a diagnostic and a therapeutic tool in couples with unexplained infertility. The pregnancy rates with IVF are good, at 40% per treatment cycle. In addition, the outcome of pregnancies among women with unexplained infertility is generally comparable to that of spontaneous and other pregnancies using assisted reproductive technologies.

Unexplained infertility: a review of diagnosis, prognosis, treatment efficacy and management

The dilemma of unexplained infertility posed by Southam in 1960 remains today: despite advances in the diagnostic assessment of infertility, many couples still have no explanation for their infertility. Even the most sophisticated evaluation of semen, ovulation and genital tract competence cannot reveal all of the possible defects in the complex process leading to conception. Because it arises from these shortcomings in our knowledge of fertilization and from our inability to utilize all of the current knowledge, unexplained infertility is a challenge for both biological and clinical research. This paper attempts to summarize some clinical issues in the management of unexplained infertility: the prevalence of the disorder, problems in the definition and possible explanations for the existence of this diagnostic category. It reviews outcome-based clinical publications as a guide to decision-making on what diagnostic tests to use, provides a summary of the untreated prognosis and evaluates study results that may serve as a basis for treatment decisions in this puzzling diagnostic category of infertility.

Longitudinal analyses of the relationship between unsupportive social interactions and psychological adjustment among women with fertility problems

This study examined the association of unsupportive social interactions and psychological adjustment among 123 women with fertility problems, and tested whether threat appraisals and avoidance coping mediate this association. Cross-sectional analyses suggested that infertility-specific unsupportive responses received from other people were associated positively with adjustment problems. Avoidance coping and threat appraisals mediated this association between unsupportive social interactions and adjustment. Longitudinal analyses with 67 of these women revealed that after controlling for Time 1 adjustment, Time 1 unsupportive social interactions were associated positively with depressive symptoms and overall psychological distress only for women who remained infertile at Time 2, compared with women who were pregnant or had given birth. Associations between Time 1 unsupportive social interactions and self-esteem at Time 2 were similar for both groups of women.

Female subfertility

With an average monthly fecundity rate of only 20%, human beings are not fertile mammals. 10-15% of couples have difficulties conceiving, or conceiving the number of children they want, and seek specialist fertility care at least once during their reproductive lifetime. Dependent on the two main factors that determine subfertility, duration of childlessness and age of the woman, three questions need to be addressed before treatment is offered. Is it time to start the routine fertility investigation?--ie, has sufficient exposure to the chance of conception taken place? Are cost-effective, safe, and reliable treatments available for the disorder diagnosed? And, should the couple be referred straightaway for assisted reproduction?

The National Regional Advisory Council practice survey for 2000

A practice survey for the year 2000 was conducted through the National Regional Advisory Council. Each respondent was asked to supply detailed information on diagnostic and therapeutic procedures in the first 20 consecutive patients seen in that year with follow-up for 1 year or until an ongoing pregnancy was reached. The results show interesting patterns of geographic differences in treatment of the infertile couple. In general, American Society for Reproductive Medicine guidelines for practice were followed.

In vitro fertilisation for unexplained subfertility

BACKGROUND

In vitro fertilisation (IVF) is now a widely accepted treatment for unexplained infertility (RCOG 1998). However, with estimated livebirth rates per cycle varying between 13% and 28%, it's effectiveness has not been rigorously evaluated in comparison with other treatments. With increasing awareness of the role of expectant management and less invasive procedures such as intrauterine insemination, concerns about multiple complications and costs associated with IVF, it is extremely important to evaluate the effectiveness of IVF against other treatment options in couples with unexplained infertility.

OBJECTIVES

The aim of this review is to determine, in the context of unexplained infertility, whether IVF improves the probability of livebirth compared with 1. expectant management 2. clomiphene citrate (CC) 3. intra uterine insemination (IUI) alone 4. IUI with controlled ovarian stimulation and 5. Gamete IntraFallopian Transfer (GIFT).

SEARCH STRATEGY

RCTs were identified using the search strategies developed for the Menstrual Disorders and Subfertility Group. See Review group for more information.

SELECTION CRITERIA

Only randomised controlled trials were included. Livebirth rate per woman was the primary outcome of interest.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed eligibility and quality of trials.

MAIN RESULTS

Nine randomised controlled trials were identified. In two we could not extract data separately for unexplained infertility cases, two were non-randomised, one reported no valid rates (included in the review and not in the meta-analysis), leaving four trials for analysis. One trial compared two different interventions (IVF versus IUI with or without ovarian stimulation) and one study compared three interventions (IVF versus IUI with ovarian stimulation and GIFT). The number of trials assessing the effectiveness of IVF with the other treatments were as follows: IVF versus expectant management (one), IVF versus IUI (one), IVF versus IUI with ovarian stimulation (two) and IVF versus GIFT (three). Livebirth rate per woman was reported in two studies and three studies determined clinical pregnancy rate per woman. Multiple pregnancy rate was reported in three trials. Two studies reported ovarian hyperstimulation syndrome (OHSS) as an outcome measure. There were no comparative data for clomiphene citrate, and no comparative data on livebirth rates for expectant management or GIFT. There was no evidence of a difference in livebirth rates between IVF and IUI either without (OR 0.51, 95% CI 0.23 to 1.1) or with (OR 0.87, 95% CI 0.42 to 1.8) ovarian stimulation. There was no evidence of a difference in clinical pregnancy rates between IVF and expectant management. There was no significant difference in the clinical pregnancy rates between IVF and GIFT (OR 0.47, 95% CI 0.24 to 0.92). There was no evidence of a difference in the multiple pregnancy rates between IVF and either IUI with ovarian stimulation (OR 1.59, 95% CI 0.68 to 3.70) or GIFT (OR 0.47, 95% CI 0.08 to 0.58). Clinical heterogeneity was present among the studies included. However, there was no evidence of statistical heterogeneity, which allowed the studies to be combined for statistical analysis.

REVIEWER'S CONCLUSIONS

Any effect of IVF relative to expectant management, clomiphene citrate, IUI with or without ovarian stimulation and GIFT in terms of livebirth rates for couples with unexplained subfertility remains unknown. The studies included are limited by their small sample size, so that even large differences might be hidden. Livebirth rates are seldom reported. Adverse effects such as multiple pregnancies and ovarian hyperstimulation syndrome have also not been reported in most studies. Larger trials with adequate power are warranted to establish the effectiveness of IVF in these women. Future trials should not only report rates per woman /couple but also include adverse effects and costs of the treatments compared as outcomes. Factors that have a major effect on these outcomes such as fertility treatment, female partner's age, duration of infertility and previous pregnancy history should also be considered.

Investigation of the infertile couple: should diagnostic laparoscopy be performed after normal hysterosalpingography in treating infertility suspected to be of unknown origin?

Traditionally, a diagnosis of unexplained infertility is established only when all standard clinical investigations yield normal results. When tubal patency has been established by hysterosalpingography (HSG), laparoscopy has been suggested as a mandatory step to preclude the existence of peritubal adhesions and endometriosis as causes of infertility. In women without a previous history suggestive of tubal disease and who have a normal HSG, it was demonstrated that the probability of clinically relevant tubal disease or endometriosis is very low and that laparoscopy does not seem justified or cost effective. In the minority of these cases, laparoscopy might reveal minimal or mild endometriosis or peritubal adhesions. In these cases, either surgery or medical treatment has not been proven to improve fecundity. With the current success rates of assisted reproductive technologies (ART) and the relatively low contribution of diagnostic laparoscopy to the decision-making process of treating patients with a normal HSG, we suggest that laparoscopy should be omitted in couples suspected of having unexplained infertility. These patients should be treated by 3-6 cycles of combined gonadotrophins and intrauterine insemination, and if unsuccessful switched to ART.

Funding in vitro fertilization treatment for persistent subfertility: the pain and the politics

OBJECTIVE

To consider the arguments for and against funding for in vitro fertilization (IVF) and to explore potential avenues for policy change.

DESIGN

Narrative literature review, policy analysis.

SETTING

University Department of Obstetrics and Gynecology.

PATIENT(S)

Sub-fertile women and men.

INTERVENTION(S)

Fertility treatments, in particular IVF.

RESULT(S)

The two main arguments used against funding for IVF are that [1] subfertility is a social, not a medical problem, and therefore its treatment is not medically indicated or necessary, and [2] the clinical effectiveness of IVF is unproven. These and other major arguments are critiqued.

CONCLUSION(S)

Dismissing IVF as medically unnecessary seems premature because medical necessity has not been operationally defined. Demonstrating IVF effectiveness through a randomized trial has not been done but is feasible: a multicenter trial is currently underway in Canada. Dealing with the concern that subfertility treatment challenges the role of women in society, as well as with questions of cost-effectiveness, are more difficult challenges that deserve further debate. The potential for unethical uses and broader social implications of IVF add to its dubious status and provide a convenient rationale for refusing to pay. However, none of these concerns is unique to IVF: many currently covered health services are susceptible to the same criticisms. For all services, judgments of eligibility for coverage should be consistent and transparent and should explicitly separate the issues of cost from other factors.

Management of long-standing unexplained infertility: A prospective study

OBJECTIVE

Our purpose was to evaluate a protocol for the management of long-standing unexplained infertility.

STUDY DESIGN

A prospective study was conducted at an in vitro fertilization-embryo transfer center with 485 patients with the diagnosis of long-standing unexplained infertility. Patients were treated by means of controlled ovarian hyperstimulation and intrauterine insemination for a maximum of 3 cycles. Those who did not become pregnant underwent in vitro fertilization and intracytoplasmic sperm injection on sibling oocytes.

RESULTS

Among 485 patients, 921 cycles of controlled ovarian hyperstimulation and intrauterine insemination were performed. The pregnancy rate was 15.7% per cycle and 29.8% per patient. Among those who did not become pregnant, 131 patients underwent in vitro fertilization and intracytoplasmic sperm injection into sibling oocytes; 48 women became pregnant (36.7%). There was total failure of the in vitro fertilization oocytes in 23 cycles (17.6%).

CONCLUSION

Management of long-standing unexplained infertility with controlled ovarian hyperstimulation and intrauterine insemination resulted in a reasonable pregnancy rate. Treatment by means of in vitro fertilization and intracytoplasmic sperm injection into sibling oocytes among patients who did not become pregnant resulted in a good pregnancy rate. The overall results showed that the proposed protocol for management of unexplained infertility is satisfactory.

The clinical efficacy of low-dose step-up follicle stimulating hormone administration for treatment of unexplained infertility

The present study was designed to compare the clinical efficacy of low-dose step-up follicle stimulating hormone (FSH) administration with conventional FSH protocol (FSH was injected daily starting with a dose of 150 IU), both combined with intrauterine insemination (IUI), for the treatment of unexplained infertility. A total of 97 unexplained infertility couples was randomly assigned to one or other of the two treatment groups, either conventional FSH with IUI (48 patients) or low-dose step-up FSH with IUI (49 patients), and only the first treatment cycle was evaluated in each protocol. The difference in pregnancy rates per cycle was not statistically significant between the low-dose FSH group and the conventional group [seven of 49 (14.3%) and seven of 48 (14.6%) respectively]. A significant reduction in the incidence of ovarian hyperstimulation syndrome (OHSS) was observed in the low-dose group (8.3% versus 27.1%, P < 0.05). The incidence of moderate OHSS requiring hospitalization was reduced significantly in the low-dose group (low-dose 0% versus conventional 16.7%, P < 0.01). However, the low-dose protocol did not completely prevent multiple pregnancies. Our results suggest that the low-dose step-up FSH treatment appeared to be useful for the treatment of unexplained infertility because of the high pregnancy rates and the significant decrease in the incidence of OHSS.

Fecundity in the modern city: a comparison of couples attending antenatal clinics in Manchester (UK) and Melbourne (Australia)

To determine the characteristics of couples with resolved subfecundity and to compare these findings in two geographically distant centres, a self-reporting questionnaire was completed by a sample of women attending six antenatal clinics in Greater Manchester, UK and five antenatal clinics in Melbourne, Australia. A total of 2158 pregnant women, 1106 from Manchester and 1052 from Melbourne participated in the study. The prevalence of subfecundity (proportion of women who failed to conceive current pregnancy within 12 months of unprotected intercourse) and demographic and medical factors potentially related to subfecundity were measured. The samples from the two cities had similar medical characteristics, but several socioeconomic and cultural differences were detected. Characteristics which independently correlated with decreased fecundity were increasing parental age, previous pregnancy, previous miscarriage, maternal smoking before conception and low socioeconomic status. Increased body mass index was also a significant, independent predictor of decreased fecundity, but in the Melbourne sample only. Subfecundity was found to be influenced by a combination of parental and socioeconomic factors as well as previous pregnancy. The factors identified were similar in two modern industrial societies in very different geographical locations, only their relative importance differing between Australia and the UK.

Canadian semen quality: an analysis of sperm density among eleven academic fertility centers

OBJECTIVE

To determine whether sperm quality has declined among Canadian men during the past 13 years and whether there are regional differences in sperm quality.

DESIGN

Retrospective temporal series of cross-sectional studies.

SETTING

University fertility centers across Canada.

PATIENT(S)

Men being investigated as part of the normal infertility work-up.

MAIN OUTCOME MEASURE(S)

Sperm concentrations among all the samples were compared on an annual basis to assess any changes over 13 years from 1984 through 1996.

RESULT(S)

There were regional differences and trends in both up and down directions. Linear regression analysis of the means of each center for each year showed no significant trend. However, when all the samples were analyzed by regression analysis there was a significant downward trend.

CONCLUSION(S)

Linear regression analysis showed a significant downward trend in sperm concentration among 48,968 samples from Canadian men obtained from 1984 through 1996. A significant difference was seen in the mean concentrations between centers, ranging from 48.6 to 104.5 X 10(6)/mL. Secular trends in sperm density are dependent on the statistical method used for analysis.

Epidemiologic and etiologic aspects of primary infertility in the Kashmir region of India

OBJECTIVE

To assess the magnitude of primary infertility and to study its etiologic aspects in India.

DESIGN

After proper randomization, 10,063 married couples were interviewed to ascertain the prevalence of primary infertility. A definitive protocol was followed to determine the etiology of primary infertility in 250 consecutive couples.

SETTING

Tertiary care medical center in the Kashmir valley of India.

PATIENT(S)

Couples married for > or = 1 year; 250 consecutive couples attending an endocrine clinic for primary infertility.

INTERVENTION(S)

A logical investigative protocol was followed to identify the etiology of infertility.

MAIN OUTCOME MEASURE(S)

Magnitude of primary infertility in the community as well as the male, female, or combined etiology of infertility.

RESULT(S)

Fifteen percent of the couples interviewed had primary infertility, among whom 4.66% had unresolved infertility at the time of the survey. The etiology of infertility in 250 consecutive couples revealed a female factor in 57.6%, a male factor in 22.4%, combined factors in 5.2%, and an undetermined cause in 14.8%.

CONCLUSION(S)

Primary infertility is as common and distressing a problem in India as in other parts of the world. Semen abnormalities (22.4%), anovulation (17.2%), ovarian failure (8.8%), hyperprolactinemia (8.4%) and tubal disease (7.2%) are common causes of infertility. The pattern of infertility in India is the same as in other parts of the world, except that infertile couples report late for evaluation.

Basal estradiol and follicle-stimulating hormone predict fecundity in women of advanced reproductive age undergoing ovulation induction therapy

OBJECTIVE

To determine the prognostic value of single basal E2 and FSH levels as predictors of fecundity in women of advanced reproductive age who are undergoing ovulation induction with IUI therapy.

DESIGN

Prospective, observational.

SETTING

Fertility service of university medical center.

PATIENT(S)

Infertile couples in which the female partner was > or = 38 years old.

INTERVENTION(S)

Single assessment of basal E2 and FSH levels and ovulation induction with IUI.

MAIN OUTCOME MEASURE(S)

Cumulative and clinical pregnancy rates and live birth rates.

RESULT(S)

All live births occurred in patients with a basal E2 < or = 80 pg/mL (conversion factor to SI unit, 3.671), a basal FSH < or = 13 mIU/mL (conversion factor to SI unit, 1.00), and a chronological age < or = 42 years. In women 38 to 42 years of age, 10.3% had elevated basal E2 (> 80 pg/mL) in combination with normal basal FSH (< or = 13 mIU/mL), and no live births occurred in these couples. The cumulative live birth rate after four treatment cycles in women 38 to 42 years of age with both normal basal E2 (< or = 80 pg/mL) and FSH levels (< or = 13 mIU/mL) was 43.9%.

CONCLUSION(S)

Basal E2 improves the ability to predict fertility potential compared with basal FSH and chronological age alone. Basal E2, in combination with basal FSH and chronological age, has useful prognostic value in prospectively counseling patients of advanced reproductive age who are considering ovulation induction and IUI therapy.

Prognosis for fertility analyzing different variables in men and women

A cohort of 123 infertile couples was studied by life tables over a 30-month follow-up period to determine the influence on reproductive prognosis of clinical features, namely the women's age, previous gestational events, evolution time, and a number of conditioning infertility factors. The cumulative pregnancy rate (CPR) was 60% at 30 months. Women aged 32 years or less had a CPR of 65% and those over 32 years had a CPR of 31%. Couples with previous pregnancy had a CPR of 88%, while those with primary infertility had a CPR of 45% (marginal statistical difference). The group with infertility evolution of 36 months or less had a CPR of 75% and those with greater than 36 months infertility evolution had a CPR of 43% (p < .05). With one conditioning infertility factor a CPR of 75% was found, and with multiple factors a CPR of 47% (p < .05) was found. With these results a grading chart was created using all the analyzed criteria, determining the proportion of pregnancies per number of negative points obtained; at greater grades the proportion of pregnancy was reduced (p < .01). This report establishes the prognostic value of different variables observed in the evaluation of infertile men and women, and a simple procedure to calculate the probability to achieve pregnancy is proposed.

Clomiphene citrate with intrauterine insemination: is it effective therapy in women above the age of 35 years?

OBJECTIVES

To evaluate the influence of female age on clomiphene citrate (CC) with IUI therapy and to compare the efficacy of this therapy between patients with ovulatory and anovulatory infertility.

SETTING

A university fertility clinic.

SUBJECTS

Six hundred sixty-four CC with IUI cycles from 290 women aged 22 to 48 years.

MAIN OUTCOME MEASURES

Cumulative and clinical pregnancy rates (PRs).

RESULTS

Both cumulative and clinical PRs declined substantially in women > 35 years when compared with those < or = 35 years. In addition, no difference in these parameters was noted between patients with ovulatory and anovulatory infertility diagnoses. The vast majority of pregnancies occurred within the first four treatment cycles, irrespective of age or ovulatory versus anovulatory infertility diagnoses.

CONCLUSIONS

The age-related decline in clinical PR is most rapid beginning at the age of 35 years. For any given age group, CC with IUI therapy has similar cumulative and clinical PRs for both ovulatory and anovulatory infertility diagnoses. This therapy usually should not extend beyond four cycles. Couples should be counseled about the dramatic fall in PRs occurring beyond the age of 35 years.

Subfertility in the era of assisted reproduction: changes and consequences

OBJECTIVE

To review the major changes that have occurred during the last decade of assisted reproduction technology (ART) practice, looking at the various conditions that cause subfertility.

DESIGN

A short review describing the progress that has been made during the last decade of ART practice, analyzing the various conditions that cause subfertility, is presented. The efficacy of ART as a treatment of these conditions is discussed.

CONCLUSIONS

Assisted reproductive technology currently is used for a wide range of indications and has become an acceptable tool in the treatment of subfertile couples. Yet, there is an ongoing debate regarding the effectiveness of ART versus conventional treatment for the various conditions that cause subfertility. The effectiveness of IVF in terms of pregnancy rate (PR) was demonstrated only for patients with severe bilateral tubal disease and male subfertility. For couples with other causes of infertility the differences in PRs do not reach statistical significance, and the efficacy of IVF has not been demonstrated clearly to date. Moreover, much of the discussion about management of subfertility has centered on costs of ART and the cost-benefit of ART versus conventional therapy for subfertility. It has been shown that, in women with unexplained infertility, menotropin treatment is as successful, less expensive, and carries a smaller risk than the surgical approach used in ART. However, the exact role of ART in the management of polycystic ovarian syndrome, immunological infertility, and endometriosis still is to be determined. Yet, as embryo implantation after ART still is considerably lower than that of fertile couples who conceive naturally, we expect that the next major thrust improving the effectiveness of ART will occur after future elucidation of factors influencing embryonic implantation.

A three step protocol for the treatment of idiopathic subfertility

650 couples with idiopathic subfertility (mean duration: 5.7 year, range 2-21 years) were treated during 2870 cycles by three assisted conception methods (each involving mild ovarian stimulation): I timed intercourse (TI), II intrauterine insemination (IUI). III in vitro fertilization/embryo transfer (IVF/ET). Treatment started with TI in most cases and then changed to IUI after three to six cycles. Couples who failed to conceive were treated after another 3-9 cycles by IVF/ET. An overall cumulative pregnancy rate of 80.2% was reached after 18 treatment months. The pregnancy rates per treatment cycle were: TI 5.3%, IUI 6.9%, IVF/ET 15.8% (per oocyte retrieval).

Score prognosis for the infertile couple based on historical factors and sperm analysis

OBJECTIVE

To identify variables, obtained from historical factors and sperm analysis, associated with greater chances of pregnancy in infertile couples.

METHODS

The study was carried out in Córdoba, Argentina. The characteristics of 247 couples consulting for infertility who achieved pregnancy within 3 years of their first visit were compared with those of 312 couples who did not become pregnant. We evaluated the relationship between the age of the woman and her partner, the type and duration of infertility, length of the last three menstrual cycles, history of pelvic surgery in the woman, and testicular volume, sperm density, motility and morphology in her partner, and the achievement of pregnancy. For the analysis, logistic regression was used.

RESULTS

Six variables had a predictive value: sperm morphology, the woman's age, type and duration of infertility, her history of pelvic surgery, and duration of menstrual cycles.

CONCLUSIONS

The best prognosis for future fertility in infertile couples is correlated with a higher percentage of normal sperm morphology, younger woman's age, secondary infertility, fewer years of infertility, negative history of pelvic surgery, and abnormal menstrual cycles.

The validity of the postcoital test for estimating the probability of conceiving

OBJECTIVE

We determined the prognostic value of the postcoital test in subfertile couples.

STUDY DESIGN

A retrospective study relates the result of the postcoital test to the occurrence of a spontaneous pregnancy. In a fertility center of a university hospital, data from the complete fertility workup of 956 couples who were examined because of infertility due to cervical hostility, male subfertility, or unexplained causes were collected. Statistical analysis was done with Cox regression.

RESULTS

The postcoital test result 9 to 12 hours after intercourse is strongly associated with future pregnancy during the first year after intake; the association is also present when the relation with other prognostic variables is taken into account.

CONCLUSIONS

The postcoital test result is a strong predictor of possible fertility within the following year.

The prediction of the chance to conceive in subfertile couples

OBJECTIVE

To develop a model that can predict the chance to conceive spontaneously in subfertile couples.

DESIGN

In a cohort study, a consecutive series of patients consulting infertility was followed up. We related information from previous history, physical examination, postcoital tests (PCT), semen analyses, and sperm penetration meter tests with the occurrence of a spontaneous pregnancy.

SETTING

Fertility center in a university hospital.

PATIENTS

Nine hundred ninety-six couples consulting for infertility due to cervical hostility, male subfertility, or unexplained infertility.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE(S)

Time between intake and occurrence of the first spontaneous pregnancy.

RESULTS

Information from the previous history (duration of infertility, primary or secondary female infertility, age of the woman, fertility problems in male's family), the percentage motile sperm in the first semen analysis, and the result of the first PCT are sufficient to predict the chance to conceive. A pocket chart is presented for easy use of the model.

CONCLUSIONS

With a limited amount of diagnostic information, the chance to conceive spontaneously can be predicted.

The relationship of Chlamydia trachomatis infection and male infertility

OBJECTIVES

Infertility affects at least 2 million couples in the United States. One third of infertility is attributed to male causes, but the etiology of most male infertility remains obscure. This study was designed to investigate the relationship between Chlamydia trachomatis and unexplained infertility in men.

METHODS

Questionnaires and serum were collected prospectively from 52 case subjects (men from couples with explicitly defined idiopathic infertility) and 79 control subjects (first-time expectant fathers).

RESULTS

Case subjects were significantly more likely than control subjects to be seropositive for antibody to C trachomatis at a titer of 1:64 or higher. By test of trend, higher titers were associated with higher odds ratios. Adjustment for age of either partner at initiation of pregnancy attempt, race, income, previous genitourinary symptoms or diagnoses, number of previous sexual partners, and barrier contraceptive use had no significant effect on the estimate of the odds ratio. One half of the men who were antibody positive had no history of genitourinary symptoms.

CONCLUSIONS

Our results suggest an association between infection with C trachomatis in men and unexplained infertility and imply that infection is frequently asymptomatic.