Intrauterine insemination before transfer of frozen-thawed embryos may improve the pregnancy rate for couples with unexplained infertility: preliminary results of a randomized prospective study

The definition of unexplained infertility: A systematic review

BACKGROUND

There is no consensus on tests required to either diagnose unexplained infertility or use for research inclusion criteria. This leads to heterogeneity and bias affecting meta-analysis and best practice advice.

OBJECTIVES

This systematic review analyses the variability of inclusion criteria applied to couples with unexplained infertility. We propose standardised criteria for use both in future research studies and clinical diagnosis.

SEARCH STRATEGY

CINAHL and MEDLINE online databases were searched up to November 2022 for all published studies recruiting couples with unexplained infertility, available in full text in the English language.

DATA COLLECTION AND ANALYSIS

Data were collected in an Excel spreadsheet. Results were analysed per category and methodology or reference range.

MAIN RESULTS

Of 375 relevant studies, only 258 defined their inclusion criteria. The most commonly applied inclusion criteria were semen analysis, tubal patency and assessment of ovulation in 220 (85%), 232 (90%), 205 (79.5%) respectively. Only 87/220 (39.5%) studies reporting semen analysis used the World Health Organization (WHO) limits. Tubal patency was accepted if bilateral in 145/232 (62.5%) and if unilateral in 24/232 (10.3%). Ovulation was assessed using mid-luteal serum progesterone in 115/205 (56.1%) and by a history of regular cycles in 87/205 (42.4%). Other criteria, including uterine cavity assessment and hormone profile, were applied in less than 50% of included studies.

CONCLUSIONS

This review highlights the heterogeneity among studied populations with unexplained infertility. Development and application of internationally accepted criteria will improve the quality of research and future clinical care.

Stimulation of the endometrium with high-grade blastocyst culture supernatant (SEHB) can improve pregnancy outcome for couples undergoing intracytoplasmic sperm injection (ICSI): a randomized clinical trial

PURPOSE

To evaluate the impact of stimulating the endometrium with high-grade blastocyst culture supernatant (SEHB) perfusion before blastocyst transfer (BT) on implantation rate, pregnancy rate, and pregnancy outcome in ICSI cycles.

MATERIALS AND METHODS

Ninety-four infertile couples who were referred to the Valiasr department of Imam Hospital complex between January 2010 and March 2011 enrolled in this randomized clinical trial. They were randomly divided into only BT or SEHB groups. Implantation rates, pregnancy rates, abortion, preterm and term delivery rates were compared between the two groups.

RESULTS

Implantation rates and pregnancy rates did not differ significantly between the two groups. The abortion rate was significantly higher in the BT only group while term delivery was significantly higher in SEHB group. Odds ratios of term delivery and abortion were 4.5 (p = 0.001) and 0.3 (p = 0.04), respectively.

CONCLUSION

The SEHB application may improve pregnancy outcome in infertile couples who are candidates for the ICSI reproductive method.

Stimulation of endometrium embryo transfer can improve implantation and pregnancy rates for patients undergoing assisted reproductive technology for the first time with a high-grade blastocyst

OBJECTIVE

To evaluate whether stimulation of endometrium embryo transfer (SEET) can improve implantation rate and pregnancy rate (PR) for patients undergoing assisted reproductive technology (ART) for the first time by injecting embryo culture supernatant into the uterus before blastocyst transfer (BT).

DESIGN

Randomized, controlled trial.

SETTING

Private in vitro fertilization clinic.

PATIENT(S)

Forty-eight women in the BT group, 48 women in the stimulation group who had culture medium injected into the uterus before BT, and 48 women in the SEET group.

INTERVENTION(S)

Injection of embryo culture supernatant and injection of culture medium.

MAIN OUTCOME MEASURE(S)

Implantation rates and PRs.

RESULT(S)

Odds ratios of successful implantation rate for stimulation and SEET in patients with high-grade blastocysts, having BT as reference, were 2.58 and 6.46 without adjustment, and 5.91 and 9.20 after adjusting for basal FSH levels and period of infertility. Odds ratios of clinical pregnancies were 2.47 and 4.32 without adjustment, and 4.46 and 5.10 with adjustment, respectively. In groups with low-grade blastocysts, such tendencies were not observed.

CONCLUSION(S)

The SEET may be an effective method for increasing implantation rate and PR for first-time ART patients who have a high-grade blastocyst.

Putative Predictors of Antibodies Against Follicle-Stimulating Hormone in Female Infertility: A Study Based on In Vitro Fertilization Patients

PROBLEM

We have previously demonstrated the presence of naturally occurring antibodies against follicle-stimulating hormone (FSH) in patients with endometriosis and polycystic ovary syndrome (PCOS). Here, we investigated the parameters associated with anti-FSH antibodies in in vitro fertilization (IVF) patients.

METHODS OF STUDY

The following parameters were studied in 135 patients: peripheral FSH levels, FSH beta-subunit gene (FSHB) haplotypes, history of previous IVF, and susceptibility to autoimmune reactions in general [seven common autoantibodies (against nuclear antigens on human and rodent substrates, smooth muscle, gastric parietal cells, beta2-glycoprotein I, cardiolipin, and thyroid peroxidase) and HLA-DQB1 alleles].

RESULTS

Although the anti-FSH levels were higher in patients when compared with controls, those higher levels were not associated with FSHB haplotypes. The anti-FSH IgM associated with (i) the levels of FSH in women with male and tubal factor infertility; (ii) the history of IVF in patients with PCOS, endometriosis, and unexplained infertility; and (iii) the production of common autoantibodies among all IVF patients. The anti-FSH IgA associated with HLA-DQB1*03. The anti-FSH IgG correlated with the values of anti-FSH IgA and IgM.

CONCLUSION

Anti-FSH may be naturally occurring antibodies associated with peripheral FSH concentrations, but increased in infertile women with dysregulation of immune reactions and repeatedly performed IVF.

Clinical evaluation of frozen/thawed embryo transfer following transport of oocytes and embryos

Background and Aims:  We evaluated the efficacy of the transport oocyte/embryo frozen/thawed embryo transfer method, in which oocytes or embryos were transported from satellite clinics to the main assisted reproductive technology (ART) center, and surplus embryos were placed in cryopreservation. Methods:  We evaluated 41 cycles in 34 patients in the transport oocyte group (TO group). In the TO group the oocytes were collected at the satellite clinics, transported to the main ART center and underwent in vitro fertilization or intracytoplasmic sperm injection. Surplus embryos were used for frozen/thawed embryo transfer. We also evaluated 17 cycles in 10 patients in the transport embryo group (TE group), where surplus embryos were transported to the main ART center and used for frozen/thawed embryo transfer; and 189 cycles in 134 patients in the center group (C group), where surplus embryos collected at the same time at the main ART center were used for frozen/thawed embryo transfer. Oocytes were transported from satellite clinics in HEPES buffered human tubal fluid (HTF) culture medium, and embryos in 30% synthetic serum substitute + HEPES buffered HTF, using a portable incubator we devised. Results:  The proportions of undamaged embryos after freeze/thawing were 47% for the C group, 46% for the TO group, and 46% for the TE group. The numbers of embryos transferred were 2.0 ± 0.7 for the C group, 2.0 ± 0.6 for the TO group, and 2.2 ± 0.4 for the TE group. The rate of embryo transfer was 63% for the C group, 68% for the TO group, and 76% for the TE group. Pregnancy rates per patient were 16% for the C group, 24% for the TO group, and 40% for the TE group. The embryo survival rates (number of embryos with ≥50% viable blastomeres/total number of embryos) were 55% for the C group, 60% for the TO group, and 54% for the TE group. No significant differences were seen between the C group and either the TO or TE groups in any of these parameters. Conclusions:  Favorable results were achieved with the transport oocyte/embryo frozen/thawed embryo transfer method, and it is suitable for widespread clinical application. (Reprod Med Biol 2004; 3: 1-8).

Physiology of gamete and embryo transport through the fallopian tube

A great deal is now known about the migration of spermatozoa within the female reproductive tract, and how they interact with the oocyte and achieve fertilization in a variety of species. The process involves a series of complex features. It is a mixture of active and passive transport and active migration, with drastic jumps in the numbers of spermatozoa that migrate beyond specific physiological checkpoints, and with interactions occurring between spermatozoa, epithelium and luminal fluid. A reservoir of spermatozoa forms, at a discrete location, to hold and liberate spermatozoa in a gradual fashion. After fertilization has occurred, zygotes are passively transported to the uterus by a series of closely coordinated mechanical events where activities of cilia and smooth muscle predominate. Passage of the embryo from oviduct to uterus is regulated and timed by ovarian hormones, signals associated with mating, and zygotic substances. The diverse and exquisite patterns and regulatory signals typical of sperm migration and ovum transport across many species provide fascinating examples of adaptations according with differing reproductive strategies in various mammals.