Evaluation of pregnancy rates after intrauterine insemination according to indication, age, and sperm parameters

How low is too low? Postwash total motile sperm count effect on pregnancy outcomes in intrauterine insemination

Intrauterine insemination (IUI) is a frequently used method to treat couples with infertility. There is evidence of decreased pregnancy rates with a total motile sperm count (TMSC) of less than 10 million, yet there remains to be a consensus on semen parameters for which to recommend IUI in the infertile population. The aim of this study was to determine a minimum threshold of TMSC on semen analysis to offer IUI cycles. This is a retrospective cohort study of all IUI cycles at a private practice infertility centre over four years. Our primary outcome of interest was the presence of clinical pregnancy after each cycle. A total of 999 women underwent 2,169 IUI cycles. The overall clinical pregnancy rate was 19.8% per cycle. During the first IUI each woman underwent, there was an increase in clinical pregnancy with increasing TMSC (OR 0.44) for TMSC ≤1 M to (OR 0.99) for TMSC 6-10 M, compared to TMSC >10 M. Among all IUI with a TMSC between 6 and 10 M, pregnancy outcomes improved with morphology >4% (OR 0.84), compared to morphology <4% (OR 0.25), relative to TMSC >10 M. Using receiver operating characteristic curves, we did not identify a TMSC threshold to offer IUI, although there was a positive correlation between TMSC and IUI success.

Effect of male age on reproductive function: A comparison of young and middle-aged men

PURPOSE

There have been concerns regarding potential effects of older paternal age on male reproductive function. However, currently available data on this topic are insufficient and controversy exists. We analyzed semen characteristics and reproductive hormones in young men and middle-aged men to investigate the effect of age on male reproductive function.

MATERIALS AND METHODS

This study examined healthy males of reproductive age who visited a single infertility center from January 2016 to July 2021. The young group consisted of men who were less than 35 years-old, and the middle-age group consisted of men who were more than 45 years-old.

RESULTS

The two groups had no significant differences in sperm concentration ([89.9±59.4]×10⁶/mL vs. [104.4±82.1]×10⁶/mL, p=0.108) or sperm morphology (normal forms: 3.6%±1.5% vs. 3.4%±1.6%, p=0.131). However, the middle-age group had a smaller semen volume (3.2±1.5 mL vs. 2.5±1.4 mL, p<0.001), lower sperm motility (42.3%±9.8% vs. 31.2%±12.4%, p<0.001), lower progressive sperm motility (39.2%±10.3% vs. 28.4%±12.6%, p<0.001), and a higher serum follicle-stimulating hormone level.

CONCLUSIONS

Our results suggest that advanced male age might have a negative effect on fertility potential, as in women. This finding has important clinical implications because more couples are choosing to have children when they are older. Further studies on this issue, especially those that examine reproductive outcome, are warranted.

Ovulation induction and intrauterine insemination in women of advanced reproductive age: a systematic review of the literature

PURPOSE

The objective of this review is to define live birth rate (LBR) and clinical pregnancy rate (CPR) for women ≥ 40 undergoing ovulation induction (OI)/intrauterine insemination (IUI).

METHODS

A systematic review was performed in accordance with PRISMA guidelines using PubMed and Google Scholar. The primary and secondary outcomes of interest were LBR and CPR, respectively.

RESULTS

There were 636 studies screened of which 42 were included. In 8 studies which provided LBR for partner sperm, LBR/cycle ranged from 0 to 8.5% with majority being ≤ 4%. Cumulative LBR was 3.6 to 7.1% over 6 cycles with the majority of pregnancies in the first 4. In the four studies providing LBR for donor sperm cycles, LBR/cycle ranged from 3 to 7% with cumulative LBR of 12 to 24% over 6 cycles. The majority of pregnancies occurred in the first 6 cycles. There were three studies with LBR or CPR/cycle ≥ 1% for women ≥ 43. No studies provided data above this range for women ≥ 45. In 4 studies which compared OI/IUI and IVF, the LBR from IVF was 9.2 to 22% per cycle. In 7 studies which compared outcomes by stimulation protocol, no significant differences were seen.

CONCLUSION

For women ≥ 40 using homologous sperm, the highest probability of live birth is via IVF. However, if IVF is not an option, OI/IUI may be considered for up to 4 cycles in those using partner sperm or 6 cycles with donor sperm. For women > 45, OI/IUI is likely futile but a limited trial may be considered for psychological benefit while encouraging consideration of donor oocyte IVF or adoption. Use of gonadotropins does not appear to be more effective than oral agents in this age group.

Is intrauterine insemination a viable treatment option for women over 43 years old? An analysis by ovarian stimulation protocol and sperm source

PURPOSE

The aim of this study was to determine how female age at the end of the reproductive spectrum effects success of natural cycle intrauterine insemination (IUI) or IUI in combination with ovarian stimulation.

METHODS

We performed a retrospective cohort study of women 43 years of age and older at the time of IUI in a single academic fertility center between January 2011 and March 2018. Primary outcomes were both pregnancies and live births per cycle of IUI. Data are presented as percentage or mean ± SD. Fisher exact and chi-squared analyses were performed.

RESULTS

There were 9334 IUI cycles conducted during the study period. Of these cycles, 325 IUIs (3.5%) were for women aged 43 years and over at the time of insemination (43.6 ± 0.8, range 43 to 47 years). Analysis of these 325 IUI cycles revealed 5 biochemical pregnancies (1.5%) and only 1 live birth (0.3%). The pregnancy rate did not differ between IUIs using donor sperm (N = 1/49, 2.0%) compared to IUIs with partner sperm (N = 4/276, 1.4%). The pregnancy rate did not differ between IUIs with gonadotropins (N = 2/211, 0.9%), clomiphene or letrozole (N = 2/78, 2.6%), or natural cycle (N = 1/36, 2.8%).

CONCLUSIONS

The use of intrauterine inseminations in women 43 years of age and older is an ineffective treatment strategy. This is irrespective of the use of ovarian stimulation or donor sperm. Costly gonadotropin injections did not increase the chance of pregnancy nor did oral medication when compared to natural cycle IUIs.

Live birth after intrauterine insemination: is there an upper cut-off for the number of motile spermatozoa inseminated?

RESEARCH QUESTION

To date, most studies have investigated the minimum number of spermatozoa available for intrauterine insemination (IUI), with no data on the maximum number of motile spermatozoa inseminated (NMSI) having been published. This study aimed to determine whether an upper cut-off for the NMSI during IUI exists above which the live birth rate (LBR) is negatively affected.

DESIGN

Retrospective analysis of autologous IUI cycles performed between January 2010 and July 2018 in women <43 years old with a NMSI >1 million. The main outcome was the LBR per IUI cycle as a function of the NMSI.

RESULTS

A total of 2592 IUI cycles performed in 1017 couples were included. The LBR increased with NMSI up to 30 million without any upper threshold (AUC = 0.5441). The LBR per IUI cycle were 14.5%, 17.9% and 22.7% for NMSI of >1 to ≤10, >10 to ≤20 and >20 to ≤30 million, respectively (P = 0.003). By univariate analysis, the NMSI, female age, number of mature follicles and oestradiol concentrations on day of ovulation triggering, cycle number and infertility aetiology influenced the LBR. Multivariate analysis showed that the LBR was 1.49 and 1.78 times higher when IUI was performed with a NMSI >10 to ≤20 million (odds ratio [OR] 1.49; 95% confidence interval [CI] 1.10-2.02]) and >20 to ≤30 million (OR 1.78; 95% CI 1.08-2.94), respectively, compared with IUI with a NMSI >1 to ≤10 million.

CONCLUSIONS

The LBR after IUI can be optimized by inseminating a maximum of motile spermatozoa up to 30 million. Thus, in this specific cohort, IUI preparations should not be diluted when more than 10 million motile spermatozoa are obtained.

Effect of cholesterol loaded cyclodextrin on semen cryopreservation of Aksaray Malakli shepherd dogs of different ages

The objective of the study was to determine the effect of cholesterol-loaded cyclodextrin (CLC) on the quality parameters of semen from Aksaray Malakli Shepherd dogs of different age groups. Forty-eight male dogs were divided into 3 groupings according to their ages (young age (Y): ≤3 years, n: 20; middle age (M): 4-6 years, n: 20; old age (O): ≥7 years; n: 8). The sperm-rich portion of the ejaculate from each dog was divided into four aliquots and extended with either tris as a control (C) or tris loaded with 0.5, 1.0, and 1.5 mg/120 × 10⁶ CLC as low (L), intermediate (I), and high (H) doses, respectively. Following equilibration for at least half an hour, the straws were frozen in nitrogen vapor and then stored in liquid nitrogen at least for 48 h. Later, the frozen straws were thawed in a water bath for spermatological evaluation. Significant differences were observed between different age groups in terms of the spermatological parameters (p < 0.05). The evidence suggests that increasing age is associated with poor in-vitro spermatological parameters and CLC was able to protect the acrosome integrity from cryo-damage during the freeze-thawing process. Better semen freezability characteristics were obtained at young ages, considering the overall parameters.

The impact of semen processing on sperm parameters and pregnancy rates after intrauterine insemination

BACKGROUND

The objective of this retrospective study was to evaluate the effect of semen processing on computer analyzed semen parameters and pregnancy rates after intrauterine insemination (IUI).

METHODS

Over a two-year period, a total of 981 couples undergoing 2231 IUI cycles were evaluated and the freshly collected non-donor semen was analyzed before and after density gradient centrifugation (DGC).

RESULTS

DGC led to significant increases in sperm concentration by 66±74 ×106/mL (P=0.0001), percentage of motile sperm by 24±22% (P=0.0001), concentration motile by 27±58 ×106/mL (P=0.0001), and forward sperm progression by 18±14 µ/s (P=0.0001). In 95% of cases, there was a decrease in the total motile sperm count (TMSC), with an average decrease of 50±124% compared to pre-processed samples (P=0.0001). Importantly, the decrease in TMSC did not negatively affect pregnancy rates (P=0.45).

CONCLUSIONS

This study proves that DGC leads to significant increases in most sperm parameters, with the exception of TMSC. Remarkably, the decrease in TMSC did not affect the pregnancy rate. This should reassure clinicians when the TMSC is negatively affected by processing.

Factors affecting clinical pregnancy rates after IUI for the treatment of unexplained infertility and mild male subfertility

OBJECTIVE

The aim of the present retrospective study was to evaluate intrauterine insemination (IUI) clinical experiences and to define the variables for predicting success.

MATERIAL AND METHODS

The present study was an observational trial performed in a private IVF center on subfertile couples who had applied for treatment between 2002 and 2012, in which the data of 503 IUI cases were retrospectively reviewed. Couples who had been diagnosed with unexplained and mild male subfertility were included. The primary outcome measure was the clinical pregnancy rate in an attempt to form a predictive model for the odds of a clinical pregnancy. Recorded parameters were used to determine the prediction model.

RESULTS

Utilizing univariate logistic regression analysis, clinical pregnancy was positively associated with the duration of infertility (OR=1.09, p=0.089), secondary infertility (OR=1.77, p=0.050), and +4 sperm motility after preparation (OR=1.03, p=0.091). Following an adjustment analysis involving a multivariate logistic regression, clinical pregnancy was still found to positively associate with secondary infertility (OR=2.51, p=0.008).

CONCLUSION

IUI success in secondary infertile couples who were in the unexplained infertility and mild male subfertility groups was higher than that in primary infertile couples, and the chances of pregnancy increased as sperm numbers with +4 motility increased. It is difficult to concomitantly evaluate all these parameters and to determine a predictive parameter in IUI independent from other factors.

Predicting suitable timing for artificial reproductive technology treatment in aged infertile women

It has been widely accepted that the age of women plays a fundamental role in fecundity, and age-related fertility decline has one of the most significant and detrimental effects on the success rate of infertility treatment. Therefore, treatment cycles of non-in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) treatment for infertile women of advanced aged have been limited due to their lack of efficacy, and they are often optimized, compared to IVF/ICSI treatment. Recent trends in infertility treatment apparently indicate that IVF/ICSI treatment, including egg donation, is frequently offered to aged women for first-line management, despite its heavy burden, but hasty IVF/ICSI treatment should be avoided, considering its socioeconomic problems. It is important to distinguish women who could conceive by non-IVF/ICSI treatment, although the optimization of non-IVF/ICSI treatment protocols remains poorly understood. This review focuses on extracting aged patients who have higher chance of conceiving with non-IVF/ICSI treatment and providing necessary and sufficient infertility treatment. After initial evaluation for fertility, including tubal factor, male factor, the presence of endometriosis and/or adenomyosis, and ovarian reserve, the outcomes of fertility treatment can be predicted to some extent in aged infertile women.

Pregnancy rates with intrauterine insemination: comparing 1999 and 2010 World Health Organization semen analysis norms

Over the past 30 years, The World Health Organization has serially measured norms for human sperm. In this study, 1999 and 2010 semen analysis norms as predictors of pregnancy were compared during intrauterine insemination (IUI). A retrospective cohort study was conducted using data collected from the Stanford Fertility Center, between 2005 and 2007, with 981 couples undergoing 2231 IUI cycles. Collected semen was categorized according to total motile sperm counts (TMSC): 'normal (N.) 1999 TMSC', 'abnormal (AbN.) 1999/N. 2010 TMSC', or 'AbN. 2010 TMSC'. Sample comparison was also based on individual semen parameters: 'N. 1999 WHO', 'AbN. 1999/N. 2010 WHO', or 'AbN. 2010 WHO'. Pregnancy (defined by beta-HCG concentration) rates were calculated. Data were compared using correlation coefficients, t-tests and chi-squared tests, with and without adjusting for confounders. Pregnancy rate comparison based on TMSC ('N. 1999 TMSC', 'AbN. 1999/N. 2010 TMSC' and 'AbN. 2010 TMSC') showed a negative correlation (r = -0.41, P = 0.05). Pregnancy rate did not differ when comparisons were based on the presence of abnormal parameters, even when controlling for confounders. Therefore, TMSC based on the 1999 parameters shows best correlation with pregnancy rate for IUI; updating these norms in 2010 has little clinical implication in infertile populations.

Semen preparation techniques in intrauterine insemination: A comparison of non-temperature and temperature controlled centrifugation in cases of unexplained infertility

AIM:

The aim of the following study is to compare pregnancy rates between the use of non-temperature and temperature controlled centrifugation on semen preparation technique in intrauterine insemination.

MATERIALS AND METHODS:

The retrospective study was conducted on 671 patients of idiopathic infertility who underwent homologous artificial insemination at Fertility Research Center from the period of January 2007 to September 2012. The couples were randomized into two groups namely, Group A-patients (n = 303) being treated with sperm prepared by using non-temperature controlled centrifuge and Group B-Patients (n = 368) being treated with sperm prepared by temperature (37°C) controlled centrifuge.

RESULTS AND CONCLUSION:

The clinical pregnancy rate Group A was 13.86% and Group B was 12.77%. The clinical pregnancy fetal loss rate between the two groups was 38% and 42% respectively. The delivery rate per transfer was 62% and 58% respectively. No statistically significant difference was found between these two groups.

Semen quality and prediction of IUI success in male subfertility: a systematic review

Many variables may influence success rates after intrauterine insemination (IUI), including sperm quality in the native and washed semen sample. A literature search was performed to investigate the threshold levels of sperm parameters above which IUI pregnancy outcome is significantly improved and/or the cut-off values reaching substantial discriminative performance in an IUI programme. A search of MEDLINE, EMBASE and Cochrane Library revealed a total of 983 papers. Only 55 studies (5.6%) fulfilled the inclusion criteria and these papers were analysed. Sperm parameters most frequently examined were: (i) inseminating motile count after washing: cut-off value between 0.8 and 5 million; (ii) sperm morphology using strict criteria: cut-off value ⩾5% normal morphology; (iii) total motile sperm count in the native sperm sample: cut-off value of 5-10 million; and (iv) total motility in the native sperm sample: threshold value of 30%. The results indicate a lack of prospective studies, a lack of standardization in semen testing methodology and a huge heterogeneity of patient groups and IUI treatment strategies. More prospective cohort trials and prospective randomized trials investigating the predictive value of semen parameters on IUI outcome are urgently needed. It is generally believed that intrauterine insemination (IUI) with homologous semen should be a first-choice treatment to more invasive and expensive techniques of assisted reproduction in cases of cervical, unexplained and moderate male factor subfertility. The rationale for the use of artificial insemination is to increase gamete density at the site of fertilization. Scientific validation of this strategy is difficult because literature is rather confusing and inconclusive. Many variables may influence success rates after IUI treatment procedures. It seems logical that sperm quality has to be one of the main determinants to predict IUI success. Clinical practice would benefit from the establishment of threshold levels for sperm parameters above which IUI pregnancy outcome is significantly improved and below which a successful outcome is unlikely. We performed a literature search to investigate if such threshold levels are known. Most striking were the lack of standardization in semen-testing methodology and the huge heterogeneity of patient groups and IUI treatment strategies. The four sperm parameters most frequently examined were: (i) inseminating motile count after washing: cut-off value between 0.8 and 5 million; (ii) sperm morphology using strict criteria: cut-off value >4% normal morphology; (iii) total motile sperm count in native sperm sample: cut-off value of 5-10 million; and (iv) total motility in native sperm sample: threshold value of 30%. This review identified an urgent need for more and better prospective cohort trials investigating the predictive value of semen parameters on IUI pregnancy rate.

The effects of advanced paternal age on fertility

Modern societal pressures and expectations over the past several decades have resulted in the tendency for couples to delay conception. While women experience a notable decrease in oocyte production in their late thirties, the effect of age on spermatogenesis is less well described. While there are no known limits to the age at which men can father children, the effects of advanced paternal age are incompletely understood. This review summarizes the current state of knowledge regarding advanced paternal age and its implications on semen quality, reproductive success and offspring health. This review will serve as a guide to physicians in counseling men about the decision to delay paternity and the risks involved with conception later in life.

Predictive value of sperm motility characteristics assessed by computer-assisted sperm analysis in intrauterine insemination with superovulation in couples with unexplained infertility

Objective

To determine whether characteristics of sperm motility obtained by computer-assisted sperm analysis (CASA) could predict pregnancy after intrauterine insemination (IUI) in couples with unexplained infertility.

Methods

Three hundred eighty-three cycles of intrauterine insemination with superovulation were retrospectively analyzed. Semen analysis was performed with CASA before and after swim-up and the parameters were compared between pregnant and non-pregnant women.

Results

The pregnancy rate per cycle was 14.1%. Pregnant and non-pregnant women were comparable in terms of age, infertility duration, the number of dominant follicles. While sperm concentration, motility, and parameters such as average path velocity (VAP) and percentage rapid (RAPID) before semen preparation were significantly different between the pregnancy and non-pregnancy groups, there were no differences in sperm parameters when comparing the two groups after preparation. Using a receiver operating characteristic curve to measure sensitivity and specificity, the optimal threshold value for the predictors of pregnancy was revealed to be a concentration of ≥111×10⁶/mL, a motility of ≥51.4%, and RAPID ≥30.1% before preparation for IUI.

Conclusion

Sperm parameters including concentration, motility, and RAPID before sperm preparation could have predictive value for pregnancy outcome after intrauterine insemination with superovulation in couples with unexplained infertility, and would be helpful when counseling patients before they make the decision to proceed with IVF/ICSI-ET.

The influence of sperm morphology, total motile sperm count of semen and the number of motile sperm inseminated in sperm samples on the success of intrauterine insemination

BACKGROUND

The present study aimed to analyze the prognostic value of sperm morphology , total motile sperm count (TMSC) and the number of motile sperm inseminated (NMSI) on the outcome of intrauterine insemination (IUI).

MATERIALS AND METHODS

This cross sectional study was carried out 445 women undergoing 820 IUI cycles. All of the patients underwent controlled ovarian hyper stimulation with clomiphen citrate and human menopausal gonadotropin (HMG) followed by intrauterine insemination with the husband's sperm. Pregnancy rate (PR) per cycle in correlation to sperm morphology, TMSC and NMSI was obtained. Statistical analysis of the data was done by the SPSS version 13 (Chicago,USA).

RESULTS

A total of 81 clinical pregnancies were obtained for a pregnancy rate per cycle of 9.9%. When the TMSC was 5×10(6)to <10×10(6), the PR per cycle was significantly higher than the subgroups <1×10(6), 1×10(6)to <5×10(6)and ≥10×10(6)(15%, 5.6%, 5.1%, 10.8%, respectively). Sperm morphology was in itself a significant factor that affected the likelihood of IUI success. Nonetheless, the most significant difference of the PR per cycle with sperm morphology was in the subgroup <5 % (2.1% vs. 97.9%).When the NMSI was ≥10×10(6), the PR per cycle was significantly higher than the subgroups<5×10(6)and 5×10(6)to< 10× 10(6)(11.2%, 4.1%, 5.2%, respectively).

CONCLUSION

The study showed that TMSC 5×10(6)to < 10×10(6)and normal sperm morphology ≥ 5% and NMSI ≥ 10×10(6)are useful prognostic factors of IUI cycles.

[Assisted reproductive technologies place]

There are three kinds of infertility treatment: medical treatment, surgical treatment and assisted reproductive technology (ART). ART includes intra uterine insemination (IUI), in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). ART technologies made a lot of progress last years and their field of applications extended. Through literature reviews, IUI is recommended for unexplained infertility and discussed for male or cervical infertility. IVF is recommended for tubal and unexplained infertility. Limits between IVF and ICSI in case of male infertility remains unclear. In non mal infertility ICSI is not recommended.

The role of hyaluronic acid binding assay in choosing the fertilization method for patients undergoing IVF for unexplained infertility

PURPOSE

Patients with unexplained infertility may have fertilization problems. Split fertilization (ICSI and conventional IVF on sibling oocytes) is often used to avoid poor fertilization. Our aim was to assess the ability of hyaluronic acid binding (HA-binding) assay to predict spontaneous fertilization during IVF.

METHODS

Prospective, blinded, controlled trial. Patients undergoing their first IVF cycle for unexplained infertility were eligible. Split fertilization was used. IVF and ICSI fertilization rates and embryo development based on 3 HA-binding cut-offs (< 60%; 60-80%; >80%) were compared.

RESULTS

ICSI fertilization was higher than IVF, but none of the HA-binding cut-off levels predicted those cases where IVF was less effective, therefore ICSI only would have lead to improved outcome. Embryo development and morphology were similar in all cut-off groups.

CONCLUSIONS

HA-binding did not predict spontaneous fertilization in patients with unexplained infertility undergoing IVF treatment. When it was used for "screening" it did not help to select the method of fertilization.

Cumulative clinical pregnancy rates after COH and IUI in subfertile couples

To evaluate the influence of female age and cause of infertility on the outcome of controlled ovarian hyperstimulation (COH) and intrauterine insemination (IUI), we studied 2717 COH cycles in 1035 subfertile couples. The cumulative clinical pregnancy rates were 39% and 58% after three and six COH cycles, respectively. The cumulative pregnancy rate significantly decreased with maternal age and differed by cause of infertility. The cumulative pregnancy rate continued to increase with an increase in COH cycle number up to the third, or forth cycle, in patients with mechanical and combined infertility, respectively, and in up to the second cycle in patients aged 40 years or more. These findings provide treatment guidelines for clinicians in determining the likelihood of treatment success and the point at which to proceed to the next treatment strategy.

Evaluation of Endometrial Urocortin Secretion for Prediction of Pregnancy after Intrauterine Insemination

Background: Urocortin is a neuropeptide produced by the human endometrium and has biological effects putatively important for promoting blastocyst implantation. We measured urocortin concentrations in samples of endometrial wash fluid collected from women with unexplained infertility who underwent intrauterine insemination (IUI).

Methods: Patients 28–42 years of age (n = 71) were consecutively enrolled after a complete clinical evaluation. Endometrial wash fluid was retrieved before IUI, at the time of ultrasound evaluation of endometrial thickness. Urocortin concentrations were assayed with a specific ELISA.

Results: After IUI, 28 patients (39%) became pregnant. Urocortin concentrations were significantly higher in women who became pregnant than in those who did not (0.38 μg/L vs 0.13 μg/L, P &lt;0.0001). At a cutoff of 0.321 μg/L, urocortin results were positive in 61% [95% confidence interval (CI), 41%–78%] of women who had successful implantation and negative in 98% (95% CI, 88%–99.6%) of those who did not. The pregnancy rate for women with urocortin concentrations &gt;0.32 μg/L was 94%, which differed significantly (P &lt;0.05) from the overall pregnancy rate of 39% in the study population.

Conclusions: Urocortin is measurable in endometrial wash fluid, and its concentrations before IUI are higher in women who subsequently achieve pregnancy. These data suggest that the probability of having a successful pregnancy-producing IUI may be better estimated by measuring urocortin in endometrial wash fluid.

Fertility treatment in male cancer survivors

The present study reviews the use of assisted reproductive technology in male cancer survivors and their partners. As antineoplastic treatment with chemotherapy or radiation therapy, has the potential of inducing impairment of spermatogenesis through damage of the germinal epithelium, many male cancer survivors experience difficulties in impregnating their partners after treatment. The impairment can be temporary or permanent. While many cancer survivors regain spermatogenesis months to years after treatment, some become infertile with a-, oligo- or azoospermia. An option to secure the fertility potential of young cancer patients is to cryopreserve semen before cancer treatment for later use. A desired pregnancy may be obtained in couples where the husband has a history of cancer, using assisted reproductive technology with either fresh or cryopreserved/thawed semen. Successful outcomes have been obtained with intrauterine insemination (IUI) as well as in vitro fertilization (IVF) with or without the use of intracytoplasmic sperm injection (ICSI). In conclusion, male cancer survivors and their partners who have failed to obtain a pregnancy naturally within a reasonable time frame after end of treatment should be referred to a fertility clinic.

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.

Cost-effectiveness of primary offer of IVF vs. primary offer of IUI followed by IVF (for IUI failures) in couples with unexplained or mild male factor subfertility

Background

In unexplained and mild male factor subfertility, both intrauterine insemination (IUI) and in-vitro fertilisation (IVF) are indicated as first line treatments. Because the success rate of IUI is low, many couples failing IUI subsequently require IVF treatment. In practice, it is therefore important to examine the comparative outcomes (live birth-producing pregnancy), costs, and cost-effectiveness of primary offer of IVF, compared with primary offer of IUI followed by IVF for couples failing IUI.

Methods

Mathematical modelling was used to estimate comparative clinical and cost effectiveness of either primary offer of one full IVF cycle (including frozen cycles when applicable) or "IUI + IVF" (defined as primary IUI followed by IVF for IUI failures) to a hypothetical cohort of subfertile couples who are eligible for both treatment strategies. Data used in calculations were derived from the published peer-reviewed literature as well as activity data of local infertility units.

Results

Cost-effectiveness ratios for IVF, "unstimulated-IUI (U-IUI) + IVF", and "stimulated IUI (S-IUI) + IVF" were £12,600, £13,100 and £15,100 per live birth-producing pregnancy respectively. For a hypothetical cohort of 100 couples with unexplained or mild male factor subfertility, compared with primary offer of IVF, 6 cycles of "U-IUI + IVF" or of "S-IUI + IVF" would cost an additional £174,200 and £438,000, representing an opportunity cost of 54 and 136 additional IVF cycles and 14 to 35 live birth-producing pregnancies respectively.

Conclusion

For couples with unexplained and mild male factor subfertility, primary offer of a full IVF cycle is less costly and more cost-effective than providing IUI (of any modality) followed by IVF.

Age-related decline in sperm deoxyribonucleic acid integrity in patients evaluated for male infertility

The purpose of this study was to analyze the relationship of male age and DNA integrity in men presenting for investigation of infertility. We found that men 45 years and older had significantly greater DNA fragmentation than younger men.

Value of the sperm chromatin dispersion test in predicting pregnancy outcome in intrauterine insemination: a blind prospective study

BACKGROUND

Sperm DNA integrity has been used as a new marker of sperm quality in the prediction of pregnancy. Nevertheless, no previous study has been performed by analysing the same samples that were employed in assisted reproduction. The main objective of this work was to correlate sperm chromatin dispersion (SCD), measured by the SCD test, with semen parameters and pregnancy outcome in intrauterine insemination (IUI).

METHODS

A total of 100 semen samples obtained from males of couples undergoing IUI were analysed by the SCD test before and after swim-up, and the results were correlated with semen parameters and pregnancy outcome.

RESULTS

SCD was negatively correlated with sperm motility in both ejaculated and processed semen. Sperm recovered by swim-up did not show a significant improvement in DNA integrity. No correlation was found between SCD and pregnancy outcome in IUI.

CONCLUSIONS

DNA dispersion, as measured by the SCD test, is not correlated with pregnancy outcome in IUI.

Performance of the postwash total motile sperm count as a predictor of pregnancy at the time of intrauterine insemination: a meta-analysis

OBJECTIVE

To assess the performance and clinical value of the postwash total motile sperm count (postwash TMC) as a test to predict intrauterine insemination (IUI) outcome.

DESIGN

Meta-analysis of diagnostic tests.

SETTING

Tertiary fertility center.

PATIENT(S)

Patients undergoing IUI.

INTERVENTION(S)

None.

RESULT(S)

We detected 16 studies that reported on postwash TMC at insemination and IUI outcome. Summary receiver operating characteristics (ROC) curves indicated a reasonable predictive performance toward IUI outcome, and, at cut-off levels between 0.8 to 5 million motile spermatozoa, the postwash TMC provided a substantial discriminative performance. At these cut-off levels, the specificity of the postwash TMC, defined as the ability to predict failure to become pregnant, was as high as 100%; the sensitivity of the test, defined as the ability to predict pregnancy, was limited.

CONCLUSION(S)

The postwash TMC at insemination could potentially be used in counseling patients for either IUI or IVF. However, to enable patient counseling before the start of treatment, further studies are needed to establish the accuracy of a postwash TMC during the fertility workup rather than at insemination.

The effect of human immunodeficiency virus on sperm parameters and the outcome of intrauterine insemination following sperm washing

BACKGROUND

This is the first study to assess the outcome of sperm washing and intrauterine insemination (IUI) cycles in human immunodeficiency virus-positive (HIV(+)) men to determine any predictors of success, as well as evaluating the effect of HIV on sperm parameters.

METHODS

Semen characteristics were evaluated in 106 HIV(+) men and a control group of 234 HIV(-) men, and the effect of markers of HIV disease assessed. Age, stimulation regime, sperm parameters, markers of HIV disease and the use of anti-retrovirals were assessed as predictors of the outcome of sperm washing/IUI cycles in the HIV(+) men.

RESULTS

Ejaculate volume, sperm concentration, total count, progressive motility and normal morphology were all significantly higher in the control group compared to the HIV(+) men (P<0.05). A significant positive correlation was observed between CD4 count and sperm concentration, total count, motility, progressive motility type 'a'+'b' and post-preparation concentration and a significant negative correlation with normal sperm morphology of both raw and post-preparation samples. No correlation was observed between viral load (VL), years since diagnosis, use of anti-retrovirals or duration of use and any sperm parameter. The only factors that significantly improved IUI outcome were a VL <1000 copies/ml and the use of anti-retrovirals.

CONCLUSIONS

These data demonstrate that sperm parameters are significantly impaired by the presence of HIV infection and in particular correlate with CD4 count. Undetectable VL and the use of anti-retrovirals improve the outcome of IUI/sperm washing in HIV(+) men.

Insémination intra-utérine : état des lieux chez l’humain

Despite its being used for a long time, intrauterine insemination (i.u.i.) remains debated as to its precise place and efficacy among assisted reproductive technologies. Data issued from the French Health Ministry inquiries are strictly limited to the number of cycles and the pregnancies and births including the multiple ones. Concerning 2000, more than 44,000 cycles were registered with 8% deliveries per cycle and 12% multiple pregnancies. Apart from the cervical female infertility which is considered to have the best prognosis with i.u.i., literature data remain controversial with male and unexplained infertility. Prospective randomized studies are rather scarce, particularly when considering the inclusion of untreated control population. Meta-analyses have been published for ten years, which allowed to better define the place of i.u.i. in patient management. However one may notice that the sperm cut-off parameters for male infertility and the respective contribution of i.u.i. and ovulation treatment do not allow develop some evidence-based guidelines for i.u.i. good practice. Quite all meta-analyses modulated their conclusions by addressing the need for large randomized controlled studies. Such a need seems now quite reinforced since results were until now expressed as pregnancy rate per cycle or pregnancy rate per couple, whereas single live birth rate and drop out rate are claimed to be taken into account nowadays. Moreover the level of controlled hyperstimulation is highly questionable with both hyperstimulation ovary syndrome and multiple pregnancy risks. Patients facing with failed i.u.i. cycles may turn to i.v.f. or i.c.s.i.. Interestingly data coming from the French national register (FIVNAT) did not show major differences between couples turning to i.v.f. (i.c.s.i.) after previously failed i.u.i. cycles or using directly i.v.f. (i.c.s.i.). Moreover the prognostic as evaluated on pregnancy rate per cycle was unchanged between such patients, which does not support some selection of patients by i.u.i. failure. Thus, although i.u.i. seems likely a cost-effective treatment in infertile couples, the precise conditions of its management (spontaneous or stimulated cycle, mono-, pauci- or multi-follicular induction) remain to be assessed. Indeed large controlled randomized studies including untreated group are required even if such design might have a non negligible cost. However these rather common treatments do have a high cost and any effort to rationalise them will have some economical impact. Another practical approach, although less ambitious, might consist in developing a per cycle registry which should allow to precise the French practice at a large national level.

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.

Analysis of factors influencing pregnancy rates in homologous intrauterine insemination

OBJECTIVE

To identify predictors of pregnancy rate (PR) among women undergoing homologous IUI.

DESIGN

Cross-sectional analysis of IUI cycles carried out from January 2000 to September 2002.

SETTING

Private infertility center in Alicante, Spain.

PATIENT(S)

Four hundred seventy women undergoing 1,010 cycles of IUI.

INTERVENTION(S)

Single IUI with ovarian stimulation using hMG.

MAIN OUTCOME MEASURE(S)

Preovulatory follicles (>15 mm), motile spermatozoa count, type and duration of infertility, female age, insemination timing, and cycle number.

RESULT(S)

Overall PR per cycle and multiple pregnancy and miscarriage rates were 9.2%, 8.6%, and 11.8%, respectively. Three significant predictors of pregnancy were identified by multiple logistic regression analysis: preovulatory follicles, spermatozoa count, and infertility duration. Interuterine insemination with three follicles almost tripled the PR with respect to only one, odds ratio (OR) = 2.89 (95% confidence interval [CI], 1.54-5.41). Compared with insemination with a motile sperm count >30 x, 20.1-30, 10.1-20, 5.1-10, and < or =5 x10(6), insemination progressively decreased the PR, from 15.3% in the highest category to 3.6% in the lowest (OR lowest/highest = 0.20 [95% CI: 0.09-0.45]), with a statistically significant dose-response trend. Infertility duration > or =3 years was marginally associated with a lower PR, OR = 0.65 (95% CI, 0.40-1.04). Overall, female age was not a significant predictor of pregnancy, and although PR slightly decreased beyond two IUI cycles and when a single IUI was performed 36-40 hours after hCG administration, results were not statistically significant.

CONCLUSION(S)

Homologous IUI achieves the best results with two or three induced follicles, a high motile spermatozoa count, and infertility duration <3 years, irrespective of female age and fertility history.

Clomiphene citrate intrauterine insemination (IUI) before gonadotropin IUI affects the pregnancy rate and the rate of high-order multiple pregnancies

OBJECTIVE

To determine if previous treatment with clomiphene citrate intrauterine insemination (CC-IUI) affects pregnancy and high-order multiple pregnancy (HOMP) rates in subsequent hMG-IUI or FSH-IUI cycles.

DESIGN

Retrospective cohort study.

SETTING

Private infertility clinic.

PATIENT(S)

Five hundred fifty-one patients (age <38 years) without tubal factor infertility, treated with 918 cycles of hMG/FSH-IUI after one or more unsuccessful cycles of CC-IUI; 908 patients treated with 1459 cycles of hMG/FSH-IUI without prior CC-IUI.

INTERVENTION(S)

CC-IUI, hMG-IUI, FSH-IUI.

MAIN OUTCOME MEASURE(S)

Pregnancy rate per cycle, HOMP (three or more gestational sacs).

RESULT(S)

Pregnancy rates during the first three hMG-IUI or FSH-IUI cycles averaged 21.8 +/- 1.1% without previous CC-IUI, 19.6 +/- 1.3% after one to four cycles of CC-IUI, and 3.6 +/- 2.6% after >or= five previous CC-IUI cycles. The HOMP rates were 8.8% without previous CC-IUI, 7.5% after one, 5.7% after two and <2.6% (0 out of 38) after >or= three previous CC-IUI cycles.

CONCLUSION(S)

Pregnancy rates in hMG/FSH-IUI cycles are significantly reduced after four unsuccessful CC-IUI cycles. High-order multiple pregnancies due to hMG/HMG-IUI are reduced following previous unsuccessful CC-IUI cycles.

Comparison of the effectiveness of single intrauterine insemination (IUI) versus double IUI per cycle in infertile patients

OBJECTIVE

To compare a single periovulatory intrauterine insemination (IUI) with a regimen based on double IUI, performed during preovulatory and periovulatory periods, in patients undergoing controlled ovarian hyperstimulation (COH).

DESIGN

Prospective, randomized study.

SETTING

Infertility and endocrinology units of a medical university.

PATIENT(S)

One hundred ten patients with male factor, cervical factor, and unexplained infertility who were undergoing 486 cycles of COH with IUI.

INTERVENTION(S)

The patients were randomly divided into two groups. One group underwent single IUI in the first cycle and double IUI in the second cycle; this alternating pattern was continued up to six cycles unless pregnancy occurred. For patients in the second group, double IUI was performed in the first cycle and single IUI in the second cycle; this pattern was repeated as in the first group.

MAIN OUTCOME MEASURE(S)

Relationship of single and double IUI to rates of clinical pregnancy and abortion.

RESULT(S)

Forty-two women became pregnant, with an overall pregnancy rate per cycle of 8.6% and pregnancy rate per couple of 38.2%. Pregnancy rate per cycle was 7.9% in single IUI cycles and was 9.4% in double IUI cycles; these findings were not statistically significant.

CONCLUSION(S)

Among patients undergoing COH-IUI, results of single and double IUI do not statistically differ.

Efficacy and pregnancy outcome of two methods of semen preparation for intrauterine insemination: a prospective randomized study

OBJECTIVE

To examine pregnancy outcome with two methods of semen preparation for intrauterine insemination (IUI).

DESIGN

Prospective and randomized study.

SETTINGS

Academic tertiary center.

PATIENT(S)

Three hundred eleven couples undergoing 676 consecutive cycles of assisted conception using IUI.

INTERVENTION(S)

Semen samples collected for IUI were randomized to wash only or density gradient centrifugation (DGC) processing.

MAIN OUTCOME MEASURE(S)

Various prepreparation and postpreparation semen parameters were used for IUI. The influence of the method of semen processing, and impact of various semen parameters and female factors on pregnancy were examined by receiver operating characteristics (ROC) curves, logistic regression, and life table analysis.

RESULT(S)

Of the 676 cycles, 88 resulted in conception leading to an overall clinical pregnancy rate of 13.0% per cycle and 28.3% per patient with a miscarriage rate of 34.0%. Eighty-eight percent of pregnancies occurred in the first three cycles of IUI and 95.5% within the first four cycles. The pregnancy rate for wash only was 11.6% (37 of 319) and the rate for DGC was 14.3% (51 of 356). However, in samples with <22 million motile sperm in the inseminate, pregnancy rates were 4% for wash and 18% for DGC. The woman's age for both methods and the percentage of sperm in the original semen with a velocity of > or =80 micro m/s for the wash method influenced pregnancy outcome.

CONCLUSION(S)

Although samples with an acceptable number of motile sperm can be processed efficiently by wash only, poor quality semen samples should be processed using DGC.

Semen quality and intrauterine insemination

There is good evidence in literature that intrauterine insemination (IUI) is the best first line treatment and most cost-effective procedure for moderate male factor subfertility. It seems very difficult to identify individual semen parameters predicting the likelihood of pregnancy after IUI. This can be explained by a lack of standardization of semen analysis, but many other methodological variables may also influence IUI success rates such as the patient selection, type of ovarian stimulation and number of inseminations per cycle. A review of the literature confirmed that sperm morphology using strict criteria and the inseminating motile sperm count (IMC) after sperm preparation are the two most important sperm parameters to assess the real impact of semen quality on IUI outcome. A universal threshold level above which IUI can be performed with acceptable pregnancy rates has not been determined yet, although IUI success seems to be impaired with <5% normal spermatozoa and an IMC of <1 x 10(6). Until now, no method of sperm preparation has been shown to be superior with regard to pregnancy rate after IUI. Whether supplementation of culture media with substances such as antioxidants and platelet activating factor may improve the results remains the subject of further research.

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.

Effects of male age on semen quality and fertility: a review of the literature

OBJECTIVE

To review the literature on the association between male age and semen quality (semen volume, concentration, motility, and morphology) and fertility status (pregnancy rate and time to pregnancy/subfecundity).

METHOD(S)

Review of English language-published research over the last 20 years from January 1, 1980, through December 31, 1999, using MEDLINE and Biosis databases. Studies with insufficient numbers of subjects, case reports, case series, or anecdotal data were excluded.

RESULT(S)

Among the methodologically stronger studies, decreases in semen volume of 3%-22%, decreases in sperm motility of 3%-37%, and decreases in percent normal sperm of 4%-18% were likely when comparing 30-year-old men to 50-year-old men. Most studies examining fertility status suggest a relationship between male age and fertility, but the results are most likely confounded by female partner age. Among studies that did control for female age, comparisons between men under 30 and men over 50 found relative decreases in pregnancy rates between 23% and 38%. A comparison of the various age categories showed that the increased risks for subfecundity ranged from 11% to 250%.

CONCLUSION(S)

The weight of the evidence suggests that increased male age is associated with a decline in semen volume, sperm motility, and sperm morphology but not with sperm concentration.

Controlled ovarian hyperstimulation and intrauterine insemination for treatment of unexplained infertility should be limited to a maximum of three trials

OBJECTIVE

To investigate the optimum number of cycles of controlled ovarian hyperstimulation and intrauterine insemination in the treatment of unexplained infertility.

DESIGN

Observational prospective study.

SETTING

In vitro fertilization embryo transfer center.

PATIENT(S)

Five hundred ninety-four couples with unexplained infertility.

INTERVENTION(S)

Controlled ovarian hyperstimulation (COH), intrauterine insemination (IUI), in vitro fertilization (IVF), and intracytoplasmic sperm injection (ICSI).

MAIN OUTCOME MEASURE(S)

Cycle fecundity.

RESULT(S)

One to 3 cycles of COH/IUI were performed in 594 patients (group A) undergoing 1,112 cycles (mean, 1.9 cycles/patient). Up to 3 further trials (cycles 4-6) of COH/IUI were then performed in 91 of these women (group B), a total of 161 cycles (mean, 1.8 cycles/patient). A historical comparison group C consisted of 131 patients with 3 failed cycles of COH/IUI who underwent 1 cycle of IVF and ICSI at our center. In group A, 182 pregnancies occurred, with a cycle fecundity of 16.4% and a cumulative pregnancy rate (PR) of 39.2% after the first 3 cycles. In group B, 9 pregnancies occurred in cycles 4-6, with a cycle fecundity of 5.6%, significantly lower than that of group A (P<.001). The cumulative PR rose to 48.5% by cycle 6, a further increase of only 9.3%. In the women undergoing IVF and ICSI in group C, 48 pregnancies occurred, with a cycle fecundity of 36.6% per cycle, significantly higher than that of group B (P<.001).

CONCLUSION(S)

In unexplained infertility, the cycle fecundity in the first three trials of COH and IUI was higher than in cycles 4-6, with a statistically significant difference. Patients should be offered IVF or ICSI if they fail to conceive after three trials of COH and IUI.

Relationship of total motile sperm count and percentage motile sperm to successful pregnancy rates following intrauterine insemination

PURPOSE

This study sought (i) to investigate the relationship between postwash total motile sperm count and postwash percentage motile sperm in predicting successful intrauterine insemination and (ii) to determine the minimal postwash total motile sperm count required to achieve pregnancy with intrauterine insemination.

METHODS

Five hundred four women, who underwent 1636 intrauterine insemination cycles with their partner's sperm for infertility treatment from 1993 through 1995, were included in this retrospective study. All patient charts were reviewed for age, infertility etiology, ovarian stimulation regimens, semen characteristics, and treatment outcome. To determine the relationship between total motile sperm count and intrauterine insemination outcome, patients were grouped as (1) less than 0.5 million, (2) 0.5 to 1 million, (3) 1 to 5 million, (4) greater than 5 million, and (5) greater than 20 million.

RESULTS

Similar live birth rates (per cycle) were seen among the postwash total motile sperm count groups: group 1, 3.5%; group 2, 2.4%; group 3, 7.0%; group 4, 6.9%; and group 5, 7.0% (P = 0.37). However, regardless of the postwash total motile sperm count, the postwash motility predicted intrauterine insemination success at a cutoff value of 40%.

CONCLUSIONS

The percentage of postwash sperm motility, and not the postwash total motile sperm count, can predict successful intrauterine insemination outcome. Such information can be useful in counseling patients regarding their chance of success with intrauterine insemination and in determining when alternate methods of assisted reproduction may be a better approach.