Microfluidics as an emerging paradigm for assisted reproductive technology: A sperm separation perspective

Millions of people are subject to infertility worldwide and one in every six people, regardless of gender, experiences infertility at some period in their life, according to the World Health Organization. Assisted reproductive technologies are defined as a set of procedures that can address the infertility issue among couples, culminating in the alleviation of the condition. However, the costly conventional procedures of assisted reproduction and the inherent vagaries of the processes involved represent a setback for its successful implementation. Microfluidics, an emerging tool for processing low-volume samples, have recently started to play a role in infertility diagnosis and treatment. Given its host of benefits, including manipulating cells at the microscale, repeatability, automation, and superior biocompatibility, microfluidics have been adopted for various procedures in assisted reproduction, ranging from sperm sorting and analysis to more advanced processes such as IVF-on-a-chip. In this review, we try to adopt a more holistic approach and cover different uses of microfluidics for a variety of applications, specifically aimed at sperm separation and analysis. We present various sperm separation microfluidic techniques, categorized as natural and non-natural methods. A few of the recent developments in on-chip fertilization are also discussed.

The impact of thyroid autoimmunity on pregnancy outcomes in women with unexplained infertility undergoing intrauterine insemination: a retrospective single-center cohort study and meta-analysis

Introduction

Infertility affects 8-12% of couples worldwide, with 15-30% classified as unexplained infertility (UI). Thyroid autoimmunity (TAI), the most common autoimmune disorder in women of reproductive age, may impact fertility and pregnancy outcomes. However, the underlying mechanism is unclear. This study focuses on intrauterine insemination (IUI) and its potential association with TAI in UI patients. It is the first meta-analysis following a comprehensive literature review to improve result accuracy and reliability.

Methods

Retrospective cohort study analyzing 225 women with unexplained infertility, encompassing 542 cycles of IUI treatment. Participants were categorized into TAI+ group (N=47, N= 120 cycles) and TAI- group (N=178, N= 422 cycles). Additionally, a systematic review and meta-analyses following PRISMA guidelines were conducted, incorporating this study and two others up to June 2023, totaling 3428 IUI cycles.

Results

Analysis revealed no significant difference in independent variables affecting reproductive outcomes. However, comparison based on TAI status showed significantly lower clinical pregnancy rates (OR: 0.43, P= 0.028, 95%CI: 0.20-0.93) and live birth rate (OR: 0.20, P= 0.014, 95%CI: 0.05 ~ 0.71) were significantly lower than TAI- group. There was no significant difference in pregnancy rate between the two groups (OR: 0.61, P= 0.135, 95%CI: 0.32-1.17). However, the meta-analysis combining these findings across studies did not show statistically significant differences in clinical pregnancy rates (OR:0.77, P=0.18, 95%CI: 0.53-1.13) or live birth rates (OR: 0.68, P=0.64, 95%CI: 0.13-3.47) between the TAI+ and TAI- groups.

Discussion

Our retrospective cohort study found an association between TAI and reduced reproductive outcomes in women undergoing IUI for unexplained infertility. However, the meta-analysis incorporating other studies did not yield statistically significant associations. Caution is required in interpreting the relationship between thyroid autoimmunity and reproductive outcomes. Future studies should consider a broader population and a more rigorous study design to validate these findings. Clinicians dealing with women with unexplained infertility and TAI should be aware of the complexity of this field and the limitations of available evidence.

Bio-inspired progressive motile sperm separation using joint rheotaxis and boundary-following behavior

Infertility, as a daunting ever-increasing challenge, poses a worldwide issue to both couples and the healthcare sector. According to the World Health Organization, half of infertility cases are attributed to male factor infertility, either partly or completely. Semen parameters of concern including sperm count, morphology, and motility are deemed to play a vital role in the insemination process. Density gradient centrifugation, being a clinically established procedure for improving on the mentioned parameters, has long been proven to inflict damage on the DNA content of the sperm cells, inducing DNA fragmentation. Herein, a bio-inspired microfluidic device is proposed that capitalizes on the geometry of the uterotubal junction (UTJ) of the female reproductive tract, which can act as a rheological barrier. The device leverages sperm rheotaxis and boundary-following behavior which have been considered as major migratory mechanisms used by sperm during the fertilization process in the female body. The device consists of a series of parallel channels that guide progressive motile sperms into the main sorting channel, where the hydrodynamic barriers created by two consecutive UTJ-like constrictions select sperms based on their propulsive velocity and linearity of motion. The sequential sorting employed here allows for the fractionation of the sperm population into two subpopulations with varying degrees of motility. Both sorted populations showed a significant increase in straight line velocity, reaching 63.4 ± 14.4 μm s-1 and 74 ± 13.8 μm s-1 in the first and second pools, respectively from 35.2 ± 27.2 μm s-1 in raw semen. Additionally, sorted populations demonstrated over 30% reduction in DNA fragmentation index, an indication that the proposed device selects for undamaged sperms with high quality. Apart from the biological superiority of the sorted sperms, this device presents itself as an easy and clinically-applicable method for the separation of progressive motile sperms, while at the same time, benefiting from a straightforward procedure for sperm retrieval.

Association between follicle size, endometrial thickness, and types of ovarian stimulation (Clomiphene citrate and Letrozole) with biochemical pregnancy rate in women undergone intrauterine insemination

OBJECTIVE

There was also a lack of data regarding the effect of follicle size, endometrial thickness, and ovarian stimulation as predictors of intrauterine insemination (IUI) success rate in Indonesia, especially in the Aster Clinic and Bandung Fertility Centre. This study was performed to explore the relationship between follicle size, endometrial thickness, and types of ovarian stimulation (Clomiphene citrate/CC vs Letrozole) with biochemical pregnancy rate in women undergone IUI. We performed a case-control study in 122 women aged 20-40 years with unexplained infertility who had completed the IUI program for a maximum of three cycles. Data were extracted from medical records. Independent T-test and multivariate analyses were used to analyse the difference between variables using IBM SPSS 24.0. P-value < 0.05 was considered statistically significant.

RESULT

Follicle sizes of 18-22 mm in both Clomiphene citrate (CC) and Letrozole groups were shown to increase biochemical pregnancy rate (P = 0.001). There is no relationship between endometrial thickness and pregnancy rate. Biochemical pregnancy rate in women using Letrozole was 1.513 times higher than women using CC. The follicle size of 18-22 mm and using Letrozole rather than CC as ovarian stimulators are predictive factors associated with a higher pregnancy rate in women undergone IUI.

Pregnancy outcomes of intrauterine insemination in young patients with diminished ovarian reserve: a multicenter cohort study

BACKGROUND

To date, there is no consensus on whether intrauterine insemination (IUI) treatment is required in young patients with diminished ovarian reserve (DOR). Pregnancy outcomes in young DOR patients undergoing IUI are controversial. The existing studies are all single-center studies, with no existing multicenter cohort studies. The purpose of this multicenter study was to investigate the pregnancy outcomes of young DOR patients undergoing IUI.

METHODS

This multicenter cohort study included a total of 4600 cycles in 2204 infertile patients who underwent IUI treatment in three reproductive medical centers between September 2018 and January 2022. The research subjects were divided into two groups according to their serum anti-Müllerian hormone (AMH) levels. Propensity score matching (PSM) was used to match the research subjects at a ratio of 1:4. The pregnancy outcomes in the two groups were compared.

RESULTS

There was no significant difference in the clinical pregnancy rates (CPR), biochemical rates, and ectopic pregnancy rates between the two groups (P > 0.05). There were, however, significant differences in the miscarriage rates between the groups (P < 0.05). The live birth rates (LBR) were 6.6 vs. 9.9 between the two groups. The multivariable logistic regression models reveal that body mass index, AMH were significantly correlated with CPR; AMH were significantly correlated with LBR; BMI, follicle stimulating hormone were significantly correlated with miscarriage rate.

CONCLUSIONS

The clinical pregnancy rate of DOR patients was not significantly different from that of NOR patients; however, the miscarriage rates were significantly different from those of NOR patients.

The impact of different sperm preparation methods on clinical pregnancy and live birth rates in intrauterine insemination cycles: a retrospective single-center cohort study

OBJECTIVE

To assess the impact of 2 different sperm preparation methods, density gradient centrifugation and simple wash, on clinical pregnancy and live birth rates in intrauterine insemination (IUI) cycles with and without ovulation induction.

DESIGN

Retrospective single-center cohort study.

SETTING

Academic fertility center.

PATIENTS

In total, 1,503 women of all diagnoses sought IUI with fresh-ejaculated sperm.

EXPOSURE

Cycles were divided into 2 groups on the basis of sperm preparation technique: density gradient centrifugation (n = 1,687, unexposed group) and simple wash (n = 1,691, exposed group).

MAIN OUTCOME MEASURES

Primary outcome measures consisted of clinical pregnancy and live birth rates. Furthermore, adjusted odds ratios and 95% confidence intervals for each outcome were calculated and compared between the 2 sperm preparation groups.

RESULTS

Odds ratios did not differ between density gradient centrifugation and simple wash groups for clinical pregnancy and live birth (1.10 [0.67-1.83] and 1.08 [0.85-1.37], respectively). Additionally, when cycles were stratified using ovulation induction rather than adjusted for, no differences in clinical pregnancy and live birth odds were noted between sperm preparation groups (gonadotropins: 0.93 [0.49-1.77] and 1.03 [0.75-1.41]; oral agents: 1.78 [0.68-4.61] and 1.05 [0.72-1.53]; unassisted: 0.08 [0.001-6.84] and 2.52 [0.63-10.00], respectively). Furthermore, no difference was seen in clinical pregnancy or live birth when cycles were stratified using sperm score or when the analysis was limited to first cycles only.

CONCLUSION

Overall, no difference was noted in clinical pregnancy or live birth rates between patients who received simple wash vs. density gradient-prepared sperm, suggesting similar clinical efficacy between the 2 techniques for IUI. Because the simple wash technique is more time-efficient and cost-effective compared with the density gradient, adoption of this technique could lead to comparable clinical pregnancy and live birth rates for IUI cycles, although optimizing teamwork flow and coordination of care.

Exogenous GSH Supplementation to Raw Semen Alters Sperm Kinematic Parameters in Infertile Patients

Glutathione is an important antioxidant found in all mammalian cells. Sperm motility is positively correlated with seminal reduced glutathione (GSH) levels, and infertile men are known to have lower GSH levels. Studies on GSH supplementation in improving sperm functions in infertility patients are limited. Here, we re-investigate the effect of exogenous GSH supplementation on human sperm motility and kinematic parameters. Residual semen samples from 71 infertility patients who came for routine semen analysis for infertility assessment were studied. Liquefied raw semen was supplemented with GSH (0-10 mM) for 1 h. The untreated sample was the blank control. Only a 5 mM concentration was tested in all 71 samples. After two washes, the sperm was incubated and then analyzed for sperm motility and kinematic parameters by computer-assisted semen analysis (CASA), followed by adenosine triphosphate (ATP), reactive oxygen species (ROS) levels, free thiols, and DNA damage analyses. At 2 hrs post-treatment, GSH supplementation significantly altered many of the kinematics, compared to the control. Straight line velocity (VSL) (p = 0.0459), curvilinear velocity (VCL) (p < 0.0001), average path velocity (VAP) (p < 0.0001), and lateral head amplitude (ALH) (p < 0.0001) were decreased, whereas straightness (STR) (p = 0.0003), linearity (LIN) (p = 0.0008), and beat cross frequency (BCF) (p = 0.0291) were increased in 5 mM group. Wobble (WOB) (p = 0.4917), motility (MOT) (p = 0.9574), and progressive motility (PROG) (p = 0.5657) were unchanged. ATP level was significantly increased in the 5 mM group (p < 0.05). It is concluded that exogenous GSH supplementation does alter sperm kinematics in humans. These altered kinematic parameters together with increased energy (ATP) may have a positive role in influencing the success rates of ART procedures.

An Algorithm to Predict the Lack of Pregnancy after Intrauterine Insemination in Infertile Patients

Increasing intrauterine insemination (IUI) success rates is essential to improve the quality of care for infertile couples. Additionally, straight referral of couples with less probability of achieving a pregnancy through IUI to more complex methods such as in vitro fertilization is important to reduce costs and the time to pregnancy. The aim of the present study is to prospectively evaluate the threshold values for different parameters related to success in intrauterine insemination in order to provide better reproductive counseling to infertile couples, moreover, to generate an algorithm based on male and female parameters to predict whether the couple is suitable for achieving pregnancy using IUI. For that, one hundred ninety-seven infertile couples undergoing 409 consecutive cycles of intrauterine insemination during a two-year period were included. The first year served as a definition of the parameters and thresholds related to pregnancy achievement, while the second year was used to validate the consistency of these parameters. Subsequently, those parameters that remained consistent throughout two years were included in a generalized estimating equation model (GEE) to determine their significance in predicting pregnancy achievement. Parameters significantly associated with the lack of pregnancy through IUI and included in the GEE were (p < 0.05): (i) male age > 41 years; (ii) ejaculate sperm count < 51.79 x 10⁶ sperm; (iii) swim-up alkaline Comet > 59%; (iv) female body mass index > 45 kg/m²; (v) duration of infertility (>84 months), and (vi) basal LH levels > 27.28 mUI/mL. The application of these limits could provide a pregnancy prognosis to couples before undergoing intrauterine insemination, therefore avoiding it in couples with low chances of success. The retrospective application of these parameters to the same cohort of patients would have increased the pregnancy rate by up to 30%.

The impact of anti-Müllerian hormone on endometrial thickness in gonadotropin stimulation/intrauterine insemination cycles: is there an effect on pregnancy outcomes?

PURPOSE

To study the association, if any, between anti-Müllerian hormone (AMH) and pre-ovulatory endometrial thickness (ET) in gonadotropin/intrauterine insemination (IUI) cycles.

METHODS

This retrospective cohort study included a total of 964 patients undergoing 1926 gonadotropin/IUI cycles at an academic fertility center. Primary outcome measure was the association between serum AMH and measured ET on the day of and the day before human chorionic gonadotropin hormone (hCG) ovulation trigger. The effect of a model combining AMH and ET on early pregnancy outcomes was a secondary measure.

RESULTS

In 52.8% of cycles, ET was last assessed and recorded on the day of hCG administration, while in the remaining 47.2% on the day prior to trigger. In unadjusted regression models, AMH was weakly correlated with ET on hCG trigger day [bAMH (95%CI) = 0.032 (- 0.008, 0.070), p = 0.015]. When adjusting for potential confounders, the positive correlation became significant [0.051 (0.006, 0.102), p = 0.047]. Similar findings were observed when assessing the correlation between AMH and ET on the day prior to hCG trigger. ET was non-significantly associated with the odds of clinical pregnancy, when adjusting for potential confounders, except for when restricting the analysis to couples with idiopathic infertility [OR (95%CI), p-value: 0.787 (0.623, 0.993), 0.044].

CONCLUSION

Our findings support an effect of serum AMH on endometrial development in gonadotropin induced cycles, even when adjusting for the diagnosis of PCOS. ET was not associated with the odds of achieving a clinical pregnancy, except for couples with idiopathic infertility.

Pregnancy outcomes after oral and injectable ovulation induction in women with infertility with a low antimüllerian hormone level compared with those with a normal antimüllerian hormone level

OBJECTIVE

To determine the ongoing pregnancy rate among patients with infertility with a low antimüllerian (AMH) level compared with those with a normal AMH level after oral and injectable ovulation induction (OI)/intrauterine insemination (IUI).

DESIGN

Retrospective cohort.

SETTING

Academic center.

PATIENT(S)

Patients completing ≥1 medicated OI/IUI cycle at our center between 2015 and 2019 were included. The AMH levels were measured within 12 months of treatment initiation. The cohort was stratified into low AMH (AMH level, <1.0 ng/mL) and normal AMH (AMH level, ≥1.0 ng/mL) groups. All subsequent medicated OI/IUI cycles occurring within 1 year of initial cycle start date were included up to the third completed cycle or until an ongoing pregnancy was recorded. Patients were stratified by age (<35, 35-40, and >40 years), and the relationship between the low and normal AMH groups and each binary endpoint were quantified as risk ratios using the age-adjusted Poisson models.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Ongoing pregnancy.

RESULT(S)

A total of 3,122 patients completed 5,539 oral antiestrogen cycles, and 1,060 completed 1,630 injectable gonadotropin cycles. For oral antiestrogen treatment, pregnancy outcomes, including ongoing pregnancy rate per cycle, for patients with a low AMH level were comparable with those for patients with a normal AMH level (<35 years, 15.4% vs. 14.9%; 35-40 years, 10.0% vs. 11.0%; and >40 years, 2.8% vs. 3.3%). For injectable gonadotropin treatment, the ongoing pregnancy rate was lower in the low AMH group than in the normal AMH group for the ages of <35 (12.1% vs. 23.5%; relative risk [RR], 0.52 [95% confidence interval {CI}, 0.28-0.97]) and 35-40 (12.5% vs. 18.5%; RR, 0.70 [95% CI, 0.49-0.99]) years but comparable with that for patients aged >40 years (3.0% vs. 4.0%; RR, 0.86 [95% CI, 0.31-2.35]). The proportion of multifetal gestations was similar between the low and normal AMH groups treated with oral antiestrogens (13.1% vs. 10.8%); however, for injectable gonadotropin treatment, patients with a normal AMH level had a higher proportion of multifetal gestations (18.6% vs. 31.1%).

CONCLUSION(S)

Compared with normal ovarian reserve, treatment with oral antiestrogens for OI/IUI for patients with low ovarian reserve results in comparable follicular development and ongoing pregnancy rates for all age groups. When patients with low ovarian reserve are treated with gonadotropins for OI/IUI, multifollicular recruitment is less likely resulting in a significantly decreased ongoing pregnancy rate for patients aged <35 and 35-40 years but also a decrease in multifetal gestations. Overall, the ongoing pregnancy rates of 8.7% per oral antiestrogen cycle and 8.1% per injectable gonadotropin cycle in patients with low ovarian reserve are comparable with the expected rates in the general infertility population.

Effect of ovulation before or after intrauterine insemination on pregnancy outcome in patients with unexplained infertility or polycystic ovarian syndrome

OBJECTIVE

To investigate the relationship between ovulation and pregnancy outcomes in patients undergoing intrauterine insemination (IUI).

METHODS

The clinical data from 784 patients, diagnosed with polycystic ovarian syndrome (PCOS) or unexplained infertility, underwent 1624 IUI cycles were analyzed retrospectively. Ovulation was observed by transvaginal ultrasonography on the day of IUI. The clinical pregnancy rate (CPR), abortion rate (AR), and live birth rate (LBR) were analyzed.

RESULTS

The study included 1031 pre-ovulation IUI cycles (63.49%) and 593 post-ovulation IUI cycles (36.51%). The CPR was 13.05%, the AR was 15.57%, and the LBR was 11.02%. Ovulation before or after IUI affected the CPR (11.06% VS 16.53%, p = .002) and LBR (9.41% VS 13.83%, p = .006) per cycle, but did not affect the AR (14.91% VS 16.33%, p = .149). The sex ratio of children was not related to ovulation (p = .948). After adjusting for baseline characteristics and logistic regression, the CPR (OR = 1.931, 95% CI 1.062-1.931, p = .019) and LBR (OR = 1.389, 95% CI 1.007-1.916, p = .045) of post-ovulation insemination were higher than those of pre-ovulation insemination significantly.

CONCLUSION

Pregnancy outcomes were affected by ovulation on the day of IUI in patients with unexplained infertility or PCOS. Post-ovulation insemination may improve the CPR of IUI.

The relationship of total progressive motile sperm count with the outcome of IUI? An analysis of 5171 cycles

Background: The role of motile sperm count in intrauterine insemination (IUI) success rate is controversial. This retrospective cohort study performed among unselected infertile couples undergoing IUI was to explore the association between the total progressive motile sperm count (TPMSC) and the live birth rate (LBR) following IUI.Methods: The total cohort of 5363 cycles, 2666 infertile couples between January 2015 and December 2018 and finally 5171 cycles, 2647 couples were included for analysis in Sun Yat-sen memorial hospital of Sun Yat-sen University. The primary outcome was LBR per cycle. And the secondary outcome measure was clinical pregnancy rate (CPR) per cycle.Results: From the receiver operating characteristic (ROC) analysis of female age predicting live birth, female age cutoff was defined as 28 years. With a female age of ≤28 years, the CPRs were 11.5%, 14.9%, 16.1%, and 15.8% in quartile groups of pre-wash TPMSC, respectively. For the LBRs the values were 9.4%, 12.9%, 14.4%, and 11.3%, and there were also no significant differences in quartile groups of pre-wash TPMSC with ≤24 million (M), [24M-50M], [50M-97M], >97M. No statistically significant differences in the CPRs (p = .051) and LBRs (p = .088) were also observed in the quartiles groups of post-wash TPMSC. With a female age of >28 years, the CPR in couples with post-wash TPMSC ≤22.32 M was significantly lower than with post-wash TPMSC >81.0 M (p = .007). There was an obvious trend in which CPRs and LBRs increased with the post-wash TPMSC during the <81 M interval in women >28 years.Conclusions: The optimal female age cutoff for live birth was 28 years in IUI cycles. Pre-wash and post-wash TPMSC were not significantly associated with CPR and LBR per cycle. When female age >28 years, there was a better outcome with post-wash TPMSC >22.32 million.

The effect of semen collection at home on intrauterine insemination outcomes

BACKGROUND

The WHO 2010 guidelines recognize at-home semen collection as an acceptable alternative to standard collection at the clinic in "exceptional circumstances". There is lack of sufficient data to determine the need for revisiting these recommendations for treatment purposes.

OBJECTIVES

To determine whether at home semen collection has any effect on intrauterine insemination (IUI) cycle outcomes.

MATERIALS AND METHODS

This is a retrospective cohort study of 729 IUI treatment cycles (382 patients) performed at an academic fertility center from 9/19/2019 to 12/31/2020. Semen collected at the "clinic" was used for 343 cycles before the Coronavirus Disease 2019 (COVID-19) pandemic (09/19/2019-3/21/2020), and "at-home" collected specimens were used for 386 cycles following revised protocols with COVID-19 driven changes (5/30/2020-12/31/2020). Logistic regression models were performed to evaluate the effect of "at-home" semen collection on achieving a positive pregnancy test (PPT) and a clinical pregnancy (CP).

RESULTS

Male and female partners' age, ovarian reserve biomarkers, and stimulation regimens used were similar in the "clinic" and "at-home" groups. In unadjusted models, "at-home" collection had no significant effect on the odds for a PPT [OR (95%CI): 0.733(0.503-1.069)] or CP [0.816(0.543-1.226)]. These results persisted even when adjusting for maternal age and anti-Müllerian Hormone: PPT [0.739(0.505-1.081)] and CP [0.826(0.547-1.248)]. Of the semen analysis parameters under evaluation, only motility appeared to significantly impact the odds of achieving a PPT [1.014(1.004-1.025)] and a CP [1.017(1.006-1.029)]. This effect was slightly attenuated for samples collected "at-home" [1.012(0.997-1.027) and 1.015(0.999-1.031), respectively for PPT and CP].

DISCUSSION

This study adds important information to the limited literature regarding the effect of at-home semen collection on IUI outcomes. Under adequate protocols, at-home semen collection should be considered a safe alternative. Additional research is needed to optimize such protocols.

CONCLUSION

Our data suggest that at-home semen collection does not negatively impact IUI pregnancy outcomes. This article is protected by copyright. All rights reserved.

Retrospective analysis: The application of human menopausal gonadotropin combined with letrozole for IUI in patients undergoing artificial insemination by husband due to unexplained or mild male factors

OBJECTIVE

To compare the effects of human menopausal gonadotropin (HMG) combined with letrozole (LE) to HMG only for ovarian stimulation on pregnancy outcome of infertile patients undergoing artificial insemination by husband (AIH) due to unexplained or mild male factors.

MATERIALS AND METHODS

Infertile patients with unexplained or mild male factors treated from July 2015 to December 2021 were selected as subjects. The patients were divided into two groups according to the ovarian stimulation schemes they received, namely HMG combined with LE or HMG only. We analyzed the laboratory examination results before drug treatment (baseline) and during ovarian stimulation and compared the pregnancy outcomes of the two groups using univariable analysis and multivariable logistic regression analysis.

RESULTS

In total, 526 cycles of 372 couples were included. The univariate analysis showed that the clinical pregnancy rate of the HMG combined with LE group was 24.8%, significantly higher than that of the HMG group (14.8%, P = 0.007). The live birth rate (19.9%) of the HMG combined with LE group were also significantly higher than those of the HMG group (11.2%, respectively). In multivariate logistic analysis, the age of males was negatively associated with the clinical pregnancy rate (OR 0.874, 95% CI 0.793~0.963, P=0.006) and live birth (OR0.875, 95% CI 0.783~0.977, P=0.018). Moreover, ovarian stimulation with HMG+LE was the only beneficial factor significantly associated with clinical pregnancy (OR 1.929, 95% CI 1.068~3.485, P=0.029) and live birth (OR 2.255, 95% CI 1.188~4.282, P=0.013).

CONCLUSION

Ovarian stimulation using HMG combined with LE can increase the clinical outcomes (live birth and clinical pregnancy) among infertile patients undergoing AIH due to explained or mild male factors.

The influence of the female reproductive tract and sperm features on the design of microfluidic sperm-sorting devices

Although medical advancements have successfully helped a lot of couples with their infertility by assisted reproductive technologies (ART), sperm selection, a crucial stage in ART, has remained challenging. Therefore, we aimed to investigate novel sperm separation methods, specifically microfluidic systems, as they do sperm selection based on sperm and/or the female reproductive tract (FRT) features without inflicting any damage to the selected sperm during the process. In this review, after an exhaustive studying of FRT features, which can implement by microfluidics devices, the focus was centered on sperm selection and investigation devices. During this study, we tried not to only point to the deficiencies of these systems, but to put forth suggestions for their improvement as well.

Aspiration of excess follicles before intrauterine insemination in high response cycles

Purpose

To assess the outcome of excess follicle aspiration before intrauterine insemination (EFABI) in intrauterine insemination (IUI) cycles with 4-6 follicles ≥14 mm.

Methods

A retrospective case-control study with 1559 patients undergoing IUI (donor and husband's sperm), of whom 86 underwent EFABI. We studied also an historical series of 2213 patients before EFABI implementation. For 3.5 years, all women undergoing IUI developing 4-6 follicles ≥14 mm were offered EFABI on the day of hCG administration. Pregnancy rates (PRs), multiple PRs, and adverse effects were measured.

Results

EFABI was associated with a similar multiple PR (17.8% vs 17.5% in non-EFABI cases), with no triplets in EFABI patients. Live birth rates were significantly higher in EFABI cycles in IUI overall (25.5% vs 15.2%). When considered separately, the performance of EFABI resulted in significantly increased live birth rates in IUI-donor cycles (32.5% vs 18.5%), whereas the differences in IUI-husband cycles (19.5% vs 12.9%) did not reach statistical significance. The PR was 21.2% during the EFABI implementation period and 19.4% in the pre-EFABI period.

Conclusions

EFABI in cycles in which 4-6 follicles reach ≥14 mm is a simple option that reduces cycle cancellation rates, results in higher PRs than cycles with 1-3 follicles, and lowers the risk of multiple pregnancy.

The efficiency of low-dose letrozole plus clomiphene citrate for ovulation induction in intrauterine insemination cycles: A randomized clinical trial

OBJECTIVE

To investigate if combination therapy with clomiphene citrate (CC) plus letrozole (L) was associated with a higher efficacy than L and CC alone in patients undergoing ovarian induction plus intrauterine insemination.

METHODS

The present multicenter randomized controlled clinical trial was performed between 2018 and 2020. Participants were randomized into three groups: L (n = 167; 5 mg/day), CC (n = 167; 100 mg/day), and L + CC (n = 167) (2.5 mg/day + 50 mg/day) from day 3. Ovarian stimulation was continued with the appropriate dose of gonadotropins daily starting from day 8 and continued until follicular size was 20 mm or more followed by administration of human chorionic gonadotropin (10 000 IU). Semen samples were prepared by direct swim-up technique.

RESULTS

In the CC group, gonadotropin dose was significantly higher but endometrial thickness was significantly lower compared with other groups. Number of follicles of 18 mm or more was significantly lower in the L group compared with the other two groups. Number of follicles less than 15 mm was meaningfully higher in the CC group compared with the other groups. In the L + CC group, total and largest follicular size, and the rates of chemical, clinical, and ongoing pregnancy, and live birth were significantly higher compared with other groups.

CONCLUSION

Combination therapy with L + CC was superior to either L or CC for achieving pregnancy in women undergoing ovarian induction plus intrauterine insemination.

The Effect of Prednisolone Treatment on Pregnancy Rates in in vitro Fertilization Patients with Positive Thyroid Autoantibodies

Objective:

This study aims to investigate the effect of prednisolone treatment on the pregnancy rates of in vitro fertilization (IVF) patients with positive thyroid autoantibodies.

Methods:

This study was conducted in the IVF unit of Gazi University Faculty of Medicine. It included 158 patients who underwent intracytoplasmic sperm injection using the long-term protocol of a gonadotropin-releasing hormone (GnRH) agonist that was positive for thyroid autoantibodies. Each test’s reference value was used as a positive measure of anti-thyroid peroxidase and anti-TG antibodies. On the day of oocyte intake, 44 of 158 patients were started on prednisolone, and the other 114 patients were followed up without medication.

Results:

In the control group, pregnancy did not occur in 67.5% of the patients; it was determined that 21.1% were pregnant, 5.3% had biochemical pregnancies, 4.4% had twin pregnancies, 0.9% had triplet pregnancies, and 0.9% had ectopic pregnancies. In the extended prednisolone group, pregnancy did not occur in 56.8% of the patients; it was determined that 36.4% of them were pregnant, 4.5% had twin pregnancies, and 2.3% had biochemical pregnancies. An increase in pregnancy rate was observed in the extended prednisolone group, while a statistically significant difference was found between the groups in terms of the mean values of prednisolone according to pregnancy status (p<0.05). It was thus determined that the rate of conception increased in the extended prednisolone group compared to the controls.

Conclusion:

There is a strong relationship between the presence of thyroid autoantibodies and poor IVF results. The coadministration of prednisolone can improve the clinical pregnancy rate in women affected by thyroid autoimmunity.

Predictive value of sperm motility before and after preparation for the pregnancy outcomes of intrauterine insemination

Objective

This study aimed to investigate sperm motility and its changes after preparation as predictors of pregnancy in intrauterine insemination (IUI) cycles.

Methods

In total, 297 IUI cycles from January 2012 to December 2017 at a single tertiary hospital were retrospectively analyzed. Patient and cycle characteristics, and sperm motility characteristics before and after processing were compared according to clinical pregnancy or live birth as outcomes.

Results

The overall clinical pregnancy rate per cycle was 14.5% (43/297) and the live birth rate was 10.4% (30/289). Patient and cycle characteristics were similar between pregnant and non-pregnant groups. Sperm motility after preparation and the total motile sperm count before and after processing were comparable in terms of pregnancy outcomes. Pre-preparation sperm motility was significantly higher in groups with clinical pregnancy and live birth than in cycles not resulting in pregnancy (71.4%±10.9% vs. 67.2%±11.7%, p=0.020 and 71.6%±12.6% vs. 67.3%±11.7%, p=0.030, respectively). The change in sperm motility after processing was significantly fewer in the non-pregnant cycles, both when the comparison was conducted by subtraction (post-pre) and division (post/pre). These relationships remained significant after adjusting for the female partner’s age, anti-Müllerian hormone level, and number of pre-ovulatory follicles. According to a receiver operating characteristic curve analysis, an initial sperm motility of ≥72.5% was the optimal threshold value for predicting live birth after IUI.

Conclusion

Initial sperm motility, rather than the motility of processed sperm or the degree of change after preparation, predicted live birth after IUI procedures.

Factors Affecting Artificial Insemination Pregnancy Outcome

Objective

The aim of the present study was to explore related clinical pregnancy outcome factors in intrauterine insemination (IUI).

Materials and Methods

The clinical data of 3984 IUI cycles in 1862 couples experiencing infertility who attended the Reproductive Center of Binzhou Medical University Hospital between July 2006 and July 2017 were retrospectively analyzed. Female and male patient age, endometrial thickness (EMT), the post-wash total motile sperm count (PTMC), artificial insemination timing, insemination frequency, and ovarian stimulation protocols were compared between the study’s pregnant group and non-pregnant group in order to explore any correlation.

Results

There were statistically significant differences in female and male age, EMT, artificial insemination timing, insemination frequency, and ovarian stimulation protocols between the two groups (p < 0.05). The clinical pregnancy rate was significantly higher in ovarian stimulation cycles than in natural cycles (21.2% and 11.6%, respectively; p < 0.01), the clinical pregnancy rate was significantly higher in double IUI than in single IUI (17.8% and 12.1%, respectively; p < 0.01), and EMT was significantly greater in the pregnant group than in the control group (p < 0.05). However, the differences in clinical pregnancy rates among the PTMC groups were not statistically significant (14.8%, 14.4%, 17.3%, and 17.3%, respectively; p > 0.05).

Conclusion

The results of the present study demonstrate that the clinical IUI pregnancy rate is correlated with the factors of female age, male age, EMT, artificial insemination timing, insemination frequency, and ovarian stimulation protocols; the ovarian stimulation protocol can noticeably improve the patient pregnancy outcome. Furthermore, compared with single IUI, double IUI can significantly increase the clinical pregnancy rate.

Does the time interval from the end of sperm processing to intrauterine insemination (lab-to-uterus time) affect treatment outcome?

BACKGROUND

Intra-uterine insemination is an essential component in the treatment of infertility. Success rates are dependent on clinical factors of the female partner, sperm quality, and preparation technique. The effect of the time interval between the end of sperm preparation in the lab, and its injection into the uterine cavity (lab-to-uterus time) is yet to be determined.

AIM

To investigate the association between the lab-to-uterus time and the pregnancy rate.

MATERIALS AND METHODS

Partner and donor spermatozoa intra-uterine insemination cycles were included. Preparation for intra-uterine insemination of partners' fresh ejaculate or donor thawed spermatozoa was identical. The time interval from the completion of this stage to the actual intra-uterine injection was recorded. The lab-to-uterus intervals were divided into groups A (0-29 min), B (30-59 min), C (60-89 min), and D (90-180 min). Pregnancy was defined as two adequate consecutive doubling levels of hCG and the pregnancy rates were compared between the groups.

RESULTS

A total of 267 female patients (138 partner spermatozoa, 129 donors) who had 470 intra-uterine insemination cycles (218 partner spermatozoa, 252 donors) were included. No significant differences in pregnancy rates per treatment cycle were found between the four lab-to-uterus interval groups: A (n = 96 cycles; 16.7%), B (n = 217; 19.4%), C (n = 121; 16.5%), and D (n = 36; 36.1%). No difference was found in the pregnancy rates between partner and donor spermatozoa. In the case of fresh partner spermatozoa, the pregnancy rates for groups were as follows: A (n = 40 cycles, 20%); B (n = 94; 14.9%), C (n = 70; 17.1%), and D (n = 14; 35.7%) (NS). In the case of thawed donor spermatozoa, the pregnancy rates (per cycle) for groups were as follows: A (n = 56; 14.3%), B (n = 123; 22.8%), C (n = 51; 15.7%), and D (n = 22; 36.4)% (NS).

CONCLUSIONS

The intra-uterine insemination outcome was not affected by the lab-to-uterus time interval. Extended waiting up to 3 h for insemination did not have any detrimental effect on pregnancy rates, regardless if partner or donor spermatozoa was used.

Can methods of artificial intelligence aid in optimizing patient selection in patients undergoing intrauterine inseminations?

Purpose

AI and its machine learning algorithms have proven useful in several fields of medicine, including medically assisted reproduction. The purpose of the study was to construct several predictive models based on clinical data and select the best models to predict IUI procedure outcomes.

Methods

Clinical data (patient baseline characteristics, sperm quality, hormonal status, and cycle data) from 1029 IUI procedures performed in 413 couples stimulated by clomiphene citrate, letrozole, or gonadotropins were used to build several models to predict clinical pregnancy. The models included ANN, random forest, PLS, SVM, and linear models using the caret package in R. The models were evaluated using ROC analysis by means of random CV on test data.

Results

Out of the best performing models, the random forest model achieved an AUC of 0.66, a sensitivity of 0.432, and a specificity of 0.756. This performance was followed by the PLS model, which achieved a sensitivity of 0.459 and specificity of 0.734. The other models achieved significantly lower AUCs. When adjusting the predictive cutoff value, confusion matrices show that clinical pregnancy is twice as likely in the case of positive prediction.

Conclusion

Among the compared methods, the random forest and PLS models demonstrated superior performance in predicting the clinical outcome of IUI. With additional research and clinical validation, AI methods may be successfully used in improving patient selection and consequently lead to better clinical results.

Impact of a Pozzi tenaculum forceps use on the success rate of intrauterine insemination (IUI) : protocol for a randomised control trial

INTRODUCTION

A therapeutic option frequently proposed for infertility is to proceed first with intrauterine insemination (IUI) cycles. Little is known on the effect of uterine contractions on IUI success rates. We postulated that uterine contractions may help with sperm migration in the women's genital tract. Our objective is to compare the efficacy of IUI when performed with and without a tenaculum forceps on the cervix.

METHODS AND ANALYSIS

We are conducting a randomised controlled trial with women aged 18-40 years old, diagnosed with primary or secondary infertility due to endometriosis, mild to moderate male factor, unexplained infertility or ovulatory dysfunction, receiving IUI treatments. On the day of their IUI, women will receive standard care treatment plus or minus the planned use of a Pozzi tenaculum forceps on the cervix. Each of the 800 women will be randomised only once for their first three IUI. They will be randomised in one of the following sequences: tenaculum-no tenaculum-tenaculum or, no tenaculum-tenaculum-no tenaculum. We will compare the live birth rate (primary outcome) and the clinical pregnancy rate (secondary outcome) after IUI treatment. We also plan on assessing global satisfaction of women, pain levels felt during IUI and discrepancies in primary and secondary outcomes in interventions performed by attendings compared with trainees.

ETHICS AND DISSEMINATION

This research project was approved by the Centre Hospitalier Universitaire de Québec's ethics review board (no 2018-4084). Pozzi tenaculum application is associated with mild pain, estimated at 33 on a Visual Analogue Scale ranging from 0 to 100. We plan on publishing an article to present our findings in a peer-reviewed journal as well as presenting the research abstract at conferences.

TRIAL REGISTRATION NUMBER

NCT03435809.

Comparing the Effectiveness of Doing Intra-uterine Insemination 36 and 42 Hours After Human Chorionic Gonadotropin (HCG) Injection on Pregnancy Rate: A Randomized Clinical Trial

Objective: Intrauterine insemination (IUI) is an assisted conception technique that involves the deposition of a processed semen sample in the upper uterine cavity, overcoming natural barriers to sperm ascent in the female reproductive tract. Hence, we compared the results of doing intra-uterine insemination 36 and 42 hours after human chorionic gonadotropin (hCG) hormone injection to achieve clinical and chemical pregnancy rates. Materials and methods: One hundred and sixty infertile women with unexplained infertility participated in this clinical trial. They were divided into two groups: those who underwent IUI 36 hours after hCG injection (control group), and those who underwent IUI 42 hours after hCG injection (case group). Statistical analyses were done using IBM-SPSS 25.0. and Chi-square test were used for data analysis. Results: The percentages of clinical and chemical pregnancies were significantly higher in the 42h group compared to the other group (P = 0.038 vs. P = 0.009, respectively). There was no significant difference regarding frequency of abortion, twin and ectopic pregnancies between the two groups (P > 0.05). Conclusion: Doing IUI 42 hours after hCG injection can significantly increase chances of fertility compared to doing it 36 hours after hCG injection.

Clarifying the relationship between total motile sperm counts and intrauterine insemination pregnancy rates

OBJECTIVE

To study the relationship between postwash total motile sperm count (TMSC) and intrauterine insemination (IUI) outcomes.

DESIGN

Retrospective review SETTING: Large fertility clinic PATIENT(S): A total of 92,471 insemination cycles from 37,553 patients were included in this study.

INTERVENTION(S)

All stimulated clomiphene citrate, letrozole, and/or injectable gonadotropin IUI cycles performed at a single institution from 2002 through 2018 were reviewed. Generalized estimating equations (GEE) analysis was used to account for multiple cycles by individual patients and to adjust for female partner age, body mass index, and stimulation protocol.

MAIN OUTCOME MEASURE(S)

Successful clinical pregnancy was defined as ultrasound confirmation of an intrauterine gestational sac with fetal cardiac activity.

RESULT(S)

A total of 92,471 insemination cycles were available to evaluate the relationship between postwash TMSC and clinical pregnancy. Pregnancy rates were highest with TMSC of ≥9 × 10⁶ and declined gradually as TMSC decreased. Complete data for the adjusted GEE analysis were available for 62,758 cycles. Adjusted GEE analysis among cycles with TMSC of ≥9 × 10⁶ (n = 46,557) confirmed that TMSC in this range was unrelated to pregnancy. Conversely, TMSC was highly predictive of pregnancy (Wald χ² = 39.85) in adjusted GEE analysis among cycles with TMSC of <9 × 10⁶ (n = 16,201), with a statistically significant decline.

CONCLUSIONS

IUI pregnancy is optimized with TMSC of ≥9 × 10⁶, below which the rates gradually decline. Although rare, pregnancies were achieved with TMSC of <0.25 × 10⁶. Since the decline in pregnancy is gradual and continuous, there is no specific threshold above which IUI should be recommended. Rather, these more specific quantitative predictions can be used to provide personalized counseling and guide clinical decision making.

Current Insights and Latest Updates in Sperm Motility and Associated Applications in Assisted Reproduction

Spermatozoon is a motile cell with a special ability to travel through the woman’s reproductive tract and fertilize an oocyte. To reach and penetrate the oocyte, spermatozoa should possess progressive motility. Therefore, motility is an important parameter during both natural and assisted conception. The global trend of progressive reduction in the number and motility of healthy spermatozoa in the ejaculate is associated with increased risk of infertility. Therefore, developing approaches for maintaining or enhancing human sperm motility has been an important area of investigation. In this review we discuss the physiology of sperm, molecular pathways regulating sperm motility, risk factors affecting sperm motility, and the role of sperm motility in fertility outcomes. In addition, we discuss various pharmacological agents and biomolecules that can enhance sperm motility in vitro and in vivo conditions to improve assisted reproductive technology (ART) outcomes. This article opens dialogs to help toxicologists, clinicians, andrologists, and embryologists in understanding the mechanism of factors influencing sperm motility and various management strategies to improve treatment outcomes.

Does the effectiveness of IUI in couples with unexplained subfertility depend on their prognosis of natural conception? A replication of the H2Oil study

STUDY QUESTION

Can we replicate the finding that the benefit of IUI-ovarian stimulation (IUI-OS) compared to expectant management for couples with unexplained subfertility depends on the prognosis of natural conception?

SUMMARY ANSWER

The estimated benefit of IUI-OS did not depend on the prognosis of natural conception but did depend on when treatment was started after diagnosis, with starting IUI-OS later yielding a larger absolute and relative benefit of treatment.

WHAT IS KNOWN ALREADY

IUI-OS is often the first-line treatment for couples with unexplained subfertility. Two randomized controlled trials (RCTs) compared IUI-OS to expectant management using different thresholds for the prognosis of natural conception as inclusion criteria and found different results. In a previous study (a Dutch national cohort), it was found that the benefit of IUI-OS compared to expectant management seemed dependent on the prognosis of natural conception, but this finding warrants replication.

STUDY DESIGN SIZE DURATION

We conducted a secondary analysis of the H2Oil study (n = 1119), a multicentre RCT that evaluated the effect of oil-based contrast versus water-based contrast during hysterosalpingography (HSG). Couples were randomized before HSG and followed up for 3-5 years. We selected couples with unexplained subfertility who received HSG and had follow-up or pregnancy data available. Follow-up was censored at the start of IVF, after the last IUI cycle or at last contact and was truncated at a maximum of 18 months after the fertility workup.

PARTICIPANTS/MATERIALS SETTING METHODS

The endpoint was time to conception leading to an ongoing pregnancy. We used the sequential Cox approach comparing in each month the ongoing pregnancy rates over the next 6 months of couples who started IUI-OS to couples who did not. We calculated the prognosis of natural conception for individual couples, updated this over consecutive failed cycles and evaluated whether prognosis modified the effect of starting IUI-OS. We corrected for known predictors of conception using inverse probability weighting.

MAIN RESULTS AND THE ROLE OF CHANCE

Data from 975 couples were available. There were 587 couples who received at least one IUI-OS cycle within 18 months after HSG of whom 221 conceived leading to an ongoing pregnancy (rate: 0.74 per couple per year over a median follow-up for IUI of 5 months). The median period between HSG and starting IUI-OS was 4 months. Out of 388 untreated couples, 299 conceived naturally (rate: 0.56 per couple per year over a median follow-up of 4 months). After creating our mimicked trial datasets, starting IUI-OS was associated with a higher chance of ongoing pregnancy by a pooled, overall hazard ratio of 1.50 (95% CI: 1.19-1.89) compared to expectant management. We did not find strong evidence that the effect of treatment was modified by a couple's prognosis of achieving natural conception (Akaike's Information Criterion (AIC) decreased by 1 point). The effect of treatment was dependent on when couples started IUI-OS (AIC decreased by more than 2 points). The patterns of estimated absolute chances over time for couples with increasingly better prognoses were different from the previous study but the finding that starting later yields a larger benefit of treatment was similar. We found IUI-OS increased the absolute chance of pregnancy by at least 5% compared to expectant management. The absolute chance of pregnancy after IUI-OS seems less variable between couples and starting times of treatment than the absolute chance after expectant management.

LIMITATIONS REASONS FOR CAUTION

This is a secondary analysis, as the H2Oil trial was not designed with this research question in mind. Owing to sample size restrictions, it remained difficult to distinguish between the ranges of prognoses in which true benefit was found.

WIDER IMPLICATIONS OF THE FINDINGS

We replicated the finding that starting IUI-OS later after diagnosis yields a larger absolute and relative benefit of treatment. We did not replicate the dependency of the effect of IUI-OS on the prognosis of natural conception and could not identify clear thresholds for the prognosis of natural conception when IUI-OS was and/or was not effective. Because many of these couples still have good chances of natural conception at the time of diagnosis, we suggest clinicians should advise couples to delay the start of IUI-OS for several months to avoid unnecessary treatment.

STUDY FUNDING/COMPETING INTERESTS

The H2Oil study (NTR 3270) was an investigator-initiated study that was funded by the two academic institutions (AMC and VUmc) of the Amsterdam UMC. The follow-up study (NTR 6577) was also an investigator-initiated study with funding by Guerbet, France. The funders had no role in study design, collection, analysis and interpretation of the data. B.W.M. is supported by an Investigator grant (GNT1176437) from the Australian National Health and Medical Research Council (NHMRC). K.D. reports receiving travel and speaker fees from Guerbet. B.W.M. reports consultancy for ObsEva, Merck, Merck KGaA, iGenomix and Guerbet. V.M. reports receiving travel- and speaker fees as well as research grants from Guerbet.

High DNA integrity sperm selection using surface acoustic waves

Male infertility is a global reproductive issue, several clinical approaches have been developed to tackle it, but their effectiveness is limited by the labour-intensive and time-consuming sperm selection procedures used. Here, we present an automated, acoustic based continuous-flow method capable of selecting high quality sperm with considerably improved motility and DNA integrity compared to the initial raw bull semen. The acoustic field translates larger sperm and guides highly motile sperm across the channel width. The result is the selection of sperm with over 50% and 60% improvement in vitality and progressive motility and more than 38% improvement in DNA integrity, respectively, while providing a clinically relevant volume and selected sperm number for the performance of in vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI) by selecting over 60 000 sperm in under an hour.

Treatment Strategies for Unexplained Infertility

Unexplained infertility is a common diagnosis among couples with infertility. Pragmatic treatment options in these couples are directed at trying to improve chances to conceive, and consequently intrauterine insemination (IUI) with ovarian stimulation and in vitro fertilization (IVF) are standard clinical practice, while expectant management remains an important alternative. While evidence on IVF or IUI with ovarian stimulation versus expectant management was inconclusive, these interventions seem more effective in couples with a poor prognosis of natural conception. Strategies such as strict cancellation criteria and single-embryo transfer aim to reduce multiple pregnancies without compromising cumulative live birth. We propose a prognosis-based approach to manage couples with unexplained infertility so as to expose less couples to unnecessary interventions and less mothers and children to the potential adverse effects of ovarian stimulation or laboratory procedures.

Influence of Catheter Type and Tenaculum Use on Intrauterine Insemination Outcome

Background

We investigated the impact of the choice of catheter type and tenaculum use on pregnancy related out- comes in intrauterine insemination (IUI) treatments.

Materials and Methods

A total of 338 consecutive IUI cycles were assessed in this retrospective study. Participants were divided according to the insemination technique - soft catheter (group 1; n=175), firm catheter (group 2; n=100), or tenaculum (group 3; n=63). Clinical, laboratory, semen parameters and pregnancy related outcomes were compared.

Results

Demographic characteristics and laboratory parameters were similar between the groups (P>0.05). The clini- cal pregnancy rate (CPR) was significantly higher in the firm catheter (19%, 19/100) and tenaculum (31.7%, 20/63) groups compared to the soft catheter group (5.1%, 9/175, P<0.001). There were no significant differences between the groups in live birth and miscarriage rates per clinical pregnancy (P>0.05).

Conclusion

Our findings indicate that the use of a firm catheter or tenaculum for IUI might result in a higher CPR, but might not have a considerable effect on the live birth rate (LBR). Further prospective randomized studies are required to determine the long-term effects of the catheter type or tenaculum use on IUI success.

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.

Improving reproductive outcomes of intrauterine insemination: Does endometrial scratch injury help? A randomised controlled trial

OBJECTIVE(S)

Current evidence suggests that endometrial injury improves clinical pregnancy rate while having no effect on miscarriages in women undergoing IVF/ICSI. However, there is no substantial evidence to advocate the use of endometrial injury to benefit the outcomes of IUI treatment. Additionally, there is no clear consensus about the ideal timing, underlying mechanism and optimum intensity of endometrial injury required. The study examines the effect of intentional endometrial injury/scratch in the early proliferative phase of stimulated cycle on reproductive outcomes (clinical and ongoing pregnancy rates and miscarriage occurrence) of intra-uterine insemination treatment (IUI).

STUDY DESIGN, SIZE, DURATION

This prospective, randomized control interventional study was conducted in a tertiary level teaching institution from April 2018 to February 2020. 150 eligible couples requiring IUI treatment who agreed to participate were randomly allocated on 1:1 basis to either control or intervention group. The trial participants received up to 3 cycles ovulation induction with clomiphene citrate and intra-uterine insemination. In addition, women in intervention group were subjected to endometrial scratch injury on day 6-7 of their stimulated cycle. 154 cycles in control arm and 128 cycles in intervention group were analyzed for clinical pregnancy, miscarriages and pain experienced by the women during endometrial scratch injury using the statistical package SPSS (version 21).

RESULT

Similar cumulative clinical pregnancy rates (12.5% Vs 13.6%, RR 1.21, 95% CI 0.44-3.37, p = 0.713), biochemical pregnancy rates (17.1% vs 22.9%, RR 1.43, CI 0.59-3.47, p = 0.421) and ongoing pregnancy rates (10.93% Vs 11.47%, RR 1.05, CI 0.35-3.21, p = 924) were observed in control and intervention arms. Likewise, the relative risk of miscarriage occurrence in the intervention arm was 1.32 (95% CI 0.39-4.32, p = 1.000) which was not statistically different from control group. Mean pain score of 6.93 on numerical pain rating scale was experienced by women whilst having endometrial scratch injury.

CONCLUSIONS

There is insufficient evidence to defend the use of endometrial scratch injury in intra-uterine insemination treatment, as it is moderately painful and have uncertain beneficial influence on reproductive outcomes.

Effect of HCG-Triggered Ovulation on Pregnancy Outcomes in Intrauterine Insemination: An Analysis of 5,610 First IUI Natural Cycles With Donor Sperm in China

Objective: To evaluate the effect of human chorionic gonadotropin (hCG) trigger ovulation on pregnancy outcomes in natural IUI cycles with donor sperm. Methods: This retrospective cohort study included 5,610 first-natural IUI cycles with donor sperm in infertile couples during the period from January 2012 to December 2017. To control for other confounding factors, our analysis was restricted to normo-ovulatory women without tubal infertility. The main outcome measure was live birth rate; the secondary outcomes included rates of clinical pregnancy and miscarriage. Results: In the crude analysis, both the clinical pregnancy (27.40 vs. 22.73%; P = 0.001) and live birth rates (24.52 vs. 20.13%; P = 0.007) were significantly higher for the hCG group than for the spontaneous LH group. After adjustment for a number of confounding factors, the reproductive outcomes were still significantly worse for the spontaneous ovulatory group. Conclusions: Among women undergoing natural cycle IUI with donor sperm, hCG triggered ovulation for timing insemination offers beneficial impacts on both clinical pregnancy rates and live birth rates.

Impact of a nutritional supplement (Impryl) on male fertility: study protocol of a multicentre, randomised, double-blind, placebo-controlled clinical trial (SUppleMent Male fERtility, SUMMER trial)

INTRODUCTION

Infertility is a worldwide problem and about 10%-15% of all couples will be affected by the inability to have children. In approximately 50% of infertile couples, a male factor is involved. Most of the male infertile cases are characterised as 'idiopathic', except for a small percentage of cases which are causative by a genetic aetiology. In the past decade, the role of oxidative stress related to sperm quality has been researched thoroughly and estimated to be the problem in 25%-87% of male infertility cases. Impryl is a nutritional supplement which works on the metabolic system and the regulation of oxidative stress by activating the 1-carbon cycle and therefore recycling of homocysteine. We hypothesise that the nutritional supplement Impryl in men of infertile couples might improve the ongoing pregnancy rate.

METHODS AND ANALYSIS

We designed a multicentre, randomised, double-blind, placebo-controlled clinical trial. We aimed to include 1200 male adults aged 18-50 years, part of a couple that is diagnosed with infertility. The couple will either start or has already been started with fertility treatment, that is, expectative management (duration of 6 months), intrauterine insemination (IUI) with or without mild ovarian stimulation or ovulation induction, either in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) treatment. Male participants will be randomised in either the Impryl or the placebo group, with identical appearance of the tablets to be distributed (doses: one tablet each day), for a total duration of maximal 6 months. Patients can start directly with fertility treatment and/or natural conception. The primary outcome is the number of ongoing pregnancies confirmed by ultrasound at ≥10 to 12 weeks, and conceived in the time window between randomisation up to and including month 6 of intervention use. Secondary outcomes are change in semen parameters between baseline and after 3 months of intervention in the IUI/IVF/ICSI group, based on (prewash) total motile sperm count. Furthermore the number of pregnancies conceived in the optimal intervention time window (after full spermatogenesis of 72 days), overall number of pregnancies, time to pregnancy, embryo fertilisation rate in IVF/ICSI, embryo-utilisation rate in IVF/ICSI, number of miscarriages, live birth rate and adverse events are documented within the study period of 15 months.

ETHICS AND DISSEMINATION

The protocol is approved by the local medical ethical review committee at the Radboud University Medical Centre and by the national Central Committee on Research Involving Human Subjects. Findings will be shared with the academic and medical community, funding and patient organisations in order to contribute to optimisation of medical care and quality of life for patients with infertility.

TRIAL REGISTRATION NUMBERS

NCT03337360 and NTR6551.

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

RESEARCH QUESTION

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

DESIGN

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

RESULTS

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

CONCLUSIONS

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

Twenty-one year experience with intrauterine inseminations after controlled ovarian stimulation with gonadotropins: maternal age is the only prognostic factor for success

PURPOSE

To report our experience on homologous intrauterine insemination (IUI) with gonadotropin controlled ovarian stimulation (COS) cycles and to examine different variables which could predict IUI success.

MATERIALS AND METHODS

This is a retrospective analysis of IUIs performed between January 1997 and December 2017. A total of 7359 COS IUI's procedures (2901 couples) were reviewed. Clinical pregnancy, live birth rate and age, body mass index (BMI), smoking habit, duration of infertility, sperm characteristics before and after treatment (total motile count, morphology, and vitality), day 3 FSH, total gonadotropin dose, and number of follicles were assessed by multivariate logistic regression analysis, and data were expressed as odds ratio (OR).

RESULTS

The mean female age at the time of COS was 35.10 ± 3.93 years. The most common single infertility diagnoses were unexplained infertility (53.55%), mild male factor (19.69%), and anovulation (10.95%). The total progressive motile sperm count (TPMC) was > 1 × 106/ml (mean 1.34 ± 1.08 × 106/ml). The clinical pregnancy rate was 9.38%, and the live birth rate was 7.19% per cycle. Twin pregnancies were 12.17%. Cumulative pregnancy was 21.89% and cumulative live birth rate was 17.58% per couple. Clinical pregnancy and live birth rates were significantly associated with female age [OR 0.97 (95% CI 0.95-0.99) and 0.95 (95% CI 0.93-0.97), respectively] and day 3 FSH [OR 0.91 (95% CI 0.87-0.94) e 0.90 (95% CI 0.87-0.94), respectively].

CONCLUSIONS

Clinical pregnancy rate and live birth rates after COS-IUIs were significantly influenced by female age and FSH levels.

TRIAL REGISTRATION

Clinical trial registration number: NCT03836118.

Low-dose human menopausal gonadotrophin versus natural cycles in intrauterine insemination for subfertile couples with regular menstruation

BACKGROUND

Women with irregular menstruation should be considered to benefit from the ovarian stimulation. However, most literature did not separate ovulatory disorders from normal menstrual cycles. Our purpose was to assess the superiority of ovarian mild stimulation compared with the natural cycle in IUI for subfertile couples when the women with regular menstruation.

METHODS

A retrospective study in a single medical center in which 2413 couples with 3573 IUI cycles were studied from 2013 to 2018. The results of IUI in natural cycles versus low-dose HMG induced cycles were analyzed.

RESULTS

For young women (age < 35 years) with normal menstrual cycle, HMG induced ovulation combined with IUI can improve clinical pregnancy outcome (13.55% in two follicular induced cycles vs. 7.23% in natural cycles, p < 0.01); even if only one follicle was induced, the clinical pregnancy rate was increased to 10.32% (p < 0.01). When two growth follicles were induced in HMG cycles, a remarkable improvement of the live birthrate (10.28% vs. 5.91% in natural cycles, p < 0.05) was noted. Simultaneously, twin pregnancy rates were increased to 20.69% (p < 0.01). Twin pregnancies showed significantly increased risk of both ectopic pregnancy and preterm birth (p = 0.00 for both). For advanced women (age ≥ 35 years) with regular menstrual cycle, ovulation induction didn't improve clinical pregnancy and live birthrates, while age was the only relevant factor.

CONCLUSIONS

Combining HMG induced ovulation and IUI can improve pregnancy outcome in young women with normal menstrual cycles. 1-2 follicles with diameter ≥ 14 mm served as the purpose of ovulation induction. Further, both twin and ectopic pregnancy rate in HMG cycles with two growth follicles were significantly higher than those in natural cycles were. Therefore, doctors must evaluate the risk before making choices and inform the patients to achieve the best results. For advanced women with normal menstrual cycles, natural IUI cycles were optional.

A Randomized Trial to Evaluate the Effects of Folic Acid and Zinc Supplementation on Male Fertility and Livebirth: Design and Baseline Characteristics

The Folic Acid and Zinc Supplementation Trial (FAZST) was a multicenter, double-blind, block-randomized, placebo-controlled trial to determine whether folic acid and zinc supplementation in men improves semen quality and increases livebirth rate among couples seeking infertility treatment (2013-2017). Eligible men were aged 18 years or older with female partners aged 18-45 years, seeking infertility treatment. Men were randomized (1:1) to 5 mg folic acid and 30 mg elemental zinc daily or matching placebo for 6 months. Randomization was stratified by site and intended infertility treatment (in vitro fertilization (IVF), non-IVF/study site, and non-IVF/outside clinic). Follow-up of men continued for 6 months, and female partners were passively followed for a minimum of 9 months. Women who conceived were followed throughout pregnancy. Overall, 2,370 men were randomized during 2013-2017 (1,185 folic acid and zinc, 1,185 placebo); they had a mean age of 33 years and body mass index (weight (kg)/height (m)2) of 29.8. Most participants were white (82%), well educated (83% with some college), and employed (72%). Participant characteristics were balanced across intervention arms. Study visits were completed by 89%, 77%, and 75% of men at months 2, 4, and 6, respectively. Here we describe the study design, recruitment, data collection, lessons learned, and baseline participant characteristics.

Associated factors to pregnancy in intrauterine insemination

Objective

To define the factors associated with clinical pregnancy after intrauterine insemination.

Methods

Retrospective study involving 633 infertility couples, which made up to 1053 cycles of intrauterine insemination. We analyzed the clinical pregnancy rate associated with different factors through the Chi-square test or Fisher's exact test.

Results

The clinical pregnancy rate was 8.2% per insemination cycle and 13.6% per treated couple. The factors with greater association to clinical pregnancy were to have more than two follicles, to perform the procedure without difficulty, to have 3 years or less of infertility, cervical factor as indication, use of gonadotropins and age less than 38 years.

Conclusion

Intrauterine insemination requires to be accompanied by proper selection and couples' preparation.

Effect of Folic Acid and Zinc Supplementation in Men on Semen Quality and Live Birth Among Couples Undergoing Infertility Treatment: A Randomized Clinical Trial

IMPORTANCE

Dietary supplements marketed for male fertility commonly contain folic acid and zinc based on limited prior evidence for improving semen quality. However, no large-scale trial has examined the efficacy of this therapy for improving semen quality or live birth.

OBJECTIVE

To determine the effect of daily folic acid and zinc supplementation on semen quality and live birth.

DESIGN, SETTING, AND PARTICIPANTS

The Folic Acid and Zinc Supplementation Trial was a multicenter randomized clinical trial. Couples (n = 2370; men aged ≥18 years and women aged 18-45 years) planning infertility treatment were enrolled at 4 US reproductive endocrinology and infertility care study centers between June 2013 and December 2017. The last 6-month study visit for semen collection occurred during August 2018, with chart abstraction of live birth and pregnancy information completed during April 2019.

INTERVENTIONS

Men were block randomized by study center and planned infertility treatment (in vitro fertilization, other treatment at a study site, and other treatment at an outside clinic) to receive either 5 mg of folic acid and 30 mg of elemental zinc (n = 1185) or placebo (n = 1185) daily for 6 months.

MAIN OUTCOMES AND MEASURES

The co-primary outcomes were live birth (resulting from pregnancies occurring within 9 months of randomization) and semen quality parameters (sperm concentration, motility, morphology, volume, DNA fragmentation, and total motile sperm count) at 6 months after randomization.

RESULTS

Among 2370 men who were randomized (mean age, 33 years), 1773 (75%) attended the final 6-month study visit. Live birth outcomes were available for all couples, and 1629 men (69%) had semen available for analysis at 6 months after randomization. Live birth was not significantly different between treatment groups (404 [34%] in the folic acid and zinc group and 416 [35%] in the placebo group; risk difference, -0.9% [95% CI, -4.7% to 2.8%]). Most of the semen quality parameters (sperm concentration, motility, morphology, volume, and total motile sperm count) were not significantly different between treatment groups at 6 months after randomization. A statistically significant increase in DNA fragmentation was observed with folic acid and zinc supplementation (mean of 29.7% for percentage of DNA fragmentation in the folic acid and zinc group and 27.2% in the placebo group; mean difference, 2.4% [95% CI, 0.5% to 4.4%]). Gastrointestinal symptoms were more common with folic acid and zinc supplementation compared with placebo (abdominal discomfort or pain: 66 [6%] vs 40 [3%], respectively; nausea: 50 [4%] vs 24 [2%]; and vomiting: 32 [3%] vs 17 [1%]).

CONCLUSIONS AND RELEVANCE

Among a general population of couples seeking infertility treatment, the use of folic acid and zinc supplementation by male partners, compared with placebo, did not significantly improve semen quality or couples' live birth rates. These findings do not support the use of folic acid and zinc supplementation by male partners in the treatment of infertility.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01857310.

A comparison of the beta-geometric model with landmarking for dynamic prediction of time to pregnancy

We conducted a simulation study to compare two methods that have been recently used in clinical literature for the dynamic prediction of time to pregnancy. The first is landmarking, a semi-parametric method where predictions are updated as time progresses using the patient subset still at risk at that time point. The second is the beta-geometric model that updates predictions over time from a parametric model estimated on all data and is specific to applications with a discrete time to event outcome. The beta-geometric model introduces unobserved heterogeneity by modelling the chance of an event per discrete time unit according to a beta distribution. Due to selection of patients with lower chances as time progresses, the predicted probability of an event decreases over time. Both methods were recently used to develop models predicting the chance to conceive naturally. The advantages, disadvantages and accuracy of these two methods are unknown. We simulated time-to-pregnancy data according to different scenarios. We then compared the two methods by the following out-of-sample metrics: bias and root mean squared error in the average prediction, root mean squared error in individual predictions, Brier score and c statistic. We consider different scenarios including data-generating mechanisms for which the models are misspecified. We applied the two methods on a clinical dataset comprising 4999 couples. Finally, we discuss the pros and cons of the two methods based on our results and present recommendations for use of either of the methods in different settings and (effective) sample sizes.

Effects of letrozole combined with human menopausal gonadotrophin in ovarian stimulation for intrauterine insemination cycles

Background

The effects of letrozole plus human menopausal gonadotropin (HMG) on ovarian stimulation (OS) of intrauterine insemination (IUI) cycles were examined.

Methods

In all, 1,005 IUI cycles were included in this study. Couples underwent natural cycle (NC) IUI (n=150) or IUI after OS with letrozole (n=207) or IUI after OS with letrozole + HMG (n=648).

Results

The clinical pregnancy rates were 9.0%, 13.0%, and 17.0%, and the live birth rates were 7.0%, 9.0%, and 14.0% in the NC, letrozole, and letrozole + HMG IUI groups, respectively. The twin pregnancy rate of the letrozole + HMG group (11.0%) was higher than that of the NC (7.0%) and letrozole groups (4.0%). To date, the only triplet pregnancies to occur were in the letrozole + HMG group. On the day of human chorionic gonadotropin (hCG), the number of follicles with an average follicle diameter greater than 18 mm in the letrozole + HMG group (1.21±0.56) and letrozole group (1.14±0.48) was greater than that in the NC group (0.85±0.36). The thickness of the endometrium in the letrozole + HMG group (8.8±2.1 mm) was significantly greater than that in the letrozole group (7.3±1.6 mm).

Conclusions

The letrozole + HMG protocol of OS in IUI can improve follicular development, increase the thickness of endometrium, significantly increase the live birth rate, but not significantly increase the multiple pregnancy rate.

The role of sperm DNA fragmentation testing in predicting intra-uterine insemination outcome: A systematic review and meta-analysis

There is a growing body of literature that recognizes the importance of sperm DNA fragmentation as a candidate test for the assessment of sperm function and thus male reproductive potential. Research on the subject has mostly been focused on couples undergoing IVF/ICSI treatment whilst much uncertainty still exists about the relationship between sperm DNA fragmentation and IUI. This study systematically reviews the literature, aiming to define the value of sperm DNA fragmentation measurement in predicting clinical pregnancy outcome in couples undergoing intra-uterine insemination From inception until March 2018, the relevant databases were searched for studies investigating the relationship between sperm DNA fragmentation as measured by SCSA, TUNEL, SCD or Comet assay and pregnancy outcome after IUI. The Quality in Prognosis Studies (QUIPS) tool was utilized for quality assessment. This review is reported according to the 2009 PRISMA statement. The literature search resulted in 433 studies of which we finally retained nine studies for the qualitative analysis and four studies for the meta-analysis, accounting for 940 IUI cycles. In summary, the observed effect of low sperm DNA fragmentation on clinical pregnancy after IUI as analyzed with the random effects model reveals a relative risk of 3.15 (95% CI: 1.46-6.79; I2 = 13.1%) and pooled sensitivity and specificity of respectively 94% (95% CI: 0.88; 0.97) and 19% (95% CI: 0.14; 0.26). Taken together, the included studies show a limited capacity of sperm DNA fragmentation in discriminating between couples who will benefit from the test, namely in either predicting IUI outcome or in advising for or against IUI as first choice of treatment instead of advancing to more invasive medically assisted reproduction. This review has thrown up many questions in need of further investigation. As such, future studies might explore issues such as determining relevant cut-off values for prediction of spontaneous pregnancy and pregnancy after IUI as well as the assessment of the stability of the test over time and before and after density gradient centrifugation.

Is IUI with ovarian stimulation effective in couples with unexplained subfertility?

STUDY QUESTION

Does starting IUI with ovarian stimulation (IUI-OS) within 1.5 years after completion of the fertility workup increase ongoing pregnancy rates compared to expectant management in couples with unexplained subfertility?

SUMMARY ANSWER

IUI-OS is associated with higher chances of ongoing pregnancy compared to expectant management in unexplained subfertile couples, specifically those with poor prognoses of natural conception, i.e. <15% over 6 months or <25% over 1 year.

WHAT IS KNOWN ALREADY

IUI-OS is often the first-line treatment for couples with unexplained subfertility. Two randomized controlled trials compared IUI-OS to expectant management using different thresholds for the prognosis of natural conception as inclusion criteria and found conflicting results. A cohort of couples with unexplained subfertility exposed to expectant management and IUI-OS offers an opportunity to determine the chances of conception after both strategies and to evaluate whether the effect of IUI-OS depends on a couple's prognosis of natural conception.

STUDY DESIGN, SIZE, DURATION

A prospective cohort study on couples with unexplained or mild male subfertility who could start IUI-OS at any point after completion of the fertility workup, recruited in seven Dutch centres between January 2002 and February 2004. Decisions regarding treatment were subject to local protocols, the judgement of the clinician and the wishes of the couple. Couples with bilateral tubal occlusion, anovulation or a total motile sperm count <1 × 106 were excluded. Follow up was censored at the start of IVF, after the last IUI cycle or at last contact and truncated at a maximum of 1.5 years after the fertility workup.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The endpoint was time to conception leading to an ongoing pregnancy. We used the sequential Cox approach comparing in each month ongoing pregnancy rates over the next 6 months of couples who started IUI-OS to couples who did not. We calculated the prognosis of natural conception for individual couples, updated this over consecutive failed cycles and evaluated whether prognosis modified the effect of starting IUI-OS. We corrected for known predictors of conception using inverse probability weighting.

MAIN RESULTS AND THE ROLE OF CHANCE

Data from 1896 couples were available. There were 800 couples whom had at least one IUI-OS cycle within 1.5 years post fertility workup of whom 142 couples conceived (rate: 0.50 per couple per year, median follow up 4 months). The median period between fertility workup completion and starting IUI-OS was 6.5 months. Out of 1096 untreated couples, 386 conceived naturally (rate: 0.31 per couple per year, median follow up 7 months). Starting IUI-OS was associated with a higher chance of ongoing pregnancy by a pooled, overall hazard ratio of 1.96 (95% CI: 1.47-2.62) compared to expectant management. The effect of treatment was modified by a couple's prognosis of achieving natural conception (P = 0.01), with poorer prognoses or additional failed natural cycles being associated with a stronger effect of treatment. The predicted 6-month ongoing pregnancy rate for a couple with a prognosis of 25% at completion of the fertility workup over the next six cycles (~40% over 1 year) was 25% (95% CI: 21-28%) for expectant management and 24% (95% CI: 9-36%) when starting IUI-OS directly. For a couple with a prognosis of 15% (25% over 1 year), these predicted rates were 17% (95% CI: 15-19%) for expectant management and 24% (95% CI: 15-32%) for starting IUI-OS.

LIMITATIONS, REASONS FOR CAUTION

The effect estimates are based on a prospective cohort followed up for 1.5 years after completion of the fertility workup. Although we balanced the known predictors of conception between treated and untreated couples using inverse probability weighting, observational data may be subject to residual confounding. The results need to be confirmed in external datasets.

WIDER IMPLICATIONS OF THE FINDINGS

These results explain the discrepancies between previous trials that compared IUI-OS to expectant management, but further studies are required to establish the threshold at which IUI-OS is (cost-)effective.

STUDY FUNDING/COMPETING INTEREST(S)

This study was facilitated by (Grant 945/12/002) from ZonMW, The Netherlands Organization for Health Research and Development, The Hague, The Netherlands. B.W.M. is supported by a NHMRC Practitioner Fellowship (GNT1082548). B.W.M. reports consultancy for ObsEva, Merck and Guerbet. S.B. reports acting as Editor-in-Chief of HROpen. The other authors have no conflicts of interest.

External validation of a dynamic prediction model for repeated predictions of natural conception over time

STUDY QUESTION

How well does a previously developed dynamic prediction model perform in an external, geographical validation in terms of predicting the chances of natural conception at various points in time?

SUMMARY ANSWER

The dynamic prediction model performs well in an external validation on a Scottish cohort.

WHAT IS KNOWN ALREADY

Prediction models provide information that can aid evidence-based management of unexplained subfertile couples. We developed a dynamic prediction model for natural conception (van Eekelen model) that is able to update predictions of natural conception when couples return to their clinician after a period of unsuccessful expectant management. It is not known how well this model performs in an external population.

STUDY DESIGN, SIZE, DURATION

A record-linked registry study including the long-term follow-up of all couples who were considered unexplained subfertile following a fertility workup at a Scottish fertility clinic between 1998 and 2011. Couples with anovulation, uni/bilateral tubal occlusion, mild/severe endometriosis or impaired semen quality according to World Health Organization criteria were excluded.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The endpoint was time to natural conception, leading to an ongoing pregnancy (defined as reaching a gestational age of at least 12 weeks). Follow-up was censored at the start of treatment, at the change of partner or at the end of study (31 March 2012). The performance of the van Eekelen model was evaluated in terms of calibration and discrimination at various points in time. Additionally, we assessed the clinical utility of the model in terms of the range of the calculated predictions.

MAIN RESULTS AND THE ROLE OF CHANCE

Of a total of 1203 couples with a median follow-up of 1 year and 3 months after the fertility workup, 398 (33%) couples conceived naturally leading to an ongoing pregnancy. Using the dynamic prediction model, the mean probability of natural conception over the course of the first year after the fertility workup was estimated at 25% (observed: 23%). After 0.5, 1 and 1.5 years of expectant management after the completion of the fertility workup, the average probability of conceiving naturally over the next year was estimated at 18% (observed: 15%), 14% (observed: 14%) and 12% (observed: 12%). Calibration plots showed good agreement between predicted chances and the observed fraction of ongoing pregnancy within risk groups. Discrimination was moderate with c statistics similar to those in the internal validation, ranging from 0.60 to 0.64. The range of predicted chances was sufficiently wide to distinguish between couples having a good and poor prognosis with a minimum of zero at all times and a maximum of 55% over the first year after the workup, which decreased to maxima of 43% after 0.5 years, 34% after 1 year and 29% after 1.5 years after the fertility workup.

LIMITATIONS, REASONS FOR CAUTION

The model slightly overestimated the chances of conception by ~2-3% points on group level in the first-year post-fertility workup and after 0.5 years of expectant management, respectively. This is likely attributable to the fact that the exact dates of completion of the fertility workup for couples were missing and had to be estimated.

WIDER IMPLICATIONS OF THE FINDINGS

The van Eekelen model is a valid and robust tool that is ready to use in clinical practice to counsel couples with unexplained subfertility on their individualized chances of natural conception at various points in time, notably when couples return to the clinic after a period of unsuccessful expectant management.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by a Chief Scientist Office postdoctoral training fellowship in health services research and health of the public research (ref PDF/12/06). There are no conflicts of interest.

[Medical service use for infertility in French private sector]

OBJECTIVES

This study presents nationally representative estimates and trends for infertility service use among women aged 25-43 and men aged 25-49 in France in 2013-2016.

METHODS

Two retrospective repeated cross-sectional analyses for years 2013 to 2016 were performed on the statutory French health care insurance reimbursement database for independent workers. Use rate was calculated on the number of individuals who underwent at least one infertility service within the studied year per women and men who utilized health services the same year.

RESULTS

1.69% [IC 95%: 1.65; 1.72] of women aged 25-43 who utilized health services had used infertility services during the year 2016: 1.5% used ovulation induction, 0.7% ultrasound monitoring of follicles, 0.3% embryo transfer, 0.3% in vitro fertilization.The use increased significantly from 2013 to 2016 for the following services: ultrasound monitoring of follicles (+ 10%), intracytoplasmic sperm injection (+ 12%), freezing of embryos (+ 32%), thawing of embryos (+ 29%), embryo cryopreservation (+ 88%).In a multivariate analysis, the use was higher among women aged 30-39 years, with a liberal profession, living in the North-east or the south-east, in Corsica or over-seas, receiving health care outside the French territory.0.19% [IC 95%: 0.18; 0.20] of men aged 25-49 years had used infertility services during the year.There was a significant increase from 2013 to 2016 of the proportion of users for sperm freezing (+ 19.18%) and sperm cryopreservation for fertility preservation when cytotoxic therapy is required (+ 84.92%).

CONCLUSION

Some increases resulted from expanded indications. Follow-up will be required in case of legislative enlargement for access to certain techniques.

Ultrasound guidance versus the blind method for intrauterine catheter insemination: A randomized controlled trial

OBJECTIVE

The primary objective of this study was to compare clinical pregnancy rates in intrauterine insemination (IUI) treatment cycles with transabdominal ultrasound guidance during intrauterine catheter insemination (US-IUI) versus the "blind method" IUI without ultrasound guidance (BM-IUI). The secondary objective was to compare whether US-IUI had better patient tolerability and whether US-IUI made the insemination procedure easier for the clinician to perform compared to BM-IUI.

METHODS

This was a randomized controlled trial done at the Reproductive Medicine Unit of General Hospital Kuala Lumpur, Malaysia. We included women aged between 25 and 40 years who underwent an IUI treatment cycle with follicle-stimulating hormone injections for controlled ovarian stimulation.

RESULTS

A total of 130 patients were recruited for our study. The US-IUI group had 70 patients and the BM-IUI group had 60 patients. The clinical pregnancy rate was 10% in both groups (p> 0.995) and there were no significant difference between the groups for patient tolerability assessed by scores on a pain visual analog scale (p= 0.175) or level of difficulty for the clinician (p> 0.995). The multivariate analysis further showed no significant increase in the clinical pregnancy rate (adjusted odds ratio, 1.07; 95% confidence interval, 0.85-1.34; p= 0.558) in the US-IUI group compared to the BM-IUI group even after adjusting for potential covariates.

CONCLUSION

The conventional blind method for intrauterine catheter insemination is recommended for patients undergoing IUI treatment. The use of ultrasound during the insemination procedure increased the need for trained personnel to perform ultrasonography and increased the cost, but added no extra benefits for patients or clinicians.

The pregnancy outcomes of intrauterine insemination with husband's sperm in natural cycles versus ovulation stimulated cycles: A retrospective study

To compare the clinical outcomes of intrauterine insemination (IUI) with or without ovulation induction (OI), IUI cycles from January 2008 to December 2017 in Zhoushan Maternity and Child Healthcare Hospital were included, consisting of 455 natural cycles and 536 OI cycles. The overall clinical pregnancy rate did not differ between the two groups (P > 0.05). Stratified by OI medications such as clomiphene (CC), human menopausal gonadotropin (HMG) and follicle stimulating hormone (FSH), the pregnancy rates in HMG, CC, CC+HMG, and FSH/FSH+HMG groups were 11.70%, 13.58%, 15.95%, and 13.46%, respectively, but the difference was not significant compared with natural cycles (P > 0.05). Stratified by infertility etiology, the pregnancy rate was significantly higher in stimulated cycles than natural cycles with ovulation disorders (P < 0.01) and unexplained factors (P < 0.01) while it was significantly lower regarding cervical factors (P < 0.01), endometriosis (P < 0.05), male factor (P < 0.01) and other female factors. There was no strong difference of pregnancy rate for biparental causes (P > 0.05). Stratified by age category, women over 35 had higher pregnancy rate in stimulated cycles compared with natural cycles (18.75 vs. 12.24%; P < 0.05), while women under 35 had no significant difference of pregnancy rate between the two groups (13.65 vs 13.05%; P > 0.05). However, there was no significant difference between each ovarian stimulation group and natural cycle group regardless of the infertility causes or age categories. To conclude, IUI-OI could achieve a higher overall pregnancy rate for women over 35 and infertile patients with ovulation disorders and unexplained factors.