Should laparoscopy be a mandatory component of the infertility evaluation in infertile women with normal hysterosalpingogram or suspected unilateral distal tubal pathology?

OBJECTIVE: To assess the diagnostic benefit of laparoscopy in infertile women with normal hysterosalpingography (HSG) or suspected unilateral pathology on HSG. STUDY DESIGN: Charts of infertile women that underwent complete infertility evaluation between 1996 and 1998 were retrospectively reviewed. Eighty-six patients in whom both HSG and laparoscopy were performed were included in the study. HSG results were compared with laparoscopic findings and the suggested treatment based on HSG results was compared with the treatment plan based on laparoscopic findings. RESULTS: Among 63 patients with a normal HSG or suspected unilateral tubal pathology, who were assigned to ovulation induction and intrauterine insemination (IUI), 60 patients were found to have laparoscopic findings that did not necessitate any change in the original treatment plan. In three patients (4.8%), abnormalities discovered at laparoscopy were of such an extent that a change in the original treatment regimen and referral to in vitro fertilization (IVF) was needed. Among 23 patients with suspected bilateral tubal occlusion on HSG, 16 patients (69.6%) were found to have an abnormal laparoscopy with bilateral tubal adhesions, 6 patients (26%) had unilateral tubal adhesions, and 1 patient (4.3%) had pelvic adhesions with no obstruction. These latter findings led to changes in the original treatment plan of these seven patients from IVF to ovulation induction and IUI. CONCLUSIONS: Laparoscopy may be omitted in women with normal HSG or suspected unilateral distal tubal pathology on HSG, since it was not shown to change the original treatment plan indicated by HSG in 95% of the patients. However, laparoscopy should be recommended in cases with suspected bilateral tubal occlusion on HSG, since it altered the original treatment plan in 30% of the patients from IVF to induction of ovulation with IUI. The reassuring results found in the present study may be related to the low prevalence of pelvic inflammatory diseases and endometriosis in our population.     

The impact of the modified speculum application technique on the success rates of intrauterine insemination: A randomized controlled study

ObjectiveIntrauterine insemination (IUI) is frequently used to treat patients with ovulation disorders, cervical factor, mild male infertility and unexplained infertility. The aim of this study was to investigate the impact of modified speculum application on the success of IUI in patients with unexplained infertility.Materials and methodsThis prospective randomized study reviewed 219 women who had undergone controlled ovarian hyperstimulation (COH)-IUI treatment. In the modified speculum application group (109 patients with 124 cycles), the screw of the vaginal speculum was loosened after passing the internal os with catheter and the vaginal speculum remained in this position to ensure closure of the cervix during the procedure. In the conventional speculum application group (110 patients with 132 cycles), the screw of the vaginal speculum was not loosened to close the lips of cervix after passing the internal os with the catheter and the vaginal speculum was removed after withdrawal of the insemination catheter. The primary outcome was live birth rate.ResultsThe modified and conventional speculum application groups had statistically similar demographic and clinical characteristics. There were no significant differences between the study and the control groups in terms of the clinical pregnancy rate per cycle and per patient (24.1% vs 18.9% and 26.6% vs 22.7%, respectively), as well as the live birth rate per cycle and per patient (19.3% vs 15.1% and 22% vs 18.1% respectively).ConclusionApplying gentle mechanical pressure on the portio vaginalis of the cervix using a vaginal speculum during IUI does not improve pregnancy and live birth rates in patients with unexplained infertility.     

Hysteroscopic selective salpingography.

OBJECTIVE: To evaluate the effectiveness of hysteroscopic selective salpingography (HSS) as a method for diagnosing the tubal proximal occlusion shown by hysterosalpingography (HSG). DESIGN: Prospective study. SETTING: Outpatient Department of Obstetrics and Gynecology, Social Insurance Saitama Chuo Hospital, Urawa, Japan. PATIENT(S): A total of 572 infertile women underwent HSG. Forty-seven of 50 women with unilateral or bilateral proximal tubal occlusion demonstrated by HSG underwent HSS. INTERVENTION(S): Hysteroscopic selective salpingography was performed for the diagnosis of tubal occlusion in cases in which the proximal tubal occlusion was shown by HSG. MAIN OUTCOME MEASURE(S): Number of patients who underwent HSS and pregnancy rate after HSS. RESULT(S): Twenty-seven (79.4%) of 34 patients with unilateral occlusion diagnosed by HSG were shown to have normal patency by HSS. Of 12 women with bilaterally normal patent tubes confirmed by HSS, 8 (66.7%) achieved normal pregnancies within 1 year. Seven (53.8%) of 13 patients with bilateral occlusion found by HSG were shown to have normally patent tubes by HSS. CONCLUSION: The simple method of HSS was clinically effective for evaluating the presence of proximal tubal occlusion.     

Fallopian sperm perfusion versus intrauterine insemination: a randomized controlled trial and metaanalysis of the literature

OBJECTIVE: To determine whether fallopian sperm perfusion significantly improves pregnancy rates over intrauterine insemination (IUI) in infertile patients. DESIGN: Prospective, randomized, controlled trial and metaanalysis of the literature. SETTING: University-based infertility practice. PATIENT(S): Patients undergoing controlled ovarian stimulation were included in the prospective trial. They were <40 years of age and had no tubal obstructions, and their partners had no history of severe oligospermia. The metaanalysis was done using the patients with unexplained infertility from this study and from other randomized controlled trials found through a MEDLINE data base search. INTERVENTION(S): After undergoing controlled ovarian stimulation, the patients were randomly assigned to receive either IUI or fallopian sperm perfusion. MAIN OUTCOME MEASURE(S): Clinical pregnancy rates. RESULT(S): Only the patients with unexplained infertility had a statistically higher pregnancy rate with fallopian sperm perfusion (odds ratio, 4.1; confidence interval, 1.1-16.4). A metaanalysis of the prospective randomized trials that provided data on patients with unexplained infertility showed a significant improvement in pregnancy rates with fallopian sperm perfusion (odds ratio, 1.9; confidence interval, 1.2-3). CONCLUSION(S): Fallopian sperm perfusion does not improve the chances of pregnancy in patients with infertility other than those with unexplained infertility. Fallopian sperm perfusion does significantly improve the pregnancy rates of patients with unexplained infertility who undergo controlled ovarian stimulation with gonadotropin/insemination protocols.     

Prospective randomized study for hydrotubation with or without lidocaine before intrauterine insemination in unexplained infertility

ObjectiveTo investigate the therapeutic yield of hydrotubation using low-dose lidocaine conducted one-day before intrauterine insemination (IUI) in stimulated cycles for couples with unexplained infertility.DesignProspective randomized controlled trial.Patients and methodsTwo hundred and nineteen women with unexplained infertility were scheduled randomly for hydrotubation either with saline (109 patients) or low dose Lidocaine in saline (110 patients). Hydrotubation was carried on one-day before intrauterine insemination in clomiphene citrate stimulated cycle. Outcome measures were rates of pregnancy, first trimester abortion, ectopic pregnancy, multiple pregnancy, and ovarian hyperstimulation syndrome, and procedure related pain.ResultsLidocaine group had higher clinical pregnancy rates when compared with saline group with no significant difference (17.43% vs 11.2%, respectively; p = 0.193). There were no statistical significant differences as regards the rates of multiple pregnancy, first trimester abortion, and ectopic pregnancy between both groups. No ovarian hyperstimulation syndrome occurred in either group. Using the visual analog score, patients in both groups felt mild to moderate pains without significant differences in frequencies of pain intensity in both groups.ConclusionHydrotubation with low dose Lidocaine in saline one day before IUI allowed a nonsignificant higher pregnancy rate when compared to saline alone in couples with unexplained infertility.     

Controlled ovarian hyperstimulation and intrauterine insemination for infertility associated with endometriosis: a retrospective analysis

Objective To evaluate the efficacy of controlled ovarian hyperstimulation and intrauterine insemination for infertility associated with endometriosis. Material and methods A retrospective analysis of 260 patients with the only diagnosis of endometriosis, or male factor, or tubal factor, or unexplained infertility were performed: a total of 56 patients with different stages of endometriosis, a control group consisting of 38 patients with male factor infertility, a group of 26 patients with tubal factor infertility and a group of 140 patients with others (unexplained infertility, ovulation disorders, cervical factor). Pregnancy rate, hormone levels, endometrial thickness and number of follicles were analyzed. Results Clinical pregnancy rates per patient were similar between endometriosis, male factor, tubal factor, and others including unexplained infertility, ovulation disorders and cervical factor groups (10.7%, 5.4%, 11.5%, 17.9%, respectively; p>0.05). Clinical pregnancy rates per patient were not effected between the 2 subgroups of endometriosis as minimal to mild and moderate to severe [5.1% (2/39) versus 23.5% (4/17), p=0.19]. Conclusion Endometriosis did not affect the clinical pregnancy rate per patient compared to the other infertility factors. Endometriosis of various stages have no effect on the success of controlled ovarian hyperstimulation combined with intrauterine insemination. Received: 8 December 2000 / Accepted: 19 February 2001     

Comparison between multidetector computed tomography and hysterosalpingography in assessment of infertile couples

ObjectiveTo compare the efficacy of multidetector CT (MDCT) with conventional X-ray hysterosalpingography (HSG) in the evaluation of infertile couples.MethodsThirty-four patients with diagnosis of infertility, were evaluated with 4-row MDCT prior to HSG. All patients underwent diagnostic laparoscopy in the following period. Sensitivity, specificity, negative predictive value and positive predictive value of MDCT and HSG for the detection of tubal obstruction and pelvic adhesions were calculated.ResultsMean duration of the procedure for HSG and MDCT respectively was 26 ± 3.3 and 7 ± 1.1 min. MDCT has shown significantly less patient discomfort and mean effective dose of radiation. MDCT was able to diagnose a case of adenomyosis and a case of ovarian tumor further to HSG. HSG diagnosed two cases of unilateral tubal block, four cases of bilateral tubal block and six cases were suggested as pelvic adhesions due to abnormal smearing at the second film. MDCT diagnosed one case of unilateral tubal block, four cases of bilateral tubal block being unable to detect pelvic adhesions because of lack of delayed imaging. Using laparoscopy as a reference standard; sensitivity, specificity, positive predictive value and negative predictive value of MDCT and HSG in detecting tubal block were as follows: (100%, 96.7%, 83.3% and 100% for MDCT in comparison to 100%, 93.7%, 66.7% and 100% for HSG.Sensitivity, specificity, positive predictive value and negative predictive value of HSG in detecting pelvic adhesions were 42.8%, 88.8%, 50%, and 85.7.ConclusionThis study demonstrated the feasibility of evaluating the female reproductive system by MDCT.     

A second hysterosalpingography reduces the use of selective technique for treatment of a proximal tubal obstruction

OBJECTIVE: To assess whether a second hysterosalpingography (HSG) can permit tubal patency, reducing the use of selective salpingography in patients with proximal tubal obstruction. DESIGN: Prospective study.Setting: University hospital. PATIENT(s): The study population consisted of 360 infertile women. INTERVENTION(s): In patients with unilateral or bilateral proximal tubal obstruction, a second HSG was performed after about 1 month. In those cases with persistent obstruction, an immediate selective salpingography and tubal catheterization were performed. MAIN OUTCOME MEASURE(s): Tubal opacification. RESULT(s): Forty patients underwent a second HSG procedure for proximal tubal occlusion. Among these, 24 achieved bilateral tubal patency. Thus, repetition of a conventional HSG after 1 month avoided unnecessary salpingography in 60% of patients. CONCLUSION(s): In infertile women with proximal tubal obstruction, we believe it is best to perform a second HSG. HSG is easy to carry out and subjects patients to a lower dosage of radiation and fewer risks than selective salpingography. The latter technique should be reserved for unsuccessful cases.     

Diagnostic laparoscopy is needed after abnormal hysterosalpingography to prevent over-treatment with IVF

The additional value of laparoscopy was investigated with respect to diagnosis and further treatment decisions after abnormal hysterosalpingography (HSG) and prior to intrauterine insemination (IUI). In a retrospective chart review, the number of patients with abnormal HSG who finally need IVF treatment based on the laparoscopic findings was evaluated. Independent of whether HSG showed unilateral or bilateral tubal pathology, IVF was the final treatment decision in only 74 (29%) cases where laparoscopy showed bilateral abnormalities. IUI treatment was advised in 121 (48%) patients with laparoscopically normal findings or unilateral abnormalities. Fifty-seven (23%) patients were treated by IUI after receiving laparoscopic surgery of unilateral adhesions or endometriosis stage 1-2 or after ablation of moderate-severe endometriosis in a second operation. In cases of bilateral tubal abnormalities revealed by HSG, bilateral pathology was confirmed by laparoscopy in at least 58 (46%) patients and they were advised to be treated by IVF after laparoscopy. The agreement between abnormalities found by HSG and abnormalities found by laparoscopy requiring IVF treatment was poor even when HSG showed bilateral pathology. Based on these findings, it is concluded that laparoscopy is mandatory after abnormal HSG findings in the work-up prior to IUI to prevent over-treatment with IVF.     

Diagnosis and management of unexplained infertility: an update

Unexplained infertility constitutes around 15% of patients presenting with infertility. A lack of agreement exists among infertility specialists with regard to the diagnostic tests to be performed and their prognostic value as well as criteria of normality. It seems that serum progesterone for detection of ovulation, hysterosalpingography and or laparoscopy for tubal patency and semen analysis are the basic tests for diagnosis of unexplained infertility. Expectant treatment is the option of choice for young patients with short period of infertility. The spontaneous pregnancy rate is very high in this group of patients. The world literature have shown that controlled ovarian hyperstimulation and intrauterine insemination (COH and IUI) is an effective treatment of unexplained infertility. According to the available data, this procedure could be limited to three trials. There is evidence that both COH and IUI are important independent positive factors in achieving better pregnancy rate in unexplained infertility. If the above measures fail to achieve pregnancy, GIFT or IVF/ICSI could be performed as it yields a high pregnancy rate.     

Fallopian tube sperm perfusion versus intrauterine insemination in unexplained infertility: a randomized, prospective, cross-over trial

OBJECTIVE: To compare the results of fallopian tube sperm perfusion (FSP) versus standard intrauterine insemination (IUI) in patients with unexplained infertility undergoing controlled ovarian hyperstimulation (COH). DESIGN: Randomized, prospective, cross-over study. SETTING: Reproductive medicine unit of a university hospital. PATIENT(S): Fifty-six couples with unexplained infertility. INTERVENTION(S): COH was induced by recombinant FSH and monitored by serial transvaginal ultrasound. On the day of hCG administration during the first treatment cycle, patients were randomized to either IUI or FSP. Thereafter, in case no pregnancy was achieved, patients went on being treated with FSP and IUI in alternate cycles. A maximum of four treatment cycles per couple was performed. FSP was performed using a pediatric Foley's catheter inseminating 4 mL of sperm-enriched suspension; a Kremer-Delafontaine catheter delivering 0.5 mL of sperm suspension was used for IUI. MAIN OUTCOME MEASURE(S): Clinical pregnancy rate per cycle. RESULT(S): One hundred twenty-seven cycles (58 FSP, 69 IUI) were performed. The clinical pregnancy rate per cycle was 21.7% for IUI and 8.6% for FSP, respectively. No major adverse effects were recorded for either technique. CONCLUSION(S): After COH, FSP is less effective than IUI in couples with unexplained infertility.     

Intrauterine insemination results are not affected if Hysterosalpingo Contrast Sonography is used as the sole test of tubal patency

OBJECTIVE: To assess whether women can be assigned to intrauterine insemination (IUI) treatment on the basis of fallopian tubal patency, diagnosed by Hysterosalpingo Contrast Sonography (Hy Co Sy). DESIGN: Case controlled, clinical study. SETTING: Tertiary referral center. PATIENT(S): The cases were consecutive, infertile women who underwent Hy Co Sy and IUI. The control group was women who had IUI over the same period but whose tubal patency was assessed by hysterosalpingogram (HSG) or laparoscopy and dye (lap and dye). INTERVENTION(S): Women with bilateral patency at Hy Co Sy and with unexplained, anovulatory, or male factor infertility underwent IUI using the partner's (IUI-H) or donor's (IUI-D) semen. Their outcome was compared with that of cohorts of women who had been examined using HSG or lap and dye. MAIN OUTCOME MEASUREMENT(S): Clinical pregnancy rate per cycle and cumulative pregnancy rates at IUI-H or IUI-D. RESULT(S): The clinical pregnancy rates per cycle at IUI-H or IUI-D did not differ among the three groups. The cumulative pregnancy rates after three cycles of IUI-H were 0.17, 0.15, and 0.17 in the Hy Co Sy, HSG, and lap and dye cohorts, respectively, and 0.69, 0.77, and 0.54 in the same groups after six cycles of IUI-D. There were no differences in the clinical characteristics or stimulation regimes used. CONCLUSION(S): Women screened as "normal" by Hy Co Sy may be allocated to treatments that rely on accurate assessment of tubal patency without compromising their chance of conception.     

Subfertility: causes,treatment and outcome

Common causes of subfertility include ovulatory disorders, tubal disease, peritoneal adhesions, endometriosis, uterine abnormalities, abnormalities of sperm and advancing female age. Infertility is unexplained after thorough evaluation in about 5-10% of cases. Significant caveats must be attached to the interpretation of available data regarding infertility treatments. Successful ovulation induction in anovulatory women is possible for nearly all women except in cases of ovarian failure. Surgery is an option for some patients with tubal damage, adhesions, endometriosis and uterine abnormalities. Male factor infertility may be amenable to treatment of a specific cause, but is often empirical with the use of intra-uterine insemination (IUI) or in vitro fertilization (IVF). Egg donation is currently the most effective treatment available for age-related infertility when other treatments have not been successful. Couples with unexplained infertility may be effectively treated with ovulation induction plus IUI or IVF.     

Case series of a single centre's treatment of ovulatory infertility with clomiphene citrate and intrauterine insemination in 2002

The present paper reports a single department's retrospective case series of all clomiphene citrate (CC) combined with intrauterine insemination (IUI) treatment cycles for ovulatory infertility performed during 2002. Thirty-eight couples with unexplained, endometriosis, male or unilateral tubal factor infertility had undergone 71 cycles of CC and IUI. The clinical and ongoing cycle pregnancy rates were 20 and 17%, respectively. Seven percent of the clinical pregnancies were multiple pregnancies, with all multiple pregnancies being twin gestations. The current use of CC and IUI is an effective early treatment option in couples with ovulatory infertility presenting to our department.     

The impact of the total motile sperm count on the success of intrauterine insemination with husband's spermatozoa

Purpose: The purpose of this study was to evaluate the relationship between the total motile sperm count and the success of IUI treatment cycles with postwashed husband spermatozoa in couples with infertility in a large patient population. Patients: When 939 couples underwent 1375 cycles of IUI with varying etiologies of infertility which included male factor, endometriosis, tubal factor, ovulatory dysfunction, uterine factor, cervical factor, and unexplained infertility, the results were 207 pregnancies. Results: The overall pregnancy rate per cycle was 15.1% (207/1375). The total motile sperm count were significantly increased in the pregnant group than the nonpregnant group (38.7×10⁶ versus 28.6 × 10⁶;P<0.001). There was a trend toward an increased success rate with increased total motile sperm count. Significance was reached when the total motile sperm count exceeded 5×10⁶. Life table analysis was performed and the curve representing a cumulative chance of pregnancy calculated from our data reached 72%. Conclusions: Our findings suggest that a final postwashed total motile sperm count used for IUI may be considered predictive of the success for pregnancy and allow couples to be informed of the chances of success.     

Diagnosis and treatment of cornual obstruction using a flexible tip guidewire

Proximal tubal obstruction, either unilateral or bilateral, is a frequent finding on hysterosalpingogram (HSG). Approximately two-thirds of the fallopian tubes resected for proximal tubal obstruction reveal an absence of luminal occlusion. The distinction between true pathologic occlusion and either spasm or plugging is crucial in determining therapy. We combined hysteroscopic cannulation of the proximal fallopian tube with laparoscopy in 11 patients with proximal tubal obstruction diagnosed by HSG and confirmed at laparoscopy. Hysteroscopic cannulation was able to be performed in 72% of the fallopian tubes attempted, and there was a postcannulation patency rate by HSG of 73%. Six of the 11 patients became pregnant after tubal cannulation and adjunctive distal tubal surgery. Hysteroscopic cannulation of the fallopian tube is a safe diagnostic procedure that can be used to identify those patients with true proximal occlusion, and may also serve as a therapeutic procedure in some of these patients.     

Ovarian Response to Gonadotropins in Patients With Tubal Factor Infertility: Salpingectomy Versus Nonsalpingectomy

Study ObjectiveTo evaluate the effects of salpingectomy on the ovarian response to gonadotropins and in vitro fertilization–embryo transfer (IVF-ET) cycle outcomes in women with tubal factor infertility.DesignA retrospective study (Canadian Task Force Classification II-3)SettingAn in vitro fertilization laboratory in a university hospital in Taiwan.PatientsWe analyzed the outcomes of 288 consecutive fresh IVF-ET cycles in 251 consecutive women with tubal factor infertility from January 2001 to December 2011. Two hundred eighty-eight cycles were divided into 2 groups comprising 103 cycles with laparoscopic salpingectomy and 185 cycles with prior bilateral tubal sterilization, laparoscopic tuboplasty, or proximal tubal occlusion as the control group.InterventionsControlled ovarian hyperstimulation and IVF-ET.Measurements and Main ResultsThe main outcome was measured by comparing the duration of stimulation, number of gonadotropin ampoules per cycle, number of follicles, number of oocytes retrieved, fertilization rate, implantation rate, clinical pregnancy rate, and live birth rate. We observed no significant difference in any ovarian response parameter between the salpingectomy and nonsalpingectomy groups. Implantation rates, clinical pregnancy rates, and live birth rates were similar. The mean numbers of follicles and oocytes retrieved ipsilateral to the operated side in the salpingectomy group were similar to the numbers of follicles and oocytes retrieved from the nonoperated ovary.ConclusionsLaparoscopic salpingectomy did not have a negative effect on the ovarian response in women with tubal factor infertility.     

The case for initial treatment with intrauterine insemination as opposed to in vitro fertilization for idiopathic infertility

The recent questioning of the validity of evidence used by the Royal College of Obstetricians and Gynaecologists in recommending ovarian stimulation with intrauterine insemination (IUI) as an effective treatment for couples with unexplained infertility, has re-ignited the debate on what the initial treatment for idiopathic infertility should be. The current best available evidence is used here with the conclusion that the initial treatment for idiopathic infertility should be IUI as opposed to IVF. This conclusion is reached using the results of randomized controlled trials wherever possible, live birth rates rather than pregnacy rates and taking into account efficacy; complications, especially multiple pregnancy rates; patient compliance and cost efficiency. None of these factors indicate that a change of policy to use IVF as first-line treatment in lieu of IUI for unexplained infertility is justified.     

Use of laparoscopy in unexplained infertility

Objective

The use of laparoscopy in unexplained infertility work-up is still a subject of debate, although laparoscopy remains the gold standard for diagnosis and treatment of several pelvic pathologies. The objective of this study was to assess the rates and types of pelvic pathologies observed during diagnostic laparoscopy, and the pregnancy rate in couples with unexplained infertility following laparoscopy.

Study design

Prospective study, from November 2003 to October 2009, including 114 infertile, spontaneously ovulating women with normal clinical examination, ovarian reserve assessment, pelvic ultrasound scan and patent tubes on hysterosalpingography. Semen analyses were normal according to the World Health Organization criteria. After three cycles of ovulation induction with or without intra-uterine insemination and no pregnancy, women were referred for diagnostic laparoscopy.

Results

Laparoscopy revealed pelvic pathology in 95 patients. Endometriosis, pelvic adhesions and tubal disease were observed and treated in 72, 46 and 24 patients, respectively. Following laparoscopy, bilateral and unilateral tubal patencies were observed in 107 and five patients, respectively. Pregnancy was observed in 77 out of 102 patients who tried to conceive after surgery, 35 of whom conceived using their own tubes.

Conclusion

Diagnostic laparoscopy should be strongly considered in unexplained infertility work-up, and tubal efficiency should not be underestimated.     

Influence of age, diagnosis, and cycle number on pregnancy rates with gonadotropin-induced controlled ovarian hyperstimulation and intrauterine insemination.

OBJECTIVE: To determine whether age, diagnosis, and cycle number influence cycle fecundity associated with gonadotropin-induced controlled ovarian hyperstimulation/IUI. DESIGN: Retrospective analysis. SETTING: The Center for Reproductive Medicine at the Brigham and Women's Hospital, a tertiary care academic medical center. PATIENT(S): Two hundred seventy-four women who underwent controlled ovarian hyperstimulation with gonadotropins and IUI. INTERVENTION(S): Infertility treatment with gonadotropins and IUI. MAIN OUTCOME MEASURE(S): Pregnancy rates according to patient age, infertility diagnosis, and number of treatment cycles. RESULT(S): Pregnancy rates decreased with increasing patient age. The cumulative pregnancy rates varied greatly by diagnosis from 13% for patients with male factor infertility to 84% for patients with ovulatory factor infertility. Average cycle fecundity was considerably less varied by diagnosis. All pregnancies among patients with male factor infertility and tubal factor infertility were achieved during the first two cycles. CONCLUSION(S): There is a clear age-related decline in fecundity associated with gonadotropin-induced controlled ovarian hyperstimulation/IUI. Patients <40 years of age and those with male factor infertility or tubal factor infertility have a particularly poor prognosis.