Intrauterine insemination as treatment for antisperm antibodies in the female

Ninety-one women with long-standing infertility in the presence of humoral antisperm antibodies (ASA) underwent 473 cycles of intrauterine insemination of washed sperm (IUI), resulting in 26 pregnancies. Nine pregnancies were achieved in 67 women who underwent 285 IUI during unstimulated cycles (13% pregnancy rate; 3% pregnancy/cycles of treatment). Twenty women underwent 86 IUI after clomiphene citrate (CC) stimulation, resulting in 6 pregnancies (30%; 7% per cycle), while 28 underwent 102 cycles of IUI after human menopausal gonadotropins (hMG) stimulation, resulting in 11 pregnancies (39%; 11% per cycle). Twenty-one of the 26 pregnancies (81%) were achieved in the first 2 IUI cycles. During unstimulated and CC IUI cycles, all pregnancies occurred in the first two cycles of treatment, while with hMG stimulation pregnancies also occurred in the third, fourth, and fifth IUI cycles. Nine of these 91 women subsequently conceived spontaneously, and three others conceived through in vitro fertilization. Only 6 of the 38 pregnancies resulted in spontaneous abortion (16%). Thus, pregnancies achieved in women with ASA have no increased risk of abortion.     

Análisis de los factores de influencia sobre el resultado de 500 ciclos de inseminación intrauterina homóloga

Objective

To evaluate the results and analyse different factors influencing pregnancy rate using homologous intrauterine insemination.

Subjects and methods

Retrospective analysis of 500 homologous intrauterine insemination cycles in 183 infertile couples. Only one insemination per stimulated ovarian cycle was performed in patients with: mild endometriosis, ovulatory factor, male subfertility or unexplained infertility. We studied female age, duration of infertility, stimulation protocol, number of cycle, number of preovulatory follicles, motile sperm count and endometrial thickness related to pregnancy rate.

Results

Pregnancy rate per couple was 24% and per intrauterine insemination 9%, 11% was multiple pregnancies. Best outcome has been got in women younger than 37 years (P=.048) and in cycles with more than one preovulatory follicle. Other studied factors did not have influence in homologous intrauterine insemination outcome.

Conclusions

Female age is a prognostic factor for homologous intrauterine insemination with poor outcome in women older than 38 years. Cycles with more than one preovolatory follicle have better outcome. No differences in pregnancy rate have been achieved with motile sperm count over 1.5 millions/0.3 ml.     

Pregnancy after endometrial scratching in infertile couples undergoing ovulation induction and intrauterine insemination cycles—a randomized controlled trial

Purpose

To study the effect of endometrial scratching in infertile couples undergoing ovulation induction and intrauterine insemination (IUI) cycles.

Methods

A prospective randomized controlled trial was conducted in the Department of Obstetrics and Gynaecology, AIIMS, New Delhi, India. One hundred forty-four women with primary/secondary infertility were recruited. Couples were either unexplained or male factor infertility. Subjects were randomized into intervention (scratching) and control group. All patients received ovulation induction with clomiphene citrate (day 2–6) 50 mg/day +75 IU HMG on days 6 and 7. In addition, endometrial scratching was done on day 8 of ovulation induction cycle in intervention group. All couples were planned for three cycles of ovulation induction and IUI over 6 months. After each failed cycle, couple was advised to try for natural conception for one cycle. Those who conceived were excluded from further analysis. Primary outcome was clinical pregnancy rate. Secondary outcome measures included conception rate, ongoing pregnancy, abortion and ectopic rate.

Results

Baseline characteristics were comparable in both groups. Clinical pregnancy rate was significantly higher in intervention group (31.9%; 23/72) as compared to control group (16.7%; 12/72) (p value 0.030). On per cycle analysis, first IUI cycle had significantly high pregnancy rate (18.1%; 13/72) as compared to control group (5.6%; 4/72). Three patients in intervention group and one in control group conceived in wash out cycle. Ongoing pregnancy rate was significantly higher in scratching group (30.0%; 21/70) as compared to control group (15.7%; 11/70) (p value0.044).

Conclusions

Endometrial scratching can be used as a low cost-effective tool to improve clinical pregnancy and ongoing pregnancy rate in IUI cycles. Further large number studies are required to document its role in improving live birth rate.

Trial registration number

CTRI/2015/12/006419

     

Advantages of recombinant follicle-stimulating hormone over human menopausal gonadotropin for ovarian stimulation in intrauterine insemination: a randomized clinical trial in unexplained infertility

Objective

To compare two different gonadotropin preparations, human menopausal gonadotropin (hMG) and recombinant follicle-stimulating hormone (rFSH), combined with clomiphene citrate (CC) in women with unexplained infertility undergoing intrauterine insemination (IUI).

Study design

In this prospective clinical trial, couples prepared for IUI cycles were randomly allocated to two groups either to receive CC and hMG (group A, n = 127) or CC and rFSH (group B, n = 132) for ovarian stimulation. Outcomes including rates of clinical pregnancy, miscarriage, OHSS, multiple pregnancy, cancelation, and live birth were compared between groups.

Results

Duration of gonadotropin therapy was significantly shorter in group B (5.1 ± 0.84 vs. 4.7 ± 0.8 days, CI = 95%, P < 0.001). The total dose of administered gonadotropin was also significantly lower in group B (386.9 ± 68.2 vs. 348.2 ± 56.3 IU, CI = 95%, P < 0.001). Dominant follicle number (>17 mm), mean follicular diameter, and endometrial thickness on the day of hCG injection were similar. Clinical pregnancy, multiple pregnancies, abortion, live birth, ovarian hyperstimulation syndrome (OHSS), and cancelation rates were not statistically different between the groups.

Conclusion

IUI cycles in which rFSH had been administered may require shorter duration and a lower total gonadotropin dose.     

Is letrozole superior to clomiphene for ovarian stimulation prior to intrauterine insemination?

Objective

To compare the efficacy of letrozole with clomiphene citrate for ovarian stimulation prior to intrauterine insemination.

Methods

A total of 272 patients underwent 362 cycles of stimulation prior to IUI from January 2009 to May 2011. One hundred and twenty-six patients (170 cycles) received letrozole 5 mg and 146 patients (192 cycles) received clomiphene citrate 100 mg for 5 days starting on day 3 of the cycle. Intrauterine insemination was done 36 ± 4 h after hCG injection in 99 patients (131 cycles) in the letrozole group and 115 patients (136 cycles) in the clomiphene group. The number of mature follicles and serum E2 levels was monitored on the day of hCG. Endometrial thickness was noted on the day of hCG and IUI as well. The pregnancy rate, the miscarriage rate, and other parameters were evaluated only for patients who underwent IUI.

Results

The mean number of mature follicles was significantly more in the clomiphene group (1.66 ± 1.69 vs. 1.41 ± 1.53) than in the letrozole group. No significant difference in endometrial thickness on the day of hCG administration was found; however, endometrial thickness was statistically significantly higher in the clomiphene group on the day of IUI (9.28 ± 1.43 vs. 8.77 ± 1.34). Serum E₂ levels on the day of hCG were statistically significantly higher in the clomiphene group (501.09 ± 2.45 vs. 214.79 ± 2.43 pg/ml). Pregnancy rate was 9.2 %/cycle and 12.12 %/patient in the letrozole group, and 8.1 %/cycle and 9.5 %/cycle in the clomiphene group; these differences were not statistically significant.

Conclusion

This study found no superiority of letrozole over clomiphene when used for ovarian stimulation and IUI.     

Cribado de aneuploidía en gestación gemelar: resultados de la aplicación del test combinado

Objective

To evaluate the effectiveness of the Combined Test for trisomy 21 screening in twin pregnancies. To assess the performance of biochemical markers and nuchal translucency (NT) measurement in pregnancies with euploid fetuses and in twin pregnancies with one or two affected fetuses. To compare the value of markers according to chorionicity and the mode of conception.

Material and methods

Retrospective study including 161 twin pregnancies. Maternal serum fß-hCG and PAPP-A were determined at 8 to 12 weeks and fetal NT was measured at 11 to 14 weeks. The individual risk of trisomy 21 was calculated in each fetus using the Combined Test. In monochorionic pregnancies, the single risk for the pregnancy was obtained with the largest NT. An invasive diagnostic procedure was offered when the risk was 1:250 or more in one or both of the fetuses.

Results

All trisomy 21 pregnancies were identified (three pregnancies and four fetuses) by the combined testfor a false-positive rate of 6.4% of pregnancies and 3.5% of fetuses. The median fß-hCG level, expressed in MoM, was 1.72 and the median PAPP-A level was 2.01. The median NT was 1.05 MoM. Both fß-hCG and PAPP-A levels were significantly decreased in monochorionic pregnancies and PAPP-A was significantly decreased in pregnancies resulting from assisted reproduction. No significant differences were observed in NT measurement between monochorionic and dichorionic fetuses or between those conceived naturally or by assisted reproduction.

Conclusions

The combined test shows high sensitivity and specificity in screening for trisomy 21 in twin pregnancies. The differences obtained in the biochemical markers according to chorionicity or the mode of conception require confirmation in further studies with a larger number or cases.     

Luteal phase support may improve pregnancy outcomes during intrauterine insemination cycles

Objectives

To determine the impact of luteal phase support with vaginal progesterone on pregnancy outcomes in infertile couples undergoing intrauterine insemination when recombinant follicle-stimulating hormone was used for ovulation induction.

Study design

This prospective randomized study was undertaken at the Infertility Unit, Armed Forces Hospital Southern Region, Kingdom of Saudi Arabia, and included 71 patients with either primary or secondary infertility who met the inclusion criteria. All 71 patients underwent intrauterine insemination. Thirty-seven were randomized to start with a supported cycle and 34 started with an unsupported cycle. In supported cycles, patients received vaginal progesterone once daily from the day after insemination for 14 days. No progesterone was given during unsupported cycles. For the second cycle, crossover occurred such that women who initially had a supported cycle underwent an unsupported cycle, and vice versa. The cycle types were alternated until the end of the study. The main outcome measures were clinical pregnancy rates and livebirth rates per cycle and per patient.

Results

In total, 132 supported cycles and 126 unsupported cycles were performed successfully. The clinical pregnancy rate per patient was higher for supported than unsupported cycles (54.92% vs. 35.21%, respectively; p = 0.016), but the per-cycle difference was not significant (29.54% vs. 19.84%, respectively; p = 0.07). Twenty-five pregnancies in supported cycles and seven pregnancies in unsupported cycles resulted in live births. When these rates were compared per cycle and per patient, significant differences were detected between the cycle types (18.9% and 35.2% vs. 5.5% and 9.8%; p = 0.001 and <0.001, respectively).

Conclusion

Luteal phase support with vaginal progesterone improved the success of intrauterine insemination cycles when recombinant follicle-stimulating hormone was used for ovulation induction.

Condensation

Luteal phase support may improve pregnancy outcomes during intrauterine insemination cycles, but large multicentre, placebo-controlled, double-blind trials are needed.     

Poor prognosis in cycles following “genuine” empty follicle syndrome

Objectives

The aim of this study was to investigate the prognosis in future IVF cycles of patients with empty follicle syndrome (EFS).

Study design

EFS cases and their future cycles were reviewed. Clinical pregnancy rate per started cycle was taken as the primary outcome in assessing the future outcome in IVF treatment cycles.

Results

A total of 3023 patients underwent 5238 IVF treatment cycles. Twenty-six patients (1%) had a total of 58 (1%) cycles of EFS. Thirteen women went through 32 further IVF treatment cycles following the diagnosis of EFS, yielding only two clinical pregnancies, giving a clinical pregnancy rate of 6.25% per started cycle. In addition, four patients had recurrence in a total of 15 cycles.

Conclusions

The occurrence of EFS will indicate poor IVF success in subsequent IVF cycles. Patients with “genuine EFS” should be counselled about the outcome of their future IVF cycles.     

Translucencia nucal y ductus venoso: valores de referencia en el primer trimestre de la gestación

Objective

To establish the reference ranges for nuchal translucency (NT) and ductus venosus (DV) pulsatility index for veins (PIV) in our population.

Methods

During a 4-year period, pregnancies originated from the general population undergoing 11.1-14.0 weeks ultrasound examination were studied. Reference intervals were constructed following the methodology described by the National Committee for Clinical and Laboratory Standards. According to the conclusion of the partition test, gestational age-related reference intervals were estimated using linear regression models for the NT. Deviances from linearity in the estimated models were evaluated using fractional polynomials of 1st or 2nd degree.

Results

2,612 pregnancies were studied. No significant differences were found for DV PIV between gestational age groups. There was a significant difference of the NT values between age groups (p < 0.001) and the gestational age-related estimation of reference intervals showed a no-linear increase.

Conclusion

A significant increase was found for NT with gestational age, whereas the DV PIV remained constant.     

Effect of cervical mucus aspiration before intrauterine insemination

Objective

To determine whether cervical mucus aspiration before intrauterine insemination (IUI) has any effect on clinical pregnancy rates.

Method

The outcomes of 186 IUI cycles in 95 consecutive patients in whom mucus was aspired prior to IUI were compared retrospectively with those of 1057 IUI cycles in 505 women.

Results

The pregnancy rate was 15.1% (28 pregnancies for 186 cycles) in the cervical mucus aspiration group and 9.9% (105 pregnancies for 1057 cycles) in the control group (P = 0.05). Mucus aspiration led to significantly increased pregnancy rates for women with unexplained infertility (24% in the aspiration group vs 9.5% in the control group; P = 0.04).

Conclusion

Cervical mucus aspiration before IUI might improve clinical pregnancy rates by yet-to-be-defined mechanisms.     

The effect of progesterone supplementation on pregnancy rates in controlled ovarian stimulation and intrauterine insemination cycles: a randomized prospective trial

Objective

To evaluate the effect of vaginal progesterone as luteal phase support on pregnancy rates in controlled ovarian stimulation and intrauterine insemination cycles in couples with unexplained or mild male factor infertility.

Study design

290 Patients who met the inclusion criteria were included in a prospective randomized controlled trial. All patients underwent controlled ovarian stimulation and intrauterine insemination: 148 patients were randomized to start with a supported cycle and 142 patients with an unsupported cycle. In supported cycles, patients received vaginal progesterone once daily from the day after insemination until 12 weeks of pregnancy or, in non-pregnant women, for 14 days. No progesterone was given during unsupported cycles. The main outcome measures were clinical pregnancy rates per cycle.

Results

In total, 148 cycles with luteal phase support and 142 cycles without luteal phase support were performed. The clinical pregnancy rates per cycle were higher for cycles with luteal phase support than for the unsupported cycles (24.3% vs. 14.1% respectively, p = 0.027).

Conclusion

The use of vaginal suppositories as luteal phase support significantly improved clinical pregnancy rates in controlled ovarian stimulation and intrauterine insemination in patients with unexplained or mild male factor infertility.     

Efficacy of luteal phase support with vaginal progesterone in intrauterine insemination: a systematic review and meta-analysis

Purpose

To evaluate the efficacy of luteal phase support with vaginal progesterone in women undergoing intrauterine insemination (IUI).

Methods

Systematic review and meta-analysis. Randomized controlled trials (RCT) comparing supplementation of luteal phase with vaginal progesterone among women undergoing IUI versus a control group were included. The main outcome assessed was live birth rate.

Results

Five RCT met the inclusion criteria. In all 1,271 patients were included (951 IUI cycles in the progesterone group, 935 in the control group). Women treated with vaginal progesterone achieved significantly higher live birth rate (risk ratio [RR] 1.94, 95 % confidence interval [CI] 1.36 to 2.77,), and clinical pregnancy rate (RR 1.41, 95 % CI 1.14 to 1.76) as compared with controls. In the subgroup analysis per stimulation protocol, this beneficial effect of receiving progesterone was only observed in the group stimulated with gonadotropins (RR 2.28, 95 % CI 1.49 to 3.51), compared to the group stimulated with clomiphene citrate (CC) (RR 1.30, 95 % CI 0.68 to 2.50). No differences were observed in the miscarriage and multiple pregnancy rates.

Conclusions

The supplementation of luteal phase with vaginal progesterone significantly increases live birth among women undergoing IUI when receiving gonadotropins for ovulation induction. Women receiving CC to induce ovulation do not seem to benefit from this treatment.     

Good efficiency of intrauterine insemination programme for serodiscordant couples with HIV-1 infected male partner: A retrospective comparative study

Objective

Assisted reproduction techniques can minimize the risk of HIV female contamination when the male partner is HIV-infected. The aim of this study was to investigate the efficiency of sperm washing and intrauterine insemination (IUI) in these couples.

Study design

Retrospective comparative study. Eighty-four HIV-1 serodicordant couples underwent 294 IUI. The control group was composed of 90 couples (320 IUI cycles) with donor sperm. Spermatozoa from HIV-1 infected male partner were prepared and tested for HIV-1 according to sperm washing method. Spermatozoa from HIV-1 and donor male were frozen before IUI. IUI were performed after ovarian stimulation. Main outcomes measures were pregnancy rate per cycle and baby take-home rate per couples.

Results

Although the pregnancy rate and baby take-home rate were higher in IUI with sperm washing than in IUI using donor sperm (18.0 versus 14.7 and 52.4 versus 41.1, respectively), the differences were not statistically significant. In serodiscordant couples, blood estradiol levels under ovarian stimulation and total motile sperm inseminated were a determining factor in achieving pregnancy. No female HIV-1 contamination occurred.

Conclusion

This study demonstrates that sperm washing and IUI are highly effective in enabling serodiscordant couples with an HIV-1 infected male partner to have a child.     

Intrauterine Insemination (IUI)

Background

Intrauterine insemination (IUI) with or without ovarian stimulation is a common treatment for infertility. Despite its popularity, the effectiveness of IUI treatment is not consistent, and the role of IUI and in vitro fertilization (IVF) treatment in practice protocols has not been clarified.

Methods

Medline searches were done by individual topics (utilization, procedures, effectiveness of partner but not donor IUI and related endocrine issues). Effectiveness of IUI was evaluated in relevant randomized controlled trials, using meta-analysis and meta-regression where necessary.

Results

Stimulated IUI is ineffective in male infertility and the effect on other diagnoses is small. With clomiphene citrate and IUI, the most common IUI protocol, pregnancy rates average 7% per cycle. FSH ovarian stimulation and IUI treatment is only modestly better than observation only with pregnancy rate 12% per cycle but multiple birth rates averaging 13%. Mildly stimulated (1–2 follicles) cycles might reduce the cost and multiple birth rates but may require more cycles of treatment. Prevention of premature luteinizing hormone surges and luteal phase support do not appear to be major requirements in IUI cycles.

Conclusions

IUI treatment requires ovarian stimulation to achieve modest results, but the high multiple pregnancy rates mean that it is no more than a poor substitute for IVF treatment. More trials are needed on IUI treatment with mild stimulation and on the order of IUI and other treatments.     

Comparación de la efectividad de la pulsioximetría y el electrocardiograma fetal en las situaciones de riesgo de pérdida de bienestar fetal

Objective

To evaluate the effectiveness of pulse oximetry and fetal electrocardiogram in the management of labor with fetal heart rate patterns associated with a risk of loss of fetal well-being.

Subjects and methods

We performed an open, randomized, experimental trial with two groups: pulse oximetry was used in one group and the STAN® technique was used in the other. Each group included 40 women with single, term pregnancies in cephalic presentation and fetal heart rate patterns associated with a risk of loss of fetal well-being. The overall cesarean section rate, indications of risk of fetal distress, and neonatal acid-base balance were evaluated.

Results

No significant differences were found in the rate of cesarean section (47.5 vs 40%; P = .33), indications of risk of fetal distress (32.5 vs 37.5%; P = .41), or neonatal outcomes.

Conclusions

The use of pulse oximetry and STAN®21, as auxiliary methods to cardiotocographic recording, showed no superiority in reducing the cesarean section rate or improving neonatal outcomes.     

Epidemiología de las estrías gravídicas en España

Objective

To assess the influence of different factors on the presence of striae prior to pregnancy as well as the development of new lesions during and after pregnancy.

Subjects and methods

An observational epidemiologic study was carried out on the prevalence and incidence of striae gravidarum and stretch marks in pregnant women. Data from 519 pregnant women were registered, including obstetric history, family history of striae gravidarum, weight prior to pregnancy, skin type, Fitzpatrick skin phototype, and current use of body creams and lotions. A multivariate analysis was used to determine the factors associated with the incidence of striae gravidarum during current pregnancy.

Results

The prevalence of pre-pregnancy stretch marks was 85.5%, mainly observed in patients with a first pregnancy (OR = 2.6), body mass index ≥ 25 (OR = 2.2), and family history of striae gravidarum (OR = 2.1). The overall incidence of striae gravidarum during pregnancy was 36.8% and most of these patients had a body mass index ≥ 25 (OR = 2.2) and were younger (< 30 years old; OR = 1.9). Risk analysis of all the variables registered indicated a higher risk of striae gravidarum in women who were overweight prior to pregnancy (OR = 1.8), those aged under 30 years (OR = 2.4), and those with previous pregnancies (OR = 4.3).

Conclusions

Prevention of striae gravidarum should be recommended in all cases, with special emphasis on younger women and those who are overweight or obese due to their higher risk for the development of these marks during pregnancy.     

Histología e inmunohistoquímica de los carcinomas de mama en pacientes intervenidas de más de 70 años de edad

Objective

We retrospectively analyzed tumoral characteristics (histology and immunohistochemistry) in a group of elderly patients (≥ 70 years old) after surgery between 2003 and 2005, and compared these characteristics with those of younger patients.

Material and methods

We studied the characteristics of 483 breast carcinomas diagnosed sfrom 2003 to 2005 in the Gynecology Service of the 12 de Octubre Hospital in Madrid. Of these, 153 (31.7%) corresponded to patients aged 70 years old or older. Data were analyzed using the SPSS 12.0 program, and the groups were compared using chi-square analysis (or Fisher’s test when required). Quantitative data were expressed as mean ± standard deviation and median with interquartile range.

Results

In our patients aged 70 years or older, diagnosis after mammography was less frequent. In situ and microinvasive carcinomas were less frequent and the mean size of invasive carcinomas was larger. These findings can be explained by the lack of mammographic screening. No other histological or immuno-histochemical differences were found in comparison with younger patients and no differences were found in axillary lymph node involvement in women with axillary dissection.

Conclusions

Treatment in elderly patients should be individually tailored according to the biological characteristics of the tumor, comorbidity, and life expectancy. Age per se should not be considered a predictive factor of worse outcome.     

Conocimiento de los mecanismos de acción de los métodos de planificación familiar

Objective

To investigate women's knowledge of the mechanisms of action of birth control methods, especially those that act after fertilization, and to identify whether women want more information on this issue.

Methods

We performed a cross sectional study in a sample of 725 fertile women from primary care health centers in Pamplona (Spain) through a self-administered, anonymous, 30-item questionnaire on family planning. Univariate and multivariate logistic regression analyses were performed.

Results

Less than 5% knew all the mechanisms of action of oral contraceptives and the intrauterine device and only 7% knew those of the emergency contraception pill. Regardless of their beliefs, most women (91%) believed that they should be informed of any postfertilization effects.

Conclusions

To ensure their right to free choice,women should be informed of all the mechanisms of action of birth control methods.     

Implementación de la terapia láser endoscópica para las complicaciones de gestaciones gemelares monocoriales

Objective

To evaluate the outcomes of monochorionic diamniotic (MCDA) twin pregnancies with severe twin-to-twin transfusion syndrome (TTTS) or selective fetal growth restriction (FGR) treated by endoscopic laser separation of placental vessels in our unit.

Material and methods

Fetoscopic laser therapy was performed in 22 MCDA pregnancies, including 17 for severe TTTS, and five for selective FGR. Presurgical severity, obstetric complications, and fetal survival were analyzed.

Results

In 15 of the 17 (88%) cases of severe TTTS, at least one twin survived. In the five cases of selective FGR, the fetus with normal growth survived in three cases, including one in which the growth restricted fetus also survived.

Conclusions

The results demonstrate the successful implementation of endoscopic laser surgery in a fetal medicine center in Spain after appropriate training of the operator.