Intrauterine insemination, what do we really know? A critical appraisal of the literature
Pieternel Steures, Jan Willem van der Steeg, Peter G.A. Hompes, Patrick M. Bossuyt, Ben W.J. Mol, and Fulco van der Veen

Centre for Reproductive Medicine, Academic Medical Centre, Amsterdam, The Netherlands. †Department of Obstetrics & Gynecology, Vrije Universiteit Medical Centre, Amsterdam, The Netherlands. Department of Biostatistics & Epidemiology, Academic Medical Centre Amsterdam, The Netherlands. Department of Obstetrics & Gynecology, Máxima Medical Centre, Veldhoven, The Netherlands

ABSTRACT

Intrauterine insemination (IUI) is the first line treatment in couples with unexplained subfertility, cervical factor subfertility and male subfertility. To appraise the effectiveness of IUI for these three indications, we performed a systematic review and a comprehensive series of meta-analyses. We included Cochrane reviews and searched the literature for additional studies. Outcomes were live birth, ongoing pregnancy, clinical pregnancy and multiple pregnancy.

We were able to include 14 studies reporting on IUI for unexplained subfertility, two studies reporting on IUI for cervical factor subfertility and nine studies reporting on IUI in male subfertility.

In couples with unexplained subfertility, IUI without controlled ovarian hyperstimulation (COH) was associated with higher ongoing pregnancy rates than expectant management (relative risk (RR) 1.3, [95% CI 0.84 to 1.9]), whereas IUI with COH was more effective than IUI without COH (RR 1.8, [95% CI 1.2 to 2.7]). However, in couples with relatively good prospects for spontaneous pregnancy, there was no benefit from IUI with COH over expectant management. In couples with a cervical factor, IUI without COH was associated with higher pregnancy rates compared to expectant management (RR 1.6, [95% CI 0.87 to 3.1], but addition of COH did not further improve the pregnancy rates (RR 1.0, [95% CI 0.59 to 1.8]). In couples with male subfertility, IUI was more effective than expectant management, although the limited power of the included studies hampers strong conclusions. In these couples, addition of COH also had no extra benefit (RR 0.92, [95% CI 0.46 to 1.8]). Studies comparing IUI and IVF were rare, limiting assessment of the strategy of IVF as first line treatment.

Despite the fact that IUI is one of the most frequently used treatments in reproductive medicine, our review shows that the number of studies assessing its effectiveness is limited and that most of these studies had small sample sizes. This results in imprecise effect estimates, as demonstrated by the non significant effects and large confidence intervals. Also, many studies did not adhere to present quality standards for design, conduct and report of clinical trials.

Therefore, there is an urgent need for more RCTs in which IUI is compared to expectant management or IVF.

Key words: cervical factor, effectiveness, intrauterine insemination, male subfertility, unexplained subfertility.

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Current management of infertility related to polycystic ovary syndrome
Bassam Elhelw

ABSTRACT

The need to establish universally accepted diagnostic criteria led to the Rotterdam meeting in 2003, during which experts in PCOS from all over the world arrived at a consensus regarding the diagnosis of PCOS.

Criteria proposed for the diagnosis of PCOS in the Rotterdam meeting were set to allow the performance of properly designed trials with good external validity in PCOS patients. Revised 2003 diagnostic criteria for PCOS (2 out of 3): 1. Oligo- and/or anovulation, 2. Clinical and/or biochemical signs of hyperandrogenism, 3. Polycystic ovaries; with exclusion of other disorders with a similar clinical presentation, such as congenital adrenal hyperplasia, androgen-secreting tumors and Cushing's syndrome.

The treatment of infertile women with polycystic ovary syndrome (PCOS) is surrounded by many controversies. Before any intervention is initiated, preconceptional counseling should be provided emphasizing the importance of lifestyle, especially weight reduction and exercise in overweight women. The recommended first-line treatment for ovulation induction remains the anti-estrogen clomiphene citrate (CC). Recommended second-line treatment, should CC fail to result in pregnancy, is either exogenous gonadotrophins or laparoscopic ovarian surgery (LOS). The use of exogenous gonadotrophins is associated with increased chances for multiple pregnancy, and, therefore, close monitoring of ovarian response is required. Laparoscopic ovarian surgery alone is usually effective in less than 50% of women, and additional ovulation induction medication is required. Recommended third-line treatment is in vitro fertilization (IVF). Metformin use in PCOS should be restricted to women with glucose intolerance. Based on recent data available in the literature, the routine use of metformin in ovulation induction is not recommended. Insufficient evidence is currently available to recommend the clinical use of aromatase inhibitors for routine ovulation induction.

Key words: PCOS, LOD, metformin, anti-estrogen, infertility, IVF.

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Color Doppler study of the subendometrial area (junctional zone) of the uterus in unexplained infertility
Dina Gamal El-Deen El-Kholi and Mohamed Abd El-Geleel Hefaida

ABSTRACT

Objective: to study by color Doppler the vascularity of the subendometrial area to assess the endometrial perfusion and receptivity in unexplained infertility.

Design: a case control study

Materials and Methods: thirty-five cases of unexplained infertility and 16 fertile females were submitted, in the midluteal phase of the menstrual cycle; to color Doppler study of the subendometrial area which is the inner most part of the myometrium, 5 mm outside the echogenic basal layer of the endometrium.

Results: study of vascularization of this area by color flow mapping showed that, blood flow was detected in 51.4% of the group of unexplained and 93.8 % of the control group. The difference is statistically significant. Mean pulsatility index (PI) in the subendometrial arteries, if detected by color flow mapping was 2.65 ± 0.37 in unexplained infertility and 1.95 ±0.24 in control group. The difference is statistically significant. The mean peak systolic velocity (PSV) in the subendometrial arteries in unexplained infertility was 0.29 ± 0.0,02 mand in the control group was 0.42 ± 0.03 m. The difference is statistically significant. Our color Doppler study of the uterine arteries showed also that PI, resistance index (RI) are higher in unexplained infertility than in control fertile group. Our study showed that in midluteal phase of the menstrual cycle, in patients with unexplained infertility, blood perfusion of the subendometrial area was impaired.

Conclusion: Though the number of patients is too small to draw a firm conclusion and large studies are awaited to confirm the results of our study, blood perfusion of the endometrium was also impaired as the blood supply to it passes through the subendometrial area. A possible treatment of these patients is uterine perfusion enhancers as sildenafil (Viagra), low dose aspirin and glyceryl trinitrate.

Key words: Color Doppler, Subendometrial Area of the uterus, Unexplained Infertility

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Optimization of r-FSH concentration in cultured media for human oocytes in-vitro maturation
Ismail Mahmoud Samy

ABSTRACT

Objective: In-vitro maturation (IVM) of human oocytes is becoming increasingly important in treating some aspects of infertility. It is a potential tool to minimize the risk of severe ovarian hyper-stimulation (OHSS) representing an alternative and affordable treatment for women with polycystic ovary syndrome. Our aim is to study the effect of concentration of recombinant follicle stimulating hormone (r-FSH) in culture media on oocytes maturation, fertilization, cleavage and pregnancy rates in women with polycystic ovaries.

Material and Methods: In a randomized study of 50 women in an IVF program with 674 germinal vesicle (GV) oocytes were allocated to study the effect of three concentrations of r-FSH (0.0, 0.075, and 7.5IU) supplemented in culture media on oocytes maturation, fertilization, cleavage, and pregnancy rate.

Results: Oocytes maturation rate had significantly (P <0.05) increased from 47% at 0.0 (control) to 81% and 83% at 0.075 IU/ml and 7.5 IU/ml of r-FSH concentration, respectively. Fertilization, cleavage, and clinical pregnancy rates showed similar trend and significantly increased from 45% to 83% and 80%; from 32% to 80% and 77% and from 0 to 17% and 14% at the three r-FSH concentrations, respectively. The results however showed that increasing r-FSH concentration to more than 0.075 IU/ml did not further improve the rates of the above parameters even when the concentration was increased 100 folds.

Conclusion: The results suggested that r-FSH supplementation in the culture media concentrations of 0.075 IU/ml was optimum in the present study and improving GV maturation, fertilization, cleavage and pregnancy rate.

Keywords: follicles, IVM, ICSI, fertilization, pregnancy

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Assessment of the endometrium in postmenopausal bleeding: the role of transvaginal sonography and Doppler velocimetry
Ahmed Aboul Nasr, Ahmed Soliman, Rasha Mohamed, Hesham Gaber Al-Inany and Mohammed Ali

ABSTRACT

Objective: to study the role of Transvaginal ultrasonography and Doppler in the assessment of the endometrium in patients with postmenopausal bleeding.

Material and methods: The present study included 40 patients from kasr El-aini outpatient gynecologic clinic in the period from January 2006 to December 2006. All patients were subjected to the following transvaginal ultrasonography, transvaginal pulsed Doppler on both uterine arteries and fractional Curettage was done only for the study group.

Results: there were significant differences between the study and the control groups regarding to uterine length (P = 0.005) and uterine width (P < 0.05), Taking 6mm endometrial thickness as a cut-off value in our study transvaginal ultrasound showed a sensitivity of 81.8%, specificity of 22.2%, Regarding the Doppler study Its sensitivity to detect pathological abnormalities was 10.0% specificity 88.9%

Conclusion: Although both transvaginal ultrasonographic endometrial examination and Doppler velocimetric study of the uterine artery posses high sensitivity and specificity that makes each of them clinically useful as a single diagnostic tool in discriminating atrophic from abnormal pathological endometrium in cases with postmenopausal bleeding. Yet, the present study emphasizes the importance of the combined examination using both techniques to increase the diagnostic accuracy also our study highlights the importance of fractional curettage in completing the assessment of the endometrium.

Keywords: Transvaginal ultrasonography, endometrium, Doppler

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Intrauterine versus intracervical insemination in the treatment of unexplained infertility
Abdulrazak H. Alnakash

ABSTRACT

Objective: To compare the efficacy of Intra-uterine insemination (IUI) and Intra-cervical Insemination (ICI) when managing couples suffering from unexplained Infertility.

Design: Randomized Clinical Trial.

Setting: Institution of Infertility Treatment and Embryo Research, Baghdad -Iraq.

Materials and Method: One hundred and fifteen couples suffering from unexplained primary infertility were involved in this study. The wives had undergone 247 insemination cycles with their husband's washed sperms. The cycles were stimulated by gonadotrophins and monitored by serial vaginal sonography to determine number and sizes of the follicles. The ladies were selected randomly to undergo either Intra-uterine or Intra-cervical Inseminations (IUI) (ICI).

Results: The study reported 19.1% total pregnancy rate (22 out of 115 women). After 247 Insemination cycles, pregnancy rate per cycle was 8.9%. IUI was done in 128 cycles to 59 couples resulted in 14 pregnancies (23.73%). On the other hand, ICI was done in 119 cycles to 56 couples and resulted in 8 pregnancies (14.28%). when compared to evaluate their effectiveness in achieving pregnancy, the two procedures were statistically not significant, P value = 0.198.

Conclusions: Artificial Insemination enhances pregnancy in those couples with unexplained infertility and IUI carries higher pregnancy rate than ICI but it is not statistically significant.

Key words: Intra-uterine insemination, intra-cervical insemination, unexplained infertility.

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Difficult embryo transfer and the presence of blood on the post-transfer catheter negatively affect clinical pregnancy rates
Ahmed M. Abou-Setta, Sherif El-Sharkawy, Maha Shahed and Medhat Amer

ABSTRACT

Objective: To determine whether the ease of the embryo transfer, the presence or absence of blood, mucus or retained embryos on the tips of the post-transfer catheter are correlated with the probability of a clinical pregnancy in a large cohort of women undergoing ultrasound-guided embryo transfer with high quality embryos.

Materials and Methods: A retrospective cohort study was performed for 943 women, aged 18-39 years old, who underwent 1,122 ETs between January 1, 2005, and December 31, 2006. A semi-quantitative system for grading and recording the difficulty of transfer, presence of retained embryos, mucus and blood found inside and outside the transfer catheter after ET was used to determine the correlation of each factor with the clinical pregnancy rate.

Result(s): Difficult transfer (RD = 29.84%, O.R = 4.52, 95% CI = 2.00 to 10.20) and presence of blood on the outside (RD = 18.06%, O.R = 2.20, 95% CI = 1.38 to 3.52) or inside of the transfer catheter after ET (RD = 11.49%; O.R = 1.63, 95% CI = 0.94 to 2.82) was associated with decreased clinical pregnancy rates, but the latter did not reach statistical significance. In addition, there was a correlation between difficult transfers and the presence of blood. In contrast, presence of retained embryos or mucus did not significantly affect the outcomes.

Conclusion(s): The relationship between difficult embryo transfer and the presence of blood on the outside or inside of the transfer catheter has been demonstrated to decrease the clinical pregnancy rates. Every effort should be made to minimalize difficulty, and hence bleeding, during embryo transfer.

Keywords: Difficult embryo transfer, blood, embryo catheter, retained embryos, IVF

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An in vitro comparative study of the effects of ascorbic acid and FSH on the maturation of Syrian mice follicles
 Aisha Javed, Saeed rezaei-Zarchi, Amer jamil and Seyed Mehdi Kalantar

ABSTRACT

Objective: To investigate the combined and comparative effects of FSH and ascorbic acid on the in vitro maturation of mouse follicles and enclosed oocytes.

Materials and Methods: For recent analysis, intact preantral follicles were isolated from the ovaries of 6 week-old female Syrian mice and cultured in TCM-199 medium. To check the effect of FSH and ascorbic acid on the maturation of the isolated follicles, following quantities of FSH and ascorbic acid were added to the culture medium (containing 25-30 follicles) during separate experiments: 10, 25, 50 and 100 IU/l FSH and 10, 50, 100, 200, 300 and 400 nmol/ml ascorbic acid. Follicles were cultured, for 6 days, in an incubator at 37 °C, 92 % humidity and 5% CO2 in air.

Results: FSH concentration of 100 IU/l showed increased follicle diameter, survival, germinal vesicle breakdown (GVBD) and oocyte maturation rates (P < 0.0001). Ascorbic acid showed increased (59%) survival rate (P < 0.0001) but unaffected diameter, GVBD and oocyte maturation rates (P > 0.05) while, ascorbic acid and FSH containing medium showed a marked increase in all the parameters (P < 0.05) but follicle diameter was unaffected (P > 0.05).

Conclusion: It is concluded from the experiment that FSH and ascorbic acid increase the maturation rate of follicles and enclosed oocytes but if they are supplied in a combination, this growth rate can increase significantly.

Key words: Follicle stimulating hormone, Ascorbic acid, Preantral follicles

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