Intrauterine insemination versus fallopian tube sperm perfusion for non-tubal infertility.

BACKGROUND: Intrauterine insemination (IUI) is a common treatment for couples with subfertility that does not involve the fallopian tubes. It is used to bring the sperm close to the released oocyte. Another method of introducing sperm is fallopian tube sperm perfusion (FSP). Fallopian tube sperm perfusion ensures the presence of higher sperm densities in the fallopian tubes at the time of ovulation than does standard IUI. These treatments are often used in combination with ovarian hyperstimulation. OBJECTIVES: To compare intrauterine insemination versus fallopian tube sperm perfusion in the treatment of non-tubal subfertility, for live birth and pregnancy outcomes. SEARCH METHODS: We searched the Menstrual Disorders and Subfertility Group Trials Register, MEDLINE, CINAHL and EMBASE from inception to September 2013. We also searched study reference lists and trial registers. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing IUI with FSP in couples with non-tubal subfertility were included. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies for inclusion, assessed study quality and extracted the data. If studies were sufficiently similar, data were combined using a fixed-effect model to calculate pooled odds ratios (ORs) and 95% confidence intervals (CIs). A random-effects model was used if substantial statistical heterogeneity was detected. Studies that included participants with unexplained or mixed (non-tubal) subfertility were analysed separately from studies restricted to participants with mild or moderate male factor subfertility. The overall quality of evidence for the main outcomes was summarised using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. MAIN RESULTS: The review included 16 RCTs. Fourteen RCTs (1745 women) were included in the meta-analysis. Only three studies reported live birth per couple. No evidence of a statistically significant difference was noted between IUI and FSP in live birth (OR 0.94, 95% CI 0.59 to 1.49, three RCTs, 633 women, I(2) = 0%, low-quality evidence) or clinical pregnancy (OR 0.75, 95% CI 0.49 to 1.12, 14 RCTs, 1745 women, I(2) = 52%, low-quality evidence). These findings suggest that for a couple with a 13% chance of live birth using FSP, the chance when using IUI will be between 8% and 19%; and that for a couple with a 19% chance of pregnancy using FSP, the chance of pregnancy when using IUI will be between 10% and 20%. Nor was evidence found of a statistically significant difference between IUI and FSP in per-pregnancy of multiple pregnancy (OR 0.96, 95% CI 0.44 to 2.07, eight RCTs, 197 women, I(2) = 0%, low-quality evidence), miscarriage (OR 1.23, 95% CI 0.60 to 2.53, seven RCTs, 199 women, I(2) = 0%, low-quality evidence) or ectopic pregnancy (OR 1.71, 95% CI 0.42 to 6.88, four RCTs, 111 women, I(2) = 0%, very low quality evidence). Substantial heterogeneity was noted for the outcome of clinical pregnancy (I(2) = 54%), for which no clear explanation was provided. AUTHORS' CONCLUSIONS: Currently no clear evidence suggests any difference between IUI and FSP with respect to their effectiveness and safety for treating couples with non-tubal subfertility. However, a high level of uncertainty is evident in the findings, and additional research may be useful.

Successful pregnancy outcome following gamete intra-Fallopian transfer in a patient with Müllerian dysgenesis.

A 29-year-old lady with Müllerian dysgenesis was keen to have a baby. Clinically, she was medium built with well-developed secondary female sexual characteristics. There was a short and blind vagina. She had undergone surgery for an imperforated hymen. Her FSH and LH concentrations were normal. Laparoscopy revealed a patent right Fallopian tube, a rudimentary right uterus and extensive pelvic endometriosis. She subsequently underwent gamete intra-Fallopian transfer (GIFT). Oocyte retrieval was carried out laparoscopically and a total of nine oocytes were retrieved. Four of the oocytes were transferred together with motile spermatozoa into the right Fallopian tube and the remaining five oocytes were inseminated with spermatozoa for IVF. Three embryos resulted and were frozen. She subsequently developed moderate ovarian hyperstimulation syndrome. Serum ß-human chorionic gonadotrophin concentration 14 days after GIFT was 1612 IU/l. Her antenatal care was relatively uneventful until 31 weeks of gestation when she was diagnosed to have intrauterine growth retardation and oligohydramnios. She then underwent an emergency Caesarean section at 32 weeks of pregnancy delivering a normal baby. This case study describes a successful pregnancy outcome following gamete intra-Fallopian transfer (GIFT) in a woman with malformation of the vagina (Müllerian dysgenesis). A 29-year-old lady with Müllerian dysgenesis diagnosed at 16 years of age was keen to become pregnant. Upon examination, a decision was made for a William's vulvovaginoplasty but as the patient was indecisive the surgery was deferred. Clinically, she is a medium-built lady with well-developed secondary female sexual characteristics. There was a short and blind vagina. Her serum FSH and LH concentrations were normal. Laparoscopy revealed a patent right Fallopian tube, a rudimentary right uterus and extensive pelvic endometriosis. She subsequently underwent GIFT. Nine oocytes were retrieved through laparoscopy. Four of the oocytes were transferred together with motile sperm into the right Fallopian tube and the remaining five oocytes were inseminated with sperm for IVF. Three embryos resulted and were frozen. Serum ß human chorionic gonadotrophin concentration measured 14 days after GIFT was 1612 IU/l. An abdominal ultrasonography performed at 5 weeks showed one intrauterine gestational sac. Her antenatal care was uneventful until 31 weeks of gestation when she developed a deficiency of amniotic fluid in the amniotic sac. She then underwent an emergency Caesarean section at 32 weeks of pregnancy. She delivered a healthy, normal 1.24 kg baby boy. Her post-natal care was uneventful.

Ovulation stimulation and induction.

Evaluation of gonadotropins, prolactin, and thyroid function in anovulatory women directs subsequent therapy. Treatment should be initiated with the agent that is the safest and least costly for the specific indication. Except in cases of FSH elevation, pregnancy rates should approximate those of normally ovulating women. Bromocriptine, the drug of choice for hyperprolactinemia, restores ovulation in greater than 90% of women treated. Clomiphene citrate remains the drug of choice for normoestrogenic anovulation. Although drug-resistant women may respond to extended regimens, failure to ovulate or to conceive within six ovulatory cycles with clomiphene is an indication for menotropin therapy. Menotropins and pulsatile GnRH should be considered first line therapy for women with hypogonadotropic anovulation. When using hMG or pulsatile GnRH in clomiphene-resistant patients, pretreatment with GnRH analogs may normalize their response and result in higher pregnancy rates. GnRH analogs prevent premature luteinization in hMG-induced in vitro fertilization and gamete intrafallopian transfer cycles, resulting in lower cancellation rates and improved oocyte quality. Superovulation with clomiphene citrate should be attempted in patients with unexplained infertility prior to using menotropin therapy.

Gamete intrafallopian transfer: prospective randomized comparison between hysteroscopic and laparoscopic transfer techniques.

OBJECTIVE: To test the efficiency and overall acceptability of hysteroscopic GIFT when compared with laparoscopic GIFT. DESIGN: We performed a randomized comparison between these techniques as regards pregnancy rate (PR), implantation rate, miscarriage rate, and ectopic pregnancy rate (ectopic PR). SETTING: All patients were enrolled for GIFT procedures in our Reproductive Medicine Unit. PATIENTS: We enrolled 133 patients showing documented tubal patency at a previous diagnostic laparoscopy. INTERVENTIONS: Gonadotropin-releasing hormone analog and FSH were administered to induce superovulation in all patients, who were then randomized for hysteroscopic GIFT or laparoscopic GIFT. Laparoscopic GIFT was performed under general anesthesia while, during hysteroscopic GIFT, oocyte retrievals were transvaginal ultrasound guided and transfers were performed by cannulating tubal ostia after hysteroscopic visualization. MAIN OUTCOME MEASURE: The efficacy was evaluated comparing PR, implantation rate, miscarriage rate, and ectopic PR. RESULTS: Pregnancy rate and implantation rate of hysteroscopic GIFT procedures (29.8% and 9%, respectively) are not significantly different from those obtained with laparoscopic GIFT (43.3% and 14%). CONCLUSIONS: Hysteroscopic GIFT is safe and easy and quick to perform. Moreover, it does not require hospital admission, general anesthesia, or the operating theater, reducing costs and assuring advantages in terms of low psychophysical involvement and repeatability.

Comparison of carbon dioxide and air pneumoperitoneum for gamete intrafallopian transfer under conscious sedation and local anesthesia.

OBJECTIVE: To compare patient tolerance and pregnancy rates (PRs) between two cohorts that underwent GIFT under local anesthesia with air versus carbon dioxide (CO2) pneumoperitoneum. DESIGN: Retrospective study. SETTING: University clinic. PATIENT(S): Eighty-five patients who underwent 125 laparoscopies under conscious sedation for GIFT using air pneumoperitoneum were compared with 42 patients who had 70 GIFT procedures with CO2 pneumoperitoneum. INTERVENTION(S): Transvaginal ultrasound-guided egg retrieval followed by GIFT with compressed air or CO2 for pneumoperitoneum under local anesthesia and i.v. sedation. MAIN OUTCOME MEASURE(S): Patient tolerance and viable PR. RESULT(S): The percentage of patients scoring "very good" was lower in the CO2 group (73% for air versus 57% for CO2), but the combined percentage of those scoring "very good" or "good" was comparable at 89% and 87%. The difference in the viable PRs between the two groups (43% versus 37%) for patients < 40 years old was not statistically significant. CONCLUSION(S): Patient tolerance and PRs are similar for air and CO2 pneumoperitoneum during GIFT under local anesthesia. Given the theoretical risk of air embolus and lack of detrimental effect of CO2 on patient tolerance and success rate, it seems prudent to use CO2 in such a setting.

Successful pregnancies resulting from the use of prolonged-incubation human spermatozoa in gamete intrafallopian transfer.

Human spermatozoa that were incubated overnight at room temperature before intrafallopian transfer with freshly collected oocytes gave rise to successful pregnancies and normal live births. The resulting pregnancy rate per transfer of 50% (4 of 8) compared favorably with the average pregnancy rate of 41.8% (38 of 91), achieved by our standard spermatozoal preparation procedure that prepared the spermatozoa approximately 2 hours before the GIFT operation. This new approach for the preparation of human spermatozoa would be applicable to oligospermic patients and some GIFT patients whose partners may have difficulties in producing a semen specimen immediately before the GIFT operation.

The effect of unilateral versus bilateral tubal cannulation and the number of oocytes transferred on the outcome of gamete intrafallopian transfer.

A comparison of results of GIFT procedures using unilateral and bilateral tubal cannulation was made. There was no difference in outcome between these two methods, with the unilateral approach having some advantages over the bilateral procedure. Pregnancy rates decreased as the number of oocytes transferred was reduced.

Culdoscopic gamete tubal transfer: a new approach to gamete intrafallopian tubal transfer.

Twelve infertile couples who failed to conceive by previous infertility treatments and who qualified for culdoscopy had oocyte retrieval and gamete transfer through an operative culdoscopy method. Six patients achieved clinical pregnancy. Five are ongoing pregnancies, and one patient miscarried. There were no complications of the procedures.

Laparoscopic zygote intrafallopian transfer using augmented local anesthesia.

In this study, 29 laparoscopic ZIFTs were performed in 21 patients using local anesthesia augmented with intravenous analgesia. The technique was well tolerated; significant discomfort arose only when the fallopian tubes were manipulated and was minimized by transferring zygotes to one tube only. Seven pregnancies resulted, of which three have delivered and one is ongoing.

Transvaginal versus laparoscopic gamete intrafallopian transfer: a case-controlled retrospective comparison.

OBJECTIVE: To compare pregnancy rates (PRs) obtained by transvaginal ultrasound (US)-guided GIFT with PRs from conventional laparoscopy-based GIFT. DESIGN: Retrospective case-controlled study. SETTING: Large, private assisted conception service. PATIENTS: Twenty consecutive cycles of transvaginal GIFT, each matched with three cycles of laparoscopic GIFT on the basis of patient age, number of previous unsuccessful attempts at GIFT, number of eggs transferred, and total number of eggs obtained. MAIN OUTCOME MEASURE: Probability of clinical pregnancy. RESULTS: The PR from transvaginal GIFT was 20.0% (95% confidence limits 13% to 27%), compared with a PR from laparoscopic GIFT of 35.0% (23% to 50%). CONCLUSION: Transvaginal GIFT with present techniques seems to be less effective than laparoscopic GIFT, but it can be considered as a practical alternative to ovarian stimulation and intrauterine insemination and to peritoneal ovum-sperm transfer.

Gamete intrafallopian transfer: assessment of the optimal number of oocytes to transfer.

The optimum number of oocytes that should be transferred at the time of gamete intrafallopian transfer (GIFT) is important information. Nonessential oocytes can be inseminated and frozen for later use or the extra oocytes can be donated to another women. In this preliminary study, the results of 399 consecutive GIFT procedures were evaluated retrospectively as a function of the number of oocytes transferred. Women who received four or more oocytes were three times more likely to achieve a clinical pregnancy than those who received three or less. There was no statistically significant difference in pregnancy rates between patients who received five, six, seven, or eight oocytes. Oocytes in excess of five may be more effectively used if they are fertilized and frozen as embryos for later transfer rather than replacing them all at the time of GIFT.

Gamete intrafallopian transfer by hysteroscopy as an alternative treatment for infertility.

OBJECTIVE: To evaluate efficacy and safety of the hysteroscopic cannulation by flexible catheter of the fallopian tubes for gamete intrafallopian transfer (GIFT). DESIGN: We studied the pregnancy rate (PR) and the safety of this new technique. SETTING: All patients were enlisted for GIFT at our Reproductive Medicine Unit. PATIENTS: We treated 26 patients whose infertility causes were terminal tubal damage, male factors, unexplained factors, and endometriosis. Patients with uterine tubal ostia unsuitable for gamete transfer or cervical incontinence were not included in the group. INTERVENTIONS: The patients underwent ovulation induction and oocyte retrieval by transvaginal ultrasonically guided puncture. The gamete transfers were carried out by hysteroscopic procedure using a flexible catheter put through the operating channel. MAIN OUTCOME MEASURE: The efficacy was evaluated by the PR (25.9%). RESULTS: Seven clinical pregnancies were obtained, but two patients aborted during the first weeks of pregnancy. No ectopic pregnancies were observed. CONCLUSIONS: Our results indicate that hysteroscopic GIFT is an alternative, safe, effective, and not invasive technique for fertility problems.

Predicting success of gamete intrafallopian transfer.

OBJECTIVES: To examine seminal parameters predictive for success in a cycle of GIFT and to construct an algorithm using pertinent seminal data as well as easily obtained historical data to predict pregnancy and viable pregnancy rates. DESIGN: A retrospective study of 544 cycles in 376 couples. SETTING: A private IVF-ET and GIFT center. PATIENTS: Couples in a GIFT program with a mean of 53.6 months of infertility who had failed to conceive with other therapies. INTERVENTIONS: Gamete intrafallopian transfer. MAIN OUTCOME MEASURES: Pregnancy as a function of laboratory historical data with emphasis on seminal parameters. RESULTS: Motility was the only seminal parameter that was predictive. Success was correlated with the number of oocytes returned and inversely related to female age. An algorithm to predict pregnancy in a GIFT cycle as well as viable pregnancy was constructed. CONCLUSIONS: Motility is the only seminal parameter predictive for success in a GIFT cycle. An easily programmable algorithm can be constructed to help patient and physician decide on the appropriateness of GIFT for each couple.

Tubal selection for gamete intrafallopian transfer.

When both fallopian tubes appear normal, tubal selection for GIFT is left to the surgeon's discretion. We were interested to learn whether pregnancy rates were influenced by the choice of tubal transfer in relation to ovarian dominance. Ovarian dominance was defined sonographically as the ovary containing the greater number of follicles having a mean diameter > 16 mm. In a retrospective analysis of 144 GIFT procedures, the clinical pregnancy rate for transfers performed to the tube ipsilateral to the dominant ovary was significantly higher than that of transfers made to the contralateral tube (0.414 versus 0.228, P = 0.042). This difference could not be attributed to either patient characteristics or cycle performance. We suggest that gamete transfer be performed ipsilateral to the side with the greater number of dominant follicles to optimize pregnancy rates.

Ultrasound-guided fallopian tube catheterization per vaginum: a feasibility study with the use of laparoscopic control.

The fallopian tube can be cannulated per vaginum under ultrasound control. The sensation and ultrasound appearance of smooth passage without visible kinking are accurate predictors of success. The average time taken for each cannulation was 7.2 minutes. Adequate practice in non treatment cycles is essential before proceeding to cell transfer, while further modification of the catheters used may improve overall success.

Clomiphene citrate-induced gamete intrafallopian transfer with diagnostic and operative laparoscopy.

STUDY OBJECTIVE: To examine the efficacy of clomiphene citrate (CC) gamete intrafallopian transfer (GIFT) with operative laparoscopy. DESIGN: Retrospective. SETTING: Private office and outpatient surgical center. PATIENTS: Sixty-two patients who were to undergo diagnostic and operative laparoscopy as part of their infertility evaluation underwent concomitant CC-stimulated GIFT. Any significant pelvic pathology was treated in conjunction with the GIFT procedure. RESULTS: The average number of oocytes retrieved per laparoscopy was 3.4 and an ongoing pregnancy rate (PR) of 24.6% was attained. Endometriosis, pelvic adhesive disease, and myoma were treated laparoscopically in conjunction with the GIFT procedure. CONCLUSION: Clomiphene citrate-induced GIFT in conjunction with diagnostic and operative laparoscopy results in an acceptable ongoing PR without significantly interfering with any operative laparoscopy procedure required.

High-order oocyte transfer in gamete intrafallopian transfer patients 40 or more years of age.

OBJECTIVE: To analyze whether a policy of high-order oocyte transfer would be effective in women > or = 40 years of age who are undergoing GIFT, and further, whether a specific subgroup of these patients could be identified where clinical pregnancy was more likely to occur. DESIGN: Prospective descriptive study. SETTING: Patients in a university-based reproductive endocrinology and infertility practice. PATIENTS: Infertile women > or = 40 years of age who underwent GIFT cycles between January, 1990 and December, 1993 after not having achieved pregnancy with at least three previous cycles of superovulation and intrauterine insemination. INTERVENTIONS: Gamete intrafallopian transfer was performed after controlled ovarian hyperstimulation with hMGs. High-order oocyte transfer was employed. MAIN OUTCOME MEASURES: Clinical pregnancy rates (PRs). RESULTS: The overall clinical PR was 24.5% per retrieval (12/49) and 25.5% per transfer (12/47). A significantly higher number of oocytes were retrieved in patients who became pregnant than those who did not. Patient age, cycle day 3 FSH level, E2 level on the day of hCG administration, number of oocytes transferred, and total number of motile sperm transferred did not differ significantly between the two groups. The clinical PR per transfer was significantly higher in patients with more than five oocytes transferred (10/27, 37%) versus those with five or less oocytes transferred (2/20, 10%). No multiple gestations were obtained. CONCLUSION: The number of oocytes retrieved in women > or = 40 years of age undergoing GIFT is the main determinant predicting clinical pregnancy. High-order oocyte transfer seems to lead to a favorable PR while the risk of multiple gestation is limited.

Correlation of serum inhibin concentrations with results in an ovarian hyperstimulation program.

In order to appraise follicular development, human serum inhibin was measured daily by radioimmunoassay in 18 women undergoing ovarian hyperstimulation. Serum inhibin in the early follicular phase correlated with the number of follicles greater than or equal to 17 mm in diameter (r = 0.57, n = 18, P less than 0.05), follicles greater than or equal to 14 mm in diameter (r = 0.67, n = 18, P less than 0.01) on the day of human chorionic gonadotropin (hCG) administration and the number of oocytes retrieved (r = 0.67, n = 15, P less than 0.01). The number of oocytes retrieved showed a significant correlation with serum inhibin level on the day of hCG administration (r = 0.84, n = 15, P less than 0.001). These data suggest that: (1) In the early follicular phase, serum inhibin may be a valid index to predict ensuing follicular growth; (2) In the preovulatory phase, serum inhibin may be one of applicable indexes of follicular development during the hyperstimulation cycle.

Gamete intrafallopian transfer: benefits of programmed stimulation.

Fifty-six cycles of gamete intrafallopian transfer (GIFT) were performed after programming by administration of norethisterone in the previous cycle. Ovarian hyperstimulation was achieved with clomifene citrate and human menopausal gonadotropins. Only one GIFT was performed during a weekend (1.8%). The implantation rate was 41.1% and the evolutive pregnancy rate 30.4%. The endocrinological influence of these regimens are discussed by comparison of those observed in an in vitro fertilization program. The main influence is a decreased serum luteinizing hormone (LH) level in the preovulatory phase.

Nonhysteroscopic falloposcopy: a proposed method for visual guidance and verification of tubal cannula placement for endotuboplasty, gamete and embryo transfer procedures.

A simplified method for visualization of the uterotubal ostium using a nonhysteroscopic falloposcopic technique has been described. This transvaginal microendoscopic technique is proposed as a realistic method for the visual monitoring of tubal cannula placement for facilitating endotuboplasty, gamete and embryo transfer procedures.