Determinant Factors for Ongoing Pregnancy in Homologous Intrauterine Insemination Cycles - A Prospective Study.

BACKGROUND/AIM: Intrauterine insemination (IUI) is the most common assisted-reproduction treatment. However, it has lower success rate in comparison to other treatments. Therefore, determining factors that contribute to IUI success is of particular interest and this was the purpose of this prospective study. PATIENTS AND METHODS: In this study, only homologous inseminations with fresh semen samples were included. All women received mild ovarian stimulation with clomiphene citrate and gonadotropins. Before IUI, basic semen analysis, evaluation of DNA fragmentation index (DFI), as well as measurement of sperm redox potential, were performed on each semen sample. Semen was processed with density-gradient centrifugation and 500 µl of processed sperm was used for insemination. RESULTS: In 200 cycles, there were 36 pregnancies, six of them ectopic. Cycles with ongoing pregnancies were characterized by younger male and female age and higher number of follicles. Multivariate logistic regression analysis showed that only female age was significantly associated with ongoing pregnancy. DFI was positively correlated with male age and negatively correlated with sperm concentration and progressive motility. Semen redox potential showed a strong negative correlation with sperm concentration and positive correlation with DFI. CONCLUSION: Female age seems to be the most important determinant factor for the achievement of an ongoing pregnancy in homologous IUI cycles with fresh semen.

Double versus single intrauterine insemination (IUI) in stimulated cycles for subfertile couples.

BACKGROUND: In subfertile couples, couples who have tried to conceive for at least one year, intrauterine insemination (IUI) with ovarian hyperstimulation (OH) is one of the treatment modalities that can be offered. When IUI is performed a second IUI in the same cycle might add to the chances of conceiving. In a previous update of this review in 2010 it was shown that double IUI increases pregnancy rates when compared to single IUI. Since 2010, different clinical trials have been published with differing conclusions about whether double IUI increases pregnancy rates compared to single IUI. OBJECTIVES: To determine the effectiveness and safety of double intrauterine insemination (IUI) compared to single IUI in stimulated cycles for subfertile couples. SEARCH METHODS: We searched the Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase and CINAHL in July 2020 and LILACS, Google scholar and Epistemonikos in February 2021, together with reference checking and contact with study authors and experts in the field to identify additional studies. SELECTION CRITERIA: We included randomised controlled, parallel trials of double versus single IUIs in stimulated cycles in subfertile couples. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. MAIN RESULTS: We identified in nine studies involving subfertile women. The evidence was of low quality; the main limitations were unclear risk of bias, inconsistent results for some outcomes and imprecision, due to small trials with imprecise results. We are uncertain whether double IUI improves live birth rate compared to single IUI (odds ratio (OR) 1.15, 95% confidence interval (CI) 0.71 to 1.88; I2 = 29%; studies = 3, participants = 468; low quality evidence). The evidence suggests that if the chance of live birth following single IUI is 16%, the chance of live birth following double IUI would be between 12% and 27%. Performing a sensitivity analysis restricted to only randomised controlled trials (RCTs) with low risk of selection bias showed similar results. We are uncertain whether double IUI reduces miscarriage rate compared to single IUI (OR 1.78, 95% CI 0.98 to 3.24; I2 = 0%; studies = 6, participants = 2363; low quality evidence). The evidence suggests that chance of miscarriage following single IUI is 1.5% and the chance following double IUI would be between 1.5% and 5%. The reported clinical pregnancy rate per woman randomised may increase with double IUI group (OR 1.51, 95% CI 1.23 to 1.86; I2 = 34%; studies = 9, participants = 2716; low quality evidence). This result should be interpreted with caution due to the low quality of the evidence and the moderate inconsistency. The evidence suggests that the chance of a pregnancy following single IUI is 14% and the chance following double IUI would be between 16% and 23%. We are uncertain whether double IUI affects multiple pregnancy rate compared to single IUI (OR 2.04, 95% CI 0.91 to 4.56; I2 = 8%; studies = 5; participants = 2203; low quality evidence). The evidence suggests that chance of multiple pregnancy following single IUI is 0.7% and the chance following double IUI would be between 0.85% and 3.7%. We are uncertain whether double IUI has an effect on ectopic pregnancy rate compared to single IUI (OR 1.22, 95% CI 0.35 to 4.28; I2 = 0%; studies = 4, participants = 1048; low quality evidence). The evidence suggests that the chance of an ectopic pregnancy following single IUI is 0.8% and the chance following double IUI would be between 0.3% and 3.2%. AUTHORS' CONCLUSIONS: Our main analysis, of which the evidence is low quality, shows that we are uncertain if double IUI improves live birth and reduces miscarriage compared to single IUI. Our sensitivity analysis restricted to studies of low risk of selection bias for both outcomes is consistent with the main analysis. Clinical pregnancy rate may increase in the double IUI group, but this should be interpreted with caution due to the low quality evidence. We are uncertain whether double IUI has an effect on multiple pregnancy rate and ectopic pregnancy rate compared to single IUI.

Donor IUI is equally effective for heterosexual couples, single women and lesbians, but autologous IUI does worse.

STUDY QUESTION: Are there differences in the clinical outcomes of IUI among different populational groups (heterosexual couples, single women and lesbian couples)? SUMMARY ANSWER: The outcome of donor IUI (D-IUI) is similar in all populational groups and better than that seen with autologous insemination. WHAT IS KNOWN ALREADY: A vast body of literature on clinical outcome is available for counselling heterosexual couples regarding decisions related to ART. The reproductive potential of single women, lesbian couples and heterosexual couples who need donor semen is assumed to be better, but there is a scarcity of data on their ART performance to actually confirm it. STUDY DESIGN, SIZE, DURATION: In this retrospective multicentric cohort study, a total of 7228 IUI treatment cycles performed in 3807 patients between January 2013 and December 2016 in 13 private clinics belonging to the same reproductive medicine group in Spain were included. Patients with previous IUI attempts were excluded from the study. Only 1.9% of cycles were lost to follow-up. PARTICIPANTS/MATERIALS, SETTING, METHODS: A total of 5318 D-IUI cycles were performed in three different populational groups: heterosexual couples (D-HC, 1167 cycles), single women (SW, 2839 cycles) and lesbian couples (LC, 1312), while a total of 1910 autologous IUI cycles were performed in heterosexual couples (A-HC). This last one was considered the control group and was composed of cycles performed in couples with a male partner with sperm parameters equivalent to those requested from donors. In order to identify factors with an impact on clinical outcome, a multivariate logistic regression analysis was performed. Regarding live birth rate (LBR), mixed effect models were employed to control for the fact that different patients were submitted to different numbers of treatments. MAIN RESULTS AND THE ROLE OF CHANCE: Parameters that were significant to the primary outcome (LBR) according to the multivariate analysis were the populational group (D-HC, SW, LC and A-HC) to which the patient belonged, female age and a diagnosis of low ovarian reserve. At the age range of good prognosis (≤37 years), LBR was similar in all groups that underwent D-IUI (18.8% for D-HC, 16.5% for SW and 17.6% for LC) but was significantly lower in the autologous IUI (A-HC) group (11%). For all these significant findings, the strength of the association was confirmed by P values <0.001. From 38 years of age on, no significant differences were observed among the populational groups studied, and for all of them, LBR was below 7% from 40 years of age on. LIMITATIONS, REASONS FOR CAUTION: To the best of our knowledge, a smoking habit was the only known factor with a potential effect on ART outcome that could not be controlled for, due to the unavailability of this information in a significant percentage of the clinical files studied. Our study was not capable of precisely quantifying the impact of a diagnosis of low ovarian reserve on the LBR of both IUI and D-IUI, due to the number of cycles performed in patients with such diagnosis (n = 231, 3.2% of the total). WIDER IMPLICATIONS OF THE FINDINGS: For the first time, a comparison among D-HC, SW, LC and A-HC was performed in a study with a robust sample size and controlling for potential sources of bias. There is now sound evidence that equivalent clinical outcome is seen in the three groups treated with donor semen (D-HC, SW and LC). Specifically, regarding the comparison between SW and LC, our findings rule out differences in LBR proposed by previous publications, with very similar clinical outcomes within the same age ranges. At age ranges of good prognosis (≤37 years), reproductive performance of D-IUI is significantly better than that seen in heterosexual couples undergoing autologous IUI, even when only cases of optimal sperm quality are considered in this last group. This finding is in agreement with the concept that, as a group, A-HC are more prone to have female factor infertility, even when their infertility assessment finds no contraindication to IUI. Age affects all these groups equally, with none of them reaching a 7% LBR after the age of 40 years. Our findings will be useful for the counselling of patients from the different populations studied here about ART strategies. STUDY FUNDING/COMPETING INTEREST(S): None.

Comparison of microfluid sperm sorting chip and density gradient methods for use in intrauterine insemination cycles.

OBJECTIVE: To compare the effect of microfluiding sperm sorting chip and density gradient methods on ongoing pregnancy rates (PRs) of patients undergoing IUI. DESIGN: Retrospective cohort study. SETTING: Hospital IVF unit. PATIENT(S): Couples with infertility undergoing IUI cycles between 2017 and 2018. INTERVENTION(S): Not applicable. MAIN OUTCOME MEASURE(S): Ongoing PRs. RESULT(S): A total of 265 patients were included in the study. Microfluid sperm sorting and density gradient were used to prepare sperm in 133 and 132 patients, respectively. Baseline spermiogram parameters, including volume, concentration, motility, and morphology, were similar between the two groups. Total motile sperm count was lower in the microfluiding sperm sorting group at baseline (35.96 ± 37.69 vs. 70.66 ± 61.65). After sperm preparation sperm motility was higher in the microfluid group (96.34 ± 7.29 vs. 84.42 ± 10.87). Pregnancy rates were 18.04% in the microfluid group and 15.15% in the density gradient group, and ongoing PRs were 15.03% and 9.09%, respectively. After using multivariable logistic regression and controling for confounding factors, there was a significant increase in ongoing PRs in the microfluid sperm sorting group. The adjusted odds ratio for ongoing pregnancy in the microfluid group compared with the density gradient group was 3.49 (95% confidence interval 1.12-10.89). CONCLUSION(S): The microfluid sperm sorting method significantly increased the ongoing PRs compared with the density gradient group in IUI cycles.

Follicle stimulating hormone or clomiphene citrate in intrauterine insemination with ovarian stimulation for unexplained subfertility: a role for treatment selection markers?

RESEARCH QUESTION: Can women be identified, on the basis of baseline patient characteristics, as having better chances of an ongoing pregnancy with FSH instead of clomiphene citrate as stimulation agent in intrauterine insemination for unexplained subfertility? DESIGN: A secondary analysis of a multicentre randomized controlled superiority trial; the SUPER study. Between July 2013 and March 2016, couples with unexplained subfertility undergoing intrauterine inemination (IUI) were allocated to an FSH or clomiphene citrate group. Female age, body mass index, duration of subfertility, primary versus secondary subfertility, antral follicle count and total motile count were assessed. For each of these factors, a logistic regression model was developed to assess if different estimated effects of FSH versus clomiphene citrate on ongoing pregnancy occurred within strata of each factor. RESULTS: A total of 684 couples received 2259 IUI cycles; 338 couples were allocated to FSH, of which 84 conceived leading to ongoing pregnancy and 346 couples were allocated to clomiphene citrate, of which 71 conceived leading to ongoing pregnancy. None of the treatment selection markers was associated with better ongoing pregnancy chances after IUI with FSH compared with clomiphene citrate. CONCLUSION: In couples with unexplained subfertility undergoing IUI, no baseline treatment selection markers could be identified to determine whether ovaries should be stimulated with FSH or clomiphene citrate.

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

STUDY QUESTION: Does starting IUI with ovarian stimulation (IUI-OS) within 1.5 years after completion of the fertility workup increase ongoing pregnancy rates compared to expectant management in couples with unexplained subfertility? SUMMARY ANSWER: IUI-OS is associated with higher chances of ongoing pregnancy compared to expectant management in unexplained subfertile couples, specifically those with poor prognoses of natural conception, i.e. <15% over 6 months or <25% over 1 year. WHAT IS KNOWN ALREADY: IUI-OS is often the first-line treatment for couples with unexplained subfertility. Two randomized controlled trials compared IUI-OS to expectant management using different thresholds for the prognosis of natural conception as inclusion criteria and found conflicting results. A cohort of couples with unexplained subfertility exposed to expectant management and IUI-OS offers an opportunity to determine the chances of conception after both strategies and to evaluate whether the effect of IUI-OS depends on a couple's prognosis of natural conception. STUDY DESIGN, SIZE, DURATION: A prospective cohort study on couples with unexplained or mild male subfertility who could start IUI-OS at any point after completion of the fertility workup, recruited in seven Dutch centres between January 2002 and February 2004. Decisions regarding treatment were subject to local protocols, the judgement of the clinician and the wishes of the couple. Couples with bilateral tubal occlusion, anovulation or a total motile sperm count <1 × 106 were excluded. Follow up was censored at the start of IVF, after the last IUI cycle or at last contact and truncated at a maximum of 1.5 years after the fertility workup. PARTICIPANTS/MATERIALS, SETTING, METHODS: The endpoint was time to conception leading to an ongoing pregnancy. We used the sequential Cox approach comparing in each month ongoing pregnancy rates over the next 6 months of couples who started IUI-OS to couples who did not. We calculated the prognosis of natural conception for individual couples, updated this over consecutive failed cycles and evaluated whether prognosis modified the effect of starting IUI-OS. We corrected for known predictors of conception using inverse probability weighting. MAIN RESULTS AND THE ROLE OF CHANCE: Data from 1896 couples were available. There were 800 couples whom had at least one IUI-OS cycle within 1.5 years post fertility workup of whom 142 couples conceived (rate: 0.50 per couple per year, median follow up 4 months). The median period between fertility workup completion and starting IUI-OS was 6.5 months. Out of 1096 untreated couples, 386 conceived naturally (rate: 0.31 per couple per year, median follow up 7 months). Starting IUI-OS was associated with a higher chance of ongoing pregnancy by a pooled, overall hazard ratio of 1.96 (95% CI: 1.47-2.62) compared to expectant management. The effect of treatment was modified by a couple's prognosis of achieving natural conception (P = 0.01), with poorer prognoses or additional failed natural cycles being associated with a stronger effect of treatment. The predicted 6-month ongoing pregnancy rate for a couple with a prognosis of 25% at completion of the fertility workup over the next six cycles (~40% over 1 year) was 25% (95% CI: 21-28%) for expectant management and 24% (95% CI: 9-36%) when starting IUI-OS directly. For a couple with a prognosis of 15% (25% over 1 year), these predicted rates were 17% (95% CI: 15-19%) for expectant management and 24% (95% CI: 15-32%) for starting IUI-OS. LIMITATIONS, REASONS FOR CAUTION: The effect estimates are based on a prospective cohort followed up for 1.5 years after completion of the fertility workup. Although we balanced the known predictors of conception between treated and untreated couples using inverse probability weighting, observational data may be subject to residual confounding. The results need to be confirmed in external datasets. WIDER IMPLICATIONS OF THE FINDINGS: These results explain the discrepancies between previous trials that compared IUI-OS to expectant management, but further studies are required to establish the threshold at which IUI-OS is (cost-)effective. STUDY FUNDING/COMPETING INTEREST(S): This study was facilitated by (Grant 945/12/002) from ZonMW, The Netherlands Organization for Health Research and Development, The Hague, The Netherlands. B.W.M. is supported by a NHMRC Practitioner Fellowship (GNT1082548). B.W.M. reports consultancy for ObsEva, Merck and Guerbet. S.B. reports acting as Editor-in-Chief of HROpen. The other authors have no conflicts of interest.

Effect of time intervals from the end of sperm collection to intrauterine insemination on the pregnancy rates in controlled ovarian hyperstimulation-intrauterine insemination cycles.

OBJECTIVE: To analyze the effect of time intervals from the end of sperm collection to IUI on the pregnancy rates in couples who treated by COH-IUI cycles with gonadotropin due to unexplained infertility. METHODS: 556 couples who underwent the first COH-IUI treatment with gonadotopin due to unexplained infertility were included. Semen samples were obtained by masturbation in a private room near the laboratory on the day of insemination. For each semen samples, time between the delivery time to the laboratory and starting time of sperm washing procedure was noted as semen collection to sperm washing (SC-SW) interval, the time between the starting time of sperm washing procedure and insemination time was noted as sperm washing to insemination (SW-IUI) interval and the time between the delivery time to the laboratory and insemination was noted as semen collection to insemination (SC-IUI) interval. Clinical pregnancy was defined as positive pregnancy test followed by the presence of an intrauterine gestational sac with fetal cardiac activity by transvaginal ultrasonography at least 4 weeks after IUI. RESULTS: Among 556 couples, there were 84 cases of succesful clinical pregnancy and pregnancy rate was calculated as 15.1%. Intervals from SW to IUI and SC to IUI were significantly shorter in pregnant women than in non-pregnant (p<0.001 and p=0.007, respectively). SW performed ≤40min after SC resulted in higher clinical pregnancy rates than did SW performed >40min after SC (19.1% vs. 6.3%, respectively) (p<0.001). IUI performed ≤60min after the end of SW had higher pregnancy rates (16.9%) compared to IUI performed >60min after the end of SW (4.0%) (p=0.017). Likewise, IUI performed ≤90min after SC resulted in higher pregnancy rates than did IUI performed >90min after SC (18.9% vs. 12.0%, respectively) (p=0.029). CONCLUSION: IUI outcome is enhanced by shorter intervals from SC to SW, from SW to IUI, and from SC to IUI in gonadotropin-IUI cycles for unexplained infertile couples.

Optimization of laboratory procedures for intrauterine insemination: survey of methods in relation to clinical outcome.

BACKGROUND: There is a wide practice variation of used methods and outcomes in IUI in fertility laboratories. Standardization of the IUI procedure is important for reducing inconsistency among laboratories in counseling infertile couples and in pregnancy results. The aim of the study was to evaluate the currently used laboratory procedures of IUI in Dutch fertility laboratories and their effect on IUI pregnancy results. Additionally, the methods for semen analysis (SA) were evaluated, as SA is related to IUI in terms of inseminated sperm number and IUI counseling. MATERIAL AND METHODS: This questionnaire survey study was sent to laboratories participating in the Dutch external quality control program for semen analysis (SKML) and consisted of 46 questions concerning laboratory management, methods for semen analysis and IUI, and clinical results. The results were analyzed using univariable and multivariable logistic regression models. RESULTS: A total of 52 laboratories (out of 99) provided information on used methodologies for SA or laboratory procedures of IUI and the organization of the laboratory. A wide variability was confirmed in used methods for both SA and IUI. Evaluation of pregnancy results obtained during 3 years (2013-2015) showed that specific used laboratory methods have a significant effect on the probability of becoming pregnant. DISCUSSION AND CONCLUSION: Important to remark is that in this survey study cycle-specific data, including variables of the individual couples (age, stimulation protocol, etc), were not included and may have effects on the results. The reported results provide an overview of the current practice performance; however, the organization of fertility laboratories is changing rapidly. The use of standardized methods in IUI is important for optimizing the performance of care and improving pregnancy results. The knowledge on used procedures, however, is limited, and further research on factors involving SA and the IUI procedure is necessary.

The SUPER study: protocol for a randomised controlled trial comparing follicle-stimulating hormone and clomiphene citrate for ovarian stimulation in intrauterine insemination.

OBJECTIVE: To study the effectiveness of four cycles of intrauterine insemination (IUI) with ovarian stimulation (OS) by follicle-stimulating hormone (FSH) or by clomiphene citrate (CC), and adherence to strict cancellation criteria. SETTING: Randomised controlled trial among 22 secondary and tertiary fertility clinics in the Netherlands. PARTICIPANTS: 732 women from couples diagnosed with unexplained or mild male subfertility and an unfavourable prognosis according to the model of Hunault of natural conception. INTERVENTIONS: Four cycles of IUI-OS within a time horizon of 6 months comparing FSH 75 IU with CC 100 mg. The primary outcome is ongoing pregnancy conceived within 6 months after randomisation, defined as a positive heartbeat at 12 weeks of gestation. Secondary outcomes are cancellation rates, number of cycles with a monofollicular or with multifollicular growth, number of follicles >14 mm at the time of ovulation triggering, time to ongoing pregnancy, clinical pregnancy, miscarriage, live birth and multiple pregnancy. We will also assess if biomarkers such as female age, body mass index, smoking status, antral follicle count and endometrial aspect and thickness can be used as treatment selection markers. ETHICS AND DISSEMINATION: The study has been approved by the Medical Ethical Committee of the Academic Medical Centre and from the Dutch Central Committee on Research involving Human Subjects (CCMO NL 43131-018-13). Results will be disseminated through peer-reviewed publications and presentations at international scientific meetings. TRIAL REGISTRATION NUMBER: NTR4057.

The correlation of the degree of abnormal sperm morphology using strict criteria and pregnancy rates following intrauterine insemination (IUI).

OBJECTIVE: To determine the effect of extremely low sperm morphology on pregnancy rates following intrauterine insemination (IUI) where all other semen parameters were normal. MATERIALS AND METHODS: Retrospective review of all IUI cycles over a two-year period on infertile women age ≤ 35 where all parameters, but morphology had to be normal. The data were evaluated according to seven levels of percentage of normal morphology (NM): 0, 1, 2, 3, 4, 5, and ≥ 6%. RESULTS: The percent live delivery was 9.5, 16.7, 8.8, 16.1, 11.4, 12.3, and 10.9%. CONCLUSIONS: Morphology of 0% or 1% did not seem to impair pregnancy rates following IUI. More studies are needed but should include determining the confounding effect of the type of morphologic abnormality.

Replacing IUI with IVF for initial treatment of unexplained infertility: why this NICE recommendation is cause for concern.

The latest guidelines from the National Institute for Health and Care Excellence (NICE) for assisted conception recommend that people experiencing unexplained infertility should no longer be offered stimulated intra-uterine insemination (IUI) as a first-line treatment, but rather be directed towards IVF or alternatively be left to expectant management. NICE has acknowledged that the cited evidence leading to this decision was not sufficiently robust. As such, we are concerned that accordance with these new NICE guidelines may result in people with no identifiable cause of their infertility being prematurely referred for IVF treatment. Since IVF constitutes a more invasive and expensive treatment process, which also represents an additional and unnecessary cost pressure to the National Health Service, there is a longstanding need for a robust clinical trial to resolve the uncertainty as to whether one treatment is more appropriate than another. Until such data is available, we suggest that provision of stimulated IUI, in centres achieving a satisfactory live birth rate, represents a significant cost-saving to those commissioning fertility services, with lower risks to people treated.

Comparison of pregnancy rates in pre-treatment male infertility and low total motile sperm count at insemination.

PURPOSE: In intrauterine insemination (IUI), total motile sperm count (TMSC) is an important predictor of pregnancy. However, the clinical significance of a poor TMSC on the day of IUI in a patient with prior normal semen analysis (SA) is unclear. We performed this study to determine if these patients perform as poorly as those who had male factor infertility diagnosed prior to commencing treatment. METHODS: 147 males with two abnormal SA based on the 2010 World Health Organization criteria underwent 356 IUI with controlled ovarian hyper-stimulation (COH). Their pregnancy rates were compared to 120 males who had abnormal TMSC at the time of 265 IUI with COH, in a retrospective university-based study. RESULTS: The two groups were comparable in female age (p = 0.11), duration of infertility (p = 0.17), previous pregnancies (p = 0.13), female basal serum FSH level (p = 0.54) and number of mature follicles on the day of ovulation trigger (p = 0.27). Despite better semen parameters on the day of IUI in the pre-treatment male factor infertility group (TMSC mean ± SD: 61 ± 30 million vs. 3.5 ± 2 million, p < 0.001), pregnancy rates were much higher in the group with low TMSC on the day of IUI (5 % vs. 17 %, p < 0.001). CONCLUSION: A patient with a recent (within 6 months) normal pre-treatment SA but low TMSC on the day of IUI likely has a reasonable chance to achieve pregnancy, and does not perform as poorly as subjects previously diagnosed with male factor infertility. More studies should be performed to confirm these findings.

Treatment of Infertility in Men with Post-traumatic Stress Disorder (PTSD) with the Method of Intrauterine Insemination.

OBJECTIVE: Our objective was to determine the effect of PTSD on changing the quality of sperm in veterans with PTSD, and the percentage of successful procedures intrauterine insemination (IUI) as a first-line treatment of male infertility patients with post-traumatic stress disorder (PTSD). PATIENTS AND METHODS: The study is designed as a prospective observational study. The study was started from February 2013 until May of 2014. Our study included a total of 51 patients who were treatment for infertility in private Hospital for gynecology, endocrinology and infertility, IVF Center in Peja, and those who were outpatients treated for chronic PTSD in the Polyclinic, Biolab-Zafi, in Klina the Republic of Kosovo. All subjects divide into two groups; The first, consisting of 21 respondents to the participants of the war in Kosovo, which was established diagnosis of PTSD. The second group of 30 who have not lived in Kosovo for the time War, and without signs of PTSD. RESULTS: Subjects with PTSD were somewhat older than the control group (p = 0.235) but it was not a significant difference (44.5 ± 5.6 vs 43.8 ± 2.3). When the question of type of infertility, secondary infertility is significantly higher in patients with PTSD (62% vs 20%). The total number of sperm and semen volume no significant differences between the two groups (p > 0.05). Sperm motility showed a significant reduction in cases of PTSD (p <0.0001), from observation semen parameters were found more abnormal forms of spermatozoa in the ejaculate cases with PSD (p < 0.0001) (Table 2). The percentage of pregnancies IUI procedure was slightly higher in patients with PTSD than the control group without PTSD (19% vs. 16.6%). CONCLUSION: A combination of analytical oriented psychotherapy techniques and assisted reproductive techniques (ART) such as IUI procedures, increases the chances for healing infertility in patients with PTSD.

Treatment of Infertility in Men with Post-traumatic Stress Disorder (PTSD) with the Method of Intrauterine Insemination.

OBJECTIVE: Our objective was to determine the effect of PTSD on changing the quality of sperm in veterans with PTSD, and the percentage of successful procedures intrauterine insemination (IUI) as a first-line treatment of male infertility patients with post-traumatic stress disorder (PTSD). PATIENTS AND METHODS: The study is designed as a prospective observational study. The study was started from February 2013 until May of 2014. Our study included a total of 51 patients who were treatment for infertility in private Hospital for gynecology, endocrinology and infertility, IVF Center in Peja, and those who were outpatients treated for chronic PTSD in the Polyclinic, Biolab-Zafi, in Klina the Republic of Kosovo. All subjects divide into two groups; The first, consisting of 21 respondents to the participants of the war in Kosovo, which was established diagnosis of PTSD. The second group of 30 who have not lived in Kosovo for the time War, and without signs of PTSD. RESULTS: Subjects with PTSD were somewhat older than the control group (p = 0.235) but it was not a significant difference (44.5 ± 5.6 vs 43.8 ± 2.3). When the question of type of infertility, secondary infertility is significantly higher in patients with PTSD (62% vs 20%) (Table 2). The total number of sperm and semen volume no significant differences between the two groups (p > 0.05). Sperm motility showed a significant reduction in cases of PTSD (p <0.0001), from observation semen parameters were found more abnormal forms of spermatozoa in the ejaculate cases with PTSD (p < 0.0001) (Table 2). The percentage of pregnancies IUI procedure was slightly higher in patients with PTSD than the control group without PTSD (19% vs. 16.6%). CONCLUSION: A combination of analytical oriented psychotherapy techniques and assisted reproductive techniques (ART) such as IUI procedures, increases the chances for healing infertility in patients with PTSD.

Evaluating non-disclosure of errors and healthcare organization: a case of bioethics consultation.

Sometimes medical errors should not be disclosed. We report a case of semen samples exchange, during a homologous artificial insemination procedure, where a bioethics consultation was required. The bioethics consultation addressed ethical and legal elements in play, supporting non-disclosure to some of the subjects involved. Through a proper methodology, gathering factual and juridical elements, a consultant can show when a moral dilemma between values and rights-privacy versus fatherhood, in our case-is unsubstantial, in a given context, because of the groundlessness of the value or the right itself. However, being the error elicited by organizational factors, a broader ethical pronouncement was needed. Under such circumstances, ethical evaluation should engage in a sort of 'ethical-based root-cause analysis', linking ethical principles to quality aims and showing the opportunity to integrate ethical methodology in healthcare management. From this perspective, errors may become an incentive to promote high-quality organizations, attending to the central value of person even through the organizational process.

[Effect of sexual abstinence on pregnancy rates after an intrauterine insemination]. / Efecto de la abstinencia sexual en las tasas de embarazo posterior a inseminación intrauterine.

BACKGROUND: There are many studies showing that more days of sexual abstinence increased sperm concentration, however, the direct influence between the days of abstinence and pregnancy rates has not been evaluated. The usual recommendation is 3-4 days prior to intrauterine insemination; this based on the interval that maximizes the number of motile sperm in the ejaculate. There are some reports with better success rate when abstinence is less than three days. OBJECTIVE: To evaluate the pregnancy rate post-intrauterine insemination according to days of sexual abstinence prior to obtaining semen sample. PATIENTS AND METHODS: A retrospective, observational and transversal study in patients attending the Mexican Center for Fertility (CEPAM) to intrauterine insemination. For analysis patients were grouped by age group, success rate and days of sexual abstinence. Continuous variables are reported as means and standard deviations; to determine statistical significance univariate logistic regression was performed. Categorical variables were evaluated in frequencies and percentages. The calculations were performed using JMP software program. RESULTS: 3,123 couples were included and increased success rate for intrauterine insemination was obtained with less than seven days of sexual abstinence. The rate of sperm retrieval is inversely proportional to the days of abstinence. CONCLUSION: A better pregnancy rate in intrauterine insemination was achieved with less than seven days of sexual abstinence and sperm retrieval rate was also recorded with fewer days of abstinence.

Recombinant FSH increases live birth rates as compared to clomiphene citrate in intrauterine insemination cycles in couples with subfertility: a prospective randomized study.

OBJECTIVE: To compare the efficacy of intrauterine insemination (IUI) cycles undergoing ovarian hyperstimulation with recombinant FSH (rFSH) or clomiphene citrate (CC) in couples with unexplained and male subfertility. STUDY DESIGN: Two hundred and nineteen subfertile couples were enrolled in this randomized prospective study. Patients were randomly assigned to receive 75IU rFSH or 100mg CC for two cycles. Cycles with more than four dominant follicles and/or serum E2 levels higher than 1500pg/ml were cancelled. Primary outcomes were live birth rates per patient and per cycle, secondary outcomes were clinical and multiple pregnancy rates. RESULTS: One hundred and nine women received rFSH and 110 received CC. Both cumulative clinical pregnancy and live birth rates per patient were significantly higher in gonadotropin group (43.1% and 37.6%) as compared to CC group (28.2% and 20%) (p<0.05 and p<0.01, respectively). Live birth rate per cycle were significantly higher in gonadotropin group (24.3%) in comparison with CC group (13.8%) (p<0.05). However, clinical pregnancy rate per cycle was not different between groups (28.4% vs 20%) (p>0.05). There was no significant difference between gonadotropin and CC group groups in terms of multiple pregnancy rates (10.4% vs 12.5%, p>0.05). Continuous variables were compared with Student's t test. Categorical variables were compared with Chi square test. CONCLUSION: rFSH has significantly higher cumulative clinical pregnancy and live birth rates when compared to CC with similar multiple pregnancy rates in subfertile patients undergoing IUI.

Failure of intrauterine insemination as rescue treatment in low responders with adequate HCG timing with no oocytes retrieved.

In this retrospective study, the efficiency of carrying out rescue intrauterine insemination (IUI) in low-responder patients undergoing IVF when no oocytes were retrieved after follicular aspiration and when HCG timing was adequate was analysed. A historical control group was used. Over 13 years, women undergoing IVF with failure to obtain oocytes at follicular aspiration underwent rescue IUI if the following criteria were met: adequate HCG timing; one normal tube; motile sperm count after preparation over 3 million/ml; and ultrasound visualization of one to six follicles over 13 mm. The rescue IUI was carried out 1 h after follicular aspiration. Results were compared with those of a standard IUI population (5394 cycles) in the same period. Confidence intervals were calculated using Poisson 97.5% confidence upper tail limits when no event was observed in the study sample. No pregnancies were achieved among the 54 cases who underwent rescue IUI (confidence interval: 0 to 6.8%). This pregnancy rate was lower than that observed in the general IUI population (17.5%) (relative risk, 19.2). After adjusting for age and endometriosis, the relative risk was 11.7. The rescue IUI is an inefficient procedure. Its efficacy is unlikely to exceed 7% pregnancy rate per IUI.

The evaluation of pre and post processing semen analysis parameters at the time of intrauterine insemination in couples diagnosed with male factor infertility and pregnancy rates based on stimulation agent. A retrospective cohort study.

OBJECTIVE: To identify pre or post processing semen analysis parameters that may be predictive of successful pregnancy in couples with male factor infertility undergoing intra uterine insemination (IUI). To evaluate the pregnancy rate based on ovulation inducing agent in couples with male factor infertility per the 2010 world health organization criteria treated with IUI. STUDY DESIGN: This retrospective study was performed at Stanford University medical center. All couples with male factor infertility fitting inclusion criteria were included over a 2 year period of time. 147 couples with male factor infertility were included and 356 IUIs were analyzed. All subjects in this study had Kruger strict analysis >4% normal forms. Logistic regression analysis was used to control for confounding effects and multiplicity. RESULTS: The overall pregnancy rate was 5.3%. No parameter in either the pre or post analysis predicted pregnancy. Furthermore, it was found that natural cycle and letrazole treatment had similar pregnancy rates (3% and 3%) p=ns. Similar outcomes were also observed between clomiphene citrate and gonadotropin stimulated cycles (7.5% and 6.0%) p=ns. CONCLUSIONS: Total motile sperm count which has been found to be a predictor of pregnancy when evaluated in isolation, may be due to a confounding effect. These low pregnancy rates should be considered when deciding whether to suggest IUI and when selecting a protocol for ovulation induction for couples with male factor infertility.