Total fertilization failure and idiopathic subfertility.

BACKGROUND: To gain more insight in whether failure of intrauterine insemination (IUI) treatment in patients with idiopathic subfertility could be related to diminished fertilization, the aim of this study is to compare the fertilization of an initial IVF procedure after six cycles of IUI and the fertilization of an initial IVF procedure without preceding IUI cycles in couples with idiopathic subfertility. METHODS: We performed a complimentary analysis of a randomized controlled trial, in which the number of total fertilization failure (TFF) in the first IVF procedure after unsuccessful IUI was compared to those of IVF without preceding IUI in patients with idiopathic subfertility. These patients participated in a previous study that assessed the cost effectiveness of IUI versus IVF in idiopathic subfertility and were randomized to either IUI or IVF treatment. RESULTS: 45 patients underwent IVF after 6 cycles of unsuccessful IUI and 58 patients underwent IVF immediately without preceding IUI. In 7 patients the IVF treatment was cancelled before ovum pick. In the IVF after unsuccessful IUI group TFF was seen in 2 of the 39 patients (5%) versus 7 of the 56 patients (13%) in the immediate IVF group. After correction for confounding factors the TFF rate was not significantly different between the two groups (p = 0.08, OR 7.4; 95% CI: 0.5-14.9). CONCLUSION: Our data showed that TFF and the fertilization rate in the first IVF treatment were not significantly different between couples with idiopathic subfertility undergoing IVF after failure of IUI versus those couples undergoing IVF immediately without prior IUI treatment. Apparently, impaired fertilization does not play a significant role in the success rate of IUI in patients with idiopathic subfertility.

Influence of varicocele embolization on the choice of infertility treatment.

OBJECTIVE: To investigate whether embolization of a varicocele improves semen quality and enables use of less-invasive modes of assisted reproductive technology (ART) in infertile men with a physically palpable varicocele confirmed by phlebography. DESIGN: Retrospective chart review. SETTING: University infertility clinic. PATIENT(S): Fifty patients with varicoceles that were treated with embolization and 11 patients with untreated varicoceles (control group). In both groups the clinical varicoceles had been phlebographically confirmed. INTERVENTION(S): Phlebography and embolization. MAIN OUTCOME MEASURE(S): Semen characteristics and mode of ART before and after treatment. RESULT(S): Median improvements of semen parameters, such as concentration and motility after processing, were significantly greater in the embolization group than in the untreated group. In the embolization group, semen samples improved to levels requiring less-invasive modes of ART in significantly more patients than in the untreated group. Deterioration of semen samples, requiring more invasive techniques, was significantly more frequent in the untreated group than in the embolization group. CONCLUSION(S): Embolization of a varicocele in infertile men significantly improved semen, such that much more often a less-invasive form of ART than was planned before treatment became feasible. Embolization of a varicocele might even prevent further deterioration of semen samples to levels requiring more-invasive ART.

Investigation of the infertile couple: should diagnostic laparoscopy be performed in the infertility work up programme in patients undergoing intrauterine insemination?

Diagnostic laparoscopy is normally the standard procedure performed as the final test in the infertility work up before progressing to infertility treatment. Recently, there has been a growing tendency to bypass diagnostic laparoscopy after a normal hysterosalpingogram and instead to start direct infertility treatment [intrauterine insemination (IUI) or IVF] for indications such as unexplained infertility, male subfertility and cervical hostility. In our clinic, laparoscopy revealed abnormalities that resulted in changed treatment decisions in 25% of the patients who would normally have been scheduled for IUI if laparoscopy had not been performed. The changed treatments mainly concerned surgery for minimal/mild endometriosis and periadnexal adhesions, both performed during the diagnostic laparoscopy. Because the effect of such interventions on the success rate of IUI has never been described, it still remains unclear whether laparoscopy is usefully performed in these cases. Therefore, further prospective studies should be performed to assess whether delaying, or bypassing entirely, diagnostic laparoscopy is more cost effective and if laparoscopic interventions for intra-abdominal abnormalities are effective in terms of higher pregnancy rates after treatment with IUI.