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COMPARISON BETWEEN INTRAUTERINE
INSEMINATION WITH OVULATION INDUCTION VERSUS
NATURAL OVULATORY CYCLE IN MALE FACTOR OF
INFERTILITY
Thesis
Submitted to the Faculty of Medicine
Alexandria University
In partial fulfillment of the requirements of the degree of
Master
of
Obstetrics and Gynecology
ByMohammed Ahmed Abd El Aty Abou El Maaty Azab
MBBCh, Alex.Resident El-Shatby Maternity University Hospital
Department of Obstetricsand Gynecology
Faculty of Medicine
Alexandria University
2013
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COMPARISON BETWEEN INTRAUTERINE
INSEMINATION WITH OVULATION INDUCTION VERSUS
NATURAL OVULATORY CYCLE IN MALE FACTOR OF
INFERTILITY
Presented by
Mohammed Ahmed Abd El Aty Abou El Maaty Azab
MBBCH. Alex
for the Degree of
Master
in
Obstetrics and Gynecology
Examiners committee Approved
Prof. Dr. . Emad Abd El Meniem Darwish
Professor of Obstetrics and Gynecology,
Faculty of Medicine
University of Alexandria
.........................................
Prof. Dr. Mohammed Salah El Din AbdRabbo
Professor of Obstetrics and Gynecology,
Faculty of MedicineUniversity of Alexandria
.........................................
Prof. Dr. Mostafa Abd El Khalik Abd Allah
Atya
Professor of Obstetrics and Gynecology,Faculty of Medicine
University of Sohag.
.........................................
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SUPERVISORS
Prof. Dr. . Emad Abd El Meniem Darwish ..
Professor of Obstetrics and Gynecology,
Faculty of Medicine,
University of Alexandria.
Dr. Yasser Saad El-Kassar
Lecturer of Obstetrics and Gynecology,
Faculty of Medicine,
University of Alexandria.
..
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ACKNOWLEDGEMENTS
I wish to express my sincere gratitude and gratefulness toProf. Dr . Emad
Abd El Meniem Darwish,Professor of Obstetrics and Gynecology, Faculty of
Medicine, University of Alexandria, for his kind supervision and constant
encouragement . In fact, it has been a great honor to work under his
supervision.
I am greatly indebted and appreciating toDr. Yasser Saad El -Kassar, lecturerof Obstetrics and Gynecology, Faculty of Medicine, University of Alexandria.
His useful suggestions, generous help and hard work have made it possible to
complete this work. I find no wards of appreciation for his careful hard work
and help.
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LISTOFCONTENTS
Chapter Page
ACKNOWLEDGMENT ........................................................................... i
LIST OF CONTENT ............................................................................... ii
LIST OF TABLES .................................................................................. iii
LIST OF FIGURES ................................................................................. ii
I. INTRODUCTION ........................................................................ 1
II. AIM OF THE WORK ................................................................ 11
III. PATIENTS ................................................................................... 12
IV. METHODS .................................................................................. 13
V. RESULTS ................................................................................... 14
VI. DISCUSSION : .............................................................................
VII. SUMMARY ................................................................................. 42
VIII. CONCLUSIONS ......................................................................... 44
IX. RECOMMENDATIONS ............................................................ 45
X. REFERENCES ............................................................................ 46
PROTOCOL
ARABIC SUMMARY
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iii
LIST OF TABLES
Table Page
(1) Comparison between the two studied groups according todemographic data.
14
(2) Comparison between the two studied groups according to day3 FSH.
15
(3) Comparison between the two studied groups according tomale age and smoking habit.
16
(4) Comparison between the two studied groups according spermparameters regarding sperm count.
19
(5) Comparison between the two studied groups according tosperm sperm parameters regarding sperm motility by
percentage (%).
21
(6) Comparison between the two studied groups according tosperm morphology.
22
(7) Distribution of the studied cases of group II according tonumber of follicles at day of hCG.
23
(8) Distribution of the studied cases of group II according tonumber of ampoules of HMG used for induction of ovulation.
25
(9) Comparison between the two studied groups according toclinical pregnancy rate.
27
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iv
LIST OF FIGURES
Figure Page
(1) Comparison between the two studied groups according to age. 17(2) Comparison between the two studied groups according to
Duration of infertility17
(3) Comparison between the two studied groups according toBMI.
18
(4) Comparison between the two studied groups according to day3 FSH.
20
(5) Comparison between the two studied groups according tomale age.
21
(6) Comparison between the two studied groups according tosmoking habit..
22
(7) Comparison between the two studied groups according spermcount.
24
(8) Comparison between the two studied groups according tosperm motility by percentage (%).
26
(9) Comparison between the two studied groups according tosperm abnormal forms.
27
(10) Distribution of the studied cases of group II according tonumber of follicles at day of hCG.
28
(11) Distribution of the studied cases of group II according tonumber of ampoules of HMG used for induction of ovulation.
30
(12) Comparison between the two studied groups according toclinical pregnancy rate.
32
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v
LIST OF ABBREVIATION
BMI : Body mass index
HSG : Hystero salpingogram
TSH : Thyrotropin
FSH : Follicle stimulating hormone
PCOS : Polycystic ovary syndrome
LH : leuteinizing hormone
CCCT : clomiphene citrate challenge test
ml : Milli litre
mIU : Milli international unit
pg : Pictogram
IVF : In-vitro Fertilization
mg : Milligram
AFC
AMH
:
:
Antral follicle countAnti-mullerian hormone
TGF-beta
ng
:
:
Tissue growth factor betaNanogram
HyCoSy : hysterosalpingo-contrast sonographyWHOICSI
CC
hCG
hMG
:
:
:
:
:
world health organizationintracytoplasmic sperm injectionClomiphene citrateHuman chorionic gonadotropinHuman menopausal gonadotropin
rFSH : Recombinant follicle stimulating hormone
GnRH
HASHTF
BWW
:
::
:
Gonadotropin releasing hormone
Human serum albumin
Human tubal fluid
Biggers, Whitten and Whittingham
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vi
INTRODUCTION
INFERTILITY
Definition:
Infertility is a unique medical condition because it involves a couple, rather
than a single individual. It is defined as failure of a couple to conceive after
12 months of regular intercourse without use of contraception in women less
than 35 years of age; and after six months of regular intercourse without use
of contraception in women 35 years and older.(1)
Fecundability, the probability of achieving a pregnancy in one menstrual
cycle, is a more accurate descriptor because it recognizes varying degrees of
infertility.
Causes of infertility:
One population-based study reported that26 percent of cases of infertility are
due to male factor (hypogonadism, post-testicular defects, seminiferous tubule
dysfunction) ,21 percent due to ovulatory dysfunction,14 percent due to tubal
damage ,6 percent are due to endometriosis ,6 percent are due to coitalproblems,3 percent are due to cervical factor and 28 percent are unexplained
cause of infertility.(2)
Timing of infertility evaluation:
The general consensus among infertility experts is that infertility evaluation
should be undertaken for couples who have not been able to conceive after 12
months of unprotected and frequent intercourse, but earlier evaluation should
be undertaken based on medical history and physical findings, and in womenover 35 years of age.(3,4) Some authorities have proposed initiating an
infertility work-up after six months of fertility-oriented intercourse without
conception since prospective cohort studies have shown that a significant
decline in fecundity occurs by this time .(5,6,7) The timing of initial evaluation
of infertility depends upon the age of the female partner, as well as the
couple's historical risk factors . Women experience a decline in fecundity as
the ovary ages, especially after age 30. (8) Significantly delaying the
evaluation and treatment of an infertile woman in her mid-thirties may
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diminish the success rate once therapy is initiated. For these reasons, in
women between 35 and 40 years of age, we initiate the infertility evaluation
after six months of frequent unprotected intercourse without conceptionand
we initiate the evaluation after less than six months in women over 40 yearsof age.(4)
Evaluation is also initiated promptly if the female partner has a history of
risk factors for premature ovarian failure (previous extensive ovarian surgery,
exposure to cytotoxic drugs or pelvic radiation therapy, autoimmune disease,
smoking, strong family history of early menopause/premature ovarian failure,
advanced stage endometriosis, or known or suspected uterine/tubal disease .(9)
Male factors can also be indications for initiating early evaluation of the male
partner. These factors include a history of testicular trauma requiring
treatment, adult mumps, impotence or other sexual dysfunction,
chemotherapy and/or radiation, or a history of subfertility with another
partner.(9)
Evaluation of female infertility
History and physical examination.
History :
The most important points in the history are:
Duration of infertility and results of previous evaluation and therapy. Menstrual history (cycle length and characteristics), which helps indetermining ovulatory status. For example, regular monthly cycles withmolimina (breast tenderness, ovulatory pain, bloating) suggest that the patientis ovulatory and characteristics such as severe dysmenorrhea suggest
endometriosis. Medical, surgical, and gynecological history (including sexuallytransmitted infections, pelvic inflammatory disease, and treatment ofabnormal Pap smears) to look for conditions, procedures, or medications
potentially associated with infertility. At a minimum, the review of systemsshould determine whether the patient has symptoms of thyroid disease,galactorrhea, hirsutism, pelvic or abdominal pain, dysmenorrhea, ordyspareunia.
Young women who have undergone unilateral oophorectomy generally do
not have reduced fertility since young women have many primordial follicles
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per ovary; however, prior unilateral oophorectomy may impact fertility in
older women as they may develop diminished ovarian reserve sooner than
women with two ovaries. (10)
Obstetrical history to assess for events potentially associated withsubsequent infertility or adverse outcome in a future pregnancy. Sexual history, including sexual dysfunction and frequency of coitus.Infrequent or ineffective coitus can be an explanation for infertility. Family history, including family members with infertility, birth defects,genetic mutations, or mental retardation. Women with fragile X mutation maydevelop premature ovarian failure, while males may have learning problems,developmental delay, or autistic features. Personal and lifestyle history including age, occupation, exercise,
stress, dieting/changes in weight, smoking, and alcohol use, all of which canaffect fertility.Physical examination:
The physical examination should assess for signs of potential causes of
infertility.
The patient's body mass index (BMI) should be calculated and fatdistribution noted, as extremes of BMI are associated with reduced fertility
and abdominal obesity is associated with insulin resistance. Incomplete development of secondary sexual characteristics is a sign ofhypogonadotropic hypogonadism. A body build that is short and stocky, with a squarely shaped chest,suggests Turner syndrome. Abnormalities of the thyroid gland, galactorrhea, or signs of androgenexcess (hirsutism, acne, male pattern baldness, virilization) suggest the
presence of an endocrinopathy (eg, hyper - or hypothyroidism,hyperprolactinemia, polycystic ovary syndrome, adrenal disorder).
Tenderness or masses in the adnexae or posterior cul-de-sac (pouch ofDouglas) are consistent with chronic pelvic inflammatory disease orendometriosis. Palpable tender nodules in the posterior cul-de-sac, uterosacralligaments, or rectovaginal septum are additional signs of endometriosis. Vaginal and cervical structural abnormalities or discharge suggest the
presence of a mllerian anomaly, infection or cervical factor. Uterine enlargement, irregularity, or lack of mobility are signs of auterine anomaly, leiomyoma, endometriosis, or pelvic adhesive disease.Diagnostic tests:
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In addition to the history and physical examination, the initial diagnostic
evaluation consists of:
Documentation of normal ovulatory function.
Women with regular menses approximately every four weeks with
moliminal symptoms are almost always ovulatory.
A test to rule out tubal occlusion either hystero salpingogram (HSG), but
laparoscopy with chromotubation may be more appropriate in women
suspected of having endometriosis.
Assessment of ovulatory function:In women who do not have grossly abnormal menstrual cycles indicative of
ovulatory dysfunction, laboratory assessment of ovulation should be
performed. Ovulation is most easily documented by a mid-luteal phase serum
progesterone level, which should be obtained approximately one week before
the expected menses. For a typical 28-day cycle, the test would be obtained
on day 21. A progesterone level >3 ng/mL is evidence of recent ovulation .(11)
If the progesterone concentration is
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x
The identification of diminished ovarian reserve is an increasingly important
component of the initial infertility evaluation as patients are presenting for
diagnostic evaluation later in their reproductive life span.
1. Day 3 FSH and CCCT (clomiphene citrate challenge test):we obtain a day 3 FSH concentration and consider that:
A value less than 10 mIU/mL is suggestive of adequate ovarian reserve. levels of 10to 15 mIU/ml are borderline. A level above 15 mIU/ml indicates poor reserve
Cycle day 3 estradiol level also is checked, although there are conflicting
data as to whether it is predictive of ovarian reserve and the response to
ovarian stimulation. (12, 13) We consider a value 80
pg/mL resulted in higher cycle cancellation rates andlower pregnancy rates,
and estradiol levels >100 pg/mL were associated with a 0 percent pregnancy
rate .(14)
If CCCT is performed, we consider FSH less than 15 mIU/mL on both day
3 and day 10 after five days of clomiphene intake suggestive of adequate
ovarian reserve; an elevated FSH level on either day 3 or day 10 suggests
decreased ovarian reserve. Estradiol can be measured on day 3, but a cycle
day 10 estradiol is not part of the standard CCCT as it reflects the magnitude
of the ovarian follicular response to clomiphene 100 mg daily for five days,
not ovarian reserve.
2. Antral follicle count (AFC):
Ultrasound examination can be used to determine the number of antral
follicles (defined as follicles measuring 2 to 10 mm in diameter). On
transvaginal ultrasound, the presence of four to 10 antral follicles between
days two and four of a regular menstrual cycle suggests good ovarian reserve,
whereas a low AFC suggests poor reserve .( 15, 16,17)
3. Anti-mullerian hormone (AMH):
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Anti-mllerian hormone (AMH) is a member of the TGF-beta family and is
expressed by the small (
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Semen analyses Genetic tests Endocrine testing
HISTORY :
The evaluation of an infertile man should begin with a detailed history that
focuses on potential causes of infertility. The clinician should inquire about:
Developmental history, including testicular descent, pubertal development,
loss of body hair, or decrease in shaving frequency .
Chronic medical illness
Infections, such as mumps orchitis, sinopulmonary symptoms, sexually
transmitted infections, and genitourinary tract infections including prostatitisSurgical procedures involving the inguinal and scrotal areas such as
vasectomy, orchiectomy, and herniorrhaphy
Drugs and environmental exposures, including alcohol, radiation therapy,
anabolic steroids, cytotoxic chemotherapy, drugs that cause
hyperprolactinemia, and exposure to toxic chemicals (eg, pesticides,
hormonal disrupters)
Sexual history, including libido, frequency of intercourse, and previous
fertility assessments of the man and his partnerSchool performance, to determine if he has a history of learning disabilities
suggestive of Klinefelter's syndrome
PHYSICAL EXAMINATION :
The physical examination should include a general medical examination
with a focus on finding evidence of androgen deficiency, which may
accompany decreased fertility. The clinical manifestations of androgen
deficiency depend upon the age of onset. Androgen deficiency during earlygestation presents as ambiguous genitalia; in late gestation as micropenis; in
childhood as delayed pubertal development; and in adulthood as decreased
sexual function, infertility, and eventually, loss of secondary sex
characteristics.
The examination of the man should include the following components.
General appearance :
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Eunuchoidal proportions (upper/lower body ratio standing height) suggest androgen deficiency antedating puberty. On the
other hand, increased body fat and decreased
muscle mass suggest current androgen deficiency.Skin:
Loss of pubic, axillary, and facial hair, decreased oiliness of the skin, and
fine facial wrinkling suggest long-standing androgen deficiency.
External genitalia :
Several abnormalities that can affect fertility can be recognized by
examination of the external genitalia:
Incomplete sexual development can be recognized by examining the
phallus and testes and finding a Tanner stage other than 5 Diseases that affect sperm maturation and transport can be detected byexamination of the scrotum for absence of the vas, epididymal thickening,varicocele, and hernia. The presence of a varicocele should be confirmed withthe man standing and performing a Valsalva maneuver. Decreased volume of the seminiferous tubules can be detected bymeasuring testicular size by Prader orchidometer or calipers. The Praderorchidometer consists of a series of plastic ellipsoids with a volume from 1 to35 mL. In an adult man, testicular volume below 15 mL and testicular length
below 3.6 cm are considered small.(25)
Breasts :
Gynecomastia suggests a decreased androgen to estrogen ratio.
STANDARD SEMEN ANALYSIS:The semen analysis is the cornerstone of the assessment of the male partner
of an infertile couple. In addition to the standard analysis, specialized
analyses can be performed in some laboratories. (26)
The standard semen analysis consists of the following:Measurement of semen volume and pH
Microscopy for debris and agglutination
Assessment of sperm concentration, motility, and morphology
Sperm leukocyte count
Search for immature germ cells
WHO lower reference limits :
The World Health Organization (WHO) has published revised lower
reference limits for semen analyses.
(27)
The following parameters represent
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xiv
the generally accepted 5th percentile (lower reference limits and 95%
confidence intervals in parentheses), derived from a study of over 1900 men
whose partners had a time-to-pregnancy of 12 months.(27)
Volume : 1.5 mL (95% CI 1.4-1.7)Sperm concentration : 15 million spermatozoa/mL (95% CI 12-16)
Total sperm number : 39 million spermatozoa per ejaculate (95% CI 33-46)
Morphology : 4 percent normal forms (95% CI 3-4), using "strict" Tygerberg
method. (28)
Vitality : 58 percent live (95% CI 55-63)
Progressive motility : 32 percent (95% CI 31-34)
Total (progressive + non progressive motility) : 40 percent (95% CI 38-42)
Semen volume : The mean semen volume in the WHO study was 3.7 mL; the
lower reference limit was 1.5 mL .(27) A low volume in the presence of
azoospermia (no sperm) or severe oligozoospermia (severely subnormal
sperm concentration) suggests genital tract obstruction (eg, congenital
absence of the vas deferens and seminal vesicles or ejaculatory duct
obstruction). Congenital absence of vas deferens is diagnosed by physical
examination and low semen pH, whereas ejaculatory duct obstruction is
diagnosed by the finding of dilated seminal vesicles on transrectalultrasonography.
Low semen volume with normal sperm concentration is most likely due to
semen collection problems (loss of a portion of the ejaculate) and partial
retrograde ejaculation. Androgen deficiency is also associated with low
semen volume and low sperm concentration. The patient should be asked to
return for a carefully collected repeat semen sample after emptying the
bladder; post-ejaculation urine can be collected to assess whetherthere is retrograde ejaculation .(27)
Sperm concentration : The lower reference limit for sperm concentration is
15 million/mL (95% CI 12-16) .(41) However, some men with sperm counts
considered to be low can be fertile, while others above the lower limit of
normal can be subfertile . (29-31) and, for the purposes of fertilization in vitro,
10 million/mL or even less can be satisfactory .(28)
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If no spermatozoa are seen, the semen should be centrifuged and the pellet
examined for the presence of spermatozoa before the diagnosis of
azoospermia is given. The presence of any sperm in the pellet will allow
intracytoplasmic sperm injection (ICSI) to be performed with ejaculatedspermatozoa instead of sperm collected by testicular aspiration.
Round cells observed in the semen smear may be leukocytes, immature germ
cells or degenerating epithelial cells .(42) Presence of immature germ cells in
the semen usually indicated disorders of spermatogenesis.
Leukocytes can also be seen microscopically and counted with the
hemocytometer. Agglutination suggests autoimmunity, which should be
confirmed by tests for sperm surface antibodies.
Sperm motility: Sperm motility is assessed microscopically and is classified
as progressive motility, non-progressive motility, and immotile spermatozoa.
At least 40 percent of spermatozoa should be motile and at least 32 percent
should have progressive motility. If sperm motility is poor, sperm vitality
should be assessed by supravital stains or the hypoosmotic swelling test to
determine whether the majority of immotile spermatozoa
are dead .(28)
The distinction between living, non-moving sperm, and deadsperm influences the type of assisted reproductive treatment that can be used
for the induction of pregnancy.
Sperm morphology: The criteria for normal morphology were previously
based mainly on shape, as observed microscopically. They now also include
length, width, width ratio, area occupied by the acrosome, and neck and tail
defects. (27, 31)These criteria are called strict criteria and have good
predictive value in terms of fertilization in vitro and pregnancy rates after invitro fertilization (IVF). (31) Based upon these correlations
between "strict criteria" sperm morphology and IVF pregnancy rate, the lower
limit of normal sperm morphology was estimated to be about 4 percent of
spermatozoa. (27,30,31)
Leukocytes: White blood cells, mainly polymorphonuclear leukocytes, are
frequently present in the seminal fluid. Assessment of white blood cells is
usually performed by using the peroxidase stain. The peroxidase
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positive cells are counted using the hemocytometer. (27) Presence of increased
white blood cells in the ejaculate may be a marker of genital
infection/inflammation and may be associated with poor semen quality
because of the release of reactive oxygen species from the leukocytes. Thesuggested cut-off for the diagnosis of a possible infection is one million
leukocytes/mL of ejaculate. However, this cut-off is not evidence-based
. (32)
Hyperviscosity: Hyperviscosity may interfere with the semen analysis, in
particular, evaluation of sperm motility. Hyperviscous samples should be
treated in the laboratory to reduce viscosity by passing the sample via a large
gauge needle, diluting with a physiological solution or use of enzyme
digestion before testing for sperm parameters in the laboratory. Although thecause of hyperviscosity is unclear, it is thought to be due to inflammation of
the genitourinary tract. (33)
GENETIC TESTS : The introduction of ICSI has made it possible for men
with severe oligozoospermia and azoospermia to father children, but the
genetic risks of this highly invasive technique must be considered. These
include the risks of transferring the cystic fibrosis conductance regulator
(CFTR) gene, somatic and sex chromosome abnormalities, andmicrodeletions of the Y chromosome .(34)
ENDOCRINE TESTS: The endocrine assessment of an infertile man
includes measurements of serum testosterone, luteinizing hormone (LH), and
follicle-stimulating hormone (FSH), and other tests if needed: (35)
Serum testosteroneMeasurement of a morning serum total testosterone is
usually sufficient. In men with borderline values, the measurement should be
repeated and measurement of serum free testosterone may be helpful.(35)
Serum LH and FSHWhen the serum testosterone concentration is low,high serum FSH and LH concentrations indicate primary hypogonadism and
values that are low or normal indicate secondary hypogonadism.(35)
Men with low sperm counts and low serum LH concentrations who are well-
androgenized should be suspected of exogenous anabolic or androgenic
steroid abuse. (35)
Other: Serum prolactin should be measured in any man with a low serum
testosterone concentration and normal to low serum LH concentration.(35)
Although inhibin assays are not widely available outside of research
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laboratories, low serum inhibin concentrations may be an even more sensitive
test of primary testicular dysfunction than high serum FSH concentrations,
provided the assay is specific for inhibin B.(36)
OVULATION INDUCTION
Rationale for Inducing Ovulation while carrying out IUI is that ovarian
stimulation has been shown to significantly improve the outcome in IUIcycles. Ovarian stimulation may improve the results of IUI by increasing the
number of eggs available for fertilization and overcoming a subtle defect in
ovulatory function and luteal phase.
Ovarian Stimulation or Induction
Patients requiring ovarian stimulation or induction can be categorized in
two groups.
1. Ovulatory Patients (Ovarian Stimulation):In these patients there is an established ovulatory pattern. Multiple studies
have shown improved pregnancy rates with ovarian stimulation in these
patients as compared to non-stimulated natural cycles. The aim of ovarian
stimulation in ovulatory patients is to bring about multiple follicular
development in order to increase the number of eggs produced & hence the
number of embryos potentially available for implantation.
2. Anovulatory Patients (Ovarian Induction):Ovulatory disorders can be identified in the woman in 18 to 25 percent of
couples presenting with infertility.(2)Anovulatory patients are further divided
by WHO into 3 categories:
Group I: Hypogonadotrophic hypogonadism
Group II: PCOS
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Group III: Ovarian failure
Ovarian stimulation is aimed at achieving monofollicular development.
Drugs used for controlled ovarian hyperstimulation:-
1. Clomiphene Citrate (CC)Mechanism of action:
Hypothalamus and pituitary:
Most evidence suggests that the primary site of clomiphene action is the
hypothalamus, where it appears to bind to hypothalamic estrogen receptors,thereby blocking the negative feedback effect of circulating endogenous
estradiol .(37)
In vitro data suggest that clomiphene citrate also has a pituitary site of
action where it causes an increase in the gonadotropin response to GnRH. (38)
Clomiphene acts primarily as an antiestrogen in the uterus, cervix, and
vagina. The following findings may explain the low pregnancy rates in
clomiphene-induced ovulatory cycles:
The normal increase in uterine volume and endometrial thickening thatoccurs during spontaneous menstrual cycles is largely absent during
clomiphene-induced cycles, despite higher estradiol levels. (39) Abnormal
luteal phase endometrial morphology has been found in some,(40) but not all,(41) studies.
Clomiphene citrate directly impairs implantation efficiency in mice. (42)
Data on the effect of clomiphene on cervical mucus are conflicting. While one
study found no detrimental effect, (43) another noted a decrease in the quality
and quantity of cervical mucus at all clomiphene doses.(44)
In a meta-analysis, a detrimental effect was seen only with doses 100 mg/day.
(45)
Indications:
Clomiphene citrate is the traditional drug of choice for ovulation induction
in anovulatory infertile women with normal thyroid function, normal serum
prolactin levels, and normal endogenous estrogen production, as determined
by clinical observations (oligomenorrhea, estrogenic cervical mucus), a serum
estradiol determination (greater than approximately 40 pg/mL), or a normal
menstrual response to a progestin challenge (WHO Group II).(46)
Although the
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xix
drug also frequently is used empirically to stimulate multi-follicular
development in ovulatory women with unexplained infertility (usually in
combination with IUI),(47)
Clomiphene Treatment Regimens
Clomiphene is administered orally, typically beginning on the third to fifth
day after the onset of a spontaneous or progestin-induced menses.
Treatment usually starts with a single 50 mg tablet daily for a 5-day interval
and, if necessary, increases by 50 mg increments in subsequent cycles until
ovulation is achieved.
Results of Clomiphene Treatment
Clomiphene will induce ovulation successfully in 70-80 percnt; of properly
selected women. (48) Among anovulatory infertile women who respond to
clomiphene treatment, the overall cycle fecundability is approximately 15
percent.
Monitoring of clomiphen treatment:
Detection of ovulation with clomiphene using the same method to detect
anovulation such as mid luteal phase progesterone, LH surge, serial
ultrasonography to detect the development of follicle.
hCG with clomiphen citrate
In anovulatory women who fail to ovulate in response to clomiphene alone,
adjuvant hCG treatment is based on the premise that clomiphene may be
successful in stimulating the emergence of a preovulatory follicle but
ultimately fail to trigger an endogenous LH surge and to induce ovulation.
Serial transvaginal ultrasonography is required to demonstrate the
phenomenon and to ensure that the ovulatory stimulus is delivered at the
appropriate time. If administered blindly and prematurely, before the
dominant follicle is mature enough to respond, hCG is more likely to induce
atresia than ovulation. The question of when to administer hCG presents a
dilemma. Although hCG commonly is administered when the lead follicle
reaches 18-20 mm,(49) clinical studies indicate that the peak preovulatory
follicular diameter in successful clomiphene-induced ovulatory cycles ranges
between 18 and 30 mm (mean 25 mm). (50,51) Considering that the
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preovulatory follicle grows approximately 2 mm per day as it approaches
maturity,(52,53) the corresponding interval may thus span up to 6 days.
Normally, the preovulatory follicle triggers its own ovulatory stimulus at the
peak of maturity by generating and maintaining the estrogen levels that arerequired to induce the LH surge. The timing of the spontaneous LH surge is
therefore always optimal, but that of hCG treatment can never be more than
an educated guess.
Exogenous Gonadotropins
Since their introduction into clinical practice in 1961, gonadotropins
extracted from the urine of postmenopausal women (human menopausalgonadotropins [hMG]), in which the ratio of LH to FSH bioactivity is 1:1,
have assumed a central role in ovulation induction. (54) Refinement of the
initially crude preparation resulted in the availability of purified and highly
purified urinary FSH. Since 1996, recombinant human FSH (rFSH, >99
percent purity) has been available. Recombinant preparations are appealing
due to their ease of administration (subcutaneous rather than intramuscular),
purity, and batch-to-batch consistency.
Indications for Gonadotropin Treatment
1- Hypogonadotropic HypogonadismIn women with hypogonadotropic hypogonadism, the drug of choice is
menotropins because it contains both FSH and LH. luteal phase support with
supplemental hCG (2,000-2,500 IU every 3-4 days) (55) or progesterone
generally is needed to compensate for low levels of endogenous LH secretion
that can prove insufficient to support normal luteal function.2- Clomiphene-Resistant Anovulation:
Exogenous gonadotropins can be used intentionally to stimulate the
development and ovulation of more than one mature ovum in efforts to
increase cycle fecundity in older subfertile women and those with otherwise
unexplained infertility; superovulation is most effective when combined with
timely IUI.
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Luteal support is not required because the combined contributions of two or
more corpora lutea may be reliably expected to yield supraphysiologic luteal
phase serum progesterone concentrations.
Treatment regmines for gonadotropins use in super ovulation
1- Step up regimen :Designed to to define the effective threshold of response .In both women
with hypogonadotropic hypogonadism (WHO Group I) and those with
clomiphene-resistant anovulation (WHO Group II).
Initial attempts to induce ovulation generally should begin with a low daily
dose (75 IU daily) . After 4 to 7 days of stimulation, a serum estradiol level,
with or without transvaginal ultrasonography, provides the first measure ofresponse. Thereafter, the dose of gonadotropins may be maintained or
increased, as indicated. Once the serum estradiol level begins to rise, ovarian
ultrasonography to determine the number and size of developing follicles
becomes essential and the frequency of evaluation increases to every 1-2
days. When the mean diameter of the lead follicle reaches 16-18 mm, hCG is
administered to trigger ovum release; ovulation generally may be expected to
occur approximately 36-48 hours later. In subsequent stimulation cycles, the
initial dose of gonadotropins should consider the response threshold andpattern of follicular development observed in previous cycles.
2- Low slow regimenBecause women with PCOS often are exquisitely sensitive to low doses of
gonadotropin stimulation, early and frequent monitoring generally is wise.
Such women typically have a larger number of small antral follicles poised to
respond to FSH stimulation (recruitable follicles).(56) Ovarian
hyperstimulation, higher risks of multiple pregnancy, and the expense and
frustration associated with canceled cycles usually can be avoided by usingthis regimen that involves low doses (37.5-75 IU daily), small increments, and
a longer duration of stimulation.(57) Although most gonadotropin stimulations
span an interval of 7-12 days, low-dose stimulations in women with PCOS
can take longer. Insulin resistant women may be less sensitive to
gonadotropin stimulation than those who are not. (58) In some such women,
metformin treatment before and during gonadotropin stimulation can help to
improve response, limit the number of smaller developing ovarian follicles,(59)
and reduce the likelihood of cycle cancellation for excessive stimulation.
(60)
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3- Step-down regimenIt is designed to more closely approximate the pattern of serum FSH
concentrations observed in spontaneous ovulatory cycles. Treatment begins
with a higher dose (150-225 IU daily) and decreases gradually thereafter in aneffort to promote continued development of only the more sensitive dominant
follicle while withdrawing support from the less sensitive smaller follicles in
the cohort. Considering that many anovulatory women are quite sensitive to
low doses of exogenous gonadotropin stimulation, the step-down method
generally is best applied only after the response threshold has been
established in one or more previous stimulation cycles. However, the two
approaches can be effectively combined, first gradually increasing the dose of
gonadotropins until a response is observed, and then decreasing the dose oncea dominant follicle has emerged.
Sequential clomiphengonadotropine regimen
Some clomiphene-resistant anovulatory women can benefit from sequential
treatment with clomiphene and gonadotropins. The typical cycle involves a
standard course of clomiphene treatment (50-100 mg daily), followed by low
dose FSH or hMG (75 IU daily) beginning on the last day of clomiphene
therapy or the next day; treatment is monitored and individualized thereafter
as in standard gonadotropin-stimulated cycles. In most,(61,62 )
but not allstudies, (63 ) cycle fecundity in sequential treatment cycles has approached or
equaled that achieved with gonadotropins alone. In all, the dose and duration
of gonadotropin therapy and the associated costs of monitoring were
decreased significantly by 50 percnt; or more. Logically, sequential therapy
generally is useful only in women who respond to clomiphene, at least to
some extent. Otherwise, treatment does not effectively begin until
gonadotropin therapy starts.
4- Addition of GnRH agonistThe elevated endogenous LH levels in many clomiphene-resistantanovulatory women with PCOS predispose to premature follicular
luteinization during exogenous gonadotropin stimulation (64,65) and have been
implicated as a contributing factor in the higher incidence of spontaneous
miscarriage observed in those who conceive.(66) Adjuvant treatment with a
long-acting GnRH agonist before exogenous gonadotropin stimulation
suppresses endogenous LH levels and continued GnRH agonist treatment
during gonadotropin stimulation can prevent premature luteinization.
(67)
The
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risk that residual GnRH agonist-induced LH suppression might result in poor
luteal function after ovulation induction appears more theoretical than real. (68)
Monitoring Gonadotropin Therapy
1- Serum Estradiol LevelsTo best reflect the ovarian response to stimulation and provide for anefficient flow of information, gonadotropins generally are administered in the
evening, typically between 5:00 and 8:00 p.m., and serum estradiol
measurements are obtained early in the morning. Results usually are available
for review by midday, and new instructions regarding the dose and duration
of treatment and the next scheduled evaluation are communicated before the
evening dose that day is due. In general, follicles less than approximately 10
mm in mean diameter produce relatively little measurable estrogen and largerfollicles secrete progressively more as they grow and approach maturity.
Usually, estradiol levels rise at a constant exponential pace, doubling
approximately every 2-3 days over the days before peak follicular
development is achieved. A shallower or steeper slope of increase suggests
the need to increase or decrease the level of stimulation.
In the natural ovulatory cycle, estradiol levels peak between 200 and 400
pg/mL just before the LH surge. Comparable levels of estradiol should be
expected in gonadotropin-stimulated cycles, for each mature follicle observed.Clinical judgements also must consider the number and size of smaller
follicles and their lesser but collective contributions to the serum estradiol
concentration. Not surprisingly, cycle fecundability increases with serum
estradiol levels; unfortunately, so do the risks of multiple pregnancy and
ovarian hyperstimulation. With existing gonadotropin stimulation regimens,
best results generally are obtained when estradiol concentrations peak
between 500 and 1500 pg/mL; pregnancies are uncommon at levels below
200 pg/mL.(69-72)
2- Ultrasonography
Ovarian ultrasonography defines the size and number of follicles
contributing to the measured estradiol level. In the normal ovulatory cycle,
the recruited cohort of antral follicles can be identified by cycle day 5-7, the
dominant follicle emerges by day 8-12, grows approximately 1-3 mm per day
thereafter (most rapidly over the 1-2 days immediately preceding ovulation),
and measures approximately 20-24 mm in mean diameter when the LH surge
occurs; lesser follicles rarely exceed approximately 14 mm in diameter.
(73,74 )
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In 5-10 percnt; of spontaneous cycles, two preovulatory follicles may
develop.
In exogenous gonadotropin-stimulated cycles, dominant follicles exhibit a
similar linear growth pattern, but reach maturity at a smaller mean diameterand over a wider range of sizes. The likelihood of ovulation increases with
follicular diameter. As judged by serial ultrasonography after hCG
administration, follicles 14 mm and smaller occasionaly ovulate, but about 40
percnt; of those 15-16 mm, 70 percnt; measuring 17-18 mm, 80 percent;
measuring 19-20 mm in size, and virtually all larger follicles will ovulate. (75)
The larger range of follicle size at maturity complicates clinical judgments.
The risk of multiple gestation rises with the number of follicles likely to
ovulate. Consequently, hCG generally should not be administered when therisk of multiple ovulation is high and the goal of treatment is unifollicular
ovulation. A large number of intermediate and small follicles also increases
risk for ovarian hyperstimulation syndrome .(76 )
Results of Gonadotropin Treatment
Although exogenous gonadotropin therapy can successfully induce
ovulation in over 90% of women with either hypogonadotropic
hypogonadism (WHO Group I) or clomiphene resistant anovulation (WHOGroup II), the pregnancy rates achieved in the two populations differ
significantly.(77,78 ) In women with hypogonadotropic hypogonadism, cycle
fecundity is approximately 25 percent;, equal to or even greater than that
observed in normal fertile women; cumulative pregnancy rates after up to six
cycles of gonadotropin stimulation approach 90 percent;. By comparison,
cycle fecundity is significantly lower in clomiphene-resistant anovulatory
women. Overall, cycle fecundity ranges between 5 percent; and 15 percent;
and cumulative conception rates range between 30 percent; and 60 percent;;within the group, those with hyperandrogenic chronic anovulation have the
poorest prognosis.(77,78)
The incidence of multifetal gestation is greatly increased in pregnancies
resulting from exogenous gonadotropin-induced ovulation, even in
anovulatory women where the goal of treatment is unifollicular ovulation.
Whereas approximately 1 in 80 (1.25 percent;) spontaneous pregnancies and
5-8 percent; of those following clomiphene treatment are multiples,(79,80 )
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approximately 15 percnt; of all pregnancies following gonadotropin-induced
ovulation in ano-vulatory women are multiples. (77,7 8 )
The overall incidence of spontaneous miscarriage in gonadotropin-induced
conception cycles is approximately 20-25 percent; (77, 78 ) moderately higherthan is generally observed (15 percent ).
As with clomiphene, there is no evidence that gonadotropin therapy is
associated with any increased prevalence of congenital anomalies. (81)
INTRAUTERINE INSEMINATION
Definition: Intrauterine insemination is a technique that processes semen
and separates motile, morphologically normal spermatozoa from dead sperm,
leukocytes, and seminal plasma. (1) This highly motile fraction is then inserted
through the cervix via a flexible or rigid catheter near the anticipated time ofovulation. (82)
History
Undocumented tales exist of Arabs obtaining sperm from mated mares
belonging to rival groups and using the sperm to inseminate their own mares.(83)
Leeuwenhoek (1678) and his assistant, Hamm, were the first persons to see
sperm. In a letter to William Bounker of the Royal Society the Royal Society
of London in which he showed a picture of sperm cells of the human and thedog. Van Leeuwenhoek described the spermatozoa as zaaddiertjes or
living animalcules in human semen ... less than a millionth the size of a
coarse grain of sand and with thin, undulating transparent tails. (84) He draws
the conclusion that the tails must be operated by means of muscles, tendons
and joints.(85) Leeuwenhoek did not have an advanced formal education, so he
did not study Latin, the scientificlanguage of the day. However, he was a
clever, capable individual who ground lenses so precisely (one still exists
today with 270 magnifications) that sperm were visible.(83)
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More than 100 years later, in 1784, the first artificial insemination in a dog
was reported by the scientist Lazzaro Spallanzani (Italian physiologist,1729-
1799).(86) This insemination resulted in the birth of three puppys 62 days
later (Belonoschkin, 1956;Zorgniotti, 1975).(87)The first documented application of AI in human was done in London in
the 1770s by John Hunter,which has been called in medical history the the
founder of scientific surgery. A cloth merchant with severe hypospadias was
advised to collect the semen (which escaped during coitus) in a warmed
syringe and inject the sample into the vagina. (83) In 1899 the first attempts to
develop practical methods for artificial insemination were described by Ilya
Ivanovich Ivanov (Russia, 1870-1932). (88) Although Ivanov studied artificial
insemination in domestic farm animals, dogs, rabbits and poultry, he was thefirst to develop methods as we know today,also in human medicine.(88)
The first reports on human artificial insemination originated from
Guttmacher (1943), Stoughton, (89) and Kohlberg . (90,91 ) It was the real
start of a new era in assisted reproduction.
Phillips and Lardy (1939) were the first to use egg yolk to protect bull
sperm cells from temperature shock upon cooling. This protection was
explained by the effect of phospholipids and lipoproteins in the egg yolk. (92)
Salisbury et al. (1941) improved the media by using egg yolk with sodiumcitrate, permitting theuse of semen at 5 C for up to three days.(93) Polge and
co-workers (1949) were the first to freeze fowl and bull spermatozoa by
using glycerol in the extender media.(94)
In 1953 the first successful pregnancy from artificial insemination with
frozen and thawed sperm was reported, a major breakthrough in history. (83)
Indications of intrauterine insemination
Various clinical indications where IUI can be helpful in improving
chances of conception are the following.(95)
1. Ejaculatory failure
a. Anatomical (e.g. hypospadias)
b.Neurological (e.g. spinal cord injury , diabetic neuropathy)
c. Retrograde ejaculation ( e.g. multiple sclerosis )
2. Psychological (e.g. impotence )
3. Cervical Factor
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a. Cervical mucus hostility
b. Poor cervical mucus
4. Mild to Moderate Male Subfertility.
a.
Oligospermiab. Asthenospermia
c. Teratospermia
d. Oligo-asthenoteratozoospermia
e. Highly Viscous Semen
f. Pyospermia
g. Hypospermia
h. Delayed Lique faction
5.
Immunological factors :a. Male Antisperm Antibodies
b. Female antisperm antibodies
6. Unexplained infertility
7. Endometrosis
8. Mild & Moderate with Normal Tubo Ovarian relations.
9. Ovulatory dysfunction
10.Human immunodeficiency virus (HIV)-positive male partner and HIV-
negative female partner11.Corrected Tubo-peritoneal factor
12.Combined infertility factors
Sperm Preparation for IUI
There are a variety of methods for extracting sperm from the seminal
plasma for IUI. The most common methods include conventional washing,the swim-up procedure, and density gradient centrifugation.
The best choice among them may vary with the quality of the semen
sample.(96,97) The results of a randomized study comparing the pregnancy rates
achieved with IUI after a variety of sperm preparation methods suggest that
swim-up and density gradient centrifugation may offer a greater chance for
success than conventional sperm washing.(96) Another study found that
density gradient centrifugation yielded better results than conventional
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washing when the insemination specimen contains less than approximately 20
million sperm.(97) However, a recent meta-analysis including five trials
involving over 250 couples and comparing three techniques concluded that
evidence is insufficient to recommend any specific preparation technique.(98)Both the conventional washing and swim-up methods allow sperm to remain
in contact with dead or defective sperm and leukocytes, which produce high
levels of reactive oxygen species that may cause oxidative damage to sperm
membranes and motility.(99) Whereas methods more sophisticated than
conventional washing or swim-up may be used to prepare sperm (density
gradient centrifugation, glass wool filtration, others), and often are when
preparing sperm for IVF,(100) they generally are not required for IUI.
Reagents used for semen preparation are:(28)
1. BWW, Earles, Hams F-10 or human tubal fluid (HTF).supplemented
preferably with human serum albumin (HSA), or serum.
2. HSA, highly purified and free from viral, bacterial and prion contamination
and endotoxins.
3. HSA supplement: to 50 ml of medium add 300 mg of HSA, 1.5 mg of
sodium pyruvate, 0.18 ml of sodium lactate (60% (v/v) syrup) and 100 mg of
sodium bicarbonate.4. Serum supplement: to 46 ml of medium add 4 ml of heat-inactivated (56 C
for 20 minutes) clients serum, 1.5 mg of sodium pyruvate, 0.18 ml of sodium
lactate (60% (v/v) syrup) and 100 mg of sodium bicarbonate.
5. Isotonic density-gradient medium: to 10 ml of 10 concentrated culture
medium add 90 ml of density-gradient medium, 300 mg of HSA, 3 mg of
sodium pyruvate, 0.37 ml of sodium lactate (60% (v/v) syrup) and 200 mg of
sodium bicarbonate.
6. Gradient 80% (v/v): to 40 ml of isotonic gradient medium add 10 ml ofsupplemented medium.
7. Gradient 40% (v/v): to 20 ml of isotonic gradient medium add 30 ml of
supplemented medium.
Methods of semen preparation are:
1. Simple washing
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This simple washing procedure provides the highest yield of spermatozoa
and is adequate if semen samples are of good quality. It is often used for
preparing spermatozoa for IUI.Procedure
(28)
First we Mix the semen sample well .then we Dilute the entire semen sample
1 + 1 (1:2) with supplemented medium to promote removal of seminal
plasma. Then the diluted suspension is transferred into multiple centrifuge
tubes, with preferably not more than 3 ml per tube. Centrifugation is then
done at 300500gfor 510 minutes. We carefully aspirate and discard the
supernatants. We resuspend the combined sperm pellets in 1 ml of
supplemented medium by gentle pipetting. Another Centrifugation at 300500gfor 35 minutes is done. Then we carefully aspirate and discard the
supernatant. Then we resuspend the sperm pellet, by gentle pipetting, in a
volume of supplemented medium appropriate for final disposition.
2. Direct swim-upSpermatozoa may be selected by their ability to swim out of seminal plasma
and into culture medium. This is known as the swim-up technique. Thesemen should preferably not be diluted and centrifuged prior to swim-up,
because this can result in peroxidative damage to the sperm membranes.(99)
Thus, a direct swim-up of spermatozoa from semen is the preferred method
for separating out motile spermatozoa .(101) The direct swim-up technique can
be performed either by layering culture medium over the liquefi ed semen or
by layering liquefi ed semen under the culture medium. Motile spermatozoa
then swim into the culture medium. This procedure gives a lower yield of
spermatozoa than washing, but selects them for their motility and is usefulwhere the percentage of motile spermatozoa in semen is low, e.g. for IVF and
ICSI.
Procedure(28)
First we mix the semen sample well. Then we place 1 ml of semen in a sterile
15-ml conical centrifuge tube, and gently layer 1.2 ml of supplemented
medium over it. Alternatively, pipette the semen carefully under the
supplemented culture medium. we then incline the tube at an angle of about
45, to increase the surface area of the semenculture medium interface, and
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incubate for 1 hour at 37 C. we gently return the tube to the upright position
and remove the uppermost 1 ml of medium. This will contain highly motile
sperm cells. Then we dilute this with 1.52.0 ml of supplemented medium.
Centrifugation at 300500gfor 5 minutes is done and we discard thesupernatant. Then we resuspend the sperm pellet in 0.5 ml of supplemented
medium for assessment of sperm concentration, total motility and progressive
motility. And the specimen may be used directly for therapeutic or research
purposes.
3. Discontinuous density gradientsDiscontinuous density gradients can provide the best selection of good-
quality spermatozoa, giving good separation from other cell types and debris.It is easier to standardize than the swim-up technique, and thus results are
more consistent. This technique is used to recover and prepare spermatozoa
for use in IVF and ICSI.(28)
This method uses centrifugation of seminal plasma over density gradients
consisting of colloidal silica coated with silane, which separates cells by their
density. In addition, motile spermatozoa swim actively through the gradient
material to form a soft pellet at the bottom of the tube. A simple two-stepdiscontinuous density-gradient preparation method is most widely applied,
typically with a 40% (v/v) density top layer and an 80% (v/v) density lower
layer. Sperm preparation using density gradient centrifugation usually results
in a fraction of highly motile spermatozoa, free from debris, contaminating
leukocytes, non-germ cells and degenerating germ cells.(28)
Procedure(28)
First we prepare the density-gradient medium in a test-tube by layering 1 mlof 40% (v/v) density-gradient medium over 1 ml of 80% (v/v) density-
gradient medium. Then we mix the semen sample well. Then we place 1 ml of
semen above the density-gradient media and centrifuge at 300400gfor 15
30 minutes. Then we remove most of the supernatant from the sperm pellet.
Then we resuspend the sperm pellet in 5 ml of supplemented medium by
gentle pipetting (to aid removal of contaminating density-gradient medium)
and centrifuge at 200gfor 410 minutes. We repeat the washing procedure
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.Then we resuspend the final pellet in supplemented medium by gentle
pipetting so that concentration and motility can be determined.
Timing of insemination
For obvious reasons and for best results, IUI should be timed to coincide
with the time of spontaneous or induced ovulation. Normal sperm can survive
in the female reproductive tract and retain the ability to fertilize an egg for at
least 3 days, but an oocyte can be successfully fertilized for only
approximately 12-24 hours after it is released.(102) In normal fertile couples,
the probability of conception rises progressively over an interval of 5-6 days
and peaks when intercourse occurs on the day before or day ofovulation.(103,104) The longevity of normal sperm in the female genital tract
relates, in part, to their retention within the cervical mucus which, of course,
is bypassed by IUI. Although unproven, there is reason to believe that sperm
may have a significantly shorter functional lifespan after IUI. Logically, the
lower numbers and motility of infertile partner sperm may be even more
limiting. Cryopreservation damages sperm (105) and even frozen-thawed donor
sperm lose viability and motility more rapidly than fresh normal sperm. The
timing of IUI in the treatment of male factor infertility is therefore far morecritical for success than the timing of natural intercourse in infertile couples,
regardless whether infertile partner sperm or frozen donor sperm are used.
Generally ovulation may be expected to occur on the day before the
midcycle rise in basal body temperature (BBT) (104) or 14-26 hours after the
urinary LH surge is first detected. (106) In natural and clomiphene-stimulated
cycles, the most practical and reliable method for timing IUI involves urinary
LH monitoring beginning approximately 3 days before expected ovulationand insemination on the day following detection of the LH surge. When
ovulation is triggered by injection of exogenous hCG in natural or stimulated
cycles, IUI generally is best performed approximately 34-40 hours later.
Technique of insemination
Immediately before performing IUI, removal of any excess mucus that
might clog the catheter tip is recommended. The tip of the insemination
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catheter is then simply inserted into the cervical os and advanced slowly into
the uterine cavity. A large variety of specialized catheters having varying
rigidity is readily available from commercial sources and any may be used.
Designs involving a stiffer moldable outer sheath over a more atraumatic andflexible inner catheter are the most versatile. The insemination specimen
(approximately 0.5 mL) should be introduced slowly over 10-30 seconds.
Although there are no data to indicate that it matters, it is customary to have
the patient remain supine for approximately 10-15 minutes after insemination.
Although some have suggested that two inseminations (12 and 34 hours after
hCG-induced ovulation) yield a higher cycle fecundability than a single
IUI,(107) other similarly designed studies have found no such advantage.(108) A
meta-analysis including three randomized controlled parallel trials involvingnearly 400 couples concluded that available data do not allow a confident
conclusion.(109) Two studies of cycle fecundability after therapeutic donor
inseminations have observed that two inseminations are no more effective
than one.(110)
In our study we compare between natural ovulatory cycle with IUI versus
ovulation induction with IUI in male factor of subfertility and their effect on
clinical pregnancy rate.
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AIM OF THE WORK
The aim of the work is to compare between intrauterine insemination
with natural ovulatory cycle and intrauterine insemination with controlled
ovarian hyperstimulation in cases of male factor of infertility and its effect on
clinical pregnancy rate.
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PATIENTS
The study was carried out on forty eight women who had anintrauterine insemination recruited from EL-Shatby Maternity University
Hospital.
Inclusion criteria:
Women undergone intrauterine insemination for male subfertility in
case of total sperm concentration 10106
/ml with motility rate type A +B 30 %.
Exclusion criteria:
Women undergone intrauterine insemination for any other reason either
cervical factor of infertility or unexplained infertility.
Women undergone intrauterine insemination with normal semen
parameters.
Women undergone intrauterine insemination and had anovulation
problem.
Women undergone intrauterine insemination and had abnormal tubal
factor.
Women undergone intrauterine insemination and had an abnormal
peritoneal factor.
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All cases signed an informed consent to declare their agreement.
All patients divided randomely by computer generated randomization
into two study groups:
Group (): 24 women undergone intrauterine insemination subjected to
insemination after natural cycle with no ovarian
hyperstimulation.
Group (II): 24 women undergone intrauterine insemination subjected
to controlled ovarian hyperstimulation with HMG.
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METHODS
All patients were subjected to the following:
Investigation workup of infertility, which include:
1- Full history and thorough physical examination.
1. Semen analysis.
2. Ovulation assessment using day 3 FSH level, antral follicle count and
serial transvaginal ultrasound.3. Evaluation of uterine morphology by transvaginal ultrasound and
hysterosalpingography.
4. Evaluation of tubal patency by either hysterosalpingography or
laparoscopy.
In patients selected to be in group (I):
Monitoring of follicular growth and endometrial development by:
Serial transvaginal ultrasound, women underwent a basal transvaginal
ultrasound assessment at the beginning of their menstrual period, and on the
10th day of the cycle. Patients tested their urine samples once daily between
18.00 h and 19.00 h with a urinary semi quantitative monoclonal antibody
based kit with a detection level of 40 IU (Planney, Dkt, Switzerland) starting
on an individually calculated cycle day for the occurrence of an endogenous
LH surge. As soon as they had detected the LH surge, A single IUI was done
about 24 hours after the detection of the LH peak.
Time of insemination:
About 24 hours after detection of LH surge using LH surge detection
kit.
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In patients selected to be in group (II)
Ovulation induction by:
Human menopausal gonadotropin using step down protocol using twoampoules of HMG ,Merional 75 IU (IBSA international, Switzerland), per
day . Then, the dose was tailored by repeat transvaginal ultrasound.
Monitoring of follicular growth and endometrial development by:
Serial transvaginal ultrasound. First, day 3 ultrasound is done to
exclude ovarian cyst .Then, another ultrasound done after 5 days ,if dominant
follicle equals or more than 10 mm the dose is decreased to one ampoule and
another transvaginal ultrasound made 3 days later .But, if dominant follicle
less than 10 mm ,the same dose is continued for 3 days. Then, another
ultrasound is done.
Triggering of ovulation:
By human chorionic gonadotropine (hCG) when the leading follicle isat least 17-18 mm.
Time of insemination:
About forty hours after the hCG injection. .(111)
In patients of both groups:
Bed rest in supine position after insemination for 15 minutes.
Timed intercourse within 12-18 hours after insemination.
Sperm preparation:
By swim up technique. First mixing the semen sample well, then we place 1
ml of semen in a sterile 15-ml conical centrifuge tube, and gently we layer 1.2
ml of supplemented medium over it. Alternatively, pipette the semen carefully
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under the supplemented culture medium. Then we incline the tube at an angle
of about 45, to increase the surface area of the semenculture medium
interface, and incubate for 1 hour at 37 C, we gently return the tube to theupright position and remove the uppermost 1 ml of medium. This will contain
highly motile sperm cells, then we dilute this with 1.52.0 ml of
supplemented medium, then we centrifuge at 300500g for 5 minutes and
discard the supernatant, we resuspend the sperm pellet in 0.5 ml of
supplemented medium for assessment of sperm concentration, total motility
and progressive motility. The specimen may be used directly.
The media used is Hams F-10 supplemented by with human serum albumin
(HSA)
Technique of insemination:
Insertion of vaginal speculum, then removal of any excess mucus that
might clog the catheter tip is recommended. The tip of the outer sheath of the
insemination catheter is then simply inserted into the cervical os and the inner
advanced slowly into the uterine cavity. The insemination specimen
(approximately 0.5 mL) should be introduced slowly over 10-30 seconds.
The catheter used is embryo transfer catheter set (Labotect , Germany).
Measured outcome:
Clinical pregnancy rate which is defined as a rising level of beta
subunit of human chorionic gonadotropin( - hCG) combined with ultrasound
visualization of a pulsating gestational sac.
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RESULTS
There were no significant difference between the two studied groups
according to age ,duration of infertility, and body mass index as p values
were 0.18, 0.59, and 0.16 respectively.
Table (1): Comparison between the two studied groups according to demographic
data
Group I Group II Test of sig.
Age
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Figure (1): Comparison between the two studied groups according to age
Figure (2): Comparison between the two studied groups according to Duration of
inferility
0
10
20
30
40
50
60
70
80
90
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xli
Figure (3): Comparison between the two studied groups according to BMI
0
5
10
15
20
25
30
Group I Group II
MeanofBMI
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There was no significant statisticaldifference between two studied
Groups according day 3 FSH as p value was 0.85 .
Table (2): Comparison between the two studied groups according to day 3 FSH
Group I Group II P
Day 3 FSH
Min.Max. 5.011.0 5.010.0
0.851Mean SD 7.42 1.73 7.33 1.37
Median 7.0 7.0
p: p value for Student t-test for comparing between the two studied group
Figure (4): Comparison between the two studied groups according to day 3 FSH
0
1
2
3
4
5
6
7
8
9
10
Group I Group II
Meanofday3F
SH
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xliii
There were no significant statistical differences between the two studied
groups according to male age and number of smokers as p value
were 0.22 and 0.56 .
Table (3): Comparison between the two studied groups according to male age and
smoking habit.
Group I Group II Test of sig.
Male age
Min.Max. 23.042.0 24.042.0t
p = 0.217Mean SD 31.42 5.45 29.58 4.91Median 30.0 29.0
Smokers
-ve 12 (50%) 14 (58.3%)p = 0.562
+ve 12 (50%) 10 (41.7)
p: p value for comparing between the two studied groupt: Student t-test
2: Chi square test
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xliv
Figure (5): Comparison between the two studied groups according to male age
Figure (6): Comparison between the two studied groups according to smoking
habit.
0
5
10
15
20
25
30
35
Group I Group II
Meanofmaleage(years)
0
10
20
30
40
50
60
-ve +ve
Percentage
Smoker
Group I
Group II
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There was no significant statistical difference between the two studied
groups regarding sperm count per ml
Table (4): Comparison between the two studied groups according sperm
parameters regarding sperm count
Group I Group II P
Sperm Count (million/ml)
Min.Max. 12.045.0 13.0120.0
0.018*
Mean SD 23.83 10.70 43.33 32.38Median 19.0 35.0
p: p value for Mann Whitney testfor comparing between the two studied group*: Statistically significant at p 0.05
Figure (7): Comparison between the two studied groups according sperm count
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Although there was no statistical significant difference between the twostudied groups according the percentage of sperm motility type (A) per mlsemen ,there was statistical significant difference between the two studied
groups according to percentage of sperms with motility type (B) per mlsemen .as p values were 0.13, 0.001 respectively.Table (5): Comparison between the two studied groups according to sperm sperm
parameters regarding sperm motility by percentage (%)
Group I Group II P
Motility A (%)
Min.Max. 15.050.0 20.045.0
0.133Mean SD 32.92 10.76 28.83 7.93
Median 32.50 28.0
Motility B (%)
Min.Max. 10.040.0 25.050.0
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Figure (8): Comparison between the two studied groups according to sperm
motility by percentage (%)
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There was no significant statistical difference between the two studied
groups regarding sperm morphology per ml as p value was 0.98
Table (6): Comparison between the two studied groups according to sperm
morphology .
Group I Group II P
Abnormal forms
Min.Max. 50.090.0 50.095.0
0.981Mean SD 76.42 10.76 76.33 14.23
Median 79.0 76.50
p: p value for Student t-test for comparing between the two studied group
Figure (9): Comparison between the two studied groups according to sperm
abnormal forms
0
10
20
30
40
50
60
70
80
90
Group I Group II
Meanofabnorm
alforms
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There was 29 percent of cases of group II (ovulation induction group )
has had one leading follicles at day of hCG and 50 percent of cases has
had two follicle and 21 percent has had three leading follicles at day of hCG.
Table (7): Distribution of the studied cases of group II according to number of
follicles at day of hCG
No %
Follicle HMG
1 7 29
2 12 503 5 21
Figure (10): Distribution of the studied cases of group II according to number of
follicles at day of hCG.
17%
33%
50%
No. of follicles at day of hcg
1 2 3
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l
There were 25 % of cases of group II (ovulation induction group) used
13 ampoules ,33 % used 14 ampoule ,25 % used 15 ampoule , and 17 %
used 16 ampoule of HMG for induction of ovulation .
Table (8): Distribution of the studied cases of group II according to number of
ampoules of HMG used for induction of ovulation.
No %
Number of ampoules of HMG
13 6 25.0
14 8 33.315 6 25.0
17 4 16.7
Figure (11): Distribution of the studied cases of group II according to number of
ampoules of HMG used for induction of ovulation.
0
5
10
15
20
25
30
35
13 14 15 17
Percentage
Number of ampoules of HMG
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There was no statistical significant difference between the two studied
groups regarding the clinical pregnancy rate as p value was 0.48
Table (9): Comparison between the two studied groups according to clinical
pregnancy rate
Group I Group IIP
No. % No. %
Pregnancy
-ve 18 75.0 20 83.30.477
+ve 6 25.0 4 16.7
p: p value for Chi square test for comparing between the two studied group
Figure (12): Comparison between the two studied groups according to clinical
pregnancy rate
0
10
20
30
40
50
60
70
80
90
-ve +ve
Percentag
e
Pregnancy
Group I
Group II
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DISCUSSION
Artificial insemination is one of the most common assistedreproductive technique .it has been used for more than 200 years since John
Hunter in 1770 s made first insemination. One of most common indications of
intrauterine insemination is mild and moderate male subfertility.
The aim of our work was to compare between intrauterine
insemination with natural ovulatory cycle and intrauterine insemination with
controlled ovarian hyperstimulation in cases of male factor of infertility and
its effect on clinical pregnancy rate.In our study forty eight patient were recruited from El Shatby Maternity
university hospital between June 2012 and March 2013.All of them have had
intrauterine insemination. These patients were allocated into two groups:
Group (): 24 women underwent intrauterine insemination were
subjected to insemination after natural cycle with no ovarian
hyperstimulation.
Group (II): 24 women underwent intrauterine insemination were
subjected to controlled ovarian hyperstimulation with HMG.
Our study showed that there is no statistically significant difference
regarding clinical pregnancy rate between ovulation induction with
intrauterine insemination group (25 %) and natural cycle intrauterine
insemination group (16.7 %) .
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Goverde (112) studied pregnancy outcome of 310 natural and 334
mildly hyperstimulated cycles for IUI in 171 couples with unexplained or
mild male factor subfertility was analysed on a patient level with randomcoefficient models. His results showed that pregnancy rates were similar: 35
% and 39.8% per couple in the natural and mildly hyperstimulated cycles
respectively (P = 0.60).So, He concluded that the application of a mild
hyperstimulation protocol as an alternative to a standard hyperstimulation
protocol for IUI does not result in higher pregnancy rates than IUI in the
natural cycle. This result is in agreement with our study although he used a
larger number of patients in comparison with ours.
Cohlen (113) in a randomized crossover trial that investigated whether
the efficacy of IUI in natural or stimulated cycles was related to the severity
of male subfertility. Seventy-four couples completed 308 treatment cycles.
Thirteen pregnancies occurred after IUI in a natural cycle (pregnancy rate per
completed cycle: 8.4%) and 21 after IUI in a stimulated cycle (pregnancy rate
per completed cycle: 13.7%). The efficacy of IUI in stimulated cycles was
related to the severity of the semen defect. In couples with a total motile
sperm count less than 10106, ovarian stimulation did not improve treatment
outcome, while it did in couples with a total motile sperm count more than
10106. Compared with the expected chance of conceiving spontaneously
without treatment, both natural and stimulated cycles improved theprobability of conception. They conclude that, for the group as a whole,
ovarian stimulation did not improve the probability of conception. This result
is in agreement with our study.
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Guzick(114),Who studied 932 couples in which the woman hadno
identifiable infertility factor and the man had motile sperm. He founded that
the 231 couples in the group treated with superovulation and intrauterineinsemination had a higher rate of pregnancy (33 percent) than the 234
couples in the intrauterine-insemination group (18 percent), so he concluded
that treatment with induction of superovulation and intrauterine insemination
is as twice as likely to result in pregnancy as is treatment with intrauterine
insemination alone. this is in contrary to our study.
The conflict with our study may be due to that he divided the cases into
four different groups of patients with a group of a 231 couples that treated
with super ovulation and IUI and a group of 234 couples treated with IUI
alone and a third group of 234 couples treated with ovarian hyperstimulation
and intracervical insemination and the forth group of 233 couple treated by
intracervical insemination alone. This large number of groups increase the
possibility of bias and he used different statistical analysis of stratified,
discrete-time Cox proportional-hazards analysis thats different from ours.
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SUMMARY
Artificial insemination is one of the most common assisted reproductivetechnique .It has been used for more than 200 years since John Hunter in 1770
s made first insemination. One of most common indications of intrauterine
insemination is mild and moderate male subfertility.
The aim of our work was to compare between intrauterine insemination
with natural ovulatory cycle and intrauterine insemination with controlled
ovarian hyperstimulation in cases of male factor of infertility and its effect on
clinical pregnancy rate.
In our study forty eight patient were recruited from El Shatby Maternity
university hospital between June 2012 and March 2013.All of them have had
intrauterine insemination and were fulfilling the required .These patients were
allocated into two groups:
Group (): 24 women underwent intrauterine insemination were
subjected to insemination after natural cycle with no ovarian
hyperstimulation.
Group (II): 24 women underwent intrauterine insemination were
subjected to controlled ovarian hyperstimulation with HMG.The measured outcome was