{"paper_id":"ed993382-3f95-40d0-ad10-554d33c5a1dd","body_text":"Infertility is a public health concern that drives many couples to seek assisted\nreproductive technology (ART) therapies. However, due to the high cost of  in\nvitro  fertilization (IVF), less invasive and more affordable procedures\nsuch as intrauterine insemination (IUI) have become more popular ( Ashrafi  et al. , 2013 ;  Fauque  et al. , 2014 ). However,\nthe distress associated with the treatment should be considered, since the procedure\ninvolves a strong emotional investment for the couple. Therefore, it is important to\nfind the prognostic factors favoring IUI over IVF.\nIUI is indicated in cases of unexplained infertility, male subfertility, unilateral\ntubal blockage, cervical or ovulatory dysfunction, and mild or minimal endometriosis\n( Azantee  et al. , 2011 ;\n Fauque  et al. , 2014 ).\nDespite the improvements in semen preparation and controlled ovarian stimulation\ntechniques, the success rates reported for IUI are lower than the rates reported for\nother ART procedures ( Ghaffari  et\nal. , 2015 ). Data from the European Society of Human\nReproduction and Embryology showed that the pregnancy rate per cycle has remained\nstable for years at 12.4% ( Ferraretti  et\nal. , 2012 ;  Dinelli  et\nal. , 2014 ). Global pregnancy rates as high as 30% have been\nreported in some studies on IUI, although results vary depending on the population\nstudied ( Luco  et al. , 2014 ;\n European IVF-Monitoring Consortium,\n2016 ).\nRegardless of the treatment used, couples are keen to know their chances of success.\nTherefore, it is crucial to identify and assess the factors that influence the\nattainment of pregnancy ( Ghaffari  et\nal. , 2015 ). Several prognostic factors linked to the outcome\nof IUI have been identified and related to type of ovarian stimulation and couple\ncharacteristics such as female patient age, type and duration of infertility, number\nof mature follicles recruited, endometrial thickness, number of sperm with\nprogressive motility, sperm morphology, and number of sperm used in insemination\n( Dinelli  et al. , 2014 ;\n Fauque  et al. , 2014 ;\n Ghaffari  et al. ,\n2015 ).\nSince 1992, the Assisted Reproduction Service of the Hospital das Clínicas of\nthe Ribeirão Preto Medical School of the University of São Paulo\n(HC-FMRP/USP) has offered ART and IUI with patients paying only for the medication\nused in the procedures. The service has recorded strong inflows of patients from the\ncountryside of the State of São Paulo and other parts of Brazil. The high\ndemand for the services at hand has fostered the development of systems to track the\ncost of each procedure. In order to encourage the use of low complexity over high\ncomplexity techniques, the clinical pregnancy rates of patients offered IUI from\n2011 to 2015 in the Assisted Reproduction Service at HC-FMRP/USP was analyzed.\nClinical pregnancy rates were then compared for ovulation induction method, cause of\ninfertility, female patient age, number of mature follicles and sperm with\nprogressive motility, in order to determine possible prognostic factors.\n\nThis retrospective observational study was carried out from an analysis of the\ndata collected from 237 IUI cycles performed in 198 women treated from February\nof 2011 to December of 2015 in the Assisted Reproduction Service at HC-FMRP/USP.\nThe study was conducted in accordance with the guidelines set by the ethics\ncommittee at HC-FMRP/USP and the tenets of the Declaration of Helsinki. The\nethics committee approved the study design, and the need to obtain informed\nconsent was waived due to the retrospective nature of the study. The included\ncouples had been diagnosed with infertility and were assessed to determine the\ncause of infertility. The tests included seminograms to assess semen quality,\nhormone measurements to evaluate the presence of ovulation or menstrual\ndisorders, analysis of the uterine cavity and tubal patency using pelvic\nultrasonography and hysterosalpingography and/or hysteroscopy and\nvideolaparoscopy. Assessment of vaginal infection through cytology and detection\nof couple viral infections through serology tests were also conducted.\nTreatments and ART procedures were chosen once the cause of infertility was\nestablished. Couples prescribed IUI had to have at least one permeable tube of\nnormal diameter and a motile sperm concentration of 5×10 6 /mL\non the day of the seminogram.\nThe induction of ovulation for IUI was performed according to the standard\nprotocols in effect at the hospital: protocol 1 consisted of Clomiphene Citrate\nat a dose of 50 to 100 mg/day for 5 days from the second or third day of the\nmenstrual cycle, alone or combined with Gonadotropins - Follicle Stimulating\nHormone (FSH) and Luteinizing Hormone (LH) - (Menopur ® ) at a\ndose of 75 IU on alternate days from the second day of ovulation induction;\nprotocol 2 consisted of Gonadotropins (Menopur ® ) at a dose of\n75 IU or recombinant FSH (Gonal ®  or\nPuregon ® ) at a dose of 50 to 75 IU on consecutive or alternate\ndays from the second or third day of the menstrual cycle. Ovulation was\nmonitored with transvaginal pelvic ultrasound, starting on the eighth day from\nthe start of ovulation induction medication (Protocols 1 or 2). When a follicle\nreached a mean diameter of 17 to 18 mm, Human Chorionic Gonadotropin (hCG)\n(Choriamon ® ) was administered at a dose of 5000 IU or\nrecombinant hCG (Ovidrel ® ) was administered at a dose of 250\nmg for oocyte maturation, followed by IUI after 36 to 40 hours. For cases of\novulation induction for IVF using Gonadotropins at 150 to 300 IU/day, IUI was\noffered only when one or two follicles were recruited or when the patient had\npatent fallopian tubes and her partner had a motile sperm count of\n5×10 6 /mL on the day of the seminogram. The luteal phase\nwas supplemented with Utrogestan ®  200 mg or\nDuphaston ®  20 mg per day. Only 12 cycles occurred with no\nsupplementation in the luteal phase.\nSemen preparation for IUI was performed through sperm washing or density gradient\ncentrifugation. The first method was used for samples with sperm concentration\n<10×10 6  regardless of motility, for samples with\n≥50% immotile sperm regardless of concentration, and for thawed semen.\nSemen was added to Human Tubal Fluid (HTF) -\n4-(2-hydroxyethyl)-1-piperazineethanesulfonic acid (HEPES) (Irvine Scientific)\nsupplemented with 10% Serum Substitute Supplement (SSS) (Irvine Scientific) at\nthe same proportion; the samples were then homogenized. The samples were\ncentrifuged for 10 minutes at 1000 rpm. The supernatant was discarded and the\nresulting pellet diluted in 0.5 mL HTF-HEPES + 10% SSS.\nThe second method consisted of two protocols: 1.0 mL of colloidal suspension was\nused for samples with progressive motility >32% and 0.5 mL for samples with\nprogressive motility <32%. According to the protocol, 1.0 mL or 0.5 mL of 90%\ncolloidal gradient was first added to the tube and 1.0 mL or 0.5 mL of 45%\ncolloidal gradient was pipetted carefully onto the wall of the tube. Afterwards,\na maximum of 3.0 mL of liquefied semen was deposited gently on top of the\nsolution. The sample was centrifuged for 30 minutes at 1000 rpm, the supernatant\ndiscarded, and the pellet homogenized in 2.0 mL of HTF-HEPES + 10% SSS medium. A\nsecond centrifugation was performed to eliminate residual particles from the\ncolloidal gradient, the supernatant was discarded, and the resulting sediment\ndiluted in 0.5 mL of HTF-HEPES + SSS 10%.\nAfter sperm preparation, the new concentrations and sample motility were\ndetermined. The number of sperm with progressive motility to be inseminated was\nthen calculated. Using a 1.0 mL syringe, a LABORATOIRE CCD (Paris-France)\ninsemination catheter was filled with the resulting semen sample. The procedure\nwas performed with the aid of abdominal and pelvic ultrasound guidance.\nSoftware package SAS version 9.3 (SAS Inc Cary, CN) was used for data analysis,\nwith the level of significance set at  p <0.05. Exploratory\ndata analysis was performed using measurements of central tendency and scatter.\nQualitative variables were described in terms of absolute numbers and\nproportions. Student's t-test was used to compare the groups with regard to\nquantitative variables. The distribution of variables was assessed through\nnormal probability plots. The chi-square test was used for qualitative variables\nto test the null hypothesis of absence of association between qualitative\nvariables and clinical pregnancy rates.\n\nTwo hundred and thirty-seven IUI cycles were performed, and 33 patients (14%)\nunderwent more than one cycle (two to four cycles). Clinical data such as patient\nage, number of follicles recruited on the day of hCG, and semen characteristics on\nthe day of insemination are presented in  Table\n1 .\nClinical and laboratory characteristics of 237 Intrauterine Insemination\ncycles\nSptz=sperm,\nStandard deviation,\nFirst quartile,\nThird quartile\nThe overall clinical pregnancy rate was 7.59% (n=18 cycles). Laboratory and clinical\nparameters of the IUI cycles with regard to pregnancy outcomes are presented in\n Table 2 . With the exception of age, there\nwas no significant difference between the groups.\nClinical and laboratory characteristics of 237 Intrauterine Insemination\ncycles versus pregnancy outcome\nSptz=sperm\nQuantitative analysis of the mature follicles recruited (≥17 mm) during\novulation induction was conducted and results were compared for clinical pregnancy\noutcomes. Two or more mature follicles were recruited in only 30 patients (12.6%).\nAmong the patients who became pregnant, 16 had one mature follicle and two had two\nmature follicles.\nIn 75.5% of the cases (n=179 cycles), ovulation induction was indicated and performed\nfor IUI. IVF was initially indicated in 24.5% of cases (n=58 cycles), but IUI was\nperformed due to low follicular recruitment. The data on the cycles of these two\nsubgroups are shown in  Table 3 .\nClinical and laboratory characteristics of 237 intrauterine insemination\ncycles versus type of ovulation induction\nSptz=sperm, IUI=intrauterine insemination, IVF= in vitro \nfertilization\nThe causes of infertility were categorized into seven subgroups.  Table 4  shows that none of the causes was\nstatistically correlated with clinical pregnancy rates.\nCauses of infertility of 237 cycles of intrauterine insemination versus\npregnancy outcome\nIUI = intrauterine insemination\nAge was the only variable to present a statistically significant correlation\n( p =0.001) with pregnancy. The mean age of the patients who\nachieved pregnancy was 32.56 (±4.64) ( Figure\n1 ). Clinical pregnancy rates from IUI had no statistically significant\nassociation with cause of infertility, number of mature follicles or sperm with\nprogressive motility.\nFigure 1 Mean age of patients submitted to intrauterine insemination versus\npregnancy outcome\nMean age of patients submitted to intrauterine insemination versus\npregnancy outcome\nThe subgroup of patients showing ideal conditions to undergo IUI was described as\nhaving age ≤ 35 years and causes of infertility including unexplained\ninfertility, ovarian factor infertility, minimal endometriosis, and partners with\nrecovered sperm counts ≥2.5×10 6  on the day of insemination.\nIn this subgroup, 102 IUI cycles were performed, or 43% of all cycles, resulting in\na pregnancy rate of 12.74% (n=13 cycles).\n\nVarious parameters were analyzed in this study, including female patient age,\novulation induction method, cause of infertility, number of mature follicles, and\nnumber of sperm with progressive motility, but only age was significantly related to\nsuccessful IUI.\nAlthough ovulation was induced based on the procedure indicated for each patient (IUI\nor IVF), no difference was found in the outcome of pregnancy between induction\nmethods. Fifteen clinical pregnancies occurred in the 179 cycles (83.33%) indicated\nfor IUI, whereas three pregnancies occurred in the 58 cycles indicated for IVF\n(16.67%). This finding agrees with two studies that showed no significant\ndifferences in chemical and clinical pregnancy rates between intracytoplasmic sperm\ninjection and patients converted to IUI ( Shahine\n et al. , 2009 ;  Shohieb  et al. , 2012 ). Another study reported higher\nclinical pregnancy rates among individuals converted from IVF to IUI than in the\ngroup offered IVF. This suggests that conversion from IVF to IUI is a valid\nalternative for poor respondents ( Freour  et\nal. , 2010 ). In contrast with these findings, a 2010 study\nshowed that, in certain cases, IVF yielded higher pregnancy rates when compared to\nconversion to IUI ( Norian  et al. ,\n2010 ). As illustrated by these studies, there is still no consensus in\nthe literature regarding conversion to IUI for cycles with induced ovulation and\npoor response during follicular recruitment in ovulation induction for IVF.\nPatient age was the only statistically significant variable observed in our study. In\nline with our findings, previous studies have shown that there is a decrease in\nclinical pregnancy rates as the age of patients undergoing IUI increases ( Zadehmodarres  et al. , 2009 ;\n Ghaffari  et al. , 2015 ;\n Honda  et al. , 2015 ).\n Merviel  et al.  (2010) \nand  Azantee  et al.  (2011) \nreported that patients aged <30 years have a better chance of achieving\npregnancy. In our study, the patients considered ideal for IUI were aged ≤35\nyears and yielded a pregnancy rate of 12.74%.  Ashrafi\n et al.  (2013) , however, found no association between\ndeclining pregnancy rates and increasing age for women aged <40 years, indicating\nthat IUI is also a good alternative for patients aged 40 years and younger.\nMoreover, some studies have emphasized that female patient age is the most important\nprognostic factor in the success of IUI after a period of infertility ( Yousefi & Azargon, 2011 ). However, some\nstudies found no association between patient age and outcomes of clinical pregnancy\nfor IUI ( Ibérico  et al. ,\n2004 ;  Erdem  et al. ,\n2008 ;  Akl  et al. ,\n2011 ;  Wu  et al. ,\n2013 ).\nCauses of infertility were not related to successful pregnancy in our study group.\nSome studies have found higher rates of clinical pregnancy with IUI in patients with\nunexplained infertility ( Merviel  et\nal. , 2010 ;  Azantee  et\nal. , 2011 ;  Ombelet,\n2013 ), moderate masculinity, and ovulatory disorders ( Merviel  et al. , 2010 ;  Azantee  et al. , 2011 ;  Dinelli  et al. , 2014 ;  Ghaffari  et al. , 2015 ). Causes\nof infertility such as endometriosis and tubal factor, however, produced negative\neffects and lower pregnancy rates after IUI ( Merviel\n et al. , 2010 ;  Wu\n et al. , 2013 ;  Ghaffari  et al. , 2015 ).\nThe number of recruited mature follicles was not correlated with clinical pregnancy\nrates in this study, although the proportion of cycles with more than one recruited\nfollicle was very low, possibly due to the low doses of ovulation induction drugs\nused in our protocols. Interestingly, among the cycles that achieved clinical\npregnancy, approximately 89% had only one mature follicle. In agreement with our\nstudy,  Akl  et al.  (2011)  and\n Wu  et al.  (2013)  did not\nfind significant differences between the results of IUI and the number of mature\nfollicles. However, these studies revealed that greater numbers of mature follicles\nwere correlated with higher clinical pregnancy rates. A study conducted in 2013\nreported a pregnancy rate of 22.5% in cycles with three preovulatory follicles and\nof 6.5% in cycles with a single follicle ( Ashrafi\n et al. , 2013 ). In a cross-sectional analysis,  Ibérico  et al.  (2004) \nreported that the application of IUI in cycles with three mature follicles almost\ntripled pregnancy rates when compared to cycles with only one follicle. In a\nliterature review,  Merviel  et al. \n(2010)  reported that the strongest predictive factor for pregnancy after\nIUI was ovulation stimulation enabling the recruitment of at least two follicles\n>16 mm.\nOur study also looked into the pre- and post-processing number of sperm with\nprogressive motility, and found no association between these parameters and clinical\npregnancy rates. Accordingly, studies by  Akl\n et al.  (2011) ,  Ghaffari  et al.  (2015) ,  Luco  et al.  (2014) , and  Ombelet  et al.  (2014)  indicated that sperm parameters\ndid not significantly affect IUI success. In contrast, other authors including  Azantee  et al.  (2011)  reported\nthat sperm parameters were correlated with IUI success, adding that one of the more\nsignificant prognostic factors for the success of the procedure was semen quality,\nas patients with low sperm counts (oligospermia) and low counts of sperm with\nprogressive motility (asthenozoospermia) had more adverse IUI results ( Barros Delgadillo  et al. ,\n2006 ).\nAnother variable that might influence the outcome is total motile sperm count (TMSC),\nwhich is the product of the sperm volume collected based on sperm concentration and\nthe percentage of sperm with progressive motility in the ejaculate ( Nikbakht & Saharkhiz, 2011 ). However, due\nto a partial lack of data, this variable was not calculated in our study. Some\nauthors reported that higher total motile sperm counts lead to greater likelihood of\npregnancy after IUI ( Ibérico  et\nal. , 2004 ;  Merviel\n et al. , 2010 ;  Yousefi & Azargon, 2011 ).  Nikbakht\n& Saharkhiz (2011)  evaluated the prognostic value of TMSC and the\nnumber of motile sperm inseminated (NMSI) in IUI, and showed that pregnancy rates\nwere higher when the TMSC ranged between 5×10 6  and\n10×10 6  (15%), and lower in subgroups that had counts\n<1×10 6 , from 1×10 6  to\n<5×10 6 , and ≥10×10 6  (5.6%; 5.1%;\n10.8% respectively). NMSI ≥10×10 6  resulted in higher\npregnancy rates (11.2%) versus subgroups with counts <5×10 6  and\nfrom 5×10 6  to <10×10 6  (4.1% and 5.2%,\nrespectively). Supporting  Nikbakht & Saharkhiz\n(2011) ,  Lemmens  et al. \n(2016)  reported that IUI is particularly relevant for couples with NMSI\nranging from 5 to 10×10 6 .\nIt has been shown that pregnancy rates may vary significantly depending on the number\nof motile sperm inseminated ( Badawy  et\nal. , 2009 ;  Merviel\n et al. , 2010 ;  Cao\n et al. , 2014 ).  Dinelli  et al.  (2014)  reported that the main problem\nrelated to male infertility was moderated asthenozoospermia, and that pregnancy\nrates were significantly higher when the number of motile sperm with progressive\nmotility used in insemination was at least 1×10 6 .\nFinally, although the clinical pregnancy rate seen in our population was 7.59%, the\nsubgroup of patients thought to have ideal conditions for intrauterine insemination\n(age ≤ 35 years, unexplained infertility, ovarian factor infertility or\nminimal endometriosis, and partners with sperm count\n≥2.5×10 6  retrieved on the day of insemination) had a\npregnancy rate of 12.74%.  Geisler  et\nal.  (2017)  recently aimed to find the factors that might\nsupport more individualized applications of IUI, and reported that IUI associated\nwith controlled ovarian hyperstimulation, especially in younger patients, produced\ngood live birth rates. More than 90% of the live births with IUI were achieved\nduring the first two cycles. Our findings for this age group were similar, in that\nyounger patients had better pregnancy results with IUI. These findings suggest that\nprobabilities of success may be used to individualize treatment decisions, while IUI\nbefore IVF for carefully chosen patients still is a treatment option.\nA possible limitation of our study was the size of the sample, which may not have\nbeen large enough to detect differences in some of the analyzed parameters. Further\nstudies with larger sample sizes may be necessary to confirm the results of this\nstudy.\n\nThe clinical pregnancy rate found in this study was 7.59%. When ideal conditions were\npresent for the indication of IUI, the pregnancy rate was 12.74%. Female patient age\nwas the only variable significantly associated with IUI success. Ovulation induction\nmethod, cause of infertility, number of mature follicles, and number of sperm with\nprogressive motility were not associated with pregnancy outcome. Due to\naffordability and when accompanied by appropriate patient selection, IUI remains an\neffective method among the available options for infertile couples.","source_license":"public-domain-us","license_restricted":false}