comparison between intrauterine insemination with ovulation induction versus natural ovulatory cycle...

7/30/2019 Comparison Between Intrauterine Insemination With Ovulation Induction Versus Natural Ovulatory Cycle in Male Fa

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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


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 ..


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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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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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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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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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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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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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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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&percnt; 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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xxviii

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



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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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xlii

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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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


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

comparison between intrauterine insemination with ovulation induction versus natural ovulatory cycle...

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