Comparison of Controlled Ovarian Superstimulation with or Without Intrauterine Insemination for the Treatment of Unexplained Infertility
Abstract
This retrospective study was performed to compare the pregnancy rates (PR) in patients treated with either controlled ovarian superstimulation (COS) and intrauterine insemination (IUI) or COS and timed intercourse (TI) in patients with unexplained infertility. Fifty-seven females underwent 98 treatment cycles of COS and IUI and 30 females underwent 96 treatment cycles of COS and TI. Pregnancy rates (PR) per cycle in the groups treated with COS and either IUI or TI were 18.4% and 3.1% respectively (P<0.05). We concluded that COS and IUI are an effective treatment compared with COS and TI in patients with unexplained infertility.
Introduction
Infertility is said to be unexplained when a couple fails to conceive and no definite cause of the infertility can be found. The average incidence of unexplained infertility is about 15% among infertile couples.1 The role of COS and IUI in the treatment of unexplained or idiopathic infertility remains controversial.2 Other workers showed that COS and IUI are effective in comparison with no treatment.3 The aim of this study is to evaluate the efficacy of COS and IUI for the treatment of unexplained infertility and to compare this with COS and TI.
Material and Methods
Patients reviewed for this prospective study were those with unexplained infertility and treated with COS and either IUI or TI in the last three years. In group A, 57 females underwent 98 treatment cycles of COS and IUI. In group B, 30 females underwent 96 cycles of COS and TI.
Diagnosis of unexplained infertility was made after at least three years’ duration with normal menstrual rhythm and a normal pelvis at laparoscopy. The male partner showed normal semen analyses on at least two occasions, showing a count of >20 million motile sperm per ejaculate. There was a normal profile of estradiol (E2) and progesterone (P) on menstrual cycle day 21 >30 nmol/L, follicle-stimulating hormone (FSH) and luteinizing hormone (LH) through the cycle.
All groups were treated simultaneously. In all patients, ovarian superstimulation was achieved by employing a long course of gonadotropin-releasing hormone analogue (GnRH-a) (Buserelin; Hoechst, UK, Ltd.) which was administered by nasal insufflation at a dose of 150 μg × 4 a day from menstrual cycle day 21, followed by human menopausal gonadotropin (hMG) (Pergonal; Serono Laboratories, UK, Ltd.) 150 IU per day intramuscularly on day five of the cycle. All patients were monitored by daily serum estradiol E2 and vaginal ultrasound scan.
When there were at least one to a maximum of three leading follicles of >16 mm in diameter and serum E2 concentration was at least 250 pg/mL, human chorionic gonadotropin (hCG) 10,000 IU (Profassi, Serono Laboratories, UK, Ltd.) was given intramuscularly and IUI was performed 32 to 42 hours later. Patients were advised to have sexual intercourse 24 and 48 hours after hCG administration. In all patients, ovulation was confirmed by monitoring serum LH and P after hCG administration. Semen preparation for IUI was performed using the swim-up technique.
Statistical Analyses
Statistical analyses were performed using Mann-Whitney and chi-square tests where appropriate. The differences were considered significant when P <0.05.
Results
Table 1 shows that there were no significant differences in patients’ ages and infertility duration between the two groups. In group A, 57 females underwent 98 treatment cycles of COS and IUI. In group B, 30 females under-went 96 treatment cycles of COS and TI. Pregnancy rates per cycle in group A and group B were 18.4% and 3.1% respectively. This difference in PR was statistically significant (P<0.005).
| Group A (IUI) | Group B (TI) | P value | ||
|---|---|---|---|---|
| Patients | (n) | 57 | 30 | |
| Age | (yrs) | 31.6±2.7 | 30.89±3.2* | ns** |
| Infertility duration | (yrs) | 4.7±1.8 | 5.1±2.1 | ns |
| Cycle | (n) | 98 | 96 | |
| Pregnant per cycle | 18 (18.4%) | 3 (3.1%) | <0.005 |
Discussion
Empirical treatment techniques of unexplained infertility are popular, despite the lack of adequately controlled studies to demonstrate their efficacy.
The cost effectiveness of these therapies is to be addressed. The advent of IVF technology introduced modern methods for semen separation that made IUI a safe and painless procedure.4
Several investigators used IUI in unstimulated cycles with cycle PR varied between 2% and 13%.5 Unexplained infertility was treated with COS without IUI with variable results.5 Treatment of unexplained infertility was treated with COS and IUI has been evaluated by several workers.5,6 In COS, the number of preovulatory follicles increases and may correct other ovulatory disorders such as luteinized unruptured follicle.7
Considerable increase in the ovarian size may bring the ovary in close proximity to the fimbria and superstimulation may have an effect on tubal motility and may enhance the ovum pickup mechanism.8 Treatment of sperm before insemination may enhance fertilizing capacity9 and IUI may increase the number of sperm reaching the distal portion of the fallopian tube;10 this appears to enhance the chances of pregnancy.
In this study, single insemination was performed. Recently it was reported that increasing the frequency of IUI does not provide a significant increase in cycle pregnancy rate.11 Our results showed a higher PR in the group treated with COS and IUI compared with the group treated with COS and TI.
In conclusion, in patients with unexplained infertility, COS and TI are not an effective treatment and are not cost effective, since the cost per cycle is almost the same as COS and IUI with a much lower success rate and should be replaced with COS and IUI, which are effective, simple and relatively noninvasive.
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