Abstract
We retrospectively analyzed 6,360 artificial insemination cycles of husband's semen through intrauterine insemination (AIH-IUI) or artificial insemination with donor semen through intrauterine insemination (AID-IUI) in patients with infertility between August, 1998 and August, 2010. The relationship between processed total motile sperm count (PTMS) and pregnancy outcome was determined. The study was divided into 6 groups according to PTMS. Group 1: ≤ 2.0 million, Group 2: 2.1-4.0 million, Group 3: 4.1-6.0 million, Group 4: 6.1-8.0 million, Group 5: 8.1-10.0 million, and Group 6: >10.0 million. There was no statistically significant difference in age, duration of infertility, unilateral tubal patency, induced ovulation, and single IUI or double IUI between the 6 groups in both AIH-IUI and AID-IUI. The total clinical pregnancy rate of AIH-IUI was 10.81 % and AID-IUI was 27.52 %. Among the 6 groups, the clinical pregnancy rate was the lowest in Group 1 (P < 0.05) in both AIH-IUI and AID-IUI. With the increased PTMS, the clinical pregnancy rate of IUI was improved. However, a statistical difference between groups was only observed for Group 1. When PTMS is ≤ 2 × 106 the clinical pregnancy rate of IUI is significantly decreased. In this case in vitro fertilization (IVF) should be adopted.
Introduction
In preparation for intrauterine insemination (IUI), the seminal plasma are removed from the semen and then the motile spermatozoa are injected into the uterine cavity. IUI can be carried out with the husband's semen (AIH) or with donor semen (AID).
There has been considerable debate about the optimal processed total motile sperm count (PTMS) to routinely achieve pregnancy. It has been reported that a PTMS of 20 × 106 achieves a higher pregnancy rate than 10-20 × 106 and that in vitro fertilization (IVF) should be adopted when PTMS is less than 10 × 106 [Miller et al. Citation2002; Lu et al. 2006]. Others have argued that a PTMS of 10 × 106 can achieve a better pregnancy rate [Dickey et al. Citation1999; Horvath et al. Citation1989; Van Voorhis et al. Citation2001]. However, Huang and Lai [1996] have indicated that approximately 5 × 106 PTMS is even better. To resolve these conflicting reports, the minimum PTMS that was required to achieve a satisfactory pregnancy rate through a 12-year retrospective analysis of 6,360 IUI cycles was determined.
Results
Effect of PTMS on pregnancy outcome of AIH-IUI
The mean age of the women within the AIH-IUI group was 31.14 y (range 20-50). The mean duration of infertility was 4.86 y (3 months - 20 y). The total clinical pregnancy rate of AIH-IUI was 10.81 %. Among the 6 groups of AIH-IUI, there was no statistically significance difference in age, duration of infertility, unilateral tubal patency, induced ovulation, and single IUI or double IUI (all P > 0.05) (). The clinical pregnancy rate per cycle in single IUI and double IUI groups were 10.30% and 11.97%, respectively, without statistical significance (P > 0.05, ). Among the 6 groups, the clinical pregnancy rate was the lowest in Group 1 (P < 0.05) (). As shown in , the clinical pregnancy rate of IUI improved with the increased PTMS. Statistical significance was only achieved when Group 1 was considered.
Table 1. The relationship between PTMS and clinical pregnancy rate in AIH-IUI.
Table 2. Clinical pregnancy rates of single IUI and double IUI in AIH-IUI.
Effect of PTMS on pregnancy outcome of AID-IUI
The mean age of the women within the AID-IUI group was 27.48 y (range 20-43). The mean duration of infertility was 4.19 y (3 months-20 y). The total clinical pregnancy rate was 27.52 %. Among the 6 AID-IUI groups, there was no statistically significant difference in age, duration of infertility, unilateral tubal patency, induced ovulation, and single IUI or double IUI (all P > 0.05) (). As shown in , the clinical pregnancy rate per cycle in single IUI and double IUI groups were 24.11% and 32.28%, respectively, with statistical significance (P < 0.05). Among the 6 groups, the clinical pregnancy rate was the lowest in Group 1 (P < 0.05) (). As shown in , as the amount of PTMS increased above Group 1, the clinical pregnancy rate of IUI was significantly improved.
Table 3. The relationship between PTMS and clinical pregnancy rate in AID-IUI.
Table 4. Clinical pregnancy rates of single IUI and double IUI in AID-IUI.
Discussion
The incidence of infertility is increasing with a greater number of couples choosing artificial insemination. IUI has been widely used in medical practice, because it is simple, effective, minimally invasive, and economical. In this study, the relationship between PTMS and pregnancy outcome was explored through retrospective analysis of 6,360 AIH-IUI and AID-IUI cycles performed in our Reproductive Medical Center between August, 1998 and August, 2010.
Some indications of AIH candidacy include cervical factor, male factor, endometriosis, immunologic abnormality, unexplained infertility, ovulation failure, as well as reproductive tract anomalies. The clinical pregnancy rate of AIH-IUI is approximately 10 % which is lower than that of in vitro fertilization and embryo transfer (IVF-ET). The pregnancy rate is associated with the woman's age, ovulation stimulations, time of insemination, frequency of insemination, semen quality, and the degree of tubal patency [Ibérico et al. Citation2004; Dickey et al. Citation2002]. However, injection of sufficient motile sperm into the uterine cavity is a key factor for successful IUI. It has been generally thought that in order to achieve the desired AIH-IUI pregnancy rate, a minimum concentration of PTMS are required, but optimum concentration appears to vary. PTMS is strongly and positively associated with IUI pregnancy outcome. Van Voorhis et al. [2001] suggest that when PTMS is ≥ 20 × 106, the pregnancy rate significantly increases and when PTMS is ≤ 10 × 106, the pregnancy rate is significantly less. Brasch et al. [1994] have reported a minimal threshold of 3 × 106 for IUI, and when PTMS exceeds 20 × 106 the pregnancy rate can increase significantly. At present, it is generally held that when PTMS is ≥10 × 106, the IUI pregnancy rate does not vary. Similarly Guo et al. [2007] did not observe any statistically significant difference in pregnancy rates when PTMS varied from > 40 × 106, 20-40 × 106, 10-20 × 106 and <10 × 106. However, the pregnancy rate significantly decreased when PTMS was ≤10 × 106 (P < 0. 05), suggesting that a PTMS of >10 × 106 is required. Li et al. [2009] examined pregnancy rate as a function of the PTMS using PTMS≤ 3 × 106, 3 × 106 <PTMS≤ 10 × 106, 10 × 106 <PTMS≤ 30 × 106, 30 × 106 <PTMS≤ 55 × 106, and PTMS > 55 × 106. Their results indicated that from 3-55 ×106 PTMS was ideal. However, when PTMS was ≤ 3 ×106 or ≥ 55 ×106 other assisted reproductive techniques were suggested.
As reported above, the total clinical pregnancy rate achieved with AIH-IUI was 10.81%. Among the 6 groups, the clinical pregnancy rate was the lowest in Group 1 (P < 0.05). As PTMS increased, the clinical pregnancy rate of IUI improved, but was only statistically significant when compared to Group 1.
Azoospermia accounts for about 7% to 14 % of male infertility, and is generally caused by bilateral cryptorchidism, testicular hypoplasia, and Klinefelter syndrome. Males with non-obstructive azoospermia or hereditary disease require donor sperm to reproduce. Females presenting unilateral or bilateral tubal patency and normal ovulation are AID candidates. Couples who receive donor semen must be informed of the risk of donor semen and ethical considerations.
The Chinese Ministry of Health has set quality standards for the use of frozen-thawed sperm in AID. The motility rate of progressive + nonlinear that is a + b grade sperm must be greater than 40 % and the PTMS injected into the uterine cavity must exceed 10 × 106 and this must be determined before AID as total motile sperm after freeze thawing is considerably different. Achard et al. [2005] have reported that the total motile sperm count after freeze thawing is a main pregnancy-related factor, and AID pregnancy rate is significantly higher when the total motile sperm count is >1.5 × 106 than when it is <1.5 × 106. Liu et al. [2004] assessed frozen-thawed motile sperm as a function of 3 groups of ≤20 × 106, 20-30 × 106, and ≥30 × 106. In comparison to ≥ 30 × 106, the pregnancy rate at ≤ 20 × 106 was significantly decreased.
Effect of single IUI or double IUI on pregnancy outcome
There has been considerable debate about whether the frequency of IUI increases pregnancy rates. It has been reported that the pregnancy rate is higher in double IUI than in single IUI [Matilsky et al. Citation1996; Ragni et al. Citation1999] suggesting that generally there is more than one mature follicle, which extends the ‘insemination window.’ Therefore, double IUI has more fertilization opportunities. Cantineau et al. [2003] have also reported that the pregnancy rate is higher in double IUI than in single IU. However, Alborzi et al. [2003] observed no difference in pregnancy rate between single and double IUI. A meta-analysis failed to indicate a higher pregnancy rate in double IUI [Osuna et al. 2004]. Different results may be associated with differences in ovarian stimulation and insemination time. However, as reported in this study the clinical pregnancy rate was significantly higher in double IUI than in single IUI in AID-IUI.
In summary, PTMS is strongly positively associated with clinical pregnancy rate. However, when PTMS is 2 × 106or less, clinical pregnancy rate of IUI is significantly decreased, so IVF should be adopted.
Materials and Methods
All study methods were approved by the Ethics Committee of the First Affiliated Hospital of Zhengzhou University. All of the subjects enrolled into the study gave written formal consent to participate.
Subjects
We retrospectively analyzed 6,360 IUI cycles including 4,532 AIH-IUI cycles and 1,828 AID-IUI cycles performed in our Reproductive Medical Center between August, 1998 and August, 2010. The married couples at reproductive age who failed to achieve pregnancy during one-year normal sexual activity and without contraception were diagnosed with infertility. However, in this study, although the duration of infertility was less than one year in some couples, when non-obstructive azoospermia or asthenospermia was identified in the male or cervical mucus was viscous in the female, these couples were also included.
AIH-IUI
Primary infertility was 2,733 cycles, and secondary infertility 1,799 cycles. Women underwent hystero-salpingogram (HSG) to confirm at least unilateral tubal patency, and men's semen analysis indicated normal semen or slight oligospermia or asthenozoospermia before IUI. All couples underwent routine physical examination and signed informed consent.
AID-IUI
Primary infertility was 1,654 cycles, and secondary infertility 174 cycles. Before IUI, men still had nonobstructive azoospermia or chromosomal abnormalities after examination and (or) treatment, and women underwent HSG or hydrotubation under hysteroscope, laparoscope, or open abdomen to confirm at least one side of tubal patency. Routine physical examination was performed to exclude systemic disease, infectious disease, and acute inflammation of the reproductive system in all patients. All couples voluntarily received donor semen and signed informed consent. Medical staff explained the risk of donor semen, ethical problems, and significance of follow-up.
Ovulation detection
Among 4,532 AIH-IUI cycles, there were 2,834 natural cycles and 1,698 induction cycles. Among 1,828 AID-IUI cycles, there were 1,438 natural cycles and 390 induction cycles. Clomifene Citrate (Cyprusgote Pharmaceutics, Limassol, Cyprus), human menopause gonadotropin (HMG, Lizhu Pharmaceutics, Zhuhai, China), follicle stimulating hormone (FSH, Lizhu Pharmaceutics, Zhuhai China), and letrozole (Jiangsu Hengrui Pharmaceutics, Lianyungang, China) were used for ovulation induction. From the fifth or seventh day of the menstrual cycle, follicular development was monitored by trans-vaginal sonography. When the leading follicle had a diameter ≥14 mm, a urine luteinizing hormone (LH) test was performed twice a day.
Collection of semen
The AIH-IUI semen samples were collected according to WHO procedures (1999). After the semen was treated and washed through Percoll or Pureception density gradient centrifugation, 0.5 ml of semen was used for artificial insemination. Routine analysis and PTMS were performed in the semen. PTMS = post-treated density × activity ratio of post-treated a + b grade sperm × a volume of semen injected into the uterine cavity.
For AID-IUI, frozen sperm was purchased from the Human Sperm Banks of Henan Province, Reproductive and Genetic Hospital of CITIC Xiangya, and Shanghai. The choice of semen samples must conform to the principles including anonymous sperm, mutual blindness, the same blood type as recipient husband, and similar facial features to recipient. After the semen was treated according to the method described by Li et al. [2010a, 2010b], 0.5 ml of semen was used for artificial insemination. Routine analysis and PTMS were performed in the semen.
Time of IUI
Routine time of IUI in our Reproductive Medical Center [Li et al. 2010a, 2010b] was adopted in this study including single IUI and double IUI. The patients in whom ovulation failed to be found were excluded from this study. Stratified analysis of pregnancy rate was performed according to single IUI and double IUI.
IUI procedures
Patients were placed in lithotomy position. After vaginal and cervical secretions were cleaned, semen was slowly injected into the uterine cavity followed by 20 min-dorsal decubitus.
Diagnosis of pregnancy
Blood β-hCG was determined in all patients 16 days after IUI, and then B-ultrasound was performed in the patients with positive β-hCG 35 days after IUI. Gestational sac, primitive heart tube pulsation, abortion, and eccyesis confirmed by pathology were regarded as clinical pregnancy.
Grouping
The study was divided into 6 groups according to PTMS: Group 1: ≤ 2.0 million, Group 2: 2.1- 4.0 million, Group 3: 4.1- 6.0 million, Group 4: 6.1- 8.0 million, Group 5: 8.1- 10.0 million, and Group 6: >10.0 million.
Statistical analysis
Statistical treatment was performed with SPSS 13.0 software. Measurement data were expressed as (). Numeration data were expressed as rate. t test was used in measurement data. χ2 test was used for comparison of rates. Statistical significance was established at P <0.05.
Declaration of Interest: There was no conflict of interest in this study.
Abbreviations
| IUI: | = | intrauterine insemination |
| AIH: | = | artificial insemination with husband semen |
| AID: | = | artificial insemination with donor semen |
| AIH-IUI: | = | artificial insemination with husband semen through intrauterine insemination |
| HSG: | = | hystero-salpingogram |
| AID-IUI: | = | artificial insemination with donor semen through intrauterine insemination |
| PTMS: | = | processed total motile sperm count |
| FSH: | = | follicle stimulating hormone |
| LH: | = | luteinizing hormone |
| IVF: | = | in vitro fertilization |
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