Intrauterine Insemination After Ovarian Stimulation As ATreatmentFor Subfertility Because Of Subnormal Semen

摘要

Objective: To determine whether intrauterine insemination (IUI) after ovarian stimulation with clomiphen citrate (CC) gives a better pregnancy rate (PR) than natural intercourse in couples with subfertility because of subnormal semen.Design: prospective randomized controlled trial.Patients: Couples with subnormal semen as only identifiable cause of subfertility.Interventions: In control cycles, the couples had natural intercourse. In IUI cycles, IUI was performed after ovarian stimulation with CC and human chorionic gonadotropin.Main Outcome Measure: The clinical PRs and complications of IUI cycles and control cycles were compared.Results: There were four clinical pregnancies in the 32 IUI cycles, whereas there was no clinical pregnancy in the 32 control cycles. The clinical Pr in IUI cycles (12.5%per cycle) was significantly higher than that in control cycles (0%). None patients developed ovarian hyperstimulation syndrome in IUI cycles. Conclusion: Intrauterine insemination after ovarian stimulation with CC is useful in treatment of subfertil couples with subnormal semen. Introduction Although intrauterine insemination (IUI) has been performed for a long time treatment of various forms of sub fertility, only few control trials confirm its therapeutic efficacy (1). In the past few years, there was increased interest in the use of IUI after ovarian stimulation with human menopausal gonadotropin and pregnancy rate was significantly better than the natural cycle (2,3). Cruz et al. (4) showed that in couples with sub fertility due to oligoasthenospermia receiving hMG with or without clomiphen citrate (CC) for ovarian stimulation, the pregnancy rate (PR) of IUI was significantly better than intracervical insemination. However, a control group having natural intercourse without ovarian stimulation was not included in their study. Kemmann et al.(5) reported that ovarian stimulation with CC and / or hMG improved the PRs of patients treated with IUI, but their study group included couples with either subnormal semen or poor postcoital test (PCT). Moreover the study was not a prospective randomized study, and only historical controls were used. Recently, Chaffkin et al. (6) reported that the PRs of IUI combined with hMG was significantly higher than hMG or IUI alone, but the study was only a retrospective analysis. In a prospective randomized comparative trial, Martinez et al. (7) found that after ovarian stimulation with hMG the PRs of timed intercourse and IUI were similar. Because of the designs of these studies, it is difficult to concluded whether IUI after ovarian stimulation with hMG gives a better PR than natural intercourse alone. In this study we have been a prospective randomized controlled trial, to determine whether intrauterine insemination (IUI) after ovarian stimulation with clomiphen citrate (CC) gives a better pregnancy rate (PR) than natural intercourse in couples with sub fertility because of subnormal semen. Method and Material Couples with sub fertility because of subnormal semen were recruited for the study and were assessed at our infertility clinic. The husband was examined by an endocrinologist and surgeon to exclude medical and surgical problems and was asked to submit at least three samples of semen for routine analysis (8,9). Semen would be sent for culture if there were an increase in leukocytes in the semen. The PCT was performed as described by Glass (10). The selection criteria were as follows: the duration of infertility was>2 years; at least three semen analyses of the male partner were subnormal: sperm count was <2000000 / ml, progressive motility at 2 hours was < 50% or normal morphology was < 50% (8); there was no other identifiable factor responsible for the sub fertility. The female partner was ovulating regularly (with cycle length usually between 25 and 35 days). With midluteal progesterone > 32 nmol/ L there should be no coital problem. HSG was performed in all patients and they were recruited