FERTILITY AND STERILITY

Vol. 58, No.5, November 1992

Copyright (:) 1992 The American Fertility Society

Printed on acid-free paper in U.S.A.

Intrauterine insemination after ovarian stimulation as a treatment for subfertility because of subnormal semen: a prospective randomized controlled trial

Pak-Chung Ho, M.D.* Wai-Ki SO, M.B., B.S. Yuen-Fai Chan, M.B., B.S. William Shu-Biu Yeung, Ph.D. Department of Obstetrics and Gynecology, University of Hong Kong, Hong Kong.

Objective: To determine whether intrauterine insemination (lUI) after ovarian stimulation with human menopausal gonadotropin (hMG) gives a better pregnancy rate (PR) than natural intercourse in couples with sub fertility because of subnormal semen. Design: Prospective randomized controlled trial. Setting: University based subfertility clinic. Patients: Couples with subnormal semen as the only identifiable cause of subfertility. Interventions: In control cycles, the couples had natural intercourse. In lUI cycles, lUI was performed after ovarian stimulation with hMG and human chorionic gonadotropin. Main Outcome Measure: The clinical PRs and complications of lUI cycles and control cycles were compared. Results: There were six clinical pregnancies in the 42 lUI cycles, whereas there was no clinical pregnancy in the 42 control cycles. The clinical PR in lUI cycles (14.3% per cycle) was significantly higher than that in control cycles (0%). Six patients (14.3%) developed moderate degree of ovarian hyperstimulation syndrome in lUI cycles. Conclusion: Intrauterine insemination after ovarian stimulation with hMG is useful in treatment of subfertile couples with subnormal semen. Fertil Steril 1992;58:995-9 Key Words: Intrauterine insemination, male subfertility, ovarian stimulation

Although intrauterine insemination (lUI) has been performed for a long time for treatment of various forms of subfertility, controlled trials confirming its therapeutic efficacy are few. We have previously shown in a prospective randomized controlled trial that lUI in natural cycles is not useful for treatment of oligoasthenospermia (1). In the past few years, there is increased interest in the use of lUI after ovarian stimulation with human menopausal gonadotropin (hMG) (2, 3). Cruz et al. (4) showed that in couples with subfertility because of Received February 11, 1992; revised and accepted July 27, 1992.

* Reprint requests: Pak-Chung Ho, M.D., Department of Obstetrics and Gynecology, 6th Floor, Professorial Block, Queen Mary Hospital, Hong Kong. Vol. 58, No.5, November 1992

oligoasthenospermia receiving hMG with or without clomiphene citrate (CC) for ovarian stimulation, the pregnancy rate (PR) of lUI 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 lUI, 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 PR of lUI combined with hMG was significantly higher than hMG or lUI alone, but the study was only a retrospective analysis. Ho et at. lUI after hMG in male subfertil{ty

995

In a prospective randomized comparative trial, Martinez et al. (7) found that after ovarian stimulation with hMG, the PRs oftimed intercourse and lUI were similar. Because of the designs of these studies, it is difficult to conclude whether lUI after ovarian stimulation with hMG gives a better PR than natural intercourse alone. Therefore, we have conducted a prospective randomized controlled trial to find out the answer. MATERIALS AND METHODS

Couples with sub fertility because of subnormal semen were recruited for study; these couples were assessed at our combined male subfertility clinic. The husband was examined by an endocrinologist and a surgeon to exclude medical and surgical problems and was asked to submit at least three samples of semen for routine analysis (8). Direct immunobead test (Biorad, Richmond, CA) for spermbound antisperm antibodies was performed at least once. The sera of the husband and wife were tested for antisperm antibodies with indirect immunobead test (9). Semen would be sent for culture ifthere was an increase in leukocytes in the semen. The PCT was performed as described by Glass (10). The selection criteria were as follows: [1] the duration of infertility was >2 years; [2] at least three semen analyses of the male partner were subnormal: sperm count was 16 days after the ovulating dose of hCG with a positive pregnancy test, but there was no ultrasonographic or histologic evidence of a pregnancy. A clinical pregnancy was diagnosed when there was ultrasonographic evidence of an intrauterine pregnancy or in the case of an abortion, the uterine curettings showed evidence of products of gestation. Differences in proportions were analyzed witl~ X2 and Fisher's exact test. Differences in means were analyzed with Student's t-test. For serum E2 and sperm counts, the data were analyzed after logarithmic conversion because they were skewed in distribution. RESULTS

Altogether, 15 couples were enrolled for the trial. The mean age of the women was 32.3 years (SD, 3.4) Fertility and Sterility

and that of the husbands was 33 years (SD, 9.5). The mean duration of infertility was 4.4 years (SD, 2.9). Thirteen ofthese couples (86.7%) had primary infertility, and 2 had secondary infertility. The semen parameters showed a single defect in 6 patients (40%), double defects in 7 patients (46.7%), and triple defects in 2 patients (13.3%). The sperm count was subnormal in 9 patients (60%), the motility was

Intrauterine insemination after ovarian stimulation as a treatment for subfertility because of subnormal semen: a prospective randomized controlled trial.

To determine whether intrauterine insemination (IUI) after ovarian stimulation with human menopausal gonadotropin (hMG) gives a better pregnancy rate ...
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