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18 results

  • Chapter 6 - Unexplained Infertility

  • Edited by Siladitya Bhattacharya, University of Aberdeen, Mark Hamilton, University of Aberdeen
  • Book:
    Reproductive Medicine for the MRCOG
    Published online:
    25 February 2021
    Print publication:
    25 February 2021, pp 54-67

  • Summary

    Unexplained infertility refers to the inability to conceive within 12 months of unprotected intercourse, not attributable to any known causes of infertility such as ovulatory dysfunction, reduced sperm quality, tubal pathology or other causes. Treatment for unexplained infertility can be done predominantly through intrauterine insemination with or without hyperstimulation or in vitro fertilisation. Given that these treatments are utilised to improve likelihood of conception in relation to the couple’s chances of spontaneous pregnancy, rather than targeting any specific pathology, a comparison should be drawn between these treatments and their natural conception prognosis. Utilisation of prognostic models can allow differentiation between those likely to benefit from immediate treatment from such individuals who have reasonable natural conception prognosis and thereby can delay treatment for 6 months in hopes of spontaneous pregnancy. This comparison is valuable given the aforementioned treatments have implications for both the woman and her future child, and the cost of such procedures also compromises care accessibility.

  • Chapter 13 - Artificial Insemination with Partner’s Sperm for Male Subfertility

  • Edited by R. John Aitken, University of Newcastle, New South Wales, David Mortimer, Gabor Kovacs
  • Book:
    Male and Sperm Factors that Maximize IVF Success
    Published online:
    24 May 2020
    Print publication:
    30 April 2020, pp 154-165

  • Summary

    According to a number of high-quality studies, intrauterine insemination (IUI) with homologous semen should be the first choice of treatment in the case of moderate male factor subfertility. IVF and ICSI are clearly over-used in this selected group of infertile couples. The limited value of IUI in infertility treatment, as mentioned in the 2013 NICE guidelines, was surely a premature statement and should be adapted to the actual literature. Oxidative stress and high sperm DNA damage is associated with lower pregnancy rates after IUI. Concerning clinical outcome, there is no clear evidence of any sperm preparation technique to be superior. More evidence-based data are becoming available on different variables influencing the success rates after IUI. It can be expected that these findings may lead to a better understanding and use of IUI in the near future.

  • 5 - Endometriosis-related infertility

  • Edited by Siladitya Bhattacharya, University of Aberdeen, Mark Hamilton
  • Book:
    Management of Infertility for the MRCOG and Beyond
    Published online:
    05 June 2014
    Print publication:
    30 January 2014, pp 57-66

  • Summary

    Endometriosis causes pain and infertility for millions of women worldwide. The prevalence of endometriosis is 6-10% in women of reproductive age, and 30-50% of women with pelvic pain and/or infertility. For definitive diagnosis and staging of endometriosis, a surgical procedure, generally a laparoscopy, is necessary to visualise disease implants. More recently, magnetic resonance imaging (MRI) has been used as a non-invasive tool in the diagnosis of deep endometriosis. The aim of treatment of endometriosis is to remove or reduce disease deposits. This may be attempted through medical or surgical means. Although assisted conception treatments such as ovulation induction with intrauterine insemination (IUI), or in vitro fertilisation (IVF), do not treat endometriosis per se, they can successfully treat the associated infertility. All couples presenting with failure to conceive should undergo a full evidence based fertility work-up. This includes a semen analysis, confirmation of ovulation and tubal patency testing.

  • 7 - Unexplained infertility

  • Edited by Siladitya Bhattacharya, University of Aberdeen, Mark Hamilton
  • Book:
    Management of Infertility for the MRCOG and Beyond
    Published online:
    05 June 2014
    Print publication:
    30 January 2014, pp 77-84

  • Summary

    Expectant management has a key role in the management of unexplained infertility. The decision to treat couples with unexplained infertility should take into account their chances of spontaneous conception, which is affected by female age, duration of infertility and occurrence of a previous pregnancy. The rationale for the use of oral clomifene citrate in unexplained infertility is the belief that it corrects subtle ovulatory dysfunction and encourages the release of more than one oocyte. Clomifene is inexpensive, non-invasive and requires little clinical monitoring, but it can cause multiple pregnancies, including high-order multiples. Intrauterine insemination (IUI) has been used widely for the treatment of unexplained infertility. It is thought to enhance the chance of pregnancy by increasing the number of motile spermatozoa within the uterus, bringing them in close proximity to the oocyte. Although more effective than IUI, superovulation (SO) along with IUI is associated with high rates of multiple births.

  • Chapter 10 - Polycystic ovarian syndrome

  • from Section 3: - Difficulties and complication of ovarian stimulation
  • Edited by Mohamed Aboulghar, Botros Rizk, University of South Alabama
  • Book:
    Ovarian Stimulation
    Published online:
    05 August 2011
    Print publication:
    23 December 2010, pp 87-102

  • Summary

    This chapter focuses on the indications for intrauterine insemination (IUI) in combination with mild ovarian hyperstimulation (MOH), its methods and risks. Optimal timing of the insemination is a crucial factor in IUI programs. After ovulation oocytes should be fertilized within several hours. Inseminated sperm (bypassing the cervix which acts as a reservoir for spermatozoa) has a limited period of survival, and sperm should therefore not be inseminated too early. When MOH is applied in IUI programs, one should strive after multifollicular growth of two to three dominant follicles to obtain the highest probability of conception with reasonable risks. When multiple pregnancies are kept to a minimum, MOH/IUI is more cost-effective compared with in vitro fertilization (IVF). Gonadotropins are the most effective drugs and should be offered in a low-dose, step-up protocol. Future randomized trials should investigate the cost-effectiveness of luteal support.

  • Chapter 14 - Using donor oocytes

  • Edited by Gab Kovacs
  • Book:
    The Subfertility Handbook
    Published online:
    06 December 2010
    Print publication:
    11 November 2010, pp 158-165

  • Summary

    The rationale behind intrauterine insemination (IUI) with partner sperm is bypassing the cervical-mucus barrier and increasing the number of motile spermatozoa with a high proportion of normal forms at the site of fertilization. This chapter examines the value and position of homologous intrauterine insemination in an assisted reproductive technology (ART) program. Some of the factors influencing IUI success include site of insemination, number of inseminations, exact timing of IUI, sperm preparation methods and fallopian tube sperm perfusion. Artificial inseminations can be done intravaginally, intracervically (ICI), pericervically using a cap, intrauterine (IUI), transcervical intrafallopian (IFI) or directly intraperitoneal (IPI). Most studies refer to IUI, which seems to be an easy and better way of treatment. IUI should be promoted as the best first-line treatment in most cases of subfertility provided at least one tube is patent and an IMC after sperm preparation of more than 1 million can be obtained.

  • Chapter 23 - Management of ejaculatory duct obstruction

  • Edited by Larry I. Lipshultz, Stuart S. Howards, University of Virginia, Craig S. Niederberger, University of Illinois, Chicago
  • Book:
    Infertility in the Male
    Published online:
    19 May 2010
    Print publication:
    24 September 2009, pp 421-429

  • Summary

    This chapter summarizes normal immune function and its relationship to immunologic infertility. The normal immune system identifies and destroys antigen within the body. The humoral immune system is suited to the destruction of whole, extracellular antigens, including most bacteria, larger parasites, and viruses. Antispermatogenic autoantigens induce autoimmunity to the germinal epithelium, resulting in a specific decline in sperm production due to germ cell destruction. Tail-directed sperm antibodies are more likely to impair motility and cause agglutination, sperm head-directed antibodies may preferentially affect zona binding and fertilization, as suggested by immobilization and penetration assays. Corticosteroids prevent the chemotaxis of inflammatory cells, impede cytokine release, decrease antibody production, and even weaken antigen-antibody association. Intrauterine insemination (IUI) is suited for treatment of infertility when there is evidence of cervical mucus problem, whether it is due to antibodies or not, as demonstrated by the inability of sperm to penetrate the cervical mucus.

  • Chapter 35 - Sperm processing techniques

  • Edited by Larry I. Lipshultz, Stuart S. Howards, University of Virginia, Craig S. Niederberger, University of Illinois, Chicago
  • Book:
    Infertility in the Male
    Published online:
    19 May 2010
    Print publication:
    24 September 2009, pp 582-592

  • Summary

    Intrauterine insemination (IUI) is indicated for couples with unexplained infertility, mild to moderate male-factor infertility, or certain female factors, such as antisperm antibodies or a hostile cervical environment. Pre-screening for couples attempting an IUI procedure includes testing for infectious diseases, genetic abnormalities, and general medical problems, such as anemia. Oligospermic men have an increased likelihood of harboring genetic anomalies, such as Y-chromosome microdeletions. The use of fertility drugs has been associated with neoplasia, particularly borderline ovarian tumors. Pregnancy complications include multiple gestations, birth defects, low birthweight, and ectopic pregnancies. Chain of custody is a concept that dictates exactly which person or facility has physical control of a laboratory specimen from the time it leaves the patient's body until it arrives at its ultimate destination. In IUI, the initial specimen is the man's ejaculate and the final destination is his designated partner's uterus.

  • Chapter 7 - Preimplantation genetics

  • from Section 1 - Background
  • Edited by Joyce Harper, University College London
  • Book:
    Preimplantation Genetic Diagnosis
    Published online:
    09 November 2009
    Print publication:
    28 May 2009, pp 137-150

  • Summary

    In vitro fertilization (IVF) was initially developed to treat patients with damaged Fallopian tubes. IVF treatment has since been extended far beyond tubal infertility to treat a whole host of indications, including unexplained infertility, endometriosis, and male infertility. Infertility treatments include timed intercourse, ovulation induction, intrauterine insemination (IUI), gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), IVF, and intracytoplasmic sperm injection (ICSI). Standard stimulation protocols require pituitary desensitization with a GnRH agonist, and this strategy has become almost a universal practise in assisted conception clinics with the induced hypogonadotropic hypogonadism enabling almost complete control over follicular development. The presence of endometrial polyps, submucous fibroids, and intrauterine adhesions may be associated with reduction in pregnancy rates and increase in risk of miscarriage with IVF. Cryopreservation of supernumerary good-quality embryos is vital to optimize pregnancy rates per cycle started without the need to superovulate the patient again.

  • 36 - Unexplained Infertility

  • from PART II - INFERTILITY EVALUATION AND TREATMENT
  • Edited by Botros R. M. B. Rizk, University of South Alabama, Juan A. Garcia-Velasco, Hassan N. Sallam, Antonis Makrigiannakis, University of Crete
  • Book:
    Infertility and Assisted Reproduction
    Published online:
    04 August 2010
    Print publication:
    15 September 2008, pp 332-338

  • Summary

    Unexplained infertility is a diagnosis made by exclusion after a complete infertility evaluation. Standard testing for infertility should include semen analysis (evaluated according to the WHO criteria), assessment of ovulation (serum progesterone determination in the midluteal phase), and an evaluation of tubal patency. At present, other additional investigations contribute relatively little to effective diagnosis of unexplained infertility. Laparoscopy is required to make a diagnosis of endometriosis or adnexal adhesions, but in the presence of tubal patency, these lesions seem to be of lesser significance. The use of intrauterine insemination (IUI) together with ovulation induction in normally ovulating women carries a risk of ovarian hyperstimulation syndrome and multiple pregnancy. Based on the available information, it is reasonable to recommend an escalating course of gonadotropin ovarian stimulation with IUI and then in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI).

  • 20 - Male Factor Infertility: State of the ART

  • from PART II - INFERTILITY EVALUATION AND TREATMENT
  • Edited by Botros R. M. B. Rizk, University of South Alabama, Juan A. Garcia-Velasco, Hassan N. Sallam, Antonis Makrigiannakis, University of Crete
  • Book:
    Infertility and Assisted Reproduction
    Published online:
    04 August 2010
    Print publication:
    15 September 2008, pp 178-186

  • Summary

    Rational treatment of the infertile male requires a correct and complete etiological diagnosis. Varicocele develops during puberty, and it is the most common cause of male infertility with prevalence varying between 30 and 60 percent. Thermography, endovascular treatment, and transcatheter embolization are treatment options for varicocele patients. Male accessory gland infection (MAGI) may result from infestation by sexually transmitted pathogens. The prevalence of immunological infertility is related to that of the diseases initiating the antibody formation, but it is no more than 5 percent in our population. Idiopathic sperm deficiency probably results from the combination of unfavorable external and lifestyle factors which includes conditions like idiopathic oligozoospermia, asthenozoospermia, or teratozoospermia. Intrauterine insemination (IUI) is an effective mode of treatment but if IUI remains unsuccessful after a maximum of four cycles, intracytoplasmic sperm injection (ICSI) should be recommended.

  • 23 - Clomiphene Citrate for Ovulation Induction

  • from PART II - INFERTILITY EVALUATION AND TREATMENT
  • Edited by Botros R. M. B. Rizk, University of South Alabama, Juan A. Garcia-Velasco, Hassan N. Sallam, Antonis Makrigiannakis, University of Crete
  • Book:
    Infertility and Assisted Reproduction
    Published online:
    04 August 2010
    Print publication:
    15 September 2008, pp 202-219

  • Summary

    Clomiphene revolutionized the management of infertility in 1967 when it was approved for treatment of anovulation due to polycystic ovaries (PCO). The pharmacokinetics and pharmacodynamics of clomiphene explain its characteristic actions. After ovulation induction with clomiphene, serum progesterone and estradiol serum levels are increased during the luteal phase of the cycle in a direct dose-response relationship. Ultrasound of the ovaries should always be performed before initiating clomiphene treatment for the first time to rule out preexisting ovarian neoplasm, endometriomas, and persistent corpus luteum cysts to evaluate the number and size of antral follicles. Progesterone is used to confirm ovulation to determine if the dose of clomiphene is sufficient. Pregnancy rates may be increased in clomiphene cycles by increasing the number of follicles that develop, by improving endometrial conditions and cervical mucus, and by intrauterine insemination (IUI) when numbers of sperm on a postcoital test are low or absent.

  • 32 - Endometriosis-Associated Infertility

  • from PART II - INFERTILITY EVALUATION AND TREATMENT
  • Edited by Botros R. M. B. Rizk, University of South Alabama, Juan A. Garcia-Velasco, Hassan N. Sallam, Antonis Makrigiannakis, University of Crete
  • Book:
    Infertility and Assisted Reproduction
    Published online:
    04 August 2010
    Print publication:
    15 September 2008, pp 302-308

  • Summary

    This chapter illustrates the different opinions regarding the pathophysiology and management of endometriosis-associated infertility. Pelvic inflammation due to endometriosis may cause adhesion formation and scarring, which leads to a disruption and decrease in fertility. Medical treatment using GnRH agonists can only be used prior to in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). When moderate or severe endometriosis causes anatomic distortion of the pelvis in women who wish to maintain or restore fertility, surgery may be the treatment of choice. Clomiphene citrate and intrauterine insemination (IUI) treatment triple the monthly fecundity rate from 3.3 to 9.5 percent, as compared with nontreatment cycles, in patients with surgically corrected endometriosis. If laparoscopic surgery will be performed before IVF-ICSI cycles, a less invasive and conservative technique should be used during the operation such as cyst aspiration or fenestration.

  • 18 - The Basic Semen Analysis: Interpretation and Clinical Application

  • from PART II - INFERTILITY EVALUATION AND TREATMENT
  • Edited by Botros R. M. B. Rizk, University of South Alabama, Juan A. Garcia-Velasco, Hassan N. Sallam, Antonis Makrigiannakis, University of Crete
  • Book:
    Infertility and Assisted Reproduction
    Published online:
    04 August 2010
    Print publication:
    15 September 2008, pp 157-160

  • Summary

    This chapter establishes fertility/subfertility thresholds for sperm concentration, motility, progressive motility, and sperm morphology using Tygerber strict criteria. It seems as if the sperm morphology threshold of 0-4 percent normal forms indicates a higher risk group for subfertility and fits the in vitro fertilization (IVF) and intrauterine insemination (IUI) data calculated previously. A concentration of below fifteen million per ml and percent motility below 30 percent also reflect parameters in the subfertile range. Swim-up and sperm functional tests must be encouraged to assist clinicians in the day-to-day handling of male factor infertility and be of immense help to make a good decision on a specific male problem. It is estimated that intracytoplasmic sperm injection (ICSI) should be indicated when male infertility is properly diagnosed based upon a state-of the- art extended evaluation of the male partner and also in cases with previous failed fertilization.

  • 42 - Endometriosis and Assisted Reproductive Technology

  • from PART III - ASSISTED REPRODUCTION
  • Edited by Botros R. M. B. Rizk, University of South Alabama, Juan A. Garcia-Velasco, Hassan N. Sallam, Antonis Makrigiannakis, University of Crete
  • Book:
    Infertility and Assisted Reproduction
    Published online:
    04 August 2010
    Print publication:
    15 September 2008, pp 381-385

  • Summary

    Most of the available evidence supports the hypothesis that endometriosis compromises fertility. According to ESHRE 2005 guidelines for the diagnosis and treatment of endometriosis, treatment with intrauterine insemination (IUI) improves fertility in minimal-mild endometriosis: IUI with ovarian stimulation is effective but the role of unstimulated IUI is uncertain. Lower pregnancy and implantation rates have been documented in women with severe (stage III or IV) endometriosis when compared to mild (stage I or II) endometriosis. Assisted Reproductive Technology (ART) may bypass some of the mechanisms of endometriosis-associated infertility, but the disease may have an impact on cycle outcome. Oocyte donation appears as an alternative in patients with endometriosis with low response, poor embryo quality, or repeated ART failures. Surgery for endometriomas in women undergoing ART is indicated in symptomatic women; otherwise, it does not add any benefit to cycle outcome. However, careful surgery does not compromise ovarian reserve.

  • 5 - Treatment options prior to IVF

    • By Roger Hart, UWA School of Women's and Infant's Health, Subiaco, Australia, Melanie Davies, Reproductive Medicine Unit, Elizabeth Garrett Anderson Hospital and Obstetric Hospital, London, UK
  • Edited by Paul Serhal, Caroline Overton
  • Book:
    Good Clinical Practice in Assisted Reproduction
    Published online:
    22 October 2009
    Print publication:
    01 July 2004, pp 100-111

  • Summary

    The treatment options that face a couple prior to in vitro fertilisation (IVF) depend upon the cause of their infertility. To clarify the definition of male factor subfertility to produce a pragmatic approach to treatment, Van Voorhis published a study that correlates the effect of the total motile sperm count with the outcome of assisted reproduction. A diagnosis of unexplained infertility cannot be made without a laparoscopy to exclude the presence of pelvic adhesions or endometriosis. There is evidence that in couples with otherwise unexplained infertility, the fecundity of women with minimal and mild endometriosis is improved by laparoscopic ablation of the endometriotic deposits. The commonest cause of anovulatory infertility is polycystic ovarian syndrome (PCOS). Unexplained infertility is reported to occur in up to 60% of couples. The simplest, least invasive and cheapest regime for superovulation and intrauterine insemination (IUI) is the use of clomiphene citrate.