Intrauterine insemination versus fallopian tube sperm perfusion in non tubal infertility
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Intrauterine insemination versus fallopian tube sperm perfusion in non tubal infertility

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Background: Controlled ovarian hyper stimulation (COH) combined with intrauterine insemination (IUI), using a volume of 0.5 mail of inseminate is commonly offered to couples with non tubal ...

Background: Controlled ovarian hyper stimulation (COH) combined with intrauterine insemination (IUI), using a volume of 0.5 mail of inseminate is commonly offered to couples with non tubal infertility. Another method is Fallopian tube sperm perfusion (FSP) which is based on a pressure injection of 4 ml of sperm suspension while attempting to seal the cervix to prevent semen reflux. This technique ensures the presence of higher sperm density in the fallopian tubes at the time of ovulation than standard IUI. The aim of this study was to compare the efficiency of IUI and FSP in the treatment of infertility.

Methods: 200 consecutive patients with infertility in 404 stimulated cycles were included in the study. Those randomized to standard IUI included 100 patients in 184 cycles [158 Clomiphene citrate/human menopausal gonadotrophin cycles and 26 Letrozole/FSH cycles exclusively for polycystic ovarian disease patients] (group A). Patients subjected to FSP included 100 patients in 220 cycles (193 Clomiphene citrate/human menopausal gonadotrophin cycles and 27 Letrozole/FSH cycles exclusively for polycystic ovarian disease patients] (group B). Swim up semen preparation technique was used in all cases. Insemination was performed in both groups 34-37 hours after hCG administration. Standard IUI was performed using 0.5 ml of inseminate. In FSP 4ml inseminate was used.

Results: In group A (184 IUI cycles in 100 patients), 22 clinical pregnancies (presence of gestational sac with fetal cardiac activity) occurred (11.95% per cycle over four cycles). In group B, (220 cycles of FSP in 100 patients), 48 clinical pregnancies occurred (21.81%per cycle over four cycles) and this difference was statistically significant (p<0.05).

Conclusions: For non-tubal sub fertility, the results indicate clear benefit for FSP (Fallopian tube sperm perfusion) over IUI (Intrauterine insemination).

Key Words: Intrauterine insemination, Fallopian tube sperm perfusion, Non-tubal infertility.

Authors: Dr. Col (Retd) G S Shekhawat, MD(Obst & Gyn) * (Corresponding. Author), Dr Priyanka S, MBBS+

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Intrauterine insemination versus fallopian tube sperm perfusion in non tubal infertility Document Transcript

  • 1. Title of the article: Intrauterine insemination versus Fallopian tube spermperfusion in non-tubal infertilityType of article: Original articleName of the Author:Dr. Col (Retd) G S Shekhawat, MD(Obst & Gyn) * (Corresponding. Author)Dr Priyanka S, MBBS+Place of Research work : Assisted Reproductive Technology center, ArmedForces Medical College/ Command Hospital (Southern Command), Pune-411040 and 92 Base Hospital PIN -901218 C/O 56 APOAddress of the Authors:Associate professor, Dept of Obstetrics & Gynecology, Smt Kashibai NavaleMedical College, Narhe, Pune-411041, Maharashtra.Email: gsshekhawata@yahoo.co.in, Tel :( M) 9372897090,+Medical Officer, Smt Kashibai Navale Medical College, Narhe, Pune-411041,Maharashtra.Intellectual contribution of AuthorsStudy concept: Dr G S ShekhawatDrafting and Manuscript revision: Dr Priyanka SStatistical analysis: Dr Priyanka SStudy supervision: Dr G S ShekhawatWord Count: 2542 1
  • 2. AbstractBackground: Controlled ovarian hyper stimulation (COH) combined withintrauterine insemination (IUI), using a volume of 0.5 mail of inseminate iscommonly offered to couples with non tubal infertility. Another method isFallopian tube sperm perfusion (FSP) which is based on a pressure injection of4 ml of sperm suspension while attempting to seal the cervix to prevent semenreflux. This technique ensures the presence of higher sperm density in thefallopian tubes at the time of ovulation than standard IUI. The aim of this studywas to compare the efficiency of IUI and FSP in the treatment of infertility.Methods: 200 consecutive patients with infertility in 404 stimulated cycles wereincluded in the study. Those randomized to standard IUI included 100 patients in184 cycles [158 Clomiphene citrate/human menopausal gonadotrophin cyclesand 26 Letrozole/FSH cycles exclusively for polycystic ovarian disease patients](group A). Patients subjected to FSP included 100 patients in 220 cycles (193Clomiphene citrate/human menopausal gonadotrophin cycles and 27Letrozole/FSH cycles exclusively for polycystic ovarian disease patients] (groupB). Swim up semen preparation technique was used in all cases. Inseminationwas performed in both groups 34-37 hours after hCG administration. StandardIUI was performed using 0.5 ml of inseminate. In FSP 4ml inseminate was 2
  • 3. used.Results: In group A (184 IUI cycles in 100 patients), 22 clinical pregnancies(presence of gestational sac with fetal cardiac activity) occurred (11.95% percycle over four cycles). In group B, (220 cycles of FSP in 100 patients), 48clinical pregnancies occurred (21.81%per cycle over four cycles) and thisdifference was statistically significant (p<0.05).Conclusions: For non-tubal sub fertility, the results indicate clear benefit forFSP (Fallopian tube sperm perfusion) over IUI (Intrauterine insemination).Key Words: Intrauterine insemination, Fallopian tube sperm perfusion, Non-tubal infertility. 3
  • 4. IntroductionIntrauterine insemination (IUI) with mild ovarian stimulation has been used formany years in the treatment of non tubal infertility. During IUI, pretreated semenis concentrated in a small volume of 0.5 ml and deposited by a catheter into theuterine cavity. The overall pregnancy rates reported in the literature ranged from5.7% to 17.7% per cycle [1]. Although the number of available oocytes can beincreased by ovarian stimulation, the pregnancy rates in IUI are still notpromising, mainly because of suboptimal spermatozoa at the site of fertilization[2]. An alternative procedure, termed Fallopian tube sperm perfusion (FSP), hasbeen reported with improved pregnancy rates in comparison with IUI [3, 4, and5]. In FSP, sperm preparation is identical to that used in IUI, but thespermatozoa are diluted in a larger volume of medium up to 4 ml [6]. Thisvolume has been considered sufficient for bilateral passage of the spermatozoathrough the fallopian tubes. Theoretically, this would increase the density ofcapacitated spermatozoa near the oocytes and result in higher pregnancy rates.A prospective randomized study was designed to determine whether FSP 4
  • 5. resulted in higher pregnancy rates than IUI.Material & MethodsTwo hundred infertile patients, aged 17 to 39 years, undergoing 404consecutive cycles of ovarian stimulation were studied from June 2007 to Jan2009. Institutional board approval was obtained. These patients underwent abasic infertility workup including confirmation of tubal status byhysterosalpingogram or laparoscopy and hormone profile including serumfollicle stimulating hormone (FSH), luteinizing hormone (LH), prolactin andthyroid hormone tests. Menstrual cycle day 3 basal transvaginalultrasonography was done in all cases to rule out ovarian cysts prior toovulation stimulation. Exclusion criteria were age > 39 years, obstructedfallopian tubes and cases with marked oligospermia sperm count<10X106perml). 5
  • 6. The patients were classified for purpose of etiology of infertility as having mildand moderate endometriosis; ovulatory disorders (hormonal profile andtransvaginal sonography characteristic of polycystic ovarian syndrome);cervical hostility (poor properly timed post-coital test); male sub fertility (as perWHO criteria) [7]; unexplained infertility (where no infertility causes werefound).These patients underwent ovulation induction with either Clomiphene citrateand Human menopausal gonadotrophin (351 cycles in 174 patients) orLetrozole and FSH used exclusively for polycystic ovarian disease patients (53cycles in 26 patients). The ovarian stimulation protocol of clomiphene and hMG(Human menopausal gonadotrophin) was used in 170 patients. It consisted ofclomiphene citrate 100 mg daily on days 3-7 of the cycle, and 75 IU daily of hMG(Human menopausal gonadotrophin) on days 6-9 of the cycle. For some of thewomen, hMG was increased to 150 IU in subsequent cycles, depending on theprevious ovarian response. Rotterdam ESHRE consensus workshop criteria(2003) was used for diagnosis of PCOS. In all PCOS patients (26 patients),who had been on Metformin 500 mg t.i.d , Letrozole was given orally in a dose of2.5mg/day for 5 days starting from day 3 of a spontaneous or progesteroneinduced menstrual bleeding . Inj purified FSH 75 IU administered on 6-9 day ofmenstrual cycle.Cycles were monitored from day 9 onwards by transvaginal ultrasound 6
  • 7. measurement of the number and diameter of the growing follicles along withthe thickness and morphology of the endometrium. A dose of 10,000 IUhuman chorionic gonadotrophin (hCG) was administered when at least oneleading follicle had reached a diameter of 18 mm and at least 8 mmendometrial thickness with tri laminar ‘halo’ appearance seen. Patients werecalled 34 to 36 hours later, and either standard IUI (group A: 184 cycles in 100patients) or FSP (group B: 220 cycles in the 100 patients) was performed. Thepatients were counseled about the two alternative procedures and informedconsents were obtained before randomization. Patients were allocatedrandomly to standard IUI or FSP on the day of insemination in the first cycleitself, according to even or odd serial number in the register. Maximum of fourcycle treatments of IUI or FSP were considered for those patients who couldnot conceive in previous attempts. However those who failed to conceive withIUI were offered IUI only and vice versa.132 male partners were normozoospermic with count > 20X106 sperm per ml,>50% motile with forward progression (categories a and b) within 60 min ofejaculation and > 60% morphologically normal spermatozoa (WHO criteria) [7].Male partners with sperm count ranging from 10X106 to 20X106 were asked toproduce a second semen sample within 2 hours of the first sample on the day ofinsemination. Sixty-eight males having sub fertility as per WHO criteria didconsent to the study. However 04 could not produce a second sample at the time 7
  • 8. of IUI, and 1 patient had total sperm immotility and was excluded from the study.A fresh ejaculate was delivered in a sterile 60 ml jar by masturbation on theday of insemination. Neat semen was left at room temperature for liquefactionfor 30 minutes.The liquefied semen samples were analyzed for density andmotility using a fixed-depth counting chamber (Makler). The liquefied ejaculatewas transferred to a labeled sterile 14 ml round-bottomed disposablecentrifuge tube (Falcon No.2095) and 4 ml flushing media (Medicult) added toit. After thorough mixing the sample was centrifuged at 5000 rpm for 10minutes. Then, the supernatants were discarded and the pellet wasresuspended and mixed in 3 ml of fresh flushing media (Medicult) andcentrifuged for second wash again at 5000 rpm for 10 minutes. Once again thesupernatants were discarded. Each pellet was now gently layered with 0.5 mlfor IUI and 4 ml for FSP of universal IVF media (Medicult), and incubated at37oC in a humidified incubator with 5% Carbon dioxide for 1 hour. Post washsemen analysis was done in all cases using Makler’s counting chamber beforeinsemination.Intrauterine insemination was performed with conventional catheter using 0.5ml of inseminate. To eliminate dead space problem, IUI catheter was firstattached to syringe and then inseminate was aspirated. In FSP 4ml inseminatewas used and backflow of inseminate was occluded at the cervical opening bythe long size Allis clamp (Figure-1), which was suitably modified by attaching 8
  • 9. cervical occluding prongs with rubber cushions to avoid trauma to the cervixand was kept in place for about 3 to 4 minutes after insemination. In bothgroups, the patient rested for 30 minutes after insemination and received oralmicronized progesterone 100 mg, two tablets per day for luteal-phase support.Values were recorded as mean ± SD using Microsoft Excel version 4. Statisticalanalysis were performed using student’s t-test for testing significance ofdifference between the means and the X2test to compute p-values for testing theagreement between proportions. MedCalc statistical software (Meriakerke,Belgium) version 9.5.0.0 was used for all statistical analysis. The significancewas defined as p < 0.05. 9
  • 10. ResultsThe patient characteristics for group A and B were not significantly differentconcerning patient’s age (28.42 ± 2.78 years and 28.19 ± 2.80 years), type ofsterility (primary infertility 74% versus 72% respectively) and duration ofinfertility (5.6 ± 2.1 and 5.3 ± 1.9 years respectively). The clinical indications forIUI or FSP were also not significantly different for the two groups(endometriosis 12% versus 12%, polycystic ovarian syndrome 34% versus36%, cervical 4% versus 4%, unexplained 18% versus 12% and male factorsub fertility 32% versus 36% respectively). The ovarian stimulation protocol forgroup A and B were not significantly different (clomiphene citrate/hMG 85%versus 87% and Letrozole/FSH 15% versus 13% respectively). Theparameters of cycle monitoring for group A and B including number of follicles≥18 mm diameter(3.93±1.37 versus 3.90±1.17), endometrial thickness on theday of hCG administration (9.19±0.58mm versus 9.14±2.1mm) and thenumber of spermatozoa(38.83±16.57X106 versus 36.68±13.44X106)inseminated were not significantly different. However the day of hCGadministration (12.8±3.4 versus 11.1±2.1) was significantly different betweenthe two groups as shown in table-1and 2. 10
  • 11. Clinical pregnancy was defined by the presence of fetal cardiac activity,detected by ultrasound examination. Pregnancy rates were similar whencompared for the etiology of infertility: for ovarian (PCOS) cause (17.7% versus21.8%), endometriosis cause (8.4% versus 10.1%), male infertility (12.8%versus 16.4%) and unexplained infertility (14.4% versus 24%) for the twogroups, respectively as shown in table-3. There was statistically significantdifference (p<0.05) in the overall pregnancy rate per cycle over four treatedcycles (11.95% per cycle for IUI versus 21.81% per cycle for FSP over fourcycles) as shown in table-4. Two missed abortions and one twin pregnancyoccurred among the patients in group A (IUI). Three missed abortions and twotwin pregnancies occurred among the patients in group B (FSP). However, thislimited number of abortions and multiple pregnancies are too low to allow testingfor statistical significance. Three cases of mild ovarian hyper stimulationsyndrome (OHSS) occurred in both groups. 11
  • 12. DiscussionThe purpose of this prospective, randomized study was to study pregnancy ratesin couples with nontubal infertility when treated with FSP (inseminate volume 4ml), in comparison with standard IUI (inseminate volume 0.5 ml). Pregnancyrates were 21.81 and 11.95% respectively over four treatment cycles. The sameprotocols for ovarian stimulation were used in both groups. There was nostatistically significant difference regarding the age of the patients treated, meannumber of follicles, endometrial thickness on the day of hCG administration andthe total number of motile spermatozoa inseminated. However the day of hCG(12.8±3.4 for FSP versus 11.1±2.1 for IUI) administration was statistically 12
  • 13. different between the two groups (p value <0.05).Kahn et al. reported the first clinical experience with FSP. In their study, theyused a Frydman catheter for FSP and reported a pregnancy rate per cycle of26.9% in patients with unexplained infertility and of 2.7% to 7.7% in patients withother etiologies. These excellent results, particularly in patients with unexplainedinfertility, were confirmed by other studies [8]. Some investigators used apaediatric Foley catheter or cervical clamp double-nut bivalve speculum and veryencouraging results were reported by Fanchin et al, in which FSP using an autoblocking device (FAST system) doubled their pregnancy rates from 20% to 40%[1].The different types of catheters used for IUI have been compared but nostudy reports a significantly higher rate of pregnancy with any one type ofcatheter [9, 10,].The FSP increases the intrauterine pressure(70-200 mmHg) necessary for aflush influx of spermatozoa directly into the fallopian tubes. The high pregnancyrate per cycle for FSP as compared with standard IUI can be due to severalcauses as follows: firstly, the pressure injection of inseminate can either removeand/or circumvent transitory or partial obstruction of fallopian tubes, such as thatcreated by thick mucus or tubal polyps; secondly, the concentration of motilespermatozoa around the oocytes after FSP is higher than that obtained afterstandard IUI; and thirdly, FSP leads to inseminate overflowing into the pouch ofDouglas. The more accepted hypothesis is the existence of a similar mechanicaleffect created following a hysterosalpingography [10]. 13
  • 14. In this study, we tried to evaluate FSP not only in patients with unexplainedinfertility but also in patients with other causes of infertility including male causes.Two different stimulation regimes were used; however, the distribution of the twotypes of stimulation protocols (clomiphene citrate/hMG and Letrozole/FSH)appeared homogenous in both studies groups.Clinical pregnancy was defined by the presence of fetal cardiac activity,detected by ultrasound. When comparing the pregnancy rates in both IUI andFSP in relation to the etiology of infertility, it is found to be statistically similar asshown in table-3. Though the pregnancy rates of FSP in PCOS and unexplainedinfertility group of patients is superior to IUI, this finding is statistically notsignificant. This analysis revealed that couples suffering from any specificetiological sub fertility did not benefit from FSP over IUI.However, there was statistically significant difference in the overall pregnancyrate per cycle over four cycles of treatment (11.95% per cycle over four cyclesfor IUI versus 21.81% per cycle for FSP over four cycles) as shown in table-4(pvalue<0.009). Pregnancy rates improved in subsequent attempts with FSP incomparison to IUI. The cumulative pregnancy rates even after the secondattempt, over two cycle treatment, were statistically significant (p value <0.03),however there was no statistical difference when each attempt of treatmentcycles was compared between the two groups (p value >0.05).Four studies [2, 4, 6, and 11] mentioned a maximum of three cycles per couple;one study [12] reported a maximum of four cycles. We also allowed maximum of 14
  • 15. four cycles treatment of IUI or FSP before considering them for In vitrofertilization and embryo transfer (IVF-ET).The type of catheter has no impact on the pregnancy rate after intrauterineinsemination [13]. We suitably modified the long size allis clamp, by attachingcervical occluding prongs with rubber cushions, which was kept in place forabout 3 to 4 minutes after insemination to prevent any significant reflux. Mildreflux does not seem to influence the results of the FSP but the significant reflux(> 0.4 ml) may reduce the pregnancy [14]. If more than 1 ml comes back in thecatheter, the operator needs to wait for a few minutes and re-inseminate again.All the authors agreed that women tolerated the FSP technique very well. In ourstudy some patients complained of post insemination pelvic transient pain, moreso in FSP than in IUI. Other interesting domain of FSP application is theimmunological infertility in the presence of anti-sperm antibodies [15, 16].Thisaspect could not be studied in this study because pre and post FSP anti-spermantibody assay was not done.In this study by comparing the overall results, we conclude that FSP over fourcycles of treatment offers an advantage over the standard IUI, and can replacethe IUI for all its indications because of its better pregnancy rates. However FSPis more expensive than IUI due to the increased media usages. It could be usedas an alternative for couples with non tubal infertility before embarking on IVF-ETtreatment. 15
  • 16. References • Fanchin R, Oliveness F. A new system for fallopian tube sperm 16
  • 17. perfusion leads to pregnancy rates twice as high as standard intrauterine insemination. Fertility and Sterility 1995; 64(3):505–10.• Kahn JA, Sunde A, Von During V, et al. Treatment of unexplained infertility. Acta Obstetrica Gynaecologica de Scandinavia 1993; 72 (3):193–9.• Trout SW. Fallopian tube sperm perfusion versus intrauterine insemination: a randomized controlled trial and meta-analysis of the literature. Fertility and Sterility 1999; 71(5):881–5.• Ng EHY, Makkar G. A randomized comparison of three insemination methods in an artificial insemination program using husbands’ semen. The Journal of Reproductive Medicine 2003; 48(7):542–6.• Nuojou-Huttunen S, Tuomivaara L, Juntunen K. Comparison of fallopian tube sperm perfusion with intrauterine insemination in the treatment of infertility. Fertility and Sterility 1997; 67(5):939–42.• Gregoriou O, Pyrrgiotis E, Konidaris S. Fallopian tube sperm perfusion has no advantage over intra-uterine insemination when used in 17
  • 18. combination with ovarian stimulation for the treatment of unexplained infertility. Gynecologic and Obstetric Investigations 1995; 39: 226-8.• World Health Organization. WHO laboratory manual for the examination of human semen and sperm cervical mucus interaction. WHO laboratory manual. Cambridge: Cambridge University Press, 1992.• Mamas L. Comparison of fallopian tube sperm perfusion and intrauterine tuboperitoneal insemination: a prospective randomized study. Fertility and Sterility 2006; 85(3):735–40.• SmithKL, GrowDR, WiczykHP, et al. Does catheter type effect pregnancy rate in intrauterine insemination cycles? Journal of Assisted Reproduction and Genetics 2002; 19(2):49–52.• Noci I, Dabizzi S, Evangelisti P, et al. Evaluation of clinical efficacy of three different insemination Techniques in couple infertility. Minerva Ginecologica 2007; 59(1):11–8.• Ricci G, Nucera G, Pozzob et al. A simple method for fallopian tube sperm perfusion using a blocking device in the treatment of unexplained infertility. Fertility and Sterility 2001; 7 Suppl 1:1242–8. 18
  • 19. • Biacchiardi CP, Revelli A, Gennarelli G, et al. Fallopian tube sperm perfusion versus intrauterine insemination in unexplained infertility: a randomized, prospective, crossover trial. Fertility and Sterility 2004; 81 (2):448–51.• Vermeylen AM, D’Hooghe T, Debrock S, et al. The type of catheter has no impact on the pregnancy rate after intrauterine insemination: a randomized study. Human Reproduction 2006; 21(9):2364–7.• Kahn JA, von During V, Sunde A, et al. Fallopian tube sperm perfusion. First clinical experience. Hum. Reprod. 1992; 7: 19-24.• El Sadek MM, Amer MK, Abdel-Malak G. Questioning the efficacy of fallopian tube sperm perfusion. Human Reproduction 1998; 13 (11):3053–6.• Elhelw B, Matar H, Soliman EM. A randomized prospective comparison between intrauterine insemination and two methods of fallopian tube sperm perfusion. Middle East Fertility Society Journal 2000; 5(1):83–4. 19
  • 20. TABLE 1- Type of Infertility, clinical indications and ovarian stimulationprotocols in group A (IUI) and B (FSP)___________________________________________________________________________________ Group A Group Bz- Statistic p-value (Standard IUI) (FSP) value (100 patients) (100 patients)___________________________________________________________________________________Type of Infertility Primary Infertility 74% 72%0.054 0.873 Secondary Infertility 26% 28%0.025 0.873Clinical Indications for IUI/FSP Endometriosis 12% 12% 0.047 0.827 Ovulatory dysfunction 34% 36% 0.022 0.882 Cervical Factor 4% 4% 0.130 0.718 20
  • 21. Male factor 32% 36% 0.201 0.654 Unexplained 18% 12% 0.980 0.322Ovarian stimulation methods Clomiphene citrate/hMG (86%) (88%)0.044 0.833 (158 cycles in 86 patients) (193 cycles in 88patients) Letrozole/FSH (14%) (12%)0.044 0.833 (26 cycles in 14 patients) (27 cycles in 12 patients)___________________________________________________________________________________Differences between groups A and B were not statistically significant as p>0.05hCG = human chorionic gonadotrophin; IUI = intrauterine insemination, FSP =Fallopian tube sperm perfusion; hMG = human menopausal gonadotrophin, FSH = follicle stimulating hormoneTABLE 2- General characteristics, ovarian stimulation protocols, number offollicles, endometrial thickness on hCG administration and number ofmotile spermatozoa in groups A (IUI) and B (FSP)___________________________________________________________________________________ Group A Group B t-value p-value 21
  • 22. (Standard IUI) (FSP) (Mean ±SD) (Mean ±SD) n=100 patients n=100 patients_______________________________________________________________________________Age (years) 28.42±2.78 28.19±2.800.825 0.409Duration of Infertility (years) 5.6±2.1 5.3±1.91.506 0.132No. of follicles ≥17mm diameter 3.93 ± 1.37 3.90 ± 1.170.237 0.812Endometrial thickness (mm) 9.19 ± 0.58 9.14 ± 0.500.930 0.352On the day of HCGNumber of sperm inseminated(X106) # 38. 83 ± 16.57 36.68 ± 13.441.440 0.152Day of hCG administration 12.8±3.4 11.1±2.16.146 0.000___________________________________________________________________________________Differences between groups A and B were not statistically significant except dayof hCG administration#Total number of spermatozoa with forward progressive motilityhCG = human chorionic gonadotrophin; IUI = intrauterine insemination, FSP =Fallopian tube sperm perfusion; CC = clomiphene citrate; hMG = humanmenopausal gonadotrophin, FSH = follicle stimulating hormone; 22
  • 23. TABLE 3 – Clinical pregnancies (%) in relation to etiology of the infertility.___________________________________________________________________________________ Group A Group B z-statistic p-value (Standard IUI) (FSP) value Patients 100 Patients 100___________________________________________________________________________________Mild/Moderate Endometriosis 8.4% 10.1% 0.028 0.595(CC+hMG protocol) (12 patients) (12 patients)PCOS 17.7% 21.8% 0.016 0.896(Letrozol+FSH protocol) (34 patients) (36 patients)Cervical causes 0% 0% 0.000 1.000(CC+hMG protocol) (4 patients ) (4 patients)Unexplained 14.4% 24% 0.034 0.853(CC+hMG protocol) (18 patients) (12patients) Male subfertility 12.8% 16.4% 0.005 0.939(CC+hMG protocol) (32 patients) (36 patients)___________________________________________________________________________________ 23
  • 24. IUI = intrauterine insemination, FSP = Fallopian tube sperm perfusion; CC =clomiphene citrate; hMG = human menopausal gonadotrophin, FSH = folliclestimulating hormone; PCOS= Polycystic ovarian syndrome,TABLE 4- Clinical pregnancies (%) per cycles in relation to number of attemptedtreatment cycles in group A (IUI) and group B (FSP) IUI (100 patients) FSP(100 patients) z-statistic p- value___________________________ ___________________________Treatment No. of No. of Pregnancy No.of No.of PregnancyCycle cycles pregnancies rate (%) cycles pregnancies rate (%)First 100 16 16.00 100 24 24.001.531 0.215Second 40 4 10.00 66 16 24.240.335 0.562Third 30 2 6.66 34 06 17.64 0.897 0.343 24
  • 25. Fourth 14 0 0 20 02 10.00 0.230 0.631Total 184 22 11.95 220 48 21.815.860 0.0001_________________________________________________________________________________________IUI = intrauterine insemination, FSP = Fallopian tube sperm perfusion 25
  • 26. FIGURE -1 Digitally signed by Thomas F. Heston, MD, FAAFP, FASNC Reason: I have reviewed this document for the Internet Medical Journal. 26 Date: 2012.01.24 13:18:24 -0800