Human Reproduction Unit, Department of Obstetrics and Gynaecology, Hospital De Cruces, País Vasco University, Baracaldo, Vizcaya, Spain
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Abstract |
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Key words: intrauterine insemination/oestradiol/ovarian stimulation/pregnancy rate/recombinant FSH
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Introduction |
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Materials and methods |
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The pre-study work-up for the women included pelvic and systemic examination, blood chemistry, endometrial biopsy, plasma progesterone and prolactin concentration, postcoital test, hysterosalpingography, pelvic ultrasound and laparoscopy. The following pathologies were detected in the women, some of whom had more than one condition: 22.0% mild tubal factor, 31.9% endometriosis, 12.1% ovulatory disorders, 5.5% hyperprolactinaemia, 9.9% cervical factor, 17.0% uterine myomata (<4 cm), and 3.3% immunological factor. Semen samples were obtained after 4 days of sexual abstinence and studied according to the WHO standards (WHO, 1992), except for progressive motility which was analysed following our laboratory reference values. Asthenozoospermia was defined if there were <30% of progressive motile spermatozoa (Matorras et al., 1998). The main male diagnoses were: oligozoospermia (4.4%), asthenozoospermia (58.2%), teratozoospermia (29.7%), and immunological factor (5.5%). In all cases of male factor infertility there was asthenozoospermia, alone or in combination with the other male conditions described above.
The IUI method has been reported previously (Matorras et al., 1995, 1997
). Ovarian cycle stimulation was started on the second day of the menstrual cycle, with 150 IU of rFSH (Gonal F; Laboratorios Serono, Madrid, Spain) or with 150 IU of uFSH (Metrodin HP; Laboratorios Serono). After a short period of training, patients self-administered either drug s.c. Ovarian monitoring was carried out by means of vaginal ultrasound and oestradiol monitoring, starting on day 67 of the menstrual cycle, and adjusting the dose of gonadotrophins according to response. Human chorionic gonadotrophin (HCG, 5000 IU) (Profasi; Laboratorios Serono) was given on the day on which there were two or more follicles of
17 mm diameter, the oestradiol concentration being >400 pg/ml (conversion factor to SI units, 3.671). If the two aforementioned criteria were not reached, the cycle was cancelled because of low response. Patients with declining oestradiol concentrations were also cancelled. If there were more than six follicles
17 mm diameter and/or oestradiol concentrations >2000 pg/ml, then the cycle was cancelled because of hyper-response (risk of hyperstimulation/multiple pregnancy). In patients in whom two cycles were cancelled, in the following cycles the ovarian stimulation was performed under gonadotrophin-releasing hormone (GnRH) agonist treatment with 0.75 mg/day leuprolide acetate (Procrin; Abbott, Madrid, Spain), beginning on the 22nd day of the previous cycle.
A single insemination per cycle was performed with 0.30.5 ml of prepared spermatozoa, 36 h after HCG administration. Sperm preparation was performed with PureSperm (Centola et al., 1998; Claassens et al., 1998
). In all cases the luteal phase was supplemented as reported previously (Matorras et al., 1996
, 1997
): with HCG in cases with oestradiol concentrations <1500 pg/ml (2500 units on day +1, +3, +5 and +7 following IUI); or with vaginal micronized progesterone in cases with oestradiol concentrations >1500 pg/ml (Utrogestan; Laboratoires Besins-Iscovesco, Paris, France) (100 mg/12 h during the 15 days following IUI). A total of six cycles of IUI was performed if pregnancy was not obtained previously. In all cases, pregnancy was defined by the visualization of a gestational sac at the sixth to seventh week of amenorrhoea.
Design of the study
The 91 couples studied were divided randomly into two groups, by means of sealed envelopes: 45 in the rFSH group (out of 163 started cycles, 24 were dropped, corresponding to 139 IUI cycles) and 46 in the uFSH group (out of 182 started cycles, 27 were dropped, corresponding to 155 cycles). The randomization was performed by a person not involved in the study. Computer-generated random numbers were placed into sealed envelopes. Patients were blinded with regard to the type of treatment, as were the ultrasound staff, oestradiol analysis and sperm laboratory. The prescribing gynaecologist was not blinded. Patients were randomized at the beginning of the study and remained in the same treatment during all the IUI cycles. The frequency of the number of cycles in each group was as follows: one cycle (45 rFSH, 46 uFSH); two cycles (30 and 34); three cycles (23 and 26); four cycles (21 and 20); five cycles (11 and 17); and six cycles (nine and 12). The numbers of patients in each group undergoing the varying numbers of stimulation cycles are shown in Table I.
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Results |
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With regard to pregnancy rates, one spontaneous pregnancy occurred in one rFSH patient, after failure to obtain pregnancy in one IUI cycle, another cycle being cancelled. Thus, the PR has been calculated both including this case (per intention to treat PR) and excluding it (corrected PR) (Table III). The PR calculated on a per woman basis were somewhat higher in rFSH, both on a per intention to treat basis (57.8% versus 52.2%) and on a per woman corrected PR (56.8% versus 52.2%; OR = 1.20, 95% CI = 0.483.0) and cumulative PR (69.6% versus 61.0%), but without statistical significance. The per cycle crude PR was 17.99% in rFSH versus 15.48% in uFSH, which again lacked statistical significance (Table II
). Nor were there differences concerning the per cycle corrected PR (18.12% versus 15.48%; OR = 1.21, 95% CI = 0.622.33). The first cycle PR was 28.88% (13/45) in rFSH versus 23.91% (11/46) in uFSH (not significant; OR = 1.29, 95% CI = 0.463.64).
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The number of FSH ampoules consumed in cancelled cycles was also lower in the rFSH group (17.04 ± 5.46 versus 25.5 ± 13.68; P = 0.006), the number of oestradiol determinations and ultrasounds being similar. No cases of ovarian hyperstimulation syndrome (OHSS) or other adverse effects were detected in the rFSH or uFSH groups.
The proportion of multiple pregnancies was similar in both groups, as follows: one twin, one triplet and two quadruplets (one of which evolved spontaneously to a twin) in rFSH; and five twin, one triplet and one quadruplet in uFSH. The abortion rate was 12.5% (3/24) in uFSH compared with 28% (7/25) in rFSH; these were not significantly different. There was one ectopic pregnancy in uFSH and two ectopic pregnancies in rFSH.
It was calculated that with a similar study design (one case/one control), to demonstrate that the per woman PR found here were statistically different, with a power of 90% and an -value of 0.05, a total of 1227 study couples and 1227 control couples would be required. Similarly, under the same methodological conditions, totals of 2131 study cycles and 2131 control cycles would be required to achieve statistical significance with regard to per cycle PR.
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Discussion |
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In our study, no statistical difference was obtained in PR, although the rates appeared somewhat higher in the rFSH group (18.12% versus 15.48% per cycle). However, the possibility of a ß error cannot be discarded, since to demonstrate that such differences were of statistical significance would require studying about 2500 women and 4200 cycles. It should be noted that the OR obtained in our study for rFSH, both per cycle and per woman (1.21 and 1.20), were similar to the overall total OR (1.20) reported in the aforementioned meta-analysis (Daya and Gunby, 1999), although in the meta-analysis statistical significance was reached.
With regard to the potency of the two FSH preparations, we did not find significant differences concerning the duration of stimulation, the insemination day or oestradiol concentrations. As the treatment was adjusted according to response, these findings indicate that ovarian stimulation was similar in both groups. However, the number of ampoules used was about 20% lower in rFSH; thus, when the oestradiol/ampoules ratio was calculated, a higher value was found among rFSH patients, with an increase of 33% compared with uFSH. This finding was consistent with the higher ovarian response reported in IVF programmes with rFSH (Out et al., 1995; Bergh et al., 1997
; Jacob et al., 1998
), as well as in WHO group II anovulatory patients (Balasch et al., 1998
).
In our study, in spite of similar oestradiol concentrations, the number of follicles 16 mm diameter was somewhat lower in rFSH, with statistical significance (P = 0.004), the oestradiol/follicle ratio being higher (P < 0.001). One could speculate that a better follicle development occurred in terms of oestradiol production when stimulated by rFSH. Our results are in contrast to the lower ratio of oestradiol per follicle in rFSH reported in IVF (Jacob et al., 1998
). Although in IUI the follicle count is less accurate than in IVF when follicle aspiration takes place, if this finding is confirmed we consider that the difference might also be due to a different follicle response occurring secondary to the different number of follicles obtained, namely 11 in the study by Jacob et al. and 3.75 in the present study.
With regard to other parameters of clinical interest, the cancellation rate, the multiple pregnancy rate and oestradiol analyses and ultrasounds performed were similar in both groups. There was no case of OHSS in either of the two groups. In a larger population, it is possible to calculate the estimated frequency of OHSS for rFSH to be <0.7% (<1/139).
It is concluded that in IUI, rFSH has a somewhat higher potency than uFSH, as shown by the higher oestradiol concentrations obtained per ampoule. On the other hand, rFSH was found to be a safe therapy, from which PR at least equal to those obtained with uFSH were obtained. The apparently higher per cycle PR (not significant), which was consistent with that reported in a meta-analysis of IVFICSI data (Daya and Gunby, 1999) needs to be confirmed in much larger studies.
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Notes |
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References |
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Submitted on October 18, 1999; accepted on February 23, 2000.