1 Department of Obstetrics & Gynaecology, St Bartholomew's and The Royal London School of Medicine & Dentistry, Royal London Hospital, Whitechapel, London E1 1BB and 2 Bridge Centre, 1, St Thomas Street, London SE1 9RY, UK
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Abstract |
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Key words: donor/insemination/lesbian/single women
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Introduction |
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The inability to conceive in this group of women is independent of the male factor causes of infertility and they generally cannot be considered to have reduced fertility. A number of studies have considered IUI-DI therapy in both single patients and couples where the partner is oligozoospermic or azoospermic, reporting a pregnancy rate of 13.5% (Kang and Wu, 1996) falling to 6.7% in the presence of other infertility factors (Bordson et al., 1986
).
Despite the increasing number of same-sex couples and single women undergoing donor insemination, little information is available on the treatment outcome in these women, the majority of reports addressing ethical considerations (Englert, 1994; Baetens et al., 1995
). In addition, some authors have tended to group single heterosexual women and lesbian women under the possibly misleading heading of `single women' (Bordson et al., 1986
; Ahmed Ebbiary et al., 1994
).
As we were unable to identify any literature comparing the outcome of IUI-DI in single women and lesbians, we undertook a retrospective analysis of the outcome of the treatment of lesbian couples and single women receiving IUI-DI in relation to age, diagnostic and treatment variables.
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Materials and methods |
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Patients with anovulation were treated with clomiphene citrate (daily for 5 days, 50100 mg). Ovarian stimulation was used as well empirically i.e. on the woman's request or if pregnancy had not occurred after IUI-DI during spontaneous ovulation to increase the number of oocytes available (Khalifa et al., 1995; Hunges, 1997
), with both clomiphene citrate or human menopausal gonadotrophins (Pergonal, Metrodin HP; Serono, Welwyn Garden City, UK; or Humegon; Organon, London, UK; typically 75150 units on alternate days) until 23 follicles, diameter 1620 mm, were seen.
In women undergoing ovarian stimulation, transvaginal ultrasonography and serum oestradiol measurements were performed to assess the follicular development and reduce the risk of ovarian hyperstimulation syndrome and the possibility of multiple pregnancy (Haning et al., 1983).
The optimum time for insemination was defined by the determination of the urinary luteinizing hormone (LH) surge by measuring urinary LH (Clearplan-Unipath Ltd, Bedford, UK); ultrasound monitoring was followed by 10 000 IU of human chorionic gonadotrophin (HCG) injection in the stimulated cycles. In stimulated cycles, the insemination was performed ~36 h after HCG injection for single insemination and ~24 h later and 48 h post-HCG in women in whom insemination was performed twice.
Frozen donor sperm samples were thawed, centrifuged and prepared using discontinuous Percoll gradients (Pharmacia AB, Uppsala, Sweden) until January 1996, after which the samples were prepared with IxaPrep (Medicult-Lerso Parkalle 4Z, DK-2100, Copenhagen, Denmark). IUI-DI is the first-intention treatment in our Centre, and this was performed without difficulty in all the women. Clinical pregnancy was confirmed by the detection of a gestational sac by ultrasound, usually at 68 weeks gestation.
Statistical analysis
Comparison between successful and failed treatments was performed by application of 2-test followed by Fisher's exact test when the numerator was <5. The mean values among groups were compared using a standard analysis of variance (ANOVA). Data for life table analysis were analysed by published methods (Cramer et al., 1979
). P < 0.05 was considered statistically significant.
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Results |
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The overall pregnancy rate per patient was 40%, being statistically significantly lower in single women (43/122, 35%) than in lesbians (20/35, 57%; P = 0.02), as was the overall pregnancy rate per treatment cycle, being 8% in single women and 14% in lesbians (P < 0.05).
Of 63 pregnancies, 55 (87%) occurred within the first six cycles, of which 36 were in single and 19 in lesbian women. After the sixth treatment cycle, only eight women (13%) achieved a pregnancy (seven single women and one lesbian woman). In patients over 40 years old, four pregnancies occurred after six treatment cycles.
Life table analysis of IUI-DI pregnancy rates in single and lesbian women
The cumulative pregnancy rate after eight cycles was 70% in lesbians and 47% in single women, increasing until the eighth cycle in lesbian and the 10th in single women. A statistically significant difference in cumulative probability of pregnancy was observed in the two groups (P < 0.05) (Figure 1). Pregnancy had not occurred in two women who were still receiving treatment after the ninth cycle. In the majority of cases, women who dropped out of treatment (14 lesbians and 77 single women) did so for personal, social or economic reasons and not because of medical reasons or advice.
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Fifty-two (43%) of single women had previously achieved a pregnancy, nine of which followed IUI-DI. Thirteen single women (11%) had had a live birth, (five following IUI-DI). Eight of the remaining 39 women had had a miscarriage, whilst 31 women had a termination of pregnancy (Table I).
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Discussion |
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Our analysis has examined the possible effects of age, stimulation regime, previous obstetric history and other factors on treatment outcome in order to determine what may affect the success of IUI-DI in single women in comparison with women in a lesbian relationship.
The higher proportion of single women in our analysis is not intended to reflect accurately the proportions of single women and lesbian couples wishing to conceive in society at large, as lesbian couples may conceive by acquiring spermatozoa from male acquaintances to adminster themselves pericervically, thus avoiding medical intervention. In addition, there may be another source of bias in the proportion of single women in relation to lesbians in our study group because some lesbian women may have been classified incorrectly as `single women', perhaps fearing that they may not obtain treatment if their sexual orientation was declared at the fertility unit.
In general, single women in our sample appeared to be statistically significantly older than the lesbian women who were included (mean age 38.5 for single women; 34.5 lesbian. P < 0.005). A possible explanation is that the process of deciding to have IUI-DI for single women may take years before acknowledgement that an enduring heterosexual relationship may not occur or that one needs to prepare for the financial and other responsibilities of being a single parent (Cook and Golombok, 1995). Alternatively, most of the women in the lesbian group, having acknowledged their gender preference and being in a relationship, seek to fulfil their wish for a child as a couple and opt to become pregnant without a male partner at a younger age (Polge et al., 1949
).
The pregnancy rate observed here was 9.3% (i.e. 63 of 675) for all cycles and 10.2% (i.e. 55 of 539) when only the first six cycles were considered, which is in accord with the rate of 9.7% recently reported in unmarried women treated with IUI-DI (Kang and Wu, 1996). However, when our population was reclassified into lesbian and single women, the pregnancy rate per treatment cycle was statistically significantly higher in lesbian women [14% (20/1390 versus 8% (48/536) in single women; P < 0.005], 57% of the lesbian and 35% of the single women achieving pregnancy.
It is reasonable to speculate that lesbian women have a higher fecundability than those women who may have had a heterosexual partner but not conceived. In addition, the heterosexual single women may have delayed seeking IUI-DI, perhaps having tried to conceive prior to referral to a specialist centre. This view is supported by our data in that the single women when compared with lesbian women under the age of 35 appeared less likely to conceive (12% versus 24%; not significant). But this difference was not significant when adjusted for age (Table II).
The incidence of significant pelvic pathology at laparoscopy was similar in both groups, being 52% (14/27) in single and 37.5% (3/8) in lesbian women (not significant). However, laparoscopy was only performed as indicated by gynaecological history or failure to conceive after a number of cycles of IUI-DI. Given the high pregnancy rate in lesbian patients early after the commencement of treatment, the incidence of pelvic pathology can be considered to be less amongst lesbian women. We did not observe any significant differences in pregnancy rates in relation to patency of one or both tubes (Table III) or between single and lesbian women.
Our review of the impact of confounding factors that may, directly or indirectly, affect pregnancy outcome subsequent to IUI-DI treatment did not show a significant difference in women undergoing ovulation induction and intrauterine insemination in comparison with women treated in unstimulated ovarian cycles, in contrast to observations of many earlier reports (Haning et al., 1983; Patton et al., 1992
; Khalifa et al., 1995
). However, although an apparently higher pregnancy rate was seen in women receiving ovulation induction with gonadotrophins in comparison with clomiphene citrate, the lesbian women had a higher pregnancy rate than single women when IUI-DI was carried out in a natural cycle (22% and 8% respectively; P < 0.01).
The rate of miscarriage in single women was 35%, statistically significantly higher than that seen in lesbian women (15%) and that previously reported (Cramer et al., 1979; Lannou et al., 1995
). An increase of miscarriage rate in relation to age has been described in the general population: 15% in women aged 2029 years versus 46% in women aged 40 years or older (Cramer et al., 1979
), a similar high incidence of miscarriage being seen in the overall study population (Table V
). However, when considered separately, there was a statistically significant difference seen in the miscarriage rate between lesbian and single women in the age group 3035 years. The explanation for these findings is not readily obvious but may be related to possible deleterious consequences of heterosexual activity such as low grade chronic infection undetected by routine fertility investigations.
In conclusion, IUI-DI is an effective strategy for single women and women in a lesbian relationship. Pregnancy rates are similar in both groups when corrected for age but lesbian women seem more likely to conceive in the group aged less than 35 years.
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Acknowledgments |
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Notes |
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References |
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Submitted on August 19, 1999; accepted on November 16, 1999.