1 Infertility Clinic, The Family Federation of Finland, Kiviharjuntie 11 A, FIN-90220 Oulu, 2 STAKES, National Research and Development Centre for Welfare and Health, PO Box 220,FIN-00531 Helsinki and 3 Department of Obstetrics and Gynaecology, University of Oulu, Kajaanintie, FIN-90220 Oulu, Finland
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Abstract |
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Key words: antenatal care/intrauterine insemination/in-vitro fertilization/obstetric outcome/perinatal outcome
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Introduction |
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Intrauterine insemination (IUI) combined with ovarian stimulation remains a widely used treatment option for couples with male factor infertility, ovulatory dysfunction, mild endometriosis or unexplained infertility. Intrauterine insemination is a simpler, less invasive and cheaper first-line treatment than IVF for subfertility, resulting in an acceptable pregnancy rate (PR) of 1220% per cycle (Dodson and Haney, 1991; Nulsen et al., 1993
; Nuojua-Huttunen et al., 1997
). The multiple PR varies from 7 to 18% (Nulsen et al., 1993
; Brzechffa et al., 1998
). Although information concerning the outcome of pregnancies and newborns after infertility treatment is essential, so far, the results of studies of pregnancies after IUI with partner's spermatozoa have not been published.
In the present study, we evaluated the obstetric and perinatal outcome of pregnancies after IUI with the partner's spermatozoa. The results were compared with those of matched controls of spontaneous and IVF pregnancies.
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Materials and methods |
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Data on 111 IUI pregnancies and births (92 singleton, 16 twin and three triplet births) was found in the Finnish Medical Birth Register (MBR), but information on 14 cases was missing: one woman had emigrated, and 13 women gave birth in the latter half of the year 1997; therefore, their data were not available at the time of data collection. Thus, the study involved 111 pregnancies and deliveries and 133 newborns. The MBR, which was the main data source of the study, is a nationwide register, which includes information on maternal background, pregnancy, delivery and perinatal outcome. The MBR is linked to the Central Population Register (live births) and Cause-of-Death Register (perinatal deaths), and its data quality is high for most of the variables (Gissler et al., 1995). The studied factors were the total number of antenatal care visits, intensity of use of antenatal care, visits to outpatient clinics, gestational age at birth, pregnancy and delivery complications, mother's hospitalization, mode of delivery, infant's outcome and need for intensive care. Intensity of use of antenatal care was measured by means of a relative index (Gissler et al., 1995
). This was calculated by dividing the actual number of visits by the gestation-adjusted recommendation given by the Ministry of Health and Social Affairs (12 visits for a pregnancy of average gestational length). A score of 1.0 indicates the norm.
As controls, two different groups were chosen from the Finnish MBR. In both control groups three controls for each IUI case were selected. One group included women with birth after IVF (IVF group, n = 333), and the other consisted of women with non-assisted pregnancy and birth (spontaneous group, n = 333). Each control group involved 399 infants. The controls were matched according to year of delivery, number of fetuses, number of previous deliveries, maternal age, residence of mothers (12 counties), maternal smoking and socio-economic class of the mothers defined by maternal occupation (upper white-collar, low white-collar, blue-collar workers and others; Gissler et al., 1998). Detailed data on matching are shown in Table I
. Because of the high number of multiple births, we were not able to match the controls with the cases for all items. Differences between cases and controls were statistically significant as regards residence and socio-economic class.
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Results |
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The Caesarean section rate was high in the IUI group: 25% in singleton and 58% in multiple pregnancies. Approximately half of the Caesarean sections were classified as emergency. The other groups were similar.
The incidence of term breech presentation was 1% in IUI singletons and 21% in IUI multiples, and pregnancy complications as placenta praevia, placental abruption, eclampsia or insulin-treated diabetes mellitus of the mother occurred rarely in each group. The data of pregnancy outcome are shown in Table III.
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Low Apgar scores (06 at 1 min) were found in 8.3% of IUI infants, and 12.8% were treated in a newborn surveillance unit and 14.3% in an intensive care unit. One major malformation (Potter's syndrome) and two perinatal deaths occurred in the IUI group. In addition to the infant with lethal Potter's syndrome, one triplet with severe growth retardation for an unknown reason died in utero at 30 weeks of gestation. In both control groups, reliable data on congenital malformations were not available. The number of complications among newborns did not differ between groups. More detailed data on the perinatal outcome are presented in Table IV.
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Discussion |
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In our study, most IUI parturients were primiparous (81%), the mean number of previous deliveries was low (0.24) and the mean age of the parturients was high (32 years). These values differed clearly from the average national figures (39%, 1.1 and 30 years respectively) for all Finnish parturients in 1995 (Gissler et al., 1996), but were comparable to those associated with assisted reproduction technology pregnancies (Wennerholm et al., 1996
, 1997
; Dhont et al., 1997
; Reubinoff et al., 1997
). In addition, the number of multiple gestations (17%) was much higher in the study population than in general (1.4%; Gissler et al., 1996
), but slightly lower than in IVF pregnancies (25%; Gissler et al., 1995
).
Overall, the intensity of use of antenatal care was high in all groups. It did not differ in multiple pregnancies or between IUI and spontaneous singletons, but was significantly higher in IVF singletons compared with IUI singletons. An explanation for the frequent need of antenatal care in all groups might be the high number of mothers of advanced age, primiparity and multiple pregnancy. All these factors have been documented to be predictive of increased obstetric risk and adverse outcome of pregnancy (Hartikainen-Sorri et al., 1990; Chattingius et al., 1992
; Sipilä et al., 1994
). In addition, the restructuring policy in the maternity health care system in our country might be reflected in the frequent use of maternal care. Generally, a trend towards an increasing number of antenatal care visits has been seen in the last few years in Finland (Gissler et al., 1996
). The difference between IUI and IVF singleton pregnancies in respect to the use of antenatal care could be partly explained by inaccurate recommendations concerning the follow-up of IVF pregnancies, based on the results of previous studies (Doyle et al., 1992
; Olivennes et al., 1993
). In addition, IVF mothers' own desire for close follow-up might increase the intensity of follow-up. The number of pregnancy complications was not increased in the IVF group compared with the IUI group. Optimal and cost-effective follow-up of assisted pregnancies should be based on clear recommendations and should be carried out according to the individual needs of the patient.
In total, 36% of IUI, 34% of normally conceiving and 40% of IVF mothers were hospitalized during pregnancy. As expected, the frequency of hospitalization was increased with multiples compared with singletons. The reasons for hospitalization included diagnoses of haemorrhage, hypertension, threatened premature delivery, and other reasons. As regards the distribution of the first three diagnoses, there was no significant difference between the groups. The hospitalization rates of our study and control groups were higher than the average value of 21% reported in Finnish Perinatal Statistics 1995 (Gissler et al., 1996). Pregnancies after IUI did not carry any increased risk of placenta praevia, placental abruption or eclampsia, which has also been shown to be the case in IVF pregnancies (Reubinoff et al., 1997
; Wennerholm et al., 1997
). Because there was no difference between spontaneous and other pregnancies, it can be suggested that the assisted reproductive techniques as such do not influence the complication risk during pregnancy, but that individual patient characteristics and plurality are the most important factors in this respect.
There was no significant difference between the IUI, spontaneous and IVF groups in the Caesarean section rate, which was 25% in singleton and 58% in multiple IUI pregnancies. This is in accordance with recent results (Dhont et al., 1997) reporting no difference between Caesarean section rates of IVF/intracytoplasmic sperm injection (ICSI) and spontaneous pregnancies, but contradictory to some other reports, in which higher Caesarean section rates have been seen among IVF pregnancies (Tanbo et al., 1995
; Reubinoff et al., 1997
). The present Caesarean section rates were generally higher than average (16%) in Finland (Gissler et al., 1996
), the probable reasons again being multiplicity and the mothers' characteristics.
In the present study, the mean birth weight of IUI singletons (3285 g) was significantly lower than in the spontaneous group, but there was no difference compared with the IVF group. The difference between the IUI and the spontaneous group was mainly explained by shorter gestational age of IUI singletons, but it could also partly be related to infertility itself (Ghazi et al., 1991; Wang et al., 1994
; Sundström et al., 1997
; Isaksson et al., 1998
). This finding might not be clinically significant, because the incidences of low birth weight and premature delivery did not differ between spontaneous and other pregnancies. The results of studies comparing the birth weight of IVF and naturally conceived infants are somewhat contradictory (Gissler et al., 1995
; Reubinoff et al., 1997
; Wennerholm et al., 1997
).
The mean gestational age at delivery was similar among the three groups, and it was comparable to those of some reports evaluating IVF, ICSI and IUI (with donor semen) pregnancies (Wisanto et al., 1995; Dhont et al., 1997
; Lansac et al., 1997
, Wennerholm et al., 1997
). The outcome of newborns was not worse in the IUI or IVF group compared with the spontaneous group in respect to the number of malformations and perinatal mortality.
In conclusion, IUI treatment does not adversely influence the outcome of pregnancy or the newborn compared with matched spontaneous and IVF pregnancies. The overall intensity of antenatal care and the hospitalization rate was high in all groups obviously as a result of the high number of multiple pregnancies and the special characteristics of the studied mothers: advanced age and primiparity. The use of antenatal care services in singleton pregnancies was significantly lower in the IUI and spontaneous groups than in the IVF group. Optimal follow-up of assisted pregnancies should be based on the individual characteristics of pregnancies and mothers. On the other hand, to avoid excessive use of maternal health care services, recommendations concerning the follow-up of assisted pregnancies and education of the staff of maternal care units are needed. The main challenge as regards improved outcome of assisted pregnancies is to lower the high incidence of multiple gestation.
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Notes |
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References |
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Submitted on January 4, 1999; accepted on April 19, 1999.