Document Type : Original Article
Couples that fail to concieve despite regular
intercourse for at least one year are evaluated
for infertility. The workup of such patients include basic infertility tests. These tests involve
the spermiogram, a marker of sperm production, a hysterosalpingogram (HSG) which
determines tubal patency, and the evaluation
of ovulation. The pregnancy rate in normally
fertile couples is 20-25%, while this rate averages between 2-4% in infertile couples (
Hysterosalpingography, which is one of the basic tests of infertility, has a mechanical washing
effect on the uterine cavity and tubes. Particularly
after performing this test with an oil-based contrast
medium, the chance of spontaneous pregnancy increases. Given that the HSG is normal, expectant
management reveals a pregancy rate of up to 40%
in such patients. If the same patients were to undergo
appropriate treatment, the pregnancy rate generally
reaches 30%. Therefore, following an HSG with an
oil-based contrast, management with an average duration of six months is preferred in most centers (
The positive effect of this phenomenon may be utilized by introducing uterine cavity pertubation prior
to infertility treatment. Considering cases of early
stage endometriosis, the mechanical effect of pertubation may decrease minor tubal adhesions. The proposed immunologic effect is based on the prevention
of sperm phagocytosis and the removal of peritoneal
cytokins and immunological factors (
We considered the mechanical and immunological effect of uterine cavity pertubation on treatment protocols for patients with unexplained infertility. To demonstrate a possible beneficial impact of this procedure we designed a randomized prospective study, in which uterine washing was administered prior to insemination in patients diagnosed with unexplained infertility.
This study was carried out in patients who presented to Gazi University Hospital, Division of Infertility Services with diagnoses of unexplained infertility. This was a single-center, prospective, randomized, blinded control trial undertaken at a tertiary care university fertility center between January 2010-March 2011
Patients who fulfilled the inclusion criteria (180 cases) were randomized by systemic randomization in which they were sequentially allocated to two treatment groups. This systemic randomization was performed by the nurse coordinator on the hCG injection day in the absence of the clinicians.
We included 180 patients in the study. It was initially planned to form to equal groups, namely the
control and study groups, however only 79 eligible
participants gave writen consent and accepted the
pertubation procedure. The other 101 participants received the planned treatment protocol only (control
group). We excluded one patient from the study group
due to cycle cancellation. The study group eligibility
criteria included: age of 18-44 years; presence of regular menstrual cycles and ovulation; absence of tubal
occlusion on HSG; sperm concentration >15 million
spermatoza/ml and total sperm number >39 million/
ml according to WHO criteria (
Follitropin alpha (Gonal F, rec-FSH, Serona, Turkey), follitropin beta (Puregon, rec-FSH Organon, Turkey), urinary hMG (Merional, Aris, Turkey veya Menogon, Erkim, Turkey) and urofolitropin (Fostimon, Aris, Turkey) were used for ovarian stimulation. Ovulation induction was started between 2-5 days of menstruation on patients who had no residual cysts larger than 15 mm as visualized with basal transvaginal USG (ultrasound). All patients had 75-150 Iu/day drug as an initial dose. On cycle day 5-6, stimulated follicles were measured ultrasonographically. Induction doses were increased or decreased between 37.5-75 IU/day according to follicle size. Blood estriol and LH levels were monitored and recorded during follow up. When 1-2 follicles reached a mean diameter of 17 mm, we administered 250 µg of recombinant hCG to trigger ovulation. Treatment was discontinued when two or more follicles showed equal maturation in order to avoid the risk of multiple pregnancies. In case of maturation of two follicles because of the risk of a twin pregnancy, treatment was discontinued. At 35-36 hours after the hCG injection, IUI was performed. Two days following insemination micronized vaginal progesterone (400-600 mg/day, Progestan, Kocak, Turkey) was administered to support the luteal phase until the pregnancy was confirmed. Two weeks after insemination, blood beta-hCG levels were analyzed. If the result was negative, progesterone support was discontinued. Patients with positive hCG titers received progesterone support until nine weeks of gestation.
The swim up prcedure was used for sperm washing. A Rocket Embryo IUI catheter was used during insemination.
Since our study aimed to evaluate the use of
pertubation prior to ovulation, the procedure
was performed on the same day as the hCG
injection, prior to its administration. The pertubation procedure was performed in the dorsal lithotomy position after the application of
a vaginal speculum. The vaginal portion of the
cervix was cleansed with a povidone-iodine
(PVP-I) solution to prevent potential uterine infections. Povidone-iodine is a stable chemical
complex of polyvinylpyrrolidone (povidone,
PVP) and elemental iodine (I). It is used for
the prevention and treatment of skin infections,
and the treatment of wounds. This solution has
cytotoxic effects on sperm and embryo. However PVP-I is used on the hCG injection day,
36 hours before IUI. Similarly, many clinics
use betadine for cervical preparation prior to
the oocyte pick-up procedure. Vaginal preparation by betadine does not seem to affect the IVF
Uterine washing was accomplished by introducing a silicone catheter through the internal cervical os, after which 20 cc saline and 1 cc jetocain were slowly injected. Special attention was given to infuse the solution over a few seconds, since rapid injections could give rise to pelvic pain. Jetocain was used for its local anesthetic effects. The speculum was removed and the procedure completed after the injection.
Two weeks after insemination, a blood beta hCG level was obtained. Two days later, patients whose results were positive had a repeat test to ascertain a healthy increase in beta hCG levels. Patients whose control beta hCG level decreased or those who experienced vaginal bleeding were classified as biochemical pregnancies. Patients with a healthy beta hCG increase were evaluated two weeks later for clinical pregnancy status. A regular intrauterine gestational sac and presence of fetal cardiac activity confirmed the clinical pregnancy. Patients who experienced pregnancy loss after the sac was visualized were considered as clinical miscarriages. Pregnancies over 20 gestational weeks that resulted in births were defined as live births.
This study was approved by the Ethics Committee clinical studies in Ankara and received approval on 25.11.2009.
Pertubation was considered the independent variable. Pregnancy rate (chemical and clinical) was the primary dependent outcome variable.
Data were analyzed with the SPSS software version 15.0 for Windows (SPSS Inc., Chicago, Illinois, USA). Continuous variables (age, duration of infertility, total motile sperm count, 3rd day FSH, initial and total dose of ovulation induction agent, follicle count and size, and endometrial thickness) were presented as mean ± SD. Categorical variables (alcohol or cigarette use, agent of ovulation induction, fertilization rate or pregnancy outcomes) as frequency and percentage. Student’s t test was used to compare normally distributed continuous variables and the Mann-Whitney U test for variables without normal distribution. Categorical variables were compared using the chi-square test. A two-tailed p value of <0.05 was considered statistically significant.
Among the 180 patients included, 135 were primarily infertile. There were 51 (64%) primary infertile patients in the study group and 84 (83%) primary infertile patients included in the control group. In a comparison between groups, we noted that secondary infertility was more common in the control group (p<0.05).
Participants included in the study were be- tween the ages of 18-44 years. The mean age of the study group was 28.8 ± 5.3 years and 28.2 ± 4.7 for the control group (p=0.401). The average infertility period was 3.6 ± 2.3 years in the study group and 3.8 ± 2.8 years in the con- trol group. This difference was not statistically significant (p=0.684). As seen in table 1, day-3 basal FSH levels were not significantly different between groups (p>0.05).
There were 21 smokers in the study, of which 7 (8.9%) were from study group and 14 (13.9%) were in the control group. There was no statistical difference between both groups when compared for distribution of smokers (p=0.300). Both groups did not include patients that had a background of regular alcohol use.
There was no significant difference between
the types and initial or total doses of gonadotrophins (p>0.05, Tables 2,
The mean total motile sperm number in the study group was 99.706 ± 85.214 and for the control group, it was 86.304 ± 61.057. A comparison of both groups showed no significant differnce in total motile sperm count (p=0.405).
From the 180 participants, 39 concieved. A total of 15 pregnancies were from the study group
and 24 from the control group. In the study
group 3 patients had biochemical pregnancies,
1 miscarried and 10 patients had live births. In
the control group, 1 patient had a biochemical
pregnancy, 3 patients miscarried and 20 patients
had live births. Between the two groups, there
was no significant difference in pregnancy rates
(p=0.296, Tables 4,
Patients’ demographic characteristics
|Demographic data||Pertubation||P value||Minimum/maximum|
|Performed Mean ± SD||Not performed Mean ± SD|
|28.8 ± 5.3||28.2 ± 4.7||0.401||18-44|
|3.6 ± 2.3||3.8 ± 2.8||0.684||1-17|
|5.9 ± 1.7||5.8 ± 1.8||0.827||0.8-15.1|
Distribution of gonadotropins within groups
|Pertubation||Agent used in ovarian inductionn (%)|
|rec–FSH||Urinary hMG||rec–FSH+ urinary hMG||Urofollitropin|
|66 (83.5)||5 (6.3)||2 (2.5)||6 (7.6)|
|73 (72.3)||11 (10.9)||1 (1.0)||16 (15.8)|
|139 (77.2)||16 (8.8)||3 (1.6)||22 (12.2)|
İnitial and total dose of ovulation induction agents
|Performed Mean ± SD||Not performedMean ± SD|
|84.5 ± 32.7||83.2 ± 27.4||0.962||75-300|
|877.5 ± 469||784.7 ± 31.5||0.385||375-2997.5|
|Performed n (%)||Not performed n (%)|
|64 (81.0)||77 (76.2)||0.440|
|3 (3.8)||1 (1.0)||0.205|
|1 (1.3)||3 (3.0)||0.441|
|10 (12.7)||20 (19.8)||0.202|
|1 (1.2)||0 (0)||0.257|
Distribution of pregnancy outcomes.
Infertility affects 10-15% of the reproductive
age group (
In order to obtain a homogenous patient population we only included patients diagnosed with unexplained infertility in this study.
At least three cytokines are synthesized by the
endometrium, colony stimulating factor-1 (CSF-
T helper (Th) 1 and 2 expression increases in
peripheral lymphocytes of patients with recurrent
artificial reproductive tecnology (ART) failure (
We can analyze the effect of immunological
factors on implantation success in patients with
hydrosalpinx. The liquid of the hydrosalpinx
blocks implantation either by a direct embrotoxic effect, a negative impact on the endometrium, and mechanical impact. Implantation
and pregnancy rate is lower in patients with hydrosalpinx than in a normal control group (
The downfall of the current study was the use
of an open randomized technique during patient
recruitment. As a result when we compared both
groups, it was evident that in the study group secondary infertile patients outnumbered primary
infertile couples, whereas in the control group
primarily infertile patients were more common.
According to one study performed at our center,
independent factors which increased clinic pregnancy rates were secondary infertiliy and unexplained infertility. However these factors did not
affect live birth rates (
Although the pregnancy rate was higher in the control group, this was not statistically significant when compared with the study group (p=0.296). When we evaluated both biochemical and clinical pregnancies, the pregnancy rate was 17.8% in the study group and 23.8% in the control group. The rate of live births, which was the main purpose of this treatment was 12.7% in the study group and 19.8% in the control group.
Spontaneous miscarriage occurs in 15-20% of
known pregnancies. If serial hCG is measured to
detect early subclinical pregnancy loss, this rate
would increase to 30% (
Aboulghar et al. included 213 patients in a study
where they performed hydropertubation on 103
patients. They used clomiphen citrate and urinary
HMG for ovulation induction followed by IUI. In
our study, we only used gonadotropins for ovulation induction. Both studies have performed intrauterine insemination after ovulation induction.
Generally the expected fecundability rate associated with this type of treatment protocol is approximately 17% (
In our study the control group’s fecundability rate was 23.8% and the continued pregnancy rate was 19.8%. There was no significant difference between the study and control groups. However the relatively higher rate in the control group suggested the negative effects of pertubation.
Yapça et al. investigated the effectivity of
hydrotubation in unexplained infertility therapy by evaluating 80 patients and 144 cycles
Lei et al. have reported the effects hydrotubation in 50 formerly proven tubal occlusive patients
Edelstam et al. performed out a prospective
randomized study to evaluate the effect of pertubation on pregnancy rates in patients with
unexplained infertility (
In sum, results of this study revealed that pertubation prior to insemination did not effect pregnancy rates.