Document Type : Original Article
1 Department of Obstetrics and Gynecology, Assisted Conception Unit, College of Medicine, King Saud University, Riyadh, Saudi Arabia
2 Department of Surgery, Division of Urology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
3 Western Ontario University, London, Ontario, Canada
The advantages of intrauterine-insemination (IUI)
with and without mild ovarian stimulation were
early recognized and IUI was applied for treating
couples with borderline male, cervical, immunological,
or unexplained infertility factors (
Following IUI, pregnancy rates vary widely due
to multiple factors including heterogeneity and
variability of studied patients and parameters (
The objective of the present study is to audit the clinical outcomes of IUI as a mild infertility treatment in a set of female patients in Saudi Arabia and to examine whether clinical outcomes were related to patient demographic factors such as age and BMI, as well as, the number of IUI treatments, in order to be used as success prediction factors.
During a 24-month period, between January 2010 and December 2011 inclusive, 301 Saudi women with infertility underwent extensive investigation consecutively. That included pertinent infertility-related history, general physical and pelvic examination, and assessment of the reproductive organs by appropriate imaging and endoscopy. Baseline serum levels of follicular stimulating hormone (FSH), luteinizing hormone (LH), thyroid stimulating hormone, and prolactin were always analyzed. In addition, assessment of the male partner included at least two semen analyses, with at least one analysis being performed before and after sperm wash to determine the total motile sperm count and modes of sperm progression. Further evaluation of the male partner included analysis of serum levels of FSH and testosterone, when indicated. Eligible women for IUI-treatment were then stimulated with different kinds of ovulation induction hormones. Most patients were stimulated with highly purified gonadotropins (hMG), such as Merional, 75 i.u./day or Puregon, 50 i.u./day (both from IBSA, Switzerland). Only cases that did not show any sign of response within the first ten days of treatment were excluded. The number of treatment days differed based on various factors, like age, body mass index (BMI), and cause and history of infertility. A number of patients were stimulated with clomiphene citrate, 100 mg/day (Merk, Germany) for 5-6 days. All patients were monitored with ultrasound for ovulation induction and follicle maturation. When a maximum of two leading follicles reached at least 17 mm in diameter, patients were injected with 5,000 IU of human chorionic gonadotropin hormone (HCG) 36 hours prior to IUI.
On the day of IUI, fresh semen of the husband was prepared for insemination. The final sperm specimen was mixed in 0.5 ml of HEPES-buffered media (Quinn’s Advantage Medium, with HEPES, SAGE (Pasadena, USA), supplemented with serum (Quinn’s Advantage Serum Protein Substitute SPS, SAGE (Pasadena, USA). All pre- and postpreparation semen parameters were recorded.
Pregnancy was determined by βHCG values obtained on the sixteenth day after IUI, and then confirmed by ultrasound four weeks later.
Data were analyzed using the SPSS statistical software package, version 19 (SPSS Inc., Chicago, USA). Chi-squared test was used to compare pregnancy rates with respect to all variables. P-value less than 0.05 were considered statistically significant.
The Institutional review board of the College of Medicine at King Saud University approved this study with approval number E-12-642. Informed written consents were also obtained from all human adult participants in the study.
Women were stratified by age as shown in table 1. The median age of the entire group was 31, with a range of 19-45. The highest pregnancy rate was 14.89% in age group 19-25, as compared with the lowest PR of 4.16% in age group 41-45. This difference was not statistically significant (p=0.225). One pregnancy occurred, at age 44, among 24 women over 41 years.
BMI was stratified according to the World Health
Organization (WHO) definition (
The relationship between the number of IUI cycles performed and pregnancy rates is shown in table 3. The differences between one, two, and three to five cycles did not reach statistical significance (p=0.167), however, there was a trend that suggested the first treatment cycle to be the most successful.
Relationship between age and pregnancy rate of infertile women treated with intrauterine insemination
|Age (Y)||Number of patients and (%)||Number of pregnancies and (PR%)||P value/χ2|
PR; pregnancy rate.
Relationship between body mass index (BMI), and pregnancy rate of infertile women treated with intrauterine-insemination
|BMI (Kg/m2)||Number of patients and (%)||Number of pregnancies and (PR)||P value/χ2|
PR; Pregnancy rate and BMI; Body mass index.
Relationship between Number of intra-uterine insemination cycles performed and pregnancy rate in saudi infertile women
|Number of IUI Cycles||Number of patients and (%)||Number of pregnancies and (PR)||P value/χ2|
|One||148 (49.17%)||19 (12.84%)||0.167|
PR; Pregnancy rate and IUI; Intra-uterine insemination.
We audited results from a single infertility clinic in the Kingdom of Saudi Arabia, to determine whether women’s age, and BMI, as well as, the number of IUI treatments performed could be used as prognostic indicators of pregnancy success.
Data in table1 shows relatively good outcome up to the age of 40, while some studies reported good outcomes only up to 30 years of age, (
The lowest pregnancy rate (4.16%) was in the over-40 group (one success out of 24 cycles). These findings are in agreement with those of others (
We found that normal BMI was found in only 16.8% of women while 27.8% were highly obese. These statistics are very disturbing from a public health point of view as this group of patients is a random sample of Saudi women. It has been proven that overweight/obesity has become a world epidemic, (
We found, however, no statistically significant difference in PR between different BMI groups, including the highly obese group (BMI ≥35). A study (
On the other hand, some studies (
About half (49.17%) of the patients underwent IUI only once, with PR of 12.84%. Then the PR declined to 5.75% with 29.04% of the patients who tried IUI twice. The PR then climbed up again to 17.24% with those who underwent 3-5 IUI cycles (21.93% of the patients), although with no significant difference among all three groups. A study (
We audited a group of 301 infertile Saudi women treated with IUI and found that the pregnancy rate remained approximately 10% for age groups between 19 and 40. While after 40 it declined noticeably, which means that direct IVF treatment would be in their favor. There was a positive but not statistically significant correlation of pregnancy rates with BMI; (from 8% PR, for normal BMI, to 13%, for highly obese), i.e. female high BMI is not a discouraging factor for IUI treatment. There was also no clear correlation between PR and the number of IUI trial; and it is therefore the patient’s choice when to move to IVF treatment instead.