Journal of Gynecology Obstetrics and Human Reproduction 48 (2019) 805–809 Available online at ScienceDirect www.sciencedirect.com Original Article Intrauterine insemination versus timed intercourse in ovulation induction cycles with clomiphene citrate for polycystic ovary syndrome: A retrospective cohort study Ece Atalay*, M. Gulnur Ozaksit, Aytekin Tokmak, Yaprak Engin-Ustun Zekai Tahir Burak Women’s Health Education and Research Hospital, University of Health Sciences, Ankara, Turkey A R T I C L E I N F O A B S T R A C T Article history: Aim: The aim of this study is to evaluate the effect of intrauterine insemination (IUI) on clinical pregnancy Received 6 July 2018 rates in women with polycystic ovary syndrome (PCOS) undergoing ovulation induction (OI) cycles. Received in revised form 13 June 2019 Methods: We evaluated the medical records of one hundered and forty-seven infertil anovulatory women Accepted 1 July 2019 with PCOS who attended to the infertility outpatiens clinics of the current hospital. All women Available online 2 July 2019 underwent either IUI or timed intercourse (TIC) following OI with clomiphene citrate (CC) according to their requests. Some demographic and clinical features, baseline hormone levels and treatment cycle Keywords: characteristics were recorded for each woman. IUI Results: Of a total 147 cycles, 56 cycles were with IUI and 91 others with TIC. The IUI and TIC groups were PCOS similar in terms of age, BMI, gravidity numbers, parity numbers, number of abortion and infertility Clinical pregnancy rate > fi > Timed intercourse duration (p 0.05). There were also no signi cant differences in hormone parameters (p 0.05). fi Clomiphene citrate Moreover, no signi cant difference was observed between the groups regarding semen parameters and weekly coit frequency. However, a significant difference was found in clinical pregnancy rates between the IUI group (48.2%) and the TIC group (11%) (p < 0.001). Conclusion: Compared to TIC, IUI increases clinical pregnancy rates in infertile women with PCOS who underwent OI with CC. © 2019 Elsevier Masson SAS. All rights reserved. Introduction Intrauterine insemination (IUI) is a simple, cheap and non- invasive method which widely used in treatment of many Polycystic ovary syndrome (PCOS) is one of the most common infertility problems, although it is not considered as an assisted endocrinopaties in women of reproductive age, affecting between reproductive technique. The selection of accurate patient group, 6.5 and 8% of women overall [1,2]. PCOS as it defines a syndrome, patient’s age, permeability of fallopian tubes, duration of infertility, has a multiple potential etiologies and variable clinical presenta- total motile sperm count, sperm morphology and preovulatory tions. Oligo- or anovulation and hyperandrogenism are the most follicle number are important determinants for success in common findings of PCOS. Other features are polycystic ovaries on predicting the outcomes of this method. Although the necessity pelvic ultrasonography, infertility due to oligoovulation, obesity, of IUI in women with unexplained or mild male subfertility who and insülin resistance. The main cause of infertility in women with have undergone OI with CC is widely accepted [5–9], its role and PCOS is chronic anovulation [3]. Although significant progress has success for anovulatory patients remains unclear [10,11]. been made towards the universally accepted diagnostic criteria for In this study, we aimed to evaluate the effect of IUI on clinical PCOS, the optimal treatment for infertile women with PCOS is pregnancy rates in women with PCOS undergoing OI cycles with various. Treatments include lifestyle modifications and pharma- CC. ceutical agents such as clomiphene citrate (CC), gonadotropins and letrozol. However, CC is still the first choice for ovulation induction Materials and methods (OI) in those anovulatory women [4]. We evaluated the medical records of one hundred and forty- seven infertile women with PCOS who attended University of Health Sciences Zekai Tahir Burak Women’s Health Research and Education Hospital, for infertility treatment between June 2017 * Corresponding author. E-mail address: [email protected] (E. Atalay). and January 2018. All consecutive patients diagnosed with http://dx.doi.org/10.1016/j.jogoh.2019.07.002 2468-7847/© 2019 Elsevier Masson SAS. All rights reserved. 806 E. Atalay et al. / J Gynecol Obstet Hum Reprod 48 (2019) 805–809 anovulatory PCOS were included in the study. PCOS was diagnosed preparation media (SpermRinse Solution, Vitrolife, Gothenburg, by using the Rotterdam criteria of of European Society of Human Sweden). The swim-up process which is a method of floating of Reproduction and Embryology (ESHRE)-American Society for progressive motility sperm in the medium, started with the Reproductive Medicine (ASRM) [12]. Chronic anovulation was placement of semen sample in a falcon conical centrifuge tube. confirmed by displaying a serum level of progesterone < 3 ng/mL Media and sperm were mixed at a ratio of 1/1. After pipetting, the during the midluteal phase. All semen parameters were evaluated sample was centrifuged at 1200–1500 rpm for 10 min. The according to the modified criteria of World Health Organization supernatant was removed using a pipette. After the supernatant [13] and normozoospermia was shown on all semen analysis. All of was dumped, 1 ml of the same medium was added and the same the patients underwent hysterosalpingography which showed cycle was repeated for 5 min. The tube was placed at an angle of 45 patency at least one tube. All women initially had the following degrees and 0.5–1 mL of medium was added onto the pellet. This basal hormonal assays including follicule stimulating hormone was incubated for 1 h at 37 C without deterioration of the angle. A (FSH), luteinizing hormone (LH), thyroid-stimulating hormone small amount was taken from the supernatant, and post wash (TSH), prolactin on Day 2 or 3 spontaneus or progestrone-induced analysis was again performed by the computer-assisted semen menstruation, and mid-luteal progestrone. Hormone parameters analyzer and recorded. Finally, the sperm solution was withdrawn were run with UnicelDxI 800 Immunoassay System (Beckman from the tube surface with a pipette to aid in totaling 0.5–1 mL of Coulter, Fullerton, CA, USA). the tube without distortion the angle, and it was transferred in to During the study period, only the last cycles of 147 patients falcon 5 mL tube to be used for IUI. Sperm analysis was performed were included. Exclusion criterias were other causes of infertility, by the same andrology laboratory technician according to a quality semen analysis levels which suboptimal for IUI, women who had control program at the Andrology Laboratory of the current received ovarian stimulation with gonadotrophins, who had hospital. systemic medical conditions and age under the 18 years or above the 40. The study was approved by the Zekai Tahir Burak Women’s Evaluation of pregnancy Health Research and Education Hospital Ethics Committee. All women underwent serum beta chronic gonadotrophin (ß Ovulation induction protocol -hCG) measurement 14 days after IUI and TI. Patients with ß-hCG >10 mIU/ mL were accepted pregnant. In patients with positive 1 The patients were administered CC (Klomen , Kocak Farma, pregnancy test, the increase in ß-hCG was evaluated after 2 days. Istanbul, Turkey) 50–150 mg/day from day 2 to 5 of the Patients who had an increase in ß-hCG rather than normal spontaneous or induced cycle after basal transvaginal ultrasonog- doubling in serial measurements (non viable pregnancy), whose raphy. The doses were determined based on the patient character- ß-hCG value is decreasing while their vaginal bleeding starts or istics such as body mass index (BMI) and previous cycle features. those with pregnancy of unknown location (no visible intrauterine All women were monitored by serial transvaginal ultrasound with or extrauterine pregnancy on ultrasound) at the 6th weeks of Logiq ProSeries 200 ultrasound device (General Electrics Company, gestation were accepted as biochemical pregnancy. Clinical Niskayuna, NY, USA) equipped with 6.5 mHz transvaginal probe for pregnancy was diagnosed 5 weeks after the IUI by evidence of mean follicular diameter and endometrial thickness during OI. intrauterine gestational sac and/or fetal heart activity. Follicle diameters were measured on two planes and their mean diameters were taken. When at least one follicle reached a Statistical analysis maximum diameter of 17–18 mm, 250 mcgr of recombinant human chorionic gonadotropin (rhCG) was administered subcuta- Statistical analysis Statistical Package for the Social Sciences neously. The decision whether or not to perform IUI was made version 22.0 (SPSS Inc., Chicago, IL, USA) was used for statistical according to the couple’s decision. IUI was performed 34–36 h after analysis. Descriptive statistics were used to demonstrate the hCG injection. A single insemination catheter (TecnoCath insemi- mean Æ standard deviation and median (range) for constant nation catheter, Ankara, Turkey) was used for IUI. The cervix was variables, whereas nominal variables were expressed as case exposed with a bivalve speculum, the mucus was removed with a number and percentages. As to the analysis of the data, normality cotton swab, and the tip of the catheter was gently introduced into in the repeated measures was tested with Shapiro-Wilks test. To the uterus until it lay about 0.5 cm from the top of the uterine determine the differences between the groups, parametric cavity in the fundal region. An experienced infertility specialist (Independent samples t test) and non-parametric analyzes performed the all IUI procedures. Women remained supine (Mann–Whitney U) were performed after normality analysis. position for 10 min after the procedure. For those who did not Proposrtions were compared with Chi Square test or Fisher exact undergo IUI, the couples were instructed to have unprotected TIC test. Binary logistic regression analysis was used to estimate the on hCG day and every two days for subsequent one week.