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Middle East Fertility Society Journal (2014) 19, 183–186

Middle East Fertility Society

Middle East Fertility Society Journal
www.mefsjournal.org
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ORIGINAL ARTICLE

Effect of postponing hCG injection after
intrauterine insemination on pregnancy rate
Mostafa S. Mostafa, Ahmed M. El Huseiny, Badeea S. Soliman *,
Marwa M. Mohammed
Obstetrics & Gynecology, Faculty of Medicine, Zagazig University, Egypt
Received 28 May 2013; accepted 13 October 2013
Available online 21 November 2013

KEYWORDS
Intrauterine insemination;
hCG;
Timing;
Pregnancy rate

Abstract Objective: During natural cycles, the best chance to become pregnant is if intercourse
occurs up to 6 day window ending on the day of ovulation. However, in the current practice, the
insemination is performed 32–36 h after hCG injection when the ovulation is expected. The aim
of this study was to compare the effect of postponing hCG injection till after intrauterine insemination with current practice protocol, on pregnancy rate. Design: a prospective, randomized, controlled trial. Setting: Zagazig University hospital.
Materials and methods: This study included one hundred infertile couples with unexplained infertility that had been scheduled for artificial insemination by husband semen. Women were divided into
two groups: the study group, including fifty women in whom hCG was injected 3–5 min after IUI
(hCG after IUI) and the control group, including fifty women in whom hCG was injected 24–32 h
before IUI (hCG before IUI). Pregnancy test was done 2 weeks after insemination.
Results: The overall pregnancy rate in this study, following IUI was 9%. The pregnancy rate was
10% ‘‘5/50’’ in the study group (hCG after IUI), versus 8% ‘‘4/50’’ in the control group (hCG before
IUI). However, this difference is not statistically significant.
Conclusion: There is no difference in pregnancy rate between HCG injection immediately following IUI and standard hCG injection 24–32 h before IUI.
Ó 2013 Production and hosting by Elsevier B.V. on behalf of Middle East Fertility Society.

Introduction

* Corresponding author. Tel.: +20 553482142, mobile: +20
1222360673.
E-mail address: badia_seliem@yahoo.com (B.S. Soliman).
Peer review under responsibility of Middle East Fertility Society.

Production and hosting by Elsevier

Unexplained infertility usually refers to a diagnosis made in
couples in whom all the usual investigations such as tests of tubal patency, ovulation and semen analysis are normal. There is
no consensus about the role of IUI in the treatment of unexplained infertility particularly regarding its superiority in
unstimulated, stimulated cycles or timed intercourse (1).
The rational for the use of IUI in the management of
unexplained infertility is deposition of a bolus of prepared,

1110-5690 Ó 2013 Production and hosting by Elsevier B.V. on behalf of Middle East Fertility Society.
http://dx.doi.org/10.1016/j.mefs.2013.10.002

However it appears that among healthy women. The washed sperm sample was loaded into a IUI catheter. Traditionally. Luteal phase support by vaginal progesterone suppositories 200 mg (Prontogest. The following post-processing sperm criteria were adopted in this study: A sperm count more than 10 million per ml and sperm motility grade (a) and (b) more than 50%. (3) Normal ovulation as evidenced by regular menstrual cycles and mid luteal serum progesterone levels >10 ng/ml.S. Cases with failed previous 3 IUI trials were excluded from the study. in the majority of IUI studies. No statistically significant differences were reported regarding the mean diameter and number of dominant follicle nor endometrial thickness between both groups. This practice is based on dictum that. a period of 12–16 h after ovulation (4). If this is applied to intrauterine insemination protocol. the study done by Wilcox et al. Similarly. A chi-squared (X2) test was used to assess the statistical significance when the incidence of primary and secondary infertility as well as occurrence of pregnancy was compared. Serial TVS assessment of follicular growth and endometrial thickness was started from cycle day 7 till a mean follicular diameter of 17–18 mm was reached. oocyte is fertilizable for only. However. The following inclusion criteria were also. Statistical analysis Data were reported as mean and standard deviation (Mean ± SD). motility and abnormal forms) between both groups (Table 2). IUI should be done after observation of ovulation for this reason. this comparative study was designed to study the effect of postponing hCG immediately after IUI rather than 32 h before it (standard method) on pregnancy rate. Clomiphene Citrate 100 mg from days 3 to 7 of menstrual flow followed by Human Menopausal Gonadotropins (hMG) (Menogon. the insemination is performed 32–36 h after hCG injection (5). the hCG should be injected after the insemination rather before it. There were no statistically significant differences regarding mean age. LH. However. which was inserted through the cervical canal and into the uterine cavity. Combined sequential protocol.184 concentrated. (2) Bilateral patent tubes were based on hysterosalpingography and/or laparoscopy. the best chance to become pregnant is if intercourse occurs up to 6 days before ovulation (6). adopted: the age of female partner is less than 37 years. Table 3 shows pelvic ultrasound data at day of hCG injection. Selection was done according to definite criteria. study group: 50 women in whom hCG (10. Zagazig University Hospital during the period between October 2010 and September 2011.000 IU) was injected 24–32 h before IUI. oocytes can only be fertilizable 6 h after ovulation. Based on the above. The study included one hundred infertile couples with a diagnosis of unexplained infertility who had been scheduled for intrauterine insemination (IUI) by husband semen. M. Group (2). Therefore. the ovulation takes place 32 h (range 24– 56 h) after the onset of the luteinizing hormone (LH) surge (10). a normal basal hormonal profile (FSH.000 IU) was injected 3–5 min after IUI. 1 shows basic characteristics and basic hormonal profile of both groups. Unexplained infertility was defined based on the following criteria: (1) Satisfactory seminal analysis according to WHO reference values on 2010 (7). Differences between groups were tested using Student’s t test and A chi-squared (X2) test.9). the insemination has been performed 24–36 h following hCG administration (5. it takes place approximately 36–38 h after the hCG injection (11). Ovulation usually takes place from 24 to 56 h after the onset of the natural LH surge with a mean time of 32 h (3). Cytogenetic Unit (CGU). E2 and Prolactin) and a satisfactory basal (day-2) transvaginal ultrasound examination. TSH. control group: 50 women in which hCG (10.. The chosen level of significance was p < 0. Additionally.e. Immediately following the IUI the patient was discharged and normal activity could be resumed. All patients gave informed consent and the study was approved by local ethics committee for scientific research. but assignment into two groups was divided randomly by using random table (computer software Open Epi version 3.5 ml sperm wash media. one hundred women who had been scheduled for IUI were studied.21): group (1). motile. together with ovarian stimulation. (6) suggested that conception occurred only when intercourse took place during a six-day period that ended on the estimated day of . 24–36 h after the administration of hCG. Results Between October 2010 and September 2011. Mostafa et al. Table. in natural cycles. it is rational to schedule the insemination to the time of expected ovulation. GMP Marcyrl) twice daily was started at day of insemination and continued for 2 weeks later when a pregnancy test was scheduled. Patients and methods This is a prospective randomized controlled study that was conducted in Assisted Reproductive Technologies (ART). As the current assumption is that the oocytes are fertilizable for a limited period of time in the female reproductive tract (12–14 h). A positive pregnancy test was yielded in 5 women (10%) in group ‘‘1’’ (hCG after IUI) and 4 women (8%) in group ‘‘2’’ (hCG before IUI). This was not a statistically significant difference (Table 4). This means that even if spermatozoa meet the oocyte in the fallopian tube at the time of ovulation there are still 6 h to the fertilizable period of the oocytes to start. Ferring) 75– 150 IU/day. Discussion Intrauterine insemination (IUI). there were no statistically significant differences in the post processing seminal parameters (count. morphologically normal sperm as close as possible to oocyte (2). LH. The double wash swim up technique using Ham’s F10 culture media was used for sperm preparation in all cases.05. duration and type of infertility as well as serum level of FSH. whereas in stimulated cycles. is a less expensive and invasive treatment in comparison with other assisted reproductive techniques (8). The final sperm pellet was suspended in a total of 0. TSH and prolactin. i.

If this is applied to IUI protocol.7 ± 1.4 (3.07 0.6 0.95 ± 4. pregnancy rate Table 1 Basic characteristics of both groups.11 0.55 0.43 0.12. hCG can be administered either before or after IUI.48 0.8–9.9%). therefore. This matches with overall pregnancy rates (8– 22%) following IUI reported in other studies (5.75 ± 17.41 (55–79) 66.28 ± 1.4 (16–21) 1. Therefore.3 ± 4. the overall pregnancy rate following IUI did not significantly differ if hCG is administered immediately after IUI compared to standard protocol ‘‘hCG injection 24–32 h before IUI’’.5–22.33 0.5 (1–7) 36 (72%) 14 (28%) 7. hCG hCG after IUI Pregnancy test +ve (N–%) Pregnancy test ve (N–%) Total X2 P-value 5 4 50 0 >0.4 1.6 0.67 ± 9.5) 11. For each group.8–8.6) 2. The overall pregnancy rate reported in this study was 9%.2 ± 1.3–8.79 0.6 (35–80) 32. Compared to our results.78 ± 0.8 ± 0.19 0. Age (years) Mean ± SD (range) Duration of infertility Mean ± SD (range) Type of infertility primary secondary Basal FSH (IU) Mean ± SD range Basal LH(IU) Mean ± SD range TSH (IU) Mean ± SD range Prolactin (ng/ml) Mean ± SD range Table 2 185 hCG after IUI hCG before IUI T P 28.4) 1. the pregnancy rate was 10% [5 pregnancies in group (1)] when hCG was administered after IUI versus 8% [4 pregnancies in group (2)] when hCG was administered before IUI. TVS at day of hCG hCG after IUI hCG before IUI T P Endometrial thickness Mean ± SD/mm (range) Number of follicles Mean ± SD (range) Mean follicle diameter Mean ± SD/mm (range) 9.15–4.6) 1.33 ± 0.84 0.5) 4.18 0. in which they were divided into two groups. According to the results of this current study.48 (16–22) 8. hCG injection before IUI and hCG injection after IUI.6) 1.16 ± 5 (4.52 Table 4 Comparison between group I and group II according to pregnancy test result. hCG should be injected after the insemination rather than before it. This study was carried out to test this notion.2 ± 1. preferably.96 0.8 (5.0 (6.5 ± 15. Our study. non-significant pregnancy rate.97 0.45 ± 0. a randomized controlled one aimed to evaluate the effect of postponing the hCG injection until after IUI on pregnancy rate.3 (7–9.87 (1. (14) on 100 infertile couples.06 ± 8.5 (1–3) 18.9 (45–85) 0.Intrauterine insemination.69 (1–8) 39 (78%) 11(22%) 7.4 ± 1 (5. postponing the hCG administration till after the IUI resulted in a higher though.74 (1.6) 5.2 ± 1. This may involve changes of the media used or better techniques of IUI in the new protocol with possible better pregnancy end results. This finding suggests that the chances to conceive in the natural cycle diminish considerably after ovulation and that.77 0.64 0. the spermatozoa should be available in the reproductive tract before ovulation occurs. A recent study was carried out by Dehghani-Firouzabai et al. They found no improvement in the pregnancy rate with hCG administration after IUI.05 NS (10%) (90%) (100%) ovulation. This significantly higher pregnancy rate in that study can be attributed to the retrospective comparison of the results of the new protocol (hCG after IUI) with those of standard protocol ‘‘hCG before IUI’’ for cases done 2 years before hand. Jervela et al.5 (1–3) 18. (15) reported a significantly higher pregnancy rate when hCG was administered immediately after IUI (19.733 ± 7.2–8. Post processing semen parameter hCG after IUI hCG before IUI T P Sperm count (mil.63 (14–55) 67.4–22) 26.88 0.13).71 X2 = 0.2) 2.7 ± 1.33 (53–77) 63. larger multi-centric studies are still required before recommending adoption of this new protocol.58 Post processing seminal parameters of both groups.34 Table 3 Pelvic ultrasound data of both groups at time of hCG injection. . The main outcome measure was the pregnancy test hCG hCG before IUI Total 4 46 50 9 91 100 (8%) (92%) (100%) that was done 2 weeks after the insemination. postpone hCG. This may allow for more flexibility of IUI protocols and more convenience of infertility clinic staff.2–8.84 0.67 ± 3.15–4./ml) Mean ± SD (range) Sperm motility (%) Mean ± SD (range) Abnormal forms (%) Mean ± SD 28.12 ± 1.6 (2.71 (12–48) 64.2 (17–36) 2.3) 12.6 ± 4.17 0. However.88 1.7 (19–36) 2.2 ± 2.6%) than when administered 24– 32 h before IUI (10.7 ± 2.4 (3.57 1.

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