Comparison Of Successfulancy Pregnancy Rate Between Flexible And Rigid Catheter In Intra Uterine Insemination

(1)

COMPARISON OF SUCCESSFUL PREGNANCY RATE BETWEEN

FLEXIBLE AND RIGID CATHETER IN INTRA UTERINE

INSEMINATION

Rusda M, Halim B, Kaban YB, Sahil MF, Efendi IH, Barus RC

Fertility, Endocrinology and Reproductive Division – Departement of Obstetric and Gynecology Medical Faculty – Universitas Sumatera Utara

Medan, Indonesia, October 2013

INTRODUCTION

Background

At present, many couples

presenting with fertility problems seek

advice for subfertility. Some of these

couples will undergo intrauterine

insemination (IUI) or artificial

insemination (AI). In spite of the

success with newer and more

sophisticated assisted reproductive

technique (ART). IUI remains the

recommended treatment for couples

with unexplained subfertility. The

rationale for this is that IUI is a

successful low cost alternative when

compared to the more advanced

fertility treatments such as in-vitro

fertilisation (IVF) and intracytoplasmic

sperm injection ( ICSI ). The costs of

IUI are considerably lower, the

pregnancy rates are similar and the

procedure is less stressful and

invasive compared to IVF and ICSI.

In a systematic review of

embryo transfer ( ET ) catheters, the

softness of the catheters was found to

be a determining factor in the success

of ET procedure. It is still unclear but it

is presumed to be associated with

reduced traumatic effects of flexible

catheter during introduction of the

embryo into the uterine cavity. Number

of cycles in which blood on the

catheter tip is present to examine if

there is a difference in traumatic

effects among flexible and rigid

catheters.

In the other hand, the impact of

the choice of IUI catheter on the

treatment outcome has been poorly

investigated and data comparing

different types of IUI catheters are

limited. The aim of this study is to

evaluate comparison of succesful

pregnancy rate between flexible and

rigid catheter in intra uterine

(2)

Methods

The study design was an

analytic observational with cohort

study design to evaluate the

comparison of succesful pregnancy

rate between flexible and rigid catheter

in intra uterine insemination were

performed at the Halim Fertility Centre

and Stella Maris – Women and

Children Hospital in Medan from July

until September 2013. The samples

were all patients seeking treatment

who undergo intra uterine

insemination. All patient than got

ovarian stimulation before intra uterine

insemination was taken. Analysis

between variables was conducted

using chi square to measure

proportion, p- value under 0,05 is

consider as statistically significance

results.

Results

There is no difference between

age group of women who undergo

intra uterine insemination using flexible

or rigid catheters, 30.90 +

Montanaro et al in 2001 through

a retrospective study over 5.5 years

with 273 cycles IIU get women aged

<35 years is a good predictor for the

successful rate of the IIU. there was no

difference in duration of infertility

between the two groups. Male factor is

the most cause of infertility in the rigid

catheter group, while unexplained

factor is the most cause in unexplained

factor.

4.52 year

and 32.53 + 3,97 year, respectively.

Table 1. Patient’s Characteristics

Patient

Duration of infertility ( year)

4,12 (+ 2,58) 4,26 (+ 3,44)

The table above also shows

that the type of infertility couples who

get IIU in both groups generally

primary infertility, 24 people (80%) in

the rigid catheter group and 27 people

(90%) in flexible catheter group.

Table 2. Insemination cycle’s

characteristics

Folicle and Endometrium

Number of folicle

(3)

folicle

Endometrial thickness

Both groups have the number of

follicles with a diameter of more than

17 mm, each 23 patients (76.7%) in

the rigid group and 22 patients (73.3%)

in the flexible catheter. Farimani et al

in 2007 suggested that from 463

cycles done, the average of the

follicles> 16 mm is a good predictor

associated with increased rate of

pregnancy.

Endometrial thickness in both

groups had a mean consecutive 8.47 ±

1.77 cm at rigid catheter group and

8.63 ± 1.97 cm in flexible catheter

group. Teraporn et al in 2003 got cut

off <7.5 mm of endometrial thickness

is a good predictor for the success of

intrauterine insemination.

Number of sperm used in the

two groups both rigid catheter group

and a flexible catheter are 11.29 x 106

± 8.11 sperms and 12.04 x 106± 8.72

sperms. Based on a retrospective

study in 893 IIU cycle conducted by

Khalil et al in 2001 found that the

number of motile sperm used in IIU

more than 2 x 10 6

Table 3. Factors encountered during

insemination

related with

increasing success rate of IIU.

Factors catheter tip

Yes

The table above shows that

there are no complications found in

catheter failure in both study groups.

This suggests that both types are

relatively easy to perform insertion.

Blood on the catheter when

removed from the uterine cavity are

found more on the rigid catheter group

18 (60%) than flexible catheter, 17

(56.7%). Statistically, the Chi-square

test value is p> 0.05, which indicates

no significant differences between the

two groups in terms of the presence of

blood in the catheter after the

(4)

the possibility of injury to the

endometrium at the time of the

procedure.

Cramps / abdominal pain

subjectively assessed in the procedure

occurred in 13 cases (43.3%) with a

rigid catheter, more than on a flexible

catheter which is 9 cases (30%). But,

there is no statistically significant

difference between two groups.

Reflux during insemination

procedure might affect the success of

the IIU. In this study, reflux is more in

rigid catheter group of 8 persons

(26.7%) while 1 in the flexible group

(3.3%). Chi-square test obtained p

value <0.05 indicating there is

significant difference between the two

groups in terms of the occurrence of

reflux after the procedure IIU. This

might be due to rigid catheter has a

smaller diameter than the flexible

catheter, where the larger diameter of

the cervix can accommodate patients

who can prevent reflux.

Table 4. Successful pregnancy

during IIU

Pregnancy

n = 30 _total p- value Positive Negative

Types of

** p-value measured with Continuity correction test

Intrauterine insemination

success rates in flexible catheter group

was higher (26.7%) compared with the

rigid catheter group (20%), but from

the statistical test obtained by

Chi-square, p-value = 0.542, showed no

significant difference in terms of the

level of pregnancy success between

the two catheters. Similar with

Teraporn in 2003, of 239 cycles

performed found no statistically

significant difference in the success

rate of insemination both rigid and

flexible catheter with a p value = 0.714.

Failure rate in cases with

intrauterine insemination catheter

containing blood is higher (85.7%)

compared with cases that not contain

blood (64%), but from the statistical

test obtained by Chi-square p-value =

0.050, which showed no difference in

terms of the success rate of pregnancy

among catheters that cause bleeding.

The failure rate in the case of

(5)

sperm reflux were similar in both

groups with p-value obtained

Correction Continuity test = 1.00,

showed no significant difference in

pregnancy success rates between the

catheter and the incidence of reflux.

We can concluded that the

success rate of intrauterine

insemination in flexible catheter group

was higher (26.7%) compared with the

rigid catheter group (20%), yet the

statistic measured obtained by

Chi-square p value> 0.05, which indicates

no significant difference in pregnancy

success rates between the two

catheters.

Discussion

One aspect on FERT attention

recently is a matter of the use of a

catheter in the insemination process.

Several previous studies on flexible

catheter for embryo transfer can

improve the success of the embryo

transfer. It is still unclear why, but

theoretically associated with the

incidence of trauma to the endometrial

lining, which flexible catheter may

reduce trauma at the entry time of the

embryo into the uterine cavity

compared with a rigid catheter.

In the other hand, there is no

significant difference of the success

rate of pregnancy among two

catheters, not only in terms of there is

bleeding or reflux happened during

procedures. Perhaps this because

after the IIU, sperm is known reached

the peritoneal cavity rapidly, but the

implantation of the embryo in the

uterus occurs about 7 days after

fertilization. In contrast of embryo

transfer, embryo before implantation

will float or stick to the wall with

endometrial adhesions are not strong

in a few days (embryo transfer second

or third day) or within 1 day of

implantation (day 5 embryo transfer or

6). Therefore, the average will

decrease if embryo transfer catheter

directly damage the embryo and / or

endometrium or if the embryo get out

through the cervix or fallopian tubes.

However, we expected the

clinician to consider uncomfortable

aspects of a rigid catheter although

there was no difference of successful

pregnancies.

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