Comparison Of Successfulancy Pregnancy Rate Between Flexible And Rigid Catheter In Intra Uterine Insemination
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 insemination.
Universitas Sumatera Utara
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 + 4.52 year and 32.53 + 3,97 year, respectively.
Montanaro et al in 2001 through a retrospective study over 5.5 years with 273 cycles IIU get women aged 17 mm 1 folicle
more than 1
Rigid Catheter
n=30
Flexible Catheter
n=30
7 ( 23,3% ) 23 ( 76,7%)
8 ( 26,7% ) 22 ( 73,3 % )
Universitas Sumatera Utara
folicle Endometrial thickness ( mm )
8.47 ± 1.77 8.63 ± 1.97
Number of sperms using
11.29 x 106± 8.11
12.04 x 106 ± 8.72
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.
more than 2 x 10 6 related with increasing success rate of IIU.
Table 3. Factors encountered during insemination
Factors
Failed for insertion Blood in catheter tip
Yes No Uncomfor table Yes No Reflux Yes No
Rigid Flexible
n=30
0 ( 0% )
Flexible Catheter
n=30
0 ( 0% )
p-value
18 ( 60% ) 12 ( 40% )
17 ( 56,7% ) 13 ( 43,3% )
0,793*
13 ( 43,3% ) 17 ( 56,7% )
9 ( 30% ) 21 ( 70% )
0,284*
8 ( 26,7% ) 22 ( 73,3% )
1 ( 3,3% ) 29 ( 96,7% )
0,030**
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 0.05, which indicates no significant differences between the two groups in terms of the presence of blood in the catheter after the procedure. Blood on catheter indicates
Universitas Sumatera Utara
the possibility of injury to the
endometrium at the time of the procedure.
Blood in catheter yes
5 (14,3%) 30 (85,7%) 35 (100%) 0,050
Cramps / abdominal pain subjectively assessed in the procedure
No Reflux Yes
9 (36%) 16 (64%) 25 (100%) 2 (22,2%) 7 (77,8%) 9 (100%) 1,00**
occurred in 13 cases (43.3%) with a No
12 (23,5%) 39 (76,5%) 51 (100%)
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, 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.
REFERENCE
1. Stephen, E.H. and A. Chandra. Use of infertility services in the United States. Family Planning Perspective, l32: 132-137:2000
2. Abou Setta AM, Al Inany HG, Mansour RT, Serour GI, Aboulghar MA. Soft versus firm
Universitas Sumatera Utara
embryo transfer catheters for
assisted reproduction: a
systematic review and meta-
analysis.Human Reproduction
2005;20(11):3114–21.
3. Voorhis, V., A.F. Sparks and
B.D. Allen. Cost effectiveness of
infertility treatment. Fertile.
Steril., 67: 830-860. ISBN:
1749-6632; 1997.
4. Abdelkader, A.M. and J. Yen.
The potential use of intrauterine
insemination as a basic option
for infertility. Rev. Technol. Int.
11: 609-622; 2009.
5. Andersen, A.N., V. Goossens
and A.P. Ferraritti,. Assisted
reproductive technology in
Europe hum. Report, 23: 756-
771. 2008.
6. Pandian Z, Bhattacharya S,
Vale L, Templeton A. In vitro
fertilisation for unexplained
subfertility. Cochrane Database
of Systematic Reviews 2005,
Issue 2.
7. Steures P, van der Steeg JW,
Hompes PG, Habbema JD, et
al. Intrauterine insemination
with controlled ovarian
hyperstimulation
versus
expectant management for
couples with unexplained
subfertility and an intermediate
prognosis: a randomised clinical
trial. Lancet:2006;368:216–221.
8. TerapornV., Sreshthaputra,O et
al.Comparison of Tom Cat
and PIVET Catheter for
Intrauterine Insemination:Thai
Journal of Obstetrics and
Gynaecology December 2003,
Vol. 15, pp. 223-229.
9. Karen L, Smith, R. Daniel.Does
Catheter Type Effect Pregnancy
Rate in Intrauterine
Insemination Cycles?:Journal of
Assisted Reproduction and
Genetics, Vol. 19, No. 2,
February 2002.
10. Kamil.N, Mohammed B.Efficacy
of Intra Uterine Insemination in
the Treatment of
Infertility:American
Medical
Journal 2 (1): 47-50, 2011.
11. Cohen MR. Intrauterine
insemination.Int J Fertil
1962;7:235–240.
12. Zegers-Hochschild F, Nygren
KG, Adamson GD, et al.On
behalf of The International
Committee Monitoring Assisted
Reproductive Technologies.
The ICMART glossary on ART
terminology.Hum
Reprod
2006a;21:1968–1970.
13. Andersen AN, Gianaroli L,
Felberbaum R, et al. Assisted
Universitas Sumatera Utara
reproductive technology in
Europe, 2001. Results
generated from European
registers by ESHRE. Hum
Reprod2005;20:1158–1176.
14. Bensdorp AJ, Cohlen BJ,
Heineman MJ,et al. Intra
Uterine Insemination for male
subfertility. Cochrane Database
Syst Rev;2007.
15. Andersen AN, Gianaroli L,
Felberbaum R, de Mouzon J,
Nygren
KG.Assisted
reproductive technology in
Europe, 2001. Results
generatedfrom
European
registers by ESHRE. Hum
Reprod2005;20:1158–1176.
16. ESHRE Capri Workshop Group.
Intrauterine
Insemination.
Human Reproduction Update,
Vol.15, No.3 pp. 265–277,
2009.
17. Andersen AN, Goossens V,
Ferraretti AP, et al, The
European IVF monitoring
(EIM)Consortium, for the
European Society of Human
ReproductionEmbryology
(ESHRE). Assisted reproductive
technology in Europe,2004:
results generated from
European registers by ESHRE.
HumReprod2008;23:756–771.
18. Aboubakr
M.Insemination
intrauterine:Middle East Fertility
Society Journal;Vol. 9, No. 2,
2004.
19. Boomsma,
C.M.,
M.J.
Heineman and B.J. Cohlen.
Semen preparation techniques
for intrauterine insemination.
Cochrane Database Syst. Rev.
nm7: 1223-1235; 2007.
20. Van Voorhis BJ, Barnett MR,
Sparks AE, et al. Effect of the
total motile sperm count on the
efficacy and cost effectiveness
of intrauterine insemination
andin vitro fertilization. Fertil
Steril2001;75:661–668.
21. Duran HE, Morshedi M, Kruger
T, Oehninger S. Intrauterine
insemination: a systematic
review on determinants of
success. Human Reproduction
Update 2002;8(4):373–84.
22. Van Weering HGI, Schats R,
McDonnell J, et al. The impact
of the embryo transfer catheter
on the pregnancy rate in IVF.
Hum Reprod 17,666–670; 2002.
23. McDonald JA and Norman RJ.
A randomized controlled trial of
a soft double lumen embryo
transfer catheter versus a firm
single lumen catheter:
significant improvements in
Universitas Sumatera Utara
pregnancy rates. Hum Reprod:
2002;17,1502–1506.
24. Lavie O, Margalioth EJ, Geva-
Eldar T, et al. Ultrasonographic
endometrial changes after
intrauterine
insemination:
Technical
aspects
of
intrauterine
insemination
catheters :The Cochrane
Collaboration. parison of two
catheters. Fertility and Sterility
1997;68:731–4.
25. Smith KL, Grow DR, Wiczyk
HP, et al. Does catheter type
effect pregnancy rate in
intrauterine
insemination
cycles? J Assist Reprod Genet
19,49–52; 2002.
26. Miller PB, Acres ML, Proctor
JG, et al. Flexible versus rigid
intrauterine
insemination
catheters: a prospective,
randomised, controlled study.
Fertil Steril 83,1544–1546;
2005.
27. Ragni G, Alagna F, Brigante C
et al. GnRH antagonists and
mild ovarian stimulation for
intrauterine insemination: a
randomized study comparing
different
gonado-trophin
dosages. Hum Reprod 19,54–
58. 2004.
28. Fancovits et al, Catheter type
does not effect the outcome of
intrauterine
insemination
treatment:
prospective
randomized study. Fertil Steril
83,699-704: 2005.
29. Cantineau AEP, Heineman MJ,
Cohlen BJ. Single versus
double intrauterine insemination
(IUI) in stimulated cycles for
subfertile couples. Cochrane
Database Syst Rev 2003.
30. WHO.Examination
and
processing of human semen, WHO laboratory manual 5th
edition:164-165; 2010.
31. “Intrauterine Insemination.” In
Vitro Fertilization IVF,Web.21
Mar 2011.
http://www.fwivf.com/fertilitytreat
ment-ft-
worth/intrauterine/insemination
.html>.
32. Reproductive Medicine and
Infertility
Associates,
“Intrauterine
Insemination
Section”: 3-5; 2010.
33. Farimani M, Amiri I. Analysis of
Prognostic
Factors
for
Successful Outcome in Patients
Undergoing
Intrauterine
Insemination. Acta Medica
Iranica, Vol. 45, No. 2:2007.
Universitas Sumatera Utara
34. van der Poel N, Farquhar C, Abou-Setta AM. Soft versus firm catheters for intrauterine insemination. Cochrane review: 2010
35. Schoolcraft WB, Surrey ES and Gardner DK. Embryo transfer: techniques and variabels affecting success. Fertil. Steril 76,863–870:2001.
36. NICE guideline Fertility: assessment and treatment for people with fertility problems. Clinical guideline 11. National Institute for Clinical Excellence, February 2004.
Universitas Sumatera Utara
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 insemination.
Universitas Sumatera Utara
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 + 4.52 year and 32.53 + 3,97 year, respectively.
Montanaro et al in 2001 through a retrospective study over 5.5 years with 273 cycles IIU get women aged 17 mm 1 folicle
more than 1
Rigid Catheter
n=30
Flexible Catheter
n=30
7 ( 23,3% ) 23 ( 76,7%)
8 ( 26,7% ) 22 ( 73,3 % )
Universitas Sumatera Utara
folicle Endometrial thickness ( mm )
8.47 ± 1.77 8.63 ± 1.97
Number of sperms using
11.29 x 106± 8.11
12.04 x 106 ± 8.72
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.
more than 2 x 10 6 related with increasing success rate of IIU.
Table 3. Factors encountered during insemination
Factors
Failed for insertion Blood in catheter tip
Yes No Uncomfor table Yes No Reflux Yes No
Rigid Flexible
n=30
0 ( 0% )
Flexible Catheter
n=30
0 ( 0% )
p-value
18 ( 60% ) 12 ( 40% )
17 ( 56,7% ) 13 ( 43,3% )
0,793*
13 ( 43,3% ) 17 ( 56,7% )
9 ( 30% ) 21 ( 70% )
0,284*
8 ( 26,7% ) 22 ( 73,3% )
1 ( 3,3% ) 29 ( 96,7% )
0,030**
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 0.05, which indicates no significant differences between the two groups in terms of the presence of blood in the catheter after the procedure. Blood on catheter indicates
Universitas Sumatera Utara
the possibility of injury to the
endometrium at the time of the procedure.
Blood in catheter yes
5 (14,3%) 30 (85,7%) 35 (100%) 0,050
Cramps / abdominal pain subjectively assessed in the procedure
No Reflux Yes
9 (36%) 16 (64%) 25 (100%) 2 (22,2%) 7 (77,8%) 9 (100%) 1,00**
occurred in 13 cases (43.3%) with a No
12 (23,5%) 39 (76,5%) 51 (100%)
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, 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.
REFERENCE
1. Stephen, E.H. and A. Chandra. Use of infertility services in the United States. Family Planning Perspective, l32: 132-137:2000
2. Abou Setta AM, Al Inany HG, Mansour RT, Serour GI, Aboulghar MA. Soft versus firm
Universitas Sumatera Utara
embryo transfer catheters for
assisted reproduction: a
systematic review and meta-
analysis.Human Reproduction
2005;20(11):3114–21.
3. Voorhis, V., A.F. Sparks and
B.D. Allen. Cost effectiveness of
infertility treatment. Fertile.
Steril., 67: 830-860. ISBN:
1749-6632; 1997.
4. Abdelkader, A.M. and J. Yen.
The potential use of intrauterine
insemination as a basic option
for infertility. Rev. Technol. Int.
11: 609-622; 2009.
5. Andersen, A.N., V. Goossens
and A.P. Ferraritti,. Assisted
reproductive technology in
Europe hum. Report, 23: 756-
771. 2008.
6. Pandian Z, Bhattacharya S,
Vale L, Templeton A. In vitro
fertilisation for unexplained
subfertility. Cochrane Database
of Systematic Reviews 2005,
Issue 2.
7. Steures P, van der Steeg JW,
Hompes PG, Habbema JD, et
al. Intrauterine insemination
with controlled ovarian
hyperstimulation
versus
expectant management for
couples with unexplained
subfertility and an intermediate
prognosis: a randomised clinical
trial. Lancet:2006;368:216–221.
8. TerapornV., Sreshthaputra,O et
al.Comparison of Tom Cat
and PIVET Catheter for
Intrauterine Insemination:Thai
Journal of Obstetrics and
Gynaecology December 2003,
Vol. 15, pp. 223-229.
9. Karen L, Smith, R. Daniel.Does
Catheter Type Effect Pregnancy
Rate in Intrauterine
Insemination Cycles?:Journal of
Assisted Reproduction and
Genetics, Vol. 19, No. 2,
February 2002.
10. Kamil.N, Mohammed B.Efficacy
of Intra Uterine Insemination in
the Treatment of
Infertility:American
Medical
Journal 2 (1): 47-50, 2011.
11. Cohen MR. Intrauterine
insemination.Int J Fertil
1962;7:235–240.
12. Zegers-Hochschild F, Nygren
KG, Adamson GD, et al.On
behalf of The International
Committee Monitoring Assisted
Reproductive Technologies.
The ICMART glossary on ART
terminology.Hum
Reprod
2006a;21:1968–1970.
13. Andersen AN, Gianaroli L,
Felberbaum R, et al. Assisted
Universitas Sumatera Utara
reproductive technology in
Europe, 2001. Results
generated from European
registers by ESHRE. Hum
Reprod2005;20:1158–1176.
14. Bensdorp AJ, Cohlen BJ,
Heineman MJ,et al. Intra
Uterine Insemination for male
subfertility. Cochrane Database
Syst Rev;2007.
15. Andersen AN, Gianaroli L,
Felberbaum R, de Mouzon J,
Nygren
KG.Assisted
reproductive technology in
Europe, 2001. Results
generatedfrom
European
registers by ESHRE. Hum
Reprod2005;20:1158–1176.
16. ESHRE Capri Workshop Group.
Intrauterine
Insemination.
Human Reproduction Update,
Vol.15, No.3 pp. 265–277,
2009.
17. Andersen AN, Goossens V,
Ferraretti AP, et al, The
European IVF monitoring
(EIM)Consortium, for the
European Society of Human
ReproductionEmbryology
(ESHRE). Assisted reproductive
technology in Europe,2004:
results generated from
European registers by ESHRE.
HumReprod2008;23:756–771.
18. Aboubakr
M.Insemination
intrauterine:Middle East Fertility
Society Journal;Vol. 9, No. 2,
2004.
19. Boomsma,
C.M.,
M.J.
Heineman and B.J. Cohlen.
Semen preparation techniques
for intrauterine insemination.
Cochrane Database Syst. Rev.
nm7: 1223-1235; 2007.
20. Van Voorhis BJ, Barnett MR,
Sparks AE, et al. Effect of the
total motile sperm count on the
efficacy and cost effectiveness
of intrauterine insemination
andin vitro fertilization. Fertil
Steril2001;75:661–668.
21. Duran HE, Morshedi M, Kruger
T, Oehninger S. Intrauterine
insemination: a systematic
review on determinants of
success. Human Reproduction
Update 2002;8(4):373–84.
22. Van Weering HGI, Schats R,
McDonnell J, et al. The impact
of the embryo transfer catheter
on the pregnancy rate in IVF.
Hum Reprod 17,666–670; 2002.
23. McDonald JA and Norman RJ.
A randomized controlled trial of
a soft double lumen embryo
transfer catheter versus a firm
single lumen catheter:
significant improvements in
Universitas Sumatera Utara
pregnancy rates. Hum Reprod:
2002;17,1502–1506.
24. Lavie O, Margalioth EJ, Geva-
Eldar T, et al. Ultrasonographic
endometrial changes after
intrauterine
insemination:
Technical
aspects
of
intrauterine
insemination
catheters :The Cochrane
Collaboration. parison of two
catheters. Fertility and Sterility
1997;68:731–4.
25. Smith KL, Grow DR, Wiczyk
HP, et al. Does catheter type
effect pregnancy rate in
intrauterine
insemination
cycles? J Assist Reprod Genet
19,49–52; 2002.
26. Miller PB, Acres ML, Proctor
JG, et al. Flexible versus rigid
intrauterine
insemination
catheters: a prospective,
randomised, controlled study.
Fertil Steril 83,1544–1546;
2005.
27. Ragni G, Alagna F, Brigante C
et al. GnRH antagonists and
mild ovarian stimulation for
intrauterine insemination: a
randomized study comparing
different
gonado-trophin
dosages. Hum Reprod 19,54–
58. 2004.
28. Fancovits et al, Catheter type
does not effect the outcome of
intrauterine
insemination
treatment:
prospective
randomized study. Fertil Steril
83,699-704: 2005.
29. Cantineau AEP, Heineman MJ,
Cohlen BJ. Single versus
double intrauterine insemination
(IUI) in stimulated cycles for
subfertile couples. Cochrane
Database Syst Rev 2003.
30. WHO.Examination
and
processing of human semen, WHO laboratory manual 5th
edition:164-165; 2010.
31. “Intrauterine Insemination.” In
Vitro Fertilization IVF,Web.21
Mar 2011.
http://www.fwivf.com/fertilitytreat
ment-ft-
worth/intrauterine/insemination
.html>.
32. Reproductive Medicine and
Infertility
Associates,
“Intrauterine
Insemination
Section”: 3-5; 2010.
33. Farimani M, Amiri I. Analysis of
Prognostic
Factors
for
Successful Outcome in Patients
Undergoing
Intrauterine
Insemination. Acta Medica
Iranica, Vol. 45, No. 2:2007.
Universitas Sumatera Utara
34. van der Poel N, Farquhar C, Abou-Setta AM. Soft versus firm catheters for intrauterine insemination. Cochrane review: 2010
35. Schoolcraft WB, Surrey ES and Gardner DK. Embryo transfer: techniques and variabels affecting success. Fertil. Steril 76,863–870:2001.
36. NICE guideline Fertility: assessment and treatment for people with fertility problems. Clinical guideline 11. National Institute for Clinical Excellence, February 2004.
Universitas Sumatera Utara