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Journal of Gynecology Obstetrics and... Dec 2017The objective of this systematic review and meta-analysis was to investigate a possible association between immobilization and pregnancy rate in patients undergoing... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
The objective of this systematic review and meta-analysis was to investigate a possible association between immobilization and pregnancy rate in patients undergoing intrauterine insemination.
MATERIAL AND METHODS
To ensure the quality of the methodology, the PRISMA criteria were met at all stages of the development of this meta-analysis. We searched the Cochrane Library, EMBASE, PubMed MEDLINE, ScienceDirect and reference lists of eligible studies from inception to March 2017, without any restriction. We also interviewed the ClinicalTrials.gov database for unpublished articles. Finally, we sought potentially eligible studies in meeting abstracts. Two reviewers independently extracted study characteristics and outcome data. Estimates were pooled using random effects models and sensitivity analyses. We selected studies that compared bed rest to immediate mobilization after intrauterine insemination. The primary outcome was the ongoing pregnancy rate per couple.
RESULTS
Of 176 identified abstracts, four primary studies, all of them randomized controlled trials, met the inclusion criteria, including 1361 couples. The overall relative risk of ongoing pregnancy rate in bed rest versus immediate immobilization was 1.67 95% CI [0.86; 3.22]. The overall relative risk of the live birth rate was 1.11 95% CI [0.56; 2.20].
CONCLUSION
This systematic review and meta-analysis was not able to demonstrate that bed rest after intrauterine insemination effectively increases in pregnancy rate. For everyday practice, no specific strategy, bed rest or immediate mobilization, can be recommended at this time.
Topics: Bed Rest; Female; Humans; Immobilization; Insemination, Artificial; Pregnancy; Pregnancy Rate
PubMed: 28964965
DOI: 10.1016/j.jogoh.2017.09.005 -
Lesbian and bisexual women's likelihood of becoming pregnant: a systematic review and meta-analysis.BJOG : An International Journal of... Feb 2017Few data exist regarding pregnancy in lesbian and bisexual (LB) women. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Few data exist regarding pregnancy in lesbian and bisexual (LB) women.
OBJECTIVES
To determine the likelihood of LB women becoming pregnant, naturally or assisted, in comparison with heterosexual women SEARCH STRATEGY: Systematic review of papers published 1 January 2000 to 23 June 2015.
SELECTION CRITERIA
Studies contained details of pregnancy rates among LB women compared with heterosexual women. No restriction on study design.
DATA COLLECTION AND ANALYSIS
Inclusion decisions, data extraction and quality assessment were conducted in duplicate. Meta-analyses were carried out, with subgroups as appropriate.
MAIN RESULTS
Of 6859 papers identified, 104 full-text articles were requested, 30 papers (28 studies) were included. The odds ratio (OR) of ever being pregnant was 0.19 (95% CI 0.18-0.21) in lesbian women and 1.22 (95% CI 1.15-1.29) in bisexual women compared with heterosexual women. In the general population, the odds ratio for pregnancy was nine-fold lower among lesbian women and over two-fold lower among bisexual women (0.12 [95% CI 0.12-0.13] and 0.50 [95% CI 0.45-0.55], respectively). Odds ratios for pregnancy were higher for both LB adolescents (1.37 [95% CI 1.18-1.59] and 1.98 [95% CI 1.85, 2.13], respectively). There were inconsistent results regarding abortion rates. Lower rates of previous pregnancies were found in lesbian women undergoing artificial insemination (OR 0.17 [95% CI 0.11-0.26]) but there were higher assisted reproduction success rates compared with heterosexual women (OR 1.56 [95% CI 1.24-1.96]).
CONCLUSIONS
Heterosexuality must not be assumed in adolescents, as LB adolescents are at greater risk of unwanted pregnancies and terminations. Clinicians should provide appropriate information to all women, without assumptions about LB patients' desire for, or rejection of, fertility and childbearing.
TWEETABLE ABSTRACT
Review of likelihood of LB women becoming pregnant: LB teenagers at greater risk of unwanted pregnancies.
Topics: Female; Homosexuality, Female; Humans; Pregnancy; Pregnancy Rate; Probability; Sexual and Gender Minorities; Sexuality
PubMed: 27981741
DOI: 10.1111/1471-0528.14449 -
Fertility and Sterility May 2011To compare the pregnancy rates (PRs) in intrauterine insemination (IUI) using recombinant FSH (rec-FSH) or highly purified urinary FSH (HP-FSH). (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To compare the pregnancy rates (PRs) in intrauterine insemination (IUI) using recombinant FSH (rec-FSH) or highly purified urinary FSH (HP-FSH).
DESIGN
Systematic review and metaanalysis.
SETTING
University hospital.
PATIENT(S)
None.
INTERVENTION(S)
Electronic and manual searches.
MAIN OUTCOME MEASURE(S)
PR, per first cycle PR and per woman PR.
RESULT(S)
Six randomized trials (713 women, 1,581 cycles) were identified. In three the same doses of rec-FSH and HP-FSH were used ("equal dose" group), whereas in the other three the ratio HP-FSH:rec-FSH dose was 1.5. The global metaanalysis showed no differences in PRs. The PR per cycle was similar across the 1.5 ratio group (14.51% vs. 14.93%; relative risk [RR], 0.970; 95% confidence interval [CI], 0.687-1.369). However, the metaanalysis of the equal dose group, showed differences in the PR in favor of rec-FSH (16.36% vs. 12.31%; RR, 1.394; 95% CI, 1.004-1.936). Per woman PR analysis showed similar results (41.44% vs. 31.55%; RR, 1.273; 95% CI, 0.987-1.643). Per first cycle PR analysis showed a similar trend, although the difference did not reach significance (RR, 1.434; 95% CI, 0.934-2.203).
CONCLUSION(S)
Rec-FSH was associated with higher per cycle PR than HP-FSH, when used at the same dose, whereas the PR were similar when the dose of rec-FSH was 50% lower.
Topics: Female; Fertility Agents, Female; Follicle Stimulating Hormone; Humans; Insemination, Artificial; Male; Ovulation Induction; Pregnancy; Randomized Controlled Trials as Topic; Recombinant Proteins; Uterus
PubMed: 21429486
DOI: 10.1016/j.fertnstert.2011.02.030 -
The Cochrane Database of Systematic... Sep 2023In vitro fertilisation (IVF) is a treatment for unexplained subfertility but is invasive, expensive, and associated with risks. (Review)
Review
BACKGROUND
In vitro fertilisation (IVF) is a treatment for unexplained subfertility but is invasive, expensive, and associated with risks.
OBJECTIVES
To evaluate the effectiveness and safety of IVF versus expectant management, unstimulated intrauterine insemination (IUI), and IUI with ovarian stimulation using gonadotropins, clomiphene citrate (CC), or letrozole in improving pregnancy outcomes.
SEARCH METHODS
We searched following databases from inception to November 2021, with no language restriction: Cochrane Gynaecology and Fertility Register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL. We searched reference lists of articles and conference abstracts.
SELECTION CRITERIA
Randomised controlled trials (RCTs) comparing effectiveness of IVF for unexplained subfertility with expectant management, unstimulated IUI, and stimulated IUI.
DATA COLLECTION AND ANALYSIS
We followed standard Cochrane methods.
MAIN RESULTS
IVF versus expectant management (two RCTs) We are uncertain whether IVF improves live birth rate (LBR) and clinical pregnancy rate (CPR) compared to expectant management (odds ratio (OR) 22.0, 95% confidence interval (CI) 2.56 to 189.37; 1 RCT; 51 women; very low-quality evidence; OR 3.24, 95% CI 1.07 to 9.8; 2 RCTs; 86 women; I = 80%; very low-quality evidence). Adverse effects were not reported. Assuming 4% LBR and 12% CPR with expectant management, these would be 8.8% to 9% and 13% to 58% with IVF. IVF versus unstimulated IUI (two RCTs) IVF may improve LBR compared to unstimulated IUI (OR 2.47, 95% CI 1.19 to 5.12; 2 RCTs; 156 women; I = 60%; low-quality evidence). We are uncertain whether there is a difference between IVF and IUI for multiple pregnancy rate (MPR) (OR 1.03, 95% CI 0.04 to 27.29; 1 RCT; 43 women; very low-quality evidence) and miscarriage rate (OR 1.72, 95% CI 0.14 to 21.25; 1 RCT; 43 women; very low-quality evidence). No study reported ovarian hyperstimulation syndrome (OHSS). Assuming 16% LBR, 3% MPR, and 6% miscarriage rate with unstimulated IUI, these outcomes would be 18.5% to 49%, 0.1% to 46%, and 0.9% to 58% with IVF. IVF versus IUI + ovarian stimulation with gonadotropins (6 RCTs), CC (1 RCT), or letrozole (no RCTs) Stratified analysis was based on pretreatment status. Treatment-naive women There may be little or no difference in LBR between IVF and IUI + gonadotropins (1 IVF to 2 to 3 IUI cycles: OR 1.19, 95% CI 0.87 to 1.61; 3 RCTs; 731 women; I = 0%; low-quality evidence; 1 IVF to 1 IUI cycle: OR 1.63, 95% CI 0.91 to 2.92; 2 RCTs; 221 women; I = 54%; low-quality evidence); or between IVF and IUI + CC (OR 2.51, 95% CI 0.96 to 6.55; 1 RCT; 103 women; low-quality evidence). Assuming 42% LBR with IUI + gonadotropins (1 IVF to 2 to 3 IUI cycles) and 26% LBR with IUI + gonadotropins (1 IVF to 1 IUI cycle), LBR would be 39% to 54% and 24% to 51% with IVF. Assuming 15% LBR with IUI + CC, LBR would be 15% to 54% with IVF. There may be little or no difference in CPR between IVF and IUI + gonadotropins (1 IVF to 2 to 3 IUI cycles: OR 1.17, 95% CI 0.85 to 1.59; 3 RCTs; 731 women; I = 0%; low-quality evidence; 1 IVF to 1 IUI cycle: OR 4.59, 95% CI 1.86 to 11.35; 1 RCT; 103 women; low-quality evidence); or between IVF and IUI + CC (OR 3.58, 95% CI 1.51 to 8.49; 1 RCT; 103 women; low-quality evidence). Assuming 48% CPR with IUI + gonadotropins (1 IVF to 2 to 3 IUI cycles) and 17% with IUI + gonadotropins (1 IVF to 1 IUI cycle), CPR would be 44% to 60% and 28% to 70% with IVF. Assuming 21% CPR with IUI + CC, CPR would be 29% to 69% with IVF. There may be little or no difference in multiple pregnancy rate (MPR) between IVF and IUI + gonadotropins (1 IVF to 2 to 3 IUI cycles: OR 0.82, 95% CI 0.38 to 1.77; 3 RCTs; 731 women; I = 0%; low-quality evidence; 1 IVF to 1 IUI cycle: OR 0.76, 95% CI 0.36 to 1.58; 2 RCTs; 221 women; I = 0%; low-quality evidence); or between IVF and IUI + CC (OR 0.64, 95% CI 0.17 to 2.41; 1 RCT; 102 women; low-quality evidence). We are uncertain if there is a difference in OHSS between IVF and IUI + gonadotropins with 1 IVF to 2 to 3 IUI cycles (OR 6.86, 95% CI 0.35 to 134.59; 1 RCT; 207 women; very low-quality evidence); and there may be little or no difference in OHSS with 1 IVF to 1 IUI cycle (OR 1.22, 95% CI 0.36 to 4.16; 2 RCTs; 221 women; I = 0%; low-quality evidence). There may be little or no difference between IVF and IUI + CC (OR 1.53, 95% CI 0.24 to 9.57; 1 RCT; 102 women; low-quality evidence). We are uncertain if there is a difference in miscarriage rate between IVF and IUI + gonadotropins with 1 IVF to 2 to 3 IUI cycles (OR 0.31, 95% CI 0.03 to 3.04; 1 RCT; 207 women; very low-quality evidence); and there may be little or no difference with 1 IVF to 1 IUI cycle (OR 1.16, 95% CI 0.44 to 3.02; 1 RCT; 103 women; low-quality evidence). There may be little or no difference between IVF and IUI + CC (OR 1.48, 95% CI 0.54 to 4.05; 1 RCT; 102 women; low-quality evidence). In women pretreated with IUI + CC IVF may improve LBR compared with IUI + gonadotropins (OR 3.90, 95% CI 2.32 to 6.57; 1 RCT; 280 women; low-quality evidence). Assuming 22% LBR with IUI + gonadotropins, LBR would be 39% to 65% with IVF. IVF may improve CPR compared with IUI + gonadotropins (OR 14.13, 95% CI 7.57 to 26.38; 1 RCT; 280 women; low-quality evidence). Assuming 30% CPR with IUI + gonadotropins, CPR would be 76% to 92% with IVF.
AUTHORS' CONCLUSIONS
IVF may improve LBR over unstimulated IUI. Data should be interpreted with caution as overall evidence quality was low.
Topics: Pregnancy; Female; Humans; Letrozole; Abortion, Spontaneous; Insemination, Artificial; Fertility Agents, Female; Fertilization in Vitro; Infertility; Clomiphene; Ovarian Hyperstimulation Syndrome; Ovulation Induction; Gonadotropins; Pregnancy Rate; Live Birth
PubMed: 37753821
DOI: 10.1002/14651858.CD003357.pub5 -
Archives of Gynecology and Obstetrics Apr 2022IUI + COH is widely used in cases of unexplained infertility before resorting to IVF. Debate continues about what should be the first-line treatment for couples with... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
IUI + COH is widely used in cases of unexplained infertility before resorting to IVF. Debate continues about what should be the first-line treatment for couples with unexplained infertility.
OBJECTIVES
This systematic review assessed the relative efficacy of IUI + COH compared with IVF in couples with unexplained infertility.
SEARCH STRATEGY
We searched Medline, Embase, CIHNL, Pscy Info, and Cochrane Library from 1980 to November 2019.
SELECTION CRITERIA
Only RCTs published articles in full text with female patients aged 18-43 years and diagnosed with unexplained infertility were included.
DATA COLLECTION AND ANALYSIS
Two authors reviewed citations from primary search independently and any disagreement was resolved by mutual discussion and consultation with a third author.
MAIN RESULT
In total, eight RCTs were included. The quality of evidence was moderate to low due to inconsistency across the trials and imprecision. The pooled result showed that IVF was associated with a statistically significant higher live birth rate (RR 1.53, 95% CI 1.01-2.32, P < 0.00001 I = 86%) with no significant difference in multiple pregnancy rate or OHSS rate. Sensitivity analysis based on women's age and a history of previous IUI or IVF treatment showed no significant difference in the live birth rates (RR 1.01, 95% CI 0.88-1.15, I = 0%, 3 RCTs) in treatment-naïve women younger than 38 years. In women over 38 years, the live birth rates were significantly higher in the IVF group (RR 2.15, 95% CI 1.16-4.0, I = 42%, 1 RCT).
CONCLUSION
Further research using a standardised treatment protocol and taking into account important prognostic variables and cumulative live birth rates from fresh IVF and all sibling frozen embryos is required to further guide clinical practice.
Topics: Adolescent; Adult; Female; Fertilization in Vitro; Humans; Infertility; Insemination, Artificial; Live Birth; Ovarian Hyperstimulation Syndrome; Ovulation Induction; Pregnancy; Pregnancy Rate; Young Adult
PubMed: 34636983
DOI: 10.1007/s00404-021-06277-3 -
The Australian & New Zealand Journal of... Apr 2004Controlled ovarian hyperstimulation (COH) with clomiphene citrate (CC) combined with intrauterine insemination (IUI) is often used as treatment for ovulatory infertility... (Comparative Study)
Comparative Study Review
BACKGROUND
Controlled ovarian hyperstimulation (COH) with clomiphene citrate (CC) combined with intrauterine insemination (IUI) is often used as treatment for ovulatory infertility which includes unexplained, male, cervical, endometriosis, and tubal infertility.
AIMS
To review the effectiveness of CC and IUI in ovulatory infertility.
METHODS
Systematic review of pertinent randomised controlled trials (RCT) using the bibliographic databases MEDLINE and EMBASE. References of selected articles identified were hand-searched for additional relevant citations.
RESULTS
Six published RCT were included in the overall review. Meta-analysis demonstrated a higher cycle pregnancy rate (CPR) with CC and IUI compared to timed intercourse in the natural cycle (P < 0.001 and odds ratio = 4.6, 95% CI = 1.9-11.3). Treatment with gonadotrophins and IUI results in a higher CPR compared to CC and IUI (P = 0.005 and odds ratio = 2.9, 95% CI = 1.3-6.2). Further RCT are required comparing CC and IUI with IUI or CC alone before one can make firm conclusions.
CONCLUSIONS
Clomiphene citrate combined with IUI is more effective than timed intercourse in the natural cycle at achieving pregnancy in couples with ovulatory infertility. However, treatment with gonadotrophins and IUI is superior to CC and IUI.
Topics: Clomiphene; Coitus; Female; Fertility Agents, Female; Gonadotropins; Humans; Infertility, Female; Insemination, Artificial; Male; Ovulation Induction; Reproductive Techniques, Assisted
PubMed: 15089830
DOI: 10.1111/j.1479-828X.2004.00192.x -
Reproductive Sciences (Thousand Oaks,... May 2023The objective of this study was to evaluate the impact of endometrial scratch on the pregnancy rate among women with previous failed intrauterine insemination (IUI). A... (Meta-Analysis)
Meta-Analysis Review
The Effect of Endometrial Scratch on Pregnancy Rate in Women with Previous Intrauterine Insemination Failure: a Systematic Review and Meta-analysis of Randomized Controlled Trials.
The objective of this study was to evaluate the impact of endometrial scratch on the pregnancy rate among women with previous failed intrauterine insemination (IUI). A systematic search was done in PubMed, Cochrane Library, Scopus, and ISI web of science from inception to November 2021. We selected randomized clinical trials (RCTs) that compared endometrial scratch in the intervention group versus placebo or no intervention in the control group among infertile women with previous failure of IUI regarding different pregnancy outcomes. Revman software was utilized for performing our meta-analysis. Our main outcomes were biochemical pregnancy, clinical pregnancy, and live birth rates. Five RCTs met our inclusion criteria with a total number of 989 patients. We found endometrial scratch significantly improved the biochemical and clinical pregnancy rates in comparison with the control group among women with previous IUI failure (p < 0.001). Moreover, the live birth rate was significantly increased among the endometrial scratch group (RR = 2.00, 95% CI [1.20, 3.34], p = 0.008). In conclusion, endometrial scratch is effective in improving pregnancy outcomes among women with previous IUI failure. More trials are required to confirm our findings.
Topics: Pregnancy; Female; Humans; Pregnancy Rate; Randomized Controlled Trials as Topic; Fertilization in Vitro; Endometrium; Live Birth; Insemination; Insemination, Artificial; Ovulation Induction
PubMed: 36121616
DOI: 10.1007/s43032-022-01081-z -
The Journal of Urology Mar 2018Men with abnormal sperm morphology are often counseled that natural conception and intrauterine insemination are ineffective, and in vitro fertilization is the only... (Meta-Analysis)
Meta-Analysis
PURPOSE
Men with abnormal sperm morphology are often counseled that natural conception and intrauterine insemination are ineffective, and in vitro fertilization is the only option. Our objective was to determine the effect of sperm morphology on the pregnancy success of intrauterine insemination.
MATERIALS AND METHODS
We systematically searched for studies published prior to January 2017 that 1) reported ultrasound verified clinical pregnancies per intrauterine insemination cycle, 2) assessed sperm morphology using the Kruger strict criteria and 3) described morphology at the greater than 4% and 4% or less and/or the 1% or greater and less than 1% thresholds. In all studies mean female age was between 25 and 40 years and mean total motile sperm count was greater than 10 million. Estimates were pooled using random effects meta-analysis.
RESULTS
Data were extracted from 20 observational studies involving a total of 41,018 cycles. When comparing men at the greater than 4% and 4% or less thresholds, the rate of ultrasound verified pregnancy per intrauterine insemination cycle was not statistically or clinically different (14.2% vs 12.1%, p = 0.06) and the risk difference was 3.0% (95% CI 1.4-4.6), indicating 3.0 additional pregnancies per 100 intrauterine insemination cycles. When comparing men at the 1% or greater and the less than 1% thresholds, there were no statistical or clinical differences in the rate of ultrasound verified pregnancy per cycle of intrauterine insemination (14.0% vs 13.9%, p = 0.97) or in the risk difference (1.6%, 95% CI -4.5-7.6).
CONCLUSIONS
There appears to be no clinical difference in intrauterine insemination pregnancy success among men with normal and abnormal sperm morphology when accounting for total motile sperm count and female age. Abnormal sperm morphology alone should not exclude couples from attempting intrauterine insemination.
Topics: Female; Fertilization in Vitro; Humans; Infertility, Male; Insemination; Male; Pregnancy; Pregnancy Rate; Sperm Count; Sperm Motility
PubMed: 29129781
DOI: 10.1016/j.juro.2017.11.045 -
Asian Journal of Andrology Jul 2013Male factor infertility affects 30%-50% of infertile couples worldwide, and there is an increasing interest in the optimal management of these patients. In studies... (Meta-Analysis)
Meta-Analysis Review
Male factor infertility affects 30%-50% of infertile couples worldwide, and there is an increasing interest in the optimal management of these patients. In studies comparing double and single intrauterine insemination (IUI), a trend towards higher pregnancy rates in couples with male factor infertility was observed. Therefore, we set out to perform a meta-analysis to examine the superiority of double versus single IUI with the male partner's sperm in couples with male factor infertility. An odds ratio (OR) of 95% confidence intervals (CIs) was calculated for the pregnancy rate. Outcomes were analysed by using the Mantel-Haesel or DerSimonian-Laird model according to the heterogeneity of the results. Overall, five trials involving 1125 IUI cycles were included in the meta-analysis. There was a two-fold increase in pregnancies after a cycle with a double IUI compared with a cycle with a single IUI (OR: 2.0; 95% CI: 1.07-3.75; P<0.03). Nevertheless, this result was mainly attributed to the presence of a large trial that weighted as almost 50% in the overall analysis. Sensitivity analysis, excluding this large trial, revealed only a trend towards higher pregnancy rates among double IUI cycles (OR: 1.58; 95% CI: 0.59-4.21), but without statistical significance (P=0.20). Our systematic review highlights that the available evidence regarding the use of double IUI in couples with male factor infertility is fragmentary and weak. Although there may be a trend towards higher pregnancy rates when the number of IUIs per cycle is increased, further large and well-designed randomized trials are needed to provide solid evidence to guide current clinical practice.
Topics: Clinical Trials as Topic; Female; Humans; Infertility, Male; Insemination, Artificial; Male; Pregnancy; Pregnancy Rate
PubMed: 23708457
DOI: 10.1038/aja.2013.4 -
Journal of Assisted Reproduction and... Jan 2014To evaluate the efficacy of luteal phase support with vaginal progesterone in women undergoing intrauterine insemination (IUI). (Meta-Analysis)
Meta-Analysis Review
PURPOSE
To evaluate the efficacy of luteal phase support with vaginal progesterone in women undergoing intrauterine insemination (IUI).
METHODS
Systematic review and meta-analysis. Randomized controlled trials (RCT) comparing supplementation of luteal phase with vaginal progesterone among women undergoing IUI versus a control group were included. The main outcome assessed was live birth rate.
RESULTS
Five RCT met the inclusion criteria. In all 1,271 patients were included (951 IUI cycles in the progesterone group, 935 in the control group). Women treated with vaginal progesterone achieved significantly higher live birth rate (risk ratio [RR] 1.94, 95 % confidence interval [CI] 1.36 to 2.77,), and clinical pregnancy rate (RR 1.41, 95 % CI 1.14 to 1.76) as compared with controls. In the subgroup analysis per stimulation protocol, this beneficial effect of receiving progesterone was only observed in the group stimulated with gonadotropins (RR 2.28, 95 % CI 1.49 to 3.51), compared to the group stimulated with clomiphene citrate (CC) (RR 1.30, 95 % CI 0.68 to 2.50). No differences were observed in the miscarriage and multiple pregnancy rates.
CONCLUSIONS
The supplementation of luteal phase with vaginal progesterone significantly increases live birth among women undergoing IUI when receiving gonadotropins for ovulation induction. Women receiving CC to induce ovulation do not seem to benefit from this treatment.
Topics: Administration, Intravaginal; Female; Humans; Infertility; Insemination, Artificial; Luteal Phase; Male; Pregnancy; Pregnancy Rate; Progesterone; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 24189966
DOI: 10.1007/s10815-013-0127-6