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AIDS and Behavior Sep 2018We conducted a systematic review of safer conception strategies (SCS) for HIV-affected couples in sub-Saharan Africa to inform evidence-based safer conception...
We conducted a systematic review of safer conception strategies (SCS) for HIV-affected couples in sub-Saharan Africa to inform evidence-based safer conception interventions. Following PRISMA guidelines, we searched fifteen electronic databases using the following inclusion criteria: SCS research in HIV-affected couples; published after 2007; in sub-Saharan Africa; primary research; peer-reviewed; and addressed a primary topic of interest (SCS availability, feasibility, and acceptability, and/or education and promotion). Researchers independently reviewed each study for eligibility using a standardized tool. We categorize studies by their topic area. We identified 41 studies (26 qualitative and 15 quantitative) that met inclusion criteria. Reviewed SCSs included: antiretroviral therapy (ART), pre-exposure prophylaxis, timed unprotected intercourse, manual/self-insemination, sperm washing, and voluntary male medical circumcision (VMMC). SCS were largely unavailable outside of research settings, except for general availability (i.e., not specifically for safer conception) of ART and VMMC. SCS acceptability was impacted by low client and provider knowledge about safer conception services, stigma around HIV-affected couples wanting children, and difficulty with HIV disclosure in HIV-affected couples. Couples expressed desire to learn more about SCS; however, provider training, patient education, SCS promotions, and integration of reproductive health and HIV services remain limited. Studies of provider training and couple-based education showed improvements in communication around fertility intentions and SCS knowledge. SCS are not yet widely available to HIV-affected African couples. Successful implementation of SCS requires that providers receive training on effective SCS and provide couple-based safer conception counseling to improve disclosure and communication around fertility intentions and reproductive health.
Topics: Africa South of the Sahara; Anti-Retroviral Agents; Circumcision, Male; Counseling; Disclosure; Female; Fertility; Fertilization; HIV Infections; Health Services Accessibility; Heterosexuality; Humans; Insemination, Artificial; Intention; Male; Pre-Exposure Prophylaxis; Preconception Care; Reproductive Behavior; Reproductive Health; Sexual Partners; Social Stigma
PubMed: 29869184
DOI: 10.1007/s10461-018-2170-x -
BJOG : An International Journal of... Jan 2019Several randomised controlled trials (RCTs) have investigated the usefulness of pituitary block with gonadotrophin-releasing hormone (GnRH) antagonists during... (Meta-Analysis)
Meta-Analysis
Pituitary block with gonadotrophin-releasing hormone antagonist during intrauterine insemination cycles: a systematic review and meta-analysis of randomised controlled trials.
BACKGROUND
Several randomised controlled trials (RCTs) have investigated the usefulness of pituitary block with gonadotrophin-releasing hormone (GnRH) antagonists during intrauterine insemination (IUI) cycles, with conflicting results.
OBJECTIVE
The aim of the present systematic review and meta-analysis of RCTs was to evaluate the effectiveness of GnRH antagonist administration as an intervention to improve the success of IUI cycles.
SEARCH STRATEGY
Electronic databases (MEDLINE, Scopus, EMBASE, Sciencedirect) and clinical registers were searched from their inception until October 2017.
SELECTION CRITERIA
Randomised controlled trials of infertile women undergoing one or more IUI stimulated cycles with GnRH antagonists compared with a control group.
DATA COLLECTION AND ANALYSIS
The primary outcomes were ongoing pregnancy/live birth rate (OPR/LBR) and clinical pregnancy rate (CPR). Pooled results were expressed as odds ratio (OR) or mean differences with 95% confidence interval (95% CI). Sources of heterogeneity were investigated through sensitivity and subgroups analysis. The body of evidence was rated using GRADE methodology. Publication bias was assessed with funnel plot, Begg's and Egger's tests.
MAIN RESULTS
Fifteen RCTs were included (3253 IUI cycles, 2345 participants). No differences in OPR/LBR (OR 1.14, 95% CI 0.82-1.57, P = 0.44) and CPR (OR 1.28, 95% CI 0.97-1.69, P = 0.08) were found. Sensitivity and subgroup analyses did not provide statistical changes in pooled results. The body of evidence was rated as low (GRADE 2/4). No publication bias was detected.
CONCLUSION
Pituitary block with GnRH antagonists does not improve OPR/LBR and CPR in women undergoing IUI cycles.
TWEETABLE ABSTRACT
Pituitary block with GnRH antagonists does not improve the success of IUI cycles.
Topics: Female; Follicle Stimulating Hormone; Gonadotropin-Releasing Hormone; Humans; Infertility, Female; Insemination, Artificial; Live Birth; Male; Ovulation Induction; Pituitary Gland; Pregnancy; Pregnancy Rate; Randomized Controlled Trials as Topic
PubMed: 29862633
DOI: 10.1111/1471-0528.15269 -
The Cochrane Database of Systematic... Jan 2018The first-line treatment in donor sperm treatment consists of inseminations that can be done by intrauterine insemination (IUI) or by intracervical insemination (ICI). (Comparative Study)
Comparative Study Review
BACKGROUND
The first-line treatment in donor sperm treatment consists of inseminations that can be done by intrauterine insemination (IUI) or by intracervical insemination (ICI).
OBJECTIVES
To compare the effectiveness and safety of intrauterine insemination (IUI) and intracervical insemination (ICI) in women who start donor sperm treatment.
SEARCH METHODS
We searched the Cochrane Gynaecology and Fertility Group Trials Register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL in October 2016, checked references of relevant studies, and contacted study authors and experts in the field to identify additional studies. We searched PubMed, Google Scholar, the Grey literature, and five trials registers on 15 December 2017.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) reporting on IUI versus ICI in natural cycles or with ovarian stimulation, and RCTs comparing different cointerventions in IUI and ICI. We included cross-over studies if pre-cross-over data were available.
DATA COLLECTION AND ANALYSIS
We used standard methodological procedures recommended by Cochrane. We collected data on primary outcomes of live birth and multiple pregnancy rates, and on secondary outcomes of clinical pregnancy, miscarriage, and cancellation rates.
MAIN RESULTS
We included six RCTs (708 women analysed) on ICI and IUI in donor sperm treatment. Two studies compared IUI and ICI in natural cycles, two studies compared IUI and ICI in gonadotrophin-stimulated cycles, and two studies compared timing of IUI and ICI. There was very low-quality evidence; the main limitations were risk of bias due to poor reporting of study methods, and serious imprecision.IUI versus ICI in natural cyclesThere was insufficient evidence to determine whether there was any clear difference in live birth rate between IUI and ICI in natural cycles (odds ratio (OR) 3.24, 95% confidence interval (CI) 0.12 to 87.13; 1 RCT, 26 women; very low-quality evidence). There was only one live birth in this study (in the IUI group). IUI resulted in higher clinical pregnancy rates (OR 6.18, 95% CI 1.91 to 20.03; 2 RCTs, 76 women; I² = 48%; very low-quality evidence).No multiple pregnancies or miscarriages occurred in this study.IUI versus ICI in gonadotrophin-stimulated cyclesThere was insufficient evidence to determine whether there was any clear difference in live birth rate between IUI and ICI in gonadotrophin-stimulated cycles (OR 2.55, 95% CI 0.72 to 8.96; 1 RCT, 43 women; very low-quality evidence). This suggested that if the chance of a live birth following ICI in gonadotrophin-stimulated cycles was assumed to be 30%, the chance following IUI in gonadotrophin-stimulated cycles would be between 24% and 80%. IUI may result in higher clinical pregnancy rates than ICI (OR 2.83, 95% CI 1.38 to 5.78; 2 RCTs, 131 women; I² = 0%; very low-quality evidence). IUI may be associated with higher multiple pregnancy rates than ICI (OR 2.77, 95% CI 1.00 to 7.69; 2 RCTs, 131 women; I² = 0%; very low-quality evidence). This suggested that if the risk of multiple pregnancy following ICI in gonadotrophin-stimulated cycles was assumed to be 10%, the risk following IUI would be between 10% and 46%.We found insufficient evidence to determine whether there was any clear difference between the groups in miscarriage rates in gonadotrophin-stimulated cycles (OR 1.97, 95% CI 0.43 to 9.04; 2 RCTs, overall 67 pregnancies; I² = 50%; very low-quality evidence).Timing of IUI and ICIWe found no studies that reported on live birth rates.We found a higher clinical pregnancy rate when IUI was timed one day after a rise in blood levels of luteinising hormone (LH) compared to IUI two days after a rise in blood levels of LH (OR 2.00, 95% CI 1.14 to 3.53; 1 RCT, 351 women; low-quality evidence). We found insufficient evidence to determine whether there was any clear difference in clinical pregnancy rates between ICI timed after a rise in urinary levels of LH versus a rise in basal temperature plus cervical mucus scores (OR 1.31, 95% CI 0.42 to 4.11; 1 RCT, 56 women; very low-quality evidence).Neither of these studies reported multiple pregnancy or miscarriage rates as outcomes.
AUTHORS' CONCLUSIONS
There was insufficient evidence to determine whether there was a clear difference in live birth rates between IUI and ICI in natural or gonadotrophin-stimulated cycles in women who started with donor sperm treatment. There was insufficient evidence available for the effect of timing of IUI or ICI on live birth rates. Very low-quality data suggested that in gonadotrophin-stimulated cycles, ICI may be associated with a higher clinical pregnancy rate than IUI, but also with a higher risk of multiple pregnancy rate. We concluded that the current evidence was too limited to choose between IUI or ICI, in natural cycles or with ovarian stimulation, in donor sperm treatment.
Topics: Body Temperature; Cervix Mucus; Female; Gonadotropins; Humans; Insemination, Artificial, Heterologous; Live Birth; Luteinizing Hormone; Menstrual Cycle; Pregnancy; Pregnancy Rate; Pregnancy, Multiple; Randomized Controlled Trials as Topic
PubMed: 29368795
DOI: 10.1002/14651858.CD000317.pub4 -
Reproductive Biomedicine Online Feb 2018The aim of this study was to ascertain the incidence of pelvic inflammatory disease (PID) after intrauterine insemination (IUI). A systematic review was conducted using... (Review)
Review
The aim of this study was to ascertain the incidence of pelvic inflammatory disease (PID) after intrauterine insemination (IUI). A systematic review was conducted using three different approaches: a search of IUI registries; a search of published meta-analyses; and a search of prospective randomized trials. Search terms were 'IUI', 'complications', 'infection' and 'PID'. Two IUI registers were identified that met the inclusion criteria, totalling 365,874 cycles, with 57 PID cases being reported. The post-IUI PID rate was 0.16/1000 (95% CI 0.2 to 0.3/1000). The frequency was higher in husband sperm cycles (0.21/1000) (28/135,839) than in donor sperm cycles (0.03/1000) (1/33,712) (P < 0.05; OR 6.95). Nineteen meta-analyses were retrieved, which included 156 trials, totalling 43,048 cycles, with no PID case being reported. Seventeen prospective clinical trials published between 2013 and 2014 were identified, totalling 4968 cycles; no PID case was reported. The reported rate of post-IUI clinical PID is low (0.16/1000), about 40% higher than reported in the general population of women during their reproductive life. No antibiotic prophylaxis should be recommended unless there is an associated risk factor.
Topics: Female; Humans; Insemination, Artificial, Heterologous; Insemination, Artificial, Homologous; Male; Meta-Analysis as Topic; Pelvic Inflammatory Disease; Registries
PubMed: 29287941
DOI: 10.1016/j.rbmo.2017.11.002 -
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 -
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 -
Journal of Obstetrics and Gynaecology... Mar 2018Physical activity (PA) behaviours after assisted reproductive technology (ART) may influence its success. Bedrest is frequently recommended immediately after...
Physical activity (PA) behaviours after assisted reproductive technology (ART) may influence its success. Bedrest is frequently recommended immediately after intrauterine insemination (IUI) or embryo transfer (ET), and women are also commonly advised to restrict PA after ART. However, these recommendations are not grounded on evidence-based information. The purpose of this systematic review was to assess the impact of PA behaviours during ART on ART success (positive pregnancy test, clinical pregnancy, live birth). A systematic search of the literature was conducted in PubMed, Medline, SPORTdiscus, and CINAHL. The Grading of Recommendations Assessment, Development, and Evaluation system was applied to studies by clinical outcome and used to rate quality of evidence. Twelve studies were included in the review. Our findings suggest that the effect of bedrest immediately after IUI or ET on ART success depends on the procedure used, with favourable effects after IUI ("moderate" quality evidence on clinical pregnancy) but no effect, and even possible unfavourable effects, after ET ("very low" quality evidence on positive pregnancy test and clinical pregnancy). "Very low" quality evidence suggested a decreased live birth rate with bedrest after ET (n = 1) but an increased rate with bedrest after IUI (n = 1). "Very low" quality of evidence suggested no deleterious effect of moderate PA on clinical pregnancy and live birth after ET. On the basis of our findings, studies with more rigourous design and methodology, and considering live birth as an outcome, are needed to provide further evidence on the most appropriate PA behaviours women should adopt to improve ART success.
Topics: Bed Rest; Birth Rate; Embryo Transfer; Exercise; Female; Humans; Insemination, Artificial; Treatment Outcome
PubMed: 28826643
DOI: 10.1016/j.jogc.2017.07.001 -
Journal of Dairy Science Oct 2017The objective of this study was to conduct a systematic review to identify and assess evidence and knowledge gaps in published observational studies that have... (Review)
Review
The objective of this study was to conduct a systematic review to identify and assess evidence and knowledge gaps in published observational studies that have investigated the relationship between mastitis and pregnancy loss (PL) in dairy cows. PubMed and ScienceDirect were used to search pertinent peer-reviewed research reports of interest. Screening of research reports was conducted at 3 levels: titles, abstracts, and full-text articles. The search identified 651 records for initial screening. The final screening process identified 8 qualified articles for review after removing 10 duplicate records, 582 titles, 31 abstracts, and 20 full-text articles. Two studies produced strong epidemiologic evidence indicating that (1) exposure to clinical mastitis during early gestation (first 45 d of gestation) is associated with subsequent PL during the following 90 d; and (2) subclinical mastitis 1 to 30 d before artificial insemination (AI) is associated with subsequent PL at 35 to 41 d of gestation. An additional study showed that exposure to clinical mastitis during early lactation in combination with low body condition can increase the risk of PL in dairy cows; however, the interaction effect between clinical mastitis and low body condition on PL was considered weak. Four other studies produced inconclusive evidence indicating that mastitis is a predisposing factor for PL in dairy cows, as the exposure risk period for mastitis overlapped with the follow-up period for diagnosis of PL in dairy cows. Finally, one study failed to identify a relationship between mastitis and PL in dairy cows. Further research is needed to (1) support the hypothesis that mastitis in combination with low body condition score (or other exposure factors) can increase the risk of PL, (2) compare the effect of clinical versus subclinical mastitis on PL, (3) compare the effect of mastitis before breeding and during gestation on PL, and (4) compare the effect of mastitis on PL in dairy cows during different lactations.
Topics: Abortion, Veterinary; Animals; Cattle; Female; Insemination, Artificial; Lactation; Mastitis, Bovine; Observational Studies as Topic; Pregnancy
PubMed: 28780088
DOI: 10.3168/jds.2017-12711 -
European Journal of Obstetrics,... Aug 2017This study is focused in appraising the current evidence comparing double and single IUI for achieving a pregnancy. The primary outcomes were live birth and ectopic... (Meta-Analysis)
Meta-Analysis Review
This study is focused in appraising the current evidence comparing double and single IUI for achieving a pregnancy. The primary outcomes were live birth and ectopic pregnancy per women randomized. Secondary outcomes included clinical pregnancy and miscarriage. The evaluation of the risk of bias within each study was structured using the Cochrane risk of bias and the overall quality of the body of evidence was assessed through the GRADE criteria. Electronic searches were run in 4 databases and resulted in 15 studies included encompassing 3795 women. The subgroup 'mild male infertility' included 1246 women whilst the subgroup 'normal semen quality' included 1188 women. Clinical pregnancy was reported by all studies, and there is no evidence of a difference between single and double IUI (RR 1.22, CI 0.97 to 1.54, 15 RCTs, 3795 women, I=45%). In the subgroup analysis, we could not identify a particular group that could benefit from the intervention. No conclusion can be drawn regarding live birth, ectopic pregnancy, and miscarriage because they were reported by too few studies and the estimates were too imprecise. Currently, there is no evidence to support the use of double IUI in clinical practice. It requires a second appointment and insemination, thus making the treatment more complex and expensive, without a clear evidence of a benefit. Nevertheless, evidence is still of low quality and our confidence in the effect estimate is limited: the true effect may be substantially different from the hereby demonstrated.
Topics: Female; Fertilization in Vitro; Humans; Insemination, Artificial; Live Birth; Male; Pregnancy; Pregnancy Outcome; Pregnancy Rate
PubMed: 28605667
DOI: 10.1016/j.ejogrb.2017.05.025 -
European Journal of Obstetrics,... Jun 2017The cost of fertility treatment is expensive and interventions that reduce cost can lead to greater efficiency and fewer embryos transferred. Endometrial polyps... (Review)
Review
The cost of fertility treatment is expensive and interventions that reduce cost can lead to greater efficiency and fewer embryos transferred. Endometrial polyps contribute to infertility and are frequently removed prior to infertility treatment. It is unclear whether polypectomy reduces fertility treatment cost and if so, the magnitude of cost reduction afforded by the procedure. The aim of this study was to determine whether performing office or operative hysteroscopic polypectomy prior to infertility treatment would be cost-effective. PubMed, Embase, and Cochrane libraries were used to identify publications reporting pregnancy rates after hysteroscopic polypectomy. Studies were required to have a polypectomy treatment group and control group of patients with polyps that were not resected. The charges of infertility treatments and polypectomy were obtained through infertility organizations and a private healthcare cost reporting website. These charges were applied to a decision tree model over the range of pregnancy rates observed in the representative studies to calculate an average cost per clinical or ongoing pregnancy. A sensitivity analysis was conducted to assess cost savings of polypectomy over a range of pregnancy rates and polypectomy costs. Pre-treatment office or operative hysteroscopic polypectomy ultimately saved €6658 ($7480) and €728 ($818), respectively, of the average cost per clinical pregnancy in women treated with four cycles of intrauterine insemination. Polypectomy prior to intrauterine insemination was cost-effective for clinical pregnancy rates greater than 30.2% for office polypectomy and 52.6% for operative polypectomy and for polypectomy price <€4414 ($4959). Office polypectomy or operative polypectomy saved €15,854 ($17,813) and €6644 ($7465), respectively, from the average cost per ongoing pregnancy for in vitro fertilization/intracytoplasmic sperm injection treated women and was cost-effective for ongoing pregnancy rates greater than 26.4% (office polypectomy) and 31.7% (operative polypectomy) and polypectomy price <€6376 ($7164). These findings suggested that office or operative hysteroscopic polypectomy was cost-effective when performed prior to both intrauterine insemination and in vitro fertilization over a range of plausible pregnancy rates and procedural costs.
Topics: Cost-Benefit Analysis; Costs and Cost Analysis; Female; Fertilization in Vitro; Humans; Hysteroscopy; Infertility; Insemination, Artificial; Polyps; Pregnancy; Pregnancy Rate; Sperm Injections, Intracytoplasmic; Uterine Diseases
PubMed: 28445799
DOI: 10.1016/j.ejogrb.2017.04.025