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The present paper reports a single department's retrospective case series of all clomiphene citrate (CC) combined with intrauterine insemination (IUI) treatment cycles for ovulatory infertility performed during 2002. Thirty-eight couples with unexplained, endometriosis, male or unilateral tubal factor infertility had undergone 71 cycles of CC and IUI. The clinical and ongoing cycle pregnancy rates were 20 and 17%, respectively. Seven percent of the clinical pregnancies were multiple pregnancies, with all multiple pregnancies being twin gestations. The current use of CC and IUI is an effective early treatment option in couples with ovulatory infertility presenting to our department.

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.

Background: There is no published data assessing whether higher mid luteal serum progesterone (P4) levels are associated with a higher cycle pregnancy rate (CPR) in controlled ovarian hyperstimulation (COH) with intrauterine insemination (IUI)., Aims: To assess whether the mid luteal serum P4 level is predictive of pregnancy in COH with IUI., Methods: A retrospective cohort study of all women with unexplained, minimal endometriosis or mild male factor infertility who underwent COH with IUI between October 1999 and December 2000 at our department was analysed. The COH was achieved with follicle stimulating hormone injections. All cycles were triggered with human chorionic gonadotropin when at least one follicle > or =15 mm was visible on ultrasound and IUI performed the following day. A serum P4 and beta human chorionic gonadotropin level was measured at 7 and 14 days post-trigger, respectively., Results: There were 33 pregnancies in the 188 cycles analysed, giving a CPR of 18%. The median (range) mid luteal P4 level for all cycles was 51 nmol/L (1.8-234). This did not differ between the pregnant (55 nmol/L) and non-pregnant (50 nmol/L) cycles (P=0.282, Mann-Whitney U-test). There was also no difference in CPR between cohorts below or above the cut-off levels of 33 nmol/L (25th percentile) (13.3 vs 18.9%; P=0.39), 51 nmol/L (50th percentile) (16.0 vs 19.1%; P=0.57), or 69 nmol/L (75th percentile) (16.3 vs 21.3%; P=0.44), respectively., Conclusions: Increased mid luteal serum P4 levels are not associated with a higher CPR in women undergoing COH with IUI. However, a low mid luteal P4 level < or =25 nmol/L may help predict treatment failure.

Objective: To review the effectiveness of metformin in restoring regular menstrual cycles and ovulation and achieving pregnancy in women with polycystic ovary syndrome (PCOS)., Design: Systematic review of pertinent studies identified using the bibliographic databases MEDLINE and EMBASE. References of selected articles identified were hand-searched for additional relevant citations., Patient(s): Women with PCOS undergoing treatment with metformin alone, metformin combined with other methods of ovulation induction such as clomiphene citrate (CC) or gonadotropin injections, or metformin combined with in vitro fertilization (IVF)., Result(s): Thirty published studies were included in the overall review. Studies consisted of 12 randomized controlled trials, two cohort studies, and 16 uncontrolled descriptive studies. Due to a strong variability in the use of metformin according to study population, exposure, and outcome of interest, it was not possible to combine the data of the 12 randomized controlled trials to perform a meta-analysis. Limited data on predominately obese PCOS patients demonstrate that metformin alone improves both restoration of regular menses and spontaneous ovulation, but there are no data supporting an improvement in pregnancy rate. The addition of metformin to CC results in an improved ovulation and pregnancy rate in both unselected and CC-resistant PCOS women. There are insufficient data to make any conclusions on the effect of metformin on FSH ovulation induction or IVF., Conclusion(s): The effectiveness and role of metformin in the treatment of PCOS anovulatory infertility in clinical practice is difficult to assess from currently available research. Further well-designed prospective, perhaps multicenter, randomized controlled trials with the primary end point of pregnancy or live-birth rate are required.

Objective: To assess whether transcervical intrauterine topical instillation of a local anesthetic agent reduces pain at hysterosalpingography., Design: Prospective, randomized, double-blind, placebo-controlled study., Setting: Department of reproductive medicine at a university teaching hospital., Patient(s): One hundred ten women undergoing hysterosalpingography (HSG)., Intervention(s): Subjects were randomized to receive either 2 mL of 2% plain lignocaine or 2 mL of 0.9% sodium chloride solution (placebo) topically into the uterine cavity before the HSG was performed., Main Outcome Measure(s): The degree of lower abdominal pain experienced both during the injection of contrast media at HSG and 10 minutes after the procedure using a 20-cm visual analogue scale (VAS) and a four-point verbal descriptor scale (VDS)., Result(s): There was no difference in pain scores between lignocaine and placebo during the HSG. However, at 10 minutes after the HSG, subjects receiving lignocaine experienced more pain than those on placebo., Conclusion(s): Transcervical intrauterine topical instillation of 2 mL of 2% plain lignocaine does not reduce pain during HSG and may lead to increased pain immediately after the procedure.

Purpose: To determine whether the quality of semen has changed over time in men screened for semen donation., Methods: All 448 men volunteering for semen donation between 1983 and 2001 at a donor insemination clinic in Sydney, Australia, were included in this longitudinal single centre observational analysis of semen parameters. There was no selection for fertility or marital status but all volunteers had to be aged between 18 and 40 years., Results: There was no change in the total sperm count during the study period (r = 0.065, P = 0.17) using a linear regression model. The ejaculate volume did not change (r = 0.002, P = 0.97), while an increase in sperm motility was seen (Spearman R = 0.194, P < 0.001)., Conclusion: The semen quality of volunteers for sperm donation presenting to our donor insemination clinic in Sydney between 1983 and 2001 has not declined.

This study aimed to evaluate the prognostic value of the baseline serum oestradiol E2 level on the cycle pregnancy rate (PR) in women with unexplained infertility (UI) undergoing controlled ovarian hyperstimulation (COH). This study is unique in that it evaluates the effect of cycle day 1 (rather than day 3) E2 levels on cycle PR in a COH setting (without IVF) in women with UI (rather than multiple causes of infertility). Structured as a retrospective cohort study, the setting was the Ovulation Induction Clinic at an academic tertiary care hospital. One hundred and forty-five patients with UI underwent 374 cycles of COH with either human menopausal gonadotrophin (hMG) alone or hMG and clomiphene citrate. Outcome was measured as cycle pregnancy rate (PR) according to the cycle day 1 level of E2. Patients with an E2 level > 150 pmol/l on cycle day 1 of COH achieved a significantly lower PR (4%) compared with those with E2 levels < or = 150 pmol/l (13%). Logistic regression analysis demonstrated that women with day 1 E2 levels below 150 pmol/l were 3.2 times more likely to conceive than those with day 1 E2 levels above 150 pmol/l. Also, the impact of day 1 E2 levels on the chance of pregnancy was independent of day 1 serum FSH levels. Women with UI undergoing COH in our unit with an elevated baseline serum E2 > 150 pmol/l have a significantly lower PR and should be counselled regarding the decreased likelihood of pregnancy.

Objective: To determine whether a spontaneous luteinizing hormone (LH) surge influences the pregnancy and miscarriage rate in women with unexplained infertility undergoing controlled ovarian hyperstimulation (COH) without in vitro fertilization., Design: Retrospective cohort study., Setting: Ovulation Induction Clinic, Royal Hospital for Women, Sydney, Australia., Patients: 145 patients with unexplained infertility who underwent 374 cycles of COH., Methods: Two types of ovarian stimulation protocols were used: human menopausal gonadotrophin (hMG) alone or hMG and clomiphene citrate (CC). A spontaneous LH surge occurred in 54% of the total cycles. All patients received human chorionic gonadotrophin, whether or not a spontaneous LH surge occurred. All cycles were covered by natural intercourse., Main Outcome Measures: Cycle pregnancy rate and miscarriage rate in cycles with or without a spontaneous LH surge., Results: The cycle pregnancy rate of the LH surge group was significantly higher than that of the no LH surge group for CC/hMG cycles (16.4% and 4.3% respectively, p = 0.02) but not for hMG alone cycles (12.8% and 10% respectively, P > .05). The miscarriage rate was not significantly different between the LH surge group and no LH surge group in either the CC/hMG cycles (30% and 75% respectively, P > .05) or the hMG alone cycles (22% and 38% respectively, P > .05)., Conclusions: In women with unexplained infertility undergoing COH with CC/hMG, the occurrence of a spontaneous LH surge is a favorable event associated with a significantly increased pregnancy rate. The data showed a lower miscarriage rate, but there was insufficient power to confirm or refute this result.