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How to calculate 4 % off $ How to figure out percentages off a price. Using this calculator you will find that the amount after the discount is $ To find any discount, just use our Discount Calculator above. Using this calculator you can find the discount value and the discounted price of an item. It is helpfull to answer questions like What is 4 percent % off $ What is $ minus 4 percent % off? How to calculate 4 percent off $ How much will you pay for an item where the original price before discount is $ when discounted 4 percent %? What is the final or sale price? $ is what percent off $ Percent-off Formulas To calculate discount it is ease by using the following formulas a Amount Saved = Orig. Price x Discount % / 100 b Sale Price = Orig. Price - Amount Saved How to calculate 4 Percent-off Now, let's solve the questions stated above FAQs on Percent-off What's 4 percent-off $ Replacing the given values in formula a we have Amount Saved = Original Price x Discount in Percent / 100. So, Amount Saved = x 4 / 100 Amount Saved = / 100 Amount Saved = $ answer. In other words, a 4% discount for a item with original price of $ is equal to $ Amount Saved. Note that to find the amount saved, just multiply it by the percentage and divide by 100. What's the final price of an item of $ when discounted $ Using the formula b and replacing the given values Sale Price = Original Price - Amount Saved. So, Sale Price = - Sale Price = $ answer. This means the cost of the item to you is $ You will pay $ for a item with original price of $ when discounted 4%. In this example, if you buy an item at $ with 4% discount, you will pay - = dollars. is what percent off dollars? Using the formula b and replacing given values Amount Saved = Original Price x Discount in Percent /100. So, = x Discount in Percent / 100 / = Discount in Percent /100 100 x / = Discount in Percent / = Discount in Percent, or Discount in Percent = 4 answer. To find more examples, just choose one at the bottom of this page.
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Medical education and training Enablers and barriers to effective clinical supervision in the workplace a rapid evidence review Rothwell1, Kehoe2, Sophia Farhene Farook3, Illing41School of Medical Education, Newcastle University, Newcastle upon Tyne, UK2Health Professions Education Unit, Hull York Medical School, York, UK3Emergency Medicine, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK4Health Professions Education Centre, Royal College of Surgeons in Ireland, Dublin, IrelandCorrespondence to Dr Charlotte Rothwell; AbstractObjectives We aimed to review the international literature to understand the enablers of and barriers to effective clinical supervision in the workplace and identify the benefits of effective clinical A rapid evidence sources Five databases CINAHL, OVID Embase, OVID Medline, OVID PsycInfo and ProQuest were searched to ensure inclusion and breadth of healthcare criteria Studies identifying enablers and barriers to effective clinical supervision across healthcare professionals in a Western context between 1 January 2009 and 12 March extraction and synthesis An extraction framework with a detailed inclusion/exclusion criteria to ensure rigour was used to extract data. Data were analysed using a thematic qualitative synthesis. These themes were used to answer the research The search identified 15 922 papers, reduced to 809 papers following the removal of duplicates and papers outside the inclusion criteria, with 135 papers being included in the full review. Enablers identified included regular supervision, occurs within protected time, in a private space and delivered flexibly. Additional enablers included supervisees being offered a choice of supervisor; supervision based on mutual trust and a positive relationship; a cultural understanding between supervisor and supervisee; a shared understanding of the purpose of supervision, based on individual needs, focused on enhancing knowledge and skills; training and feedback being provided for supervisors; and use of a mixed supervisor model, delivered by several supervisors, or by those trained to manage the overlapping and potentially conflicting needs of the individual and the service. Barriers included a lack of time, space and trust. A lack of shared understanding to the purpose of the supervision, and a lack of ongoing support and engagement from leadership and organisations were also found to be barriers to effective clinical This review identified several enablers of and barriers to effective clinical supervision and the subsequent benefits of effective clinical supervision in a healthcare & training see medical education & traininghealth services administration & managementorganisational developmentorganisation of health servicesquality in healthcareData availability statementData sharing not applicable as no datasets generated and/or analysed for this is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial CC BY-NC license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See Statistics from Request Permissions If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Centerâs RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways. education & training see medical education & traininghealth services administration & managementorganisational developmentorganisation of health servicesquality in healthcareStrengths and limitations of this studyThis paper was based on evidence identified in the international literature using a rapid review, which involves a systematic search and rigorous were limited to Western only and the last 10 years for pragmatic in many areas there was a vast amount of information, which provides strength to the findings, a rapid review necessarily pays less attention to study design and sample of the data were heterogeneous in nature, and this also hindered our ability to relate the findings to specific professions and findings drawn from the overall themes were evident across much of the what makes clinical supervision effective and learning more about the barriers to and challenges of effective supervision are important concerns for the health and social care workforce. Most organisations provide some provision, but many lack an understanding about why it is important, who should be involved, what the possible benefits are and how it could be is at the core of practice for all health and social care professionals, where there should be a sense of shared responsibility for the effectiveness and safety of It is important to understand this complex process to ensure best practice for all participants involved practitioner, service delivery manager, clinical supervisor, peers, clients and other service users, the profession itself.Supervision has been described as an event that involves an ongoing professional relationship, between two and more staff members with different levels of knowledge or expertise, to support professional development and to enhance knowledge and Definitions of supervision emphasise the promotion of professional development in addition to ensuring patient safety. For example, Nancarrow et al2 focus on the progression of clinical practice through professional guidance and support and refer to Proctorâs3 three functions of supervisionâmanagerial/administrative, educational and supportive. All three functions should be overlapping and has been suggested that there are many forms of supervision internal managerial, internal reflective, external professional and external 4 At one end of this continuum, managerial supervision takes place inside the organisation and is mostly focused on task and process. At the other end, personal supervision is worker focused and centres mainly on the narrative brought into the supervision space by the This last type of supervision personal has been highly valued by workers to air their feelings; providing a safe place to connect and self-reflect. Personal supervision allowed a more intensive focus on clinical issues and personal professional development rather than organisational Two types of supervision tend to coexist when the line manager is also the clinical supervisorâa focus on practitioner learning and development, and another focused on service delivery, risk management and underperformance. Kilminster and Jolly5 argued for clarity on dealing with underperformance in addition to identifying what helps and hinders effective clinical supervision. Managing this split highlights the need for supervisor this review, we used the following definition of supervision as it encompassed both personal development and service development in the context of a relationship extending over timeThis relationship is evaluative, extends over time and has the simultaneous purposes of enhancing the professional functioning of the more junior person and monitoring the quality of the professional services. Bernard and Goodyear, p86While it is evident that supervision is important, we must now understand exactly what aspects of supervision we should be focusing on, and it is hoped that best practice can be sought from looking across such a range of different healthcare professionals. Any critical differences that impacted on supervision across health professions were also the focus of supervisionThe aim of this rapid review was 1 to syntheses the evidence of international literature on the enablers of, and barriers to effective clinical supervision in the workplace; 2 to identify the benefits of effective clinical supervision in the Rapid Evidence Assessment REA was used in this study. A REA is similar to a systematic review in that they both use rigorous methods of appraising and synthesising evidence from published However, restrictions on the data retrieved are placed on the search at the data collection strategyThe research protocol was developed with advice from a data analyst at Newcastle University. As a result, we refined our initial search strategy and targeted the most appropriate databases. The following databases were used to ensure a breadth of health and social care professions were included CINAHL, Allied and Health Professionals literature, OVID Embase, OVID Medline Medical literature, OVID PsycInfo, Psychological literature and ProQuest Social Science literature. See the Search strategy section for a breakdown of search terms systematic search see online supplemental material 1 for search strategy of each database was carried out in line with our search strategy. As is typical of rapid reviews, limits were placed on the search to ensure the research could be done in a timely manner. For example, only including papers from the last 10 years ensured we were able to capture the most relevant documents for current supervision practice in a shorter space of time. Search terms were developed to include a comprehensive list of healthcare professionals, supervision types and forms of effectiveness. Restrictions were placed on the databases in line with our search materialProcedure for screening of data, data extraction and ensuring quality assuranceAll citations were downloaded to EndNote reference management database and duplication was removed n=2683. Authors independently reviewed the same 500 titles and abstracts to make sure that the same papers were being included/excluded. Any discrepancies were discussed and the inclusion/exclusion criteria were refined as needed see box 1. All 13 239 titles and abstracts were screened by two researchers CR and AK.Box 1Revised inclusion/exclusion criteriaInclusion criteria for papersPapers that include clinical supervision and/or peer support in the that include a regulated healthcare published within the last 10 years 1 January 2009â12 March 2019.Papers that include primary research and systematic which are quantitative, qualitative or mixed written in reporting on a Western culture criteria for papersFocus not on formal and structured clinical/peer supervision by this we mean that the supervision was not a one offâ event but must have some ongoing relationship, as detailed in the very definition of supervision.Not in healthcare evidence based eg, opinion pieces, letters or weak evidence.Paper not written in English/outside review of children/animals/ culture pilot data extraction exercise was conducted to ensure quality assurance. This exercise involved all four reviewers independently reading full papers and was repeated with a further 10 papers to check consistency of inclusion/exclusion and data extraction. The data extraction framework was revised following this initial review of papers. The clear inclusion/exclusion criteria and detailed data extraction form were used to ensure rigour. The data extraction form has been added as online supplemental material 2. Regular meetings were held between all four reviewers to ensure quality was maintained and to discuss uncertainties or queries that arose from the papers, and it was during this phase that the definition of clinical supervision was identified .Supplemental materialSynthesis of papersOnce the data were entered onto the data extraction database see online supplemental material 2 for the data extraction form, the data were analysed using a qualitative thematic synthesis,8 which is a useful approach when aiming to pull out common elements across the heterogeneous literature. These themes were used to answer the research and public involvementPatients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our full review of papers was conducted on 809 publications from nearly 16 000 initially identified see figure 1. The final number of included papers was 135, with 674 being demographicsSettingA range of countries were represented within the included papers, with the majority being from Australia 38, the UK 31, the USA 24, New Zealand 11 and Canada 7. The findings were further diversified by the broad set of health and social care professions included in the review. The majority of papers included doctors, nurses, psychologists and social workers. Examples of other allied health professionals included were music therapists, physiotherapists, occupational therapists, speech and language therapists, podiatrists and designsPapers included in the review were a mix of qualitative papers 53 using interview or focus group data and quantitative papers 50 using surveys and questionnaires. Several papers used a mixed-methods approach 15 and literature reviews 15, case study 1, action research 1, unidentified 1.Type of supervisionOf the included papers, a large majority focused on clinical supervision 110, with a minority focusing on peer supervision 22 or both 3. These included both individual and group supervision sessions. Within the literature, there were several types of clinical supervision and peer supervision discussed. However, there was not always a clear distinction between different types of supervision, and terms were often used interchangeably such as peer supervision and peer mentoring. The working definition we used was clinical supervision, which was conducted either in a one-to-one or small group situation by a senior staff member or by a more experienced staff member at the same level. Clinical supervision included action planning; reflection on clinical situations; role development and training; indirect and direct supervision; and included supervision from both internal and external research questions were answered using evidence from this literature are the enablers to effective clinical supervision?An open, supportive and safe environmentThere was considerable evidence to highlight that having an open and safe environment where supervisees feel comfortable and trust their supervisor is an integral part of 9â34 Having the time to discuss personal issues based on the needs of the individual was identified as an important focus for 32 35â37 There was also evidence of the value of time spent reflecting on practice, including ethical issues14 15 18 28 38 39 and of receiving 30 32 39â42Establishing a supervisory relationship based on trustBeing able to develop a positive relationship with a supervisor that was based on trust was seen as key by a wide range of 4 10 11 28 39 42â46 Supervisors who were deemed experts in their own profession were also more likely to be viewed as credible and trustworthy, and supervisees felt they were better placed to support 12 32 46â48 Trust was also underpinned by having the opportunity to be able to explore each otherâs belief and value systems in a neutral space, away from organisational hierarchies and the workplace and where emotions could be managed in an open and reflective way10 49 and when the supervisee respected the supervisor personally and professionally and both parties could self-disclose 50Regular supervision with timely feedbackMany studies reported on the importance of receiving regular and constructive feedback during supervision2 14 15 32 40 44 51â54 and having the time to reflect on 15 18 28 42 51 55 Supervision was valued for the sharing of tacit knowledge, for providing real-time feedback41 and when it provided confirmation that staff had done the right majority of the literature reviewed did not specify supervision frequency. There was scant evidence on how often clinical supervision should take However, Dilworth et al57 reported that supervision should take place on a monthly basis to ensure sufficient support. Furthermore, McMahon and Errity27 reported that supervision that was less than fortnightly was insufficient and healthcare workers who spent at least 60 min in supervision perceived their supervision to be more relationships develop over time and are complex,59 therefore supervision should not be a one-off activity, instead, it needs to be sustained over time and from early on in a However, the importance of providing unplanned discussion time to support emerging needs and ensure staff well-being was also for supervisorsSupervisors need to have training in cultural awareness to enable them to be culturally competent. This was seen as an asset leading to improvements in communication, reflection and 10 62 Supervisors also need to be trained on listening skills30 32 63 and helping supervisees to problem Findings showed that it was important that the supervisor was able to not only provide feedback, but also receive it 15 30 32 41 42What are the benefits of effective clinical supervision?Job satisfaction and staff retentionSeveral studies reported that effective supervision was found to have a positive impact on staff retention,61 65â67 job satisfaction,13 68 69 staff well-being63 70â72 and perceptions of being Wilson et al32 found that feedback from supervisors facilitated learning and encouraged staff development. Continual Professional Development CPD and training for supervisors themselves were also found to increase Regular supervision was found to increase staff McMahon and Errity27 reported that greater supervision frequency, with regular progress reviews, was significantly related to positive stress and anxietySeveral studies found that supervision reduced stress and 22 44 47 70â72 75â78 Evidence suggested that the reduction in stress and anxiety came about as supervision provided a medium for sharing skills, knowledge and resources, in a supportive 44 47 A reduction in stress for supervisors was also found, following the provision of training and CPD support for Studies reported that supervision helped participants to manage their feelings,44 76 also improving understanding of the importance of well-being and learning to help reflect on working environmentResearch highlighted that effective supervision and a supportive working environment can improve the uptake of workplace policies as supervisees understand the importance and reason for the Better teamwork, relationships and more support in the workplace can also help with professional A study by Davis and Burke16 reported that supervision with nurse managers improved communication among staff and facilitated reflection, sharing ideas and quality of care deliverySeveral studies made links with the provision of effective supervision and an increase in quality of 23 71 72 76 80â82 A study carried out by da Silva Pinheiro and de Carvalho76 reported group supervision with nurses had helped them to manage their feelings, which they linked to an increase in quality of care for their patients. Claridge et al81 looked at whether direct supervision with resident doctors increased patient outcomes. Results showed that with direct supervision, there was a greater uptake of compliance with managerial protocols, and as a result patient outcomes were are the barriers to effective clinical supervision?Lack of time and heavy workloadsOne of the main barriers identified for effective supervision was a lack of time and heavy 17 21 25 35 41 48 57 73 83â98 Many studies reported that supervisors were unable to find time for supervision due to busy work environments, which ultimately restricted supervisor flexibility and quality when they did find the 82 99 Other studies reported a lack of opportunity and time for reflection within supervision, which left staff feeling that they had to figure things outâ for themselves without adequate 84Many noted that supervision was not a priority, for both supervisor and 27 60 71 72 94 100 As a result, supervision was sometimes perceived to be a bonus,11 feeling that they were expected to not dwellâ on stressful workplace issues. There was often an expectation that supervisors had the time to develop relationships and would take the time to complete the necessary paperwork prior to and following supervision, which could be lack of adequate resources could lead to an overstretched workforce not being able to support each other effectively, and a decline in clinical supervision due to pressures on staff Kenny and Allenby60 discussed a lack of monetary incentives for supervision, affecting how supervision was perceived and whether it was provided or attended. Supervisees only wanted to attend supervision when it was within work time and when there was protected time for of staffing, shift workingThe type of clinical environment could facilitate or hinder clinical Key factors were organisation location, shift work patterns and work-environmental factors quantitative demands, tempo, cognitive demands, influence at work and social support. Jelinek et al51 discussed that there was a reduction in supervision levels during unsociable shift patterns. Supervision was dependent on service demands and was often not seen as a priority if there was insufficient staff numbers in busy environments. Differences seemed to not only reflect culture regardless of policy asserting its importance but also ease of access to supervision. For example, there was a lack of supervision outside day shifts or in rural communities with fewer staff despite the potential for increased need due to professional 33 60 101Lack of management/organisational supportOrganisational culture and attitude toward supervisory practice were found to be important, needing managerial support and 101 If management do not recognise the importance of supervision, it is unlikely it will become embedded into the organisational culture, and a lack of commitment from organisations and managers can act as a barrier to providing the time and resources required for effective 27 31 37 73 93 101 102 In busy agency settings, supervision can often be neglected or deferred, to accommodate the latest crisis, unless it is made a priority by A study exploring which nurses decided to participate in clinical supervision found that support from empowering and fair leadership was crucial, affecting the adoption and uptake of clinical supervision, both positively and of supervisor training and supportSeveral studies reported that a lack of training for supervisors was a barrier and resulted in ineffective 38 64 76 91 92 104â107 Supervision was varied and individual when no direction about how to approach it was Studies also reported a lack of quality in supervision when supervisors were unfamiliar with professional guidelines ie, standards set by regulators, their role and responsibilities as a supervisor, ethical standards set in place by employers and inadequate educational of supervisor competence and skills was identified in a number of studies highlighting barriers to effective clinical supervision, such as being intolerant, blameful and inflexible,2 being unable to deal with unmotivated supervisees76 87 and manage differing personality types,108 the lack of ability to share feelings,49 inability to give appropriate feedback51 and an inability to understand personal of understanding and support when dealing with underperformanceSupervision should facilitate learning opportunities when However, supervisors do not always have the time and opportunity to upskill staff or work with those who are Kilbertus et al111 also found that some supervisors reported not feeling able or comfortable in recognising and managing a failing trainee. Issues arose when either the supervisor or supervisees were unaware of the superviseeâs lack of knowledge and 33 47A lack of support from employers was noted by supervisors when raising concerns about staff,51 not always being told where to signpost supervisees to if there were any concerns or needs outside of their remit eg, mental health support. Supervisors themselves may also need to seek Supervisors also feared that if they gave supervisees negative feedback, that in turn they would receive negative teaching evaluations, and this would impact on their own future promotion and There was also evidence that clinical supervision was delegated to the most junior consultants, with the least experience to deal with complex underperforming Kilbertus et al111 highlighted that a lack of continuity of feedback meant that it was easy for struggling residents to fall through the with supervision from another discipline or from an external organisationExternal supervisors who work in a different organisation to their supervisee and interprofessional supervision supervisors from a different profession may require additional training and 4 60 Interprofessional supervision can sometimes lead to misunderstanding due to differences in roles, responsibilities and levels of training. There may also be an absence of shared theory, language, differences in professional decision-making processes and codes of In addition, an oversight of ethical practice could be weaker with an interprofessional It may also disadvantage supervisors with regard to the professional role, not being able to raise all issues, and causes disempowerment due to differences in professional status1 and places a burden of responsibility on the supervisor to have a good working knowledge of the context of practice of other states that an external supervisor will hold less information about the practitioner compared with an internal supervisor, who will likely identify managerial concerns more effectively. Having an external supervisor, however, increased the likelihood that supervision took 114 115 Yet it was the supervisee who mainly set the agenda with regard to issues to be discussed, and therefore underperformance was more likely to remain concealed. This type of supervision highlights the weakness of self-assessment, which is a particular concern for those who are of relationship and trustSupervisees need to feel that they can trust their supervisor,52 yet sadly, this was sometimes 17 61 84 117 118 Unhelpful and untrusting relationships led participants to distrust their supervisorâs advice, or be selfâ 52 Palmer-Olsen et al44 found that supervisors who did not establish a secure supervisory alliance were less effective in helping their supervisees learn to implement a specific therapy. A lack of supervisor commitment, or when supervision was reduced to a tick boxâ exercise, or too bureaucratic, it was found to be less 61 85 It was also noted that sometimes people did not fitâ with their 39Lack of understanding about what supervision was and its purposeSeveral studies reported a lack of a common understanding about the role and purpose of 60 97 100 119 On such occasions, supervisees reported anxiety and sometimes perceived that supervision equated to 32 44 60 73 120 Negative associations with the term clinical supervisionâ also led to a lack of 37DiscussionThis rapid systematic review aimed to identify the enablers of and barriers to effective clinical supervision and identified the benefits of supervision for supervisees and supervisors within the in place and done well, clinical supervision has many benefits for the organisation, professional development and patient services, and each of these three levels makes an important contribution to ensure benefit is achieved. This review has highlighted evidence which indicates what needs to be in place to ensure clinical supervision is effective. Evidence from the literature review indicates that the organisation plays a key role in ensuring supervision takes place,60 95 102 that it is valued and expected,73 95 that supervisors are trained29 37 68 79 91 99 104 121 and time is 25 79 92 99 122 Supervision needs to be provided in a neutral, open, supportive environment to facilitate discussion and reflection on clinical practice, career development and any personal issues that may arise in the 9 10 13â16 18 20 21 23â26 29 30 32â34 44 117 123â125Having a relationship based on trust with the supervisor was also found to be 4 10 11 28 32 39 42â46 There was also evidence on the benefit of reflecting on practice18 28 and on receiving 40 41 Having regular but flexible supervision that fitted around all stakeholdersâ needs was also highlighted as important. Clinical supervision provides the chance to facilitate learning opportunities when needed98 and to upskill staff who were was much evidence about the positive benefits of clinical supervision, in that those who received support through clinical supervision were better able to cope with the demands of the job23 75 and were less likely to 126 Effective supervision increased resilience78 and job 69 127 There was also evidence to suggest that supervision helped with reducing stress and Supervision was also seen to drive up the quality of care and has a positive effect on the working 23 71 77 80â82 87A number of barriers were highlighted within the literature that should be taken into consideration when exploring how to implement effective supervision practice. These included a lack of time and heavy workload,2 16 17 21 35 41 48 54 57 64 73 83â85 87â96 98 a lack of resources,18 37 60 unsupportive management and colleagues,2 27 31 73 93 102 128 a lack of supervisor training,11 17 32 38 64 76 91 92 105â107 124 and a lack of trusting relationships and ongoing 17 45 61 75 84 117 118 Supervisees were also sometimes unaware of the purpose of the supervision practice,2 60 64 100 119 impacting on A recent study has highlighted the need for supervision to include patient care, concluding that the usual model of meeting for a supervisory discussion away from patient care was not found to be Although this is an interesting and important finding, our findings would suggest that the overall supervisory experience is not as simplistic as this. There is a need to take into account all of the factors and levels presented in this paper, there being no single answer leading to effective were no critical differences identified across the range of healthcare professionals in terms of ensuring effective supervision is in place, with similar themes being apparent across all. Naturally, professions such as psychologists and social workers will face different challenges and have different needs from their supervisory relationship; however, this is part of the supervisory process and identification of those needs is what will make it an effective experience for the is clear from the evidence that support from management is needed to enable effective implementation, including cost and training for staff. However, this review has highlighted that supervision is subject to different interpretations by managers, who tend to focus more on service delivery rather than on staff development, and agreeing on the shared purpose of supervision is important to reduce 10 Beddoe1 argued that managerial supervision creates a shift from being practitioner focused to a monitoring agenda. Problems seem to arise when the focus was perceived to be monitoring performance, rather than on the provision of 9 10 39 42 115 Pack72 highlights that line managers need to focus on protecting the employing organisation and their patients/clients from risk,96 whereas external supervisors can focus more on the personal development. This split may offer a solution that avoids the inevitable tension experienced by a manager who is also the clinical supervisor. The issue of managing underperformance alongside personal development further highlights this tension and indicates again that having two different supervisors might offer a solution; like experienced by junior doctors in the UK, who have an educational supervisor who overseas educational development and a clinical supervisor who overseas clinical practice. A split role, when feasible, might be the preferred solution and when this is not an option then supervisors need training to support them to manage these challenges. The model of practice which is best is a source of continued debate. However, what is clear is that there is no one size fits allâ for clinical supervision and all stakeholders need to consider how to make their supervision as effective as it can be and involve discussion to agree on the shared purpose of clinical paper was based on evidence identified in the international literature using a rapid review, which involves a systematic search and rigorous analysis. Although in many places there was a vast amount of information, which provides strength to the findings, a rapid review necessarily pays less attention to study design and sample sizes. An additional limitation of this rapid review was that the study focused on publications in English, studies set in Western only settings and publications within the past 10 years only. Much of the data were heterogeneous in nature, and this also hindered our ability to relate the findings to specific professions and settings. However, the findings drawn from the overall themes were evident across much of the review has identified the following enablers of and barriers to effective clinical supervision with regard to the organisation, the supervisor and included having a set place and a regular time slot for supervision to ensure it takes place. It is more likely to occur when a private space is made available and when protected time is available. Also, there needs to be some flexibility to enable staff working irregular hours such as night shift to access clinical supervision. Barriers to supervision happening were apparent when these issues of place and time were not in key enabler identified was when the supervisory relationship was based on a positive relationship and on mutual trust. Ideally, supervisees should be offered a choice of supervisor and there should be some cultural understanding between them. When this is not the case, when the relationship lacks trust, this becomes a barrier, as does having to accept a supervisor not well matched to the supervisee and when cultural understanding is clinical supervision to be effective, there needs to be a shared understanding of its purpose. Ideally, this is based on the individual needs of the supervisee and the focus is on enhancing knowledge and skills to support professional development and improve the service. Barriers occur when there is no agreed purpose and no agreement or conflicting views on the focus of clinical review identified that a range of types of supervision can be effective one-to-one, group, internal, external and distance supervision can all offer a range of benefits. Going forward, having different types of supervision, with different people who offer different perspectives, should be considered and may overcome some of the barriers in place when only one, poorly matched, supervisor is available. Clearly, having different supervisors also overcomes the problem of having a line manager who is both the clinical supervisor and service manager and who may need to manage the needs of the service with the potentially conflicting needs to the individual. Lastly, providing training to supervisors is helpful to ensure they are supported and developed in this role and indeed also benefit from feedback themselves, without such training barriers to effective supervision may availability statementData sharing not applicable as no datasets generated and/or analysed for this statementsPatient consent for publicationNot Supplementary materials Supplementary Data This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the authors and has not been edited for content. Data supplement 1 Data supplement 2 Read the full text or download the PDF Log in using your username and password Le04 27 84 84 85 est un numĂ©ro de tĂ©lĂ©phone de type gĂ©ographique. 13 internautes ont laissĂ© leur avis sur la ligne +33427848485. Attention, 100% des internautes pensent qu'il s'agit d'une arnaque ou d'un appel indĂ©sirable. Format de numĂ©ros rencontrĂ©s : +33427848485 / -85 / 04.27.84.84.85 DĂ©posez votre avis et aidez la communautĂ©Journal List Biomed Res Int PMC5745683 Biomed Res Int. 2017; 2017 3512784. Rosalie Cabry-Goubet, 1 , 2 Florence Scheffler, 1 , 2 Naima Belhadri-Mansouri, 1 Stephanie Belloc, 3 Emmanuelle Lourdel, 1 Aviva Devaux, 1 , 2 Hickmat Chahine, 4 Jacques De Mouzon, 4 Henri Copin, 1 and Moncef Benkhalifa 1 , 2 AbstractObjective To evaluate the IUI success factors relative to controlled ovarian stimulation COS and infertility type, this retrospective cohort study included 1251 couples undergoing homologous IUI. Results We achieved 13% clinical pregnancies and 11% live births. COS and infertility type do not have significant effect on IUI clinical outcomes with unstable intervention of various couples' parameters, including the female age, the IUI attempt rank, and the sperm quality. Conclusion Further, the COS used seemed a weak predictor for IUI success; therefore, the indications need more discussion, especially in unexplained infertility cases involving various factors. Indeed, the fourth IUI attempt, the female age over 40 years, and the total motile sperm count 1 Ă 106. The exclusion criteria were TMS †1 Ă 106; sperm donation; seropositivity for human immunodeficiency virus HIV for any couple member; inseminations performed in a natural cycle or with clomiphene citrate CC. IUI ProtocolAll couples had undergone a standard infertility evaluation, which included medical history, physical examination, and assessment of tubal patency by either hysterosalpingography or laparoscopy and hormonal analysis on cycle day 3. A transvaginal ultrasound scan was performed on the second day of the cycle. On the same day, ovarian stimulation was carried out with recombinant FSH follitropin α; rFSH; Gonal-F, Merck Serono, France, or follitropin ÎČ; Puregon, MSD, France, urinary FSH urofollitropin, Fostimon, France, or hMG menotropin, Menopur, France at a starting dose of 75 IU/day from the second day of the response and endometrial thickness were monitored by transvaginal ultrasonography starting on day 6 of stimulation and then on alternate days; the gonadotropin dose was adjusted according to the ovarian response and the patient's characteristics. When at least one mature follicle reached a diameter >17 mm and E2 level > 150 pmol/mL, the recombinant human chorionic gonadotropin hCG, Ovitrelle, Merck Serono, France was administered, and endometrial thickness was single IUI was performed 36 h after hCG injection using a soft catheter classic Frydman catheter; Laboratoire CCD, Paris, France or a hard catheter SET TDT, International Laboratory CDD. The semen samples used for insemination were processed within 1 hour of ejaculation by density gradient centrifugation, followed by washing with a culture medium after determining the TMS and semen analysis according to the WHO criteria [26]. Outcome VariableThe main clinical outcome measures were clinical pregnancy and live-birth rates per cycle. Clinical pregnancy was defined as the evidence of pregnancy by ultrasound examination of the gestational sac at weeks 5â Statistical AnalysisThe stimulation protocols were divided into 4 categories according to the gonadotropin used for COS rFSH/Gonal-F, rFSH/Puregon, uFSH/Fostimon, and hMG/ type was considered in seven categories cervical factor, dysovulation, endometriosis, tubal factor, male factor, and unexplained infertility. After statistical analysis of the results, it was necessary to determine the parameter cut-offs to give infertile couples more chances through IUI before carrying out other ART techniquesGroups were compared for all main couples' characteristics and cycle outcomes. Data are presented as mean ± standard deviation SD or percentage of the total. Data were analysed with Student's t-test for means comparisons or with the chi-squared test for comparison of percentages using Statistical Package, version SAS; Institute Inc., Cary, NC, USA; p 15 Sperm motility â„40 % versus â€39 TMS â„5 Ă 106 versus <5 s power calculation showed a power of 80% to demonstrate a difference across the COS groups in delivery rates of 10% between groups 1 and 4 and 2 and 4, of 11% between groups 3 and 4, of 8% between groups 2 and 3, of 8% between groups 2 and 4, of 7% between groups 1 and 2, 6% between recombinant FSH and urinary products, and of 9% between FSH and HMG4. DiscussionAs a first step in ART, IUI keeps a central place in the management of infertile couples for its simplicity, but it still offers weak effectiveness. Indeed, IUI success is still a subject of controversy, with a clinical pregnancy rate between 8% and 25% [16, 18, 27â31]. Furthermore, based on a recent prospective study in seven French ART centres, the overall live-birth rate was 11% per cycle, varying from 8% to 18% between centres [9]. Similarly, we attained 13% for clinical pregnancy and 11% for live-birth for the 1251 couples who underwent homologous IUI with gonadotropins for COS Table 1.Indeed, gonadotropin use had proved its superiority to improve clinical outcomes of IUI compared to other COS protocols, such as CC and letrozole [32â38]. Erdem et al. [36] showed that, for IUI success, rFSH Gonal-F was more effective than using CC to reach 28% for clinical pregnancy and 24% of live-birth. Nevertheless, it is still not clear which of the currently available medications is preferable for COS [15, 23, 39â43]. However, several studies compared different types of gonadotropin efficiency rFSH, uFSH, or hMG [15, 25, 44â47]. Indeed, in the first part of this work, we compared four gonadotropins for COS in IUI rFSH/Gonal-F; rFSH/Puregon; uFSH/Fostimon and hMG/Menopur while rFSH was the most used in 72% of couples Table 1.This preference was noticed in other studies [9, 15, 25, 36] without finding any significant improvement on clinical outcomes. Indeed, as demonstrated in our study, there was no significant difference between different protocols used for COS rFSH/Gonal-F; rFSH/Puregon; uFSH/Fostimon; and hMG/Menopur; Table 2, although, in contrast, some authors pointed to the greater potency of rFSH [22, 48]. However, other studies have reported higher pregnancy rates for hMG [33, 49â53]. Even if our study had 80% power to demonstrate differences in PR of 6% to 11% between 2 groups, according to their size, it is clear that the differences we observed were very low, in favour of a low impact of the 4 used COS regimen on the results. This was less clear for infertility origin because of the very low numbers of some groups. However, the results of the multivariate logistic model confirmed the results observed at the first step analysis, reinforcing their valueGenerally, rFSH is commonly used to minimize the possibility of developing ovarian cysts associated with LH contamination and to improve the probability of a more consistent, effective, and efficient ovarian response [22, 48].Although there was no significant difference between the efficiency of gonadotropins for COS, other COS protocol factors could be involved to improve the clinical outcomes, especially regarding the starting dose and the total doses of treatment as proved by several studies [15, 23â25, 54].To explain the absence of a significant difference between the four COS groups, we analysed other factors relative to COS protocol female age, IUI attempt rank, and sperm quality. As expected, our studied population showed its heterogeneity involving multiple factors, which was the reason not to have a real consensus about the efficiency of COS, and this made it harder to really evaluate its impact. The sperm motility significantly affected the live-birth in rFSH groups Table 3. Furthermore, the IUI attempt rank had a significant negative correlation with clinical outcomes with unequal values between groups Table 3. Indeed, it is not legitimate to consider the COS as a strong predictive factor of clinical outcomes in IUI, while other factors could not all be controlledInfertility type has been discussed throughout several studies as a nonnegligible indicator of IUI clinical outcomes [15, 30, 38, 50, 55â59], while the latest National Institute for Health and Care Excellence NICE guideline on fertility [59] recommends that IUI should not be routinely offered to people with unexplained infertility, mild endometriosis, or mild male factor infertility who are having regular unprotected sexual this reason, in the second part of this study, we were more focused on evaluating the infertility type effect on IUI success. As a result, there was no significant difference between clinical outcomes of the different groups based on the infertility type Table 4. Although unexplained infertility was most couples' indication for IUI 36% Table 1, as noticed in the recent report of Monraisin et al. [9] with a value of 39%, the lack of significant difference in clinical outcomes with other IUI indications was not unexpected, while its aetiology kept the multifactorial profile [57] shared with other infertilities. Our results are confirmed by the recent study of [38]. However, some teams report the best pregnancy rates in cervical indications [30, 55] and in anovulation infertilities [15, 50, 56]. Indeed, the pregnancy rate per cycle for patients with anovulation due to PCOS was 13%, which was probably corrected by Controlled Ovarian Hyperstimulation COH [15]. On the other hand, endometriosis was considered a bad prognostic factor for IUI success with lower pregnancy between 6% and 9% than other IUI indications [20, 50, 60]. Indeed, endometriosis, which is among the most difficult disorders to treat [21], decreased the IUI success rate for mild compared to severe cases 6% of success rate. This fact can argue the limitation of IUI to a maximum of two to three cycles [15, 19, 50, 60, 61]. This fact could explain our weak population size in the endometriosis group with just 35 couples, while the majority of couples were directed to undergo predictors of success have been widely studied on the COS effect and the infertility type effect. The most discussed effect was the age of the women, with a large debate on its impact on IUI success. Age has been accepted by many authors as a major predictive factor for pregnancy after IUI [29, 30, 60].The female age was a predictive variable for the live-birth rate but not for clinical pregnancy due to the increased miscarriage rate with age dependence, as can be observed in predictive unadjusted models [9, 57, 62]. The female age became a significant variable predictive for clinical pregnancy and live-birth rate with an adjusted model designed by Van Voorhis et al. [63] and, subsequently, Hansen et al. [57].In contrast with the aforementioned authors, our results did not show a significant correlation between the women's age and the clinical pregnancy rate Table 1, which was confirmed by several studies [11, 15, 16, 28, 64, 65]. This is due both to the intervention of other factors used in patients' selection including ovarian reserve and to the low numbers of women aged 40 or the female age impacted the success of IUI. A recent study by Bakas et al. [66] demonstrated a significant negative correlation between the age of the women and the clinical outcome of IUI r = â Indeed, with the female age cut-off of 40 years, clinical pregnancy was significantly affected Table 6 as shown throughout several studies, while the pregnancy rate decreased from 13â38% to 4â12% when the women were older than 40 years [30, 60, 67].The female age impact on IUI success could be masked in our study, because only were over 35 years and over 40 years. There may be a too low power to show a significant impact of age 40 and more in the multilogistic model, even if OR for this age category was very low Moreover, a multilogistic model including age as a continuous variable showed a significant negative impact on the delivery chance. On the other hand, age may also be linked to other factors, especially the IUI attempt rank. It is logical that, with more IUI attempts, the age advances. For this reason, Aydin et al. [68] could find no significant effect of female age on the clinical pregnancy rate in the first IUI cycle. Indeed, the rank attempt is determinant for IUI success. In our study, pregnancy rates and live births decreased significantly with the rank of insemination p = and p < resp. from rank 4 for both parameters p = see Table 6. Hendin et al. [67] and Merviel et al. [30] obtained 97% and 80%, respectively, of clinical pregnancies in their first three attempts. Plosker et al. [69] advocated a passage in IVF after three failed cycles of IUI. However, Soria et al. [15] demonstrated that from the fourth IUI cycle clinical pregnancy is negatively affected, which confirms our Blasco et al. [62] proved that the number of previous IUI cycles of the patient did not show a positive association with the cycle outcome in any of the developing steps of the models. In our study, IUI attempt rank did not have a clear correlation with clinical outcomes in different COS groups, but it did show a negative correlation with live-birth rates for patients with PCOS, unexplained infertility and male factor Tables â3 and â5. This could be explained by the evidence of severity of infertility type throughout time with an accumulation of IUI attempt failures, while IUI as a simple technique is less efficient than other ART techniques in achieving a clinical pregnancy. Particularly for infertile couples with male factor, the sperm quality becomes the determinant for IUI success [11, 70, 71], which was shown in our findings with a positive correlation of sperm concentration Table 5. It would be difficult to determine a universal threshold for sperm concentration, and each centre should define a threshold for its population and laboratory [72]. Nevertheless, Belaisch-Allart et al. [73] and Sakhel et al. [74] determined a sperm concentration cut-off at 10 Ă 106/mL and 5 Ă 106/mL, respectively. Indeed, the impact of semen quality was weak in our study, except for concentrations <5 Ă 106/mL, which remains nonsignificant due to small numbers of patients 8% of included population Table 6Sperm motility also appeared as a key factor in the study of Merviel et al. [30], where the pregnancy rate declined from 41% to 19% when the sperm motility was less than 70%. In our multivariable analysis with a sperm motility cut-off at 40%, we did not find any significant correlation with IUI clinical outcomes even with a large population size. This observation is reported also by Stone et al. [75].However, the TMS cut-off at 1 Ă 106, which was present in 21% of the included infertile patients, was a significant predictor of IUI clinical pregnancy Table 6. This finding was confirmed by two studies [9, 10] while others determined a higher threshold of TMS at 2 Ă 106 [68]; 3 Ă 106 [62, 76]; 5 Ă 106 [11, 77]; 10 Ă 106 [63, 78]. Indeed, the IUI clinical outcomes were improved with higher TMS, from Ă 106 to 12 Ă 106 [38]. Furthermore, regarding the sperm parameters, TMS was found to be an independent factor for clinical pregnancy after IUI in accordance with many authors [28, 63, 74, 77, 79â81]. However, Ozkan et al. [82] found just a minimal influence of TMS on the IUI success after TMS is a key factor for choosing IUI treatment or IVF, although a TMS threshold value of 5 Ă 106 to 10 Ă 106 has been reported as the criterion for undergoing IVF. Nevertheless, other sperm parameters could be better predictors of sperm morphology [58]. Although the predictive weakness of conventional sperm parameters for ART clinical outcomes has been demonstrated, sperm genome decay tests [83] could become a strong diagnostic tool to achieve clinical pregnancy for infertile couples undergoing homologous predictive factors for success have been found in some studies, such as duration of infertility, body mass index [15, 60, 82, 84, 85], and smoking [37], which were not regularly noted in our records and, therefore, could not be ConclusionThis study, is in concordance with our preliminary work [86] and demonstrate that there is no significant difference in clinical outcomes between different COS protocols rFSH, uFSH, or hMG and infertility types, even after taking into account the usual prognostic factors, including the female's age, the IUI attempt rank, and the sperm quality. However, unexplained infertility had a significant impact on IUI success, which revealed the need to look for more efficient ART strategies. Furthermore, since the fourth IUI attempt or with the female aged over 40 years, clinical pregnancy declined in IUI. Regarding the sperm quality, TMS with a threshold of 5 Ă 106 seemed a good predictor for IUI success. Indeed, over the obtained cut-off of the chosen indicators, other ART techniques might be more favourable for IVF live-birth infertile patients with male factor, sperm concentration was a determinant to achieve pregnancy, which necessitated some additional tests, such as sperm genome decay tests, before undergoing IUI and reviewing the couple's etiological factors for antioxidant prescriptions. Finally, every decision must be individualized to each couple's profile taking into account factors involved in the success of authors acknowledge the help of the embryology team of the IVF Centre of Amiens Hospital and the andrology team of Eylau Laboratory, Paris. This work was supported by the University Hospital and School of Medicine, Amiens, and Eyalu/Unilabs, reproductive technologiesCOSControlled ovarian stimulationIUIIntrauterine inseminationPCOSPolycystic ovaries syndromeTMSTotal motile of InterestThe authors declare that there are no conflicts of interest regarding the publication of this Boivin J., Bunting L., Collins J. A., Nygren K. G. International estimates of infertility prevalence and treatment-seeking potential need and demand for infertility medical care. Human Reproduction. 2007;2261506â1512. doi [PubMed] [CrossRef] [Google Scholar]2. Bushnik T., Cook J. L., Yuzpe A. A., Tough S., Collins J. Estimating the prevalence of infertility in Canada. Human Reproduction. 2012;273738â746. doi [PMC free article] [PubMed] [CrossRef] [Google Scholar]3. Thoma M. E., McLain A. C., Louis J. F., et al. Prevalence of infertility in the United States as estimated by the current duration approach and a traditional constructed approach. Fertility and Sterility. 2013;9951324â doi [PMC free article] [PubMed] [CrossRef] [Google Scholar]4. Slama R., Hansen O. K. H., Ducot B., et al. Estimation of the frequency of involuntary infertility on a nation-wide basis. Human Reproduction. 2012;2751489â1498. doi [PubMed] [CrossRef] [Google Scholar]5. The ESHRE Capri Workshop Group. Intrauterine insemination. Human Reproduction Update. 2009;153265â277. doi [PubMed] [CrossRef] [Google Scholar]6. Oehninger S. Place of intracytoplasmic sperm injection in management of male infertility. The Lancet. 2001;35792742068â2069. doi [PubMed] [CrossRef] [Google Scholar]7. Abdelkader A. M., Yeh J. The potential use of intrauterine insemination as a basic option for infertility a review for technology-limited medical settings. Obstetrics and Gynecology International. 2009;200911. doi [PMC free article] [PubMed] [CrossRef] [Google Scholar]8. Katzorke T., Kolodziej F. B. Significance of insemination in the era of IVF and ICSI. Der UrologeâAusgabe A. 2010;497842â846. doi [PubMed] [CrossRef] [Google Scholar]9. Monraisin O., Chansel-Debordeaux L., Chiron A., et al. Evaluation of intrauterine insemination practices a 1-year prospective study in seven French assisted reproduction technology centers. Fertility and Sterility. 2016;10561589â1593. doi [PubMed] [CrossRef] [Google Scholar]10. Campana A., Sakkas D., Stalberg A., et al. Intrauterine insemination evaluation of the results according to the woman's age, sperm quality, total sperm count per insemination and life table analysis. Human Reproduction. 1996;114732â736. doi [PubMed] [CrossRef] [Google Scholar]11. Khalil M. R., Rasmussen P. E., Erb K., Laursen S. B., Rex S., Westergaard L. G. Homologous intrauterine insemination. An evaluation of prognostic factors based on a review of 2473 cycles. Acta Obstetricia et Gynecologica Scandinavica. 2001;80174â81. doi [PubMed] [CrossRef] [Google Scholar]12. Kamath M. S., Bhave P. T. K., Aleyamma T. K., et al. Predictive factors for pregnancy after intrauterine insemination a prospective study of factors affecting outcome. Journal of Human Reproductive Sciences. 2010;33129â134. doi [PMC free article] [PubMed] [CrossRef] [Google Scholar]13. Tijani H. A., Bhattacharya S. The role of intrauterine insemination in male infertility. Human Fertility. 2010;134226â232. doi [PubMed] [CrossRef] [Google Scholar]14. Souter I., Baltagi L. M., Kuleta D., Meeker J. D., Petrozza J. C. Women, weight, and fertility the effect of body mass index on the outcome of superovulation/intrauterine insemination cycles. Fertility and Sterility. 2011;9531042â1047. doi [PubMed] [CrossRef] [Google Scholar]15. Soria M., Pradillo G., GarcĂa J., et al. Pregnancy predictors after intrauterine insemination analysis of 3012 cycles in 1201 couples. Journal of Reproduction and Infertility. 2012;133158â166. [PMC free article] [PubMed] [Google Scholar]16. Dilbaz B., Ăzkaya E., Ăinar M. Predictors of total gonadotropin dose required for follicular growth in controlled ovarian stimulation with intrauterin insemination cycles in patients with unexplained infertility or male subfertility. Gynecology, Obstetrics and Reproductive Medicine. 2001;17120016 [Google Scholar]17. Goverde A. J., McDonnell J., Vermeiden J. P. W., Schats R., Rutten F. F. H., Schoemaker J. Intrauterine insemination or in-vitro fertilisation in idiopathic subfertility and male subfertility a randomised trial and cost-effectiveness analysis. The Lancet. 2000;355919713â18. doi [PubMed] [CrossRef] [Google Scholar]18. Kim D., Child T., Farquhar C. Intrauterine insemination A UK survey on the adherence to NICE clinical guidelines by fertility clinics. BMJ Open. 2015;55 doi [PMC free article] [PubMed] [CrossRef] [Google Scholar]19. Prado-Perez J., Navarro-Maritnez C., Lopez-Rivadeneira E., Sanon-Julien Flores E. The impact of endometriosis on the rate of pregnancy of patients submitted to intrauterine insemination. Fertility and Sterility. 2002;77supplement 1p. S51. doi [CrossRef] [Google Scholar]20. Dmowski W. P., Pry M., Ding J., Rana N. Cycle-specific and cumulative fecundity in patients with endometriosis who are undergoing controlled ovarian hyperstimulation-intrauterine insemination or in vitro fertilization-embryo transfer. Fertility and Sterility. 2002;784750â756. doi [PubMed] [CrossRef] [Google Scholar]21. HĂ€rkki P., Tiitinen A., Ylikorkala O. Endometriosis and assisted reproduction techniques. Annals of the New York Academy of Sciences. 2010;1205207â213. doi [PubMed] [CrossRef] [Google Scholar]22. Matorras R., Recio V., CorcĂłstegui B., RodrĂguez-Escudero F. J. Recombinant human FSH versus highly purified urinary FSH a randomized study in intrauterine insemination with husband's spermatozoa. Human Reproduction. 2000;1561231â1234. doi [PubMed] [CrossRef] [Google Scholar]23. Gerli S., Bini V., Renzo G. C. D. Cost-effectiveness of recombinant follicle-stimulating hormone FSH versus human FSH in intrauterine insemination cycles a statistical model-derived analysis. Gynecological Endocrinology. 2008;24118â23. doi [PubMed] [CrossRef] [Google Scholar]24. Ragni G., Alagna F., Brigante C., et al. GnRH antagonists and mild ovarian stimulation for intrauterine insemination A randomized study comparing different gonadotrophin dosages. Human Reproduction. 2004;19154â58. doi [PubMed] [CrossRef] [Google Scholar]25. Demirol A., Gurgan T. Comparison of different gonadotrophin preparations in intrauterine insemination cycles for the treatment of unexplained infertility a prospective, randomized study. Human Reproduction. 2007;22197â100. doi [PubMed] [CrossRef] [Google Scholar]26. World Health Organization. WHO Laboratory Manual for the Examination and Processing of Human Semen. Geneva, Switzerland World Health Organization; 2010. [Google Scholar]27. Ombelet W., Puttemans P., Bosmans E. Intrauterine insemination a first-step procedure in the algorithm of male subfertility treatment. Human Reproduction. 1995;10supplement 190â102. doi [PubMed] [CrossRef] [Google Scholar]28. IbĂ©rico G., Vioque J., Ariza N., et al. Analysis of factors influencing pregnancy rates in homologous intrauterine insemination. Fertility and Sterility. 2004;8151308â1313. doi [PubMed] [CrossRef] [Google Scholar]29. Steures P., van der Steeg J. W., Hompes P. G., et al. Intrauterine insemination with controlled ovarian hyperstimulation versus expectant management for couples with unexplained subfertility and an intermediate prognosis a randomised clinical trial. The Lancet. 2006;3689531216â221. doi [PubMed] [CrossRef] [Google Scholar]30. Merviel P., Heraud M. H., Grenier N., Lourdel E., Sanguinet P., Copin H. Predictive factors for pregnancy after intrauterine insemination IUI an analysis of 1038 cycles and a review of the literature. Fertility and Sterility. 2010;93179â88. doi [PubMed] [CrossRef] [Google Scholar]31. Moro F., Scarinci E., Palla C., et al. Highly purified hMG versus recombinant FSH plus recombinant LH in intrauterine insemination cycles in women â„35 years a RCT. Human Reproduction. 2015;301179â185. doi [PubMed] [CrossRef] [Google Scholar]32. Dickey R. P., Olar T. T., Taylor S. N., Curole D. N., Rye P. H. Sequential clomiphene citrate and human menopausal gonadotrophin for ovulation induction comparison to clomiphene citrate alone and human menopausal gonadotrophin alone. Human Reproduction. 1993;8156â59. doi [PubMed] [CrossRef] [Google Scholar]33. Manganiello P. D., Stern J. E., Stukel T. A., Crow H., Brinck-Johnsen T., Weiss J. E. A comparison of clomiphene citrate and human menopausal gonadotropin for use in conjunction with intrauterine insemination. Fertility and Sterility. 1997;683405â412. doi [PubMed] [CrossRef] [Google Scholar]34. Guzick D. S., Sullivan M. W., Adamson G. D., et al. Efficacy of treatment for unexplained infertility. Fertility and Sterility. 1998;702207â213. doi [PubMed] [CrossRef] [Google Scholar]35. Hughes E. G. timulated intraâuterine insemination is not a natural choice for the treatment of unexplained subfertility 'Effective treatment' or 'not a natural choice'? Human Reproduction. 2003;185912â914. doi [PubMed] [CrossRef] [Google Scholar]36. Erdem M., Abay S., Erdem A., et al. Recombinant FSH increases live birth rates as compared to clomiphene citrate in intrauterine insemination cycles in couples with subfertility a prospective randomized study. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2015;18933â37. doi [PubMed] [CrossRef] [Google Scholar]37. Hassan M. A. M., Killick S. R. Negative lifestyle is associated with a significant reduction in fecundity. Fertility and Sterility. 2004;812384â392. doi [PubMed] [CrossRef] [Google Scholar]38. Dinelli L., CourbiĂšre B., Achard V., et al. Prognosis factors of pregnancy after intrauterine insemination with the husband's sperm conclusions of an analysis of 2,019 cycles. Fertility and Sterility. 2014;1014994â1000. doi [PubMed] [CrossRef] [Google Scholar]39. Cohlen B. J., Vandekerckhove P., te Velde E. R., Habbema J. D. Timed intercourse versus intraâuterine insemination with or without ovarian hyperstimulation for subfertility in men. The Cochrane Library. 2007 [PubMed] [Google Scholar]40. Bry-Gauillard H., Coulondre S., CĂ©drin-Durnerin I., Hugues J. N. Advantages and risks of ovarian stimulation before intra-uterine inseminations. GynĂ©cologie ObstĂ©trique & FertilitĂ© 2000;2811820â831. doi [PubMed] [CrossRef] [Google Scholar]41. Casadei L., Zamaro V., Calcagni M., Ticconi C., Dorrucci M., Piccione E. Homologous intrauterine insemination in controlled ovarian hyperstimulation cycles a comparison among three different regimens. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2006;1292155â161. doi [PubMed] [CrossRef] [Google Scholar]42. Cantineau A. E., Cohlen B. J., Heineman M. J. Ovarian stimulation protocols antiâoestrogens, gonadotrophins with and without GnRH agonists/antagonists for intrauterine insemination IUI in women with subfertility. The Cochrane Library. 2007 [PubMed] [Google Scholar]43. Dankert T., Kremer J. A. M., Cohlen B. J., et al. A randomized clinical trial of clomiphene citrate versus low dose recombinant FSH for ovarian hyperstimulation in intrauterine insemination cycles for unexplained and male subfertility. Human Reproduction. 2007;223792â797. doi [PubMed] [CrossRef] [Google Scholar]44. Gerli S., Casini M. L., Unfer V., Costabile L., Bini V., Di Renzo G. C. Recombinant versus urinary follicle-stimulating hormone in intrauterine insemination cycles A prospective, randomized analysis of cost effectiveness. Fertility and Sterility. 2004;823573â578. doi [PubMed] [CrossRef] [Google Scholar]45. Kocak M., Dilbaz B., Demir B., et al. Lyophilised hMG versus rFSH in women with unexplained infertility undergoing a controlled ovarian stimulation with intrauterine insemination a prospective, randomised study. Gynecological Endocrinology. 2010;266429â434. doi [PubMed] [CrossRef] [Google Scholar]46. Sagnella F., Moro F., Lanzone A., et al. A prospective randomized noninferiority study comparing recombinant FSH and highly purified menotropin in intrauterine insemination cycles in couples with unexplained infertility and/or mild-moderate male factor. Fertility and Sterility. 2011;952689â694. doi [PubMed] [CrossRef] [Google Scholar]47. Matorras R., Osuna C., Exposito A., Crisol L., Pijoan J. I. Recombinant FSH versus highly purified FSH in intrauterine insemination systematic review and metaanalysis. Fertility and Sterility. 2011;9561937âe3. doi [PubMed] [CrossRef] [Google Scholar]48. Balasch J., FĂĄbregues F., Peñarrubia J., et al. Follicular development and hormonal levels following highly purified or recombinant follicle-stimulating hormone administration in ovulatory women and WHO group II anovulatory infertile patients. Journal of Assisted Reproduction and Genetics. 1998;159552â559. doi [PMC free article] [PubMed] [CrossRef] [Google Scholar]49. Balasch J., MirĂł F., Burzaco I., et al. Endocrinology The role of luteinizing hormone in human follicle development and oocyte fertility Evidence from in-vitro fertilization in a woman with long-standing hypogonadotrophic hypogonadism and using recombinant human follicle stimulating hormone. Human Reproduction. 1995;1071678â1683. doi [PubMed] [CrossRef] [Google Scholar]50. Vlahos N. F., Coker L., Lawler C., Zhao Y., Bankowski B., Wallach E. E. Women with ovulatory dysfunction undergoing ovarian stimulation with clomiphene citrate for intrauterine insemination may benefit from administration of human chorionic gonadotropin. Fertility and Sterility. 2005;8351510â1516. doi [PubMed] [CrossRef] [Google Scholar]51. De la Fuente A. Evaluation of the effectiveness, safety and cost-effectiveness of highly purified human menopausal gonadotropin. Study of use Menopur â in Intrauterine Artificial Insemination IAC/IAD Fertility Review. 2007;24363â367. [Google Scholar]52. Filicori M., Cognigni G. E., Pocognoli P., et al. Comparison of controlled ovarian stimulation with human menopausal gonadotropin or recombinant follicle-stimulating hormone. Fertility and Sterility. 2003;802390â397. doi [PubMed] [CrossRef] [Google Scholar]53. Gomez R., Schorsch M., Steetskamp J., et al. The effect of ovarian stimulation on the outcome of intrauterine insemination. Archives of Gynecology and Obstetrics. 2014;2891181â185. doi [PubMed] [CrossRef] [Google Scholar]54. Isaza V., Requena A., GarcĂa-Velasco J. A., RemohĂ J., Pellicer A., SimĂłn C. Recombinant versus urinary follicle-stimulating hormone in couples undergoing intrauterine insemination a randomized study. Obstetrics, Gynaecology and Reproductive Medicine. 2003;482112â118. [PubMed] [Google Scholar]55. Gallot-LavallĂ©e P., Ecochard R., Mathieu C., et al. Clomiphene citrate or hMg which ovarian stimulation to chose before intra-uterine inseminations? A meta-analysis. Contraception, Fertilite, Sexualite. 1995;23115â121. [PubMed] [Google Scholar]56. Dickey R. R., Ramasamy R. Role of male factor testing in recurrent pregnancy loss or in vitro fertilization failure. Reproductive System & Sexual Disorders. 2015;0403 doi [PMC free article] [PubMed] [CrossRef] [Google Scholar]57. Hansen K. R., He A. L. W., Styer A. K., et al. Predictors of pregnancy and live-birth in couples with unexplained infertility after ovarian stimulationâintrauterine insemination. Fertility and Sterility. 2016;10561575â doi [PMC free article] [PubMed] [CrossRef] [Google Scholar]58. Erdem M., Erdem A., Mutlu M. F., et al. The impact of sperm morphology on the outcome of intrauterine insemination cycles with gonadotropins in unexplained and male subfertility. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2016;197120â124. doi [PubMed] [CrossRef] [Google Scholar]59. NICE. Nice guideline Fertility for people with fertility problems. NICE clinical guideline 156 February, Nuojua-Huttunen S., Tomas C., Bloigu R., Tuomivaara L., Martikainen H. Intrauterine insemination treatment in subfertility an analysis of factors affecting outcome. Human Reproduction. 1999;143698â703. doi [PubMed] [CrossRef] [Google Scholar]61. Toma S. K., Stovall D. W., Hammond M. G. The effect of laparoscopic ablation or danocrine on pregnancy rates in patients with stage I or II endometriosis undergoing donor insemination. Obstetrics & Gynecology. 1992;802253â256. [PubMed] [Google Scholar]62. Blasco V., Prados N., Carranza F., GonzĂĄlez-Ravina C., Pellicer A., FernĂĄndez-SĂĄnchez M. Influence of follicle rupture and uterine contractions on intrauterine insemination outcome a new predictive model. Fertility and Sterility. 2014;10241034â1040. doi [PubMed] [CrossRef] [Google Scholar]63. Van Voorhis B. J., Barnett M., Sparks A. E. T., Syrop C. H., Rosenthal G., Dawson J. Effect of the total motile sperm count on the efficacy and cost-effectiveness of intrauterine insemination and in vitro fertilization. Fertility and Sterility. 2001;754661â668. doi [PubMed] [CrossRef] [Google Scholar]64. Mathieu C., Ecochard R., Bied V., Lornage J., Czyba J. C. Andrology cumulative conception rate following intrauterine artificial insemination with husband's spermatozoa influence of husband's age. Human Reproduction. 1995;1051090â1097. doi [PubMed] [CrossRef] [Google Scholar]65. Brzechffa P. R., Daneshmand S., Buyalos R. P. Sequential clomiphene citrate and human menopausal gonadotrophin with intrauterine insemination the effect of patient age on clinical outcome. Human Reproduction. 1998;1382110â2114. doi [PubMed] [CrossRef] [Google Scholar]66. Bakas P., Boutas I., Creatsa M., et al. Can anti-Mullerian hormone AMH predict the outcome of intrauterine insemination with controlled ovarian stimulation? Gynecological Endocrinology. 2015;3110765â768. doi [PubMed] [CrossRef] [Google Scholar]67. Hendin B. N., Falcone T., Hallak J., et al. The effect of patient and semen characteristics on live birth rates following intrauterine insemination a retrospective study. Journal of Assisted Reproduction and Genetics. 2000;175245â252. doi [PMC free article] [PubMed] [CrossRef] [Google Scholar]68. Aydin Y., Hassa H., Oge T., Tokgoz V. Y. Factors predictive of clinical pregnancy in the first intrauterine insemination cycle of 306 couples with favourable female patient characteristics. Human Fertility. 2013;164286â290. doi [PubMed] [CrossRef] [Google Scholar]69. Plosker S. M., Jacobson W., Amato P. Infertility Predicting and optimizing success in an intra-uterine insemination programme. Human Reproduction. 1994;9112014â2021. doi [PubMed] [CrossRef] [Google Scholar]70. Oehninger S., Franken D., Kruger T. Approaching the next millennium How should we manage andrology diagnosis in the intracytoplasmic sperm injection era? Fertility and Sterility. 1997;673434â436. doi [PubMed] [CrossRef] [Google Scholar]71. Dorjpurev U., Kuwahara A., Yano Y., et al. Effect of semen characteristics on pregnancy rate following intrauterine insemination. Journal of Medical Investigation. 2011;581-2127â133. doi [PubMed] [CrossRef] [Google Scholar]72. Duran H. E., Morshedi M., Kruger T., Oehninger S. Intrauterine insemination a systematic review on determinants of success. Human Reproduction Update. 2002;84373â384. doi [PubMed] [CrossRef] [Google Scholar]73. Belaisch-Allart J., Mayenga J. M., Plachot M. Intra-uterine insemination. Contraception, fertilitĂ©, sexualitĂ© 1992 1999;279614â619. [PubMed] [Google Scholar]74. Sakhel K., Abozaid T., Schwark S., Ashraf M., Abuzeid M. Semen parameters as determinants of success in 1662 cycles of intrauterine insemination after controlled ovarian hyperstimulation. Fertility and Sterility. 2005;84S248âS249. doi [CrossRef] [Google Scholar]75. Stone B. A., Vargyas J. M., Ringlet G. E., et al. Determinants of the outcome of intrauterine insemination analysis of outcomes of 9963 consecutive cycles. American Journal of Obstetrics & Gynecology. 1999;1806 I1522â1534. doi [PubMed] [CrossRef] [Google Scholar]76. Strandell A., Bergh C., Söderlund B., Lundin K., Nilsson L. Fallopian tube sperm perfusion the impact of sperm count and morphology on pregnancy rates. Acta Obstetricia et Gynecologica Scandinavica. 2003;82111023â1029. doi [PubMed] [CrossRef] [Google Scholar]77. Huang Lee Lai et al. The impact of the total motile sperm count on the success of intrauterine insemination with husband's spermatozoa. Journal of Assisted Reproduction and Genetics. 1996;13156â63. doi [PubMed] [CrossRef] [Google Scholar]78. Dickey R. P., Pyrzak R., Lu P. Y., Taylor S. N., Rye P. H. Comparison of the sperm quality necessary for successful intrauterine insemination with World Health Organization threshold values for normal sperm. Fertility and Sterility. 1999;714684â689. doi [PubMed] [CrossRef] [Google Scholar]79. Miller D. C., Hollenbeck B. K., Smith G. D., et al. Processed total motile sperm count correlates with pregnancy outcome after intrauterine insemination. Urology. 2002;603497â501. doi [PubMed] [CrossRef] [Google Scholar]80. Yousefi B., Azargon A. Predictive factors of intrauterine insemination success of women with infertility over 10 years. Journal of the Pakistan Medical Association. 2011;612165â168. [PubMed] [Google Scholar]81. Yavuz A., Demirci O., Sözen H., UludoÄan M. Predictive factors influencing pregnancy rates after intrauterine insemination. Iranian Journal of Reproductive Medicine. 2013;113227â234. [PMC free article] [PubMed] [Google Scholar]82. Ozkan Z. S., Ilh
233 78 76 78 83 88 94 3:11 92 86 85 89 91 93 2:34 77 76 77 82 87 93 3:12 91 85 85 88 91 93 2:35 76 75 77 81 87 93 3:13 91 85 84 87 90 92 2:36 75 74 76 81 86 92 3:14 90 84 84 87 90 92 2:37 74 73 75 80 85 91 3:15 90 83 83 86 89 91 2:38 73 72 74 79 85 91 3:16 89 83 83 86 89 91 2:39 73 72 74 78 84 90 3:17 89 82 82 85 88 90
Journal List Biomed Res Int PMC5745683 Biomed Res Int. 2017; 2017 3512784. Rosalie Cabry-Goubet, 1 , 2 Florence Scheffler, 1 , 2 Naima Belhadri-Mansouri, 1 Stephanie Belloc, 3 Emmanuelle Lourdel, 1 Aviva Devaux, 1 , 2 Hickmat Chahine, 4 Jacques De Mouzon, 4 Henri Copin, 1 and Moncef Benkhalifa 1 , 2 AbstractObjective To evaluate the IUI success factors relative to controlled ovarian stimulation COS and infertility type, this retrospective cohort study included 1251 couples undergoing homologous IUI. Results We achieved 13% clinical pregnancies and 11% live births. COS and infertility type do not have significant effect on IUI clinical outcomes with unstable intervention of various couples' parameters, including the female age, the IUI attempt rank, and the sperm quality. Conclusion Further, the COS used seemed a weak predictor for IUI success; therefore, the indications need more discussion, especially in unexplained infertility cases involving various factors. Indeed, the fourth IUI attempt, the female age over 40 years, and the total motile sperm count 1 Ă 106. The exclusion criteria were TMS †1 Ă 106; sperm donation; seropositivity for human immunodeficiency virus HIV for any couple member; inseminations performed in a natural cycle or with clomiphene citrate CC. IUI ProtocolAll couples had undergone a standard infertility evaluation, which included medical history, physical examination, and assessment of tubal patency by either hysterosalpingography or laparoscopy and hormonal analysis on cycle day 3. A transvaginal ultrasound scan was performed on the second day of the cycle. On the same day, ovarian stimulation was carried out with recombinant FSH follitropin α; rFSH; Gonal-F, Merck Serono, France, or follitropin ÎČ; Puregon, MSD, France, urinary FSH urofollitropin, Fostimon, France, or hMG menotropin, Menopur, France at a starting dose of 75 IU/day from the second day of the response and endometrial thickness were monitored by transvaginal ultrasonography starting on day 6 of stimulation and then on alternate days; the gonadotropin dose was adjusted according to the ovarian response and the patient's characteristics. When at least one mature follicle reached a diameter >17 mm and E2 level > 150 pmol/mL, the recombinant human chorionic gonadotropin hCG, Ovitrelle, Merck Serono, France was administered, and endometrial thickness was single IUI was performed 36 h after hCG injection using a soft catheter classic Frydman catheter; Laboratoire CCD, Paris, France or a hard catheter SET TDT, International Laboratory CDD. The semen samples used for insemination were processed within 1 hour of ejaculation by density gradient centrifugation, followed by washing with a culture medium after determining the TMS and semen analysis according to the WHO criteria [26]. Outcome VariableThe main clinical outcome measures were clinical pregnancy and live-birth rates per cycle. Clinical pregnancy was defined as the evidence of pregnancy by ultrasound examination of the gestational sac at weeks 5â Statistical AnalysisThe stimulation protocols were divided into 4 categories according to the gonadotropin used for COS rFSH/Gonal-F, rFSH/Puregon, uFSH/Fostimon, and hMG/ type was considered in seven categories cervical factor, dysovulation, endometriosis, tubal factor, male factor, and unexplained infertility. After statistical analysis of the results, it was necessary to determine the parameter cut-offs to give infertile couples more chances through IUI before carrying out other ART techniquesGroups were compared for all main couples' characteristics and cycle outcomes. Data are presented as mean ± standard deviation SD or percentage of the total. Data were analysed with Student's t-test for means comparisons or with the chi-squared test for comparison of percentages using Statistical Package, version SAS; Institute Inc., Cary, NC, USA; p 15 Sperm motility â„40 % versus â€39 TMS â„5 Ă 106 versus <5 s power calculation showed a power of 80% to demonstrate a difference across the COS groups in delivery rates of 10% between groups 1 and 4 and 2 and 4, of 11% between groups 3 and 4, of 8% between groups 2 and 3, of 8% between groups 2 and 4, of 7% between groups 1 and 2, 6% between recombinant FSH and urinary products, and of 9% between FSH and HMG4. DiscussionAs a first step in ART, IUI keeps a central place in the management of infertile couples for its simplicity, but it still offers weak effectiveness. Indeed, IUI success is still a subject of controversy, with a clinical pregnancy rate between 8% and 25% [16, 18, 27â31]. Furthermore, based on a recent prospective study in seven French ART centres, the overall live-birth rate was 11% per cycle, varying from 8% to 18% between centres [9]. Similarly, we attained 13% for clinical pregnancy and 11% for live-birth for the 1251 couples who underwent homologous IUI with gonadotropins for COS Table 1.Indeed, gonadotropin use had proved its superiority to improve clinical outcomes of IUI compared to other COS protocols, such as CC and letrozole [32â38]. Erdem et al. [36] showed that, for IUI success, rFSH Gonal-F was more effective than using CC to reach 28% for clinical pregnancy and 24% of live-birth. Nevertheless, it is still not clear which of the currently available medications is preferable for COS [15, 23, 39â43]. However, several studies compared different types of gonadotropin efficiency rFSH, uFSH, or hMG [15, 25, 44â47]. Indeed, in the first part of this work, we compared four gonadotropins for COS in IUI rFSH/Gonal-F; rFSH/Puregon; uFSH/Fostimon and hMG/Menopur while rFSH was the most used in 72% of couples Table 1.This preference was noticed in other studies [9, 15, 25, 36] without finding any significant improvement on clinical outcomes. Indeed, as demonstrated in our study, there was no significant difference between different protocols used for COS rFSH/Gonal-F; rFSH/Puregon; uFSH/Fostimon; and hMG/Menopur; Table 2, although, in contrast, some authors pointed to the greater potency of rFSH [22, 48]. However, other studies have reported higher pregnancy rates for hMG [33, 49â53]. Even if our study had 80% power to demonstrate differences in PR of 6% to 11% between 2 groups, according to their size, it is clear that the differences we observed were very low, in favour of a low impact of the 4 used COS regimen on the results. This was less clear for infertility origin because of the very low numbers of some groups. However, the results of the multivariate logistic model confirmed the results observed at the first step analysis, reinforcing their valueGenerally, rFSH is commonly used to minimize the possibility of developing ovarian cysts associated with LH contamination and to improve the probability of a more consistent, effective, and efficient ovarian response [22, 48].Although there was no significant difference between the efficiency of gonadotropins for COS, other COS protocol factors could be involved to improve the clinical outcomes, especially regarding the starting dose and the total doses of treatment as proved by several studies [15, 23â25, 54].To explain the absence of a significant difference between the four COS groups, we analysed other factors relative to COS protocol female age, IUI attempt rank, and sperm quality. As expected, our studied population showed its heterogeneity involving multiple factors, which was the reason not to have a real consensus about the efficiency of COS, and this made it harder to really evaluate its impact. The sperm motility significantly affected the live-birth in rFSH groups Table 3. Furthermore, the IUI attempt rank had a significant negative correlation with clinical outcomes with unequal values between groups Table 3. Indeed, it is not legitimate to consider the COS as a strong predictive factor of clinical outcomes in IUI, while other factors could not all be controlledInfertility type has been discussed throughout several studies as a nonnegligible indicator of IUI clinical outcomes [15, 30, 38, 50, 55â59], while the latest National Institute for Health and Care Excellence NICE guideline on fertility [59] recommends that IUI should not be routinely offered to people with unexplained infertility, mild endometriosis, or mild male factor infertility who are having regular unprotected sexual this reason, in the second part of this study, we were more focused on evaluating the infertility type effect on IUI success. As a result, there was no significant difference between clinical outcomes of the different groups based on the infertility type Table 4. Although unexplained infertility was most couples' indication for IUI 36% Table 1, as noticed in the recent report of Monraisin et al. [9] with a value of 39%, the lack of significant difference in clinical outcomes with other IUI indications was not unexpected, while its aetiology kept the multifactorial profile [57] shared with other infertilities. Our results are confirmed by the recent study of [38]. However, some teams report the best pregnancy rates in cervical indications [30, 55] and in anovulation infertilities [15, 50, 56]. Indeed, the pregnancy rate per cycle for patients with anovulation due to PCOS was 13%, which was probably corrected by Controlled Ovarian Hyperstimulation COH [15]. On the other hand, endometriosis was considered a bad prognostic factor for IUI success with lower pregnancy between 6% and 9% than other IUI indications [20, 50, 60]. Indeed, endometriosis, which is among the most difficult disorders to treat [21], decreased the IUI success rate for mild compared to severe cases 6% of success rate. This fact can argue the limitation of IUI to a maximum of two to three cycles [15, 19, 50, 60, 61]. This fact could explain our weak population size in the endometriosis group with just 35 couples, while the majority of couples were directed to undergo predictors of success have been widely studied on the COS effect and the infertility type effect. The most discussed effect was the age of the women, with a large debate on its impact on IUI success. Age has been accepted by many authors as a major predictive factor for pregnancy after IUI [29, 30, 60].The female age was a predictive variable for the live-birth rate but not for clinical pregnancy due to the increased miscarriage rate with age dependence, as can be observed in predictive unadjusted models [9, 57, 62]. The female age became a significant variable predictive for clinical pregnancy and live-birth rate with an adjusted model designed by Van Voorhis et al. [63] and, subsequently, Hansen et al. [57].In contrast with the aforementioned authors, our results did not show a significant correlation between the women's age and the clinical pregnancy rate Table 1, which was confirmed by several studies [11, 15, 16, 28, 64, 65]. This is due both to the intervention of other factors used in patients' selection including ovarian reserve and to the low numbers of women aged 40 or the female age impacted the success of IUI. A recent study by Bakas et al. [66] demonstrated a significant negative correlation between the age of the women and the clinical outcome of IUI r = â Indeed, with the female age cut-off of 40 years, clinical pregnancy was significantly affected Table 6 as shown throughout several studies, while the pregnancy rate decreased from 13â38% to 4â12% when the women were older than 40 years [30, 60, 67].The female age impact on IUI success could be masked in our study, because only were over 35 years and over 40 years. There may be a too low power to show a significant impact of age 40 and more in the multilogistic model, even if OR for this age category was very low Moreover, a multilogistic model including age as a continuous variable showed a significant negative impact on the delivery chance. On the other hand, age may also be linked to other factors, especially the IUI attempt rank. It is logical that, with more IUI attempts, the age advances. For this reason, Aydin et al. [68] could find no significant effect of female age on the clinical pregnancy rate in the first IUI cycle. Indeed, the rank attempt is determinant for IUI success. In our study, pregnancy rates and live births decreased significantly with the rank of insemination p = and p < resp. from rank 4 for both parameters p = see Table 6. Hendin et al. [67] and Merviel et al. [30] obtained 97% and 80%, respectively, of clinical pregnancies in their first three attempts. Plosker et al. [69] advocated a passage in IVF after three failed cycles of IUI. However, Soria et al. [15] demonstrated that from the fourth IUI cycle clinical pregnancy is negatively affected, which confirms our Blasco et al. [62] proved that the number of previous IUI cycles of the patient did not show a positive association with the cycle outcome in any of the developing steps of the models. In our study, IUI attempt rank did not have a clear correlation with clinical outcomes in different COS groups, but it did show a negative correlation with live-birth rates for patients with PCOS, unexplained infertility and male factor Tables â3 and â5. This could be explained by the evidence of severity of infertility type throughout time with an accumulation of IUI attempt failures, while IUI as a simple technique is less efficient than other ART techniques in achieving a clinical pregnancy. Particularly for infertile couples with male factor, the sperm quality becomes the determinant for IUI success [11, 70, 71], which was shown in our findings with a positive correlation of sperm concentration Table 5. It would be difficult to determine a universal threshold for sperm concentration, and each centre should define a threshold for its population and laboratory [72]. Nevertheless, Belaisch-Allart et al. [73] and Sakhel et al. [74] determined a sperm concentration cut-off at 10 Ă 106/mL and 5 Ă 106/mL, respectively. Indeed, the impact of semen quality was weak in our study, except for concentrations <5 Ă 106/mL, which remains nonsignificant due to small numbers of patients 8% of included population Table 6Sperm motility also appeared as a key factor in the study of Merviel et al. [30], where the pregnancy rate declined from 41% to 19% when the sperm motility was less than 70%. In our multivariable analysis with a sperm motility cut-off at 40%, we did not find any significant correlation with IUI clinical outcomes even with a large population size. This observation is reported also by Stone et al. [75].However, the TMS cut-off at 1 Ă 106, which was present in 21% of the included infertile patients, was a significant predictor of IUI clinical pregnancy Table 6. This finding was confirmed by two studies [9, 10] while others determined a higher threshold of TMS at 2 Ă 106 [68]; 3 Ă 106 [62, 76]; 5 Ă 106 [11, 77]; 10 Ă 106 [63, 78]. Indeed, the IUI clinical outcomes were improved with higher TMS, from Ă 106 to 12 Ă 106 [38]. Furthermore, regarding the sperm parameters, TMS was found to be an independent factor for clinical pregnancy after IUI in accordance with many authors [28, 63, 74, 77, 79â81]. However, Ozkan et al. [82] found just a minimal influence of TMS on the IUI success after TMS is a key factor for choosing IUI treatment or IVF, although a TMS threshold value of 5 Ă 106 to 10 Ă 106 has been reported as the criterion for undergoing IVF. Nevertheless, other sperm parameters could be better predictors of sperm morphology [58]. Although the predictive weakness of conventional sperm parameters for ART clinical outcomes has been demonstrated, sperm genome decay tests [83] could become a strong diagnostic tool to achieve clinical pregnancy for infertile couples undergoing homologous predictive factors for success have been found in some studies, such as duration of infertility, body mass index [15, 60, 82, 84, 85], and smoking [37], which were not regularly noted in our records and, therefore, could not be ConclusionThis study, is in concordance with our preliminary work [86] and demonstrate that there is no significant difference in clinical outcomes between different COS protocols rFSH, uFSH, or hMG and infertility types, even after taking into account the usual prognostic factors, including the female's age, the IUI attempt rank, and the sperm quality. However, unexplained infertility had a significant impact on IUI success, which revealed the need to look for more efficient ART strategies. Furthermore, since the fourth IUI attempt or with the female aged over 40 years, clinical pregnancy declined in IUI. Regarding the sperm quality, TMS with a threshold of 5 Ă 106 seemed a good predictor for IUI success. Indeed, over the obtained cut-off of the chosen indicators, other ART techniques might be more favourable for IVF live-birth infertile patients with male factor, sperm concentration was a determinant to achieve pregnancy, which necessitated some additional tests, such as sperm genome decay tests, before undergoing IUI and reviewing the couple's etiological factors for antioxidant prescriptions. Finally, every decision must be individualized to each couple's profile taking into account factors involved in the success of authors acknowledge the help of the embryology team of the IVF Centre of Amiens Hospital and the andrology team of Eylau Laboratory, Paris. This work was supported by the University Hospital and School of Medicine, Amiens, and Eyalu/Unilabs, reproductive technologiesCOSControlled ovarian stimulationIUIIntrauterine inseminationPCOSPolycystic ovaries syndromeTMSTotal motile of InterestThe authors declare that there are no conflicts of interest regarding the publication of this Boivin J., Bunting L., Collins J. A., Nygren K. G. International estimates of infertility prevalence and treatment-seeking potential need and demand for infertility medical care. Human Reproduction. 2007;2261506â1512. doi [PubMed] [CrossRef] [Google Scholar]2. Bushnik T., Cook J. L., Yuzpe A. A., Tough S., Collins J. Estimating the prevalence of infertility in Canada. Human Reproduction. 2012;273738â746. doi [PMC free article] [PubMed] [CrossRef] [Google Scholar]3. Thoma M. E., McLain A. C., Louis J. F., et al. Prevalence of infertility in the United States as estimated by the current duration approach and a traditional constructed approach. Fertility and Sterility. 2013;9951324â doi [PMC free article] [PubMed] [CrossRef] [Google Scholar]4. Slama R., Hansen O. K. H., Ducot B., et al. Estimation of the frequency of involuntary infertility on a nation-wide basis. Human Reproduction. 2012;2751489â1498. doi [PubMed] [CrossRef] [Google Scholar]5. The ESHRE Capri Workshop Group. Intrauterine insemination. Human Reproduction Update. 2009;153265â277. doi [PubMed] [CrossRef] [Google Scholar]6. Oehninger S. Place of intracytoplasmic sperm injection in management of male infertility. The Lancet. 2001;35792742068â2069. doi [PubMed] [CrossRef] [Google Scholar]7. Abdelkader A. M., Yeh J. The potential use of intrauterine insemination as a basic option for infertility a review for technology-limited medical settings. Obstetrics and Gynecology International. 2009;200911. doi [PMC free article] [PubMed] [CrossRef] [Google Scholar]8. Katzorke T., Kolodziej F. B. Significance of insemination in the era of IVF and ICSI. Der UrologeâAusgabe A. 2010;497842â846. doi [PubMed] [CrossRef] [Google Scholar]9. Monraisin O., Chansel-Debordeaux L., Chiron A., et al. Evaluation of intrauterine insemination practices a 1-year prospective study in seven French assisted reproduction technology centers. Fertility and Sterility. 2016;10561589â1593. doi [PubMed] [CrossRef] [Google Scholar]10. Campana A., Sakkas D., Stalberg A., et al. Intrauterine insemination evaluation of the results according to the woman's age, sperm quality, total sperm count per insemination and life table analysis. Human Reproduction. 1996;114732â736. doi [PubMed] [CrossRef] [Google Scholar]11. Khalil M. R., Rasmussen P. E., Erb K., Laursen S. B., Rex S., Westergaard L. G. Homologous intrauterine insemination. An evaluation of prognostic factors based on a review of 2473 cycles. Acta Obstetricia et Gynecologica Scandinavica. 2001;80174â81. doi [PubMed] [CrossRef] [Google Scholar]12. Kamath M. S., Bhave P. T. K., Aleyamma T. K., et al. Predictive factors for pregnancy after intrauterine insemination a prospective study of factors affecting outcome. Journal of Human Reproductive Sciences. 2010;33129â134. doi [PMC free article] [PubMed] [CrossRef] [Google Scholar]13. Tijani H. A., Bhattacharya S. The role of intrauterine insemination in male infertility. Human Fertility. 2010;134226â232. doi [PubMed] [CrossRef] [Google Scholar]14. Souter I., Baltagi L. M., Kuleta D., Meeker J. D., Petrozza J. C. Women, weight, and fertility the effect of body mass index on the outcome of superovulation/intrauterine insemination cycles. Fertility and Sterility. 2011;9531042â1047. doi [PubMed] [CrossRef] [Google Scholar]15. Soria M., Pradillo G., GarcĂa J., et al. Pregnancy predictors after intrauterine insemination analysis of 3012 cycles in 1201 couples. Journal of Reproduction and Infertility. 2012;133158â166. [PMC free article] [PubMed] [Google Scholar]16. Dilbaz B., Ăzkaya E., Ăinar M. Predictors of total gonadotropin dose required for follicular growth in controlled ovarian stimulation with intrauterin insemination cycles in patients with unexplained infertility or male subfertility. Gynecology, Obstetrics and Reproductive Medicine. 2001;17120016 [Google Scholar]17. Goverde A. J., McDonnell J., Vermeiden J. P. W., Schats R., Rutten F. F. H., Schoemaker J. Intrauterine insemination or in-vitro fertilisation in idiopathic subfertility and male subfertility a randomised trial and cost-effectiveness analysis. The Lancet. 2000;355919713â18. doi [PubMed] [CrossRef] [Google Scholar]18. Kim D., Child T., Farquhar C. Intrauterine insemination A UK survey on the adherence to NICE clinical guidelines by fertility clinics. BMJ Open. 2015;55 doi [PMC free article] [PubMed] [CrossRef] [Google Scholar]19. Prado-Perez J., Navarro-Maritnez C., Lopez-Rivadeneira E., Sanon-Julien Flores E. The impact of endometriosis on the rate of pregnancy of patients submitted to intrauterine insemination. Fertility and Sterility. 2002;77supplement 1p. S51. doi [CrossRef] [Google Scholar]20. Dmowski W. P., Pry M., Ding J., Rana N. Cycle-specific and cumulative fecundity in patients with endometriosis who are undergoing controlled ovarian hyperstimulation-intrauterine insemination or in vitro fertilization-embryo transfer. Fertility and Sterility. 2002;784750â756. doi [PubMed] [CrossRef] [Google Scholar]21. HĂ€rkki P., Tiitinen A., Ylikorkala O. Endometriosis and assisted reproduction techniques. Annals of the New York Academy of Sciences. 2010;1205207â213. doi [PubMed] [CrossRef] [Google Scholar]22. Matorras R., Recio V., CorcĂłstegui B., RodrĂguez-Escudero F. J. Recombinant human FSH versus highly purified urinary FSH a randomized study in intrauterine insemination with husband's spermatozoa. Human Reproduction. 2000;1561231â1234. doi [PubMed] [CrossRef] [Google Scholar]23. Gerli S., Bini V., Renzo G. C. D. Cost-effectiveness of recombinant follicle-stimulating hormone FSH versus human FSH in intrauterine insemination cycles a statistical model-derived analysis. Gynecological Endocrinology. 2008;24118â23. doi [PubMed] [CrossRef] [Google Scholar]24. Ragni G., Alagna F., Brigante C., et al. GnRH antagonists and mild ovarian stimulation for intrauterine insemination A randomized study comparing different gonadotrophin dosages. Human Reproduction. 2004;19154â58. doi [PubMed] [CrossRef] [Google Scholar]25. Demirol A., Gurgan T. Comparison of different gonadotrophin preparations in intrauterine insemination cycles for the treatment of unexplained infertility a prospective, randomized study. Human Reproduction. 2007;22197â100. doi [PubMed] [CrossRef] [Google Scholar]26. World Health Organization. WHO Laboratory Manual for the Examination and Processing of Human Semen. Geneva, Switzerland World Health Organization; 2010. [Google Scholar]27. Ombelet W., Puttemans P., Bosmans E. Intrauterine insemination a first-step procedure in the algorithm of male subfertility treatment. Human Reproduction. 1995;10supplement 190â102. doi [PubMed] [CrossRef] [Google Scholar]28. IbĂ©rico G., Vioque J., Ariza N., et al. Analysis of factors influencing pregnancy rates in homologous intrauterine insemination. Fertility and Sterility. 2004;8151308â1313. doi [PubMed] [CrossRef] [Google Scholar]29. Steures P., van der Steeg J. W., Hompes P. G., et al. Intrauterine insemination with controlled ovarian hyperstimulation versus expectant management for couples with unexplained subfertility and an intermediate prognosis a randomised clinical trial. The Lancet. 2006;3689531216â221. doi [PubMed] [CrossRef] [Google Scholar]30. Merviel P., Heraud M. H., Grenier N., Lourdel E., Sanguinet P., Copin H. Predictive factors for pregnancy after intrauterine insemination IUI an analysis of 1038 cycles and a review of the literature. Fertility and Sterility. 2010;93179â88. doi [PubMed] [CrossRef] [Google Scholar]31. Moro F., Scarinci E., Palla C., et al. Highly purified hMG versus recombinant FSH plus recombinant LH in intrauterine insemination cycles in women â„35 years a RCT. Human Reproduction. 2015;301179â185. doi [PubMed] [CrossRef] [Google Scholar]32. Dickey R. P., Olar T. T., Taylor S. N., Curole D. N., Rye P. H. Sequential clomiphene citrate and human menopausal gonadotrophin for ovulation induction comparison to clomiphene citrate alone and human menopausal gonadotrophin alone. Human Reproduction. 1993;8156â59. doi [PubMed] [CrossRef] [Google Scholar]33. Manganiello P. D., Stern J. E., Stukel T. A., Crow H., Brinck-Johnsen T., Weiss J. E. A comparison of clomiphene citrate and human menopausal gonadotropin for use in conjunction with intrauterine insemination. Fertility and Sterility. 1997;683405â412. doi [PubMed] [CrossRef] [Google Scholar]34. Guzick D. S., Sullivan M. W., Adamson G. D., et al. Efficacy of treatment for unexplained infertility. Fertility and Sterility. 1998;702207â213. doi [PubMed] [CrossRef] [Google Scholar]35. Hughes E. G. timulated intraâuterine insemination is not a natural choice for the treatment of unexplained subfertility 'Effective treatment' or 'not a natural choice'? Human Reproduction. 2003;185912â914. doi [PubMed] [CrossRef] [Google Scholar]36. Erdem M., Abay S., Erdem A., et al. Recombinant FSH increases live birth rates as compared to clomiphene citrate in intrauterine insemination cycles in couples with subfertility a prospective randomized study. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2015;18933â37. doi [PubMed] [CrossRef] [Google Scholar]37. Hassan M. A. M., Killick S. R. Negative lifestyle is associated with a significant reduction in fecundity. Fertility and Sterility. 2004;812384â392. doi [PubMed] [CrossRef] [Google Scholar]38. Dinelli L., CourbiĂšre B., Achard V., et al. Prognosis factors of pregnancy after intrauterine insemination with the husband's sperm conclusions of an analysis of 2,019 cycles. Fertility and Sterility. 2014;1014994â1000. doi [PubMed] [CrossRef] [Google Scholar]39. Cohlen B. J., Vandekerckhove P., te Velde E. R., Habbema J. D. Timed intercourse versus intraâuterine insemination with or without ovarian hyperstimulation for subfertility in men. The Cochrane Library. 2007 [PubMed] [Google Scholar]40. Bry-Gauillard H., Coulondre S., CĂ©drin-Durnerin I., Hugues J. N. Advantages and risks of ovarian stimulation before intra-uterine inseminations. GynĂ©cologie ObstĂ©trique & FertilitĂ© 2000;2811820â831. doi [PubMed] [CrossRef] [Google Scholar]41. Casadei L., Zamaro V., Calcagni M., Ticconi C., Dorrucci M., Piccione E. Homologous intrauterine insemination in controlled ovarian hyperstimulation cycles a comparison among three different regimens. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2006;1292155â161. doi [PubMed] [CrossRef] [Google Scholar]42. Cantineau A. E., Cohlen B. J., Heineman M. J. Ovarian stimulation protocols antiâoestrogens, gonadotrophins with and without GnRH agonists/antagonists for intrauterine insemination IUI in women with subfertility. The Cochrane Library. 2007 [PubMed] [Google Scholar]43. Dankert T., Kremer J. A. M., Cohlen B. J., et al. A randomized clinical trial of clomiphene citrate versus low dose recombinant FSH for ovarian hyperstimulation in intrauterine insemination cycles for unexplained and male subfertility. Human Reproduction. 2007;223792â797. doi [PubMed] [CrossRef] [Google Scholar]44. Gerli S., Casini M. L., Unfer V., Costabile L., Bini V., Di Renzo G. C. Recombinant versus urinary follicle-stimulating hormone in intrauterine insemination cycles A prospective, randomized analysis of cost effectiveness. Fertility and Sterility. 2004;823573â578. doi [PubMed] [CrossRef] [Google Scholar]45. Kocak M., Dilbaz B., Demir B., et al. Lyophilised hMG versus rFSH in women with unexplained infertility undergoing a controlled ovarian stimulation with intrauterine insemination a prospective, randomised study. Gynecological Endocrinology. 2010;266429â434. doi [PubMed] [CrossRef] [Google Scholar]46. Sagnella F., Moro F., Lanzone A., et al. A prospective randomized noninferiority study comparing recombinant FSH and highly purified menotropin in intrauterine insemination cycles in couples with unexplained infertility and/or mild-moderate male factor. Fertility and Sterility. 2011;952689â694. doi [PubMed] [CrossRef] [Google Scholar]47. Matorras R., Osuna C., Exposito A., Crisol L., Pijoan J. I. Recombinant FSH versus highly purified FSH in intrauterine insemination systematic review and metaanalysis. Fertility and Sterility. 2011;9561937âe3. doi [PubMed] [CrossRef] [Google Scholar]48. Balasch J., FĂĄbregues F., Peñarrubia J., et al. Follicular development and hormonal levels following highly purified or recombinant follicle-stimulating hormone administration in ovulatory women and WHO group II anovulatory infertile patients. Journal of Assisted Reproduction and Genetics. 1998;159552â559. doi [PMC free article] [PubMed] [CrossRef] [Google Scholar]49. Balasch J., MirĂł F., Burzaco I., et al. Endocrinology The role of luteinizing hormone in human follicle development and oocyte fertility Evidence from in-vitro fertilization in a woman with long-standing hypogonadotrophic hypogonadism and using recombinant human follicle stimulating hormone. Human Reproduction. 1995;1071678â1683. doi [PubMed] [CrossRef] [Google Scholar]50. Vlahos N. F., Coker L., Lawler C., Zhao Y., Bankowski B., Wallach E. E. Women with ovulatory dysfunction undergoing ovarian stimulation with clomiphene citrate for intrauterine insemination may benefit from administration of human chorionic gonadotropin. Fertility and Sterility. 2005;8351510â1516. doi [PubMed] [CrossRef] [Google Scholar]51. De la Fuente A. Evaluation of the effectiveness, safety and cost-effectiveness of highly purified human menopausal gonadotropin. Study of use Menopur â in Intrauterine Artificial Insemination IAC/IAD Fertility Review. 2007;24363â367. [Google Scholar]52. Filicori M., Cognigni G. E., Pocognoli P., et al. Comparison of controlled ovarian stimulation with human menopausal gonadotropin or recombinant follicle-stimulating hormone. Fertility and Sterility. 2003;802390â397. doi [PubMed] [CrossRef] [Google Scholar]53. Gomez R., Schorsch M., Steetskamp J., et al. The effect of ovarian stimulation on the outcome of intrauterine insemination. Archives of Gynecology and Obstetrics. 2014;2891181â185. doi [PubMed] [CrossRef] [Google Scholar]54. Isaza V., Requena A., GarcĂa-Velasco J. A., RemohĂ J., Pellicer A., SimĂłn C. Recombinant versus urinary follicle-stimulating hormone in couples undergoing intrauterine insemination a randomized study. Obstetrics, Gynaecology and Reproductive Medicine. 2003;482112â118. [PubMed] [Google Scholar]55. Gallot-LavallĂ©e P., Ecochard R., Mathieu C., et al. Clomiphene citrate or hMg which ovarian stimulation to chose before intra-uterine inseminations? A meta-analysis. Contraception, Fertilite, Sexualite. 1995;23115â121. [PubMed] [Google Scholar]56. Dickey R. R., Ramasamy R. Role of male factor testing in recurrent pregnancy loss or in vitro fertilization failure. Reproductive System & Sexual Disorders. 2015;0403 doi [PMC free article] [PubMed] [CrossRef] [Google Scholar]57. Hansen K. R., He A. L. W., Styer A. K., et al. Predictors of pregnancy and live-birth in couples with unexplained infertility after ovarian stimulationâintrauterine insemination. Fertility and Sterility. 2016;10561575â doi [PMC free article] [PubMed] [CrossRef] [Google Scholar]58. Erdem M., Erdem A., Mutlu M. F., et al. The impact of sperm morphology on the outcome of intrauterine insemination cycles with gonadotropins in unexplained and male subfertility. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2016;197120â124. doi [PubMed] [CrossRef] [Google Scholar]59. NICE. Nice guideline Fertility for people with fertility problems. NICE clinical guideline 156 February, Nuojua-Huttunen S., Tomas C., Bloigu R., Tuomivaara L., Martikainen H. Intrauterine insemination treatment in subfertility an analysis of factors affecting outcome. Human Reproduction. 1999;143698â703. doi [PubMed] [CrossRef] [Google Scholar]61. Toma S. K., Stovall D. W., Hammond M. G. The effect of laparoscopic ablation or danocrine on pregnancy rates in patients with stage I or II endometriosis undergoing donor insemination. Obstetrics & Gynecology. 1992;802253â256. [PubMed] [Google Scholar]62. Blasco V., Prados N., Carranza F., GonzĂĄlez-Ravina C., Pellicer A., FernĂĄndez-SĂĄnchez M. Influence of follicle rupture and uterine contractions on intrauterine insemination outcome a new predictive model. Fertility and Sterility. 2014;10241034â1040. doi [PubMed] [CrossRef] [Google Scholar]63. Van Voorhis B. J., Barnett M., Sparks A. E. T., Syrop C. H., Rosenthal G., Dawson J. Effect of the total motile sperm count on the efficacy and cost-effectiveness of intrauterine insemination and in vitro fertilization. Fertility and Sterility. 2001;754661â668. doi [PubMed] [CrossRef] [Google Scholar]64. Mathieu C., Ecochard R., Bied V., Lornage J., Czyba J. C. Andrology cumulative conception rate following intrauterine artificial insemination with husband's spermatozoa influence of husband's age. Human Reproduction. 1995;1051090â1097. doi [PubMed] [CrossRef] [Google Scholar]65. Brzechffa P. R., Daneshmand S., Buyalos R. P. Sequential clomiphene citrate and human menopausal gonadotrophin with intrauterine insemination the effect of patient age on clinical outcome. Human Reproduction. 1998;1382110â2114. doi [PubMed] [CrossRef] [Google Scholar]66. Bakas P., Boutas I., Creatsa M., et al. Can anti-Mullerian hormone AMH predict the outcome of intrauterine insemination with controlled ovarian stimulation? Gynecological Endocrinology. 2015;3110765â768. doi [PubMed] [CrossRef] [Google Scholar]67. Hendin B. N., Falcone T., Hallak J., et al. The effect of patient and semen characteristics on live birth rates following intrauterine insemination a retrospective study. Journal of Assisted Reproduction and Genetics. 2000;175245â252. doi [PMC free article] [PubMed] [CrossRef] [Google Scholar]68. Aydin Y., Hassa H., Oge T., Tokgoz V. Y. Factors predictive of clinical pregnancy in the first intrauterine insemination cycle of 306 couples with favourable female patient characteristics. Human Fertility. 2013;164286â290. doi [PubMed] [CrossRef] [Google Scholar]69. Plosker S. M., Jacobson W., Amato P. Infertility Predicting and optimizing success in an intra-uterine insemination programme. Human Reproduction. 1994;9112014â2021. doi [PubMed] [CrossRef] [Google Scholar]70. Oehninger S., Franken D., Kruger T. Approaching the next millennium How should we manage andrology diagnosis in the intracytoplasmic sperm injection era? Fertility and Sterility. 1997;673434â436. doi [PubMed] [CrossRef] [Google Scholar]71. Dorjpurev U., Kuwahara A., Yano Y., et al. Effect of semen characteristics on pregnancy rate following intrauterine insemination. Journal of Medical Investigation. 2011;581-2127â133. doi [PubMed] [CrossRef] [Google Scholar]72. Duran H. E., Morshedi M., Kruger T., Oehninger S. Intrauterine insemination a systematic review on determinants of success. Human Reproduction Update. 2002;84373â384. doi [PubMed] [CrossRef] [Google Scholar]73. Belaisch-Allart J., Mayenga J. M., Plachot M. Intra-uterine insemination. Contraception, fertilitĂ©, sexualitĂ© 1992 1999;279614â619. [PubMed] [Google Scholar]74. Sakhel K., Abozaid T., Schwark S., Ashraf M., Abuzeid M. Semen parameters as determinants of success in 1662 cycles of intrauterine insemination after controlled ovarian hyperstimulation. Fertility and Sterility. 2005;84S248âS249. doi [CrossRef] [Google Scholar]75. Stone B. A., Vargyas J. M., Ringlet G. E., et al. Determinants of the outcome of intrauterine insemination analysis of outcomes of 9963 consecutive cycles. American Journal of Obstetrics & Gynecology. 1999;1806 I1522â1534. doi [PubMed] [CrossRef] [Google Scholar]76. Strandell A., Bergh C., Söderlund B., Lundin K., Nilsson L. Fallopian tube sperm perfusion the impact of sperm count and morphology on pregnancy rates. Acta Obstetricia et Gynecologica Scandinavica. 2003;82111023â1029. doi [PubMed] [CrossRef] [Google Scholar]77. Huang Lee Lai et al. The impact of the total motile sperm count on the success of intrauterine insemination with husband's spermatozoa. Journal of Assisted Reproduction and Genetics. 1996;13156â63. doi [PubMed] [CrossRef] [Google Scholar]78. Dickey R. P., Pyrzak R., Lu P. Y., Taylor S. N., Rye P. H. Comparison of the sperm quality necessary for successful intrauterine insemination with World Health Organization threshold values for normal sperm. Fertility and Sterility. 1999;714684â689. doi [PubMed] [CrossRef] [Google Scholar]79. Miller D. C., Hollenbeck B. K., Smith G. D., et al. Processed total motile sperm count correlates with pregnancy outcome after intrauterine insemination. Urology. 2002;603497â501. doi [PubMed] [CrossRef] [Google Scholar]80. Yousefi B., Azargon A. Predictive factors of intrauterine insemination success of women with infertility over 10 years. Journal of the Pakistan Medical Association. 2011;612165â168. [PubMed] [Google Scholar]81. Yavuz A., Demirci O., Sözen H., UludoÄan M. Predictive factors influencing pregnancy rates after intrauterine insemination. Iranian Journal of Reproductive Medicine. 2013;113227â234. [PMC free article] [PubMed] [Google Scholar]82. Ozkan Z. S., Ilhan R., Ekinci M., Timurkan H., Sapmaz E. Impact of estradiol monitoring on the prediction of intrauterine insemination outcome. Journal of Taibah University Medical Sciences. 2014;9136â40. doi [CrossRef] [Google Scholar]83. Kaarouch I., Bouamoud N., Louanjli N., et al. Impact of sperm genome decay on Day-3 embryo chromosomal abnormalities from advanced-maternal-age patients. Molecular Reproduction and Development. 2015;8210809â819. doi [PubMed] [CrossRef] [Google Scholar]84. Snick H. K. A., Snick T. S., Evers J. L. H., Collins J. A. The spontaneous pregnancy prognosis in untreated subfertile couples the Walcheren primary care study. Human Reproduction. 1997;1271582â1588. doi [PubMed] [CrossRef] [Google Scholar]85. Collins J. Current best evidence for the advanced treatment of unexplained subfertility. Human Reproduction. 2003;185907â912. doi [PubMed] [CrossRef] [Google Scholar]86. Cabry-Coubert R., Scheffler F., Belhadri-Mansouri N., et al. Effect of Gonadotropin types and indications on homologous intrauterine insemination success A Study from 1251 Cycles and a review of the literature, Rbm Online, 2016. [PMC free article] [PubMed]Articles from BioMed Research International are provided here courtesy of
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ï»żTypes d'appel Agence de recouvrement Nom Intrum huissier afficher plus... Ăvaluations 6 Recherches 6533 ApprĂ©ciation non fiable, Appel suspect, vĂ©rifie les commentaires! Commentaire le plus rĂ©cent 16/10/21 1418 dab a Ă©crit intrum justicia huissier de justice... tous Ajouter une Ă©valuation Une fois connectĂ©, vous pouvez identifier et bloquer les numĂ©ros Ă©valuĂ©s sur tous vos tĂ©lĂ©phones. Vous aidez aussi la communautĂ© avec votre Ă©valuation du numĂ©ro! DĂ©tails concernant le numĂ©ro Ville/Pays Ain, Auvergne-RhĂŽne-Alpes - France NumĂ©ro 04 27 84 85 81 International NumĂ©ro +33427848581 de Ain, Auvergne-RhĂŽne-Alpes Ă©valuĂ© 1 fois comme Agence de recouvrement . +33427848581 Titulaire et adresse En savoir plus Toutes les donnĂ©es sont fournies sans garantie ! Statistiques de recherche ActivitĂ© Dernier appel 11/08/22 Vues le mois dernier 71 Protection tellows N° 537 sur la liste noire Tendance des accĂšs Les recherches sont en diminution et sont plus frĂ©quentes pendant la semaine Score tellows pour +33427848581 RĂ©partition des types d'appel et des noms des appelants dans les Ă©valuations Types d'appel Inconnu 2 Rapports Agence de recouvrement 1 Rapports NumĂ©ro fiable 1 Rapports HarcĂšlement tĂ©lĂ©phonique 1 Rapports Arnaque 1 Rapports Nom inconnu 3 Rapports Intrum huissier 2 Rapports Appel publicitaire 1 Rapports Position approximative de l'appelant Cliquez sur la carte pour l'agrandir Qui appelle avec le 0427848581 ? Nouvelle notation pour 0427848581 Dois-je laisser une Ă©valuation? Un numĂ©ro vous a appelĂ© et vous avez des informations sur le correspondant ? La rĂ©ponse est donc oui ! Votre Ă©valuation affichera publiquement le numĂ©ro de tĂ©lĂ©phone et le nom de l'appelant dans notre rĂ©pertoire. Si les commentaires pour un seul numĂ©ro sont nombreux et indiquent donc qu'il s'agit du harcĂšlement considĂ©rable, nous vĂ©rifierons si ce numĂ©ro est autorisĂ© par les autoritĂ©s. Veuillez noter nos conditions d'utilisation! Les commentaires laissĂ©s par les utilisateurs enregistrĂ©s ne sont plus supprimables sans un examen approfondi par le biais de tellows. Blog de tellows. Si vous Ă©valuez le numĂ©ro d'une entreprise ou si vous disposez de l'information concernant cette entreprise, veuillez voir l'inscription d'entreprise pour plus de dĂ©tails. Plus de numĂ©ros attribuĂ©s au titulaire "Intrum huissier" â04 27 84 85 81 â0427 84 85 81 â0033427848581 â+33 427 84 85 81 â â+33 4 27 84 85 81 â+33427848581 â â+ â0033 4 27 84 85 81 â0033 427 84 85 81 â
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