In this prospective study we report our experience on the systematic use of rescue intra-uterine insemination (IUI) in case of failed oocyte pick-up (OPU), with no oocyte retrieved, after a mild stimulation in-vitro fertilization (IVF) protocol. In a period of twelve months we analyse predicted normal responders at their first in-vitro fertilization (IVF) or intracytoplasmatic sperm injection (ICSI) at the Infertility Unit of Policlinico Umberto I, Sapienza University of Rome. In the study period, all consecutive cases of failed OPU after a mild stimulation protocol of controlled ovarian hyperstimulation (COH) is converted to IUI, where permitting conditions are present: at least one patent tube at either hysterosonosalpingography or hysterosalpingography, normal male semen analysis according to WHO criteria, a maximum of 3 follicles larger than 14 mm at the time of OPU, in order to avoid the risk of higher-order pregnancies, and informed consent of the couple. In the cases of rescue IUI performed the following parameters are evaluated: total dose of hMG administered, peak level of estradiol on the day of hCG trigger, number of follicles larger than 14 mm at the time of hCG trigger, number of biochemical pregnancies, number of clinical pregnancies and number of term pregnancies. The results obtained in the group of patients after rescue IUI is compared to a group of patients who, in the same period, underwent a regularly scheduled IUI.
The absence of oocyte retrieved at OPU after COH is a rare event reported in 1-7% of conventional IVF/ICSI cycles (Bustillo 2004), but this occurrence, although rare, causes a lot of pressure both for the couple and for the clinical staff. This event is more common if the hCG administration is not correctly timed in the OUP procedure (Stevenson 2008). However, this event may also occur after correct timing of hCG trigger. In this case there are two different scenarios: in poor responders after a conventional COH cycle, or in mild stimulation cycles. In both cases there is an high risk to not retrieving any oocyte due to the lower number of large follicles available for puncture at the time of OPU. The absence of oocyte collected at OPU doesn¿t permit to continue with the IVF/ICSI cycles, so that the only possibility if at least one tube is patent, if there is no major male factor of infertility, and if the number of follicles at the time of hCG trigger is not too high is shifting to spontaneous conception. Another option could be rescue IUI, which has some practical advantage: the patients is already admitted to the IVF unit for the OPU procedure, the male partner is already present at IVF unit for scheduled semen collection. In a recent study, Matorras et al reported on rescue IUI performed when no oocytes were retrieved at the time of OPU in 54 cycles in low-responder patients. No pregnancy was obtained after IUI in this population, possibly due to an oocyte quality issue, together with the reduced number of follicles available for the OPU procedure. However, it is possible that, in the context of mild stimulation cycles, as opposed to the low-responder population reported by Matorras, the rescue IUI may yield different results.