Management of rhesus isoimmunization by preimplantation genetic diagnosis

A genetic assay by single blastomere analysis was developed for rhesus (RhD) blood group typing of early cleavage stage embryos. The method, which is based on the simultaneous amplification of an RhD-specific sequence and an internal control in single cells, was applied for the selective transfer of RhD-negative embryos in a family of an RhD sensitized woman and a heterozygote partner. The RhD status of two out of three biopsied embryos was determined. According to their amplified products, both were typed as RhD-negative and transferred to the uterus. Pregnancy was not achieved.

Interleukin-1-mediated stimulation of prostaglandin E production is without effect on plasminogen activator activity in human granulosa lutein cell cultures

In continuation of earlier observations on the involvement of interleukin-1 (IL-1) in ovarian function, we examined the ability of IL-1 to modulate plasminogen activator (PA) activity and prostaglandin (PG) synthesis in human granulosa lutein cells (GLCs). Toward this goal, GLCs were obtained from women undergoing in vitro fertilization, preincubated with 10% fetal calf serum for 48 h, and subsequently cultured for 48 h in serum-free media in the absence or presence of IL-1 beta (10 ng/mL). Cellular PA activity was measured by plasminogen-dependent cleavage of the chromogenic substrate H-D-valyl-L-leucyl-L-lysine-p-nitroanilide (S-2251). Prostaglandin E (PGE) levels were assayed by conventional RIA. Exposure of GLCs to IL-1 resulted in a 50% increase in PGE production, a 33% suppression of PA activity, and a 75% increase in the ability of the corresponding conditioned media to inhibit exogenous urokinase activity. The inhibitory capacity was attributable to an IL-1-mediated increase in PA inhibitor type-1 (PAI-1) production, inasmuch as urokinase inhibition could be abolished by the administration of a polyclonal antihuman PAI-1 immunoglobulin G. IL-1 treatment had no effect on plasmin or trypsin inhibition. Exposure of GLCs to IL-1 receptor antagonist abolished the ability of IL-1 to enhance PA inhibitory activity and PGE production, thereby establishing specific IL-1 receptor-mediated effects. The ability of IL-1 to suppress PA activity and to produce PAI-1 persisted in the presence of indomethacin, a potent inhibitor of PG synthesis. Likewise, transforming growth factor-beta 1 suppressed the ability of IL-1 to stimulate PGE production without affecting the IL-1-induced effects on the PA system. The present findings suggest a pluripotent response of GLCs to IL-1, characterized by the induction of PAI-1 and the suppression of PA occurring concurrent with, but independent of, PG production. These observations support the potential involvement of IL-1 in the regulation of human ovulatory processes.

Ovulation induction with clomiphene citrate complicated by deep vein thrombosis

A case of recurrent deep vein thrombosis following standard clomiphene citrate treatment, in a patient with a history of a previous episode of deep vein thrombosis, is described. This case indicates that deep vein thrombosis might be a rare but hazardous complication of clomiphene citrate treatment in patients with certain risk factors. We recommend that the use of clomiphene citrate in such cases be undertaken with caution and under close surveillance.

Reduction of an incisional hernia using the open laparoscopic technique

Recently published cases of operative laparoscopy complicated by incisional hernia reemphasizes the potential hazard of the procedure. A new approach may be an alternative to traditional laparotomy for reducing small bowel herniation through the 12-mm cannula incision. Explorative laparoscopy by the open technique was performed and a loop of small bowel was reduced using an atraumatic grasping forceps. We find this approach safe and convenient.

Cost analysis of in vitro fertilization

In vitro fertilization (IVF) has become a routine tool in the arsenal of infertility treatments. Assisted reproductive techniques are expensive, as reflected by the current "take home baby" rate of about 15% per cycle, implying the need for repeated attempts until success is achieved. Israel, today is facing a major change in its health care system, including the necessity to define a national package of health care benefits. The issue of infertility and whether its treatment should be part of the "health basket" is in dispute. Therefore an exact cost analysis of IVF is important. Since the cost of an IVF cycle varies dramatically between countries, we sought an exact breakdown of the different components of the costs involved in an IVF cycle and in achieving an IVF child in Israel. The key question is not how much we spend on IVF cycles but what is the cost of a successful outcome, i.e., a healthy child. This study intends to answer this question, and to give the policy makers, at various levels of the health care system, a crucial tool for their decision-making process. The cost analysis includes direct and indirect costs. The direct costs are divided into fixed costs (labor, equipment, maintenance, depreciation, and overhead) and variable costs (laboratory tests, chemicals, disposable supplies, medications, and loss of working days by the couples). The indirect costs are the costs of premature IVF babies, hospitalization of the IVF pregnant women in a high risk unit, and the cost of complications of the procedure. According to our economic analysis, an IVF cycle in Israel costs $2,560, of which fixed costs are about 50%. The cost of a "take home baby" is $19,267, including direct and indirect costs.

Insulin resistant and non-resistant polycystic ovary syndrome represent two clinical and endocrinological subgroups

We studied the clinical and endocrine features of 35 patients with polycystic ovary syndrome (PCOS) who are either insulin resistant or non-insulin resistant. The occurrence of insulin resistance was determined by measuring insulin and glucose concentrations following a standard 75 g oral glucose load. All patients were evaluated by anthropometric measurements: body mass index (BMI), percentage of body fat (BCF) and waist-to-hip ratio (W/H), degree of hirsutism (Ferriman-Gallwey method) and endocrine profile. Fourteen patients had insulin resistance of unknown origin whereas four were due to a type A insulin receptor mutation, and 17 were non-insulin resistant. The insulin resistant patients were significantly more obese (higher BMI P < 0.0001, BCF P < 0.002 and W/H ratio P < 0.005) and were more hirsute (P < 0.002) than the non-insulin resistant patients. Testosterone concentrations were significantly higher in the insulin resistant group than in the non-insulin resistant group (2.65 versus 1.37 nmol/l; P < 0.027), whereas sex hormone-binding globulin was lower in insulin resistant patients (30.61 versus 19.48 nmol/l; P < 0.02). Non-insulin resistant patients showed a high luteinizing hormone to follicle stimulating hormone ratio, while a normal ratio was found in the insulin resistant subpopulation (2.94 versus 1.34; P < 0.0001). We concluded that PCOS comprises two subpopulations, one with insulin resistance of different aetiologies and the other which has no insulin resistance. These two groups differ in their anthropometric and endocrine features. The diagnosis of insulin resistance in PCOS can be easily determined by the insulin response to an oral glucose tolerance test.

Embryonic cultures but not embryos transplanted to the mouse's brain grow rapidly without immunosuppression

Embryos and embryocultures can be successfully transplanted into various bodily organs. However immunosuppression or homogenicity are required for the success of such experimental manipulation. Since the brain is considered immunologically privileged, we transplanted 2-4 cell embryos of C57BL x BALB/c, embryonic stem cells (ES) or embryoid bodies (EB) cultures into the hippocampus of the heterogeneous mouse stock HS/IBg. Both ES and EB cultures developed into an extensive growth, eventually larger than the brain itself, causing the death of the host in less than 29 days. The growth was identified as teratoma, mostly made of immature cells and tissues of diverse origin. Thus, the overall histological picture was that of a malignant teratoma. On the other hand, no embryos were found at any time after the transplantation; apparently, they could not survive in the host brain. The growth rate and the relative lack of rejection suggest that the brain offers a unique medium for ES and EB cultures but, not to embryos.

Perinatal outcome of triplet pregnancies following assisted reproduction

PURPOSE

This collaborative work was undertaken to assess perinatal outcome of in vivo conceived triplets to those following in vitro fertilization and assisted reproductive technologies (ART).

METHODS

151 triplets were examined; 56 delivered following ART, 55 following ovulation induction by gonadotropins (GN), 27 following clomiphene citrate (CC), and 13 conceived spontaneously.

RESULTS

Mean gestational length of triplets following ART (33.2 wks) was not different from those conceived following GN (33.4 wks) or CC (34.2 wks), but was significantly shorter compared to triplets following spontaneous conception (35.3 wks). Mean fetal birthweight following ART (1743 g) did not differ significantly from that following GN (1683 g) or CC (1863 g) but was significantly lower compared to those delivered after spontaneous conception (1963 g). Although no difference was found in the incidence of low birthweight infants between the groups studied, the incidence of very low birthweight newborns (<1500 g) following ART or GN was significantly higher than following spontaneous conceptions (30.6%, 30.3% vs 10.3%). Differences in perinatal mortality were not significantly different between the groups examined (77.9, 60.6, 111.0, 25.6/1000 for ART, GN, CC, and spontaneous conceptions respectively).

CONCLUSION

In conclusion, a similar perinatal outcome was shown for triplets conceived following ART and those following ovulation induction by GN, suggesting that the in vitro conditions as such were not the main contributing factor influencing the clinical outcome but rather the GN treatment. Triplets conceived spontaneously have a better outcome compared to those following ovulation induction or ART in terms of gestational length and birthweight.

A comparison between a standard and reduced dose of D-Trp-6-luteinizing hormone-releasing hormone administered after pituitary suppression for in-vitro fertilization

A randomized prospective study was undertaken to compare low and standard luteinizing hormone-releasing hormone agonist (LHRHa) dosage used in combination with gonadotrophins in ovarian stimulation for in-vitro fertilization (IVF). A total of 42 ovulatory patients with mechanical infertility were administered 0.5 mg/day LHRHa (Decapeptyl) from day 21 of their cycles for 14 days. Following down-regulation, patients were randomly allocated to continue with the same dose of LHRHa (22 patients, group A) or to receive a lower dose of 0.1 mg/day LHRHa (20 patients, group B) during folliculogenesis. Luteal phase was supported by daily i.m. progesterone (50 mg) injections and human chorionic gonadotrophin (HCG; 1500 IU) every 4 days. Ovarian response, human menopausal gonadotrophin (HMG) dosage used for induction of ovulation, evidence of premature luteinization, and clinical and laboratory IVF outcome, were compared between groups A and B. The two groups were comparable in respect of: age (32.6 +/- 0.7 and 33.0 +/- 0.9 years), HMG dosage (33.0 +/- 1.6 and 36.0 +/- 2.5 ampoules), day of HCG (11.2 +/- 0.3 and 12.2 +/- 0.4), oocytes/patient (13.3 +/- 1.0 and 12.9 +/- 1.3), fertilization rate (68.5 and 65.2%), cleavage rate (95% for both), pregnancy/embryo transfer (32 and 35%) and implantation rate (10.8 and 10.5%), for groups A and B respectively. There was no evidence of premature luteinization or luteolysis in either group. It was concluded that lowering the dose of LHRHa to 0.1 mg/day during folliculogenesis had no adverse effect on ovarian response or clinical results. However, it had no advantage in reducing the HMG dose used for ovulation induction.

Preimplantation diagnosis of cystic fibrosis by simultaneous detection of the W1282X and delta F508 mutations

W1282X (W) and delta F508 (delta) are the two most common mutations of the cystic fibrosis Israeli population. Patients who are homozygotes (WW and delta delta) as well as compound heterozygotes (W delta) present a severe phenotype of the disease. In the present study, we have developed a polymerase chain reaction (PCR)-based method for the detection of both mutations simultaneously in a single blastomere. Unfertilized human oocytes and single polyspermic blastomeres were subjected to a two-round PCR amplification: a first round of multiplex PCR followed by a second round of nested PCR, done separately at each locus. Clear signals at both loci were obtained in 51% (47/65) of oocytes and 69% (24/35) of blastomeres. The genotype of the single cell analysed was determined by endonuclease digestion of the W products and by heteroduplex formation of the delta F products. This diagnostic system will allow the identification of affected embryos (WW, delta delta, W delta) as well as phenotypically normal carriers (W+, +delta), and therefore may be used for cystic fibrosis preimplantation diagnosis in families who carry either or both mutations.

The use of vaginal tablets as a vehicle for steroid replacement in a donor oocyte program

Nine women enrolled in the donor egg program received in a preparatory cycle 6 mg of E2 by vaginal tablets two times per day for the first 14 days, followed by a combined preparation of 6 mg of E2 and 50 mg of P as vaginal tablets, two times per day for another 14 days. Adequate serum levels of E2 and P and favorable sonographic endometrial thickness were achieved throughout the cycle in all patients. Eight endometrial biopsies taken on days 25 to 26 were independently assessed as being representative of day 25 +/- 2. One endometrial biopsy was out of phase. It is concluded that vaginal tablets of E2, followed by a combined preparation of vaginal tablets of E2 and P, is an effective method for establishing an appropriately developed endometrium in a donor oocyte program. Endometrial preparation in donor oocyte programs can be simplified by the use of these tablets.

The effect of estradiol depletion during the luteal phase on endometrial development

OBJECTIVE

To examine whether luteal E2 is obligatory for obtaining an adequately developed endometrium.

DESIGN

Survey of women with premature ovarian failure (POF) in a prospective, controlled, randomized study.

SETTING

In vitro fertilization unit in a tertiary care university medical center.

PATIENTS

Fourteen amenorrheic women with POF, candidates for oocyte donation, were divided into two distinct groups with seven women in each subgroup.

INTERVENTIONS

Endometrial priming with a fixed dose of oral micronized E2, 4 mg/d for 14 days, was similarly performed in the study and the control groups. Progesterone replacement during the luteal phase was also identical in the two groups and was accomplished by IM P in oil, 50 mg/d for another 14 days. Only the control group continued to have the same E2 regimen during the luteal phase.

MAIN OUTCOME MEASURES AND RESULTS

Follicular phase mean E2 levels as well as luteal phase mean P levels were similar in both groups. However, luteal E2 levels differed significantly between the study and the control groups (21 +/- 5 and 692 +/- 199 pg/mL, respectively; conversion factor to SI units, 3.671). Nevertheless, histologic evaluation of endometrial biopsies on days 21 and 26 were similar for both groups. Endometrial gland dating, using light microscopy in the study and the control groups, on day 21, was 19.1 +/- 0.8 and 18.4 +/- 0.5, respectively, and on day 26, 25.4 +/- 0.8 and 25.9 +/- 0.5, respectively. Dating of the stroma in the two biopsies was also similar in both groups. Moreover, transmission electron microscopy performed in two patients of the study group showed typical characteristics of a secretory endometrium.

CONCLUSIONS

Luteal E2 depletion in the human does not seem to adversely affect the morphological developmental capacity of the endometrium. Our results suggest that E2 secretion by the corpus luteum in the human does not appear to be obligatory for the development of a normal secretory endometrium. The actual receptivity of the endometrium after such preparation needs to be evaluated.

The effect of progesterone administration in the follicular phase of an artificial cycle on endometrial morphology: a model of premature luteinization

OBJECTIVE

To evaluate the effect of premature P administration on artificially prepared endometrium in women with ovarian failure.

DESIGN

To mimic premature luteinization, patients with ovarian failure were treated with continuous estrogen and episodic P during the follicular phase of artificial cycles.

SETTING

In vitro fertilization unit at a university hospital.

PATIENTS

The study group included 16 patients with ovarian failure who were randomly divided into two groups. Group A (8 patients) was treated by episodic P administration during the artificial follicular phase on days 2 and 7 (12.5 mg of P in oil IM), and in group B (8 patients), P (6.25 mg) was added on days 3, 4, and 5. Another 16 patients (group C), age matched to the study group, were arbitrarily allocated to serve as controls and had standard preparatory cycles without P supplementation in the follicular phase. Serum E2 and P levels and endometrial biopsies were taken on days 14 and 26.

RESULTS

Serum E2 levels were comparable between the study group (group A+B) and controls on both days 14 and 26. Although serum P levels did not differ between the groups on day 26, it was higher in the follicular phase of the study group than in the controls (1.9 +/- 4.0 and 0.2 +/- 0.1 ng/mL, respectively). In the study group, 8 of 16 patients demonstrated early secretory changes in the late follicular phase biopsies, and 9 of 16 women developed stromal-glandular discrepancy in the late luteal phase. This differed significantly from the controls in which only one late luteal biopsy was out of phase.

CONCLUSIONS

Episodic surges of P during the follicular phase may result in impaired endometrial development that cannot be corrected by P supplementation during the luteal phase. This unique model provides evidence for the potential detrimental effect of premature P secretion in the follicular phase on endometrial function.

Hyaluronic acid for preventing experimental postoperative intraperitoneal adhesions

Adhesions, which form in > 60% of patients following major abdominopelvic surgery, are a common cause of morbidity and infertility in women. Hyaluronic acid is a naturally occurring polysaccharide that has been shown to be beneficial in ophthalmic surgery and as intraarticular injections. This study was designed to examine the use of hyaluronic acid as an agent for adhesion prevention after experimental abrasion of rat uterine horns and to explore its possible mechanism of action. Twenty-nine female Sabra rats were randomly assigned to either a saline (n = 13) or hyaluronic acid (n = 16) group. Adhesions were created by local abrasion of the uterine surfaces. Five milliliters of 1% hyaluronic acid or saline was instilled intraperitoneally. Three weeks later the animals were killed and subjected to a second laparotomy. Intraabdominal adhesions were graded on the basis of gross appearance using a scoring system from 0 to 5. The adhesion score in the animals treated with hyaluronic acid was significantly (P < .001) lower than that in the control animals. Hyaluronic acid did not affect the attachment or proliferation of fibroblasts but had an inhibitory effect on platelet aggregation in a dose-dependent manner. Intraperitoneal instillation of 1% hyaluronic acid significantly minimized adhesions formed experimentally. The mechanism of action may involve inhibition of platelet aggregation.

The pattern of serum melatonin levels during ovarian stimulation for in vitro fertilization

OBJECTIVE

To characterize the relationship between the pineal gland hormone, melatonin, and gonadal hormones.

METHODS

We studied the pattern of serum melatonin at the time of ovarian stimulation for in vitro fertilization. Blood samples were obtained every morning, from 20 healthy women during the in vitro fertilization cycle.

RESULTS

A progressive rise in serum estradiol and prolactin was noted in all IVF cycles, while serum melatonin levels remained unchanged throughout the cycles. In two of the subjects the circadian rhythm of serum melatonin was assessed at 4-hour intervals for 24 hours. In both subjects the melatonin rhythm was remarkably consistent in terms of phase, amplitude, and total melatonin secreted during the treatment cycles.

CONCLUSIONS

These results indicate that endogenous estradiol, progesterone, and prolactin do not affect the levels or circadian phase of melatonin secretion in humans.

The effect of clomiphene citrate isomers on human granulosa-lutein cells in culture

The effect of racemic clomiphene citrate and its two individual isomeric forms (i.e. en and zu) on corpus luteum function was evaluated. Granulosa-lutein cells were obtained from three normal ovulatory women undergoing oocyte retrieval following ovulation induction with agents other than clomiphene citrate for in vitro fertilization--embryo transfer (IVF-ET). The granulosa cells were cultured in the presence and absence of the three forms of clomiphene citrate, and in the presence and absence of human chorionic gonadotropin (hCG). Patients were recruited from the unit for assisted reproductive technology in a university hospital. The main outcome measured was the production of estradiol and progesterone by cultured human granulosa cells under the various conditions described above. The production of estradiol and progesterone by the cultured granulosa cells was dose-dependently reduced to a similar extent by all three forms of clomiphene citrate. The addition of hCG augmented steroidogenesis in all groups at all concentrations, but this still remained lower in all clomiphene citrate-treated groups compared to controls. The data suggest that all three types of clomiphene citrate (racemic, en, and zu) have inhibitory effects on the production of estradiol and progesterone by cultured human granulosa-lutein cells.

The effect of growth hormone on granulosa cell function during in-vitro fertilization

The effect of growth hormone addition to human menopausal gonadotrophin (HMG), after pituitary down-regulation, on granulosa cell function, in in-vitro fertilization (IVF) was evaluated. Growth hormone or placebo were added in a prospective, randomized and double-blind manner to an existing IVF stimulation protocol. Forty-two normal ovulatory women (< or = 38 years old) with mechanical factor infertility and normal male factor were included in the study. Gonadotrophin-releasing hormone agonist (GnRHa) was given from day 21 of the previous cycle until human chorionic gonadotrophin (HCG) administration. Follicular stimulation with HMG was started after pituitary down-regulation. Growth hormone 12 IU/day or placebo were administered on alternate days, beginning day 1 until day 7 of HMG treatment. Granulosa cell function was evaluated, in all patients, by follicular fluid levels of ovarian steroids and insulin-like growth factor-I (IGF-I). In 14 patients, chosen arbitrarily granulosa lutein cells were cultured in the presence and absence of additional HCG. Follicular fluid levels of oestradiol, progesterone, testosterone and IGF-I were similar in both growth hormone and placebo groups. Basal and post-HCG levels of oestradiol and progesterone did not differ significantly between the two groups of granulosa lutein cell cultures. We conclude that after pituitary down-regulation, in-vivo administration of growth hormone with HMG in young ovulatory women does not seem to affect granulosa cell function when compared to the administration of HMG alone.

Interaction between human sperm cells and hamster oocytes after argon fluoride excimer laser drilling of the zona pellucida

OBJECTIVES

To provide conclusive evidence that sperm cells gain access to the perivitelline space exclusively through a laser-drilled opening. To assess the optimal size of the hole and to evaluate the efficacy of laser drilling in comparison with that of mechanical zona dissection.

DESIGN

An interspecies model of human sperm cell that interacts with a laser-drilled or partially zona-dissected hamster oocytes.

MAIN OUTCOME MEASURES

Penetration rate into the perivitelline space as related to the size of the opening (group A [5 microns], group B [10 microns], and group C [15 microns]) and to the sperm cell concentrations (1 x 10(6), 5 x 10(6), and 10 x 10(6) cells/mL) used for insemination.

RESULTS

For each sperm cell concentration, the penetration rate into the perivitelline space was lowest for group A followed by group C and highest for group B. When penetration was compared for each hole size, it was found that sperm concentration had no effect on the rate of penetration in groups A and C but significantly affected this rate in group B. The highest penetration rate of 73% was observed with a concentration of 10 x 10(6) cell/mL and declined to 58% and 23% at 5 x 10(6) cell/mL and 1 x 10(6) cell/mL, respectively. Oocytes drilled by laser (10-microns hole) demonstrated a significantly higher penetration rate when compared with those treated by partial zona dissection (73% versus 20% and 58% versus 21% for sperm densities of 10 x 10(6) cells/mL and 5 x 10(6) cells/mL, respectively).

CONCLUSION

Human sperm cells gain access into the perivitelline space of hamster oocytes exclusively through a hole drilled by an argon fluoride excimer laser. An opening of 10 microns was found to yield optimal results. Laser drilling of the zona pellucida seems to be superior to that of mechanical slitting in terms of sperm oolema interaction.

Left ventricular rupture following myocardial infarction treated with streptokinase: successful resuscitation in the cardiac catheterization laboratory using pericardiocentesis and autotransfusion

An 80-year-old female developed left ventricular rupture in the cardiac catheterization laboratory following myocardial infarction treated with streptokinase. The patient was resuscitated using pericardiocentesis and autotransfusion. This technique and the predisposing factors for left ventricular rupture are discussed.

Ovulation induction in polycystic ovary syndrome: a review of conservative and new treatment modalities

Polycystic ovary syndrome (PCOS) is a complex disorder with heterogeneous clinical and endocrine features. Chronic anovulation and infertility are common and affect about 75% of the patients. Ovulation induction in PCOS patients is a challenge for the physicians who treat these patients. Several different treatment modalities have been proposed to induce ovulation in PCOS, each of which deals with a different clinical or endocrine disorder which is present in these patients. This review presents traditional and new methods for ovulation induction in PCOS patients, the theoretical background, the pros and cons for each treatment and success rate.

Novel parameters of human sperm hypoosmotic swelling test and their correlation to standard spermatogram, total motile sperm fraction, and sperm penetration assay

OBJECTIVE

To improve the accuracy of human sperm hypoosmotic swelling test by introducing new morphological evaluation parameters for this test.

DESIGN

Individual semen samples were processed, and the standard spermatogram, total motile sperm fraction, sperm penetration assay (SPA), and hypoosmotic swelling test were performed.

SETTING

Male infertility clinic and andrologic laboratory in a university medical center.

PATIENTS

One hundred eighteen subfertile men undergoing an infertility work-up.

MAIN OUTCOME MEASURES

The results of hypoosmotic swelling test were subdivided into four groups (hypoosmotic swelling test 1, 2, 3, 4) according to the different shapes of hypoosmotically affected spermatozoa tails.

RESULTS

The hypoosmotic swelling test 3 had the best correlation with the different sperm parameters: motility, total motile sperm fraction, concentration, and SPA. The hypoosmotic swelling test 1 showed a satisfactory interrelation for concentration and for total motile sperm fraction but no correlation for motility and SPA. The hypoosmotic swelling test 2 and the hypoosmotic swelling test 4 demonstrated no correlation at all with motility, concentration, morphology and SPA.

CONCLUSIONS

The precision of hypoosmotic swelling test may be improved by using the hypoosmotic swelling test 3 type of spermatozoa tail shape as the parameter for a normally functioning spermatozoa.