Pregnancy rates with fresh versus computer-controlled cryopreserved semen for artificial insemination by donor in a private practice setting

Male fertility preservation-Methods, indications and challenges

Male fertility preservation has been steadily increasing over the past two decades. Significant improvements have been achieved in the treatment modalities of cancer and other severe chronic medical conditions, leading to an increase in patient survivorship and the resulting demand for future parenthood. Recognition and proper patient counselling before commencing therapies with a potential gonadotoxic effect are of paramount importance. Similarly, nonmedically indicated fertility preservation is on the rise. Social sperm banking, gender dysphoria prior to affirmation procedures and posthumous reproduction preservation are becoming more common. When timing and logistics are appropriate, sperm cryopreservation is considered the gold standard for fertility preservation. Testicular tissue and spermatogonial stem cell autotransplantation is considered experimental and represents a promising alternative for pre-pubertal patients. The current paper aims to review the recent trends in male fertility preservation, the common indications for sperm cryopreservation, techniques for sperm retrieval and experimental frontiers.

Effect of red light on optically trapped spermatozoa

Successful artificial insemination relies on the use of high quality spermatozoa. One measure of sperm quality is swimming force. Increased swimming force has been correlated with higher sperm swimming speeds and improved reproductive success. It is hypothesized that by increasing sperm swimming speed, one can increase swimming force. Previous studies have shown that red light irradiation causes an increase in sperm swimming speed. In the current study, 633nm red light irradiation is shown to increase mean squared displacement in trapped sperm. The methodology allows for comparison of relative swimming forces between irradiated and non-irradiated samples.

Red light improves spermatozoa motility and does not induce oxidative DNA damage

The ability to successfully fertilize ova relies upon the swimming ability of spermatozoa. Both in humans and in animals, sperm motility has been used as a metric for the viability of semen samples. Recently, several studies have examined the efficacy of low dosage red light exposure for cellular repair and increasing sperm motility. Of prime importance to the practical application of this technique is the absence of DNA damage caused by radiation exposure. In this study, we examine the effect of 633 nm coherent, red laser light on sperm motility using a novel wavelet-based algorithm that allows for direct measurement of curvilinear velocity under red light illumination. This new algorithm gives results comparable to the standard computer-assisted sperm analysis (CASA) system. We then assess the safety of red light treatment of sperm by analyzing, (1) the levels of double-strand breaks in the DNA, and (2) oxidative damage in the sperm DNA. The results demonstrate that for the parameters used there are insignificant differences in oxidative DNA damage as a result of irradiation.

Predictive factors influencing pregnancy rates after intrauterine insemination with frozen donor semen: a prospective cohort study

The extent to which certain parameters can influence pregnancy rates after intrauterine insemination with frozen donor semen was examined prospectively. Between July 2011 and September 2015, 402 women received 1264 IUI cycles with frozen donor semen in a tertiary referral infertility centre. A case report form was used to collect data prospectively. The primary outcome measure was clinical pregnancy rate (CPR), confirmed by detection of a gestational sac and fetal heartbeat using ultrasonography at 7-8 weeks of gestation. Statistical analysis was carried out using generalized estimating equations (GEE) to account for the correlation between observations from the same patient. Overall, CPR per cycle was 17.2%. Multivariate GEE analysis revealed the following parameters as predictive for a successful pregnancy outcome: female age (P = 0.0003), non-smoking or smoking fewer than 15 cigarettes a day (P = 0.0470 and P = 0.0235, respectively), secondary infertility (P = 0.0062), low progesterone levels at day zero of the cycle (P = 0.0164) and use of ovarian stimulation with HMG and recombinant FSH compared with clomiphene citrate and natural cycle (P = 0.0006 and P = 0.0004, respectively). These parameters were the most important factors influencing the success rate in a sperm donation programme.

Real-time calcium measurements of live optically trapped microorganisms

A system has been developed that allows for the real-time measurement of calcium dynamics in swimming sperm. Specifically, the ratiometric dye Indo-I is used as a fluorescent indicator of intracellular calcium dynamics. The dual emissions are collected by a high-sensitivity back-illuminated CCD camera coupled to a Dual-View imaging system. From the CCD, the images are sent to a custom developed algorithm which processes the images and outputs the calcium measurements in real-time. Additionally, sperm velocity and position data are processed and outputted in real-time. The velocity and position data are obtained using a separate coupled red light (>670 nm) phase contrast imaging setup that does not optically interfere with the fluorescent imaging. Using this system the effects of optical trapping on calcium dynamics was determined. Optical trapping of sperm with a decaying focused laser power of 510 mW to 3 mW over 8 seconds causes a statistically insignificant change in calcium dynamics between in-trap and out-of-trap conditions. Progesterone, a calcium activator, was added and sperm were trapped under the 8 second power decay conditions. Progesterone treated sperm has a statistically higher average calcium level than untreated sperm, but shows no statistical difference between progesterone treated in-trap and out-of-trap conditions. Trapping at 16 seconds at 510 mW without decay, which have been shown to decrease sperm motility, shows a statistical difference between baseline pre-trap and in-trap intracellular calcium levels.

Effects of viscosity on sperm motility studied with optical tweezers

The purpose of this study is to analyze human sperm motility and energetics in media with different viscosities. Multiple experiments were performed to collect motility parameters using customized computer tracking software that measures the curvilinear velocity (VCL) and the minimum laser power (Pesc) necessary to hold an individual sperm in an optical trap. The Pesc was measured by using a 1064 nm Nd:YVO(4) continuous wave laser that optically traps motile sperm at a power of 450 mW in the focused trap spot. The VCL was measured frame by frame before trapping. In order to study sperm energetics under different viscous conditions sperm were labeled with the fluorescent dye DiOC(6)(3) to measure membrane potentials of mitochondria in the sperm midpiece. Fluorescence intensity was measured before and during trapping. The results demonstrate a decrease in VCL but an increase in Pesc with increasing viscosity. Fluorescent intensity is the same regardless of the viscosity level indicating no change in sperm energetics. The results suggest that, under the conditions tested, viscosity physically affects the mechanical properties of sperm motility rather than the chemical pathways associated with energetics.

Prise en charge de l’infécondité dans les troubles de l’éjaculation: avis conjoints de l’andrologue, du biologiste et du gynécologue

Quatre-vingts pour cent des hommes qui présentent des troubles de l’éjaculation sont en âge de procréer, mais seul 5 à 10 % en sont spontanément capables. Du sperme antérograde et/ou rétrograde peut être recueilli par éjaculation assistée en association à des traitements pharmacologiques (chlorhydrate de minodrine-vibroéjaculation). En cas d’échecs de recueil de sperme et d’azoospermie, l’extraction chirurgicale des spermatozoïdes épididymaires ou testiculaires permet d’obtenir des spermatozoïdes, en quantité généralement moins importante que les techniques d’éjaculation assistée, mais non infectés et dépourvus de plasma séminal (souvent délétère dans les troubles de l’éjaculation). Même en cas d’éjaculation antérograde, il est impératif de recueillir les urines systématiquement à la recherche d’une éjaculation rétrograde, fréquente dans les troubles de l’éjaculation. Au laboratoire, l’analyse du sperme et de l’urine s’effectue par les méthodes de routine standardisées. La plupart des hommes présentant des troubles de l’éjaculation ont un sperme de mauvaise qualité (asthénospermie, nécrospermie, leucospermie). Les étiologies de la dégradation des paramètres du sperme sont multifactorielles, d’origine centrale et périphérique (testiculaire et extratesticulaire). Optimiser la qualité du sperme et des spermatozoïdes reste un challenge d’actualité dans les troubles de l’éjaculation. Si la cryopréservation doit être systématique, l’utilisation du sperme frais optimisé a généralement la préférence. Réussir à obtenir du sperme offre au couple une chance de grossesse naturelle (rarement) grâce à une éjaculation coïtale, par auto-insémination, par insémination intra-utérine, par fécondation in vitro conventionnelle (FIVc) ou injection intracytoplasmique de spermatozoïdes (ICSI) dans l’ovocyte. Dans les troubles de l’éjaculation, la prise en charge de la fécondité de l’homme doit être la plus rapide possible. Elle s’effectue conjointement à celle de la femme par une équipe coordonnant l’andrologue, le biologiste et le gynécologue.

Automatic annular laser trapping: a system for high-throughput sperm analysis and sorting

An automatic microscope system is designed to study the response of sperm motility to an annular laser trap. A continuous annular laser trap provides a parallel way to analyze and sort sperm based on their motility and to study the effects of laser radiation, optical force and external obstacles. In the described automatic microscope system, the phase contrast images of swimming sperm are digitized to the computer at video rates. The microscope stage is controlled in real-time to relocate the sperm of interest to the annular trap with a normal or tangential entering angle. The sperm is continuously tracked and the swimming behavior is identified. Using this system, parallel sorting on human and gorilla sperm are achieved and threshold power levels separating the "fast" group and the "slow" group are compared for those two species.

Comparison of glycolysis and oxidative phosphorylation as energy sources for mammalian sperm motility, using the combination of fluorescence imaging, laser tweezers, and real-time automated tracking and trapping

The combination of laser tweezers, fluorescent imaging, and real-time automated tracking and trapping (RATTS) can measure sperm swimming speed and swimming force simultaneously with mitochondrial membrane potential (MMP). This approach is used to study the roles of two sources of ATP in sperm motility: oxidative phosphorylation, which occurs in the mitochondria located in the sperm midpiece and glycolysis, which occurs along the length of the sperm tail (flagellum). The relationships between (a) swimming speed and MMP and (b) swimming force and MMP are studied in dog and human sperm. The effects of glucose, oxidative phosphorylation inhibitors and glycolytic inhibitors on human sperm motility are examined. The results indicate that oxidative phosphorylation does contribute some ATP for human sperm motility, but not enough to sustain high motility. The glycolytic pathway is shown to be a primary source of energy for human sperm motility.

The use of optical tweezers to study sperm competition and motility in primates

Optical trapping is a non-invasive biophysical tool which has been widely applied to study physiological and biomechanical properties of cells. Using laser 'tweezers' in combination with custom-designed computer tracking algorithms, the swimming speeds and the relative swimming forces of individual sperm can be measured in real time. This combination of physical and engineering tools has been used to examine the evolutionary effect of sperm competition in primates. The results demonstrate a correlation between mating type and sperm motility: sperm from polygamous (multi-partner) primate species swim faster and with greater force than sperm from polygynous (single partner) primate species. In addition, sperm swimming force linearly increases with swimming speed for each species, yet the regression relating the two parameters is species specific. These results demonstrate the feasibility of using these tools to study rapidly moving (microm s(-1)) biological cells.

High-throughput sorting and analysis of human sperm with a ring-shaped laser trap

Sperm motility is an important concept in fertility research. To this end, single spot laser tweezers have been used to quantitatively analyze the motility of individual sperm. However, this method is limited with throughput (single sperm per spot), lacks the ability of in-situ sorting based on motility and chemotaxis, requires high laser power (hundreds of milliWatts) and can not be used to dynamically monitor changes in sperm swimming behavior under the influence of a laser beam. Here, we report a continuous 3-D ring-shaped laser trap which could be used for multi-level and high-throughput (tens to hundred sperm per ring) sperm sorting based on their motility and chemotaxis. Under a laser power of only tens of milliWatts, human sperm with low to medium velocity are slowed down, stopped, or forced to change their trajectories to swim along the ring due to the optical gradient force in the radial direction. This is the first demonstration of parallel sperm sorting based on motility with optical trapping technology. In addition, by making the sperm swimming along the circumference of the ring, the effect of laser radiation, optical force and external obstacles on sperm energetics are investigated in a more gentle and quantitative way. The application of this method could be extended to motility and bio-tropism studies of other self-propelled cells, such as algae and bacteria.

Automated Motile Cell Capture and Analysis with Optical Traps

Laser trapping in the near infrared regime is a noninvasive and microfluidic-compatible biomedical tool. This chapter examines the use of optical trapping as a quantitative measure of sperm motility. The single point gradient trap is used to directly measure the swimming forces of sperm from several different species. These forces could provide useful information about the overall sperm motility and semen quality. The swimming force is measured by trapping sperm and subsequently decreasing laser power until the sperm is capable of escaping the trap. Swimming trajectories were calculated by custom built software, an automatic sperm tracking algorithm called the single sperm tracking algorithm or SSTA. A real-time automated tracking and trapping system, or RATTS, which operates at video rate, was developed to perform experiments with minimal human involvement. After the experimenter initially identifies and clicks the computer mouse on the sperm-of-interest, RATTS performs all further tracking and trapping functions without human intervention. Additionally, an annular laser trap which is potentially useful for high-throughput sperm sorting based on motility and chemotaxis was developed. This low power trap offers a more gentle way for studying the effects of laser radiation, optical force, and external obstacles on sperm swimming pattern.

Use of frozen semen to avoid human immunodeficiency virus type 1 transmission by donor insemination: a cost-effectiveness analysis

OBJECTIVE

Reappraisal of current guidelines mandating frozen-thawed semen.

DESIGN

Cost-effectiveness analysis comparing the use of frozen semen with the use of fresh semen from the same donors without a second antibody test.

SETTING

A Markov model computer simulation.

PATIENT(S)

A theoretical cohort of 80000 women whose husbands are azoospermic.

INTERVENTION(S)

Simulation with calculation of costs and payoffs.

MAIN OUTCOME MEASURE(S)

Total lifetime direct health care costs, costs per live birth, life expectancy, quality adjusted life years (QALY), marginal cost effectiveness (dollar/QALY).

RESULT(S)

If all 80000 women who undergo donor insemination in the United States each year chose to use fresh semen from donors screened according to the current practice guidelines but without semen cryopreservation, there would be 8881 more births and the mean cost per live birth would be US dollars 15501 less. One recipient would become infected with HIV-1 every 5.1 years, during which time over 180000 noninfected children would be born. The average life expectancy of recipients would be reduced by 2 days, but their quality-adjusted life expectancy would increase by over 1 month. Medicolegal costs to physicians would need to exceed US dollars 780 million per infection to equalize the cost effectiveness of the fresh and frozen policies.

CONCLUSION(S)

The guidelines should be revised to allow the use of fresh semen by informed recipients.

Intrauterine insemination-ready versus conventional semen cryopreservation for donor insemination: a comparison of retrospective results and a prospective, randomized trial

OBJECTIVE

To compare fecundity rates following intrauterine insemination (IUI) with donor sperm frozen conventionally versus an IUI-ready preparation.

DESIGN

Both retrospective results and a prospective, randomized study where recipients were assigned to one of two sperm cryopreservation methods in each cycle of intrauterine insemination are reported.

SETTING

University-based infertility practice, affiliated private practices, and andrology laboratory.

PATIENT(S)

Women desiring therapeutic insemination in an effort to establish pregnancy.

INTERVENTION(S)

Intrauterine insemination with donor sperm frozen conventionally or by an IUI-ready protocol.

MAIN OUTCOME MEASURE(S)

Cycle fecundity in donor IUI recipients.

RESULT(S)

In a retrospective analysis involving 642 inseminations in 209 recipients, 79 pregnancies were recorded for an overall pregnancy rate of 12.3% per insemination (or cycle): 11.3% with IUI-ready sperm and 13.9% with conventionally preserved sperm. In a follow-up prospective, randomized study, the pregnancy rate for IUI-ready sperm preparations was 36% per cycle (14 of 39) whereas that for conventionally preserved sperm was 19.6% per cycle (9 of 46). Thirteen of the 23 pregnancies occurred in the first study cycle of insemination; only two pregnancies were observed in patients undergoing more than four cycles of insemination.

CONCLUSION(S)

Cycle fecundity for IUI-ready donor sperm is equivalent to conventional cryopreserved sperm based on both prospective and retrospective assessments.

Intrauterine insemination with donor semen. An evaluation of prognostic factors based on a review of 1131 cycles

OBJECTIVE

To identify prognostic factors influencing the outcome of infertility treatment using intrauterine insemination with donor semen (IUI-D).

DESIGN

Retrospective study of all patients undergoing IUI-D between August 1st, 1990 and July 31st, 1998.

SETTING

University-affiliated infertility clinic.

PATIENTS

Three hundred and five couples undergoing 1131 IUI-D treatment cycles.

MAIN OUTCOME MEASURES

Type of hormonal treatment, number of follicles, length of follicular phase, endometrial pattern, female age, infertility diagnosis and semen quality related to clinical pregnancy rate, cumulative birth rate and multiple gestations.

RESULTS

Throughout the nine year period the overall clinical pregnancy rate per cycle was 22.3%, with an increase from 12.9% in 1990 to 34.6% in 1998. The multiple birth rate was 20.6%. The birth rate per couple was 61.1% after a mean of 3.2 treatment cycles. The pregnancy rate was highest in the first treatment cycle and the cumulative birth rate rose only slightly after the sixth treatment cycle. The following parameters were positively and significantly correlated to a successful outcome of IUI-D: i) the first treatment cycle - compared to the following up to six treatment cycles; ii) number of mature follicles - more than one - at the time of insemination, however, with an unacceptable high rate of multiple pregnancies when more than 3 mature follicles were present; iii) time of insemination after the 12th day in the cycle; iv) insemination after ovulation has occurred and; v) female age under 30 years.

CONCLUSIONS

IUI-D is a simple and inexpensive treatment giving acceptable pregnancy rates for up to six treatment cycles if at least 2 mature follicles have developed at the time of insemination, which implies that hormonal ovarian stimulation and induction of ovulation is used, and ovulation has occurred at the time of insemination, which ought to take place after cycle day (cd) 12 with at least two million motile spermatozoa.

Effects of cryopreserved semen quality and timed intrauterine insemination on pregnancy rate and gender of offspring in a donor insemination program

PURPOSE

Our purpose was to study the relationship among cryopreserved donor semen quality, pregnancy rates, and preconception sex selection after intrauterine insemination.

METHODS

We reviewed the records of the 203 women in our donor insemination program from 1987 to 1994 who became pregnant after more than one insemination cycle and had no female-factor infertility. They were categorized according to the number of cycles required for pregnancy. Semen samples from 54 donors were analyzed before freezing and after thawing. Specimens resulting in pregnancy were compared to specimens from the same donor that did not. Semen characteristics were compared to gender of the child.

RESULTS

Two hundred fifty two-women became pregnant of the 422 who were enrolled. The pregnancy rate per cycle was 13%. Semen quality was not related to pregnancy outcome or offspring gender. However, more male children (101 vs 83) were born.

CONCLUSIONS

Semen characteristics in good-quality cryopreserved donor semen do not affect pregnancy rate or offspring gender.

Success of intrauterine insemination using cryopreserved donor sperm is related to the age of the woman and the number of preovulatory follicles

OBJECTIVE

Our objective was to assess parameters associated with a successful outcome of intrauterine insemination (IUI) using cryopreserved donor sperm.

DESIGN

We analyzed 750 consecutive donor IUI cycles undertaken by 363 women in an assisted conception clinic. The main outcome measure was clinical pregnancy.

RESULTS

IUI was performed in 94.7% of the 750 IUI treatment cycles commenced and 180 clinical pregnancies occurred. The clinical pregnancy rate per cycle was 26.4%. The rate was significantly related to the patient's age (30.5% for age < or = 35 years and 18.1% for age > 35 years; P < 0.006) and whether there was one or more than one preovulatory follicles [20.9, 34.4, and 31.5% for one, two, and three or four follicles with a mean diameter of 14 or more mm at the time of human chorionic gonadotropin (hCG) administration; P = 0.006]. Two to four preovulatory follicles were present in 12.6% of the natural cycles, 43.6% of clomiphene citrate or tamoxifen, and 59.9% of gonadotropin stimulated cycles. The difference in the number of preovulatory follicles between stimulated and unstimulated cycles was highly significant (P < 0.0001). Pregnancy rates were 29.9% in gonadotropin-stimulated cycles, 23.6% in clomiphene citrate- or tamoxifen-stimulated cycles, 23.6% in clomiphene and 20.1% in unstimulated cycles. The difference in pregnancy rates between gonadotropin-stimulated and natural cycles was significant (P = 0.038). Cycle fecundity rates were not significantly affected by the number of previous treatment cycles, duration of infertility, gravidity and parity of the patient, presence of a spontaneous luteinizing hormone (LH) surge before the administration of hCG, or number of motile sperm in the insemination specimen.

CONCLUSIONS

Success of IUI using cryopreserved donor sperm is related to the age of the women and whether there is one or more than one preovulatory follicles.

Adenosine triphosphate and motility characteristics of fresh and cryopreserved human spermatozoa

The concentration of ATP and the motility of human spermatozoa was measured in fresh and cryopreserved cells from the same 15 ejaculates. No coherent picture of the relationship between motility and ATP concentration emerged in whole semen or in spermatozoa washed by repeated centrifugation and resuspension in Biggers Whitten and Whittingham medium. This may have been due to the presence of dead spermatozoa and contaminating cells. After preparation on a Percoll gradient, the ATP concentration in fresh and cryopreserved spermatozoa was the same (6 +/- 0.7 nmol/10(8) spermatozoa) but 85 +/- 2.5% of the fresh spermatozoa were progressively motile with an average path velocity of 55 +/- 3.5 microns/s compared to corresponding values of 33 +/- 5.3% and 44 +/- 3.4 microns/s in frozen/thawed spermatozoa. This suggests that the poor motility of cryopreserved spermatozoa does not result from deficient ATP production. No relationship was found between ATP concentration and the ability of motile spermatozoa in the ejaculate to survive freezing.

Glycerol permeability of human spermatozoa and its activation energy

Glycerol has commonly been employed as a cryoprotectant in cryopreservation of human spermatozoa. However, the addition of glycerol into the sperm before freezing and the removal of glycerol from the sperm after freezing and thawing result in anisotonic environments to the cells, which can cause cell injury. To define optimal procedures for the addition/removal of glycerol and to minimize the cell injury, one needs to know the kinetics of glycerol permeation across the sperm plasma membrane at different temperatures. For this, one has to determine the permeability coefficient of glycerol (Pg) and its activation energy (Ea). Values of Pg at different temperatures and at different glycerol concentrations were determined by measuring the time required for 50% spermolysis in hyperosmotic glycerol solutions which were hypotonic with respect to electrolytes. Value of the Ea was determined assuming an Arrhenius type temperature dependence of Pg. A dual fluorescent staining technique (propidium iodide and 6-carboxyfluoroscein diacetate) and flow cytometry were used to measure the spermolysis. The values of Pg in 0.5, 1.0, 1.5, and 2.0 M glycerol at 22 degrees C are 1.62, 1.88, 1.68, and 1.54 x 10(-3) cm/min, respectively. The values of Pg in 1 M glycerol at 0, 8, 22, and 30 degrees C are 0.33, 0.54, 1.88, and 2.60 x 10(-3) cm/min, respectively. The value of Ea is 11.76 kcal/mol.

Therapeutic donor insemination: a prospective randomized trial of fresh versus frozen sperm

OBJECTIVE

We evaluated the efficacy of fresh versus frozen sperm in therapeutic donor insemination.

STUDY DESIGN

Fifty-seven women underwent 72 courses of treatment (a maximum of six therapeutic donor insemination cycles--three fresh and three frozen) totaling 198 cycles. Each woman served as her own control and was prospectively randomized to receive a single, timed insemination of either fresh or frozen sperm.

RESULTS

Fecundity was 20.6% for fresh sperm cycles and 9.4% for frozen (p less than 0.03, by chi 2 analysis). Fresh cervical cap insemination fecundity was 20.3%; frozen was 7.8% (p less than 0.03, by chi 2 analysis). Fresh intrauterine insemination fecundity was 21.2%; frozen was 15.8% (p = 0.63, by chi 2 analysis). Fresh 3-month life-table pregnancy rates were 48% +/- 10%; frozen rates were 22% +/- 8% (p = 0.05 by Breslow analysis). Survival analysis with fixed covariates showed a positive association with the use of fresh sperm (p = 0.04).

CONCLUSION

Cycle fecundity was significantly greater with fresh sperm in women undergoing cervical cap insemination or intrauterine insemination and in women undergoing only cervical cap insemination. These results have important implications for contemporary management of patients undergoing therapeutic donor insemination with frozen sperm.