Intrauterine insemination in male subfertility: a comparative study of sperm preparation using a commercial Percoll kit and conventional sperm wash

The impact of different sperm preparation methods on clinical pregnancy and live birth rates in intrauterine insemination cycles: a retrospective single-center cohort study

OBJECTIVE

To assess the impact of 2 different sperm preparation methods, density gradient centrifugation and simple wash, on clinical pregnancy and live birth rates in intrauterine insemination (IUI) cycles with and without ovulation induction.

DESIGN

Retrospective single-center cohort study.

SETTING

Academic fertility center.

PATIENTS

In total, 1,503 women of all diagnoses sought IUI with fresh-ejaculated sperm.

EXPOSURE

Cycles were divided into 2 groups on the basis of sperm preparation technique: density gradient centrifugation (n = 1,687, unexposed group) and simple wash (n = 1,691, exposed group).

MAIN OUTCOME MEASURES

Primary outcome measures consisted of clinical pregnancy and live birth rates. Furthermore, adjusted odds ratios and 95% confidence intervals for each outcome were calculated and compared between the 2 sperm preparation groups.

RESULTS

Odds ratios did not differ between density gradient centrifugation and simple wash groups for clinical pregnancy and live birth (1.10 [0.67-1.83] and 1.08 [0.85-1.37], respectively). Additionally, when cycles were stratified using ovulation induction rather than adjusted for, no differences in clinical pregnancy and live birth odds were noted between sperm preparation groups (gonadotropins: 0.93 [0.49-1.77] and 1.03 [0.75-1.41]; oral agents: 1.78 [0.68-4.61] and 1.05 [0.72-1.53]; unassisted: 0.08 [0.001-6.84] and 2.52 [0.63-10.00], respectively). Furthermore, no difference was seen in clinical pregnancy or live birth when cycles were stratified using sperm score or when the analysis was limited to first cycles only.

CONCLUSION

Overall, no difference was noted in clinical pregnancy or live birth rates between patients who received simple wash vs. density gradient-prepared sperm, suggesting similar clinical efficacy between the 2 techniques for IUI. Because the simple wash technique is more time-efficient and cost-effective compared with the density gradient, adoption of this technique could lead to comparable clinical pregnancy and live birth rates for IUI cycles, although optimizing teamwork flow and coordination of care.

Semen preparation techniques for intrauterine insemination

BACKGROUND

Semen preparation techniques for assisted reproduction, including intrauterine insemination (IUI), were developed to select the motile morphologically normal spermatozoa. The yield of many motile, morphologically normal spermatozoa might influence treatment choices and therefore outcomes.

OBJECTIVES

To compare the effectiveness of three different semen preparation techniques (gradient; swim-up; wash and centrifugation) on clinical outcomes (live birth rate; clinical pregnancy rate) in subfertile couples undergoing IUI.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Group (CGFG) trials register, CENTRAL, MEDLINE, Embase, Science Direct Database, National Research Register, Biological Abstracts and clinical trial registries in March 2019, and checked references and contacted study authors to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing the efficacy in terms of clinical outcomes of semen preparation techniques used for subfertile couples undergoing IUI.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane. The primary review outcomes are live birth rate and clinical pregnancy rate per couple.

MAIN RESULTS

We included seven RCTS in the review; we included six of these, totalling 485 couples, in the meta-analysis. No trials reported the primary outcome of live birth. The evidence was of very low-quality. The main limitations were (unclear) risk of bias, signs of imprecision and inconsistency in results among studies and the small number of studies/participants included.Swim-up versus gradient technique Considering the quality of evidence, we are uncertain whether there was a difference between clinical pregnancy rates (CPR) for swim-up versus a gradient technique (odds ratio (OR) 0.83, 95% CI 0.51 to 1.35; I² = 71%; 4 RCTs, 370 participants; very low-quality evidence). The results suggest that if the chance of pregnancy after the use of a gradient technique is assumed to be 24%, the chance of pregnancy after using the swim-up technique is between 14% and 30%. We are uncertain whether there was a real difference between ongoing pregnancy rates per couple (OR 0.39, 95% CI 0.19 to 0.82; heterogeneity not applicable; 1 RCT, 223 participants; very low-quality evidence). Considering the quality of evidence, we are uncertain whether there was a difference between multiple pregnancy rates (MPR) per couple comparing a swim-up versus gradient technique (MPR per couple 0% versus 0%; 1 RCT, 25 participants; very low-quality of evidence). Considering the quality of evidence, we are also uncertain whether there was a difference between miscarriage rates (MR) per couple comparing a swim-up versus gradient technique (OR 0.85, 95% CI 0.28 to 2.59; I² = 44%; 3 RCTs, 330 participants; very low-quality evidence). No studies reported on ectopic pregnancy rate, fetal abnormalities or infection rate.Swim-up versus wash techniqueConsidering the quality of evidence, we are uncertain whether there is a difference in clinical pregnancy rates after a swim-up technique versus wash and centrifugation (OR 0.41, 95% CI 0.15 to 1.13; I² = 55%; 2 RCTs, 78 participants; very low-quality evidence). The results suggest that if the chance of pregnancy after the use of a wash technique is assumed to be 38%, the chance of pregnancy after using the swim-up technique is between 9% and 41%. Considering the quality of evidence, we are uncertain whether there was a difference between multiple pregnancy rates between swim-up technique versus wash technique (OR 0.49, 95% CI 0.02 to 13.28; heterogeneity not applicable; 1 RCT, 26 participants; very low-quality evidence). Miscarriage rate was only reported by one study: no miscarriages were reported in either treatment arm. No studies reported on ongoing pregnancy rate, ectopic pregnancy rate, fetal abnormalities or infection rate.Gradient versus wash techniqueConsidering the quality of evidence, we are uncertain whether there is a difference in clinical pregnancy rates after a gradient versus wash and centrifugation technique (OR 1.78, 95% CI 0.58 to 5.46; I² = 52%; 2 RCTs, 94 participants; very low-quality evidence). The results suggest that if the chance of pregnancy after the use of a wash technique is assumed to be 13%, the chance of pregnancy after using the gradient technique is between 8% and 46%. Considering the quality of evidence, we are uncertain whether there was a difference between multiple pregnancy rates per couple between the treatment groups (OR 0.33, 95% CI 0.01 to 8.83; very low-quality evidence). Considering the quality of evidence, we are also uncertain whether there was a difference between miscarriage rates per couple between the treatment groups (OR 6.11, 95% CI 0.27 to 138.45; very low-quality evidence). No studies reported on ongoing pregnancy rate, ectopic pregnancy rate, fetal abnormalities or infection rate.

AUTHORS' CONCLUSIONS

There is insufficient evidence to recommend any specific semen preparation technique: swim-up versus gradient versus wash and centrifugation technique. No studies reported on live birth rates. Considering the quality of evidence (very low), we are uncertain whether there is a difference in clinical pregnancy rates, ongoing pregnancy rates, multiple pregnancy rates or miscarriage rates per couple) between the three sperm preparation techniques. Further randomised trials are warranted that report live birth data.

The gradient technique improves success rates in intrauterine insemination cycles of unexplained subfertile couples when compared to swim up technique; a prospective randomized study

PURPOSE

To compare the efficacy of gradient and swim-up semen preparation techniques on pregnancy rates in couples undergoing intrauterine insemination (IUI) cycles with low dose gonadotropin stimulation with the diagnosis of unexplained or mild male subfertility.

METHODS

Two hundred and twenty three couples were randomized into swim up or gradient technique groups for sperm preperation. The clinical and on going pregnancy rates per cycle and per patient were evaluated.

RESULTS

Both clinical and ongoing pregnancy rates per cycle were significantly higher in the "gradient" group (19% and 16.9%) in comparision with the "swim up" group (9.7% and 6.9%) (p < 0.05). Clinical pregnancy and on-going pregnancy rates per patient were higher in the "gradient" group (26.1% and 23.4%) when compared to the "swim up" group (15.2% and 10.7%), (p < 0.05). In the subgroup of 191 unexplained subfertile couples with 290 cycles; the "gradient" group also revealed significantly higher clinical and ongoing pregnancy rates per cycle (21.6% and 17.9%) when compared with the "swim up" group (10.3% and 7.1%) (p < 0.05). In total of 48 treatment cycles upon 32 couples with mild male factor subfertility no significant difference were found between the two sperm preparation techniques in terms of clinical (% 5.3 vs %6.9, p > 0.05) and ongoing (% 5.3 vs %6.9, p > 0.05) pregnancy rates per cycle.

CONCLUSION

The gradient technique significantly improves clinical outcome in IUI cycles of unexplained subfertile couples when compared to swim up technique. In male subfertile patients, both techniques yield similar clinical outcomes.

Semen preparation techniques for intrauterine insemination

BACKGROUND

Semen preparation techniques for assisted reproduction, including intrauterine insemination (IUI), were developed to separate the motile morphological normal spermatozoa. Leucocytes, bacteria and dead spermatozoa produce oxygen radicals that negatively influence the ability to fertilize the egg. The yield of as many motile, morphologically normal spermatozoa as possible might influence treatment choices and therefore outcomes.

OBJECTIVES

To compare the effectiveness of gradient, swim-up, or wash and centrifugation semen preparation techniques on clinical outcome in subfertile couples undergoing intrauterine insemination (IUI).

SEARCH STRATEGY

We searched the Menstrual Disorders and Subfertility Group Trials Register (13 January 2007), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 2), MEDLINE (1966 to January 2007 ), EMBASE (1980 to January 2007), Science Direct Database (1966 to January 2007), National Research Register (2000 to 2007), Biological Abstracts (2000 to January 2007), CINAHL (1982 to October 2006) and reference lists of relevant articles. We also contacted experts and authors in the field.

SELECTION CRITERIA

Parallel randomized controlled trials (RCTs) comparing the efficacy of semen preparation techniques used for subfertile couples undergoing IUI in terms of clinical outcome were included.

DATA COLLECTION AND ANALYSIS

Two reviewer authors independently assessed trial quality and extracted data. Study authors were contacted for additional information.

MAIN RESULTS

Five RCTs, including 262 couples in total, were included in the meta-analysis (Dodson 1998; Grigoriou 2005; Posada 2005; Soliman 2005; Xu 2000). Xu compared the three techniques; Soliman compared a gradient technique versus a wash technique; Dodson and Posada compared a gradient technique versus a swim-up technique; whereas Grigoriou compared swim-up versus a wash technique. No trials reported the primary outcome of live birth. There was no evidence of a difference between pregnancy rates (PR) for swim-up versus a gradient or wash and centrifugation technique (Peto OR 1.57, 95% CI 0.74 to 3.32; Peto OR 0.41, 95% CI 0.15 to 1.10, respectively); nor in the two studies comparing a gradient technique versus wash and centrifugation (Peto OR 1.76, 95% CI 0.57 to 5.44). There was no evidence of a difference in the miscarriage rate (MR) in two studies comparing swim-up versus a gradient technique (Peto OR 0.13, 95% CI 0.01 to 1.33).

AUTHORS' CONCLUSIONS

There is insufficient evidence to recommend any specific preparation technique. Large high quality randomised controlled trials, comparing the effectiveness of a gradient and/ or a swim-up and/ or wash and centrifugation technique on clinical outcome are lacking. Further randomised trials are warranted.

Catheter type does not affect the outcome of intrauterine insemination treatment: a prospective randomized study

OBJECTIVE

To compare the main outcome of IUI with the Gynetics catheter (Gynetics Medical Products, Hamont-Achel, Belgium) or the Makler cannula (Sefi-Medical Instruments, Haifa, Israel).

DESIGN

Prospective, randomized study.

SETTING

Infertility and endocrinology unit in a university hospital.

PATIENT(S)

Two hundred fifty-one infertile couples undergoing 784 consecutive IUI treatments.

INTERVENTION(S)

Patients were randomly assigned to undergo IUI treatment with either the Gynetics catheter (124 patients) or the Makler cannula (127 patients).

MAIN OUTCOME MEASURE(S)

Primary outcome measures were pregnancy and cumulative pregnancy rates. Secondary outcome measures were the ease of introduction of the catheter, the presence of bleeding, and semen regurgitation after removal of the catheter.

RESULT(S)

The use of the Gynetics catheter resulted in similar pregnancy (10.4% vs. 9.7%) and cumulative pregnancy rates (27.9% vs. 26.4%) as compared with the Makler cannula. Difficult introduction of the catheter was more frequent in the Gynetics group than in the Makler group (19.4% vs. 8.0%, respectively), but the frequency of bleeding did not differ between groups. Sample regurgitation was observed more often in the Makler group than in the Gynetics group (49.9% vs. 17.9%, respectively).

CONCLUSION(S)

A lower frequency of sperm regurgitation and a higher frequency of difficult introduction was observed when the Gynetics catheter was used. However, there was no significant difference in pregnancy rates with use of either the Gynetics catheter or the Makler cannula.

Semen preparation techniques for intrauterine insemination

BACKGROUND

Semen preparation techniques for assisted reproduction, including intrauterine insemination (IUI), were developed to separate the motile morphological normal spermatozoa. Leucocytes, bacteria and dead spermatozoa produce oxygen radicals that negatively influence the ability to fertilize the egg. The yield of as many motile, morphologically normal spermatozoa might influence treatment choices and therefore outcomes.

OBJECTIVES

To compare the effectiveness of gradient, swim-up, or wash and centrifugation in subfertile couples undergoing intrauterine insemination (IUI) on clinical outcome as well as on semen parameters.

SEARCH STRATEGY

We searched the Menstrual Disorders and Subfertility Group's trials register (30 June 2003), MEDLINE (1966 to July 2003), EMBASE (1980 to July 2003), Science Direct Database (1966 to July 2003), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2003), National Research Register (2000 to Issue 2, 2003), Biological Abstracts (2000 to June 2003), CINAHL (1982 to July 2003) and reference lists of relevant articles. We also contacted experts and authors in the field.

SELECTION CRITERIA

Parallel randomised controlled trials (RCTs), comparing the efficacy of semen preparation techniques used for subfertile couples undergoing IUI, were included. RCTs or split sample studies examining semen parameters after different semen preparation techniques were also included.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information.

MAIN RESULTS

Two randomised controlled trials comparing clinical outcomes, including 81 participants in total, were included in the meta-analysis (Dodson 1998-I/ II; Xu 2000-I/ II). Both studies compared swim-up technique versus gradient technique in 65 subfertile couples undergoing IUI. One study compared the effectiveness of both techniques with wash technique. No trials reported the primary outcome of live birth. There was no statistically significant difference between pregnancy rates (PR) for swim-up versus gradient / wash centrifuge (Peto OR 0.55, 95% CI 0.17 to 1.76; Peto OR 1.74, 95% CI 0.2 to 14.9; PR/ couple swim-up 20%, gradient 40%, wash 12.5%) or gradient versus wash centrifuge (Peto OR 4.01, 95% CI 0.82 to 19.56; PR/ couple swim-up 15%, gradient 20%). There was no significant difference in the miscarriage rate (MR) per couple between either of the three treatment groups in the one trial reporting this outcome (MR/ couple swim-up 0%, gradient 10.3%, wash 0%. MR/ pregnancy gradient 30.3%). There was no statistically significant difference in the multiple pregnancy rate (MPR) per couple between either of the three treatment groups in Dodson 1998-I/ II (MPR/ couple swim -up 0%, gradient 0%, wash 6.3%). One triplet pregnancy was recorded. Fifteen studies comparing semen parameters after processing were included. Two studies were included in the meta-analysis, we were not able to pool results.

REVIEWERS' CONCLUSIONS

There is insufficient evidence to recommend any specific preparation technique. Large high quality randomised controlled trials, comparing the effectiveness of a gradient and/ or a swim-up and/ or wash and centrifugation technique on clinical outcome are lacking. Further randomised trials are warranted. Results from studies comparing semen parameters may suggest a preference for gradient technique, but firm conclusions cannot be drawn and the limitations should be taken into consideration.

Efficacy and pregnancy outcome of two methods of semen preparation for intrauterine insemination: a prospective randomized study

OBJECTIVE

To examine pregnancy outcome with two methods of semen preparation for intrauterine insemination (IUI).

DESIGN

Prospective and randomized study.

SETTINGS

Academic tertiary center.

PATIENT(S)

Three hundred eleven couples undergoing 676 consecutive cycles of assisted conception using IUI.

INTERVENTION(S)

Semen samples collected for IUI were randomized to wash only or density gradient centrifugation (DGC) processing.

MAIN OUTCOME MEASURE(S)

Various prepreparation and postpreparation semen parameters were used for IUI. The influence of the method of semen processing, and impact of various semen parameters and female factors on pregnancy were examined by receiver operating characteristics (ROC) curves, logistic regression, and life table analysis.

RESULT(S)

Of the 676 cycles, 88 resulted in conception leading to an overall clinical pregnancy rate of 13.0% per cycle and 28.3% per patient with a miscarriage rate of 34.0%. Eighty-eight percent of pregnancies occurred in the first three cycles of IUI and 95.5% within the first four cycles. The pregnancy rate for wash only was 11.6% (37 of 319) and the rate for DGC was 14.3% (51 of 356). However, in samples with <22 million motile sperm in the inseminate, pregnancy rates were 4% for wash and 18% for DGC. The woman's age for both methods and the percentage of sperm in the original semen with a velocity of > or =80 micro m/s for the wash method influenced pregnancy outcome.

CONCLUSION(S)

Although samples with an acceptable number of motile sperm can be processed efficiently by wash only, poor quality semen samples should be processed using DGC.

A randomized comparison of the methods of sperm preparation for intrauterine insemination

OBJECTIVE

To compare the effectiveness of three methods of sperm preparation for IUI during superovulation of infertile women.

DESIGN

Randomized assignment of one of three sperm preparation methods.

SETTING

University infertility practice.

PATIENT(S)

Infertile couples undergoing superovulation and IUI.

INTERVENTION(S)

The method of preparation of sperm for IUI during superovulation was assigned randomly to double centrifugation, multiple-tube swim-up, or Percoll density gradient.

MAIN OUTCOME MEASURE(S)

Total number and percent recovery of motile sperm, percent of recovered sperm with normal morphology, and cycle fecundity.

RESULT(S)

No method of sperm preparation provided better cycle fecundity than the others despite differences in sperm recovery.

CONCLUSION(S)

Double centrifugation, multiple-tube swim-up, and Percoll density gradient sperm preparation for IUI yield similar cycle fecundity rates.

Evaluation of quality of spermatozoa prepared by SpermPrep method as compared to those prepared by MiniPercoll

As it is quick and easy to prepare sperm with SpermPrep column, this method was assessed in the andrology laboratory for IUI preparations, as an alternative to Percoll, since Percoll is not available in market. This paper evaluates sperm prepared by SpermPrep method and compares them to those prepared by MiniPercoll for matched asthenozoospermic specimens. Spermatozoa prepared with MiniPercoll were of significantly higher quality, when compared with those prepared by SpermPrep, in terms of computer-assisted sperm motion parameters, recovery of motile fraction, morphology, hypoosmotic swelling and nuclear stability as assessed by sodium dodecyl sulphate exposure. SpermPrep did not appear to be equivalent to MiniPercoll and therefore could not be widely applied to asthenozoospermic specimens. It may be used on an individual basis, depending on the initial semen sample. Although other density gradient methods such as colloidal silica particles coated with silane appear to be equivalent to Percoll, they need to be critically evaluated with respect to their batches or different sources of vendors and be compared to Percoll as a standard method.

A randomized, prospective analysis of five sperm preparation techniques before intrauterine insemination of husband sperm

OBJECTIVE

To evaluate pregnancy rates (PRs) in women undergoing artificial insemination with sperm alternately prepared by one of five techniques: sperm washing, Percoll gradient centrifugation, swim-up, swim-down, or refrigeration/heparin treatment.

DESIGN

Each treatment group alternated in a different order through the five sperm preparations. Pregnancy rates were compared for each sperm preparation.

SETTING

Two infertility centers, one located in an academic institution and the other a regional hospital.

PATIENT(S)

Three hundred sixty-three women undergoing 898 artificial inseminations with husband semen with a progressive motile sperm count of >20 million sperm per mL were randomly placed in the five treatment groups.

MAIN OUTCOME MEASURE(S)

Pregnancy rates.

RESULT(S)

The overall ongoing PR per insemination was 9.7% (87/898), including 6.12% for natural cycles (n = 196), 12.8% for clomiphene citrate-stimulated cycles (n = 101), and 10.3% for gonadotropin-stimulated cycles (n = 601). The highest ongoing PRs for sperm preparations followed the swim-up technique (13.2%, 26/197) and the Percoll gradient centrifugation technique (12.7%, 26/204).

CONCLUSION(S)

These data suggest that the swim-up and Percoll gradient preparations result in higher PRs than the wash, swim-down, and refrigeration/heparin techniques.

The value of semen characteristics and tests of sperm function in selecting couples for intra-uterine insemination

In order to improve the selection of couples for intrauterine insemination (IUI) because of longstanding primary infertility of alleged male origin, we have performed a prospective study measuring conventional and advanced analysis of sperm characteristics, the hypoosmotic swelling test, the Shorr stain, the acidified aniline blue stain and alpha-glucosidase activity in seminal plasma, of 89 couples with no demonstrable abnormality of the female partner. Twenty-four couples attained spontaneous conception, 23 were successful within six cycles of IUI, and 42 remained without conception in spite of IUI during six unstimulated cycles. The proportion and concentration of spermatozoa with progressive motility was significantly lower (P < 0.01) in the successful IUI cases than in the couples attaining spontaneous conception, and the lower quartile value was lower in the former than in the latter. There were less pregnancies among IUI treated couples when sperm concentration and motility were within the range of normal fertile men, or when the concentration of white blood cells was elevated. More pregnancies occurred when markers of epididymal function, namely the result of the Shorr stain and alpha-glucosidase measurement, were normal. Total progressive motility and the result of the Shorr stain were the only independent variables selected by logistic regression to discriminate between successful and failed IUI cases. It is concluded that only a limited group of couples may benefit from IUI.

The effective cumulative pregnancy rate of different modes of treatment of male infertility

The clinical efficacy of conventional and advanced methods of treatment was assessed in 814 couples with infertility due to a male factor. The monthly and effective cumulative rate of ongoing or term pregnancies was calculated during 4712 couple-months. Treatment of varicocele by transcatheter embolization, resulting in 3.9% pregnancies per cycle and an effective cumulative pregnancy rate of 41% after 1 year, is more effective than counselling and timed intercourse (9% pregnancies after 12 months). Intrauterine insemination (IUI) of washed spermatozoa produced 17% pregnancies in the initial 4 months, but the success rate of the subsequent cycles (1.7% per cycle) was not different from that of the controls. In vitro fertilization (IVF) resulted in 16% pregnancies per attempt, but the effective cumulative pregnancy rate was only 31% in 12 months due to the long interval between treatment attempts and the high drop-out rate. With subzonal microinjection of sperm, the fertilization rate was higher (71%) than with regular IVF (29%) but both the pregnancy rate per attempt (9%) and the effective cumulative pregnancy rate (17% after 12 months) were low. The 10th percentile of sperm characteristics (cut-off values) of successful cases showed intrauterine insemination to be advantageous in cases with a lower percentage of spermatozoa with progressive motility (9%) than in the controls (15%). The cut-off value of sperm morphology in IVF (4%) is lower than that of IUI (8%) and of the controls (9%), but higher than that of subzonal insemination (1%). Treatment strategy must be defined selecting or combining conventional and assisted reproductive technology for each individual couple with male factor infertility.