Performance of the postwash total motile sperm count as a predictor of pregnancy at the time of intrauterine insemination: a meta-analysis

Sperm morphology by strict criteria does not predict clinical pregnancy rate following intra-uterine insemination

Objective

To determine the impact of abnormal sperm morphology of the pre-washed semen sample on the day of intrauterine insemination (IUI) on clinical pregnancy rates (CPR).

Design

Cross sectional retrospective chart review.

Setting

Academic fertility center.

Patients

Couples undergoing (IUI) from May 2014 to March 2022.

Interventions

Sperm morphology, by strict criteria, on the pre-washed IUI sample.

Main outcomes Measures

To determine the association of sperm morphology with CPR.

Results

Semen analysis reports, including Kruger strict criteria for morphology from the pre-washed IUI sample, were reviewed for 1,059 cycles, comprising 825 total treated couples.Of the total 1,059 cycles,15.1% resulted in clinical pregnancy. When categorized by strict morphology ≥4% (normal morphology), (3%-2%) [mild-moderate teratozoospermia (TZS)], and ≤1% (severe TZS), the CPR was 16%, 13%, and 10%, respectively (p value 0.30). Early spontaneous miscarriage rate was 4% and when stratified by morphology ≥4% (3%-2%), and ≤1%, was 3%, 1%, and 0%, respectively (p value 0.20).In couples with isolated TZS, the pregnancy rate was 16% in the normal morphology group, 14% in the mild-moderate group, and 8% in the severe group. (p value 0.30).In the multivariate logistic regression, sperm morphology, mild/moderate TZS vs normal forms (OR = 0.99, 95% CI [0.94-1.1]), severe TZS vs normal forms (OR = 0.98, 95% CI [0.0.83-1.1]), was not a predictor of CPR. The Pre-wash TMSC (OR = 1.0, 95% CI [0.996-1.00]) was also not predictive of CPR.The only predictive factor of CPR in IUI was the PWTMSC (OR = 1.03, 95%CI [1.00-1.06).

Conclusions

The morphology of the pre-washed sample on the day of IUI did not find a difference in CPR, neither in miscarriage rate following IUI, in couples with normal or abnormal sperm morphology, including severe TZS.Mild, moderate, or severe TZS in the semen sample should not exclude couples to attempt an IUI procedure.

Can semen parameters predict pregnancy outcomes?

Semen analysis is an integral component of the evaluation and management of men with infertility. Although it is important for patient counseling and clinical decision making, a conventional semen analysis cannot reliably predict the chance of pregnancy or differentiate fertile vs. infertile men (except in the most extreme cases). Advanced, nonstandard sperm functional tests may provide additional discriminatory and prognostic power; however, further research is needed to determine how to best incorporate these tests into modern clinical practice. Therefore, the primary applications of a conventional semen analysis should be to judge the severity of infertility, estimate the effects of future therapy, and measure the response to current therapy.

Novel modified criteria for sperm morphology in oocyte insemination could reduce ICSI rates without affecting IVF outcomes

OBJECTIVE

To evaluate the IVF outcomes of conventional insemination for less severe teratozoospermia (LST) patients (sperm morphology >2% and <4% normal forms and total motile sperm count ≥10 × 10⁶) and normal sperm patients defined by WHO criteria 2010 in the interest of reducing intracytoplasmic sperm injection (ICSI) rate in IVF.

MATERIALS AND METHODS

In this retrospective study, a total of 330 patients were recruited in the conventional IVF insemination. Among them, there were 76 patients in LST group and 254 patients in the normal sperm group. Fertilization rate, abnormal fertilization rate, embryo quality, implantation rate, chemical pregnancy rate, clinical pregnancy rate, abortion rate and live birth rate were assessed.

RESULTS

No statistical differences were achieved in the percentage of normally fertilized eggs (85.9% vs. 85.8%), abnormal fertilization rates of 1 PN (2.76% vs. 3.01%) or 3 PN (5.70% vs. 6.30%), good embryo rate (52.4% vs. 51.5%), implantation rate (20.9% vs 17.5%), chemical pregnancy rate (45.1% vs. 39.4%), clinical pregnancy rate (36.0% vs. 31.7%), live birth rate (28.9% vs. 26.7%) and abortion rate (9.6% vs. 10.2%) between LST group and normal sperm group regardless of the sperm morphology.

CONCLUSION

Patients with less severe teratozoospermia may not need ICSI in their IVF treatment since the outcomes particularly the fertilization rates were not affected by the less compromised sperm morphology at all when compared with the normal sperm patients.

Optimizing pregnancy outcomes in intrauterine insemination cycles by stratifying pre-wash total motile count and patient-specific factors: a patient counseling tool

PURPOSE

The purpose of this study is to clarify which pre-wash total motile count are associated with improved clinical pregnancy rate (CPR) and live birth rate (LBR) based on maternal age, AMH level, stimulation regimen, and infertility diagnosis.

METHODS

This was a retrospective cohort study of first completed IUI cycles at two academic fertility centers from 5/2015 to 9/2019. Cycles were stratified by pre-wash TMC, maternal age, AMH level, stimulation regimen, and infertility diagnosis. The primary outcome was CPR and secondary outcomes were live birth and miscarriage.

RESULTS

One thousand one hundred fifty-four cycles were analyzed. Of the 162 cycles that resulted in a CPR (14.0%), most had an insemination TMC > 20 million. Compared to TMC > 20 million, there was no difference in CPR or LBR for lower TMC categories, excluding the TMC < 2 million group, in which there were no pregnancies. When TMC was stratified by deciles, there was also no difference in CPR and LBR, including within the lowest decile (TMC 0.09-8.6 million). Younger age and higher ovarian reserve parameters were associated with higher pregnancy and LBR when stratified by TMC. There was no difference in pregnancy and LBR when considering different stimulation protocols.

CONCLUSIONS

Our data suggest that pregnancy and LBR are equivalent above a TMC of 2 million. Data stratified by TMC and patient parameters can be used to counsel patients pursuing ART.

The association of impaired semen quality and pregnancy rates in assisted reproduction technology cycles: Systematic review and meta-analysis

Some studies suggest a relationship between semen quality and pregnancy rates of assisted reproduction technologies (ART). Others have questioned the utility of semen quality as proxy for fertility in couples attempting to conceive with or without assistance. We aimed to investigate the current body of evidence which correlates semen parameters and clinical pregnancy among couples utilizing ART (i.e. in vitro fertilization [IVF], intracytoplasmic sperm injection [ICSI]) through a systematic review and meta‐analysis of cross‐sectional and retrospective cohort studies. Pooled Odd Ratio (OR) for oligo‐, astheno‐ and teratospermic compared to normospermic number of ART cycles were calculated among. Meta‐regression and sub‐group analysis were implemented to model the contribution of clinical/demographic and laboratory standards differences among the studies. Overall, 17 studies were analysed representing 17,348 cycles were analysed. Pooled OR for impaired sperm concentration, motility and morphology was 1 (95%Confidence Interval [CI]: 0.97–1.03), 0.88 (95%CI: 0.73–1.03) and 0.88 (95%CI: 0.75–1) respectively. Further analysis on sperm morphology showed no differences with regard of IVF versus ICSI (p = 0.14) nor a significant correlation with rising reference thresholds (Coeff: −0.02, p = 0.38). A temporal trend towards a null association between semen parameters and clinical pregnancy was observed over the 20‐year observation period (Coeff: 0.01, p = 0.014). The current analysis found no association between semen quality (as measured by concentration, motility or morphology) and clinical pregnancy rates utilizing ART. Future investigations are necessary to explore the association between semen parameters and other ART outcomes (e.g. fertilization, implantation, birth and perinatal health).

Timed intercourse in association with controlled ovarian hyperstimulation as the first-line treatment of couples with unexplained subfertility

OBJECTIVE

To report on the pregnancy outcomes of timed intercourse (TI) with controlled ovarian hyperstimulation (COH) as the first-line treatment of unexplained subfertility, and provide some evidence on the factors involved.

METHODS

The records of couples treated between January 2016 and March 2019 were retrospectively analyzed. Couples were selected for TI based on standard infertility evaluation. Semen analysis by swim-up was conducted and the total motile sperm count (TMSC) obtained. The main outcome measured was the clinical pregnancy rates. Data were analyzed with t test, Pearson's Chi-squared test, and the Wald test for logistic regression with p≤0.05.

RESULTS

The records of 275 couples (449 cycles) were included in the analysis. Patients underwent TI up to six attempts. Patient- and cycle-based pregnancy rates were 18.55% and 13.14%, respectively. Eight patients got pregnant twice, resulting in a cumulative pregnancy rate of 21.4%. Women that did not get pregnant demonstrated a statistically higher mean age value than women who did (p=0.0186). Logistic regression indicated that for every year added to the woman's age, the chances of pregnancy reduced by 6.45%, and for cycles with TMSC ≥ 5 million, the chances of pregnancy were 1.91 times higher when compared to TMSC < 5 million.

CONCLUSIONS

TI with COH should be considered as the first-line treatment for selected couples with unexplained subfertility before more traumatic and costly IVF treatments were considered. The findings can assist doctors to conduct a more educated counselling concerning the chances patients have to get pregnant with TI.

Aspiration of excess follicles before intrauterine insemination in high response cycles

Purpose

To assess the outcome of excess follicle aspiration before intrauterine insemination (EFABI) in intrauterine insemination (IUI) cycles with 4-6 follicles ≥14 mm.

Methods

A retrospective case-control study with 1559 patients undergoing IUI (donor and husband's sperm), of whom 86 underwent EFABI. We studied also an historical series of 2213 patients before EFABI implementation. For 3.5 years, all women undergoing IUI developing 4-6 follicles ≥14 mm were offered EFABI on the day of hCG administration. Pregnancy rates (PRs), multiple PRs, and adverse effects were measured.

Results

EFABI was associated with a similar multiple PR (17.8% vs 17.5% in non-EFABI cases), with no triplets in EFABI patients. Live birth rates were significantly higher in EFABI cycles in IUI overall (25.5% vs 15.2%). When considered separately, the performance of EFABI resulted in significantly increased live birth rates in IUI-donor cycles (32.5% vs 18.5%), whereas the differences in IUI-husband cycles (19.5% vs 12.9%) did not reach statistical significance. The PR was 21.2% during the EFABI implementation period and 19.4% in the pre-EFABI period.

Conclusions

EFABI in cycles in which 4-6 follicles reach ≥14 mm is a simple option that reduces cycle cancellation rates, results in higher PRs than cycles with 1-3 follicles, and lowers the risk of multiple pregnancy.

Predictive value of sperm motility before and after preparation for the pregnancy outcomes of intrauterine insemination

Objective

This study aimed to investigate sperm motility and its changes after preparation as predictors of pregnancy in intrauterine insemination (IUI) cycles.

Methods

In total, 297 IUI cycles from January 2012 to December 2017 at a single tertiary hospital were retrospectively analyzed. Patient and cycle characteristics, and sperm motility characteristics before and after processing were compared according to clinical pregnancy or live birth as outcomes.

Results

The overall clinical pregnancy rate per cycle was 14.5% (43/297) and the live birth rate was 10.4% (30/289). Patient and cycle characteristics were similar between pregnant and non-pregnant groups. Sperm motility after preparation and the total motile sperm count before and after processing were comparable in terms of pregnancy outcomes. Pre-preparation sperm motility was significantly higher in groups with clinical pregnancy and live birth than in cycles not resulting in pregnancy (71.4%±10.9% vs. 67.2%±11.7%, p=0.020 and 71.6%±12.6% vs. 67.3%±11.7%, p=0.030, respectively). The change in sperm motility after processing was significantly fewer in the non-pregnant cycles, both when the comparison was conducted by subtraction (post-pre) and division (post/pre). These relationships remained significant after adjusting for the female partner’s age, anti-Müllerian hormone level, and number of pre-ovulatory follicles. According to a receiver operating characteristic curve analysis, an initial sperm motility of ≥72.5% was the optimal threshold value for predicting live birth after IUI.

Conclusion

Initial sperm motility, rather than the motility of processed sperm or the degree of change after preparation, predicted live birth after IUI procedures.

Impaired semen quality in trans women: prevalence and determinants

STUDY QUESTION

What is the semen quality in trans women at time of fertility preservation, prior to the start of gender-affirming hormone treatment?

SUMMARY ANSWER

Before the start of gender-affirming hormone treatment, semen quality in trans women was already strongly decreased compared to the general population.

WHAT IS KNOWN ALREADY

Hormone treatment for -trans women (birth-assigned males, female gender identity) consists of anti-androgens combined with estrogens in order to achieve feminization and it is accompanied by a loss of reproductive capability. Trans women can opt for semen cryopreservation prior to their medical transition to retain the possibility to parent genetically related offspring. Post-thaw semen parameters determine which ART can be used. Knowledge of semen quality and the factors negatively influencing semen parameters in trans women are important to improve semen quality before fertility preservation.

STUDY DESIGN, SIZE, DURATION

A retrospective cohort study was performed between 1972 and 2017. In total, 260 trans women were included for this study. Due to the study design, there was no loss to follow-up or attrition.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We studied the quality of the preserved semen in trans women, prior to their medical transition, who visited our gender clinic. Semen parameters were collected, as well as data on age, alcohol consumption, smoking, cannabis use, BMI, previous use of estrogens or anti-androgens and endocrine laboratory results. Semen parameters were categorized using reference values for human semen of the World Health Organization (WHO) and compared with data from the general population. Logistic regression analyses were performed to analyze the extent to which factors known to have a negative impact on semen quality in the general population explained the impaired semen quality in the cohort.

MAIN RESULTS AND THE ROLE OF CHANCE

The cohort consisted of 260 trans women between the age of 16 and 52 years. Semen quality in trans women was significantly decreased compared to WHO data from the general population. In total, 21 trans women had an azoospermia and median semen parameters for the remaining trans women and the general population, respectively, were as follows: volume 2.7 and 3.2 ml (P < 0.05), sperm concentration 40 and 64 million/ml (P < 0.05), total sperm number 103 and 196 million (P < 0.05) and progressive motility 41% and 57% (P < 0.05). Smoking (odds ratio (OR) 2.35 (95% CI 1.06–5.21)) and a higher age at time of fertility preservation (OR 1.04 (95% CI 1.00–1.08)) were found to correlate with an impaired progressive motility. Twelve trans women reported to have used anti-androgens and estrogens, and all had discontinued for at least 3 months prior to the first attempt for semen cryopreservation. No correlation was found between previous gender-affirming hormone use and decreased semen parameters. The median post-thaw total motile sperm count was 1.0 million per vial (interquartile range 0.1–3.1) and in only 26.4% of thawed semen samples was the quality adequate for a minimally invasive IUI.

LIMITATIONS, REASONS FOR CAUTION

Limitations include the retrospective design and insufficient data on transgender-specific factors, such as bringing the testes into the inguinal position (tucking), wearing tight underwear and low masturbation frequency.

WIDER IMPLICATIONS OF THE FINDINGS

Semen quality in trans women was decreased compared to the general population, which could not be explained by known risk factors, such as BMI, alcohol consumption, cannabis use, gender-affirming hormone use or abnormal endocrine laboratory results. Although a negative impact of smoking was observed, it was insufficient to explain the overall decreased semen quality in this cohort. Since low pre-freeze semen quality results in an even lower post-thaw semen quality, the majority of trans women and their female partner or surrogate may need an invasive and burdensome treatment to establish a pregnancy.

STUDY FUNDING/COMPETING INTEREST(S)

For this study, no external funding was obtained and there were no competing interests.

TRIAL REGISTRATION NUMBER

NA.

Simplified sperm testing devices: a possible tool to overcome lack of accessibility and inconsistency in male factor infertility diagnosis. An opportunity for low- and middle- income countries

Background

Manual semen assessment (MSA) is a key component in a male’s fertility assessment. Clinicians rely on it to make diagnostic and treatment decisions. When performed manually, this routine laboratory test is prone to variability due to human intervention which can lead to misdiagnosis and consequently over- or under- treatment. For standardisation, continuous training, quality control (QC) programs and pricy Computer-Assisted Sperm Analysis (CASA) systems have been proposed, yet, without resolving intra- and inter-laboratory variability. In response, promising simplified sperm testing devices, able to provide cost-effective point-of-care male infertility diagnosis are prospected as a plausible solution to resolve variability and increase access to sperm testing.

Materials and methods

A throughout literature research for semen testing, sperm analysis, smart-phone assisted semen analysis, ‘at-home’ semen testing, male infertility, infertility in developing countries, infertility in low- and middle-income countries (LMIC) and quantitative sperm analysis was performed. A total of 14 articles, specific to ‘at-home’ simplified sperm assessment, were included to treat the core subject.

Results

Continuous training and consistent QC, are sine qua none conditions to achieve accurate and comparable MSA. Compliance does not rule-out variability, nevertheless. Emerging simplified sperm assessment devices are an actual alternative to resolve the lack of standardisation and accessibility to sperm analysis. YO ® , SEEM ® , and ExSeed ® are commercially available, user-friendly smartphone-based devices which can accurately measure volume, sperm concentration (millions/ml) and total motile sperm count. More broadly, by cost-effectiveness, availability, accuracy and convenient application, these devices could effectively select patients for first-line artificial reproduction treatments such as intrauterine insemination.

Conclusions

Accuracy and cost-effectiveness make smart-phone based sperm testing devices a practical and realistic solution to overcome variability in MSA. Importantly, these tools represent an actual opportunity to standardise and improve male subfertility diagnosis and treatment, especially in LMIC. However, before clinical application is possible, guidelines, further testing with special attention on accuracy in washed sperm, availability, cost-benefit and reliability are required.

Relationship between sperm parameters and clinical outcomes of Intra Uterine Insemination (IUI)

Background:

Intrauterine insemination (IUI) is a widely utilized method for treating the infertile couples. The aim of the present study was to determine the pregnancy and abortion rates after IUI and to examine the relationship of sperm parameters with these rates.

Methods:

This retrospective study was performed on 911 infertile couples undergoing IUI treatment in Shahid Akbarabadi IVF Centre from May 2017 to May 2019. To evaluate the correlation of sperm parameters with the clinical pregnancy and abortion rates, odds ratio (OR) with 95% confidence intervals (CI) was calculated.

Results:

In this study, the pregnancy rate following IUI was 15.7% (143/911), and among women who achieved pregnancy, the abortion rate was 42.0% (60/143). According to the multiple logistic regression analysis, none of the sperm parameters was associated with the pregnancy rate. Couples with either male or female factor infertility etiologies were more likely to get pregnant than those with unexplained infertility. Regarding the abortion rate, multiple logistic regression analysis revealed that normal sperm count was related to a lower abortion rate (adjusted OR=0.25, 95% CI=0.07–0.91).

Conclusion:

The present study did not reveal a significant relationship between none of the sperm parameters and pregnancy rate after IUI treatment. However, among women who got pregnant, continuation of the pregnancy was associated with the normal sperm count. Furthermore, analysis of all semen parameters together in comparison to one parameter alone might be more accurate to predict pregnancy or abortion. Further prospective cohort studies with a large number of couples are required.

Clarifying the relationship between total motile sperm counts and intrauterine insemination pregnancy rates

OBJECTIVE

To study the relationship between postwash total motile sperm count (TMSC) and intrauterine insemination (IUI) outcomes.

DESIGN

Retrospective review SETTING: Large fertility clinic PATIENT(S): A total of 92,471 insemination cycles from 37,553 patients were included in this study.

INTERVENTION(S)

All stimulated clomiphene citrate, letrozole, and/or injectable gonadotropin IUI cycles performed at a single institution from 2002 through 2018 were reviewed. Generalized estimating equations (GEE) analysis was used to account for multiple cycles by individual patients and to adjust for female partner age, body mass index, and stimulation protocol.

MAIN OUTCOME MEASURE(S)

Successful clinical pregnancy was defined as ultrasound confirmation of an intrauterine gestational sac with fetal cardiac activity.

RESULT(S)

A total of 92,471 insemination cycles were available to evaluate the relationship between postwash TMSC and clinical pregnancy. Pregnancy rates were highest with TMSC of ≥9 × 10⁶ and declined gradually as TMSC decreased. Complete data for the adjusted GEE analysis were available for 62,758 cycles. Adjusted GEE analysis among cycles with TMSC of ≥9 × 10⁶ (n = 46,557) confirmed that TMSC in this range was unrelated to pregnancy. Conversely, TMSC was highly predictive of pregnancy (Wald χ² = 39.85) in adjusted GEE analysis among cycles with TMSC of <9 × 10⁶ (n = 16,201), with a statistically significant decline.

CONCLUSIONS

IUI pregnancy is optimized with TMSC of ≥9 × 10⁶, below which the rates gradually decline. Although rare, pregnancies were achieved with TMSC of <0.25 × 10⁶. Since the decline in pregnancy is gradual and continuous, there is no specific threshold above which IUI should be recommended. Rather, these more specific quantitative predictions can be used to provide personalized counseling and guide clinical decision making.

Time intervals between semen production, initiation of analysis, and IUI significantly influence clinical pregnancies and live births

PURPOSE

Does IDEF mapping help monitor the technical process of IUI and explore the potential improvements which might contribute to increased pregnancy and live birth rates?

METHOD

Retrospective analysis of 1729 homologous IUI cycles of couples attending a fertility clinic in a university hospital setting. Standardized conventional semen parameters were analyzed and the semen samples prepared via discontinuous density gradient centrifugation.

RESULTS

There was no significant association between sperm concentration, motility and morphology (analysis phase), and pregnancy outcome. Only female and male ages were significantly associated with the pregnancy outcome. There was a significant difference in the odds on clinical pregnancies and live births when analysis was ≤ 21 min initiated, and < 107 min between sample production and IUI, adjusted for male and female age.

CONCLUSIONS

Adjusting for the couple's age, we could show that time intervals between semen production and analysis and IUI when kept low significantly influenced clinical pregnancies and live births.

Lactobacillus iners and gasseri, Prevotella bivia and HPV Belong to the Microbiological Signature Negatively Affecting Human Reproduction

Infertile couples undergoing the use of assisted reproductive technology are a good study model to evaluate the microbiological signatures affecting reproductive health. We tested vaginal lavages, follicular fluids, embryo culture mediums, and seminal fluids from 47 couples for their microbiome composition and HPV infection. Twenty-five infertile couples were diagnosed with unexplained infertility, whereas 22 were diagnosed with explained infertility. Lactobacilli were dominant in the vaginal lavages of both patient groups, and the most abundant species was L. iners (CST III), which is linked to a decreased fertility rate. Besides this, L. gasseri—which is known to be associated with oocyte DNA fragmentation and decreased sperm mobility—was identified in the seminal fluids, follicular fluids, and embryo culture media of the unexplained infertility group. Prevotella was increased in the seminal fluids of the explained infertility group, along with HPV-positive seminal fluids: an infection commonly associated with infertility, especially male infertility. Prevotella has been described to negatively affect sperm motility. Taken together, these results suggest that the profiling of the reproductive tract microbiome can add new perspectives to human reproduction.

Effect of body mass index on intrauterine insemination cycle success

OBJECTIVE

To determine whether body mass index (BMI) affects intrauterine insemination treatment success.

DESIGN

Retrospective cohort study.

SETTING

Academic medical center.

PATIENT(S)

A total of 3,217 intrauterine insemination treatment cycles in 1,306 patients.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Primary outcome was live birth rate stratified by BMI. Secondary outcomes included rates of clinical pregnancy (defined as an intrauterine pregnancy with a heartbeat present on ultrasound), multiple gestation, biochemical pregnancy, missed abortion, ectopic, and spontaneous abortion.

RESULT(S)

Women with BMI 25 to 29.99 kg/m² or ≥30 kg/m² were equally likely to have a live birth as women of normal BMI. Women with BMI ≥30 kg/m² did have a higher likelihood of biochemical pregnancy than women with normal BMI.

CONCLUSION(S)

A BMI between 25 and 29.99 kg/m² or ≥30 kg/m² does not appear to have a negative effect on live birth after intrauterine insemination. Obesity may be associated with a higher risk of biochemical pregnancy after intrauterine insemination.

Supplementing post-wash asthenozoospermic human spermatozoa with coenzyme Q10 for 1 hr in vitro improves sperm motility, but not oxidative stress

We investigated the effect of supplementing post-wash asthenozoospermic spermatozoa with coenzyme Q10 (CoQ10) in vitro, which may reduce oxidative stress and improve sperm motility. Semen samples were collected from 39 men with asthenozoospermia, and their spermatozoa were isolated by two-layer Percoll density-gradient centrifugation. Kinetic parameters of the isolated spermatozoa (baseline before intervention) were determined immediately by computer-aided semen analysis. Total anti-oxidant capacity and protein carbonyl levels, as markers of oxidative stress, were also measured in the baseline spermatozoa. The baseline spermatozoa suspension was divided equally into two portions, one for CoQ10 supplementation (50 µg/ml for 1 hr) and the other as an un-supplemented vehicle control. The total motility of the CoQ10-supplemented spermatozoa was significantly higher than in the control (p = .009) and progressive motility tended to be higher (p = .053). Immotile sperm concentration in the CoQ10-supplemented spermatozoa was significantly lower than in both the baseline (p = .026) and control (p = .009). Total anti-oxidant capacity and protein carbonyl levels between the baseline, CoQ10-supplemented and control spermatozoa were not significantly different. Our data suggest that CoQ10 treatment reactivated sperm motility. We propose short-term supplementation of post-wash asthenozoospermic spermatozoa with CoQ10 before intrauterine insemination.

Live birth after intrauterine insemination: is there an upper cut-off for the number of motile spermatozoa inseminated?

RESEARCH QUESTION

To date, most studies have investigated the minimum number of spermatozoa available for intrauterine insemination (IUI), with no data on the maximum number of motile spermatozoa inseminated (NMSI) having been published. This study aimed to determine whether an upper cut-off for the NMSI during IUI exists above which the live birth rate (LBR) is negatively affected.

DESIGN

Retrospective analysis of autologous IUI cycles performed between January 2010 and July 2018 in women <43 years old with a NMSI >1 million. The main outcome was the LBR per IUI cycle as a function of the NMSI.

RESULTS

A total of 2592 IUI cycles performed in 1017 couples were included. The LBR increased with NMSI up to 30 million without any upper threshold (AUC = 0.5441). The LBR per IUI cycle were 14.5%, 17.9% and 22.7% for NMSI of >1 to ≤10, >10 to ≤20 and >20 to ≤30 million, respectively (P = 0.003). By univariate analysis, the NMSI, female age, number of mature follicles and oestradiol concentrations on day of ovulation triggering, cycle number and infertility aetiology influenced the LBR. Multivariate analysis showed that the LBR was 1.49 and 1.78 times higher when IUI was performed with a NMSI >10 to ≤20 million (odds ratio [OR] 1.49; 95% confidence interval [CI] 1.10-2.02]) and >20 to ≤30 million (OR 1.78; 95% CI 1.08-2.94), respectively, compared with IUI with a NMSI >1 to ≤10 million.

CONCLUSIONS

The LBR after IUI can be optimized by inseminating a maximum of motile spermatozoa up to 30 million. Thus, in this specific cohort, IUI preparations should not be diluted when more than 10 million motile spermatozoa are obtained.

Intrauterine insemination cycles: prediction of success and thresholds for poor prognosis and futile care

PURPOSE

We aimed to define intrauterine insemination (IUI) cycle characteristics associated with viable birth, identify thresholds below which IUI treatments are consistent with very poor prognosis and futile care, and develop a nomogram for individualized application.

METHODS

This retrospective cohort study evaluated couples using fresh partner ejaculate for IUI from January 2005 to September 2017. Variables included female age, semen characteristics, and ovarian stimulation type. Using cycle-level data, we evaluated the association of these characteristics with the probability of viable birth by fitting generalized regression models for a binary outcome with a logit link function, using generalized estimating equation methodology to account for the correlation between cycles involving the same patient.

RESULTS

The cohort consisted of 1117 women with 2912 IUI cycles; viable birth was achieved in 275 (9.4%) cycles. Futile care (viable birth rate < 1%) was identified for women age > 43, regardless of stimulation type or inseminate motility (IM). Very poor prognosis (viable birth rate < 5%) was identified for women using oral medications or Clomid plus gonadotropins who were (1) age < 35 with IM < 49%, (2) age 35-37 with IM < 56%, or (3) age ≥ 38, and (4) women age ≥ 38 using gonadotropins only with IM < 60%. A clinical prediction model and nomogram was developed with an optimism-corrected c-statistic of 0.611.

CONCLUSIONS

The present study highlights the impact of multiple clinical factors on IUI success, identifies criteria consistent with very poor prognosis and futile care, and provides a nomogram to individualize counseling regarding the probability of a viable birth.

Microbiota and Human Reproduction: The Case of Female Infertility

During the last decade, the availability of next-generation sequencing-based approaches has revealed the presence of microbial communities in almost all the human body, including the reproductive tract. As for other body sites, this resident microbiota has been involved in the maintenance of a healthy status. As a consequence, alterations due to internal or external factors may lead to microbial dysbiosis and to the development of pathologies. Female reproductive microbiota has also been suggested to affect infertility, and it may play a key role in the success of assisted reproductive technologies, such as embryo implantation and pregnancy care. While the vaginal microbiota is well described, the uterine microbiota is underexplored. This could be due to technical issues, as the uterus is a low biomass environment. Here, we review the state of the art regarding the role of the female reproductive system microbiota in women's health and human reproduction, highlighting its contribution to infertility.

Twenty-one year experience with intrauterine inseminations after controlled ovarian stimulation with gonadotropins: maternal age is the only prognostic factor for success

PURPOSE

To report our experience on homologous intrauterine insemination (IUI) with gonadotropin controlled ovarian stimulation (COS) cycles and to examine different variables which could predict IUI success.

MATERIALS AND METHODS

This is a retrospective analysis of IUIs performed between January 1997 and December 2017. A total of 7359 COS IUI's procedures (2901 couples) were reviewed. Clinical pregnancy, live birth rate and age, body mass index (BMI), smoking habit, duration of infertility, sperm characteristics before and after treatment (total motile count, morphology, and vitality), day 3 FSH, total gonadotropin dose, and number of follicles were assessed by multivariate logistic regression analysis, and data were expressed as odds ratio (OR).

RESULTS

The mean female age at the time of COS was 35.10 ± 3.93 years. The most common single infertility diagnoses were unexplained infertility (53.55%), mild male factor (19.69%), and anovulation (10.95%). The total progressive motile sperm count (TPMC) was > 1 × 106/ml (mean 1.34 ± 1.08 × 106/ml). The clinical pregnancy rate was 9.38%, and the live birth rate was 7.19% per cycle. Twin pregnancies were 12.17%. Cumulative pregnancy was 21.89% and cumulative live birth rate was 17.58% per couple. Clinical pregnancy and live birth rates were significantly associated with female age [OR 0.97 (95% CI 0.95-0.99) and 0.95 (95% CI 0.93-0.97), respectively] and day 3 FSH [OR 0.91 (95% CI 0.87-0.94) e 0.90 (95% CI 0.87-0.94), respectively].

CONCLUSIONS

Clinical pregnancy rate and live birth rates after COS-IUIs were significantly influenced by female age and FSH levels.

TRIAL REGISTRATION

Clinical trial registration number: NCT03836118.

Number of motile spermatozoa inseminated and pregnancy outcomes in intrauterine insemination

Purpose

To determine whether age modifies the effect of the number of motile spermatozoa inseminated (NMSI) as a predictor of success in Intrauterine Insemination (IUI).

Methods

This retrospective cohort study included all patients who underwent IUI at an academic infertility center between October 2004 and June 2018. The primary outcome was clinical pregnancy (CP; a gestational sac and fetal heartbeat on ultrasound). Results were analyzed by patient factors including age, NMSI, duration of infertility, and cause of infertility, along with treatment factors such as number of follicles and ovulation induction protocol. Factors associated with the odds of achieving a clinical pregnancy were analyzed using binary logistic generalized estimating equations to control for clustering effects by couple. Female age was categorized as <35 years vs. ≥35 years.

Results

Seven hundred thirty-seven couples that underwent 2062 IUI cycles for heterogeneous indications were included. The overall CP rate was 15.1% per cycle, and the cumulative CP rate per couple was 35.9%. For females < 35 years, the odds of CP per cycle were reduced for NMSI categories (× 10⁶) of < 5.0 vs. ≥10.0 (OR = 0.49; 95% CI 0.29–0.83); the odds of CP per cycle did not differ for NMSI 5.0–9.9 vs. ≥10.0 (OR = 0.66; 0.37–1.18). For those ≥35 years, no difference was seen in the odds of CP per cycle for NMSI categories < 5.0 vs. ≥10.0 (OR = 1.55; 95% CI 0.72–3.31) or 5.0–9.9 vs. ≥10.0 (OR = 1.04; 95% CI 0.48–2.27).

Conclusions

These results suggest that the NMSI can be used as a predictor of success in IUI in couples with women who are < 35 years of age; these patients should be counselled about their lower pregnancy rates when the NMSI is < 5.0 × 10⁶. In patients ≥35 years, the NMSI does not appear to be a useful predictor of success. Further studies with larger sample size should be conducted.

Prognostic Factors to Achieve Higher Pregnancy and Live Birth Rate in Intrauterine Insemination Among Subfertile Women

Background: The purpose of this study was to evaluate the prognostic factors that could affect the clinical pregnancy rate (CPR) and live birth rate (LBR) among subfertile women undergoing intrauterine insemination (IUI).

Methods: A retrospective analysis study of a total of 2186 cycles of IUI among 1784 subfertile women between 2012 and 2017 at the infertility clinic in Taipei Medical University Hospital was conducted. Social demographics, CPR, and LBR were measured. Eleven prognostic factors were analysed with multivariable logistic regression.

Results: Of the 2186 cycles, 569 became pregnant (26.0%), resulting in 454 live births. The LBR per cycle and per patient were 20.8% and 24.6%, respectively. Eight factors were found to significantly predict the obstetric outcome among the women who underwent IUI (p [Formula: see text] 0.05). Age, [Formula: see text] 35.0 years old; serum anti-Müllerian hormone (AMH) level, [Formula: see text] 1.2 ng/mL; delayed sperm insemination, [Formula: see text] 36.0 hour following human chorionic gonadotropin (HCG) injection; serum estradiol level, [Formula: see text] 500 pg/mL; endometrial thickness, [Formula: see text] 7.0 mm on the day of HCG administration; and post-wash total motile sperm count (TMSC), [Formula: see text] 5 million/mL were found to be prognostic factors in determining the CPR and LBR (p [Formula: see text] 0.05). However, duration of subfertility and the presence of urine luteinizing hormone surge during the day of the HCG trigger inversely affected the LBR (p = 0.006 and p = 0.033, respectively) but not the CPR (p [Formula: see text] 0.05). The type of infertility, total antral follicle count, and pre-wash TMSC were not able to predict pregnancy outcome (p [Formula: see text] 0.05).

Conclusions: Six out of 11 factors were identified as strong prognostic factors for successful pregnancies and live births: age, serum AMH and serum estradiol levels, endometrial thickness, post-wash TMSC, and delayed sperm insemination after HCG injection.

Effects of exposure to triphenyltin (TPT) contaminant on sperm activity in adulthood of Calomys laucha exposed through breastfeeding

Triphenyltin (TPT) is an organotin compound (OT), primarily used in agriculture and in the composition of antifouling paints for ships worldwide. Studies have showed its effects as an endocrine disrupter in several organisms by preventing enzymatic expression and causing reproductive toxicity. This study aimed to evaluate the effects of exposure to TPT, via breastfeeding, on reproductive physiology in the Calomys laucha species. The experimental design was compound of five groups, two controls and three with different doses of TPT. Moreover, females were exposed by gavage to the TPT for 20 days, from the 1st day postpartum to the 21st postnatal day (PND). Then, the pups were euthanized and the kinetics, organelles, and biochemistry of the sperm were evaluated. The results presented a reduction in total motility in the groups exposed to TPT. Regarding cellular organelles analysis, a loss in membrane integrity was evidenced; the functionality of mitochondria showed diminution followed by increased acrosome reaction. In conclusion, the TPT causes alteration of the reproductive parameters, decreasing the activity and sperm quality in individuals exposed in the breastfeeding phase.

IUI: review and systematic assessment of the evidence that supports global recommendations

BACKGROUND

IUI with or without ovarian stimulation (OS) has become a first-line treatment option for many infertile couples, worldwide. The appropriate treatment modality for couples and their clinical management through IUI or IUI/OS cycles must consider maternal and perinatal outcomes, most notably the clinical complication of higher-order multiple pregnancies associated with IUI-OS. With a current global emphasis to continue to decrease maternal and perinatal mortality and morbidity, the World Health Organization (WHO) had established a multi-year project to review the evidence for the establishment of normative guidance for the implementation of IUI as a treatment to address fertility problems, and to consider its cost-effectiveness for lower resource settings.

OBJECTIVE AND RATIONALE

The objective of this review is to provide a review of the evidence of 13 prioritized questions that cover IUI with and without OS. We provide summary recommendations for the development of global, evidence-based guidelines based upon methodology established by the WHO.

SEARCH METHODS

We performed a comprehensive search using question-specific relevant search terms in May 2015. For each PICO (Population, Intervention, Comparison and Outcomes) drafted by WHO, specific search terms were used to find the available evidence in MEDLINE (1950 to May 2015) and The Cochrane Library (until May 2015). After presentation to an expert panel, a further hand search of references in relevant reviews was performed up to January 2017. Articles that were found to be relevant were read and analysed by two investigators and critically appraised using the Cochrane Collaboration's tool for assessing risk of bias, and AMSTAR in case of systematic reviews. The quality of the evidence was assessed using the GRADE system. An independent expert review process of our analysis was conducted in November 2016.

OUTCOMES

This review provides an assessment and synthesis of the evidence that covers 13 clinical questions including the indications for the use of IUI versus expectant management, the sperm parameters required, the best and optimal method of timing and number of inseminations per cycle, prevention strategies to decrease multiple gestational pregnancies, and the cost-effectiveness of IUI versus IVF. We provide an evidence-based formulation of 20 recommendations, as well as two best practice points that address the integration of methods for the prevention of infection in the IUI laboratory. The quality of the evidence ranges from very low to high, with evidence that may be decades old but of high quality, however, we further discuss where critical research gaps in the evidence remain.

WIDER IMPLICATIONS

This review presents an evidence synthesis assessment and includes recommendations that will assist health care providers worldwide with their decision-making when considering IUI treatments, with or without OS, for their patients presenting with fertility problems.

Triphenyltin exposition induces spermatic parameter alters of Calomys laucha species

The present study aims to evaluate the influence of triphenyltin (TPT) exposure on reproductive physiology on Calomys laucha species, since this species inhabits regions susceptible to exposure to this contaminant. Animals exposed to the highest dose (10.0 mg/kg) presented signs of severe intoxication in only 7 days of exposure, demonstrating a higher sensitivity of this species to triphenyltin. The 10.0 mg TPT/kg dose was analyzed separately for short-term exposure and results suggest that exposure to this dose was severely detrimental to sperm activity. Among the main results obtained in the evaluation of sperm kinetics, a reduction in total motility was observed from the 0.5 mg TPT/kg group, accentuated according to the increase in the doses of TPT. In progressive motility, there was a decrease from the dose of 0.5 mg TPT/kg and maintained the plateau until the dose of 5.0 mg TPT/kg. It was also observed an increase in the distances and velocities average path, rectilinear and curvilinear in doses of 2.5 and 5.0 mg/kg. From the flow cytometry, evaluation a decrease in mitochondrial functionality was observed as the dose increased. Increased membrane fluidity was also observed from the 5.0 mg TPT/kg dose and the acrosome reaction presented higher values at doses of 0.5 and 5.0 mg TPT/kg. We can conclude that TPT causes impairment of the sperm activity, reducing it in individuals exposed in the adult phase.

Do pregnancy rates differ with intra-uterine insemination when different combinations of semen analysis parameters are abnormal?

OBJECTIVE

To evaluate the relationship of one or a combination of semen analysis parameter results on insemination outcomes.

MATERIAL AND METHODS

A retrospective analysis was performed to evaluate the effect on pregnancy rates in relation to one or more abnormal semen analysis parameters based on the 2010 World Health Organization semen analysis guidelines.

RESULTS

Nine hundred eighty-one couples underwent 2231 intrauterine insemination cycles at the Stanford Fertility and Reproductive Medicine Center. In our study, the pregnancy rates ranged from 11-25% when an individual or combined semen analysis parameters were analyzed. Similar pregnancy rates were found when one, two, and in most cases three parameters were abnormal. When a single parameter was abnormal among volume, concentration, and motility, pregnancy rates were mainly unaffected. There was the exception of total sperm count where pregnancy rates were diminished when counts were below 39 million (p=0.04).

CONCLUSIONS

Clearly, total sperm in the specimen and not the concentration of sperm per milliliter was the critical factor for predicting pregnancy. Therefore, a reorganization of semen analysis reports should be done emphasizing the total amount of sperm present and de-emphasizing concentration of sperm.

Validating semen processing for an intrauterine program should take into consideration the inputs, actions and the outputs of the process

To validate semen preparation via density gradient centrifugation, we took into account the input via the semen sample, the action generated by technical and equipment characteristics and the output measured by the level of performance. Longer periods of abstinence reduced % yield, but increased viscosity and incomplete samples collected had no effect. Under controlled technical and equipment characteristics, precision and reproducibility were validated for density gradient. Additionally, as a good laboratory practice, internal and external quality control measures were implemented to guarantee the level of performance. Inseminating motile sperm count is an important predictive parameter for IUI success. In our group of patients, a yield of an absolute lower limit of 2 million motile spermatozoa was sufficient to contemplate IUI. Pregnancy rate of 13.8% where >2 million rapid progressive spermatozoa were inseminated was significantly higher than the pregnancies (4.4%) obtained with <2 million rapid progressive spermatozoa. This percentage was even higher than the national data registered for IUI (12.2%). To make IUI an attractive first-line treatment, standardization and proper validation of semen preparation procedure are mandatory.

Concepts in diagnosis and therapy for male reproductive impairment

An accurate medical history and directed physical examination are essential in diagnosis of male infertility. We review the hormonal assessments and specific genetic analyses that are useful additional tests, and detail other evidence-based examinations that are available to help guide therapeutic strategies. By contrast with female infertility treatments-especially hormonal manipulations to stimulate or enhance oocyte production-spermatogenesis and sperm quality abnormalities are much more difficult to affect positively. In general, a healthy lifestyle can improve sperm quality. A few men have conditions in which evidence-based therapies can increase their chances for natural conception. In this second of two papers in The Lancet Diabetes and Endocrinology Series on male reproductive impairment, we examine the agreements and controversies that surround several of these conditions. When we are not able to cure, correct, or mitigate the cause of conditions such as severe oligozoospermia, non-remedial ductal obstruction, and absence of sperm fertilising ability, assisted reproductive technologies, such as in-vitro fertilisation (IVF) with intracytoplasmic sperm injection (ICSI), can be used as an adjunctive measure to allow for biological paternity. Not considered possible just two decades ago, azoospermia due to testicular failure, including 47,XXY (Klinefelter syndrome), is now treatable in approximately 50% of cases when combining surgical harvesting of testicular sperm and ICSI. Although genetic fatherhood is now possible for many men previously considered sterile, it is crucial to discover and abrogate causes as best possible, provide reliable and evidenced-based therapy, consider seriously the health and wellness of any offspring conceived, and always view infertility as a possible symptom of a more general or constitutional disease.

Novel centrifugal technology for measuring sperm concentration in the home

OBJECTIVE

To evaluate the analytical performance and usability of the Trak Male Fertility Testing System, a semiquantitative (categorical) device recently US Food and Drug Administration (FDA)-cleared for measuring sperm concentration in the home by untrained users.

DESIGN

A three-site clinical trial comparing self-reported lay user results versus reference results obtained by computer-aided semen analysis (CASA).

SETTING

Simulated home use environments at fertility centers and urologist offices.

PATIENT(S)

A total of 239 untrained users.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Sperm concentration results reported from self-testing lay users and laboratory reference method by CASA were evaluated semiquantitatively against the device's clinical cutoffs of 15 M/mL (current World Health Organization cutoff) and 55 M/mL (associated with faster time to pregnancy). Additional reported metrics include assay linearity, precision, limit of detection, and ease-of-use ratings from lay users.

RESULT(S)

Lay users achieved an accuracy (versus the reference) of 93.3% (95% confidence interval [CI] 84.1%-97.4%) for results categorized as ≤15 M/mL, 82.4% (95% CI 73.3%-88.9%) for results categorized as 15-55 M/mL, and 95.5% (95% CI 88.9%-98.2%) for results categorized as >55 M/mL. When measured quantitatively, Trak results had a strong linear correlation with CASA measurements (r = 0.99). The precision and limit of detection studies show that the device has adequate reproducibility and detection range for home use. Subjects generally rated the device as easy to use.

CONCLUSION(S)

The Trak System is an accurate tool for semiquantitatively measuring sperm concentration in the home. The system may enable screening and longitudinal assessment of sperm concentration at home.

CLINICAL TRIAL REGISTRATION NUMBER

ClinicalTrials.gov identifier: NCT02475395.

Measuring Sperm DNA Fragmentation and Clinical Outcomes of Medically Assisted Reproduction: A Systematic Review and Meta-Analysis

Sperm DNA fragmentation has been associated with reduced fertilization rates, embryo quality, pregnancy rates and increased miscarriage rates. Various methods exist to test sperm DNA fragmentation such as the sperm chromatin structure assay (SCSA), the sperm chromatin dispersion (SCD) test, the terminal deoxynucleotidyl transferase mediated deoxyuridine triphosphate nick end labelling (TUNEL) assay and the single cell gel electrophoresis (Comet) assay. We performed a systematic review and meta-analysis to assess the value of measuring sperm DNA fragmentation in predicting chance of ongoing pregnancy with IVF or ICSI. Out of 658 unique studies, 30 had extractable data and were thus included in the meta-analysis. Overall, the sperm DNA fragmentation tests had a reasonable to good sensitivity. A wide variety of other factors may also affect the IVF/ICSI outcome, reflected by limited to very low specificity. The constructed hierarchical summary receiver operating characteristic (HSROC) curve indicated a fair discriminatory capacity of the TUNEL assay (area under the curve (AUC) of 0.71; 95% CI 0.66 to 0.74) and Comet assay (AUC of 0.73; 95% CI 0.19 to 0.97). The SCSA and the SCD test had poor predictive capacity. Importantly, for the TUNEL assay, SCD test and Comet assay, meta-regression showed no differences in predictive value between IVF and ICSI. For the SCSA meta-regression indicated the predictive values for IVF and ICSI were different. The present review suggests that current sperm DNA fragmentation tests have limited capacity to predict the chance of pregnancy in the context of MAR. Furthermore, sperm DNA fragmentation tests have little or no difference in predictive value between IVF and ICSI. At this moment, there is insufficient evidence to recommend the routine use of sperm DNA fragmentation tests in couples undergoing MAR both for the prediction of pregnancy and for the choice of treatment. Given the significant limitations of the evidence and the methodological weakness and design of the included studies, we do urge for further research on the predictive value of sperm DNA fragmentation for the chance of pregnancy after MAR, also in comparison with other predictors of pregnancy after MAR.

Total motile sperm count has a superior predictive value over the WHO 2010 cut-off values for the outcomes of intracytoplasmic sperm injection cycles

The objective of this study was to compare (i) the intracytoplasmic sperm injection outcomes among groups with different total motile sperm count ranges, (ii) the intracytoplasmic sperm injection outcomes between groups with normal and abnormal total motile sperm count, and (iii) the predictive values of WHO 2010 cut-off values and pre-wash total motile sperm count for the intracytoplasmic sperm injection outcomes, in couples with male infertility. This study included data from 518 patients undergoing their first intracytoplasmic sperm injection cycle as a result of male infertility. Couples were divided into five groups according to their total motile sperm count: Group I, total motile sperm count <1 × 10(6) ; group II, total motile sperm count 1-5 × 10(6) ; group III, total motile sperm count 5-10 × 10(6) ; group IV, total motile sperm count 10-20 × 10(6) ; and group V, total motile sperm count >20 × 10(6) (which was considered a normal total motile sperm count value). Then, couples were grouped into an abnormal and normal total motile sperm count group. The groups were compared regarding intracytoplasmic sperm injection outcomes. The predictive values of WHO 2010 cut-off values and total motile sperm count for the intracytoplasmic sperm injection outcomes were also investigated. The fertilization rate was lower in total motile sperm count group I compared to total motile sperm count group V (72.5 ± 17.6 vs. 84.9 ± 14.4, p = 0.011). The normal total motile sperm count group had a higher fertilization rate (84.9 ± 14.4 vs. 81.1 ± 15.8, p = 0.016) and lower miscarriage rate (17.9% vs. 29.5%, p = 0.041) compared to the abnormal total motile sperm count group. The total motile sperm count was the only parameter that demonstrated a predictive value for the formation of high-quality embryos on D2 (OR: 1.18, p = 0.013), formation of high-quality embryos on D3 (OR: 1.12, p = 0.037), formation of blastocysts on D5 (OR: 1.16, p = 0.011), blastocyst expansion grade on D5 (OR: 1.27, p = 0.042), and the odds of miscarriage (OR: 0.52, p < 0.045). The total motile sperm count has a greater predictive value than the WHO 2010 cut-off values for laboratory results and pregnancy outcomes in couples undergoing intracytoplasmic sperm injection as a result of male infertility.

A Survey on Main Semen Parameters in Natural Pregnancy and Intrauterine Insemination: Are There Any Significant Differences?

Intrauterine insemination (IUI) is a treatment of choice compared with other invasive and expensive techniques of assisted reproduction. Sperm quality is used to predict its outcome and success. Establishing threshold levels for sperm parameters is useful to avoid spending time and money to do other assisted reproductive techniques. This study was carried out to compare various semen parameters in a group of men eligible to participate in an IUI program with those of fertile men whose wives were pregnant at the time of the study. Two hundred and thirty-four semen samples were evaluated from subfertile men whose partners were candidates for IUI and 234 semen samples were evaluated from fertile men whose partners were pregnant less than 12 weeks. To assess the sensitivity and specificity of the main semen parameters, receiver operating characteristic (ROC) curves were used. Normal sperm morphology is more sensitive and specific compared with its progressive motility and concentration. No significant differences in various semen parameters of fertile men and those of the male partners of IUI candidates were observed. ROC analysis identified that sperm normal morphology using strict criteria may be a good indicator of fertility status in men. No significant difference in various semen parameters between the male partners of IUI candidates and the fertile men was seen. However, utilizing ROC curves, sperm morphology using strict criteria could be a good predictor of fertility.

Assisted reproductive technologies for male subfertility

BACKGROUND

Intra-uterine insemination (IUI), in vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI) are frequently used fertility treatments for couples with male subfertility. The use of these treatments has been subject of discussion. Knowledge on the effectiveness of fertility treatments for male subfertility with different grades of severity is limited. Possibly, couples are exposed to unnecessary or ineffective treatments on a large scale.

OBJECTIVES

To evaluate the effectiveness and safety of different fertility treatments (expectant management, timed intercourse (TI), IUI, IVF and ICSI) for couples whose subfertility appears to be due to abnormal sperm parameters.

SEARCH METHODS

We searched for all publications that described randomised controlled trials (RCTs) of the treatment for male subfertility. We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, PsycINFO and the National Research Register from inception to 14 April 2015, and web-based trial registers from January 1985 to April 2015. We applied no language restrictions. We checked all references in the identified trials and background papers and contacted authors to identify relevant published and unpublished data.

SELECTION CRITERIA

We included RCTs comparing different treatment options for male subfertility. These were expectant management, TI (with or without ovarian hyperstimulation (OH)), IUI (with or without OH), IVF and ICSI. We included only couples with abnormal sperm parameters.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the studies, extracted data and assessed risk of bias. They resolved disagreements by discussion with the rest of the review authors. We performed statistical analyses in accordance with the guidelines for statistical analysis developed by The Cochrane Collaboration. The quality of the evidence was rated using the GRADE methods. Primary outcomes were live birth and ovarian hyperstimulation syndrome (OHSS) per couple randomised.

MAIN RESULTS

The review included 10 RCTs (757 couples). The quality of the evidence was low or very low for all comparisons. The main limitations in the evidence were failure to describe study methods, serious imprecision and inconsistency. IUI versus TI (five RCTs)Two RCTs compared IUI with TI in natural cycles. There were no data on live birth or OHSS. We found no evidence of a difference in pregnancy rates (2 RCTs, 62 couples: odds ratio (OR) 4.57, 95% confidence interval (CI) 0.21 to 102, very low quality evidence; there were no events in one of the studies).Three RCTs compared IUI with TI both in cycles with OH. We found no evidence of a difference in live birth rates (1 RCT, 81 couples: OR 0.89, 95% CI 0.30 to 2.59; low quality evidence) or pregnancy rates (3 RCTs, 202 couples: OR 1.51, 95% CI 0.74 to 3.07; I(2) = 11%, very low quality evidence). One RCT reported data on OHSS. None of the 62 women had OHSS.One RCT compared IUI in cycles with OH with TI in natural cycles. We found no evidence of a difference in live birth rates (1 RCT, 44 couples: OR 3.14, 95% CI 0.12 to 81.35; very low quality evidence). Data on OHSS were not available. IUI in cycles with OH versus IUI in natural cycles (five RCTs)We found no evidence of a difference in live birth rates (3 RCTs, 346 couples: OR 1.34, 95% CI 0.77 to 2.33; I(2) = 0%, very low quality evidence) and pregnancy rates (4 RCTs, 399 couples: OR 1.68, 95% CI 1.00 to 2.82; I(2) = 0%, very low quality evidence). There were no data on OHSS. IVF versus IUI in natural cycles or cycles with OH (two RCTs)We found no evidence of a difference in live birth rates between IVF versus IUI in natural cycles (1 RCT, 53 couples: OR 0.77, 95% CI 0.25 to 2.35; low quality evidence) or IVF versus IUI in cycles with OH (2 RCTs, 86 couples: OR 1.03, 95% CI 0.43 to 2.45; I(2) = 0%, very low quality evidence). One RCT reported data on OHSS. None of the women had OHSS.Overall, we found no evidence of a difference between any of the groups in rates of live birth, pregnancy or adverse events (multiple pregnancy, miscarriage). However, most of the evidence was very low quality.There were no studies on IUI in natural cycles versus TI in stimulated cycles, IVF versus TI, ICSI versus TI, ICSI versus IUI (with OH) or ICSI versus IVF.

AUTHORS' CONCLUSIONS

We found insufficient evidence to determine whether there was any difference in safety and effectiveness between different treatments for male subfertility. More research is needed.

The Effects of Total Motile Sperm Count on Spontaneous Pregnancy Rate and Pregnancy After IUI Treatment in Couples with Male Factor and Unexplained Infertility

INTRODUCTION

Male infertility factor is defined if the total number of motile spermatozoa (TMSC) < 20 × 10(6)/ejaculated, and unexplained infertility if spermiogram is normal with normal female factor.

THE AIM

of this study was to determine the predictive value of TMSC for spontaneous pregnancy (ST) and pregnancy after treatment with intrauterine insemination (IUI) in couples with male factor and unexplained infertility.

WHAT IS KNOWN ALREADY

According to the WHO qualification system abnormal spermiogram can be diagnosed as oligozoospermia (O), asthenozoospermia (A), teratozoospermia (T) or combination (O+A+T) and azoospermia (A). Although this classification indicates the accuracy of findings its relevance for prognosis in infertile couple and the choice of treatment is questionable.

MATERIALS AND METHODS

The study included 98 couples with male infertility factor (bad spermiogram) and couples with normospermia and normal female factor (unexplained infertility). Testing group is randomized at: group (A) with TMSC> 3,10(6) / ejaculate and a spontaneous pregnancy, group (B) with TMSCl <3 x 10(6) / ejaculate and pregnancy after IUI, plus couples who have not achieved SP with TMSC> 3 x 10(6) / ejaculate and couples who have not achieved pregnancy.

MAIN RESULTS

From a total of 98 pairs of men's and unexplained infertility, 42 of them (42.8%) achieved spontaneous pregnancy, while 56 (57.2%) pairs did not achieve spontaneous pregnancy. TMSC was significantly higher (42.4 ± 28.4 vs. 26.2 ± 24, p <0.05) in the group A compared to group B. Couples with TMSC 1-5 × 10(6) ejaculate had significantly lower (9.8% vs. 22.2%, p <0.0001) rate of spontaneous pregnancy in comparison to couples after IUI treatment. Couples with unexplained infertility had significantly higher (56.8% vs. 29.9%, p <0.01) spontaneous pregnancy rate compared to couples after IUI treatment. Infertile couples had significant pregnancy rate with TMSC 5-10 x 10(6) / ejaculate (OR = 1.45, 95% CI:1.26-1.78, <0.01); with TMSC 10-20 x 10(6) / ejaculate (OR = 1.36, 95% CI: 1:12 to 1:46, <0.0001) with TMSC> 20 x 10(6) / ejaculate (RR = 1.7, 95% CI: 1.56-1.82, <0.001) after treatment with IUI compared to spontaneous pregnancy.

CONCLUSION / INTERPRETATION

Based on these results we can conclude that couples with the TMSC> 5 x 10(6) / ejaculate are indicated for treatment with IUI. TMSC can be used as the method of choice for diagnosis and treatment of male infertility.

Total motile sperm count: a better indicator for the severity of male factor infertility than the WHO sperm classification system

STUDY QUESTION

Does the prewash total motile sperm count (TMSC) have a better predictive value for spontaneous ongoing pregnancy (SOP) than the World Health Organization (WHO) classification system?

SUMMARY ANSWER

The prewash TMSC shows a better correlation with the spontaneous ongoing pregnancy rate (SOPR) than the WHO 2010 classification system.

WHAT IS KNOWN ALREADY

According to the WHO classification system, an abnormal semen analysis can be diagnosed as oligozoospermia, astenozoospermia, teratozoospermia or combinations of these and azoospermia. This classification is based on the fifth percentile cut-off values of a cohort of 1953 men with proven fertility. Although this classification suggests accuracy, the relevance for the prognosis of an infertile couple and the choice of treatment is questionable. The TMSC is obtained by multiplying the sample volume by the density and the percentage of A and B motility spermatozoa.

STUDY DESIGN, SIZE, DURATION

We analyzed data from a longitudinal cohort study among unselected infertile couples who were referred to three Dutch hospitals between January 2002 and December 2006. Of the total cohort of 2476 infertile couples, only the couples with either male infertility as a single diagnosis or unexplained infertility were included (n = 1177) with a follow-up period of 3 years.

PARTICIPANTS/MATERIALS, SETTING, METHODS

In all couples a semen analysis was performed. Based on the best semen analysis if more tests were performed, couples were grouped according to the WHO classification system and the TMSC range, as described in the Dutch national guidelines for male infertility. The primary outcome measure was the SOPR, which occurred before, during or after treatments, including expectant management, intrauterine insemination, in vitro fertilization or intracytoplasmic sperm injection. After adjustment for the confounding factors (female and male age, duration and type of infertility and result of the postcoital test) the odd ratios (ORs) for risk of SOP for each WHO and TMSC group were calculated. The couples with unexplained infertility were used as reference.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 514 couples did and 663 couples did not achieve a SOP. All WHO groups have a lower SOPR compared with the unexplained group (ORs varying from 0.136 to 0.397). Comparing the couples within the abnormal WHO groups, there are no significant differences in SOPR, except when oligoasthenoteratozoospermia is compared with asthenozoospermia [OR 0.501 (95% CI 0.311-0.809)] and teratozoospermia [OR 0.499 (95% CI: 0.252-0.988)], and oligoasthenozoospermia is compared with asthenozoospermia [OR 0.572 (95% CI: 0.373-0.877)]. All TMSC groups have a significantly lower SOPR compared with the unexplained group (ORs varying from 0.171 to 0.461). Couples with a TMSC of <1 × 10(6) and 1-5 × 10(6) have significantly lower SOPR compared with couples with a TMSC of 5-10 × 10(6) [respectively, OR 0.371 (95% CI: 0.215-0.64) and OR 0.505 (95% CI: 0.307-0.832)].

LIMITATIONS, REASON FOR CAUTION

To include all SOPs during the follow-up period of 3 years, couples were not censured at the start of treatment.

WIDER IMPLICATIONS OF THE FINDINGS

Roughly, three prognostic groups can be discerned: couples with a TMSC <5, couples with a TMSC between 5 and 20 and couples with a TMSC of more than 20 × 10(6) spermatozoa. We suggest using TMSC as the method of choice to express severity of male infertility.

STUDY FUNDING/COMPETING INTERESTS

None.

Predictive value of postwashed total progressively motile sperm count using CASA estimates in 6871 non-donor intrauterine insemination cycles

PURPOSE

To determine whether postwashed total progressively motile sperm count (TPMSC) obtained by CASA estimates could predict positive pregnancy test result in non-donor IUI cycles.

METHODS

Six thousand eight hundred and seventy one (6,871) IUI cycles with non-donor semen were retrospectively analyzed. Patient, cycle characteristics and prewashed and postwashed semen parameters were included in analysis. The main outcome measure was the positive pregnancy test result.

RESULTS

The pregnancy rate per cycle (PR/cycle) when postwashed TPMSC is between 0-0.5 million, 0.51-1 million, 1.01-5 million, 5.01-10 million and greater than 10 million were 8.1% (42/520), 14.4 % (41/285), 16.1% (237/1,469), 18.4% (193/1,046) and 18.8% (668/3,551) respectively. The predicted odd of positive pregnancy result is statistically significantly higher when TPMSC is >0.51 million compared to the TPMSC of <0.51 million (OR = 1.68, 95% CI: 1.04-2.71). The predicted odd of positive pregnancy result is greatest when TPMSC is at least 5 million (OR = 2, 95% CI: 1.38 to 2.9).

CONCLUSION

TPMSC is an independent predictor of pregnancy test result and TPMSC of half million or greater is adequate to achieve statistically similar pregnancy test results after non-donor IUI cycles.

The effect of intrauterine insemination time on semen parameters

OBJECTIVE

The purpose of this observational study was to determine whether semen parameters (concentration, motility) were affected by the interval between the onset of postwash sperm incubation and intrauterine insemination (IUI) time.

MATERIAL AND METHODS

Semen specimens of 100 normozoospermic men collected at the clinic were allowed 20 minutes for liquefaction at room temperature. Semen samples were subjected to both macroscopic and microscopic examinations. After centrifugation in a density gradient column and sperm-washing medium, the samples were kept in an incubator. After 30 minutes, 60 minutes, and 120 minutes, the concentration and motility were recorded.

RESULTS

According the results of the Bonferroni post hoc test, there were significant differences in values of mean sperm count, percent progressive sperm motility, and total motile sperm count between 30 minutes and 120 minutes (p=0.000, p=0.000, and p=0.000) and between 60 minutes and 120 minutes (p=0.000, p=0.000, and p=0.001), but there was no significant difference between 30 minutes and 60 minutes (p=1, p=0.173, and p=1).

CONCLUSION

This study demonstrated that sperm parameters are negatively affected from prolonged incubation time. A maximum 60-minute limit of the interval between the onset of postwash sperm incubation and IUI time may increase pregnancy rates.

Semen quality and prediction of IUI success in male subfertility: a systematic review

Many variables may influence success rates after intrauterine insemination (IUI), including sperm quality in the native and washed semen sample. A literature search was performed to investigate the threshold levels of sperm parameters above which IUI pregnancy outcome is significantly improved and/or the cut-off values reaching substantial discriminative performance in an IUI programme. A search of MEDLINE, EMBASE and Cochrane Library revealed a total of 983 papers. Only 55 studies (5.6%) fulfilled the inclusion criteria and these papers were analysed. Sperm parameters most frequently examined were: (i) inseminating motile count after washing: cut-off value between 0.8 and 5 million; (ii) sperm morphology using strict criteria: cut-off value ⩾5% normal morphology; (iii) total motile sperm count in the native sperm sample: cut-off value of 5-10 million; and (iv) total motility in the native sperm sample: threshold value of 30%. The results indicate a lack of prospective studies, a lack of standardization in semen testing methodology and a huge heterogeneity of patient groups and IUI treatment strategies. More prospective cohort trials and prospective randomized trials investigating the predictive value of semen parameters on IUI outcome are urgently needed. It is generally believed that intrauterine insemination (IUI) with homologous semen should be a first-choice treatment to more invasive and expensive techniques of assisted reproduction in cases of cervical, unexplained and moderate male factor subfertility. The rationale for the use of artificial insemination is to increase gamete density at the site of fertilization. Scientific validation of this strategy is difficult because literature is rather confusing and inconclusive. Many variables may influence success rates after IUI treatment procedures. It seems logical that sperm quality has to be one of the main determinants to predict IUI success. Clinical practice would benefit from the establishment of threshold levels for sperm parameters above which IUI pregnancy outcome is significantly improved and below which a successful outcome is unlikely. We performed a literature search to investigate if such threshold levels are known. Most striking were the lack of standardization in semen-testing methodology and the huge heterogeneity of patient groups and IUI treatment strategies. The four sperm parameters most frequently examined were: (i) inseminating motile count after washing: cut-off value between 0.8 and 5 million; (ii) sperm morphology using strict criteria: cut-off value >4% normal morphology; (iii) total motile sperm count in native sperm sample: cut-off value of 5-10 million; and (iv) total motility in native sperm sample: threshold value of 30%. This review identified an urgent need for more and better prospective cohort trials investigating the predictive value of semen parameters on IUI pregnancy rate.

Intrauterine insemination versus fallopian tube sperm perfusion for non-tubal infertility

BACKGROUND

Intrauterine insemination (IUI) is a common treatment for couples with subfertility that does not involve the fallopian tubes. It is used to bring the sperm close to the released oocyte. Another method of introducing sperm is fallopian tube sperm perfusion (FSP). Fallopian tube sperm perfusion ensures the presence of higher sperm densities in the fallopian tubes at the time of ovulation than does standard IUI. These treatments are often used in combination with ovarian hyperstimulation.

OBJECTIVES

To compare intrauterine insemination versus fallopian tube sperm perfusion in the treatment of non-tubal subfertility, for live birth and pregnancy outcomes.

SEARCH METHODS

We searched the Menstrual Disorders and Subfertility Group Trials Register, MEDLINE, CINAHL and EMBASE from inception to September 2013. We also searched study reference lists and trial registers.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing IUI with FSP in couples with non-tubal subfertility were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, assessed study quality and extracted the data. If studies were sufficiently similar, data were combined using a fixed-effect model to calculate pooled odds ratios (ORs) and 95% confidence intervals (CIs). A random-effects model was used if substantial statistical heterogeneity was detected. Studies that included participants with unexplained or mixed (non-tubal) subfertility were analysed separately from studies restricted to participants with mild or moderate male factor subfertility. The overall quality of evidence for the main outcomes was summarised using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria.

MAIN RESULTS

The review included 16 RCTs. Fourteen RCTs (1745 women) were included in the meta-analysis. Only three studies reported live birth per couple. No evidence of a statistically significant difference was noted between IUI and FSP in live birth (OR 0.94, 95% CI 0.59 to 1.49, three RCTs, 633 women, I(2) = 0%, low-quality evidence) or clinical pregnancy (OR 0.75, 95% CI 0.49 to 1.12, 14 RCTs, 1745 women, I(2) = 52%, low-quality evidence). These findings suggest that for a couple with a 13% chance of live birth using FSP, the chance when using IUI will be between 8% and 19%; and that for a couple with a 19% chance of pregnancy using FSP, the chance of pregnancy when using IUI will be between 10% and 20%. Nor was evidence found of a statistically significant difference between IUI and FSP in per-pregnancy of multiple pregnancy (OR 0.96, 95% CI 0.44 to 2.07, eight RCTs, 197 women, I(2) = 0%, low-quality evidence), miscarriage (OR 1.23, 95% CI 0.60 to 2.53, seven RCTs, 199 women, I(2) = 0%, low-quality evidence) or ectopic pregnancy (OR 1.71, 95% CI 0.42 to 6.88, four RCTs, 111 women, I(2) = 0%, very low quality evidence). Substantial heterogeneity was noted for the outcome of clinical pregnancy (I(2) = 54%), for which no clear explanation was provided.

AUTHORS' CONCLUSIONS

Currently no clear evidence suggests any difference between IUI and FSP with respect to their effectiveness and safety for treating couples with non-tubal subfertility. However, a high level of uncertainty is evident in the findings, and additional research may be useful.

Efficacy of sperm motility after processing and incubation to predict pregnancy after intrauterine insemination in normospermic individuals

BACKGROUND

Intrauterine insemination (IUI) is widely used to treat infertility, and its adequate indication is important to obtain good pregnancy rates. To assess which couples could benefit from IUI, this study aimed to evaluate whether sperm motility using a discontinuous gradient of different densities and incubation in CO2 in normospermic individuals is able to predict pregnancy.

METHODS

A total of 175 couples underwent 175 IUI cycles. The inclusion criteria for women were as follows: 35 years old or younger (age range: from 27 to 35 years) with normal fallopian tubes; endometriosis grades I-II; unexplained infertility; nonhyperandrogenic ovulatory dysfunction. Men with normal seminal parameters were also included. All patients underwent ovarian stimulation with clomiphene citrate and human hMG or r-FSH. When one or (at most) three follicles measuring 18 to 20 mm were observed, hCG (5000 UI) or r-hCG (250 mcg) was administered and IUI performed 36-40 h after hCG. Sperm processing was performed using a discontinuous concentration gradient. A 20 microliters aliquot was incubated for 24 h at 37 degrees C in 5% CO2 following a total progressive motility analysis. The Mann-Whitney and Chi-square tests, as well as a ROC curve were used to determine the cutoff value for motility.

RESULTS

Of the 175 couples, 52 (in 52 IUI cycles) achieved clinical pregnancies (CP rate per cycle: 29.7%). The analysis of age, duration and causes of infertility did not indicate any statistical significance between pregnancy and no pregnancy groups, similar to the results for total sperm count and morphology analyses, excluding progressive motility (p < 0.0001). The comparison of progressive motility after processing and 24 h after incubation between these two groups indicated that progressive motility 24 h after incubation was higher in the pregnancy group. The analysis of the progressive motility of the pregnancy group after processing and 24 h after incubation has not shown any motility difference at 24 h after incubation; additionally, in couples who did not obtain pregnancy, there was a statistically significant decrease in progressive motility 24 h after incubation (p < 0.0001). The ROC curve analysis generated a cutoff value of 56.5% for progressive motility at 24 h after incubation and this cutoff value produced 96.1% sensitivity, 92.7% specificity, 84.7% positive predictive value and 98.3% negative predictive value.

CONCLUSIONS

We concluded that the sperm motility of normospermic individuals 24 h after incubation at 37 degrees C in 5% CO2, with a cutoff value of 56.5%, is predictive of IUI success.

The effect of post-wash total progressive motile sperm count and semen volume on pregnancy outcomes in intrauterine insemination cycles: a retrospective study

OBJECTIVE

The purpose of this study was to determine the impact of post-wash total progressive motile sperm count (TPMSC) and semen volume on pregnancy outcomes in intrauterine insemination (IUI) cycles.

MATERIAL AND METHODS

The retrospective study included a total of 156 cycles (141 couples) and was performed in our center over a 24-month period. The semen parameters were recorded for each man and each insemination. The semen samples were re-evaluated after the preparation process. Post-wash TPMSC values were divided into four groups; Group 1: <1×10(6); Group 2: 1-4.9×10(6); Group 3: 5-9.9×10(6); Group 4: 10×10(6) and >10×10(6). Post-wash inseminated semen volume was divided into three groups; Group 1: 0.3 mL; Group 2: 0.4 mL; Group 3: 0.5 mL. The effect of post-wash total progressive motile sperm and semen volume on pregnancy outcomes was evaluated.

RESULTS

The pregnancy rates per cycle and per couple were 27.56% and 30.49%, respectively. There was not a significant relationship between the inseminated semen volume and pregnancy rate (p>0.05). However, a significant linear-by-linear association was documented between the TPMSC and pregnancy rate (p=0.042).

CONCLUSION

Our findings suggest that the post-wash inseminated semen volume should be between 0.3-0.5 mL. An average post-wash total motile sperm count of 10×10(6) may be a useful threshold value for IUI success, but more studies are needed to determine a cut-off value for TPMSC.