Long-term follow-up of couples after hamster egg penetration testing

The progressive simplification of the infertility evaluation

OBJECTIVE

With the advent of evidence-based medicine, much of the complex testing that infertile couples used to undergo is no longer recommended as part of the routine evaluation. Examples of tests no longer implemented include the postcoital test, Rubin test of tubal patency, endometrial biopsy, sperm antibody testing, and the zona-free hamster test. The role of routine diagnostic laparoscopy and hysteroscopy is also reviewed.

CONCLUSIONS

In 2010, the simplicity of the current evaluation of couples presenting with infertility is essential information for patients to know at the initial visit. Ideally, it can help alleviate anxiety and provide patients with a road-map during a visit that is often associated with stress and high emotions.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this educational activity, the obstetrician/gynecologist should be better able to assess the current recommendations for evaluating infertile couples; examine the various ways to assess ovarian reserve, the uterine cavity, and fallopian patency; and appraise the controversy surrounding diagnostic surgery.

Prediction of fecundability from semen analysis: problems in providing an accurate prognosis

Information from semen analysis is used to predict the likelihood that a couple will conceive within a period of time. It is only possible to provide a probability; there can be no certainty. The probability is influenced by a host of factors including semen quality, and studies in large groups or using simple models are required to overcome this. Delayed conception from natural intercourse or poor fertilization at IVF has limited predictive power for a subsequent attempt. The problem is made worse by variations in sperm parameters among different ejaculates from the same man and by differences among groups of patients. Results of studies of potential criteria should be presented in a way that allows the effect of the test result on the probability of conception to be appreciated, and results should be confirmed on independent data sets. When there is potential for fertility, estimation of fecundability can only be approximate; however, progress is possible. Effects of semen quality can be clearly identified in large groups, and computer assisted semen analysis measurements do provide useful additional information for the success of intracervical insemination.

Male partner screening before in vitro fertilization: preselecting patients who require intracytoplasmic sperm injection with the sperm penetration assay

OBJECTIVES

To determine the diagnostic accuracy of the sperm penetration assay (SPA) and standard semen parameters for subsequent fertilization in in vitro fertilization-embryo transfer (IVF-ET).

DESIGN

Prospective study.

SETTING

Andrology Laboratory, and university research laboratory.

PATIENTS

Two hundred sixteen couples undergoing male-partner screening before IVF-ET (265 cycles).

INTERVENTION(S)

Male-partner screening (semen analyses [SA] and SPA), standard IVF-ET procedures, follow-up of fertilization in IVF-ET.

MAIN OUTCOME MEASURE(S)

Diagnostic accuracy of SA and SPA for prediction of fertilization in IVF-ET.

RESULT(S)

The SPA predicted IVF fertilization with high negative (84%) and positive (98%) predictive rates, and correct prediction in 88% of cycles. In contrast, sperm concentration, motility, morphology, and complete SA showed poor diagnostic accuracy, with correct prediction of IVF fertilization in 64%, 65%, 45%, and 68% of cycles, respectively.

CONCLUSION(S)

Very low sperm concentration and/or motility were good predictors of poor IVF fertilization, however, low to normal semen parameters were not predictive of successful IVF fertilization. The SPA is a useful screening tool that predicts IVF fertilization with high diagnostic accuracy. The SPA may be useful to discriminate between those couples with a high probability of normal fertilization in IVF and those with a low probability of normal fertilization that may benefit from assisted fertilization by intracytoplasmic sperm injection (ICSI).

Is intracytoplasmic sperm injection necessary for couples undergoing in vitro fertilization-embryo transfer with normal semen analyses but failing hamster egg penetration assays?

PURPOSE

Our purpose was to assess whether in vitro fertilization (IVF)-embryo transfer (ET) candidate couples with basically normal semen analyses but failing zona-free hamster egg penetration assay (HEPA) scores benefit from intracytoplasmic sperm injection (ICSI).

METHODS

Twenty consecutive IVF candidate couples with normal-borderline semen analyses and failing HEPA scores were recruited. Mature oocytes obtained from each woman were randomly divided between ICSI (group I; n = 126 oocytes) and standard insemination techniques (group II; 138 oocytes). Fertilization (two pronuclei) and cleavage (2-4 cells) rates were assessed for both groups.

RESULTS

There were no statistically significant differences between the two groups with respect to (mean +/- standard error of the mean) fertilization (group I, 63.1 +/- 7.75; group II, 77.8 +/- 4.7%) or cleavage (group I, 87.3 +/- 2.4%; group II, 91.2 +/- 3.5%) rates.

CONCLUSIONS

ICSI is not beneficial for IVF-ET when sperm samples demonstrate a failing HEPA score but have normal or minimally compromised semen analysis parameters.

Practice patterns among reproductive endocrinologists: further aspects of the infertility evaluation

OBJECTIVE

To characterize infertility testing in clinical practice.

DESIGN

A cross-sectional study assessing differences in clinical practice based on identifiable practitioner variables, such as gender, age, and type of practice.

SETTING

A population-based national survey.

PARTICIPANT(S)

U.S. board-certified reproductive endocrinologists.

MAIN OUTCOME MEASURE(S)

Physicians' preferences in the interpretation and performance of the semen analysis, postcoital test (PCT), hysterosalpingography (HSG), laparoscopy, immunologic testing, hamster egg penetration assay, and screening for the luteinized unruptured follicle syndrome.

RESULT(S)

Younger physicians more often favor the use of Kruger strict morphology for the semen analysis, rely on urine or blood LH measurements for the timing of the PCT, and use a less strict cutoff for the definition of a normal PCT. About half of all physicians use antibiotic prophylaxis before HSG and 90% rely on water-soluble dye for imaging. Eighty percent of physicians in western U.S. practices schedule diagnostic laparoscopy during the follicular phase compared with 50% of their East Coast colleagues. Two thirds of physicians would conduct immunologic testing for infertility, but most would not use the hamster egg penetration test or screen for the luteinizing unruptured follicule syndrome.

CONCLUSION(S)

Although most board-certified reproductive endocrinologists agree on the major areas of the performance of infertility testing, there was significant variability in the details of the performance of most testing, especially with respect to physician age and geographic location.

A quality control system for the optimized sperm penetration assay

OBJECTIVE

To develop a quality control system for the optimized sperm penetration assay (SPA) and to use this system to monitor interassay variability and stability over time.

DESIGN

Four semen donors were tested consecutively for a period of weeks (7 to 139 weeks) with the SPA. Their average semen analyses and SPA scores were evaluated to monitor natural biologic variation. Intra-assay variation was obtained by dividing 11 semen samples into three aliquots and testing each separately in the SPA. A single ejaculate from seven individuals was aliquoted and frozen to be used as a control. They were tested on different assay days in 1986 and subsequently in 1991 to evaluate the assay stability over time.

MAIN OUTCOME MEASURES

Results were expressed as a sperm capacitation index (mean number of sperm penetrations per ovum).

RESULTS

Consecutive weekly semen analyses and SPAs on donors exhibited coefficients of variation ranging from 20% to > 40%. In contrast, these variations were much greater than intra-assay variability. Analysis of frozen semen specimens tested in several SPAs also displayed a low coefficient of variation. When aliquots of these frozen samples were tested in the SPA 5 years later, there were no differences in the observed values, showing the remarkable stability of this assay over time. The lower limit of the normal fertile range did not change over a period of 2 years.

CONCLUSIONS

Results show that using fresh semen samples as a positive control in the SPA is inadequate. This deficiency has been overcome with the use of frozen semen controls. With frozen semen for quality control, the optimized SPA developed in this laboratory is a highly reproducible assay that meets the strict criteria required for clinical laboratory certification.