Advanced semen analysis: a simple screening test to predict intrauterine insemination success

Fluorescence-Based Ratiometric Analysis of Sperm Centrioles (FRAC) Finds Patient Age and Sperm Morphology Are Associated With Centriole Quality

A large proportion of infertility and miscarriage causes are unknown. One potential cause is a defective sperm centriole, a subcellular structure essential for sperm motility and embryonic development. Yet, the extent to which centriolar maladies contribute to male infertility is unknown due to the lack of a convenient way to assess centriole quality. We developed a robust, location-based, ratiometric assay to overcome this roadblock, the Fluorescence-based Ratiometric Assessment of Centrioles (FRAC). We performed a case series study with semen samples from 33 patients, separated using differential gradient centrifugation into higher-grade (pellet) and lower-grade (interface) sperm fractions. Using a reference population of higher-grade sperm from infertile men with morphologically standard sperm, we found that 79% of higher-grade sperm of infertile men with substandard sperm morphology have suboptimal centrioles (P = 0.0005). Moreover, tubulin labeling of the sperm distal centriole correlates negatively with age (P = 0.004, R = -0.66). These findings suggest that FRAC is a sensitive method and that patient age and sperm morphology are associated with centriole quality.

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.

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.

The use of aniline blue chromatin condensation test on prediction of pregnancy in mild male factor and unexplained male infertility

The aim of this study was to investigate the possibility of using sperm function tests (hypoosmotic swelling test [HOS], aniline blue [AB] staining test, and sperm chromatin dispersion [SCD]) to predict intrauterine insemination [IUI] success rate. A total of 243 couples with mild male factor or unexplained male infertility who underwent IUI were evaluated prospectively. The results of basic sperm analysis and sperm function tests were compared between pregnant or nonpregnant groups. The HOS (11.9 ± 9.6% vs. 10.1 ± 8.5%, p = 0.35) and SCD tests (32.9 ± 21.0% vs. 29.9 ± 19.0%, p = 0.48) were not significantly different between pregnant (n = 22) and nonpregnant (n = 221) groups. However, the AB staining negativity rate was significantly higher in the pregnant group compared to the nonpregnant group (35.2 ± 20.8% and 24.4 ± 18.0%, p = 0.008). On ROC analysis, a cut-off value of 24% for AB negativity showed a sensitivity and a specificity value of 82.35% and 51.38% (AUC) = 0.653; 95% confidence interval: 0.571-0.72 P (Area = 0.5) = 0.0267, respectively, for prediction of pregnancy. Our study showed that the sperm chromatin maturity, assessed by AB stain, may predict the pregnancy in couples with unexplained female infertility plus mild male factor or unexplained male infertility. The HOS and SCD failed to predict the pregnancy in this group of couples.

Intrauterine Insemination: Fundamentals Revisited

Intrauterine insemination (IUI) is an assisted conception technique that involves the deposition of a processed semen sample in the upper uterine cavity, overcoming natural barriers to sperm ascent in the female reproductive tract. It is a cost-effective, noninvasive first-line therapy for selected patients with functionally normal tubes, and infertility due to a cervical factor, anovulation, moderate male factor, unexplained factors, immunological factor, and ejaculatory disorders with clinical pregnancy rates per cycle ranging from 10 to 20%. It, however, has limited use in patients with endometriosis, severe male factor infertility, tubal factor infertility, and advanced maternal age ≥ 35 years. IUI may be performed with or without ovarian stimulation. Controlled ovarian stimulation, particularly with low-dose gonadotropins, with IUI offers significant benefit in terms of pregnancy outcomes compared with natural cycle or timed intercourse, while reducing associated COH complications such as multiple pregnancies and ovarian hyperstimulation syndrome. Important prognostic indicators of success with IUI include age of patient, duration of infertility, stimulation protocol, infertility etiology, number of cycles, timing of insemination, number of preovulatory follicles on the day of hCG, processed total motile sperm > 10 million, and insemination count > 1 × 106 with > 4% normal spermatozoa. Alternative insemination techniques, such as Fallopian tube sperm perfusion, intracervical insemination, and intratubal insemination, provide no additional benefit compared to IUI. A complete couple workup that includes patient history, physical examination, and clinical and laboratory investigations is mandatory to justify the choice in favor of IUI and guide alternative patient management, while individualizing the treatment protocol according to the patient characteristics with a strict cancelation policy to limit multi-follicular development may help optimize IUI pregnancy outcomes.

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.

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.

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.

What should it take to describe a substance or product as 'sperm-safe'

BACKGROUND

Male reproductive potential continues to be adversely affected by many environmental, industrial and pharmaceutical toxins. Pre-emptive testing for reproductive toxicological (side-)effects remains limited, or even non-existent. Many products that come into direct contact with spermatozoa lack adequate testing for the absence of adverse effects, and numerous products that are intended for exposure to spermatozoa have only a general assumption of safety based on the absence of evidence of actual harm. Such assumptions can have unfortunate adverse impacts on at-risk individuals (e.g. couples who are trying to conceive), illustrating a clear need for appropriate up-front testing to establish actual 'sperm safety'.

METHODS

After compiling a list of general areas within the review's scope, relevant literature and other information was obtained from the authors' personal professional libraries and archives, and supplemented as necessary using PubMed and Google searches. Review by co-authors identified and eliminated errors of omission or bias.

RESULTS

This review provides an overview of the broad range of substances, materials and products that can affect male fertility, especially through sperm fertilizing ability, along with a discussion of practical methods and bioassays for their evaluation. It is concluded that products can only be claimed to be 'sperm-safe' after performing objective, properly designed experimental studies; extrapolation from supposed predicate products or other assumptions cannot be trusted.

CONCLUSIONS

We call for adopting the precautionary principle, especially when exposure to a product might affect not only a couple's fertility potential but also the health of resulting offspring and perhaps future generations.

Sperm Survival: Relationship to Age-Related Sperm DNA Integrity in Infertile Men

The purpose of our study was to evaluate the effect of age and sperm DNA integrity on sperm survival. Semen samples from fifty six unselected patients undergoing infertility evaluation were assessed in terms of standard semen parameters, DNA integrity, and sperm survival after 6-24 h of incubation. Prolonged incubation of density gradient selected sperm adversely effects sperm survival in older patients and patients with extensive sperm DNA damage. Immediate preparation of such samples prior to use for assisted reproductive technology (ART) may overcome the negative effect of extended incubation.

Intra-uterine insemination for male subfertility

BACKGROUND

Intra-uterine insemination (IUI) is one of the most frequently used fertility treatments for couples with male subfertility. Its use, especially when combined with ovarian hyperstimulation (OH) has been subject of discussion. Although the treatment itself is less invasive and expensive than others, its efficacy has not been proven. Furthermore, the adverse effects of OH such as ovarian hyperstimulation syndrome (OHSS ) and multiple pregnancy are a concern.

OBJECTIVES

The aim of this review was to determine whether for couples with male subfertility, IUI improves the live birth rates or ongoing pregnancy rates compared with timed intercourse (TI), with or without OH.

SEARCH STRATEGY

We searched the Cochrane Menstrual and Disorders Subfertility Group Trials Special Register, the Cochrane Central Register of Controlled Trials (the Cochrane Library, 2006, issue 3), MEDLINE (1966 to May 2006), EMBASE (1980 to May 2006), SCIsearch and the reference lists of articles. We hand searched abstracts of the American Society for Reproductive Medicine, the European Society for Human Reproduction and Embryology. Authors of identified articles were contacted for unpublished data.

SELECTION CRITERIA

Randomised controlled trials (RCT's) with at least one of the following comparisons were included: 1) IUI versus TI or expectant management both in natural cycles 2) IUI versus TI both in cycles with OH 3) IUI in natural cycles versus TI + OH 4) IUI + OH versus TI in natural cycles 5) IUI in natural cycles versus IUI + OH. Couples with abnormal sperm parameters only were included.

DATA COLLECTION AND ANALYSIS

Two co-reviewers independently performed quality assessment and data extraction. Where possible data were pooled, and a meta-analysis was performed. Sensitivity and subgroup analyses were carried out where possible and appropriate.

MAIN RESULTS

Three trials of parallel design, and five trials of cross-over design with pre-cross-over data were included in the meta-analysis. Three compared IUI with TI both in stimulated cycles. The remaining four of these studies compared IUI versus IUI + OH . Three studies reported on our main outcome of interest live birth rate per couple. For the comparison IUI versus TI both in natural cycles no evidence of difference between the probabilities of pregnancy rates per woman after IUI compared with TI was found (Peto OR 5.3, 95% CI 0.42 to 67). No statistically significant of difference between pregnancy rates (PR) per couple for IUI + OH versus IUI could be found (Peto OR 1.47, 95% CI 0.92 to 2.37). For the comparison IUI versus TI both in stimulated cycles there was no evidence of statistically significant difference in pregnancy rates per couple either (Peto OR 1.67, 95% CI 0.83 to 3.37). There were insufficient data available for adverse outcomes such as OHSS, multiple pregnancy, miscarriage rate and ectopic pregnancy to perform a statistical analysis. For the other two comparisons no RCT's were found which reported pregnancy rates per couple. A further 10 studies which included one of the comparisons of interests were found. Since these studies reported pregnancy rates per cycle only these data could not be included in the meta-analysis.

AUTHORS' CONCLUSIONS

There was insufficient evidence of effectiveness to recommend or advise against IUI with or without OH above TI, or vice versa. Large, high quality randomised controlled trials, comparing IUI with or without OH with pregnancy rate per couple as the main outcome of interest are lacking. There is a need for such trials since firm conclusions cannot be drawn yet.

Endometrial thickness and pregnancy outcome after intrauterine insemination

OBJECTIVES

To investigate whether endometrial thickness on the day of hCG administration is a predictor of intrauterine insemination (IUI) success.

DESIGN

A retrospective study.

PATIENT(S)

Two hundred forty-nine women undergoing IUI cycles.

SETTING

University hospital-based infertility center.

INTERVENTION(S)

Endometrial thickness on the day of hCG administration, cycle parameters, and sperm quality were compared between pregnant and nonpregnant patients. A similar comparison was made between ongoing pregnancies and those that resulted in a loss.

MAIN OUTCOME MEASURE(S)

Endometrial thickness versus IUI outcome.

RESULT(S)

The overall pregnancy rate was 15%. Mean (+/- standard deviation) endometrial thickness on the day of hCG administration was significantly greater in cycles where pregnancy was achieved (10.1 +/- 3.0 vs. 7.7 +/- 3.5). In the univariate analysis, the following variables affected the pregnancy rate: the woman's age, duration of infertility, the number of IUI cycles, the number of follicles, the diameter of the dominant follicle, the duration of follicle maturation, and sperm count, motility, and morphology. In the multivariate analysis, the strongest predictor of IUI success was the number of IUI cycles. The woman's age was negatively associated with pregnancy outcome, while endometrial thickness and the total motile sperm count were positively associated with pregnancy outcome.

CONCLUSION(S)

The results of the present study suggest that clinicians providing IUI for infertile couples must pay close attention to endometrial development as well as to follicle growth and sperm motility.

Intra-uterine insemination for male subfertility

BACKGROUND

Intra-uterine insemination (IUI) is one of the most frequently used fertility treatments for couples with male subfertility. Its use, especially when combined with ovarian hyperstimulation (OH) has been subject of discussion. Although the treatment itself is less invasive and expensive than others, its efficacy has not been proven. Furthermore, the adverse effects of OH such as ovarian hyperstimulation syndrome (OHSS ) and multiple pregnancy are a concern.

OBJECTIVES

The aim of this review is to determine whether for couples with male subfertility, IUI improves the live birth rates or ongoing pregnancy rates compared with timed intercourse (TI), with or without OH.

SEARCH STRATEGY

We searched the Cochrane Menstrual and Disorders Subfertility Group Trials Special Register, the Cochrane Central Register of Controlled Trials (the Cochrane Library, 2006, issue 3), MEDLINE (1966 to May 2006), EMBASE (1980 to May 2006), SCIsearch and the reference lists of articles. We hand searched abstracts of the American Society for Reproductive Medicine, the European Society for Human Reproduction and Embryology. Authors of identified articles were contacted for unpublished data.

SELECTION CRITERIA

Randomised controlled trials (RCT's) with at least one of the following comparisons were included: 1) IUI versus TI or expectant management both in natural cycles 2) IUI versus TI both in cycles with OH 3) IUI in natural cycles versus TI + OH 4) IUI + OH versus TI in natural cycles 5) IUI in natural cycles versus IUI + OH Couples with abnormal sperm parameters only were included.

DATA COLLECTION AND ANALYSIS

Two co-reviewers independently performed quality assessment and data extraction. Where possible data were pooled, and a meta-analysis was performed. Sensitivity and subgroup analyses were carried out where possible and appropriate.

MAIN RESULTS

Three trials of parallel design, and five trials of cross-over design with pre-cross-over data were included in the meta-analysis. Three compared IUI with TI both in stimulated cycles. The remaining four of these studies compared IUI versus IUI + OH . Three studies reported on our main outcome of interest live birth rate per couple. For the comparison IUI versus TI both in natural cycles no evidence of difference between the probabilities of pregnancy rates per woman after IUI compared with TI was found (Peto OR 5.3, 95% CI 0.42 to 67). No statistically significant of difference between pregnancy rates (PR) per couple for IUI + OH versus IUI could be found (Peto OR 1.47, 95% CI 0.92 to 2.37). For the comparison IUI versus TI both in stimulated cycles there was no evidence of statistically significant difference in pregnancy rates per couple either (Peto OR 1.67, 95% CI 0.83 to 3.37). There were insufficient data available for adverse outcomes such as OHSS, multiple pregnancy, miscarriage rate and ectopic pregnancy to perform a statistical analysis. For the other two comparisons no RCT's were found which reported pregnancy rates per couple. A further 10 studies which included one of the comparisons of interests were found. Since these studies reported pregnancy rates per cycle only these data could not be included in the meta-analysis.

AUTHORS' CONCLUSIONS

There was insufficient evidence of effectiveness to recommend or advise against IUI with or without OH above TI, or vice versa. Large, high quality randomised controlled trials, comparing IUI with or without OH with pregnancy rate per couple as the main outcome of interest are lacking. There is a need for such trials since firm conclusions cannot be drawn yet.

Ambient Manganese Exposure is Negatively Associated With Human Sperm Motility and Concentration

BACKGROUND

Occupational and experimental animal studies indicate that exposure to high levels of manganese impairs male fertility, but the effects of ambient manganese in humans are not known.

METHODS

We measured blood levels of manganese and selenium in 200 infertility clinic clients in a cross-sectional study. Correlations between metals and semen variables were determined, adjusting for other risk factors. Outcomes were low motility (<50% motile), low concentration (<20 million/mL), or low morphology (<4% normal). We also investigated dose-response relationships between quartiles of manganese exposure and sperm parameters.

RESULTS

High manganese level was associated with increased risk of low sperm motility (odds ratio = 5.4; 95% confidence interval = 1.6-17.6) and low sperm concentration (2.4; 1.2-4.9). We saw a U-shaped dose-response pattern between quartiles of manganese exposure and all 3 sperm parameters.

CONCLUSION

Ambient exposure to manganese levels is associated with a reduction in sperm motility and concentration. No adverse effects were seen for high selenium.

Quality of reporting of test accuracy studies in reproductive medicine: impact of the Standards for Reporting of Diagnostic Accuracy (STARD) initiative

OBJECTIVE

To evaluate the extent to which test accuracy studies published in two leading reproductive medicine journals in the years 1999 and 2004 adhered to the Standards for Reporting of Diagnostic Accuracy (STARD) initiative parameters, and to explore whether the introduction of the STARD statement has led to an improved quality of reporting.

DESIGN

Structured literature search. Articles that reported on the diagnostic performance of a test in comparison with a reference standard were eligible for inclusion. For each article we scored how well the 25 items of the STARD checklist were reported. These items deal with the study question, study participants, study design, test methods, reference standard, statistical methods, reporting of results, and conclusions. We calculated the total number of reported STARD items per article, summary scores for each STARD item, and the average number of reported STARD items per publication year.

SETTING

Not applicable.

PATIENT(S)

Not applicable.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Quality of reporting.

RESULT(S)

We found 24 studies reporting on test accuracy in reproductive medicine in 1999 and 27 studies in 2004. The mean number of reported STARD items for articles published in 1999 was 12.1 +/- 3.3 (range 6.5-20) and 12.4 +/- 3.2 (range 7-17.5) in 2004, after publication of the STARD statement. Overall, less than half of the studies reported adequately on 50% or more of the STARD items. The reporting of individual items showed a wide variation. There was no significant improvement in mean number of reported items for the articles published after the introduction of the STARD statement.

CONCLUSION(S)

Authors of test accuracy studies in the two leading fertility journals poorly report the design, conduct, methodology, and statistical analysis of their study. Strict adherence to the STARD guidelines should be encouraged.

Predictive value of the hemizona assay for pregnancy outcome in patients undergoing controlled ovarian hyperstimulation with intrauterine insemination

OBJECTIVE

The hemizona assay (HZA) is an established functional test that examines in vitro sperm-zona pellucida binding capacity with high predictive power for fertilization outcome in IVF. The objective of this study was to evaluate the value of the HZA as a predictor of pregnancy in patients undergoing controlled ovarian hyperstimulation (COH) and intrauterine insemination (IUI).

DESIGN

Prospective clinical study.

SETTING

Academic center.

PATIENT(S)

Eighty-two couples with unexplained or male factor infertility that underwent 313 IUI cycles.

INTERVENTION(S)

Basic semen analysis and HZA were performed within three months of starting COH/IUI therapy.

MAIN OUTCOME MEASURE(S)

Hemizona index (HZI) and clinical pregnancy.

RESULT(S)

Overall, patients with an HZI of <30 had a significantly lower pregnancy rate compared to patients with an HZI of > or =30 (11.1% vs. 40.6%, respectively; P<.05; relative risk for failure to conceive: 1.5 (confidence interval 1.2-1.9)). In all patients combined, and in the range of HZI 0-60, the duration of infertility (P=.000) and the HZI (P=.004) were significant determinants of conception (receiver operating characteristics (ROC) analysis). In couples with male infertility, the average path velocity and HZI were significant predictors of conception (P=.001 and P=.005, respectively, ROC analysis). The negative and positive predictive values of the HZA for pregnancy were 93% and 69%, respectively. Logistic regression analysis provided models of HZI (P=.021) and duration of infertility (P=.037) with highest predictability of conception in male factor and unexplained infertility groups, respectively.

CONCLUSION(S)

The HZA predicted pregnancy in the IUI setting with high sensitivity and negative predictive value in couples with male infertility. Results of this sperm function test are useful in counseling couples before allocating them into COH/IUI therapy.

Significance of sperm characteristics in the evaluation of male infertility

OBJECTIVE

To compare sperm characteristics among: patients undergoing infertility evaluation, patients with male factor infertility (MFI), healthy sperm donors, and men with proven fertility; to examine the overlap of sperm characteristics in all four of these groups; and to identify good discriminators of fertility versus infertility among sperm characteristics.

DESIGN

Retrospective study.

SETTING

Male infertility clinic at a tertiary care hospital.

PATIENT(S)

Proven fertile men (n = 56), normal donors (n = 91), men presenting for infertility evaluation (n = 406), and MFI patients (n = 166).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Routine semen analysis.

RESULT(S)

Using current World Health Organization (WHO) reference values, a large group of MFI patients presented with higher sperm concentration (27.5 x 10(6) to 99.2 x 10(6)), resulting in broader overlap with fertile men and poor sensitivity (0.48). Similarly, percentage normal morphology (%) using Tygerberg's strict criteria was low in most of the MFI patients (sensitivity 0.83), almost half of the fertile men also presented with abnormal morphology (specificity 0.51). Of all the variables examined, sperm motility (%) was superior, having minimum overlap range (lower and upper cut-off values 46% and 75%) and high sensitivity (0.74) and specificity (0.90). Areas under curve were higher for motility (0.90) and concentration (0.84) compared with morphology (WHO 0.65 and Tygerberg's strict criteria 0.74).

CONCLUSION(S)

Sperm motility and concentration provide more accurate information than morphology (WHO and Tygerberg's criteria) during infertility evaluation. Redefining the reference values for concentration and morphology may significantly increase the importance of routine semen analysis.

IUI in male subfertility: are we able to select the proper patients?

There is at this time no indication as to which semen parameters from the fertility work-up discriminate between couples with male subfertility who will and will not benefit from intrauterine insemination (IUI). This study evaluated the predictive capacity of semen parameters (both pre- and post-wash) and antisperm antibodies (ASA) obtained during the fertility workup on IUI outcome in couples with male subfertility in a retrospective cohort study. It included 290 couples, who underwent 722 IUI cycles. The overall ongoing pregnancy rate was 9% per cycle. Model I, with female age, duration of subfertility, secondary subfertility, the presence of anovulation, cervical hostility and cycle number had an area under the curve (AUC) of 0.59. Adding the presence of ASA to this model improved the AUC to 0.65 (model II). Further addition of the post-wash total motile count (TMC) to the model with ASA (model III) improved the AUC to 0.67. Using the models to exclude couples from IUI due to low expected pregnancy rates would increase the pregnancy rate to 11% per cycle with model I, and to 14% per cycle for model II and for model III. In conclusion, in the selection of patients with male subfertility for IUI, the use of prediction models including ASA can increase the efficiency of IUI.

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

OBJECTIVE

To assess the performance and clinical value of the postwash total motile sperm count (postwash TMC) as a test to predict intrauterine insemination (IUI) outcome.

DESIGN

Meta-analysis of diagnostic tests.

SETTING

Tertiary fertility center.

PATIENT(S)

Patients undergoing IUI.

INTERVENTION(S)

None.

RESULT(S)

We detected 16 studies that reported on postwash TMC at insemination and IUI outcome. Summary receiver operating characteristics (ROC) curves indicated a reasonable predictive performance toward IUI outcome, and, at cut-off levels between 0.8 to 5 million motile spermatozoa, the postwash TMC provided a substantial discriminative performance. At these cut-off levels, the specificity of the postwash TMC, defined as the ability to predict failure to become pregnant, was as high as 100%; the sensitivity of the test, defined as the ability to predict pregnancy, was limited.

CONCLUSION(S)

The postwash TMC at insemination could potentially be used in counseling patients for either IUI or IVF. However, to enable patient counseling before the start of treatment, further studies are needed to establish the accuracy of a postwash TMC during the fertility workup rather than at insemination.

Seminal lead concentrations negatively affect outcomes of artificial insemination

OBJECTIVE

To determine the relationships among seminal lead levels, acrosome status, and artificial insemination cycle fecundity (AI f) in semen donors.

DESIGN

Longitudinal analysis of seminal lead levels, sperm function testing, and fecundity.

SETTING

University medical center andrology and research laboratories.

PATIENT(S)

Semen donors (n = 15) participating in a therapeutic donor insemination program.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Seminal plasma lead levels, acrosome sensitivity to progesterone (P) and voltage-gated potassium channel inhibitors (e.g., charybdotoxin [CBTx]), and AI f.

RESULT(S)

Seminal plasma lead levels and AI f were strongly negatively correlated. Semen donors were divided into three groups by acrosome response to P: normal (CBTx sensitive [Rs] or CBTx resistant [Rr]: responders) and reduced (nonresponders [NR]) (Rs > Rr >> NR). Seminal lead differed among the three groups (NR > Rr > Rs). Comparison of 330 artificial insemination cycles from four Rs, four Rr, and two NR demonstrated that cycle AI f also differed significantly between groups (Rs >Rr >>NR).

CONCLUSION(S)

Measurements of seminal plasma lead, P-stimulated acrosome loss, and sensitivity to CBTx may provide prognostic information on the fertility status of potential donors as well as male infertility patients. Such evaluations may assist in donor acceptance, or in the case of patients, in selection of the appropriate treatment regimen.

The use of novel semen quality scores to predict pregnancy in couples with male-factor infertility undergoing intrauterine insemination

The purpose of this study was to determine whether 2 new semen quality (SQ) scores could predict pregnancy in patients undergoing intrauterine insemination (IUI) for male-factor infertility and whether an overall score could help in counseling these couples with assisted reproductive technique (ART) options. Ninety-three couples with male-factor infertility were examined for semen analysis. Samples were prepared by density gradient separation (47% and 90%), and IUI was performed. On the basis of the 2 semen scores (SQ and relative quality [RQ]), the IUI-semen pregnancy score (IUI-SPS) was calculated. Of the 192 IUI cycles, 14% (27 of 192) resulted in pregnancy. Both prewash SQ and RQ scores were significantly related to pregnancy (P =.02 and P <.001), as was the postwash RQ score (P <.001). Of the IUI cycles in which the postwash RQ score was greater than 125, 40% (13 of 32) resulted in pregnancy compared to 9% of cycles (14 of 160) in which the postwash SQ score was less than 125. The prewash IUI-SPS score was significantly related to IUI-induced pregnancy (P <.001). Both the pre- and postwash SQ and RQ scores can predict pregnancy in male infertility patients undergoing IUI. Patients with an IUI-SPS less than 150 may be advised to seek in vitro fertilization (IVF), whereas those with an IUI-SPS greater than 150 may be advised to seek IUI.

Semen quality and intrauterine insemination

There is good evidence in literature that intrauterine insemination (IUI) is the best first line treatment and most cost-effective procedure for moderate male factor subfertility. It seems very difficult to identify individual semen parameters predicting the likelihood of pregnancy after IUI. This can be explained by a lack of standardization of semen analysis, but many other methodological variables may also influence IUI success rates such as the patient selection, type of ovarian stimulation and number of inseminations per cycle. A review of the literature confirmed that sperm morphology using strict criteria and the inseminating motile sperm count (IMC) after sperm preparation are the two most important sperm parameters to assess the real impact of semen quality on IUI outcome. A universal threshold level above which IUI can be performed with acceptable pregnancy rates has not been determined yet, although IUI success seems to be impaired with <5% normal spermatozoa and an IMC of <1 x 10(6). Until now, no method of sperm preparation has been shown to be superior with regard to pregnancy rate after IUI. Whether supplementation of culture media with substances such as antioxidants and platelet activating factor may improve the results remains the subject of further research.

Post-thaw evaluation of dog spermatozoa using new triple fluorescent staining and flow cytometry

A new triple fluorescent staining method was developed to evaluate frozen-thawed dog spermatozoa. This method was used to compare functional parameters of canine spermatozoa cryopreserved using 2 different freezing-thawing protocols. One ejaculate from each of 10 dogs was split into 2 aliquots and processed using the Andersen method or the CLONE method. Semen samples were evaluated immediately after thawing and after 3 h of incubation at 37 degrees C. Plasma membrane integrity and acrosomal status of the spermatozoa were evaluated simultaneously by flow cytometry using a combination of 3 fluorescent dyes: Carboxy-SNARF-1 (SNARF), to identify the live spermatozoa; propidium iodide (PI), which only stains dead cells or cells with damaged membranes; and fluorescein isothiocyanate (FITC)-conjugated Pisum sativum agglutinin (PSA), which binds to the acrosomal content of spermatozoa with damaged plasma and outer acrosomal membranes. The accuracy of this new staining method in quantifying the proportions of live and dead spermatozoa by flow cytometry was evaluated by comparing it with the staining technique using carboxyfluorescein diacetate and propidium iodide (CFDA-PI), which yielded high correlation coefficients. The triple-stained sperm samples were also analyzed by epifluorescence microscopy, and both methods proved to be highly correlated. Post-thaw progressive motility and plasma membrane integrity were similar for the 2 freezing procedures, but the proportion of damaged acrosomes after thawing was lower using the Andersen method and the spermatozoa had a higher thermoresistance. This new triple staining method for assessing canine sperm viability and acrosomal integrity provides an efficient procedure for evaluating frozen-thawed dog semen samples either by flow cytometry or fluorescence microscopy.