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

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.

A comprehensive evaluation of pre- and post-processing sperm parameters for predicting successful pregnancy rate following intrauterine insemination with the husband's sperms

BACKGROUND

To determine the predictive values of sperm parameters pre- and post-processing by density gradient centrifugation for clinical pregnancy rates (CPRs) following artificial insemination by husband (AIH) in infertile Chinese couples.

METHODS

A total of 3,522 AIH cycles from 1,918 couples were retrospectively analyzed. The parameters were compared between the pregnant and non-pregnant groups and further between different etiological groups (Male-factor, Both-male-and-female-factor, and Other-factor). Multivariate logistic regression analysis was performed to create models for predicting the CPRs of each etiological group.

RESULTS

The overall CPR was 13.3%. There were significant improvements for most sperm parameters after DGC. Multivariate logistic regression analysis indicated that, in overall AIH cases, the top parameters significantly influencing the CPR of AIH were pre-STR (OR = 1.037; P = 0.048) and post-VSL (OR = 1.036; P = 0.011). In the Male-factor Group, the top influencing parameters were pre-VCL (OR = 2.096; P = 0.008), pre-LIN (OR = 1.930; P = 0.002) and post-VSL (OR = 1.316; P = 0.023). In the Both-factor Group, the top influencing parameters were pre-VCL (OR = 1.451; P = 0.008) and post-motility (OR = 1.218; P = 0.049). In the Other-factor Group, the top influencing parameters were pre-VAP (OR = 1.715; P = 0.024), pre-STR (OR = 1.20; P = 0.011) and post-VSL (OR = 1.04; P = 0.017). Moreover, receiver operating characteristic analysis showed that the logistic regression models of the Male- and Both-factor Groups had greater powers for prognostic classification than those of other groups.

CONCLUSIONS

This study demonstrated that some sperm parameters have a collinearity relationship in predicting the CPR following AIH. Moreover, the predictive capacity of a multivariate logistic regression model is better than those of individual parameters, especially for the Male- and Both-factor Groups. In these cases, pre-VCL is the common top influencing factor.

Sperm Quality and Deoxyribonucleic Acid Fragmentation after 5 and 10 min Centrifugation with Swim-Up Processing Technique: A Prospective Cohort Study

AIM: This study aimed to assess the difference in sperm concentration, total motility, progressive motility, and deoxyribonucleic acid (DNA) fragmentation index (DFI) before and after processing with 5 and 10 min swim-up (SU). METHODS: Fifty patients who met the study inclusion criteria from June 2020 to October 2020 were subjected to routine semen and sperm DNA fragmentation analysis. Each of the samples was then divided into three tubes, one as control and the others were processed using the SU method with 5 and 10 min centrifugation time, respectively. After being processed, the samples were subjected again to routine semen and sperm DNA fragmentation analysis. The results were being compared among three groups. RESULTS: The sperm concentration after 5 and 10 min SU (27.78–39.79 and 35.36–51.09, respectively; p < 0.05) was significantly higher compared to fresh semen (24.85–32.33). The total motility before and after 5 and 10 min SU were 43.78–51.08, 97.66–98.20, and 97.86–98.20, respectively. The progressive motility after 5 and 10 min SU (0–41 and 0–54, respectively) was significantly higher than fresh semen (0–24; p < 0.05). The DFI was significantly better after 5 min SU (3.82–6.98) compared to fresh semen and after 10 min SU (13.48–19.04 and 1–25, respectively; p < 0.05). CONCLUSION: Prolonged centrifugation time may yield a higher number of sperm concentration and motility, but it may also lead to a higher DFI. Hence, a shorter centrifugation time should be used for a better semen quality intended for assisted reproductive technologies.

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.

Prewash and postwash total progressively motile sperm counts have poor predictive value for clinical pregnancy after intrauterine insemination

OBJECTIVE

To evaluate the predictive value of the prewash and postwash total progressively motile sperm counts (TPMSC) on clinical pregnancy after intrauterine insemination (IUI) .

METHODS

A review of medical records of women undergoing 2064 IUI cycles in a university hospital between April 2010 and October 2018.

RESULTS

No pregnancies were seen when the prewash TPMSC was less than 9 million or the postwash TPMSC was less than 2 million. There was no correlation between TPMSC and clinical pregnancies. Further analysis was made in pregnancies after prewash TPMSC of 3-10 million and more than 10 million, and after postwash TPMSC of 10-100 million and more than 100 million. No correlation was found between TPMSC and clinical pregnancy in different strata of female age, infertility duration, type of infertility, type of IUI treatment, and the number of treatment cycles. A negative relationship was found for unstimulated IUI treatment and the number of treatment cycles. The prewash and postwash TPMSC showed no predictive value.

CONCLUSION

Prewash and postwash TPMSC have poor predictive value for clinical pregnancy in IUI. Cycles with a prewash TPMSC of 10-100 million or postwash TPMSC of 3-10 million could achieve acceptable pregnancy rates with IUI.

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.

Validation of SwimCount™, a Novel Home-Based Device That Detects Progressively Motile Spermatozoa: Correlation with World Health Organization 5th Semen Analysis

Purpose

We evaluated the usefulness of a home-based device (SwimCount™) compared with World Health Organization (WHO) 5th semen analysis in screening for male fertility in Asian men.

Materials and Methods

One hundred Asian men who visited CHA Seoul Station Fertility Center for evaluation of fertility were included. Semen samples were analyzed and compared with the SwimCount™ results. An aliquot of 0.5 mL of the semen sample was added to the SwimCount™ and a WHO 5th semen analysis was performed. Results were categorized as low (<5×10⁶/mL), and normal to high (≥5×10⁶/mL) total progressively motile sperm concentration. Receiver operating characteristic curve analysis was performed to evaluate the accuracy of the SwimCount™.

Results

The mean total progressively motile sperm concentration was 26.7×10⁶/mL. Semen analysis revealed that 28% of the samples were below the threshold count of 5 million/mL total progressively motile sperm concentration. The mean total progressively motile sperm concentration of the light color SwimCount™ result group determined by semen analysis was 7.5×10⁶/mL, and the mean total progressively motile sperm concentration of the moderate to dark color SwimCount™ result group was 34.2×10⁶/mL. An area under the receiver operating characteristic curve of 0.85 (95% confidence interval, 0.77–0.94; p<0.001) was obtained when the SwimCount™ was compared with semen analysis. The sensitivity and specificity were obtained at a cut off value of 5.0×10⁶/mL total progressively motile sperm concentration, giving a sensitivity and specificity of 87.5% and 73.4%.

Conclusions

We confirmed the reliability of the SwimCount™ as a home-based device for male fertility by evaluating the total progressively motile sperm concentration.

The relationship between semen parameters in processed and unprocessed semen with intrauterine insemination success rates

Objective:

To evaluate the relationship between semen parameters and intrauterine insemination (IUI) success rates.

Material and Methods:

This retrospective study was conducted during a 4-year period (2011-2015) on the medical records of 350 couples admitted to the infertility center of Beast Hospital in Tehran. The participants’ data such as age, duration of infertility, semen parameters [including volume, concentration, motility, normal morphology and total motile sperm count (TMSC)] before and after sperm processing, as well as the IUI results were extracted from the patients’ records. Only the first IUI cycle of the couples was considered. The main outcome criterion for the IUI success was serum positive beta human chorionic gonadtotropin 14 days after IUI. The collected data were analyzed using the Mann-Whitney U test, chi-square, and Fisher’s exact tests.

Results:

The overall pregnancy rate for each couple was reported as 23.42% (82/350). There was no significant difference in the mean age of the couple and infertility duration between the groups who achieved pregnancy and those who failed. The two groups showed no significant differences in pre and post processing of semen parameters (including volume, concentration and TMSC). Sperm motility and normal sperm morphology before and after sperm processing were significantly different between the two groups, respectively (p=0.023 before sperm processing and p=0.032 after) (p=0.032 before sperm processing and p=0.007 after).

Conclusion:

Sperm motility and normal sperm morphology have an effect in IUI success.

Clinical success of IUI cycles with donor sperm is not affected by total inseminated volume: a RCT

STUDY QUESTION

What is the impact on live birth rates (LBR) when a donor IUI (dIUI) cycle is performed with an insemination volume of 0.5 mL versus the usual 0.2 mL?

SUMMARY ANSWER

LBR after a dIUI cycle is no different when performed with 0.5 versus 0.2 mL.

WHAT IS ALREADY KNOWN

An IUI has an important role in the treatment of severe male infertility, and is often used in same-sex female couples and single parents. Different variables have been studied to determine factors correlated with clinical outcomes (IUI scheduling, ovarian stimulation, sperm parameters) but little is known about the inseminated volume. The use of conical bottom test tubes could contribute substantially to the loss of inseminated spermatozoa because it precludes the total recovery of the sample. Additionally, the insemination catheter could uphold this reduction causing sperm adhesion on the inner walls of the insemination catheter, decreasing even more the total inseminated volume. It is expected that utilizing an IUI approach that increases sperm volume in the fallopian tubes (0.5 mL rather than 0.2 mL) at the time of ovulation will lead to higher LBRs. To avoid bias related to sperm quality, the study population was restricted to dIUI cycles.

STUDY DESIGN SIZE AND DURATION

A parallel-group, double-blinded, RCT, including patients undergoing natural or stimulated dIUI, was performed between March 2013 and April 2015. dIUI cycles (n = 293) were randomized through a computer-generated list to undergo insemination with 0.2 mL (control group) or 0.5 mL (study group), of which 24 were excluded (protocol deviation) and 269 received the allocated intervention. Patients with the presence of tubal factor infertility, grades III-IV endometriosis, >3 previous dIUI cycles or with ≥3 follicles >14 mm were excluded. The study was designed with 80% power to detect a 5% difference in LBR with a reference of 15% and a two-tailed 5% significance level. The required sample size was 118 per group.

PARTICIPANTS/MATERIALS SETTING AND METHOD

There were 143 cycles (0.2 mL group) and 126 cycles (0.5 mL group). The primary end-point of the trial was LBR per dIUI cycle in both treatment groups. Clinical pregnancy rate and miscarriage rate were evaluated as secondary outcomes.

MAIN RESULTS AND THE ROLE OF CHANCE

No adverse events were reported during the study trial. Study groups (0.2 versus 0.5 mL, respectively) were similar in age (35.8 ± 3.9 versus 35.4 ± 4.0 years: mean±SD), and had similar anti-Mullerian hormone levels (2.2 ± 1.8 versus 2.0 ± 1.5 ng/mL), basal antral follicle count (13.2 ± 6.4 versus 13.6 ± 6.0), BMI (23.5 ± 3.9 versus 23.7 ± 4.1 kg/m2), number of follicles >17 mm (1.1 ± 0.5 versus 1.1 ± 0.5), total gonadotrophin dose (553.1 ± 366.3 versus 494.6 ± 237.1 IU), and total motile sperm count (8.22 ± 7.1 versus 7.7 ± 5.7 million). Similar clinical pregnancy rates (18.9% (27/143) versus 19.8% (25/126), NS), LBRs (15.4% (22/143) versus 19.0% (24/126), NS) and miscarriage rates (18.5% (5/27) versus 4.0% (1/25), NS) were observed between groups.

LIMITATIONS REASONS FOR CAUTION

The study was not powered to detect differences in the secondary outcomes, clinical pregnancy and miscarriage rates. The randomization was performed at the dIUI cycle level, therefore, the results are reported as success rate per dIUI cycle rather than per patient.

WIDER IMPLICATIONS OF THE FINDINGS

This is the first RCT to show that the inseminated volume is not correlated with the probability of a live birth. The miscarriage rate was higher in the 0.2 mL group, although this difference was not statistically significant. If the lower miscarriage rate observed in the 0.5 mL group is confirmed, this could be related to the presence of uterine contractions similar of those generated during sexual intercourse, which may be implicated in the inception of early biochemical embryo-endometrium communication.

STUDY FUNDING/COMPETING INTERESTS

All authors declare having no conflict of interest with regard to this trial. No funding was received for this study. This research was performed under the auspices of 'Càtedra d'Investigació en Obstetrícia I Ginecologia' of the Department of Obstetrics, Gynaecology and Reproductive Medicine, Hospital Universitari Quiron-Dexeus, Universitat Autònoma de Barcelona.

TRIAL REGISTRATION NUMBER

The trial was registered at clinicaltrials.gov (Identifier: NCT03006523).

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.

Effect of sperm count on success of intrauterine insemination in couples diagnosed with male factor infertility

Objective:

To exam semen parameters in predicting intrauterine insemination (IUI) outcomes in couples with male factor.

Study design:

This retrospective study was performed at department of infertility and sexual medicine from September 2007 to February 2014. 307 couples with male factor infertility were included and 672 IUI cycles were analyzed.

Results:

From 672 inseminations performed on 307 couples, there are 27.36% couples get pregnancy (84 out of 307) and the overall pregnancy rate was 12.95% (87 out of 672) of IUI. With the increase of post total progressive sperm count, the clinical pregnancy rate increased. When the initial progressive sperm count was lower than 5*10⁶, there was no pregnant in the IUI cycle. At the end of the third cycle, 85 clinical pregnancies had been achieved (97.70%).

Conclusions:

The initial total progressive sperm count lower than 5*10⁶ means the poor outcome of IUI in the infertile couples with male factor. If the infertile couples with male factor don’t get pregnancy after three IUI cycles, the couples should receive re-assessment or other artificial reproductive technology.

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.