Factors Leading to Pregnancies in Stimulated Intrauterine Insemination Cycles and the Use of Consecutive Ejaculations Within a Small Clinic Environment

Enhancing Sperm Quality Through Consecutive Ejaculation After Short Abstinence in Men with Low Semen Parameters Undergoing ICSI

Background

Longer abstinence time is believed to be associated with the production of reactive oxygen species (ROS), which in excessive amounts may be detrimental to the sperm. To enhance sperm quality, multiple research studies have proposed reducing the duration of abstinence by encouraging consecutive ejaculations. This approach has been shown to improve sperm motility and morphology, which are associated with better ICSI and IUI outcomes. The purpose of the current study was to evaluate sperm quality and fertilization rate, cleavage rate, as well as embryo quality in severe oligoasthenozoospermic men using the consecutive ejaculate collected within an hour of abstinence.

Methods

A prospective study was conducted at Halim Fertility Center from August 2020-April 2022, involving male partners undergoing ICSI treatment who presented with severe oligoasthenozoospermia on their previous semen analysis. The non-parametric Mann-Whitney and Wilcoxon tests were used to analyze the parameters of the groups, including characteristics of the study participants, oocytes and sperm samples, as well as the ICSI outcomes, using a significance level of 5%.

Results

A statistically significant improvement in the sperm total motility was recorded in the consecutive ejaculate compared to the first (31.53±11.73% vs. 22.52±8.85%; p<0.001). Both fertilization and cleavage rates were higher in the consecutive ejaculate group, although they were not statistically significant (61.41±28.04% vs. 55.45±31.76%; p=0.081 and 88.10±28.63% vs. 81.07±36.34%; p=0.262).

Conclusion

Consecutive ejaculates collected within an hour of the first may enhance sperm total motility, fertility, and cleavage rates in male partners with low sperm count and quality undergoing ICSI treatment.

Does a Very Short Length of Abstinence Improve Assisted Reproductive Technique Outcomes in Infertile Patients with Severe Oligo-Asthenozoospermia?

In recent years, a growing number of studies seem to support the beneficial effects of a very short abstinence period on sperm parameters, especially in patients with oligo-asthenozoospermia (OA). On this basis, the aim of this study was to evaluate the effects of a short period of abstinence (1 h) on intracytoplasmic sperm injection (ICSI) outcomes in infertile patients with severe OA. We performed a retrospective study on 313 ICSI cycles in which couples were divided into two different groups based on sperm parameters of the male partners. Group 1 included normozoospermic men or male partners with a mild OA (n = 223). Group 2 included male partners with severe OA (n = 90). They were asked to provide a second consecutive ejaculation after 1 h from the first one. The best ejaculate was used to perform ICSI. We found a significant increase of total (p < 0.001) and progressive motility (p < 0.001) in the second ejaculate of patients of Group 2 compared with those of the first one. Spermatozoa of the second ejaculate were chosen for ICSI for all patients in Group 2. We found statistically significant improvement of clinical pregnancy rate (p = 0.001) and embryo quality (p = 0.003) in couples in Group 2 compared to those of Group 1. No statistically significant difference was found in fertilization, implantation, live birth delivery, and miscarriage rates between the two groups. Therefore, a second semen sample collected after a very short time-interval in patients with severe OA allowed us to obtain significantly higher clinical pregnancy rate with improved embryo quality compared to normozoospermic men or patients with mild OA. Fertilization, implantation, live birth delivery, and miscarriage rates were similar between the two groups. The present study shows that a second consecutive ejaculate could represent a simple strategy to obtain better sperm parameters and assisted reproductive technology (ART) outcomes in infertile patients with mild-severe OA.

The Use of Pooled Consecutive Ejaculates in Moderate Male Factor Infertility to Increase Intrauterine Insemination Success

Background:

Male factor is a predominant cause of infertility. Success rates of intrauterine insemination(IUI) for male factor depend upon minimum semen parameters such as progressive motility > 30%, strict morphology > 4%, total motile count in the native sample (TMSC) >5 million and inseminating motile count (IMC) > 5 million. Couples with parameters lesser than these are usually advised IVF-ICSI. In developing countries, affordability for IVF is an important deterrent to its widespread utilisation.

Aims:

To evaluate pregnancy rates after the use of a pooled consecutive ejaculate in infertile men with semen parameters of < 5 million TMSC, and to compare with pregnancy rates achieved among couples with semen parameters > 5 million TMSC after processing of a single ejaculate.

Settings and Design:

Private infertility practice. Retrospective study from Oct 2012 to June 2019.

Methods and Materials:

All consecutive patients (n=1979) who underwent IUI in the given study period were included. Patients undergoing donor sperm insemination and low IMC (<1 mill) were excluded from the study. The study group (n=128) included patients in whom the total motile sperm count (TMSC) of the native sample was < 5 million. The control group (n=1851) included patients with normal semen parameters. All participants of the study group with TMSC < 5 million were asked to give a second ejaculate within an hour or two of producing the first. The pooled consecutive ejaculates were used for sample processing and insemination. The primary outcome measure was clinical pregnancy rate. The secondary outcome measures were semen quality of the second ejaculate, TMSC and IMC of both groups.

Statistical Analysis:

Quantitative parameters were compared using Independent sample t-test and Mann Whitney u test. Multivariate binary logistic regression analysis was performed to test the association between the explanatory variables and outcome variable. P value < 0.05 was considered statistically significant.

Results:

6.47% (128/1979) of men were required to give a consecutive ejaculate. The initial ejaculate had significantly higher volume (2ml vs 1 ml; P < 0.001); but lower concentration (8 million/ml vs 19 million/ml; P <0.001) and lower progressive motility (25% vs 35%; P <0.001) in comparison with the second. The final IMC of the pooled ejaculate was 9.01 million vs 21.6 million in the control group (P<0.001). The clinical pregnancy rate was comparable between the control group and the consecutive ejaculate group (15.4% vs 15.63%; P =0.94).

Conclusion:

Consecutive semen samples produced immediately after the first have significantly lower volume but higher sperm count and progressive motility. In couples with moderate male factor infertility with semen parameters inadequate for IUI, pooled consecutive ejaculates yield higher inseminating motile counts which enhance IUI success rates.

Sperm DNA Fragmentation: A New Guideline for Clinicians

Sperm DNA integrity is crucial for fertilization and development of healthy offspring. The spermatozoon undergoes extensive molecular remodeling of its nucleus during later phases of spermatogenesis, which imparts compaction and protects the genetic content. Testicular (defective maturation and abortive apoptosis) and post-testicular (oxidative stress) mechanisms are implicated in the etiology of sperm DNA fragmentation (SDF), which affects both natural and assisted reproduction. Several clinical and environmental factors are known to negatively impact sperm DNA integrity. An increasing number of reports emphasizes the direct relationship between sperm DNA damage and male infertility. Currently, several assays are available to assess sperm DNA damage, however, routine assessment of SDF in clinical practice is not recommended by professional organizations. This article provides an overview of SDF types, origin and comparative analysis of various SDF assays while primarily focusing on the clinical indications of SDF testing. Importantly, we report four clinical cases where SDF testing had played a significant role in improving fertility outcome. In light of these clinical case reports and recent scientific evidence, this review provides expert recommendations on SDF testing and examines the advantages and drawbacks of the clinical utility of SDF testing using Strength-Weaknesses-Opportunities-Threats (SWOT) analysis.

Sperm Parameters before and after Swim-Up of a Second Ejaculate after a Short Period of Abstinence

Background: Recent studies have supported the beneficial effects of a short abstinence period on sperm parameters. The aim of this study was to assess sperm motility, morphology and DNA fragmentation before and after swim-up of a second ejaculate obtained after a short abstinence period in normozoospermic men and oligo-astheno-teratozoospermic (OAT) patients. Material and methods: Semen analyses and swim-up preparations of two consecutive semen samples (collected within 1 h) were carried out in 30 normozoospermic and 35 OAT patients enrolled in an assisted reproductive technique (ART) program. Results: Compared to the first ejaculate, the second sample showed a higher percentage of spermatozoa with normal form (p < 0.01) and lower percentage of spermatozoa with DNA fragmentation (p < 0.01) in normozoospermic men, whereas a higher percentage of spermatozoa with progressive motility (p < 0.001) and normal morphology (p < 0.0001) was found in OAT patients. Swim-up separation showed a lower DNA fragmentation rate (p < 0.05) in the second ejaculate in normozoospermic men, whereas the second ejaculate of OAT patents showed an increase in normally-shaped spermatozoa (p < 0.01) and lower percentage of spermatozoa with fragmented DNA (p < 0.001) compared to the first one. Conclusions: Swim-up separation of a second ejaculate collected within 1 h might be suggested for ART procedures, especially in OAT patients.

How 1 h of abstinence improves sperm quality and increases embryo euploidy rate after PGT-A: a study on 106 sibling biopsied blastocysts

PURPOSE

The aim of our study was to evaluate the influence of different ejaculatory abstinence time frames (several days versus 1 h) on semen parameters, blastocysts ploidy rate, and clinical results in assisted reproduction cycles on sibling oocytes.

METHODS

This is a prospective study including 22 preimplantation genetic testing for aneuploidy (PGT-A) cycles performed between November 2015 and December 2018. Male partners with oligoastenoteratozoospermia produced two semen samples on the day of oocyte retrieval: the first one after several days of abstinence and the second, 1 h after the first one. Oocytes from each patient were divided into two groups: those in group 1 were injected with spermatozoa from the first ejaculate (N = 121) and oocytes in group 2 with spermatozoa from the second one (N = 144). Outcomes of aniline blue test, fertilization, blastocyst formation, ploidy rates, and clinical results were compared between the two groups.

RESULTS

Semen volume resulted lower in the second sperm retrieval. Sperm concentration, motility, and morphology were similar in the two groups. A total of 106 blasotcysts were biospied. Higher blastocyst euploidy rates resulted in group 2 (43.6%) than in group 1 (27.5%). A higher percentage of mature chromatine was observed in group 2.

CONCLUSION

Using spermatozoa from samples with a shorter abstinence could be a simple method to select higher quality spermatozoa, reducing aneuploidy rate in blastocysts. Prospective randomized controlled trials should be performed to confirm the potential advantage of using semen samples with short abstinence period to improve the outcome of assisted reproduction cycles.

Growing body of evidence supports intrauterine insemination as first line treatment and rejects unfounded concerns about its efficacy, risks and cost effectiveness

IUI has been practiced for five decades but only three unconvincing trials attempted to demonstrate the superiority of IUI over sexual intercourse (SI). In the absence of evidence of its effectiveness, the National Institute for Clinical Excellence (NICE) recommended IVF over IUI after 2 years of unprotected SI. High-quality recent data in well-constructed studies suggest that biases against IUI procedures and in favour of IVF are invalid. It is unethical to continue to misinform patients and stakeholders. The well-constructed randomised controlled trials (RCT) show IUI procedure to be efficient, with minimal risk, and above all improved cost-effectiveness when compared to IVF for live birth. IUI as first-line treatment should be offered to most patients, while funding agencies and stakeholders need to be urgently informed of the cost-benefit in offering IUI. Fertility clinics, IVF interest groups, and regulatory bodies should amend their patient information and guidance to state that IUI should be the first line treatment and that IVF should be offered only when essential. Reappraising and promoting IUI based on evidence enhances patient autonomy, choices, and trust, while allowing the fertility industry to operate within an ethical and acceptable framework not seen as exploitative toward vulnerable patients.

Techniques used for IUI: is it time for a change?

STUDY QUESTION

Are the guidelines for the technical aspects of IUI (WHO, 2010) still in accordance with the current literature?

SUMMARY ANSWER

In general, the laboratory guidelines of the World Health Organization (WHO) are a suitable protocol, although the evidence is not always conclusive and some changes are advisable.

WHAT IS KNOWN ALREADY

Lack of standardization of the technical procedures required for IUI might result in inter-laboratory variation in pregnancy rates. Most centers still use their own materials and methods even though some guidelines are available.

STUDY DESIGN, SIZE, DURATION

A structural review focusing on the association between pregnancy rates and the procedures of semen collection (e.g. ejaculatory abstinence, collection place), semen processing (e.g. preparation method, temperature during centrifugation/storage), insemination (e.g. timing of IUI, bed rest after IUI) and the equipment used.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A literature search was performed in Medline and the Cochrane library. When no adequate studies of the impact of a parameter on pregnancy results were found, its association with sperm parameters was reviewed.

MAIN RESULTS AND THE ROLE OF CHANCE

For most variables, the literature review revealed a low level of evidence, a limited number of studies and/or an inadequate outcome measure. Moreover, the comparison of procedures (i.e. semen preparation technique, time interval between semen, collection, processing and IUI) revealed no consensus about their results. It was not possible to develop an evidence-based, optimal IUI treatment protocol.

LIMITATIONS, REASONS FOR CAUTION

The included studies exhibited a lack of standardization in inclusion criteria and methods used.

WIDER IMPLICATIONS OF THE FINDINGS

This review emphasizes the need for more knowledge about and standardization of assisted reproduction technologies. Our literature search indicates that some of the recommendations in the laboratory guidelines could be adapted to improve standardization, comfort, quality control and to cut costs.

STUDY FUNDING/COMPETING INTEREST(S)

The Dutch Foundation for Quality Assessment in Medical Laboratories (SKML), Nijmegen, The Netherlands. S.K. and W.N. have no conflicts of interest to disclose. C.B. and A.W. are members of the board of the SKML. With a grant from SKML, L.L. was paid for her time to perform the research and write the publication. D.B. received grants from Merck Serono, Ferring and MSD, outside the submitted work.

REGISTRATION NUMBER

N/A.

Revisiting The Relationship between The Ejaculatory Abstinence Period and Semen Characteristics

Variation in the ejaculatory abstinence period suggested by different guidance bodies have resulted in a growing concern among researchers and clinicians over what the precise period of ejaculatory abstinence ought to be for an optimal semen sample. Several studies have thus been undertaken to examine the association between the length of sexual abstinence and semen characteristics. Not all studies, however, have arrived at the same conclusions. This study aims to review all existing literature published during the past few decades pertaining to the influence of ejaculatory abstinence on semen quality. For the purpose of this systematic review, all data related to sexual abstinence duration and seminal parameters were re-analysed to homogenize the current data. Thorough PubMed, MEDLINE and Google Scholar, a literature search was conducted using the keywords "sexual abstinence", "ejaculatory abstinence", "semen", "spermatozoa", "semen analysis", "sperm parameters", "motility", "reactive oxygen species (ROS)" and "DNA fragmentation". After carefully reviewing all the literature, 30 relevant papers, both written in English and published between January 1979 and December 2016, were included in this review. The weight of the evidence suggests that the decline in semen volume and sperm concentration with shorter abstinence periods is accompanied by a substantial improvement in sperm motility characteristics, especially progressive motility and velocity. Nevertheless, available data are insufficient to support definitive conclusions regarding the influence of the ejaculatory abstinence period on advanced semen parameters (ROS, DNA fragmentation and seminal plasma antioxidant capacity) and pregnancy rates. In conclusion, taking all data into account, shortening of the abstinence period may be beneficial to sperm quality. Furthermore, we recommend that the current guidelines regarding the prescribed abstinence period should be revisited.

A New Dawn for Intrauterine Insemination: Efficient and Prudent Practice will Benefit Patients, the Fertility Industry and the Healthcare Bodies

This review addresses the misplaced facts about the IUI procedure within a lucrative fertility industry. Evidence suggests IUI must be a first-line treatment option for most couples except in cases of bilateral tubal blockage and severe oligozoospermia. We introduce the concept of using 'consecutive ejaculation' in men with subfertility and one which can radically alter the male infertility definition, thereby providing a new approach to examining and managing male factor infertility. The review also explores various aspects affecting the IUI procedure, its determinants of success, risks and areas for future improvements. Areas such as choice of patients, clinical management of patients, the type of stimulation regime, timing and the management of sperm usage have significant bearing to whether IUI will succeed. The paper asserts that IUI should be the first choice of fertility treatment.