World Health Organization grade 'a' motility and zona-binding test accurately predict IVF outcome for mild male factor and unexplained infertilities

Establishment and validation of a nomogram for subsequent first-cycle live births in patients diagnosed with recurrent implantation failure: a population-based analysis

Background

The inability of patients with recurrent implantation failure (RIF) to achieve pregnancy and a live birth after multiple high-quality embryo transfer treatments has been recognized as a major obstacle to successful application of artificial reproductive technologies. The objective of this study was to establish and validate a nomogram for prediction of subsequent first-cycle live births to guide clinical practice in patients diagnosed with RIF.

Methods

A total of 538 patients who underwent in vitro fertilization/intracytoplasmic sperm injection treatment and were first diagnosed with RIF at the Reproductive Center of the First Affiliated Hospital of Xinjiang Medical University between January 2017 and December 2020 were enrolled. The patients were randomly divided into a training cohort (n=408) and a validation set (n=175) in a ratio of 7:3. A nomogram model was constructed using the training set based on the results of univariate and multivariate logistic regression analyses and validated in the validation set.

Results

Age, body mass index, duration of RIF, endometrial thickness, type of embryo transferred, and number of previous biochemical pregnancies were included in the nomogram for prediction of subsequent first-cycle live births in patients diagnosed with RIF. Analysis of the area under the receiver-operating characteristic curve, calibration plots, and decision curve analysis showed that our predictive model for live births had excellent performance.

Conclusion

We have developed and validated a novel predictive model that estimates a woman's chances of having a live birth after a diagnosis of RIF and provides clinicians with a personalized clinical decision-making tool.

Sperm motility assessed by deep convolutional neural networks into WHO categories

Semen analysis is central in infertility investigation. Manual assessment of sperm motility according to the WHO recommendations is the golden standard, and extensive training is a requirement for accurate and reproducible results. Deep convolutional neural networks (DCNN) are especially suitable for image classification. In this study, we evaluated the performance of the DCNN ResNet-50 in predicting the proportion of sperm in the WHO motility categories. Two models were evaluated using tenfold cross-validation with 65 video recordings of wet semen preparations from an external quality assessment programme for semen analysis. The corresponding manually assessed data was obtained from several of the reference laboratories, and the mean values were used for training of the DCNN models. One model was trained to predict the three categories progressive motility, non-progressive motility, and immotile spermatozoa. Another model was used in predicting four categories, where progressive motility was differentiated into rapid and slow. The resulting average mean absolute error (MAE) was 0.05 and 0.07, and the average ZeroR baseline was 0.09 and 0.10 for the three-category and the four-category model, respectively. Manual and DCNN-predicted motility was compared by Pearson's correlation coefficient and by difference plots. The strongest correlation between the mean manually assessed values and DCNN-predicted motility was observed for % progressively motile spermatozoa (Pearson's r = 0.88, p < 0.001) and % immotile spermatozoa (r = 0.89, p < 0.001). For rapid progressive motility, the correlation was moderate (Pearson's r = 0.673, p < 0.001). The median difference between manual and predicted progressive motility was 0 and 2 for immotile spermatozoa. The largest bias was observed at high and low percentages of progressive and immotile spermatozoa. The DCNN-predicted value was within the range of the interlaboratory variation of the results for most of the samples. In conclusion, DCNN models were able to predict the proportion of spermatozoa into the WHO motility categories with significantly lower error than the baseline. The best correlation between the manual and the DCNN-predicted motility values was found for the categories progressive and immotile. Of note, there was considerable variation between the mean motility values obtained for each category by the reference laboratories, especially for rapid progressive motility, which impacts the training of the DCNN models.

The effect of large follicle puncture and aspiration on the outcomes of IVF-ET in patients with asynchronized follicles under the long GnRH-a protocol: a retrospective cohort study

OBJECTIVE

This retrospective study aimed to explore whether puncturing and aspirating asynchronized large follicles during long GnRH-a protocol COH impacted IVF-ET outcomes.

METHODS

A total of 180 patients with asynchronized follicles during long GnRH-a protocol COH were retrospectively analyzed. They were divided into a puncture group, Group 1 (n = 81), and a non-puncture group, Group 2 (n = 99), according to whether puncture and aspiration were performed on the prematurely developing large follicles. The data of the selected patients were statistically analyzed to assess the effect of large follicle puncture and aspiration during ovulation induction on the final pregnancy results. In addition, we tentatively divided these 180 patients into either Group A (DF ≤ 14 mm) or Group B (DF > 14 mm) according to whether the diameter of the dominant large follicles (DF) exceeded 14 mm at the time of appearance. These two groups were then further divided into four subgroups: Subgroup A1 (DF ≤ 14 mm, patients underwent large follicle puncture), Subgroup A2 (DF ≤ 14 mm, patients did not undergo large follicle puncture), Subgroup B1 (DF > 14 mm, patients underwent large follicle puncture), and Subgroup B2 (DF > 14 mm, patients did not undergo large follicle puncture) based on whether large follicle puncture and aspiration were performed or not, aiming to compare the effects of large follicle puncture and aspiration on the clinical outcomes of patients with dominant large follicles at different time points.

RESULTS

Group 1 exhibited significantly higher oocyte maturation rate (92.3% vs. 88.9%, P = 0.009) and high-quality embryo rate (75.2% vs. 65.7%, P = 0.007) compared with Group 2. No differences were observed in the number of oocytes retrieved, 2PN fertilization rate, clinical pregnancy rate, abortion rate, and live birth rate between the two groups (P > 0.05). When the dominant large follicles' diameter was ≤ 14 mm, the final oocyte maturation rate (92.7% vs. 88.1%, P = 0.023), high-quality embryo rate (72.9% vs. 61.8%, P = 0.047) and live birth rate (54.5% vs. 31.9%, P = 0.043) of Subgroup A1 were significantly higher than those of Subgroup A2. In contrast, when the dominant large follicles' diameter was > 14 mm, no statistical difference was observed in all data.

CONCLUSIONS

Large follicle puncture and aspiration in long GnRH-a protocol COH could improve the oocyte maturation rate and high-quality embryo rate in patients with asynchronized follicles. However, clinical pregnancy and live birth rates were not significantly improved. In addition, when the dominant follicles' diameter did not exceed 14 mm, large follicles puncture and aspiration significantly improved the patient's oocyte maturation rate, high-quality embryo rate and live birth rate.

Development and validation of a live birth prediction model for expected poor ovarian response patients during IVF/ICSI

BACKGROUND

A number of live birth predictive model during assisted reproductive technology treatment have been available in recent years, but few targeted evaluating the chances of live birth in poor ovarian response(POR) patients. The aim of this study was to develop a nomogram based on POSEIDON criteria to predict live birth in patients with expected POR.

METHODS

This retrospective cohort study using clinical data from 657 patients in POSEIDON Groups 3 and 4 (antral follicle count [AFC] ≤5 and AMH <1.2 ng/ml) in the Center for Reproductive Medicine, First Affiliated Hospital of Xinjiang Medical University, and Construction a nomogram model t.

RESULTS

Among 657 expected POR patients, 111 (16.89%) had live births, and 546 (83.11%) did not have live births. These were divided into a training set(n=438) and a validation set (n=219). Multivariate logistic regression analysis showed that the age (OR = 0.91, 95% CI: 0.86-0.97), BMI (OR = 1.98, 95% CI: 1.09-3.67), AMH (OR = 3.48, 95% CI: 1.45-8.51), normal fertilized oocytes (OR = 1.40, 95% CI: 1.21-1.63), and the basal FSH (OR = 0.89, 95% CI: 0.80-0.98) of the female were independent factors predicting live birth in patients with expected POR. Then, an individualized nomogram prediction model was built from these five factors. The area under the ROC curve of the live birth prediction model was 0.820 in the training set and 0.879 in the validation set.

CONCLUSION

We have developed a nomogram combining clinical and laboratory factors to predict the probability of live birth in patients with an expected POR during IVF/ICSI, which can helpful for clinician in decision-making. However, the data comes from the same center, needs a prospective multicenter study for further in-depth evaluation and validation of this prediction model.

Effects of mobile phone use on semen parameters: a cross-sectional study of 1634 men in China

Mobile phones play an irreplaceable role in modern people's lives. However, the radiofrequency electromagnetic radiation produced by mobile phones has also caused increasing concern. A cross-sectional study was conducted to investigate the effect of radiofrequency electromagnetic radiation produced by mobile phones on semen parameters in 1634 men who underwent semen examination at the Department of Reproductive Endocrinology, Women's Hospital, School of Medicine, Zhejiang University, China. Analysis of variance and multivariate linear regression were used to explore differences among different groups. A P <0.05 was considered statistically significant. The results showed significant associations among different groups of daily mobile phone use time and daily duration of phone calls in the percentage of progressively motile spermatozoa (P =0.004 and P =0.007), rapid progressively motile spermatozoa (P =0.012 and P =0.006) and total motile spermatozoa (P =0.004 and P =0.046). After adjustments for the confounding effects of age and body mass index by multiple linear regression, the results showed that the daily duration of mobile phone use had a negative effect on sperm motility. However, there was no statistically significant correlation between daily phone call duration and sperm motility. Therefore, the daily duration of mobile phone use may negatively affect sperm motility and impair male fertility.

The effect of flexible low-dose GnRH antagonist on pregnancy outcome in the fresh embryo transfer cycle of IVF-ET: a randomized controlled trial

OBJECTIVE

To explore the practicality and effectiveness of a flexible low-dose protocol in the fresh embryo transfer cycle: reducing the total amount of antagonist by increasing the interval between administrations of Cetrotide.

METHODS

A total of 211 patients with normal ovarian reserve who accepted GnRH-ant protocol for IVF-ET were selected, and they were randomized to the flexible low-dose antagonist group (test group, n = 101) or the conventional dose antagonist group (control group, n = 110). The initial dose of Cetrotide in the test group was 0.25 mg every other day, and then the dose was adjusted to 0.25 mg every day based on the subsequent luteinizing hormone (LH) levels. The dosage of Cetrotide in the control group was 0.25 mg per day. The primary outcome was the clinical pregnancy rate. Secondary outcomes included the incidence of premature LH rise, total dosage of Cetrotide, number of oocytes retrieved, number of fertilized oocytes, number of high-quality embryos, biochemical pregnancy rate and ongoing pregnancy rate.

RESULTS

There was no significant difference in the general condition of the two groups. There was no significant difference in the clinical pregnancy rate (51.49% vs. 48.18%, p = 0.632) or the incidence of premature LH rise (18.81% vs. 15.45%, p = 0.584) between the two groups. However, the amount of Cetrotide used in the test group was significantly lower than that in the conventional dose antagonist group (1.13 ± 0.41 vs. 1.61 ± 0.59 mg, p < 0.001).

CONCLUSION

The flexible low-dose antagonist protocol and the conventional dose antagonist protocol were equally effective in people with a normal ovarian reserve in the fresh embryo transfer cycle of IVF-ET.

The sixth edition of the WHO manual on semen examination: ensuring quality and standardization in basic examination of human ejaculates

A basic semen investigation has established principles that are necessary for ascertaining reliable and internationally comparable results. Although these principles have been present in the WHO manual since its inception, the baseline issue across most published studies and practice in reproductive medicine (in which the male is considered) is repetitive failure to adhere to these principles, thereby leading to relevant comparable data and accuracy. To address this failure, the sixth edition of the WHO manual includes revised basic methods, and a complementary formal standard of the International Standards Organization (ISO23162:2021) for basic semen examination has been published. Perhaps the most significant change in the sixth edition is the reintroduction of the four-category distinction of sperm motility, which causes additional work for laboratories in changing reporting parameters but is clinically important. Another essential change is the widened focus from mainly a prognostic tool for medically assisted reproduction to additionally raising awareness of semen examination as a measure of male reproductive functions and general male health.

The Sixth Edition of the WHO Manual for Human Semen Analysis: A Critical Review and SWOT Analysis

Semen analysis is the cornerstone of male fertility evaluation with WHO guidelines providing the basis for procedural standardization and reference values worldwide. The first WHO manual was published in 1980, and five editions have been subsequently released over the last four decades. The 6th Edition was published in July 2021. In this review, we identify the key changes of this 6th Edition. Additionally, we evaluate the utility of this 6th Edition in clinical practice using SWOT (strengths, weaknesses, opportunities, and threats) analysis. This new Edition has made the analysis of basic semen parameters more robust, taking into account the criticisms and grey areas of the previous editions. The tests assessing sperm DNA fragmentation and seminal oxidative stress are well-described. The main novelty is that this latest edition abandons the notion of reference thresholds, suggesting instead to replace them with “decision limits”. While this seems attractive, no decision limits are proposed for either basic semen parameters, or for extended or advanced parameters. This critical review of the 6th Edition of the WHO laboratory manual combined with a SWOT analysis summarizes the changes and novelties present in this new Edition and provides an in-depth analysis that could help its global use in the coming years.

Current perspectives of CASA applications in diverse mammalian spermatozoa

Since the advent of computer-aided sperm analysis (CASA) some four decades ago, advances in computer technology and software algorithms have helped establish it as a research and diagnostic instrument for the analysis of spermatozoa. Despite mammalian spermatozoa being the most diverse cell type known, CASA is a great tool that has the capacity to provide rapid, reliable and objective quantitative assessment of sperm quality. This paper provides contemporary research findings illustrating the scientific and commercial applications of CASA and its ability to evaluate diverse mammalian spermatozoa (human, primates, rodents, domestic mammals, wildlife species) at both structural and functional levels. The potential of CASA to quantitatively measure essential aspects related to sperm subpopulations, hyperactivation, morphology and morphometry is also demonstrated. Furthermore, applications of CASA are provided for improved mammalian sperm quality assessment, evaluation of sperm functionality and the effect of different chemical substances or pathologies on sperm fertilising ability. It is clear that CASA has evolved significantly and is currently superior to many manual techniques in the research and clinical setting.

[Complete fertilization failure following conventional IVF or ICSI: is it predictable? How to manage?]

The occurrence of complete fertilization failure following conventional in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) is a rare event. Each of six physiological stages of the fertilisation can be failing. The cause of a fertilisation failure is either the spermatozoa, or the oocyte. The aim of this study was to determine if this event is predictable, and to define the later strategy. On all sperm tests available, it seems that only, tests of zona pellucida binding and acrosomique reaction are relatively predictive of a complete fertilization failure after IVF. No test allows at the moment to predict an oocyte contribution to unsuccessful fertilization. The strategy retained after a complete fertilization failure following the first attempt of IVF is to propose an ICSI; either to do an IVF if this event arises in the rank n+1, or when the number of inseminated oocytes was low. Concerning the ICSI, the low number of micro-injected oocyte is often in question; so the strategy retained following a first fertilization failure after ICSI is to perform a new ICSI attempt after optimization of the ovarian stimulation. When the cause is spermatic, it is indicated trying a modified ICSI with the use of pentoxifiline, or an intracytoplasmic morphologically selected sperm injection (IMSI), sometimes with assisted oocyte activation. In last solution, we can propose the ovum donation.

Cystic fibrosis transmembrane conductance regulator is correlated closely with sperm progressive motility and normal morphology in healthy and fertile men with normal sperm parameters

Cystic fibrosis transmembrane conductance regulator (CFTR) has been demonstrated to be expressed in mature spermatozoa and correlated with sperm quality. Sperm CFTR expression in fertile men is higher than that in infertile men suffering from teratospermia, asthenoteratospermia, asthenospermia and oligospermia, but it is unknown whether CFTR is correlated with sperm parameters when sperm parameters are normal. In this study, 282 healthy and fertile men with normal semen parameters were classified into three age groups, group (I): age group of 20-29 years (98 cases, 27.1 ± 6.2), group (II): age group of 30-39 years (142 cases, 33.7 ± 2.6) and group (III): age group of more than or equal to 40 years (42 cases, 44.1 ± 4.6). Sperm concentration, total count and progressive motility were analysed by computer-assisted sperm analysis. Sperm morphology was analysed by modified Papanicolaou staining. Sperm CFTR expression was conducted by indirect immunofluorescence staining. There was a significant positive correlation (P < 0.001) between CFTR expression and sperm progressive motility (r = 0.221) and normal morphology (r = 0.202), but there were no correlations between sperm CFTR expression and semen volume, sperm concentration, sperm total count as well as male age (P > 0.05). Our findings show that CFTR expression is associated with sperm progressive motility and normal morphology in healthy and fertile men with normal sperm parameters, but not associated with the number of spermatozoa and male age.

Body mass index is not associated with sperm-zona pellucida binding ability in subfertile males

Lifestyle factors, such as weight and nutritional status may affect male fertility, including sperm fertilization ability. The objective of this retrospective study was to evaluate the association between body mass index (BMI) and sperm-zona pellucida binding ability assessed according to the zona binding (ZB) test, which has been described to be a relevant diagnostic tool for the prediction of in vitro fertilization (IVF) ability. Three hundred and six male patients from couples diagnosed with primary idiopathic or mild male factor infertility were included. Correlations between BMI and semen parameters according to ZB test indices were assessed, together with frequencies of positive and negative tests across the BMI categories. In this selected population, BMI was not related to conventional semen parameters or sperm quality assessed according to the ability of spermatozoa to bind to the zona pellucida. The previously described poor outcomes of IVF procedures in cases of male obesity could be due to other sperm defects, such as alterations of sperm capacitation or acrosome reaction. The link between male BMI and biological outcomes during IVF procedures, such as fertilization rates, should be further evaluated.

Quantification and identification of sperm subpopulations using computer-aided sperm analysis and species-specific cut-off values for swimming speed

Motility is an essential characteristic of all flagellated spermatozoa and assessment of this parameter is one criterion for most semen or sperm evaluations. Computer-aided sperm analysis (CASA) can be used to measure sperm motility more objectively and accurately than manual methods, provided that analysis techniques are standardized. Previous studies have shown that evaluation of sperm subpopulations is more important than analyzing the total motile sperm population alone. We developed a quantitative method to determine cut-off values for swimming speed to identify three sperm subpopulations. We used the Sperm Class Analyzer(®) (SCA) CASA system to assess the total percentage of motile spermatozoa in a sperm preparation as well as the percentages of rapid, medium and slow swimming spermatozoa for six mammalian species. Curvilinear velocity (VCL) cut-off values were adjusted manually for each species to include 80% rapid, 15% medium and 5% slow swimming spermatozoa. Our results indicate that the same VCL intervals cannot be used for all species to classify spermatozoa according to swimming speed. After VCL intervals were adjusted for each species, three unique sperm subpopulations could be identified. The effects of medical treatments on sperm motility become apparent in changes in the distribution of spermatozoa among the three swimming speed classes.

Manual methods for sperm motility assessment

Progressive motility is a vital functional characteristic of ejaculated human spermatozoa that governs their ability to penetrate into, and migrate through, both cervical mucus and the oocyte vestments, and ultimately fertilize the oocyte. A detailed protocol, based on traditional manual/visual methods, is provided for performing an accurate four-category differential count including the reliable identification of rapid progressive (grade "a") spermatozoa-the most biologically, and hence clinically, important subpopulation. Thorough prior training and the use of a microscope fitted with a heated stage are both essential requirements for achieving accuracy and an acceptable uncertainty of measurement of no more than ±10%.

BMI in relation to sperm count: an updated systematic review and collaborative meta-analysis

BACKGROUND The global obesity epidemic has paralleled a decrease in semen quality. Yet, the association between obesity and sperm parameters remains controversial. The purpose of this report was to update the evidence on the association between BMI and sperm count through a systematic review with meta-analysis. METHODS A systematic review of available literature (with no language restriction) was performed to investigate the impact of BMI on sperm count. Relevant studies published until June 2012 were identified from a Pubmed and EMBASE search. We also included unpublished data (n = 717 men) obtained from the Infertility Center of Bondy, France. Abstracts of relevant articles were examined and studies that could be included in this review were retrieved. Authors of relevant studies for the meta-analysis were contacted by email and asked to provide standardized data. RESULTS A total of 21 studies were included in the meta-analysis, resulting in a sample of 13 077 men from the general population and attending fertility clinics. Data were stratified according to the total sperm count as normozoospermia, oligozoospermia and azoospermia. Standardized weighted mean differences in sperm concentration did not differ significantly across BMI categories. There was a J-shaped relationship between BMI categories and risk of oligozoospermia or azoospermia. Compared with men of normal weight, the odds ratio (95% confidence interval) for oligozoospermia or azoospermia was 1.15 (0.93-1.43) for underweight, 1.11 (1.01-1.21) for overweight, 1.28 (1.06-1.55) for obese and 2.04 (1.59-2.62) for morbidly obese men. CONCLUSIONS Overweight and obesity were associated with an increased prevalence of azoospermia or oligozoospermia. The main limitation of this report is that studied populations varied, with men recruited from both the general population and infertile couples. Whether weight normalization could improve sperm parameters should be evaluated further.

Use of laparoscopy in unexplained infertility

OBJECTIVE

The use of laparoscopy in unexplained infertility work-up is still a subject of debate, although laparoscopy remains the gold standard for diagnosis and treatment of several pelvic pathologies. The objective of this study was to assess the rates and types of pelvic pathologies observed during diagnostic laparoscopy, and the pregnancy rate in couples with unexplained infertility following laparoscopy.

STUDY DESIGN

Prospective study, from November 2003 to October 2009, including 114 infertile, spontaneously ovulating women with normal clinical examination, ovarian reserve assessment, pelvic ultrasound scan and patent tubes on hysterosalpingography. Semen analyses were normal according to the World Health Organization criteria. After three cycles of ovulation induction with or without intra-uterine insemination and no pregnancy, women were referred for diagnostic laparoscopy.

RESULTS

Laparoscopy revealed pelvic pathology in 95 patients. Endometriosis, pelvic adhesions and tubal disease were observed and treated in 72, 46 and 24 patients, respectively. Following laparoscopy, bilateral and unilateral tubal patencies were observed in 107 and five patients, respectively. Pregnancy was observed in 77 out of 102 patients who tried to conceive after surgery, 35 of whom conceived using their own tubes.

CONCLUSION

Diagnostic laparoscopy should be strongly considered in unexplained infertility work-up, and tubal efficiency should not be underestimated.

The usefulness and significance of assessing rapidly progressive spermatozoa

It is possible and clinically relevant to distinguish between slow and rapid progressive spermatozoa in basic semen analysis. This is discussed in light of the different purposes of semen analysis for the subfertile couple and the male patient. The two groups of progressive spermatozoa should be distinguished to help ensure that pertinent information available in the semen sample is not neglected.

Short gamete co-incubation during in vitro fertilization decreases the fertilization rate and does not improve embryo quality: a prospective auto controlled study

PURPOSE

Evaluate the effect of short gamete incubation on fertilization rate and embryo quality.

METHODS

A prospective study has been performed. Two thousand five hundred and forty seven sibling oocytes from 240 couples undergoing IVF attempts were allocated to a short (1 h) or a standard (18 h) insemination procedure. Diploid fertilization rate (two pronuclei, 2PN), polyspermy (>2PN) and embryo quality were compared.

RESULTS

The fertilization rate was statistically lower in the short insemination group compared to the standard insemination one (64.9% and 70.1%; P = 0.039), with a similar polyspermy rate observed between the two groups. A slight, but non significant, increase was observed concerning good embryo quality rate in the short insemination group when compared to the standard insemination, both at day 2 (60.1 vs. 58.1%; P = 0.06) and day 3 (53.2 vs. 48.5%; P = 0.22).

CONCLUSION

This new study highlights that a 1 h gamete exposure decreases the fertilization rate and does not improve embryo quality compared with a standard 18 h insemination procedure.

Relationship between human sperm-hyaluronan binding assay and fertilization rate in conventional in vitro fertilization

BACKGROUND

Sperm-hyaluronan-binding assay (HBA) is one of the commercial kits being marketed for routine testing of sperm maturity and fertility. However, there is no report of whether the HBA can provide additional information over standard semen analysis for sperm-fertilizing ability. The objective of this study was to investigate the relationship between HBA and fertilization rate in conventional IVF.

METHODS

A total of 175 IVF patients with > or = 3 mature oocytes inseminated were included in the study. Both the standard semen analysis and the HBA were performed on the same ejaculated sperm samples used for IVF treatments. Relationships between the semen analysis and the HBA results and fertilization rate were analysed by both the Spearman test and the multivariate logistic regression analysis.

RESULTS

Both total and progressive sperm motility and normal morphology were highly correlated with HBA scores. While both normal sperm morphology and HBA scores were statistically significantly related to fertilization rates, the HBA was less significant than normal sperm morphology. The HBA does not provide additional information for identifying patients with a poor fertilization rate.

CONCLUSION

HBA is highly significantly correlated with sperm motility and morphology but is less significant than sperm morphology in relation to the fertilization rate in IVF. Thus, the clinical predictive value of HBA for sperm-fertilizing ability in vitro is limited.