Effect of semen characteristics on pregnancy rate following intrauterine insemination

Intrauterine Insemination (IUI) Outcomes With Total Progressive Motile Sperm Count (TPMSC) Above and Below 5 Million

OBJECTIVE

The study aims to investigate the impact of total progressive motile sperm count (TPMSC) on pregnancy outcomes in couples diagnosed with unexplained infertility undergoing intrauterine insemination (IUI).

MATERIALS AND METHODS

A retrospective analysis was conducted on 122 IUI cycles from 98 couples with unexplained infertility who received treatment at Zeynep Kamil Women's and Children's Diseases Training and Research Hospital between 2021 and 2022. The couples were divided into two groups based on TPMSC: below 5 million and 5 million or above. Key pregnancy outcomes, including chemical pregnancy, clinical pregnancy, and live birth rates, were evaluated and compared between the groups.

RESULTS

Of the 122 IUI cycles analyzed, 69 had a TPMSC of 5 million or above, and 53 cycles had a TPMSC below 5 million. The chemical pregnancy, clinical pregnancy, and live birth rates were significantly higher in the group with TPMSC above 5 million (34.8%, 31.9%, and 23.2%, respectively) compared to the TPMSC below 5 million group, which had no pregnancies. The findings demonstrate that TPMSC is a critical predictor of IUI success, with a TPMSC threshold of 5 million associated with significantly higher pregnancy outcomes.

CONCLUSION

This study highlights that a TPMSC below 5 million is associated with poor IUI outcomes, suggesting that IUI may not be a cost-effective treatment for couples with severe oligoasthenospermia. For these couples, alternative treatments like in vitro fertilization (IVF) may be more appropriate. The findings provide valuable insights for improving the management and treatment strategies for unexplained infertility.

Sperm Migration and Hyaluronic Acid Binding: Implications for Male Fertility Evaluation

Mature, vital, and motile spermatozoa are essential for reaching the oocyte and binding to hyaluronic acid (HA) in the cumulus oophorus matrix. This study aims to determine the relationship between sperm-migration ability and HA-binding potential, as well as the relationship between sperm concentration and motility. Semen samples were collected from 702 men aged 20-56 years (median 34.8). We evaluated the sperm concentration and motility from basic semen analysis, the swim-up test (expressed as millions per mL and the migration efficiency percentage), and the hyaluronan-binding assay (HBA). A moderate positive correlation was found between the migration test results and HBA (R = 0.48). The highest correlation was observed between the concentration of motile spermatozoa and the migration test results (R = 0.85) and HBA (R = 0.4). The sperm migration efficiency strongly correlated with progressive motility (R = 0.6). Although significantly higher sperm migration was observed in patients with normal HBA results, the results of the functional tests were found to differ in some cases. For infertility treatment, the current diagnostic algorithm should be enhanced with more comprehensive seminological methods that assess the sperm-migration ability and HA-binding potential. We also recommend incorporating the swim-up method into the diagnostic protocol before planning assisted reproductive technology (ART) treatment.

The effect of Chinese herbal medicine on male factor infertility: study protocol for a randomized controlled trial

Background

The global prevalence of infertility is 9%, with male factors potentially accounting for 40% to 60% of cases. Conventional treatments can be ineffective, invasive, costly, and linked to adverse effects and high risks. Previous studies have shown that, Chinese herbal medicine (CHM) can regulate the hypothalamus-pituitary-testis axis, improve sperm abnormalities and quality, mitigate oxidative stress, and decrease DNA fragmentation index (DFI). Yet, the evidence backing the use of Chinese herbal medicine (CHM) for treating male factor infertility lacks conviction due to study design limitations, and there remains a scarcity of studies on the live birth rate following CHM treatment for male factor infertility. Here, we describe the rationale and design of a randomized waitlist-controlled trial to evaluate the effect of CHM on the live birth rate among males with infertility.

Methods

This study is a single-center, randomized, waitlist-controlled study. A total of 250 couples diagnosed with male factor infertility will be enrolled in this study and then randomly allocated into two groups in a 1:1 ratio. Male participants in CHM group (treatment group) will receive CHM once a day for 3 months. Male participants in the waitlist group (control group) will not receive any treatment for 3 months. After 3 months, participants in both groups need to be followed up for another 12 months. The primary outcome will be the live birth rate; secondary outcomes include semen quality parameters, DFI and pregnancy related outcomes. Safety will also be assessed.

Discussion

The purpose of this trial is to explore the effects and safety of CHM on the live birth rate among couples dealing with male factor infertility. The outcome of this trial may provide a viable treatment option for male factor infertility.

Trial registration

Chinese Clinical Trial Registry: ChiCTR2200064416. Registered on 7 October 2022, https://www.chictr.org.cn.

The impact of different sperm preparation methods on clinical pregnancy and live birth rates in intrauterine insemination cycles: a retrospective single-center cohort study

OBJECTIVE

To assess the impact of 2 different sperm preparation methods, density gradient centrifugation and simple wash, on clinical pregnancy and live birth rates in intrauterine insemination (IUI) cycles with and without ovulation induction.

DESIGN

Retrospective single-center cohort study.

SETTING

Academic fertility center.

PATIENTS

In total, 1,503 women of all diagnoses sought IUI with fresh-ejaculated sperm.

EXPOSURE

Cycles were divided into 2 groups on the basis of sperm preparation technique: density gradient centrifugation (n = 1,687, unexposed group) and simple wash (n = 1,691, exposed group).

MAIN OUTCOME MEASURES

Primary outcome measures consisted of clinical pregnancy and live birth rates. Furthermore, adjusted odds ratios and 95% confidence intervals for each outcome were calculated and compared between the 2 sperm preparation groups.

RESULTS

Odds ratios did not differ between density gradient centrifugation and simple wash groups for clinical pregnancy and live birth (1.10 [0.67-1.83] and 1.08 [0.85-1.37], respectively). Additionally, when cycles were stratified using ovulation induction rather than adjusted for, no differences in clinical pregnancy and live birth odds were noted between sperm preparation groups (gonadotropins: 0.93 [0.49-1.77] and 1.03 [0.75-1.41]; oral agents: 1.78 [0.68-4.61] and 1.05 [0.72-1.53]; unassisted: 0.08 [0.001-6.84] and 2.52 [0.63-10.00], respectively). Furthermore, no difference was seen in clinical pregnancy or live birth when cycles were stratified using sperm score or when the analysis was limited to first cycles only.

CONCLUSION

Overall, no difference was noted in clinical pregnancy or live birth rates between patients who received simple wash vs. density gradient-prepared sperm, suggesting similar clinical efficacy between the 2 techniques for IUI. Because the simple wash technique is more time-efficient and cost-effective compared with the density gradient, adoption of this technique could lead to comparable clinical pregnancy and live birth rates for IUI cycles, although optimizing teamwork flow and coordination of care.

Is controlled ovarian stimulation and insemination an effective treatment in older women with male partners with decreased total motile sperm counts?

OBJECTIVE

To assess the effect of the total motile sperm counts (TMSC) on the success of controlled ovarian stimulation (COH) and intra-uterine insemination (IUI) in women 38-42 years of age.

STUDY DESIGN

A database of all women aged 38-42 years who underwent IUI with stimulation at a University Reproductive Centre between 2009 and 2018 inclusive was developed. Including stimulation with clomiphene citrate, letrozole or gonadotropins and divided into TMSC 5.00-10.0 mil and < 5.00 mil. Statistics were compared with multivariate logistic regression, t tests or Chi-squared tests.

RESULTS

A total of 397 cycles of IUI in 397 patients were included, of which, 190 cycles with TMSC 5.00-10.0 and 207 cycles with TMSC < 5.00. There were no statistical differences in the baseline characteristics between the two groups including: age (P = 0.2), gravidity (P = 0.7), parity (P = 0.6), basal FSH (P = 0.2), basal E2 (P = 0.4), antral follicular count (P = 0.5) and the number of mature follicles stimulated (P = 0.2). As expected, TMSC was 7.6 ± 1.5 mil in the first group and 2.4 ± 1.6 mil in the second group (P < 0.0001). The clinical pregnancy rate per cycle in the 5.01-10.00 TMSC group was 9.5 vs. 3.4% when TMSC < 5.00 (P = 0.01). When evaluating only women 40-42 years of age (99 women in the 5.00-10.00 TMSC group and 95 in the group of TMSC < 5.00); the pregnancy rates were not statistically different between the two groups (7 vs. 7.3%, P = 1), nor was the clinical pregnancy rate (5 vs. 6.3%, P = 0.7).

CONCLUSIONS

Women 38-39 years of age have poorer outcomes at COH/IUI when TMSC < 5 million than if it is 5-10 million. Once a woman is 40 years of age, this effect is lost. With TMSC 5-10 million, women 38-39 years of age have respectable outcomes at COH/IUI. Clinical pregnancy rates are very low in women 40 years of age with TMSC ≤ 10 million or 38-39 years old with TMSC < 5 million and other treatments should be offered.

Optimizing the first-line fertility treatment

The objective of this study was to identify sperm score thresholds to achieve satisfactory intrauterine insemination (IUI) success rates according to the response to stimulation with clomiphene citrate (CC). To minimize the confounding effect of female age, we included only CC/IUI cycles of women ≤35 years old. A total of 1,194 CC/IUI cycles were included. Semen volume, concentration, and motility influenced the clinical pregnancy rate (CPR). Normal morphology (≥4%) was associated with a comparable CPR with 3%, 2%, and 1% normal forms (15.6%, 16.1%, 18.1%, and 13.1%, respectively). A combination of the total number of motile spermatozoa in the ejaculate before semen preparation (TM) at a threshold ≥20 × 10⁶ was associated with a CPR of 17.8% compared to 4.6% for a threshold <20 × 10⁶ (p < .001). Interestingly, the TM threshold to achieve satisfactory outcomes was lower (10 × 10⁶) in patients who had an optimal response to CC (≥2 dominant follicles with an endometrial thickness ≥7 mm) compared to 40 × 10⁶ for those who had a suboptimal response (one dominant follicle with an endometrial thickness <7 mm). In conclusion, the response to superovulation with CC determines each patient's TM threshold required for satisfactory outcomes. Couples whose TM is below the threshold may benefit from a superovulation with gonadotropins or in vitro fertilization.

An Intrauterine Insemination Audit at Tertiary Care Hospital: A 4½ Years' Retrospective Analysis of 800 Intrauterine Insemination Cycles

BACKGROUND

There are many variables that may influence the success rates of intrauterine insemination (IUI) treatment. Therefore, a regular audit program is needed for planning effective infertility treatment and improving pregnancy outcomes.

AIMS AND OBJECTIVES

The main objective of this study was to identify the crucial predicting factors that can influence the IUI success.

MATERIALS AND METHODS

A retrospective analysis of 800 IUI cycles done from January, 2013 to August, 2017 in 651 couples with various etiologies of infertility. The common etiologies included female factor of ovulatory dysfunction, tubal, endocrinal, male factor, male and female factors combined, and unexplained factors. Ovulation induction was done either by clomiphene citrate (CC) alone or in combination of CC with gonadotropins or pure gonadotropins only. Human chorionic gonadotropin trigger was given when at least one dominant follicle measuring ≥18 mm with an endometrial thickness of >7 mm was obtained. IUI was done post 36 h of trigger. The double-density gradient method was the preferred method of sperm preparation.

RESULTS

In 800 cycles in corresponding 651 couples, the total outcome was 113 pregnancies (14.1%) per cycle with overall pregnancy rate (PR) per couple of 17.3%. The highest PR was observed in the patient with ovulatory dysfunction (21.2%), followed by patients with combined factor (15.1%) and male factor (14.7%). In the study, a higher PR was achieved in the female ≤25 years (18.9%) P < 0.04 with significant findings with duration of infertility ≤5 years (15.1%) having primary infertility (14.5%) with low body mass index <25 (14.1%). IUI success rate was highest in the first cycle (14.6%) followed by second cycle (14.0%) and third cycle (3.5%).

CONCLUSION

IUI audit enables the characterization of prognostic factors to achieve improved PR. This study identifies the factors that can predict improved pregnancy outcome in women age ≤25 years and endometrium thickness between 9 and 11 mm. We also recommend IUI as a first line of infertility treatment for couples in low-income setting provided the women age and duration of infertility are acceptably low.

Do pregnancy rates differ with intra-uterine insemination when different combinations of semen analysis parameters are abnormal?

OBJECTIVE

To evaluate the relationship of one or a combination of semen analysis parameter results on insemination outcomes.

MATERIAL AND METHODS

A retrospective analysis was performed to evaluate the effect on pregnancy rates in relation to one or more abnormal semen analysis parameters based on the 2010 World Health Organization semen analysis guidelines.

RESULTS

Nine hundred eighty-one couples underwent 2231 intrauterine insemination cycles at the Stanford Fertility and Reproductive Medicine Center. In our study, the pregnancy rates ranged from 11-25% when an individual or combined semen analysis parameters were analyzed. Similar pregnancy rates were found when one, two, and in most cases three parameters were abnormal. When a single parameter was abnormal among volume, concentration, and motility, pregnancy rates were mainly unaffected. There was the exception of total sperm count where pregnancy rates were diminished when counts were below 39 million (p=0.04).

CONCLUSIONS

Clearly, total sperm in the specimen and not the concentration of sperm per milliliter was the critical factor for predicting pregnancy. Therefore, a reorganization of semen analysis reports should be done emphasizing the total amount of sperm present and de-emphasizing concentration of sperm.

Effect of Gonadotropin Types and Indications on Homologous Intrauterine Insemination Success: A Study from 1251 Cycles and a Review of the Literature

Objective

To evaluate the IUI success factors relative to controlled ovarian stimulation (COS) and infertility type, this retrospective cohort study included 1251 couples undergoing homologous IUI.

Results

We achieved 13% clinical pregnancies and 11% live births. COS and infertility type do not have significant effect on IUI clinical outcomes with unstable intervention of various couples' parameters, including the female age, the IUI attempt rank, and the sperm quality.

Conclusion

Further, the COS used seemed a weak predictor for IUI success; therefore, the indications need more discussion, especially in unexplained infertility cases involving various factors. Indeed, the fourth IUI attempt, the female age over 40 years, and the total motile sperm count <5 × 10⁶ were critical in decreasing the positive clinical outcomes of IUI. Those parameter cut-offs necessitate a larger analysis to give infertile couples more chances through IUI before carrying out other ART techniques.

IMPACT OF PREPARATION USING CONVENTIONAL AND MODIFIED DENSITY GRADIENT CENTRIFUGATION METHODS ON SPERM CONCENTRATION, MOTILITY AND NUMBER OF NORMAL MOTILE SPERM RECOVERY (NMSR)

Some preparation techniques, either conventional or advanced, have been provided. Advanced technique may overcome the limitations of conventional techniques. Recently, not all fertility clinics in Indonesia are able to provide advanced preparation techniques. Some techniques require expensive equipments and can only be used for intracytoplasmic sperm injection (ICSI). Some fertility clinics use a modified procedure, namely the combination of density gradient centrifugation with a swim-up method for the preparation of the sperm to be used in ART. This study aimed to determine whether the modified density gradient centrifugation, which is density gradient centrifugation followed by a swim-up, is able to yield better results than conventional density gradient centrifugation. This study was a laboratory experimental pre and pos-test control group design. Population was all adult men aged 21-40 years old and the sampling unit was the man donor’s semen which fulfilled inclusion criterias, collected during the periode of the study. Sample size was eight. Sperm analysis were done before and after preparation in conventional and modified group. Descriptive comparation analysis have been used. This study obtained NMSR 7.9+5.5 million/ejaculate and recovery rate (RR) 27.66+11.8 %. RR was lower compared to RR obtained conventional DGC method. RR might be lower because in modified DGC samples undergo two steps selection while conventional DGC only one step selection. But conventional DGC samples should be centrifuged twice, therefore sperms might experience more trauma. Lower RR sperm does not exclude the possibility to be used for ART, because still within the required number for all TRBs. In conclusion, modified DGC preparation method obtained lower NMSR and RR, nevertheless harvested sperms can still be used in all kind of ART.

Retrospective Study of Factors Affecting Intrauterine Insemination Pregnancy Outcome: The Impact of Male Habits and Working Environment

AIMS

This study is aimed at determining the prognostic factors influencing successful pregnancy following intrauterine insemination (IUI).

SETTINGS AND DESIGN

Retrospective analysis.

MATERIALS AND METHODS

A total of 2123 cycles undergone by 871 couples during the period of 5 years (2011-2015) were retrospectively studied.

STATISTICAL ANALYSIS USED

Each of the factors was compared with pregnancy outcome (PO) using statistical analysis with a confidence interval of 95% in SPSS software version 19. Chi-square test and logistic regression analysis method were used to determine the significance of each factor with the PO.

RESULTS

Among the various factors included in our study population, male habits (P = 0.004), male occupational environment (P = 0.025), male age (P = 0.002), and female age (P = 0.001) were found to significantly influence the PO following IUI.

CONCLUSION

Our results indicate that avoiding smoking and alcohol consuming prior and during the IUI treatment along with working in low-heat-generating environment might lead to better success following the treatment.

The impact of semen processing on sperm parameters and pregnancy rates after intrauterine insemination

BACKGROUND

The objective of this retrospective study was to evaluate the effect of semen processing on computer analyzed semen parameters and pregnancy rates after intrauterine insemination (IUI).

METHODS

Over a two-year period, a total of 981 couples undergoing 2231 IUI cycles were evaluated and the freshly collected non-donor semen was analyzed before and after density gradient centrifugation (DGC).

RESULTS

DGC led to significant increases in sperm concentration by 66±74 ×106/mL (P=0.0001), percentage of motile sperm by 24±22% (P=0.0001), concentration motile by 27±58 ×106/mL (P=0.0001), and forward sperm progression by 18±14 µ/s (P=0.0001). In 95% of cases, there was a decrease in the total motile sperm count (TMSC), with an average decrease of 50±124% compared to pre-processed samples (P=0.0001). Importantly, the decrease in TMSC did not negatively affect pregnancy rates (P=0.45).

CONCLUSIONS

This study proves that DGC leads to significant increases in most sperm parameters, with the exception of TMSC. Remarkably, the decrease in TMSC did not affect the pregnancy rate. This should reassure clinicians when the TMSC is negatively affected by processing.

Comparison of two sperm processing techniques for low complexity assisted fertilization: sperm washing followed by swim-up and discontinuous density gradient centrifugation

Objective

This study aimed to assess and compare sperm motility, concentration, and morphology recovery rates, before and after processing through sperm washing followed by swim-up or discontinuous density gradient centrifugation in normospermic individuals.

Methods

Fifty-eight semen samples were used in double intrauterine insemination procedures; 17 samples (group 1) were prepared with sperm washing followed by swim-up, and 41 (group 2) by discontinuous density gradient centrifugation. This prospective non-randomized study assessed seminal parameters before and after semen processing. A dependent t-test was used for the same technique to analyze seminal parameters before and after semen processing; an independent t-test was used to compare the results before and after processing for both techniques.

Results

The two techniques produced decreases in sample concentration (sperm washing followed by swim-up: P<0.000006; discontinuous density gradient centrifugation: P=0.008457) and increases in motility and normal morphology sperm rates after processing. The difference in sperm motility between the two techniques was not statistically significant. Sperm washing followed by swim-up had better morphology recovery rates than discontinuous density gradient centrifugation (P=0.0095); and the density gradient group had better concentration recovery rates than the swim-up group (P=0.0027).

Conclusion

The two methods successfully recovered the minimum sperm values needed to perform intrauterine insemination. Sperm washing followed by swim-up is indicated for semen with high sperm concentration and better morphology recovery rates. Discontinuous density gradient centrifugation produced improved concentration recovery rates.

Factors affecting clinical pregnancy rates after IUI for the treatment of unexplained infertility and mild male subfertility

OBJECTIVE

The aim of the present retrospective study was to evaluate intrauterine insemination (IUI) clinical experiences and to define the variables for predicting success.

MATERIAL AND METHODS

The present study was an observational trial performed in a private IVF center on subfertile couples who had applied for treatment between 2002 and 2012, in which the data of 503 IUI cases were retrospectively reviewed. Couples who had been diagnosed with unexplained and mild male subfertility were included. The primary outcome measure was the clinical pregnancy rate in an attempt to form a predictive model for the odds of a clinical pregnancy. Recorded parameters were used to determine the prediction model.

RESULTS

Utilizing univariate logistic regression analysis, clinical pregnancy was positively associated with the duration of infertility (OR=1.09, p=0.089), secondary infertility (OR=1.77, p=0.050), and +4 sperm motility after preparation (OR=1.03, p=0.091). Following an adjustment analysis involving a multivariate logistic regression, clinical pregnancy was still found to positively associate with secondary infertility (OR=2.51, p=0.008).

CONCLUSION

IUI success in secondary infertile couples who were in the unexplained infertility and mild male subfertility groups was higher than that in primary infertile couples, and the chances of pregnancy increased as sperm numbers with +4 motility increased. It is difficult to concomitantly evaluate all these parameters and to determine a predictive parameter in IUI independent from other factors.

A Survey on Main Semen Parameters in Natural Pregnancy and Intrauterine Insemination: Are There Any Significant Differences?

Intrauterine insemination (IUI) is a treatment of choice compared with other invasive and expensive techniques of assisted reproduction. Sperm quality is used to predict its outcome and success. Establishing threshold levels for sperm parameters is useful to avoid spending time and money to do other assisted reproductive techniques. This study was carried out to compare various semen parameters in a group of men eligible to participate in an IUI program with those of fertile men whose wives were pregnant at the time of the study. Two hundred and thirty-four semen samples were evaluated from subfertile men whose partners were candidates for IUI and 234 semen samples were evaluated from fertile men whose partners were pregnant less than 12 weeks. To assess the sensitivity and specificity of the main semen parameters, receiver operating characteristic (ROC) curves were used. Normal sperm morphology is more sensitive and specific compared with its progressive motility and concentration. No significant differences in various semen parameters of fertile men and those of the male partners of IUI candidates were observed. ROC analysis identified that sperm normal morphology using strict criteria may be a good indicator of fertility status in men. No significant difference in various semen parameters between the male partners of IUI candidates and the fertile men was seen. However, utilizing ROC curves, sperm morphology using strict criteria could be a good predictor of fertility.

Pregnancy rates with intrauterine insemination: comparing 1999 and 2010 World Health Organization semen analysis norms

Over the past 30 years, The World Health Organization has serially measured norms for human sperm. In this study, 1999 and 2010 semen analysis norms as predictors of pregnancy were compared during intrauterine insemination (IUI). A retrospective cohort study was conducted using data collected from the Stanford Fertility Center, between 2005 and 2007, with 981 couples undergoing 2231 IUI cycles. Collected semen was categorized according to total motile sperm counts (TMSC): 'normal (N.) 1999 TMSC', 'abnormal (AbN.) 1999/N. 2010 TMSC', or 'AbN. 2010 TMSC'. Sample comparison was also based on individual semen parameters: 'N. 1999 WHO', 'AbN. 1999/N. 2010 WHO', or 'AbN. 2010 WHO'. Pregnancy (defined by beta-HCG concentration) rates were calculated. Data were compared using correlation coefficients, t-tests and chi-squared tests, with and without adjusting for confounders. Pregnancy rate comparison based on TMSC ('N. 1999 TMSC', 'AbN. 1999/N. 2010 TMSC' and 'AbN. 2010 TMSC') showed a negative correlation (r = -0.41, P = 0.05). Pregnancy rate did not differ when comparisons were based on the presence of abnormal parameters, even when controlling for confounders. Therefore, TMSC based on the 1999 parameters shows best correlation with pregnancy rate for IUI; updating these norms in 2010 has little clinical implication in infertile populations.

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.

Angiotensin-converting enzymes play a dominant role in fertility

According to the World Health Organization, infertility, associated with metabolic syndrome, has become a global issue with a 10%-20% incidence worldwide. An accumulating body of evidence has shown that the renin-angiotensin system is involved in the fertility problems observed in some populations. Moreover, alterations in the expression of angiotensin-converting enzyme-1, angiotensin-converting enzyme-2, and angiotensin-converting enzyme-3 might be one of the most important mechanisms underlying both female and male infertility. However, as a pseudogene in humans, further studies are needed to explore whether the abnormal angiotensin-converting enzyme-3 gene could result in the problems of human reproduction. In this review, the relationship between angiotensin-converting enzymes and fertile ability is summarized, and a new procedure for the treatment of infertility is discussed.

Spectral Doppler sonography: a noninvasive method for predicting dyspermia

OBJECTIVES

Sonography is a noninvasive, office-based diagnostic tool often used for evaluation of subfertile men. Previous studies have suggested that a resistive index (RI) greater than 0.6 is associated with impaired spermatogenesis. We sought to validate this threshold in a urologic patient population presenting for infertility evaluation.

METHODS

We retrospectively reviewed 99 consecutive patients seen for nonobstructive male infertility at our institution. Patient demographics, semen analysis parameters, hormone profiles, lipid profiles, and penile and scrotal sonographic measurements were recorded. The RI was calculated from measurements of the peak systolic velocity and end-diastolic velocity. Ninety-one patients fit the inclusion criteria and were subsequently divided into 2 groups based on RI: group 1 with RI values of 0.6 or less (n = 49) and group 2 with RI values greater than 0.6 (n = 42).

RESULTS

Variables that were significantly different between the groups included age, total sperm count, percent motile sperm, total motile sperm, follicle-stimulating hormone, high-density lipoprotein, and testis volume. On the other hand, body mass index, forward progression, World Health Organization score, total testosterone, free testosterone, estradiol, total cholesterol, low-density lipoprotein, and triglycerides were not significantly different between the groups. A receiver operating characteristic curve revealed an area under the curve of 0.64 (confidence interval, 0.52-0.75; P = .025). At the threshold of greater than 0.6, the RI had specificity of 63.27% and a 1.56 likelihood ratio to predict total motile sperm less than 20 × 10(6) at spermatogenesis.

CONCLUSIONS

An intratesticular RI greater than 0.6 is associated with impaired spermatogenesis. This finding supports the use of testicular spectral Doppler sonography as a noninvasive tool for evaluation of testicular function.

Efficacy of the motile sperm organelle morphology examination (MSOME) in predicting pregnancy after intrauterine insemination

BACKGROUND

Although the motile sperm organelle morphology examination (MSOME) was developed merely as a selection criterion, its application as a method for classifying sperm morphology may represent an improvement in the evaluation of semen quality. The aim of this study was to determine the prognostic value of normal sperm morphology using MSOME with regard to clinical pregnancy (CP) after intrauterine insemination (IUI).

METHODS

A total of 156 IUI cycles that were performed in 111 couples were prospectively analysed. Each subject received 75 IU of recombinant FSH every second day from the third day of the cycle. Beginning on the 10th day of the cycle, follicular development was monitored by vaginal ultrasound. When one or two follicles measuring at least 17 mm were observed, recombinant hCG was administered, and IUI was performed 12-14 h and 36-40 h after hCG treatment. Prior to the IUI procedure, sperm samples were analysed by MSOME at 8400× magnification using an inverted microscope that was equipped with DIC/Nomarski differential interference contrast optics. A minimum of 200 motile spermatozoa per semen sample were evaluated, and the percentage of normal spermatozoa in each sample was determined.

RESULTS

Pregnancy occurred in 34 IUI cycles (CP rate per cycle: 21.8%, per patient: 30.6%). Based on the MSOME criteria, a significantly higher percentage of normal spermatozoa was found in the group of men in which the IUI cycles resulted in pregnancy (2.6+/-3.1%) compared to the group that did not achieve pregnancy (1.2+/-1.7%; P = 0.019). Logistic regression showed that the percentage of normal cells in the MSOME was a determining factor for the likelihood of clinical pregnancy (OR: 1.28; 95% CI: 1.08 to 1.51; P = 0.003). The ROC curve revealed an area under the curve of 0.63 and an optimum cut-off point of 2% of normal sperm morphology. At this cut-off threshold, using the percentage of normal sperm morphology by MSOME to predict pregnancy was 50% sensitive with a 40% positive predictive value and 79% specificity with an 85% negative predictive value. The efficacy of using the percentage of normal sperm morphology by MSOME in predicting pregnancy was 65%.

CONCLUSIONS

The present findings support the use of high-magnification microscopy both for selecting spermatozoa and as a routine method for analysing semen before performing IUI.