Published by : PROFESSIONAL MEDICAL PUBLICATIONS
|July - September 2006||
The relationship between total
motile sperm count and pregnancy
rate after intrauterine insemination
Objective: To determine the relationship between the total motile sperm count and the success of IUI treatment cycles with postwashed husband spermatozoa in couples with infertility in a large patient population.
Design: Retrospective descriptive study.
Setting: Academic University Hospital- based infertility center.
Patients: Eight hundred twenty four infertile couples undergoing 824 cycles of IUI.
Main outcome measure(s): To assess the significance of prognostic factors including a womanís age, duration of infertility, diagnoses, use of ovulation induction and sperm parameters for predicting the outcomes of clinical pregnancy after the first cycle of IUI.
Results: The pregnancy rate per cycle was 18.2% (150/824). Postwashed semen parameters including total motile sperm count >10◊106,motility >50%. There was a trend toward an increased success rate with increased total motile Sperm count.
Conclusion: Our finding suggest that a final postwashed total motile sperm count used for IUI may be considered predictive of the success for pregnancy.
KEY WORDS: Infertility, Intrauterine insemination, Semen analysis, Pregnancy.
Pak J Med Sci July - September 2006 Vol. 22 No. 3 223-227
1. Dr. Tooba Mehrannia PhD
University of Kermanshah Medical Sciences,
Dr. Tooba Mehrannia,
61, 16 Metery,
2nd Bahar Street,
* Received for Publication: January 7, 2006
* Accepted: April 26, 2006
Intrauterine insemination (IUI) is commonly used to treat infertile couples with varying etiologies of infertility, such as male-factor infertility1 or unexplained infertility.2 It can overcome the problems associated with husbandís inability to ejaculate inside the womanís vagina due to impotence, premature ejaculation or other medical conditions.3 Controlled ovarian stimulation has been shown to have an additive effect on the pregnancy rate when combined with IUI for unexplained infertility.2 Intrauterine insemination is used if timing of exposure to sperm is controlled and spermatozoa are placed in the uterine cavity.4 The beneficial effect of controlled ovarian stimulation may be lost if male has low sperm counts.2,5,6
The purpose of this study was to evaluate outcomes of treatment from a large database of infertile couples and determine prognostic factors for achieving a pregnancy with IUI. The effect of the number of motile sperm on the outcomes of IUI, controlled ovarian stimulation combined with IUI, has been studied and interpreted here.
PATIENTS AND METHODS
One thousand eight hundred forty one therapeutic intrauterine insemination (IUI) were done for eight hundred twenty four women with age of 20-45 years. All patients were evaluated by physicians in the Academic University Hospital and had infertility, defined by >2 year of unprotected intercourse without conception. This study was limited to the first cycle that was performed for every couple.
A standardized infertility evaluation was performed on all couples that included at least one semen analysis, a histrosalpingogram and some documentation of ovulation most commonly by a day 21 progesterone level. Other infertility evaluation including postcoital test, endometrial biopsies and laparoscopies were not performed in all couples but rather, were performed at discretion of the physician after consultation with the couple.
Women were categorized into the following groups of infertility diagnoses on the evaluation: anovulation, tubal disease (defined as any abnormality of one or both fallopian tubes or a history of any tubal surgery), or no abnormality if all tests were normal.
All patients had ovarian stimulation with a combination of clomiphen citrate (100mg from 3rd days of menstrual cycle) and hmg (75IU IM) beginning at 8th day of menstruation, which was adjusted with follicular development monitoring by vaginal ultrasound. When at least one leading follicular diameter was 18mm, 10000IU IM hcg was administered.
IUIs were performed 36 hours after the administration of hcg. Male factor infertility was not strictly defined but was assessed by analyzing the number of motile sperm in the ejaculate. Couples were considered to be candidates for treatment by IUI if the woman was ovulatory and had at least one open fallopian tube and motile sperm were present in the maleís ejaculate. All treatment decisions were made by a reproductive endocrinology staff physician after consulting with the couple.
All couples were requested to abstain from intercourse for 2-7 days before IUI semen samples were obtained at the laboratory. Immediately after Liquefaction, a drop of the well mixed specimen was placed on a clean and prewarmed glass slide at 37oc, covered with a coverslip and left for a few minutes.
The preparation was examined under a magnification of both ◊10 and ◊40 objectives. The motility assessment was done according to World Health Organization guidelines. In at least 10 separate randomly selected high-power fields. The motility was recorded. Spermatozoa were prepared by the swim-up technique. Samples were diluted in Hamís F10 medium with 5% human serum albumin (HAS) and centrifuged for three minutes (300◊g). The pellets were resuspended in 1ml of medium and centrifuged for three minutes at 300◊g and then were left at 37oc for 30 to 60 minutes in humidified incubator (5%CO2). The postprocessing volume, sperm concentration and motility were obtained and recorded. All variables were separately tested to determine their significance in predicting the occurrence of clinical pregnancy. For these evaluations, x2 analysis was used for categorical variable. Significant differences were determined at p<0.05 levels.
The characteristics of patients treated by IUI are listed. Overall clinical pregnancy rate was 18.2%. The mean age of female was 29.3(range 20-40). The majority of the pregnancies were achieved in 25-29 years old (20.8%); Table-I.
Data showed that although the differences between pregnancy rate and the kind of infertility were statistically insignificant, the highest rate of pregnancy was observed in patients with unexplained infertility (Table-II). Duration of infertility didnít influence pregnancy rate, but the pregnancy rate according to infertility duration <5years, 5-10 years and 10-15 years were observed in patients 96(18.1%), 42(21.3%), 12(17.8%) respectively. With >15 years infertility no pregnancy occurred. We examined the total motile sperm count (TMSC) in both ejaculate and in the inseminate for the first IUI cycle. We observed a threshold effect with the lowest pregnancy rate found in the lowest TMSC. The pregnancy rate was significantly increased with high number of inseminated motile sperm of over 10million/ml (Table-III). Our results demonstrated that the percentage of normal forms postwashed sperms >50 was related with pregnancy in 150 cases; and pregnancy wasnít observed with sperm motility less than 50% in postwashed sperm analysis (p<0.001).
This study sought to determine important and independent variables for predicting pregnancy after standard infertility treatments by controlling for all other variables. We found that several patientsívariables significantly predicted pregnancy after IUI. Younger female age, a history of pregnancy, the use of clomiphene citrate for controlled ovarian hyperstimulation and average total motile sperm count >10 million were all independent-predi- ctors in clinical pregnancy after IUI treatment.
Duration of infertility and infertility diagnoses in the woman were not significant predictors of pregnancy after IUI. Increasing female age resulted in reduced chances for pregnancy after IUI. Pregnancy rate following IUI performed in woman over the age of 40-year-old are less.
Many investigators have confirmed a significantly lower pregnancy rate per cycle in women over the age of 35 years (7 to 10%) compared with younger ones (15 to 23%).7-10 Some studies showed the outcome of IUI treatment was adversely affected if the femaleís age was >39 years.11 No pregnancies have been observed in women 40 years or older but the age did not have a significant effects either.12
In our study, an advanced female age has not been found to affect the pregnancy rate in controlled ovarian hyperstimulation (COH)/IUI treatment. The duration of infertility has been shown to be a prognostic factor for live births among untreated subfertile couples in several studies. After two to four years of infertility the likelihood of a live birth begin to decrease.13
In controlled ovarian hyperstimulation and IUI therapy, outcome will be significantly impaired after 3 to 8 years of infertility;7 but there are studies in which the duration of infertility has not been shown to affect the pregnancy rate.14 Our finding confirmed similar results. Controlled ovarian hyperstimulation together with IUI is widely used for the treatment of subfertility, particularly for couples with unexplained infertility, male-factor infertility or mild endometriosis.8,15,16
In our study, although the difference of pregnancy rate in categories of subfertility wasnít statically significant, the maximum pregnancy rates was observed in patients with unexplained infertility (30.5%). The average total motile sperm count proved to be a useful predictor of the chance for pregnancy after IUI as compared with individual seminal fluid analysis results. The variability in individual semen analysis results is well known, as is the significant overlap in results when comparing fertile with infertile men.17
We observed a threshold effect for the average total motile sperm count (TMSC). When the average TMSC was <10 million, pregnancy rates were very low after IUI whether or not controlled ovarian hyperstimulation was performed in the woman. IUI pregnancy rates reached a plateau with no further increases in the pregnancy rate noted at higher values.
When the average TMSC was above 30 million, we noted higher pregnancy rates when controlled ovarian hyperstimulation was used in conjunction with the IUI cycle as compared with natural cycle IUI .
Most studies evaluating the effect of semen parameters on outcomes of IUI have concluded that couples with a male-factor for infertility have low pregnancy rates after IUI.10,11,18-22 Nearly all studies have confirmed that the addition of controlled ovarian stimulation does not improve the pregnancy rate of IUI in couples with severe male-factor infer- tility.2,5,6,23,25 Differences in outcome of various studies are likely related to how the male-factor infertility is defined and severity of the male-factor. Several studies have concluded that IUI is useful in male-factor patients from the trial.5,26,27 Many of the men in our study with average TMSC >10million would still be defined as having male-factor infertility, based on World Health Organization criterion. In conclusion, postwash semen quality was the most important factor for predication of successful pregnancy in this study.
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