Abstract
Background
The present study aimed to analyze the prognostic value of sperm morphology , total motile sperm count (TMSC) and the number of motile sperm inseminated (NMSI) on the outcome of intrauterine insemination (IUI).
Materials and Methods
This cross sectional study was carried out 445 women undergoing 820 IUI cycles. All of the patients underwent controlled ovarian hyper stimulation with clomiphen citrate and human menopausal gonadotropin (HMG) followed by intrauterine insemination with the husband’s sperm. Pregnancy rate (PR) per cycle in correlation to sperm morphology, TMSC and NMSI was obtained. Statistical analysis of the data was done by the SPSS version 13 (Chicago,USA).
Results
A total of 81 clinical pregnancies were obtained for a pregnancy rate per cycle of 9.9%. When the TMSC was 5×106to <10×106, the PR per cycle was significantly higher than the subgroups <1×106, 1×106to <5×106and ≥10×106(15%, 5.6%, 5.1%, 10.8%, respectively). Sperm morphology was in itself a significant factor that affected the likelihood of IUI success. Nonetheless, the most significant difference of the PR per cycle with sperm morphology was in the subgroup <5 % (2.1% vs. 97.9%).When the NMSI was ≥10×106, the PR per cycle was significantly higher than the subgroups<5×106and 5×106to< 10× 106(11.2%, 4.1%, 5.2%, respectively).
Conclusion
The study showed that TMSC 5×106to < 10×106and normal sperm morphology ≥ 5% and NMSI ≥ 10×106are useful prognostic factors of IUI cycles.
Keywords: Intrauterine, Insemination, Motile Sperm, Morphology
Introduction
Artificial insemination has been used to treat infertile couples for almost 200 years. Intrauterine insemination (IUI) is now performed for several reasons. The cut-off level of semen parameters in predicting the likelihood of successful IUI is still unequivocal (1-5). It is not determined which parameter of semen is essential for diagnosis in couples who will benefit from IUI (6).
Some pregnancy will occur after IUI even with sever male factor. Clinicians need tests that identify which sub-fertile couples are likely to benefit from IUI (7).
The effectiveness of IUI depends mainly on semen quality, which is assessed by the total motile sperm count (TMSC) and sperm morphology.
TMSC in the ejaculate is the product of multiplying the semen volume by the sperm concentration by the percentage of progressively motile sperms. The best results are achieved when the number of TMSC exceeds a threshold of approximately 10 million (1, 3-5).
Sperm morphology is another factor that may influence the IUI result. Most studies have found a strong correlation between sperm morphology and the IUI result. In assessing sperms morphology by strict criteria, success rates with IUI are highest when 14% or more of the sperm have normal morphology, like the results observed in in vitro fertilization (IVF) cycles (1, 8-11).
The post-wash total motile count (TMC) has been proposed as a test to help distinguish the couples who would benefit from IUI, but it could not distinguish between the couples who are likely to benefit from IUI and those more likely to benefit from IVF or intracytoplasmic sperm injection (ICSI) (7). Several studies have shown the increase of pregnancy rate after IUI when the number of motile sperm inseminated (NMSI) was between 0.8×106 to 20×106 (12-14) .
The aim of our study was to assess the threshold of TMSC, sperm morphology and NMSI on the IUI outcome.
Materials and Methods
This study was a cross sectional. Four hundred forty five couples completed 820 IUI cycles in the infertility department of Imam khomieni Hospital in Ahvaz, Iran from May 2004 to May 2006. They were candidates for IUI because of male factor infertility or unexplained infertility. Informed consent forms were signed by all patients. This study was approved by the Ethics Committee of Ahvaz Jundishapour University Medical Sciences.
Inclusion criteria were normal thyroid stimulating hormone (TSH), prolactin levels and hysterosalpingography. Laparoscopy was performed for suspicious tubal and peritoneal factors before any treatment.
Serological tests human immunodeficiency virus (HIV) antibody, hepatitis B surface antigen (HbsAg) and hepatitis C virus (HCV) antibody were conducted for all the couples.
At first, all women were examined by the vaginal ultrasound (Honda 2000, 7.5 MHZ Transducer, Japan) on 1-5th days of their menstrual period to ensure that ovarian follicles were smaller than 15 mm.Then they underwent controlled ovarian hyperstimulation and received clomiphen citrate100 to 150 mg on the 3-5th day of cycle for 5days and at least 75IU HMG after the last dose of clomiphen citrate irrespective of whether they were ovulatory or anovulatory. Ovarian response was monitored by the vaginal ultrasound;when the follicular size of the leading follicle was 18- 22 mm, human chorionic gonadotropin (HCG) (5000 IU) was administered. All semen samples were collected in the laboratory after 2-3 days of sexual abstinence.
After liquefaction, the sperm volume, pH, count, motility and morphology were evaluated according to the WHO guidelines 1999 (15).
Raw semen was processed for IUI using swimup technique. The sampls were liquidated at 37°C and centrifuged at 300-500 g for 5-10 minutes. Then the supernants were discarded, the pellets were resuspended in 2 ml of medium (Ham’s F10 media, Steinheim, Germany) and centrifuged two times. In each time, the supernants were discarded. Finally, the pellets were resuspended in 0.5-1 ml of medium and the tubes were left at 37°C for 30-60 minutes in a humidified incubator to allow sperm to swimp up. Then the washed sperms were inseminated with an IUI catheter. No drug was used for luteal phase support.
Serum HCG levels were determined two weeks after the HCG injection in the absence of menstruation for diagnosis of pregnancy. A clinical pregnancy was defined as serum positive β-HCG.
The principal assessment criterion consists of the pregnancy rate per cycle according to TMSC, sperm morphology and NMSI.
Statistical analysis
Statistical analysis of the data was done by the SPSS software (version 13, SPSS, Chicago,USA). The data were expressed as the mean standard deviation, independent t test and χ2 test. Odd ratios were calculated using the Logistic regression model for comparison of categorical variables. Significance was set at p<0.05.
Results
In this study, 445 couples, who underwent 820 IUI treatment procedures ,were recruited. Demographic characteristics of the couples are listed in table 1.
Table 1.
Profile of patients (distribution of variables)
| IUI outcome | |||
|---|---|---|---|
| Variables | Positive | Negative | P |
| Female age (years) | 27.58 ± 5.1 | 28.58 ± 5.2 | 0.105 |
| Male age (years) | 33.96 ± 7.8 | 33.65 ± 6.2 | 0.675 |
| Duration of infertility (months) | 62.83 ± 39 | 74.73 ± 50 | 0.042 |
Values are mean ± SD (95% confidence interval).
The range of female and male age were between "16 to 46" and "21 to 63" years and duration of infertility was 12-456 months.
Seventy -three point eighty six percent and 26.13% of the couples had primary and secondary infertility, respectively.
Eighty one pregnancies followed 820 IUI cycles, and the total pregnancy rate per cycle was 9.9 %. There was a statistically significant difference between the clinical pregnancy rate and duration of infertility and ovulatory cycles (p=0.042, p=0.001, respectively) , but not with age of women and men and kind of infertility (Table 2).
Table 2.
The results of IUI according to the age of women, kind of infertility and ovulation
| IUI outcome | ||||
|---|---|---|---|---|
| Positive | Negative | P | X2 | |
| Age of women (year) | 0.532 | 1.262 | ||
| Age ≤30 | 54 (10.5) | 458 (89.5) | ||
| 30 ≤ Age <35 | 18 (9.9) | 163 (90.1) | ||
| Age ≥ 35 | 9 (7.2) | 116 (92.8) | ||
| Kind of infertility | 0.407 | 0.686 | ||
| Primary infertility, n (%) | 56 (6.89) | 546 (67.24) | ||
| Secondary infertility, n (%) | 24 (2.95) | 189 (23.27) | ||
| Ovulation | 0.001 | 10.744 | ||
| Positive | 43 (5.4) | 523 (65.7) | ||
| Negative | 35 (4.39) | 195 (24.49) | ||
Parentheses indicate the percentage
Table 3 shows the results of IUI with TMSC. When the TMSC is 5×106 to < 10×106 , pregnancy rate is significantly higher than the subgroups with <1×106, 1×106 to <5×106 and ≥10×106 (15%, 5.6%, 5.1% and 10.8%, respectively) (p=0.001). By considering the clinical pregnancy rate according to normal sperm morphology, the most positive IUI cycles were observed in the subgroups with normal sperm morphology (5% or more) and the most difference of the results was in the subgroups with normal sperm morphology<%5 (2.1% vs. 97.9 %) (p=0.017), (Table 3).
Table 3.
The results of IUI according to TMSC , Normal sperm morphology and NMSI
| IUI outcome | ||||
|---|---|---|---|---|
| Positive | Negative | P | X2 | |
| TMSC (×106) | 0.001 | 15.813 | ||
| n<1 | 3 (5.6) | 51 (94.4) | ||
| 1 ≤ n<5 | 14 (5.1) | 258 (94.9) | ||
| 5 ≤n<10 | 39 (15) | 221(85) | ||
| n≥10 | 25 (10.8) | 206 (89.2) | ||
| Normal sperm morphology (%) | 0.017 | 8.168 | ||
| 5< | 2 (2.1) | 94 (97.9) | ||
| 5 ≤ n<10 | 54 (10.1) | 482 (89.9) | ||
| ≥10 | 23 (12.6) | 160 (87.4) | ||
| NMSI | 0.026 | 7.311 | ||
| n<5×106 | 3(4.1) | 70 (95.9) | ||
| 5x106≤n<10×106 | 7(5.2) | 128 (94.8) | ||
| n≥10×106 | 65 (11.2) | 516 (88.8) | ||
Parentheses indicate the percentage
Table 3 also indicates the results of IUI with the number of motile sperms inseminated. The PR per cycle was significantly higher when the number of motile sperms inseminated (NMSI) ≥10×106 in comparable with the subgroups <5×106 and 5×106 to <10×106 (11.2%, 4.1% and 5.2%, respectively). The difference is statistically significant (p =0.026).
On the other hand when the NMIS was divided into two groups of ≥10×106 and <10×106, according to Logistic regression model, the rate of pregnancy was higher in the first group (p=0.001, OR=2.86; CI, 1.57-5.21).
Discussion
According to the findings of the present study, 81 clinical pregnancies were achieved after 820 IUI cycles for a total pregnancy rate per cycle of 9.9%. This rate is within the range of the previous studies (1, 3, 5, 7, 8, 16-18).
Overall, most of the previous studies have indicated that the female age, duration of infertility and ovulation are prognostic factors for IUI success (1). In this research, the duration of infertility was a prognostic factor but the female age was not. It may be due to the mean of female age in the two groups, which was approximately the same and lower than 35 years. Basirat et al. (18) reported that the female age and duration of infertility were correlated with the occurrence of pregnancy but the etiology of infertility, type of treatment regimen and the number of dominant follicles did not correlate with the pregnancy occurrence in an IUI cycle. Van Voorlis et al. (9) claimed that duration of infertility and infertility diagnosis in the women were not prognostic factors.
In the current study, we found that the most of IUI success when the range of total motile count was 5×106 to <10×106. Also, the findings of this study showed that TMC<1×106 was not justified for IUI treatment.
In accordance with the present results, some previous studies have suggested that using the total number of motile spermatozoa of semen was a criteria for choosing between IUI and IVF and have recommended the threshold values of 5 to 10×106 (1, 3-5, 8), but Akanji et al. (19) and Dorjpurev et al. (20) suggested IUI is possible in a condition that TMSC is greater than 10 million.
Sperm morphology is another factor that may influence the IUI results. It is worth mentioning that morphological assessment may vary substantially according to the condition of observation, and the kind of sperm morphology assessment, but like the results observed in IVF cycles, the probability of IUI success rises with the percentage of morphologically normal sperms. A number of prior studies have reported that IUI success rates are higher when 14% or more of the sperms have normal morphology and inseminated with the values between 4% and 14% and generally quite poor when fewer than 4% of sperms are normal (21-23).
In agreement with the above studies, the results of the present study also showed that when sperm morphology is more than 5%, the likelihood of IUI success is higher than when it is less than 5%.
Regarding the NMIS, as a factor that may influence on the IUI success, our finding showed that 11.2 % of the positive results were in the group that their NIMS was 10×106 or more. On the other hand, rate of pregnancy after IUI was 2.86 times when NMIS ≥10×106. This finding is in agreement with the study of Miller et al. (8).
Berg et al. also found a nonlinear increase in the PR per cycle with the increasing of NMIS in the uterine. They observed that insemination with <0.8×106 motile sperms after swim-up resulted in a PR of <1% per treatment cycle. But when the motile sperm count was above this level, the PR per cycle reached a plateau of 6.9% to 10.2% (24).
Van weert et al. listed 16 studies reporting that at cut-off levels of 0.8 to 5 million motile spermatozoa, the post wash TMC provided a substantial discriminative performance. At these cut-off levels, the specificity of the post wash TMC was as high as 100% and the sensitivity of the test was limited (7).
Tay et al. (25) identified that PR was significantly lower in patient with NMSI ≤20 million /ml compared to those with TMC >20 million /ml.
Dadkhah et al. (26) also found that mean of total sperms after processing was significantly higher in IUI cycles with positive results.
However, Motazedian et al. (27) declared that there was no significant difference in the IUI outcome when normal sperm morphology is more than 20% or less than 20%. Dorjpurev et al. (20) and Burr et al. (28) indicated that number of motile sperm inseminated did not significantly affect the PR as well.
Conclusion
The results of the present study identified a statistically significant difference in the TMSC, sperm morphology and the NMSI on the outcome of intra uterine insemination.
Acknowledgments
The authors thank Mrs. Mitra Shabab for statistical analysis, the nurses and lab workers in infertility department of Imam khomieni Hospital Ahvaz, Iran. There is no any financial support and conflict of interest in the article.
References
- 1.Speroff L, Fritz MarcA. Clinical gynecologic endocrinology and infertility. 7th ed. Philadelphia: Lippincott Willams and Wilkins; 2005. pp. 1156–1157. [Google Scholar]
- 2.Le Lannou D. Intrauterine insemination, indication and results. Contracept Fertil Sex. 1994;22(6):361–369. [PubMed] [Google Scholar]
- 3.Ombelet W, Puttemans P, Bossmans E. Intrauterine insemination: a first-step procedure in the algorithm of male subfertility treatment. Hum Reprod. 1995;10(suppl 1):90–102. doi: 10.1093/humrep/10.suppl_1.90. [DOI] [PubMed] [Google Scholar]
- 4.Branigan EF, Estes MA, Muller CH. Advanced semen analysis: a simple screening test to predict intrauterine insemination success. Fertil Steril. 1999;71(3):547–551. doi: 10.1016/s0015-0282(98)00503-2. [DOI] [PubMed] [Google Scholar]
- 5.Duran HE, Morshedi M, Kruger T, Oehninger S. Intrauterine insemination: a systematic review on determinants of success. Hum Reprod update. 2002;8(4):373–384. doi: 10.1093/humupd/8.4.373. [DOI] [PubMed] [Google Scholar]
- 6.Van Weert JM, Repping S, Van der Steeg JW, Steures P, Van der Veen F, Mol BW. IUI in male subfertility: are we able to select the proper patients? Reprod Biomed Online. 2005;11(5):624–631. doi: 10.1016/s1472-6483(10)61172-8. [DOI] [PubMed] [Google Scholar]
- 7.Van Weert JM, Repping S, VanVoorhis BJ, Van der Veen F, Bossuyt PM, Mol BW. Performance of the postwash total motile sperm count as a predictor of pregnancy at the time of intrauterine insemination: a metaanalysis. Fertil Steril. 2004;82(3):612–620. doi: 10.1016/j.fertnstert.2004.01.042. [DOI] [PubMed] [Google Scholar]
- 8.Miller DC, Hollenback BK, Smith GD, Randolph JF, Christman GM, Smith YR, et al. Proccessed total motile sperm count correlates with pregnancy outcome after intrauterine insemination. Urology. 2002;60(3):497–501. doi: 10.1016/s0090-4295(02)01773-9. [DOI] [PubMed] [Google Scholar]
- 9.Van Voorhis BJ, Barnett M, Sparks AE, Syrop CH, Rosenthal G, Dawson J. Effect of the total motile sperm count on the efficacy and cost-effectiveness of intrauterine insemination and in vitro fertilization. Fertil Steril. 2001;75(4):661–668. doi: 10.1016/s0015-0282(00)01783-0. [DOI] [PubMed] [Google Scholar]
- 10.Van der Westerlaken LA, Naaktgeboren N, Helmerhorst FM. Evaluation of pregnancy rates after intrauterine insemination according to indication ,age, and sperm parameters. J Assist Reprod Gende. 1998;15(6):359–364. doi: 10.1023/A:1022576831691. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Lee RK, Hou JW, Ho HY, Hwu YM, Lin MH, Tsai YC, Su JT. Sperm morphology analysis using strict criteria as a prognostic factor in intrauterine insemination. Int J Androl. 2002;25(5):277–280. doi: 10.1046/j.1365-2605.2002.00355.x. [DOI] [PubMed] [Google Scholar]
- 12.Wainer R, Albert M, Dorion A, Bailly M, Berg′ere M, Lomberse R, et al. Influence of the number of motile spermatozoa inseminated and of their morphology on the success of intrauterine insemination. Hum Reprod. 2004;19(9):2060–2065. doi: 10.1093/humrep/deh390. [DOI] [PubMed] [Google Scholar]
- 13.Ombelet W, Vande put H, Vande Putte G, Cox A, Janssen M, Jacobs P, et al. Intrauterine insemination after ovarian stimulation with clomiphene citrate: predictive potential of inseminating motile count and sperm morphology. Hum Reprod. 1997;12(7):1458–1463. doi: 10.1093/humrep/12.7.1458. [DOI] [PubMed] [Google Scholar]
- 14.Horvath PM, Bohrer M, Shelden RM, Kemmann E. The relationship of sperm parameters to cycle fecundity in super ovulated women undergoing intrauterine insemination. Fertil Steril. 1989;52(2):288–294. doi: 10.1016/s0015-0282(16)60857-9. [DOI] [PubMed] [Google Scholar]
- 15.WHO Laboratory Manual for the examination of human semen and sperm-cervical mucus interactions. 4th ed. Cambridge,United Kingdom: Cambridge University Press; 2000. pp. 4–22. [Google Scholar]
- 16.Wainer R, Merlet F, Bailly M, Lombrose R, Camus E, Bisson JP. Prognosis for intrauterine insemination with partner’s sperm according to the characteristics of the spermatozoa. Contracept Fertil Sex. 1996;24:897–903. [PubMed] [Google Scholar]
- 17.Ebrahimi M, Akbari AF, Darvish S. The effect of luteal phase support on pregnancy rates of the stimulated intrauterine insemination cycles in couples with stimulated intrauterine insemination cycles in couples with unexplained infertility. Int J Fertil Steril. 2010;4(2):51–56. [Google Scholar]
- 18.Basirat Z, Esmaeilzadeh S. Prognostic factors of pregnancy in 500 cases of intrauterine insemination in Babol, northern Iran. Int J Fertil Steril. 2010;4(1):35–39. [Google Scholar]
- 19.Akanji Tijani H, Bhattacharya S. The role of intrauterine insemination in male infertility. Hum Fertil (Camb) 2010;13(4):226–232. doi: 10.3109/14647273.2010.533811. [DOI] [PubMed] [Google Scholar]
- 20.Dorjpurev U, Kuwahara A, Yano Y, Taniguchi T, Yamamoto Y, Suto A, et al. Effect of semen characteristics on pregnancy rate following intrauterine insemination. J Med Invest. 2011;58(1-2):127–133. doi: 10.2152/jmi.58.127. [DOI] [PubMed] [Google Scholar]
- 21.Campana A, Sakkas D, Stalberg A, Bianchi PG, Comte I, Pache T, et al. Intrauterine insemination :evaluation of the results according to the woman’s age ,sperm quality ,total sperm count per insemination and life table analysis. Hum Reprod. 1996;11(14):732–736. doi: 10.1093/oxfordjournals.humrep.a019244. [DOI] [PubMed] [Google Scholar]
- 22.Kruger TF, Menkveld R, Stander FS, Lombard CJ, Van der Merwe JP, Van Zyl JA, et al. Sperm morphologic features as a prognostic factor in in vitro fertilization. Fertil Steril. 1986;46(6):1118–1123. doi: 10.1016/s0015-0282(16)49891-2. [DOI] [PubMed] [Google Scholar]
- 23.Oehninger S, Acosta AA, Morshedi M, Veeck L, Swanson RJ, Simmons K, et al. Corrective measures and pregnancy outcome in in vitro fertilization in patients with severe sperm morphology abnormalities. Fertil Steril. 1998;50(2):283–287. doi: 10.1016/s0015-0282(16)60074-2. [DOI] [PubMed] [Google Scholar]
- 24.Berg U, Brucker C, Berg FD. Effect of motile sperm count after swim- up on outcome of intrauterine insemination. Fertil Steril. 1997;67(4):747–750. doi: 10.1016/s0015-0282(97)81377-5. [DOI] [PubMed] [Google Scholar]
- 25.Tay PY, Raj VR, Kulenthran A, Sitizawiah O. Prognostic factors influencing pregnancy rate after stimulated intrauterine insemination. Med J Malaysia. 2007;62(4):286–289. [PubMed] [Google Scholar]
- 26.Dadkhah F, Nahabidian A, Ahmadi GH. The correlation between semen parameters in processed and unprocessed semen with pregnancy rate in intrauterine insemination in the treatment of male factor infertility. Urol J. 2004;1(4):273–275. [PubMed] [Google Scholar]
- 27.Motazedian SH, Hamedi B, Zolghadri J, Mojtahedi KH, Asadi N. Outcome of IUI based on sperm morphology in cases of unexplained and male factor infertility. Shiraz E Med J. 2009;10(2):79–83. [Google Scholar]
- 28.Burr RW, Siegberg R, Flaherty SP, Wang XJ, Matthews CD. The influence of sperm morphology and the number of motile inseminated on the outcome of intrauterine insemination combined with mild ovarian stimulation. Fertil Steril. 1996;65(1):127–132. doi: 10.1016/s0015-0282(16)58039-x. [DOI] [PubMed] [Google Scholar]