This Article Abstract Full Text (PDF) All Versions of this Article: 29/4/404    most recent Author Manuscript (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Küçük, T. Articles by Buluc, B. Search for Related Content PubMed PubMed Citation Articles by Küçük, T. Articles by Buluc, B.

Intrauterine Insemination With Double Ejaculate Compared With Single Ejaculate in Male Factor Infertility: A Pilot Study

ERAN SOZEN

BURCU BULUC

From the ^* GATA School of Medicine, Department of Obstetrics and Gynecology, Ankara, Turkey; and the Ankara ART Center, Turkey.

Correspondence to: Dr Tansu Küçük, Professor, Lecturer, GATA School of Medicine, Department of Obstetrics and Gynecology, 06018, Etlik, Ankara, Turkey (e-mail: tansukucuk{at}gmail.com).

Received for publication December 20, 2007; accepted for publication March 25, 2008.

	Abstract

Top Abstract Materials and Methods Results Discussion References

 
The aim of this study was to compare the efficiency of using a double ejaculate with the efficiency of using a single ejaculate for intrauterine insemination in male subfertility. Eligibility for the study was a total motile sperm count between 1 x 10⁶ and 5 x 10⁶ on postwash sperm analysis. Thirty-nine couples were randomized to the study group, while another 50 couples were randomized to serve as the control group. Males in the study group were asked to produce a second semen sample within 2 hours of the first sample on the day of insemination. In the study group, the mean total motile sperm count in the first sample was 3.83 x 10⁶ (SD ± 0.85 x 10⁶; range 1.1–4.9) and 3.99 x 10⁶ (SD ± 0.72 x 10⁶; range 0.9–4.4) in the control group. The mean total motile sperm count in the second sample was 3.52 x 10⁶ (SD ± 1.46 x 10⁶; range 0.9–3.7) in the study group. The mean total motile sperm count in the final inseminate was 7.35 x 10⁶ (SD ± 1.90 x 10⁶; range 2.9–10.6) in the study group. The difference in total motile sperm counts between the study and the control group was statistically significant (P < .001). There were 6 pregnancies in the study group, providing a pregnancy rate of 15.3%, whereas there were 5 pregnancies in the control group, representing a pregnancy rate of 10% (P = .44). We concluded that although it does not increase the pregnancy rate significantly, obtaining a second semen sample when the motile sperm yield of the first semen sample is 1 million to 5 million significantly increases the total motile sperm count in the final inseminate.

     Key words: Total motile sperm count, IUI, inseminate, second ejaculate

Total motile sperm (TMS) count is the most significant sperm parameter in predicting success of IUI (Miller et al, 2002). The threshold value of TMS concentration, below which in vitro fertilization is recommended, has been a topic of debate. IUI may not be an option if the sperm parameters are too poor. Various threshold values defined in different studies are not absolute; pregnancies still occur below those values. The cutoff values of between 5 x 10⁶ and 10 x 10⁶ motile sperm in the ejaculate (Cohlen et al, 1998; Dickey et al, 1999) and of about 0.8 x 10⁶ to 1 x 10⁶ motile sperm in the inseminate have been reported in some studies (Campana et al, 1996; Wainer et al, 2004).

Sperm washing is an inherent part of an intrauterine insemination cycle. Semen processing positively affects motility and morphology while affecting total sperm count negatively. We hypothesized that obtaining a second semen sample and increasing the sperm concentration in the final inseminate could be a logical approach to male factor subfertility. This could compensate for the decrease in total sperm count caused by semen processing, particularly in severely oligospermic subjects. The aim of the current study was to assess the efficiency of using a double ejaculate for intrauterine insemination in male subfertility.

	Materials and Methods

Top Abstract Materials and Methods Results Discussion References

 
The study was conducted in a private setting between the years 2004 and 2007. Institutional board approval was obtained. Among those undergoing IUI for male factor subfertility, 137 couples were eligible for the study. Couples with male factor infertility were counseled according to postwash sperm parameters for a better assessment of prognosis. Eligibility for the study was a total motile sperm count between 1 x 10⁶ and 5 x 10⁶ on postwash sperm analysis. Only the couples having their first IUI cycle were included in the study. Total immotility, total teratozoospermia, and additional female factor for infertility were criteria for exclusion. Couples were randomized with computer generated random numbers. Male partners randomized to the study group were asked to produce a second semen sample within 2 hours of the first sample on the day of insemination. Thirty-five males did not consent to the study. Of the remaining 101 males, 11 could not produce a second sample at the time of IUI, and 1 patient had total immotility and was excluded from the study. Data from 89 IUI cycles are presented here. Thirty-nine couples were randomized to the study group, while 50 served as the control group.

All female partners had undergone a diagnostic work-up including hysterosalpingography, transvaginal ultrasonography, and measurement of baseline levels of follicle-stimulating hormone (FSH), leutinizing hormone (LH), estradiol, thyroid-stimulating hormone (TSH), triiodothyronine (T3), thyroxine (T4), prolactin, and midfollicular progesterone. Male factor evaluation included uro-andrologic examination, periferic karyogram, Y-deletion screening, and measurement of baseline levels of FSH, LH, testosterone, TSH, T3, and T4. Male infertility was diagnosed when sperm abnormalities according to World Health Organization criteria (1999) were seen in at least 2 semen samples. All couples in the study had idiopathic male infertility. When other causes were diagnosed, patients were referred for appropriate treatment.

The female partners underwent a controlled ovarian stimulation protocol with recombinant FSH (Gonal-F; Serono, Geneva, Switzerland). Seventy-five international units (IU) of recombinant FSH (recFSH) was started on Day 2 of menstruation. This same dose was continued for 4 days; for Day 5 and onwards, the FSH dose was individualized according to follicular measurement on transvaginal ultrasonography and serum estradiol level. RecFSH administration was continued until the dominant follicle exceeded 17 mm in diameter. Then, 10 000 IU human chorionic gonatotropin (hCG; Profasi; Serono) was injected. Inseminations were scheduled between 36 and 38 hours after a midday hCG administration.

Semen samples were obtained with masturbation after 3–7 days of sexual abstinence. Neat semen was left at room temperature for liquefaction for 30 minutes; the initial sperm concentration, motility, and morphology were assessed. Then, semen was washed with an Earle's Balanced Salt Solution (EBSS)-containing medium (Ferticult, Beernem, Belgium) at 350 x g for 10 minutes. The pellet underwent centrifugation on a mini-Percoll gradient (40% to 80%) at 200 x g for 20 minutes. Ninety-five percent of the fraction was recovered and washed again with EBSS-containing medium at 350 x g for 5 minutes. The pellet was resuspended to 1 mL, then postwash motility and motile sperm count were reassessed. Finally, the sample was centrifuged again, and the pellet resuspended to 0.3 mL and was left for incubation at 37°C. The second semen sample underwent the same procedure. The final volume for insemination in the study group was 0.6 mL. In the control group, semen preparation was the same as in the study group. The control group's inseminant volume was 0.3 mL.

Insemination was performed with a catheter (IUI; CCD Laboratories, Paris, France). No mucus cleaning was done. Intrauterine inseminations were performed at the dorsal litotomy position. Patients were kept at rest for 30 minutes. No luteal support was given. Couples were advised to refrain from sexual intercourse until the next visit.

The main outcome measure was the pregnancy rate, indicated by an elevated β-hCG level on the first or second day of missed menstruation. Comparison between the pregnancy rates was made by using the paired ² test in SPSS (SPSS Inc, Chicago, Illinois). Comparison of total motile spermatozoa counts was made using the paired t test.

	Results

Top Abstract Materials and Methods Results Discussion References

 
The mean duration of infertility was 29.4 months (range 14–51 mo). The mean age of the male partners was 32.2 years (range 24–40 y) and 24.8 years (range 22–31 y) for the female partner. The neat semen parameters were not different between the study and the control groups. In the study group, the mean sperm concentration was 8 x 10⁶ (SD ± 2 x 10⁶), the mean progressive motility was 59% (SD ± 11%), and the mean percentage of normal morphology sperm was 64% (SD ± 12%) in the study group. These values were 8 x 10⁶ (SD ± 1 x 10⁶), 60% (SD ± 10%), and 61% (SD ± 9%), respectively, in the control group. After semen preparation, the mean number of total motile sperm in the first semen sample was 3.83 x 10⁶ (SD ± 0.85 x 10⁶; range 1.1–4.9) in the study group, and 3.99 x 10⁶ (SD ± 0.72 x 10⁶; range 0.9–4.4) in the control group. The mean number of total motile sperm in the second semen sample was 3.52 x 10⁶ (SD ± 1.46 x 10⁶; range 0.9–3.7) after semen preparation. The mean number of total motile sperm in the final inseminate was 7.35 x 10⁶ (SD ± 1.90 x 10⁶; range 2.9–10.6). The difference in TMS counts between the study and the control groups was statistically significant (P < .001; Table).

There were 6 pregnancies in the study group, providing a pregnancy rate of 15.3%. In the control group, 5 pregnancies were achieved (10%). The difference between the pregnancy rates was statistically insignificant (P = .44). There were no multiple pregnancies and no abortions in the follow-up of pregnancies.

The mean TMS count was 8.95 x 10⁶ (SD ± 1.05 x 10⁶) for the pregnancy-positive group and was 7.05 x 10⁶ (SD ± 1.88 x 10⁶) for the pregnancy-negative group (P = .016). The cut off-value in our study was 8.45 x 10⁶, with a sensitivity of 85% and a specificity of 75% (95% confidence interval).

	Discussion

Top Abstract Materials and Methods Results Discussion References

 
In the present study, we tested the efficiency of using a double ejaculate for IUI in male factor infertility in a selected small group of couples. IUI associated with controlled ovarian stimulation is a simple and inexpensive treatment for infertility. The pregnancy rates per cycle vary between 4% and 40% (Karlström et al, 1993; Fanchin et al, 1995). Before proceeding to more expensive and more invasive methods like in vitro fertilization, IUI with double ejaculate provided a 15.3% pregnancy rate in our hands. To the best of our knowledge, this is the first trial using a double ejaculate in an IUI cycle.

Previous studies showed increasing conception rates with increasing inseminating motile count (Dodson and Haney, 1991; Huang et al, 1996). The cutoff value for success varied between 0.25 x 10⁶ to 5 x 10⁶. The success rate increases as the TMS count exceeds 5 x 10⁶; beyond 10 x 10⁶, the pregnancy rate is doubled. The cut off-value in our study was 8.45 x 10⁶, with a sensitivity of 85% and a specificity of 75% (95% confidence interval), but the study was not designed for such a purpose. The mean TMS count was 8.95 ± 1.05 for the pregnancy-positive group and was 7.05 ± 1.88 for the pregnancy-negative group (P = .016).

The majority of studies assessing the effect of sperm parameters on pregnancy rate of IUI have reported that male factor infertility couples have low pregnancy rates with IUI (Campana et al, 1996; Berg et al, 1997; Ombelet et al, 1997). Differences in outcomes of studies are possibly related to the severity of the male factor in the study group. Some studies excluded the most severe male factor couples and consequently found better results (Goverde et al, 2000).

Improved semen quality after a 30–60 minute second ejaculation was shown previously (Check and Chase, 1985). Seven of 20 men had less than 5 x 10⁶ sperm on the baseline semen evaluation; of those, 5 had a better concentration, up to 20 x 10⁶, in the second semen sample. Although a concentration this high was not seen in our study group, the second sample was not inferior to the first one in the majority of subjects.

Consecutive ejaculates 1 day apart were analyzed in a study by Brown et al (1997). This group collected the first sample on the day of LH surge of the female partner and the second sample a day later. It has been reported that the second samples were not inferior to the first ones. Furthermore, the second samples had a superior total motile sperm count in oligoasthenospermic subjects.

Obtaining additional ejaculates was used for improving the outcome of intracytoplasmic sperm injection (ICSI) in patients with absolute immotile spermatozoa (Ron-El et al, 1998). This group reported significantly better viability and fertilizing capacity of spermatozoa in the repeated semen samples.

We concluded that, although the increase in pregnancy rate was not significant, obtaining a second semen sample when the motile sperm yield of the first semen sample was 1 million–5 million significantly increases total motile sperm count in the final inseminate. One of the most significant drawbacks of this study is the small number of couples in each arm. However, the promising results of this pilot study warrant broader, prospective, controlled studies.

	References

Top Abstract Materials and Methods Results Discussion References

 
Berg U, Brucker C, Berg FD. Effect of motile sperm count after swim-up on outcome of intrauterine insemination. Fertil Steril. 1997;67: 747 –750.[CrossRef][Medline]

Brown SE, Montgomery Rice VC, Stewart DL, Harris MA, Jordan S, Clinton TK. Effect of consecutive ejaculation on the total number of motile sperm inseminated. Fertil Steril. 1997; 68(suppl): 45 –46.

Campana A, Sakkas D, Stalberg A, Bianchi PG, Comte I, Pache T. 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: 732 –736.[Abstract/Free Full Text]

Check JH, Chase JS. Improved semen quality after a short interval second ejaculation. Fertil Steril. 1985; 44: 416 –418.[Medline]

Cohlen BJ, te Velde ER, van Kooij RJ, Looman CWN, Habbema JDF. Controlled ovarian hyperstimulation and intrauterine insemination for treating male subfertility: a controlled study. Hum Reprod. 1998; 13: 1553 –1558.[Abstract/Free Full Text]

Dickey RP, Pyrzak R, Lu PY, Taylor SN, Rye PH. Comparison of the sperm quality necessary for successful intrauterine insemination with WHO threshold values for normal sperm. Fertil Steril. 1999; 71: 684 –689.[CrossRef][Medline]

Dodson WC, Haney AF. Controlled ovarian hyperstimulation and intrauterine insemination for treatment of infertility. Fertil Steril. 1991;55: 457 –467.[Medline]

Duran HE, Morshedi M, Kruger T, Oehninger S. Intrauterine insemination: a systematic review on determinants of success. Hum Reprod Update. 2002;8: 373 –384.[Abstract/Free Full Text]

Fanchin R, Olivennes F, Righini C. A new system for fallopian tube sperm perfusion leads to pregnancy rates twice as high as standard intrauterine insemination. Fertil Steril. 1995; 64: 505 –510.[Medline]

Goverde AJ, McDonnel J, Vermeiden JPW, Schats R, Rutten FFH, Schoemaker J. Intrauterine insemination or in vitro fertilization in idiopathic subfertility and male subfertility: a randomized trial and cost-effectiveness analysis. Lancet. 2000; 355: 12 –18.

Huang HY, Lee CL, Lai YM. The impact of the total motile sperm count on the success of intrauterine insemination with husband's spermatozoa. J Assist Reprod Genet. 1996; 13: 56 –63.[CrossRef][Medline]

Karlström PO, Bergh T, Lundkvist O. A prospective randomized trial of artificial insemination versus intercourse in cycles stimulated with human menopausal gonadotropin or clomiphene citrate. Fertil Steril. 1993;59: 554 –559.[Medline]

Miller DC, Hollenbeck BK, Smith GD, Randolph JF, Christman GM, Smith YR, Lebovic DI, Ohl DA. Processed total motile sperm count correlates with pregnancy outcome after intrauterine insemination. Urology. 2002;60: 497 –501.[CrossRef][Medline]

Ombelet W, Vandeput H, Van de Putte G, Cox A, Janssen M, Jacobs P. Intrauterine insemination after ovarian stimulation with clomiphene citrate: predictive potential of inseminating motile count and sperm morphology. Hum Reprod. 1997; 12: 1458 –1463.[Abstract/Free Full Text]

Ron-El R, Strassburger D, Friedler S, Komarovsky D, Bern O, Raziel A. Repetitive ejaculation before intracytoplasmic sperm injection in patients with absolute immotile spermatozoa. Hum Reprod. 1998; 13: 630 –633.[Abstract/Free Full Text]

Wainer R, Albert M, Dorion A, Bailly M, Bergere M, Lombroso R, Bombault M, Selva J. Influence of the number of motile spermatozoa inseminated and of their morphology on the success of intrauterine insemination. Hum Reprod. 2004; 19: 2060 –2065.[Abstract/Free Full Text]

World Health Organization. WHO Laboratory Manual for the Examination of Human Semen and Semen-Cervical Mucus Interaction. 4th ed. Cambridge, United Kingdom: Cambridge University Press; 1999 .

This Article Abstract Full Text (PDF) All Versions of this Article: 29/4/404    most recent Author Manuscript (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Küçük, T. Articles by Buluc, B. Search for Related Content PubMed PubMed Citation Articles by Küçük, T. Articles by Buluc, B.