C.T. Taylor

The sperm deformity index: a reliable predictor of the outcome of oocyte fertilization in vitro *

OBJECTIVE To evaluate a novel expression of sperm morphological parameters, the sperm deformity index, as a predictor of fertilization in vitro. DESIGN Prospective blind clinical trial. SETTING Academic tertiary referral center. INTERVENTION(S) Detailed sperm morphological assessment applying strict morphological criteria and a multiple entry technique for an unselected male population undergoing IVF. The sperm deformity index, defined as the average number of deformities per sperm assessed, was calculated. PATIENT(S) One hundred fifty-eight patients undergoing IVF treatment. Females with conditions negatively influencing fertilization were excluded. MAIN OUTCOME MEASURE(S) Fertilization rates and pregnancy. RESULT(S) Seventy-three percent of patients achieved fertilization. Patients achieving fertilization had a significantly higher median proportion of normal forms and a significantly lower median sperm deformity index than the nonfertilizers. The receiver operator characteristic (ROC) curves identified cutoff points that maximized the sum of sensitivity and specificity at sperm deformity index 1.6 and normal forms 4%. The sperm deformity index had a greater sensitivity (96%), specificity (72%), positive predictive value (90%), and negative predictive value (86%) than the proportion of normal sperm morphology (87%, 69%, 89%, 66%, respectively) at the optimal cutoff points. The area under the ROC curve was greater for the sperm deformity index (0.875) than for the proportion of normal sperm morphology (0.622). Achieving pregnancy did not correlated with sperm morphology. CONCLUSION(S) The sperm deformity index is a more reliable predictor of the outcome of fertilization in vitro than the proportion of normal sperm morphology and can assist to identify patients who require techniques such as intracytoplasmic sperm injection.

Evaluation of different sperm function tests as screening methods for male fertilization potential—the value of the sperm migration test

OBJECTIVE To assess the value of different sperm function screening tests in predicting fertilization. DESIGN Prospective study. SETTING Academic tertiary referral center for fertility treatment. PATIENTS Ninety-five couples attending for initial screening and IVF-ET. Only cycles where three or more grade I oocytes were collected were included, and patients with endometriosis were excluded. INTERVENTIONS Each patient had a standard semen analysis, cervical mucus (CM) penetration test, hypo-osmotic swelling test, and sperm migration test performed between 4 and 8 weeks before IVF-ET. MAIN OUTCOME MEASURES The correlation between sperm function test results and the percentage of fertilized oocytes and the power of the tests to predict fertilization. RESULTS The sperm migration test correlated highly with fertilization rate (r = 0.62) and was most useful in identifying the group of patients likely to achieve fertilization (Odds ratio [OR] 0.07, confidence interval [CI] 0.02 to 0.2). The CM penetration test showed a moderate correlation with fertilization rate (r = 0.45) and some predictive power (OR 0.37, CI 0.13 to 1.00). Sperm concentration, but not motility or normal morphology, showed slight correlation with fertilization rate (r = 0.28) but the combination of normal semen parameters did not distinguish patients likely to achieve fertilization (OR 1.51, CI 0.62 to 3.65). The hypo-osmotic swelling test did not correlate with fertilization rate (r = 0.21). CONCLUSIONS This study evaluated the predictive power of several simple tests available for use in most laboratories as screening tests of sperm fertilization potential. Apart from sperm concentration, normal traditional semen characteristics were of little clinical benefit. The hypo-osmotic swelling test had no predictive power. The CM penetration test correlated with fertilization rate but might be difficult to perform routinely as a continuous supply of suitable CM would be required. The sperm migration test proved to be the best discriminator of sperm fertilization potential and should be considered as a first level screening test in the assessment of male fertility.

Human sperm head morphometric distribution and its influence on human fertility

OBJECTIVE To study the distribution of live sperm head size in semen and sperm preparations as a predictor of fertility. DESIGN Prospective blind clinical trial. SETTING Academic tertiary referral center. PATIENT(S) One hundred fifty-five patients undergoing IVF treatment. Females with conditions negatively influencing fertilization were excluded. INTERVENTION(S) Morphometric analysis (head area, major axis, minor axis, and elongation ratio) of video images of sperm in semen and swim-up preparations used for IVF treatment was performed with a Hamilton-Thorne analyzer V 8.1 (Hamilton-Thorn Research, Beverly, MA). MAIN OUTCOME MEASURE(S) Oocyte fertilization. RESULT(S) Seventy-four percent of patients achieved fertilization. Fertilizers and nonfertilizers had different sperm head area distribution. The fertilizers had a significantly smaller interquartile range of sperm head area and of major axis in both semen and sperm preparation compared with the nonfertilizers. A subgroup of men who had fathered a child naturally had a more uniform sperm head area in semen with a significantly smaller median compared with those who failed to father a child naturally with their healthy female partner. We used multiple logistic regression applying forward stepwise selection of variables in building three predictive models of probability of fertilization. CONCLUSION(S) Successful IVF or history of fathering a child was associated with a more uniform sperm head area in semen and sperm preparation.

Effect of abnormal hypo-osmotic swelling test on fertilization rate and pregnancy outcome in in vitro fertilization cycles

OBJECTIVE To assess the value of the hypo-osmotic swelling test in predicting fertilization, pregnancy, implantation, miscarriage, and live birth rates in IVF-ET cycles. DESIGN Prospective study. SETTING Academic tertiary referral center for fertility treatment. PATIENTS Three hundred twenty-six couples having IVF-ET for tubal damage or male factor infertility with the female partner < 38 years of age. INTERVENTIONS Each male had a hypo-osmotic swelling test performed between 4 and 8 weeks before IVF-ET. MAIN OUTCOME MEASURES Fertilization, implantation, miscarriage, and live birth rates. RESULTS Eighty of 326 men had abnormal hypo-osmotic swelling tests. An abnormal test was not associated with lower fertilization rates (odds ratio [OR] = 1.14; 95% confidence interval [CI] = 0.97 to 1.14) or pregnancy rate (OR = 0.98; CI = 0.50 to 1.96). However, although couples with a normal test had a miscarriage rate of 26.9% (14/52), in the group with an abnormal test the miscarriage rate was 50.0% (7/14) (OR = 0.37; CI = 0.09 to 1.49). This resulted in a reduction in the live birth rate from 14.1% in the group with a normal test to 11.8% in patients with an abnormal test (OR = 1.23; CI = 0.45 to 3.87). CONCLUSIONS The hypo-osmotic swelling test has little value in predicting fertilization in IVF-ET procedures. However, an abnormal test may help predict adverse outcome if pregnancy is achieved.

Exaggerated effects of progestogen on uterine artery pulsatility index in Turner's syndrome patients receiving hormone replacement therapy.

OBJECTIVE To investigate the effect of estrogen and progestogen on the resistance to blood flow in the uterine arteries of Turners syndrome patients. DESIGN Prospective clinical study. SETTING A tertiary infertility clinic. PATIENTS Five Turners syndrome patients, six patients who had surgical castration, and five patients with idiopathic primary ovarian failure. INTERVENTIONS The patients were treated with 2 mg E2 valerate to which 500 micrograms norgesterel was added for 10 days in a 28-day cycle. Transvaginal color Doppler was used to measure pulsatility index in the uterine arteries at eight regular intervals during a single cycle. MAIN OUTCOME MEASURE Pulsatility index of the uterine arteries. RESULTS The administration of norgesterel to Turners syndrome patients resulted in an increase in pulsatility index that was significantly higher than in patients who had surgical castration (confidence interval = 0.17 to 2.42). CONCLUSION The uterine arteries of Turners syndrome patients are more sensitive to the tonic effect of progestogen. If manifest in cardiac arteries also this phenomenon may be partly responsible for the increased incidence of cardiovascular disease and shorter life expectancy in Turners syndrome patients. To achieve optimal protection from cardiovascular disease, Turners syndrome patients may benefit from hormone replacement treatment containing altered doses of estrogen and progestogen.

How acute is the acute shortage of oocyte donors in the UK? Results of a British National Survey

Donated oocytes offer the only hope of pregnancy to some 110000 women in the UK who have experienced a premature menopause under the age of 40 (Barber et al. 1991). Several other groups also require oocyte donation, including women with transmissible genetic disorders or ovarian dysgenesis, those who have undergone surgical or chemical castration, and those who exhibit a poor response to ovarian stimulation in standard in vitro fertilisation (IVF) programmes. Oocyte donation can be very successful, with fecundity rates of up to 86% when two or more embryos are replaced (Sauer et al. 1990). The major reported problem with oocyte donation is an insufficient supply of oocyte donors (Abdalla 1994), and lately the search for new sources of oocytes, has been one of the most controversial ethical issues in medicine. In a recent editorial (Abdalla 1994), beginning with the assumption that the demand for oocyte donation far outstrips the supply of donors, suggested direct or indirect payment to potential donors, the use of donors over the age of 35 years, and the use of fetal or cadaveric ovarian tissue in order to alleviate this problem. All of these possible sources are controversial. Payment for donation is considered unethical as it would compromise human dignity and alter unfavourably the profile of the potential donor population. The use of donors over the age of 35 would not only expose recipients to a higher risk of having a child with a chromosomal abnormality, but would also decrease the success rate because of the lower number, and inferior quality, of oocytes obtained from older donors (Navot et al. 1991). The use of fetal tissue is not yet technically possible (Winterhalter 1994) and is highly controversial, arousing strong emotions and attracting adverse publicity (Vines 1994). We have undertaken a survey to assess whether there is a genuine shortage of oocyte donors in the UK and if so, whether this is geographically determined. This has not previously been investigated systematically.