Paul Robb

Impact of sperm morphology on the likelihood of pregnancy after intrauterine insemination

OBJECTIVE To determine whether there is a difference in ongoing pregnancy rates (PRs) between patients undergoing IUI with strict sperm morphology ≤4% compared with >4% on initial semen analysis. DESIGN Retrospective chart review with multivariate analysis. SETTING Academic outpatient reproductive center. PATIENT(S) A total of 408 couples with male and/or female factor infertility and known strict sperm morphology (SSM). INTERVENTION(S) A total of 856 IUIs with partners sperm (IUI-P). MAIN OUTCOME MEASURE(S) Ongoing PRs based on ultrasound documentation of intrauterine pregnancy with fetal heart tones. RESULT(S) There is no statistically significant difference in per cycle PRs when comparing patients with a strict sperm morphology of ≤4% versus >4% who undergo IUI-P (17.3% vs. 16.7%; odds ratio 0.954, 95% confidence interval 0.66-1.37). Multiple potential confounding factors were assessed using multivariate analysis. CONCLUSION(S) Strict sperm morphology ≤4% is not associated with lower PRs in couples undergoing IUI-P, and thus should not be the sole reason for advancing to IVF.

What is the optimal follicular size before triggering ovulation in intrauterine insemination cycles with clomiphene citrate or letrozole? An analysis of 988 cycles

OBJECTIVE To determine the optimal size of the leading follicle before human chorionic gonadotropin (hCG) administration in cycles with clomiphene citrate (CC) and letrozole, and to examine any differences in the optimal leading follicle size between cycles with CC and letrozole. DESIGN A retrospective study. SETTING University hospital-based reproductive center. PATIENT(S) 1,075 women undergoing intrauterine insemination cycles with CC or letrozole. INTERVENTION(S) Leading follicle diameters and endometrial thickness were recorded 24 hours before hCG administration, together with other cycles parameters, and were compared between pregnant and nonpregnant patients. MAIN OUTCOME MEASURE(S) Leading follicle diameter and intrauterine insemination outcome. RESULT(S) Eight percent of patients (n = 87) were excluded because their leading follicle was less than 18 mm by days 11 to 13. Pregnancy was recorded as clinical pregnancy with fetal heart activity seen at 6- to 7-week transvaginal ultrasound. For both CC and letrozole, higher pregnancy rates were achieved when the leading follicles were in the 23 to 28 mm range. The optimal size of the leading follicle was not statistically significantly different between cycles using CC or letrozole. However, for each endometrial thickness, the optimal follicular size of the leading follicle was different. Each additional millimeter of endometrial thickness increased the optimal follicular size by 0.5 mm. Thicker endometrial lining led to a higher probability of pregnancy. CONCLUSION(S) The optimal size of the leading follicle in ovulation induction with CC and letrozole is similar for both drugs and is closely related to the endometrial thickness.

Cost-Effectiveness of Vasectomy Reversal

In this era of cost-consciousness and containment, it is imperative to examine not only treatment outcomes but also cost of these treatments. With improvements of in vitro fertilization outcome and continued development of less-invasive sperm retrieval methods, physicians and couples must examine all options available after surgical sterilization. Vasectomy reversal remains the gold standard of treatment; however, certain situations may be present in which sperm acquisition/in vitro fertilization may be a better option. A physicians responsibility is to present all options with the pros and cons of each, including cost, to help arrive at an informed decision.

Outcomes After Testicular Aspiration and Testicular Tissue Cryopreservation for Obstructive Azoospermia and Ejaculatory Dysfunction

PURPOSE We examined the rate of successful sperm retrieval, fertilization, pregnancy and live births in patients with obstructive azoospermia and ejaculatory dysfunction who underwent testicular sperm aspiration in conjunction with in vitro fertilization/intracytoplasmic sperm injection using cryopreserved testicular tissue. MATERIALS AND METHODS We retrospectively reviewed the records of 40 couples who underwent testicular sperm aspiration from August 2003 to November 2007. All procedures were performed before intracytoplasmic sperm injection with the goal of tissue cryopreservation. RESULTS Mature sperm was successfully retrieved and cryopreserved in 39 of 40 patients (97%) with an average of 5 vials cryopreserved per couple. Of the women 34 underwent in vitro fertilization/intracytoplasmic sperm injection and in 5 treatment was planned. The fertilization rate was 58% with a pregnancy rate of 61.4% (27 of 44 cycles). There were 17 live births, 5 ongoing pregnancies and 5 miscarriages. No complications were noted and all patients returned to full activity within 2 to 3 days. CONCLUSIONS Testicular sperm aspiration with cryopreservation is a safe and effective sperm retrieval method in patients with obstructive azoospermia and ejaculatory dysfunction when in vitro fertilization/intracytoplasmic sperm injection will be performed.