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Two recent tests have claimed to identify the subfertile male even when other semen parameters were normal: the sperm chromatin structure assay (SCSA) and abnormal sperm nuclear morphology using much higher magnification. The present study attempted to determine if having a high (> 30%) DNA fragmentation index (DFI), thus resulting in an abnormal SCSA test, is associated with a greater likelihood of sperm with abnormal nuclei. Four males with high DFI scores (57.6%, 65.4%, 31.0%, and 35.3%) had their nuclei evaluated by a complex microscope set-up that magnifies the sperm at least 6000 × . The corresponding % of normal nuclei was 0%, 20.0%, 23.7% and 40.0%. The mean and median % of normal nuclei was 20.9±16.43 and 21.8, respectively. More studies of similarly matched refractory in vitro fertilization cases, where males have normal DFI scores, are needed to determine if having a high DFI index is associated with a lower percentage of normal nuclei.

The objective of the current study was to investigate the association between rapid motility of sperm and IVF outcome when ICSI is used for insemination of oocytes. The first IVF cycle of women up to age 42 were evaluated. Patients were classified into groups by the presence/absence of sperm with rapid motility (“A” sperm) in the specimen before and after sperm preparation. Group 1 had 0% A sperm prewash and 0% A postwash (n = 45); Group 2 had 0% A sperm prewash but some A sperm postwash (n = 47); Group 3 had A sperm both pre and postwash (n = 141). Statistical analysis demonstrated no difference in the fertilization, PRs, or implantation rates in the three groups. These data suggest that absence of sperm with rapid motility postseparation of sperm from seminal plasma is not detrimental to IVF outcome when ICSI is used for insemination.

A high DNA fragmentation index (DFI) when performing the sperm chromatin structural (SCSAr) assay was claimed to be so specific for male subfertility that even IVF with ICSI did not result in live pregnancies. The present study was designed to corroborate or refute these findings. The SCSA test was performed on the male partner from couples failing to have a successful pregnancy despite at least 2 previous IVF attempts. In contrast to the aforementioned studies, ongoing pregnancies were found despite working with a group of recalcitrant patients. Nevertheless, a high DFI score was associated with a trend for lower ongoing pregnancy rates especially related to a high miscarriage rate. Other more recent studies seem to support our conclusions. A high DFI score should influence a patient to choose IVF as a therapeutic modality sooner, especially with ICSI.

A subnormal sperm stress test has also been associated with implantation failure despite apparently normal fertilization; however, this test is cumbersome and time-consuming. The overnight sperm survival test has been considered to possibly demonstrate lipid peroxidation abnormalities similar to the sperm stress test. The present study evaluated whether lower overnight survival scores were associated with lower pregnancy and implantation rates following in vitro fertilization-embryo transfer. The results showed no adverse effect of poor overnight survival test scores. Possibly, the overnight survival test, though similar in some respects to the sperm stress test, is not similar for properties of predicting embryo implantation defects. Corroboration that subnormal stress tests predicts implantation disorders is needed.

Several studies have reported that the presence of intramural fibroids affects conception following IVF. We attempted to corroborate or refute the conclusions relating to IVF and leiomyomas of the aforementioned studies.

Men with low hypoosmotic swelling test (HOST) scores (<50%) rarely achieve a pregnancy with intercourse or conventional intrauterine insemination (IUI) or even IVF. The defect seems to be related to a toxic factor attached to the sperm that can be transferred to the zona pellucida, which ultimately interferes with implantation. A small case series showed optimistic pregnancy outcome with treatment of the sperm with low HOST scores with chymotrypsin. However, the live pregnancy rate in 90 subsequent IUI cycles in men whose low HOST scores were improved by chymotrypsin was only 3.3%. IVF with ICSI remains the only highly effective treatment of this disorder.

An overview of various sperm tests is presented. The standard semen analysis obtained by most clinicians evaluating infertility usually consists of sperm concentration, percent motility, quality of motility, and sperm morphology. Unfortunately, unless the motile density is extremely low, the count and motility are not good prognosticators of fertility potential. Values above the norm for normal fertile couples unfortunately cannot reliably predict normal fertility potential. It is important to find sperm tests that are easy to perform, are relatively inexpensive, and provide an accurate prognosis. Strict morphology was hoped to be such a tool with initial optimism that it was far superior to standard morphology. Unfortunately, this test also failed to be the ideal inexpensive prognostic test after further evaluation. One test that is inexpensive and highly correlates with fertilizability is the presence of antisperm antibodies since their presence frequently does not alter count, motility, or morphology. This test should be performed as part of the routine semen analysis. Other tests highly correlate with the achievement of pregnancy and are simple and inexpensive to perform, but, interestingly, do not correlate with fertilizability. These include the hypoosmotic swelling test (HOST) and the sperm stress test. Abnormalities in these tests imply a different abnormality of sperm that leads to conception failure and that is the transfer of a toxic factor from the sperm to oocyte to embryo that prevents the embryo from implanting. Certainly, the simple, inexpensive HOST should be performed routinely. Other tests of sperm function, e.g., sperm penetration assay, sperm-zona pellucida binding assay, and acrosome reaction, have their definite place in the evaluation of the infertile male. However, because they are expensive and difficulty to perform they lend themselves to certain specific circumstances but not to routine testing.

A study has suggested that one drawback of ICSI is that if these embryos are cryopreserved they have lower implantation rates after thawing and transfer as compared to other frozen embryos derived from conventional oocyte insemination. Other studies have not shown such adverse effects on pregnancy rates following frozen embryo transfer (ET) of embryos formed by ICSI. The study presented here evaluated the largest number of frozen ET cycles of embryos following ICSI, which were compared to couples having frozen ET with embryos formed by conventional insemination. In women age 39 and younger, the clinical, viable, pregnancy rates and implantation rates were very similar. Similar rates were reached for the older group. These data convincingly demonstrate that fertilization by ICSI does not adversely effect the implanting capacity of frozen-thawed embryos.

Recipients of donor oocytes need to be synchronized to the donor's cycle if fresh embryos are to be transferred on the cycle of oocyte retrieval. It would be much easier to merely retrieve the oocytes from the donor, fertilize the oocytes with the recipient's male partner's spermatozoa, cryopreserve the embryos, then transfer on an oestrogen/progesterone treatment programme.

This study was conducted to evaluate if in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) is an effective treatment for infertility complicated by the presence in the male partner of sperm autoantibodies. Over a 1-year study period comparisons of fertilization, pregnancy, and implantation rates were made in couples where the male partner was negative or weakly positive for sperm autoantibodies (80%) (gr 2); or autoantibodies were moderately positive (50-80%) (gr 3). Only patients having oocytes fertilized by ICSI were included. The fertilization, clinical pregnancy, implantation, and miscarriage rate for group 1 (n = 67) was 56, 43, 21, and 14%. Comparable values for group 2 (n = 20) were 55, 40, 23, and 25%, and for group 3 (n = 6) were 63, 33, 23, and 0%. IVF with ICSI demonstrates comparable fertilization, pregnancy, implantation, and miscarriage rates in female partners of males with and without sperm autoantibodies.

A study was conducted to determine if uterine vascular impedance increases with advancing age in women undergoing ovarian stimulation for IVF. A group of 162 women who had undergone conventional IVF and embryo transfer was subdivided into three subgroups by age: 30-34 years (n = 49), 35-39 years (n = 79) and 40-44 years (n = 34). The pulsatility index (PI) and resistance index (RI) of the right and left uterine arteries were measured at baseline, on the day of oocyte retrieval, and at the mid-luteal phase. There were no differences in the average PI or RI by age at any phase of the cycle. In all age groups, the luteal phase values of PI and RI were lower than those observed earlier in the cycle. Endometrial thickness was not associated with age. There was no significant correlation between PI, RI and serum oestradiol and progesterone concentrations at any phase of the cycle. Ovarian response, as measured by average number of oocytes retrieved, decreased significantly with age. Thus, reduced pregnancy rates in older women undergoing ovarian stimulation are more likely to occur because of oocyte quality and quantity rather than uterine senescence. If future studies determine that the use of ovarian stimulation does decrease implantation rates more in older versus younger women, a mechanism other than increased uterine vascular impedance must be sought.

Although the transfer of fertilized donor oocytes is the most efficacious mode of conception for infertile women with hypergonadotrophism associated with incipient or apparent ovarian failure, there are many individuals who, for religious, ethical, or personal reasons, would prefer to try to conceive with their own oocytes. The three cases presented here represent extremes to date for (i) highest serum FSH concentration in a woman with incipient ovarian failure (n = 2), and (ii) the oldest woman with apparent overt ovarian failure (n = 1) to have successful pregnancies. All three cases were treated for only a short time with pharmacological dosages of ethinyl oestradiol with luteal phase support with progesterone. The peak FSH (mIU/ml) in cases 1 and 2 was 143 and 127 respectively. The precedents set in these cases can help physician-patient consultation when patients enquire whether there is a certain critical FSH concentration above which pregnancy is not possible or an age over which successful pregnancy could not be achieved even if ovulation despite ovarian failure was possible.

The purpose of this study was to investigate the relationship between mid-luteal phase echo patterns and IVF-embryo transfer outcome in women who have demonstrated adequate endometrial development by the late proliferative phase. A prospective study was carried out of 86 patients undergoing IVF-embryo transfer and 86 patients undergoing frozen embryo transfer who all underwent sonographic monitoring of the endometrium 3 days after embryo transfer. The cycles were classified into two groups: those with the homogeneous hyperechogenic (HH) pattern and those without it. The women who had an HH pattern had higher clinical pregnancy (32.8 versus 10.7%, P < 0.05) and implantation rates in stimulated cycles (14.3 versus 4.1%, P < 0.05 respectively) than those that did not. There was no significant difference in the clinical pregnancy or implantation rates by echo pattern (18.2 and 8.1% for non-HH and 18. 7 and 8.0% for HH respectively) in frozen embryo transfer cycles. These data demonstrate that in embryo transfer cycles where ovarian stimulation was used, there were decreased pregnancy and implantation rates in cycles where the HH pattern was not observed 3 days after transfer. The failure of the endometrium to display this pattern may indicate some endometrial abnormality resulting in implantation defects.

A recent study suggested that oligoasthenozoospermia may be an etiologic factor for spontaneous abortion (SAB) after in vitro fertilization-embryo transfer (IVF-ET). However, IVF-ET with intracytoplasmic sperm injection (ICSI) did not seem to be associated with an increased SAB rate. The study presented herein compared the rate of SAB in pregnancies achieved by IVF-ET according to the type of oocyte insemination process. The 3 types evaluated were conventional insemination, which exposed the oocyte to 25,000 sperm with prolonged contact (16-24 h), intermediate contact with a short insemination protocol where contact with 25,000 sperm was limited to 2 h, and very limited contact with ICSI, where only 1 sperm was injected into the oocyte thus not exposing the zona pellucida to any sperm. The patients were further subdivided into age groups of 39 or 40. SAB rates after frozen ET were also evaluated. The clinical pregnancy and SAB rates following fresh or frozen ET for conventional, ICSI, and short insemination techniques for the 2 age groups were comparable. These data question whether oligoasthenozoospermia may be a factor in causing SAB, and whether avoidance of contact with the zona pellucida by using ICSI can negate this effect. A larger study is needed.

Previous methods of enriching sperm with a higher percentage of Y-bearing sperm have been questioned because the claims that Y enrichment was present were based on quinacrine staining of the Y chromosome, and the enrichment was not confirmed by polymerase chain reaction (PCR) or fluorescent in situ hybridization (FISH) techniques. A technique was evaluated that theoretically could increase the percentage of X-bearing sperm by isolating a fraction of the "heaviest" sperm by passing them through 12 layers of discontinuous Percoll gradient. Initially 12 specimens were checked both before and then after separation with 12 layers of Percoll for percentage of Y sperm. The median for baseline Y percentage was 49% and after processing the percentage of Y dropped to 10%. An additional 19 specimens were checked after separation only. The median was 19%. The sample with the lowest preseparation % of quinacrine staining sperm was 45% and the highest was 54%. After 12-layer Percoll, the lowest percentage was 3% and the highest was 24%. There have been claims that quinacrine staining can falsely increase apparent Y-bearing sperm enrichment following certain separation procedures, e.g., albumin separation, by nonspecific staining of autosomal chromosomes. If anything, then, it should falsely decrease X-bearing sperm enrichment. Thus, 12-layer Percoll separation may actually enrich for X-bearing sperm or possibly this procedure somehow nonspecifically inhibits the ability of quinacrine to stain the Y chromosome.

Infertility due to male factor has been associated with reduced implantation rates despite normal fertilization. The mechanism responsible for lower pregnancy rates is not known. One cause of failure to achieve pregnancy despite transfer of embryos is impairment of zona pellucida (ZP) thinning, which inhibits the embryo from hatching despite initial cell cleavage. This study was designed to evaluate whether there is an association between the ability of the ZP to thin, as measured by ZP thickness on day of transfer, and subnormal semen parameters. Significant differences in ZP thickness (p < 0.05, Kruskal-Wallis) were noted according to median concentration of sperm, total motile sperm, and motile density in that these values were the highest in the group of embryos with the thinnest zona pellucida and lowest in the group with the thickest zona pellucida. Thus, some factor may be missing from sperm from subnormal specimens that normally assists in zona thinning.

The ability of the semen analysis either by routine methods (RSA) or computer-assisted means (CSA) to predict male infertility was evaluated by determining the pregnancy rates during an 8-month span in a large group of infertile couples where a female fertility factor was identified and presumably corrected. The males were untreated. Not only was CSA less effective than RSA in predicting a male infertility factor, but also neither CSA or RSA seemed capable of identifying infertility unless severely abnormal. It would appear that there is definite need to find more accurate methods of evaluating the spermiogram.

Sixty-nine couples enrolled in 123 in vitro fertilization-embryo transfer cycles were categorized by percentage fertilization; the results of categorization were compared with those of computerized semen analysis carried out with the CellSoft semen analyzer. Four groups were established: group 1 had 75% fertilization or greater; group 2 had 34% to 74% fertilization; group 3 had 1 % to 33% fertilization; and group 4 had 0% fertilization. Statistical differences in certain semen parameters (motility, linearity, and straight-line velocity) were found comparing groups 1 and 3 using the initial ejaculate. A significant number of patients in group 1 had all normal semen parameters, but no statistical difference could be found in group 3 or 4 because of variations in specific abnormal parameters in the groups. When the straight-line velocity-motile density (SLVMD) calculation was used, a significant difference was seen between group 1 and group 3 and between group 1 and group 4 (p < 0.01); 65% of group 3 and 76% of group 4 had an abnormal SLVMD. SLVMD is a useful calculation to predict fertilization rates in vitro from the initial ejaculate.

The effect of antisperm antibodies (ASA) in males was determined in 59 men using the direct immuno-bead test (IBT). Postcoital tests were evaluated in couples for whom all female factors appeared to be corrected. Pregnancy rates in 6 months were compared in couples with good postcoital tests vs. those with poor results; the latter group was treated with timed intrauterine insemination (IUI). Thirty-one percent of males with positive ASA (≥50%) had normal postcoital tests and all four achieved pregnancies. Fifty-six percent of men with positive ASA and poor postcoital scores achieved pregnancies following IUI therapy of their wives in 6 months; 83% of couples with normal postcoital tests achieved pregnancies as did couples treated with IUI when the postcoital was poor but the male ASA negative.

Many centers have been disappointed with the pregnancy rate following the insemination of cryopreserved-thawed sperm, despite the maintenance of an adequate motile density. The possibility exists that damage to the sperm membrane might occur despite preservation of other semen parameters. Simple measurements of structural integrity (viability) and functional integrity (hypoosmotic swelling test) were performed on thawed specimens. In each instance, both the viability and HOS scores were less than the critical 50% level. Specimens from three different commercial centers had very poor HOS and viability scores from two of the centers, and, though the scores were generally ≥50% from the third center, this was achieved by eliminating 11 of 12 donors. Reducing the glycerol concentration from 12 to 7% and switching from Nunc vials to plastic embryo straws did not improve the poor sperm membrane tests. The possibility exists that if modification of the cryopreservation technique leads to improved HOS and viability scores, perhaps improved pregnancy results will be realized.

Therapeutic insemination by donor (TID) is being used with increasing frequency. Because many diseases, some of which are lethal, can be transmitted through semen, the American Fertility Society established guidelines for use of donor sperm. They limit TID to cases of male infertility or hereditary/ genetic disorders. Donor selection requires good health and absence of genetic abnormalities; criteria for semen including normal sperm motility, concentration, and normal morphology, and blood screening for infectious agents. Human immunodeficiency virus (HIV) testing should be performed initially in donors for fresh semen inseminations. If positive, the assay is verified with a Western blot test; if negative, the donor should be screened at 6-month intervals. Frozen samples should not be used until the 180 day reevaluation of the donor. Many studies show higher pregnancy rates using fresh rather than frozen semen samples for insemination. New methods of cryopreservation minimize the deleterious effects of freezing. If these effects, namely decreased sperm motility and impaired penetration ability, are eliminated, pregnancy rates can be expected to rise. Frozen semen is preferable because it allows time for sexually transmitted diseases to manifest themselves and for specimens from those donors to be rejected prior to use.

Semen analysis, which is traditionally used to evaluate male fertility, may be misleading if sample is lost or inadequately mixed. A short or excessive abstinence period may cause a low count or a high count with low motility. Damage from low temperature or delay in evaluation may decrease the reported motility. Computer-assisted semen analysis has eliminated some of the variability and has allowed the evaluation of other sperm motion variables such as sperm velocity, linearity, maximum and mean amplitude lateral head displacement, and beat-cross frequency. These measurements may also occasionally be misleading. Other tests may give a better indication of the function of sperm. The hamster egg penetration test has been used but is technically difficult, and perhaps that is why there is controversy as to the clinical value of the test in predicting subfertile sperm despite normal conventional semen analysis. Some recent data suggest that the hypo-osmotic swelling test, which determines the functional integrity of the sperm membrane, may be the appropriate prognosticator. There is a need for further studies to define the best method to determine whether a male factor is responsible for a couple's infertility.

The effects of glass, polystyrene, and polypropylene containers on semen parameters as measured by Cell Soft computer-assisted semen analysis and hypoosmotic swelling (HOS) tests were assessed in unwashed specimens and again after sperm washing and swim-up procedures. A superiority in unwashed specimens was observed in glass versus polystyrene concerning velocity, motility percentage, and HOS testing (p < 0.01). Also, superiority of glass versus polystyrene was demonstrated for linearity and ALH (p < 0.05). Glass was only superior to polypropylene in categories of motility and HOS testing (p < 0.05 and p < 0.01, respectively). There was no category in which plastic was statistically superior to glass in the unwashed specimens. Concerning washed and swim-up specimens, there were no semen parameters in which there was any superiority demonstrated of either glass or plastic. Unless some future proof that the differences in semen parameters demonstrated in this study have no clinical significance, these data suggest that the collection of semen samples for sperm analysis or therapeutic use should be performed in glass containers.

The hyperosmotic swelling (HOS) test was evaluated in 40 men whose wives had no apparent fertility factors. Only one of 29 men with normal semen parameters had a surbnormal HOS test, and that couple failed to conceive compared to 27 of 28 with normal HOS tests who did conceive. All five couples with husbands with subnormal semen parameters but with normal HOS tests achieved a pregnancy, but none of the three with abnormal HOS tests achieved a pregnancy. The results suggest that the HOS test might be of value in predicting which couples should be more patient despite low semen parameters.

Previous data have suggested there is a higher incidence of luteinized unruptured follicle (LUF) syndrome (defined as failure to release any oocyte as determined by sonography) in gonadotropin-treated patients following human chorionic gonadotropin (hCG) versus the gonadotropin releasing hormone agonist (GnRH-a) leuprolide acetate. The present study was designed to determine if an ultra low-dose gonadotropin regimen, designed not to raise the serum estradiol level much above normal for non-stimulated cycles, might result in a decrease in LUF following hCG treatment, and even reduce the rate to that seen following leuprolide acetate. The hypothesis tested was that the higher estradiol levels might suppress the preovulatory follicle stimulating hormone (FSH) surge which, in turn, would inhibit plasmin production, thus preventing detachment of the oocyte from the follicle. The data did show a reduced rate of LUF incidence with either hCG or leuprolide acetate in ultra low-dose human menopausal gonadotropin- (hMG-) treated patients compared to data from previous studies with conventional hMG/hCG therapy. Pregnancy rates were also similarfollowing hCG or leuprolide acetate for release in low-dose hMG-treated patients. Preliminary data show that leuprolide acetate is superior to hCGfor causing oocyte release when stimulation is with low-dose purified FSH, and possibly also that low-dose hMG is superior to low-dose purified FSH for producing superior pregnancy rates.

The standard semen analysis frequently fails to identify subfertile males even when findings are normal and conversely often fails to identify fertile males with subnormal semen analyses. This has created the need to produce other tests of sperm physiology that will better distinguish a fertile from a subfertile specimen. Understanding more about the nature of the sperm defect should lead to the establishment of more specific and effective therapies. Until that time, it would still be reasonable to try some of the available empirical therapies even though they may work merely by a placebo mechanism.

A previously published study reporting the use of a modified swim-up technique for sperm preparation prior to insemination which resulted in a high percentage of male births has been criticized for its lack of controls. The present prospective study was initiated to investigate further the efficacy of modified swim-up preparation for male sex-selection when applied in a properly defined control group. Our results showed that the proportion of males born in singleton pregnancies was approximately 50% in the group inseminated following sperm preparation with Percoll and in the control group with no sperm preparation compared with 88.5% in the group treated with the modified method of swim-up sperm preparation prior to insemination. This high rate of males in the group treated with modified swim-up was also observed in singleton pregnancies of women taking ovulation inducing drugs (primarily clomiphene citrate). This contrasts with previous publications in which a higher rate of females was found in clomiphene citrate patients using the albumin separation technique. How the mechanism of the swim-up procedure may result in a high male birth rate remains unclear. A high percentage of y enriched semen was found using fluorochrome quinacrine mustard staining but this procedure may falsely stain autosomal chromosomes. If analysis using sensitive DNA probes fails to confirm the y enrichment of the spermatozoa, one must hypothesize that the modified swim-up procedure damages the x-spermatozoa.

The progestagen-associated endometrial protein (PEP) level rises from the early to the late luteal phase. A study was performed in infertile women where late luteal phase endometrial biopsies and serum PEP levels were obtained. The objective of the study was to evaluate the correlation between the PEP levels and the endometrial biopsies and to determine if subnormal PEP levels could be improved by the same therapies used to correct endometrial defects. There was a poor correlation between PEP levels and endometrial biopsies (r = 0.17). Similarly, there was no significant correlation between PEP levels and levels of the following hormones: mid- and late-luteal phase progesterone (P) (r = 0.186 and 0.282 respectively), mid-luteal phase 17-hydroxyprogesterone (17-OHP) (r = 0.139) and mid-luteal phase oestradiol (r = 0.135). Furthermore, there was no correlation between PEP levels and the dosage of progesterone used in therapy (r = 0.07). There were no statistically significant differences in PEP values (U/ml) depending on whether any fertility drug was taken. Thus our data suggest that progesterone may only have a permissive role, with some other factor(s) controlling the actual rise and fall of PEP.

The use of leuprolide acetate for at least 10 days beginning in the mid-luteal phase prior to initiating human menopausal gonadotrophin (HMG) stimulation has been fairly successful in preventing cancellations for premature luteinization and allowing retrieval of more oocytes, which in turn provide more embryos for cryopreservation. However, it is theoretically possible that the long-term use of leuprolide may have some adverse effect on either pregnancy rates or on mean survival after cryopreservation and thawing. Recently, a short 3 day regimen of a gonadotrophin-releasing hormone agonist, buserelin effectively prevented premature luteinization during HMG stimulation. The present study indicated that substitution of a 3 day course of leuprolide acetate also effectively prevented premature luteinization but was less expensive, required statistically fewer ampoules of HMG and much less leuprolide.

Our previous study has demonstrated that ovulation in unstimulated cycles is random with an equal likelihood of ipsilateral or contralateral ovulation occurring in the following cycle. This study evaluated women taking ovulation-inducing drugs to see if the side of ovulation in the preceding cycle has an influence on the side of ovulation in the succeeding cycle. Ovulatory patterns in consecutive pairs of cycles in anovulatory women treated with ovulation-inducing drugs were evaluated through sonographic studies of follicular maturation. The results demonstrated that when unilateral ovulation occurred, there was an equal likelihood of ipsilateral or contralateral ovulation in the succeeding cycle. However, ovulation-inducing drugs increase the incidence of bilateral or multiple ovulation.

The achievement of pregnancies in vivo is rare in couples where the male partner has defective sperm membranes as shown by hypo-osmotic swelling (HOS) test scores of < 50%. However, there have been mixed reports on the value of the HOS test in predicting outcome following invitro fertilization; some studies suggest reduced fertilization rates and others find little, if any, predictability of decreased fertilization. The assumption has been made that fertilization rates are proportional to pregnancy rates; however, this may not necessarily be true since defective spermatozoa could lead to a less viable pre-embryo and therefore a decreased viable pregnancy rate. We performed a comparative prospective study using matched controls to evaluate fertilization rates and to determine subsequent pregnancy rates. The mean HOS scores were 70.0 and 36.7% respectively, with mean motile sperm concentrations of 35.7 and 34.0 x 10(6)/ml in 27 matched pairs. There was no difference in the mean number of oocytes retrieved, fertilization rates or number of embryos transferred between the two groups by HOS score. The clinical and viable pregnancy rates and implantation rates were 25.9, 18.5 and 9.9% for normal versus 3.7, 3.7 and 1.1% for subnormal groups. These data suggest that low HOS scores may be associated with the formation of defective embryos, leading to low pregnancy rates but normal fertilization rates.

Two women with elevated preoperative serum CA-125 levels were found to have extensive endometriosis - one, the highest level related to endometriosis ever reported in the English literature. Endometriosis was found to be etiologic as seen by the prompt reduction in serum CA-125 levels following surgical treatment limited to endometriosis. Thus, a very high CA-125 level does not necessarily forebode ovarian malignancy.

Debate continues as to whether clomiphene citrate (CC) has an adverse effect on cervical mucus. Some researchers conclude that adverse effects maybe related to hormonal abnormalities, e.g., premature luteinization or improper timing. This study evaluated the initial and accumulative effects of CC on postcoital testing (PCT) and attempted to determine if supplemental estrogen (E) improves PCT and/or inhibits follicular maturation. The majority of patients taking CC had poor PCT tests even on the first treatment cycle. Good initial PCTs tended to remain so in subsequent cycles or at least to respond to subsequent supplemental E. Poor PCTs responding to E tended to continue to respond to the combination. PCTs not responding to E therapy continued this pattern in subsequent cycles. Supplemental E did not suppress follicular maturation.

Excessive generation of reactive oxygen species and increased peroxidation of the phospholipids in the membrane is proposed as a biochemical basis for the reduced activity of spermatozoa in cryopreserved semen. The possible role of a-tocopheral (VE) and ascorbic acid (VC) in improving the quality of frozen semen was investigated. Semen samples were divided into aliquots and frozen in freezing media with and without VC or VE. Sperm parameters, including motility after thawing and also at 2 h, % grade A motility (rapid and linear forward progression), and hypoosmotic swelling (HOS) scores, were measured in all samples. Vitamin C did not result in any improvement in sperm parameters studies. Vitamin E improved the post-thaw motility minimally. This improvement, although statistically significant, was actually very small. There were, however, wide variations between the samples. The motility improvement was considered in 5 of 12 samples, and HOS improved in some of the samples tested with VE. Future studies are needed to determine if these antioxidants can produce a consistent improvement in some individuals rather than help the majority of patients.

Single daily periovulatory serum levels of luteinizing hormone (LH), estradiol (E2), and progesterone (P) may be useful to predict the time of ovulation, since serum P is known to rise to 1000 pg/ mL about 24 h after the LH surge. Intrauterine insemination (IUI) was performed based on the serum P level at the time of the LH surge; if sera P measures <1000 pg/mL, then IUI is performed 36- 40 h later; but if P is ≥1000 pg/mL, IUI is performed 12-20 h later. The relationship of sera LH, E2, and P levels and follicular diameter were evaluated at the time of the LH surge and the day before in 40 women with cervical factor who conceived following a single IUI. If E2 levels were obtained the day before and the day of the LH surge and measured <200 or ≥200 pg/mL, a shorter interval for the IUI was suggested. The 27% pregnancy rate/cycle suggests that measurement of single daily periovulatory hormonal levels are useful for precise timing of IUI.

A comparison was made of three sperm separation techniques - direct swim-up, mini-Percoll, and Sephadex G-10 - on semen parameters, including count, % motility, forward progression, and hypo-osmotic swelling (HOS) test scores. Overall, the best quality sperm (less debris, best % and quality motility, and best HOS scores) were noted with the direct swim-up procedure. Mini-Percoll resulted in the highest count, but the worst HOS score. Sephadex G-10 resulted in quality of semen specimen almost as good as the direct swim-up procedure, but did allow some noncellular debris and bacteria to filter through the column.

This study was conducted to evaluate the effect of a single abnormal semen parameter on subsequent implantation and pregnancy rates (PRs) following in vitro fertilization-embryo transfer (IVF-ET). The parameters evaluated were motile density (MD), strict normal morphology (SNM), and the hypoosmotic swelling (HOS) test. A total of 592 IVF cycles were evaluated. Patients were divided into four groups each with one abnormal semen parameter except for the control: group 1 (n = 509), control group: MD ≤ 10 × 106/mL, HOS ≤ 50%, SNM ≤ 4%; group 2 (n = 51): HOS and SNM normal, MD < 10 × 106/mL; group 3 (n = 14): MD and SNM normal, HOS < 50%; group 4 (n = 18): MD and HOS normal, SNM > 4%. The implantation rate was 10.2% for the control group. The implantation rate was similar for the low MD (9.0%) and the low SNM (16.7%) groups. However, the low HOS group had a significantly lower implantation rate (0%). The clinical PRs are similar in the control group and low MD and SNM groups, but decreased in the low HOS group (21.5, 15.0, 30.8, and 0%, respectively). Ongoing PRs were also similar with the exception of the low HOS group (0%). This comparative study supports previous conclusions that the subnormal HOS test is the best semen parameter available that predicts poor PRs. It also suggests that some qualitative defect in the embryos may result from defective sperm membranes, resulting in an apparently normal appearance but physiologically defective embryo.

There is a need to develop a sperm cryopreservation technique that will allow good pregnancy rates following intrauterine insemination of thawed semen specimens that have been frozen prior to sperm-destructive procedures, such as surgery, chemotherapy, or radiation therapy. A slower cooling rate using a commercial semiprogrammable freezer may provide improved post-thaw motility and hypoosmotic swelling (HOS) test scores. However, the cost of this apparatus precludes it from being used in most andrology centers. This study compares the efficacy of slow stage cooling using an inexpensive cellevator (a device used to freeze lymphocytes) to liquid nitrogen vapor freezing. The semen from 27 males was equally divided and one aliquot was cryopreserved with the cellevator stage cooling and the other with the liquid nitrogen vapor technique. The percent motility and percent grade A sperm post-thaw were significantly higher when cryopreserved with the cellevator than with vapor freezing, as was the mean percentage of sperm showing HOS changes.

Intrauterine insemination (IUI) has been used for the treatment of various causes of infertility, including unexplained infertility, male factor, and cervical factor. Some centers frequently use supero-vulation combined with IUI. The study presented herein attempted to evaluate the efficacy of IUI without superovulation in cases where all causes of infertility other than cervical or male factors have been eliminated. However, in the case of poor or absent cervical mucus, the use of controlled ovarian hyperstimulation (COH) may obscure the actual importance of the IUI, since it is possible that the poor cervical mucus is related to poor timing, inadequate follicular maturation, or low estradiol levels, which if corrected will obviate the need for IUI. In this study IUI was targeted for 36-40 h following the sera luteinizing hormone surge. A total of 108 patients were enrolled in this study: 47 with male factor, 61 with cervical factor. Patients were followed for a maximum of three cycles unless a pregnancy occurred within 3 months of treatment. Comparison of pregnancy rates (PRs) were based on diagnosis. The cumulative PRs per cycle for each of the three cycles studied were as follows: cervical factor-19.7, 36.8, and 36.8%; male factor-12.8, 29.3, and 38.3%. Thus, PRs were comparable for both groups after three treatment cycles. These data demonstrate that IUI is an effective therapy for cervical and/or male factor, even without superovulation.

Many previous studies evaluating various hormone levels in males with subnormal semen analyses were performed when the normal semen parameters were considerably higher than now. This study evaluated sera levels of follicle stimulating hormone (FSH), luteinizing hormone (LH), total testosterone (TET), free TET, and prolactin (PRL) in 60 males with oligospermia and decreased motility according to recent World Health Organization standards. Three separate groups were evaluated: group 1, motile density (MD) < 5 ± 106/mL (but not azoospermia); group 2, 5 ± MD < 10 ± 106/mL; group 3, MD > 10 ± 106mL, but % motility < 30%. There were no significant differences in mean FSH levels between groups. Overall FSH was increased in 47.1% of the cases. In contrast, mean LH levels were normal in all three groups. Only 17.3% of the entire group had elevated LH levels. The TET level was below normal in 32.3% of the entire group, with a fairly equal distribution between the three groups. Overall, only 7.8% had elevated PRL levels, with the highest percentage found in group 3 (22.2%). Only a small minority of patients with increased FSH had low TET levels compared to 48.0% of those with normal FSH. These data demonstrate that when using the lower semen parameters, the most common serum hormone abnormality is increased FSH; men with MD < 5 ±106/mL do not have a higher incidence of elevated FSH than those with higher MDs. Serum TET (but not free TET) was the only other hormone measured that was abnormal (i.e., low) in a sizable minority of patients. Hyperprolactinemia is not common in men with subnormal semen parameters.

A randomized study comparing the efficacy of timed intrauterine insemination (IUI) without hyper-stimulation to sexual intercourse was performed in women with cervical factor infertility. Among the strict requirements for inclusion in the study were a normal semen analysis in the male partner, as well as the failure to demonstrate any sperm with progressive forward motion in a postcoital test performed 8-12 h after intercourse at the time of a mature follicle. All other infertility factors were negative. The data demonstrated a statistically significant fecundity rate at 1 month when IUI was compared to intercourse (21.2 vs. 3.9%). These data suggest that carefully timed IUI in nonhyperstimulated cycles is an effective treatment for cervical factor infertility.

This study evaluated the use of in vitro fertilization (IVF) for patients with subnormal semen parameters without the use of micromanipulation. All patients were characterized as having male factor as follows: normal morphology (NM) ≤10% according to strict criteria [15] and motile density (MD) ≤10 × 106VmL. Strict morphology was divided into three groups: group I (n = 12), ≤2% group II (n = 24), 3-5%; and group III (n = 29), 6-10%. Modification of standard IVF techniques included manual cumulus removal (CR) from oocytes, pooling up to ten oocytes together in 1 mL of media, and supplementing media with 20% human follicular fluid (FF). Rates of fertilization and pregnancy were compared. The overall fertilization rate (FR) was 57.7% and the pregnancy rate (PR) per retrieval cycle was 14.8%. There was no significant improvement in the fertilization or PRs when IVF was modified using CR and FF, although the FR was higher in group I for patients who received the modified procedures. In patients with ≤5 × 106 sperm/mL, there were no pregnancies in five cycles and four transfers following the conventional method, but two sets of twins with the modified protocols in seven cycles. Clinical pregnancies were achieved with male factor without the need for micromanipulation. The most severe cases were automatically assigned to modified IVF techniques, e.g., CR with or without FF. Prospective randomized studies are needed to determine if modified procedures are superior to conventional therapy.

There are various methods of separating sperm from seminal plasma for subsequent intrauterine insemination. Some of these same techniques have been employed for female sex selection. The purpose of the present study was to assess and compare semen parameters following Sephadex, Percoll, and SpermPrep™II separation techniques. The SpermPrep™II is also a Sephadex preparation but uses a different bead size, less Sephadex, and is a slightly quicker method. The specimens (n = 16) were initially evaluated for count, (C; × 106/mL), percent motility (MO), grade of motility (GR; percent) and hypoosmotic swelling (HOS) test scores. Each specimen was then divided into three equal aliquots and prepared as follows: (1) layered onto a modified Percoll discontinuous density gradient column; (2) processed using SpermPrep™II; and (3) filtered through a Sephadex gel filtration column (G-50). The results show all three treatments yielded lower (P < 0.01) counts as compared to control values, but no differences were noted among them. Percoll SpermPrep™ Iiincreased MO (P<0.01) whereas Sephadex reduced it(P = NS). Percoll and SpermPrep™II ipmproved the percentage of better quality sperm but not Sephadex; SpermPrep™II was slightly higher than Percoll, but the difference was not significant. There were increases (P < 0.05) in HOS values in all experimental treatments, with SpermPrep™II having the highest scores. However, this study did not show as many males with HOS scores below 50% as noted in other studies. Percoll and SpermPrep™II seem to be equally effective methods for producing high-quality sperm for intrauterine insemination or in vitro fertilization.

The semen from two men with globozoospermia was evaluated for hypoosmotic swelling changes and morphologic evaluation of the tail using strict criteria. No abnormalities were noted. Globozoospermia is due to a genetic defect that results in the absence of acrosomal structures. The acrosomal vesicle in the Golgi region does not develop in close contact to the nucleus, which results in the formation of globe-shape heads. Although some semen parameters were abnormal in both cases, they were different types, suggesting no association with round-headed sperm.

Cryopreservation of human sperm using present methods leads to a reduced fertility potential of the specimen. In many instances this prevents the successful fertilization of the female partner from the frozen-thawed specimens of males whose semen has been cryopreserved prior to surgery, chemo-therapy, or even vasectomy. Furthermore, even though some donor specimens can be successfully used for achieving pregnancies, one needs to place the sperm intrauterine to approach the same pregnancy rates as those of fresh intracervical insemination. The main mechanism considered for sperm damage by cryopreservation is ice crystal formation. The most critical time for forming ice crystals is from 0 to -10d`C. In the present study the effect of a modified rapid cryopreservation technique with reduction of exposure time to the 0 to -10d`C temperature range was compared to standard freezing procedures on subsequent semen parameters. Though no significant differences were found on post-thaw motile densities or hypoosmotic swelling test scores, a new, equally effective, but more rapid technique for cryopreservation is reported.

Previous data has shown that subnormal motility in some semen specimens can be improved by the addition of fresh human seminal plasma (HSP). However, if the HSP was first frozen the motility-enhancing factor was lost. We hypothesized that some of the reduction in sperm motility of cryopreserved-thawed sperm may be related to damage of the "motility-enhancing factor" of HSP. This study evaluated whether the addition of fresh HSP could improve the motility of frozen-thawed sperm. Each frozen-thawed specimen was evaluated for motile density and hypoosmotic swelling and then divided into two aliquots. Equal volumes of HSP, human tubal fluid (HTF), and control media were added and the semen parameters were reevaluated. The mean scores for motile density and percent motility did not change compared with baseline thawed volumes with either HSP or HTF additives. There were some isolated cases that did improve with either HSP (21%) or HTF(14%). Future studies are needed to determine whether this improvement is coincidental or consistent, and to determine whether at least some individuals can benefit from the addition of fresh HSP to frozen-thawed sperm.