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RESEARCHOpenAccessEfficacyofspermmotilityafterprocessingandincubationtopredictpregnancyafterintrauterineinseminationinnormospermicindividualsLígiaFPdeAraújo1,2*,EdilbertodeAraújoFilho1,CássioLFácio1,MárciaCOBossoni1,LigianeAMachado-Paula1,JoséECorrente3,MárioCavagna4,5,PauloCSMatheus6andAnaglóriaPontes2AbstractBackground:Intrauterineinsemination(IUI)iswidelyusedtotreatinfertility,anditsadequateindicationisimportanttoobtaingoodpregnancyrates.
ToassesswhichcouplescouldbenefitfromIUI,thisstudyaimedtoevaluatewhetherspermmotilityusingadiscontinuousgradientofdifferentdensitiesandincubationinCO2innormospermicindividualsisabletopredictpregnancy.
Methods:Atotalof175couplesunderwent175IUIcycles.
Theinclusioncriteriaforwomenwereasfollows:35yearsoldoryounger(agerange:from27to35years)withnormalfallopiantubes;endometriosisgradesI-II;unexplainedinfertility;nonhyperandrogenicovulatorydysfunction.
Menwithnormalseminalparameterswerealsoincluded.
AllpatientsunderwentovarianstimulationwithclomiphenecitrateandhumanhMGorr-FSH.
Whenoneor(atmost)threefolliclesmeasuring18to20mmwereobserved,hCG(5000UI)orr-hCG(250mcg)wasadministeredandIUIperformed36–40hafterhCG.
Spermprocessingwasperformedusingadiscontinuousconcentrationgradient.
A20microlitersaliquotwasincubatedfor24hat37degreesCin5%CO2followingatotalprogressivemotilityanalysis.
TheMann–WhitneyandChi-squaretests,aswellasaROCcurvewereusedtodeterminethecutoffvalueformotility.
Results:Ofthe175couples,52(in52IUIcycles)achievedclinicalpregnancies(CPratepercycle:29.
7%).
Theanalysisofage,durationandcausesofinfertilitydidnotindicateanystatisticalsignificancebetweenpregnancyandnopregnancygroups,similartotheresultsfortotalspermcountandmorphologyanalyses,excludingprogressivemotility(p10millionandmorphologywas>4%.
MaleagewasalsoadeterminingfactorforIUIsuccess,evenwithanormalspermiogram.
Inourstudy,therewasnosig-nificantdifferenceinage(bothmenandwomen)inbothgroups(pregnancyandnopregnancy),andourdatareinforcethatspermmotility,whichwasverifiedinthepresentstudy,mayhelppatientsdeterminetheirchancesofIUIsuccess.
Currently,manystudiesinvestigateseminalparametersanditsimportanceinachievinggoodpregnancyoutcomesincouplesundergoingIUI.
Howevermanycontroversiesmakeitimpossibletoknowwhichcouplescouldbenefitfromthisformoftreatmentbecausethebasicsemenana-lysisisnotagoodparameterforIUIsuccess.
Moreover,wedonothaveanswersregardingthefeasibilityofselect-ivelyinsistingontheIUItechnique.
Thereisonlyonestudyintheliterature,whichwasperformedbyBraniganetal.
[20],thatanalyzedspermmotilityat24hafterpro-cessingandincubationasthepredictivetestofIUIsuc-cess.
Accordingtothestudyoutcome,thismotilitytestispredictiveofIUIsuccess.
Theauthorsassessed414cou-plesundergoingIUIbecauseofamalefactorandunex-plainedinfertility.
Theirresultsshowedthatnoneofthebasicsemenanalysisparametersofconcentration,motilityormorphologywaspredictiveofIUIsuccess.
Withthead-vancedanalysis,whentheprocessedtotalmotilespermthatwereavailableforIUIwas≥10*106andthespermsurvivalat24hafterincubationwas≥70%,89%ofthecouplesachievedpregnancy,witha21.
4%pregnancyratepercycle.
Withthecutoffvalues>70%fortheadvancedsemenanalysis,thetesthadasensitivityof94%andspeci-ficityof86%.
Interestinglytheauthorscomparedmenwithnormalsemenanalysis(groupofunexplainedinfertility)withthosemenpresentingamalefactor.
Theresultsshowedthat83%ofcoupleshadmalefactorproblems(basicsemenanalysisparameters),presentingapercyclepregnancyrateof17.
8%anda48%cumulativepregnancyrate.
Twenty-threeper-centofmenwithnormalsemenparameterspresentedapercyclepregnancyrateof1.
8%andtheydidnotmeettheadvancedsemenanalysiscutoffvaluesfor24hmotilityorprocessedtotalmotilesperm.
Therefore,theadvancedtestwaspredictive,independentofnormalorabnormalthebasicanalysisseminalparameters,becausethisadvancedanalysisaccuratelypredictedthese"occult"malefactors.
Thissametypeoftestwasperformedinthiswork,butonlyinnormospermicindividuals,whichallowedagoodsuccessrateinourIUIresults.
Somestudiesconfirmedthatpregnancyratesarehigherinnormospermicindivid-ualsasshownbyAllenetal.
[30],whichindicateda25%pregnancyratepercyclein104coupleswhenthemalefac-torwaspredominantanda60%pregnancyratepercyclein58coupleswhentherewasacervicalfactor.
ForGrigoriouetal.
[31],theratesofCPandlivebirthspercycleweresignificantlylowerintheteratozoospermiaTable3Sensitivity,specificity,positiveandnegativepredictivevaluesasdeterminedbycutoffvaluesoftheROCcurveAfterspermprocessing(cutoffvalue:69%)24hincubation(cutoffvalue:56.
5%)Sensitivity63.
5(50.
4–76.
5)96.
1(90.
9–100.
0)Specificity73.
1(65.
0–81.
0)92.
7(88.
1–97.
3)Positivepredictivevalue50(37.
9–62.
1)84.
7(75.
5–93.
9)Negativepredictivevalue82.
6(75.
5–89.
7)98.
3(95.
9–100.
0)Valuesareexpressedaspercentageand95%CI.
deAraújoetal.
ReproductiveBiologyandEndocrinology2013,11:101Page5of7http://www.
rbej.
com/content/11/1/101groupwhencomparedwiththenormozoospermiagroup,whereasthecumulativelivebirthrateafter4IUIcycleswassignificantlylowerinthegroupwithmalefactorsofinfertility.
Thesedatacorroboratetheresultspresentedhere,indicat-ingthathighpregnancyratesareobtainedinnormospermicpatientsinwhichspermmotilityafterincubationremainsunchanged.
Therefore,thetestwith24hincubationat37°Cin5%CO2afterspermprocessingallowedustoconcludethatmotilityisrelatedtothesuccessrateofIUI.
Thus,cou-plesseekingtreatmentforinfertilitycouldbesubjectedtothistest,andfromthetestresults,wewouldbeabletose-lectthosecoupleswhomightbenefitfromIUI.
Thus,cou-plesavoidsubjectiontoseveralunnecessarycyclesofIUI.
SuccessivefailedattemptsoftheIUIcanbeafrustratingex-perienceforthecouple,notonlybythedistressbetweenonecycleandanotherbutalsobythefearofnotachievingsuccess[10].
WealsobelievethatifthispredictivetestofIUIsuc-cesswasappliedtopatientsbeforetreatment,thenaconsensuscouldbedeterminedregardingtheexistingvariationinthelimitforthenumberofcyclestobeperformed.
Thepresentstudyaimsatthisgoalthroughacutoffvalueusingmotility,whichistheparameterthatappearstobethemostrelevant.
Thisobservationiscon-sistentwiththestudiesbyShulmanetal.
[22],whocon-cludedthatthedegreeofspermmotilityistheonlyparameterthatcanbecorrelatedwiththeIUIoutcomefornormalwomenwithapartnerwithgoodspermmo-tility,afterappropriatespermpreparation.
TheIUIisalesscomplextreatmentandthetestofspermmotilityat24hafterincubationat37°Cin5%CO2canbeusedtopredictCPpriortotheIUItreatmentorasanindicatortoverifywhetheranewIUIattemptmustbeperformedormorecomplexARTsarerequired.
ConclusionsInconclusion,thepresentstudysuggeststhatdeterminingthespermmotilityofnormospermicindividualsafterpro-cessingandincubationfor24hat37°Cin5%CO2,withacutoffvalueof56.
5%isabletopredictIUIsuccess.
AbbreviationsART:Assistedreproductiontechniques;CI:Confidenceinterval;COH:Controlledovarianhyperstimulation;CP:Clinicalpregnancy;hCG:Humanchorionicgonadotropin;hMG:Humanmenopausalgonadotropin;IUI:Intrauterineinsemination;IVF:invitrofertilization;mHTF:Modifiedhumantubalfluid;npv:Negativepredictivevalue;ppv:Positivepredictivevalue;r-FSH:Recombinantfolliclestimulatinghormone;r-hCG:Recombinanthumanchorionicgonadotropin;ROC:Receiveroperatingcharacteristiccurve;SSS:Syntheticserumsubstitute;TMC:Totalmotilespermcount.
CompetinginterestsTheauthorsdeclarethattheyhavenocompetinginterests.
Authors'contributionsLFPAwasresponsiblefordesigningandcoordinatingthestudy,thecollection,analysisandinterpretationofthedata,andforwritingthemanuscript.
EAFwasresponsibleforthecollection,analysisandinterpretationofthedata.
CLFandMCOBwereresponsiblefordatacollection.
LAM-Pwasresponsiblefortheanalysisandinterpretationofthedataandrevisingthemanuscript.
JECwasresponsibleforthestatisticalanalyses.
MCandPCSMwereresponsibleforrevisingthemanuscript.
APwasresponsiblefordesigningandcoordinatingthestudy.
Allauthorsreadandapprovedthefinalmanuscript.
AcknowledgementsTheauthorswishtothanktheElsevierLanguageEditinghttp://webshop.
elsevier.
com/languageediting/forrevisingtheEnglishtext.
Authordetails1CenterofHumanReproductionofSoJosédoRioPreto,SoJosédoRioPreto,SP,Brazil.
2DepartmentofGynaecologyandObstetrics,BotucatuMedicalSchool,SoPauloStateUniversity-UNESP,Botucatu,SP,Brazil.
3DepartmentofBioestatistics,InstituteofBiosciencesBotucatu,SoPauloStateUniversity-UNESP,Botucatu,SP,Brazil.
4CenterforHumanReproductionProf.
FrancoJr,RibeiroPreto,SP,Brazil.
5PaulistaCenterforDiagnosis,ResearchandTraining,RibeiroPreto,SP,Brazil.
6GERAR-FertilityClinic,Recife,PE,Brazil.
Received:22May2013Accepted:18October2013Published:22October2013References1.
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doi:10.
1186/1477-7827-11-101Citethisarticleas:deAraújoetal.
:Efficacyofspermmotilityafterprocessingandincubationtopredictpregnancyafterintrauterineinseminationinnormospermicindividuals.
ReproductiveBiologyandEndocrinology201311:101.
SubmityournextmanuscripttoBioMedCentralandtakefulladvantageof:ConvenientonlinesubmissionThoroughpeerreviewNospaceconstraintsorcolorgurechargesImmediatepublicationonacceptanceInclusioninPubMed,CAS,ScopusandGoogleScholarResearchwhichisfreelyavailableforredistributionSubmityourmanuscriptatwww.
biomedcentral.
com/submitdeAraújoetal.
ReproductiveBiologyandEndocrinology2013,11:101Page7of7http://www.
rbej.
com/content/11/1/101
ToassesswhichcouplescouldbenefitfromIUI,thisstudyaimedtoevaluatewhetherspermmotilityusingadiscontinuousgradientofdifferentdensitiesandincubationinCO2innormospermicindividualsisabletopredictpregnancy.
Methods:Atotalof175couplesunderwent175IUIcycles.
Theinclusioncriteriaforwomenwereasfollows:35yearsoldoryounger(agerange:from27to35years)withnormalfallopiantubes;endometriosisgradesI-II;unexplainedinfertility;nonhyperandrogenicovulatorydysfunction.
Menwithnormalseminalparameterswerealsoincluded.
AllpatientsunderwentovarianstimulationwithclomiphenecitrateandhumanhMGorr-FSH.
Whenoneor(atmost)threefolliclesmeasuring18to20mmwereobserved,hCG(5000UI)orr-hCG(250mcg)wasadministeredandIUIperformed36–40hafterhCG.
Spermprocessingwasperformedusingadiscontinuousconcentrationgradient.
A20microlitersaliquotwasincubatedfor24hat37degreesCin5%CO2followingatotalprogressivemotilityanalysis.
TheMann–WhitneyandChi-squaretests,aswellasaROCcurvewereusedtodeterminethecutoffvalueformotility.
Results:Ofthe175couples,52(in52IUIcycles)achievedclinicalpregnancies(CPratepercycle:29.
7%).
Theanalysisofage,durationandcausesofinfertilitydidnotindicateanystatisticalsignificancebetweenpregnancyandnopregnancygroups,similartotheresultsfortotalspermcountandmorphologyanalyses,excludingprogressivemotility(p10millionandmorphologywas>4%.
MaleagewasalsoadeterminingfactorforIUIsuccess,evenwithanormalspermiogram.
Inourstudy,therewasnosig-nificantdifferenceinage(bothmenandwomen)inbothgroups(pregnancyandnopregnancy),andourdatareinforcethatspermmotility,whichwasverifiedinthepresentstudy,mayhelppatientsdeterminetheirchancesofIUIsuccess.
Currently,manystudiesinvestigateseminalparametersanditsimportanceinachievinggoodpregnancyoutcomesincouplesundergoingIUI.
Howevermanycontroversiesmakeitimpossibletoknowwhichcouplescouldbenefitfromthisformoftreatmentbecausethebasicsemenana-lysisisnotagoodparameterforIUIsuccess.
Moreover,wedonothaveanswersregardingthefeasibilityofselect-ivelyinsistingontheIUItechnique.
Thereisonlyonestudyintheliterature,whichwasperformedbyBraniganetal.
[20],thatanalyzedspermmotilityat24hafterpro-cessingandincubationasthepredictivetestofIUIsuc-cess.
Accordingtothestudyoutcome,thismotilitytestispredictiveofIUIsuccess.
Theauthorsassessed414cou-plesundergoingIUIbecauseofamalefactorandunex-plainedinfertility.
Theirresultsshowedthatnoneofthebasicsemenanalysisparametersofconcentration,motilityormorphologywaspredictiveofIUIsuccess.
Withthead-vancedanalysis,whentheprocessedtotalmotilespermthatwereavailableforIUIwas≥10*106andthespermsurvivalat24hafterincubationwas≥70%,89%ofthecouplesachievedpregnancy,witha21.
4%pregnancyratepercycle.
Withthecutoffvalues>70%fortheadvancedsemenanalysis,thetesthadasensitivityof94%andspeci-ficityof86%.
Interestinglytheauthorscomparedmenwithnormalsemenanalysis(groupofunexplainedinfertility)withthosemenpresentingamalefactor.
Theresultsshowedthat83%ofcoupleshadmalefactorproblems(basicsemenanalysisparameters),presentingapercyclepregnancyrateof17.
8%anda48%cumulativepregnancyrate.
Twenty-threeper-centofmenwithnormalsemenparameterspresentedapercyclepregnancyrateof1.
8%andtheydidnotmeettheadvancedsemenanalysiscutoffvaluesfor24hmotilityorprocessedtotalmotilesperm.
Therefore,theadvancedtestwaspredictive,independentofnormalorabnormalthebasicanalysisseminalparameters,becausethisadvancedanalysisaccuratelypredictedthese"occult"malefactors.
Thissametypeoftestwasperformedinthiswork,butonlyinnormospermicindividuals,whichallowedagoodsuccessrateinourIUIresults.
Somestudiesconfirmedthatpregnancyratesarehigherinnormospermicindivid-ualsasshownbyAllenetal.
[30],whichindicateda25%pregnancyratepercyclein104coupleswhenthemalefac-torwaspredominantanda60%pregnancyratepercyclein58coupleswhentherewasacervicalfactor.
ForGrigoriouetal.
[31],theratesofCPandlivebirthspercycleweresignificantlylowerintheteratozoospermiaTable3Sensitivity,specificity,positiveandnegativepredictivevaluesasdeterminedbycutoffvaluesoftheROCcurveAfterspermprocessing(cutoffvalue:69%)24hincubation(cutoffvalue:56.
5%)Sensitivity63.
5(50.
4–76.
5)96.
1(90.
9–100.
0)Specificity73.
1(65.
0–81.
0)92.
7(88.
1–97.
3)Positivepredictivevalue50(37.
9–62.
1)84.
7(75.
5–93.
9)Negativepredictivevalue82.
6(75.
5–89.
7)98.
3(95.
9–100.
0)Valuesareexpressedaspercentageand95%CI.
deAraújoetal.
ReproductiveBiologyandEndocrinology2013,11:101Page5of7http://www.
rbej.
com/content/11/1/101groupwhencomparedwiththenormozoospermiagroup,whereasthecumulativelivebirthrateafter4IUIcycleswassignificantlylowerinthegroupwithmalefactorsofinfertility.
Thesedatacorroboratetheresultspresentedhere,indicat-ingthathighpregnancyratesareobtainedinnormospermicpatientsinwhichspermmotilityafterincubationremainsunchanged.
Therefore,thetestwith24hincubationat37°Cin5%CO2afterspermprocessingallowedustoconcludethatmotilityisrelatedtothesuccessrateofIUI.
Thus,cou-plesseekingtreatmentforinfertilitycouldbesubjectedtothistest,andfromthetestresults,wewouldbeabletose-lectthosecoupleswhomightbenefitfromIUI.
Thus,cou-plesavoidsubjectiontoseveralunnecessarycyclesofIUI.
SuccessivefailedattemptsoftheIUIcanbeafrustratingex-perienceforthecouple,notonlybythedistressbetweenonecycleandanotherbutalsobythefearofnotachievingsuccess[10].
WealsobelievethatifthispredictivetestofIUIsuc-cesswasappliedtopatientsbeforetreatment,thenaconsensuscouldbedeterminedregardingtheexistingvariationinthelimitforthenumberofcyclestobeperformed.
Thepresentstudyaimsatthisgoalthroughacutoffvalueusingmotility,whichistheparameterthatappearstobethemostrelevant.
Thisobservationiscon-sistentwiththestudiesbyShulmanetal.
[22],whocon-cludedthatthedegreeofspermmotilityistheonlyparameterthatcanbecorrelatedwiththeIUIoutcomefornormalwomenwithapartnerwithgoodspermmo-tility,afterappropriatespermpreparation.
TheIUIisalesscomplextreatmentandthetestofspermmotilityat24hafterincubationat37°Cin5%CO2canbeusedtopredictCPpriortotheIUItreatmentorasanindicatortoverifywhetheranewIUIattemptmustbeperformedormorecomplexARTsarerequired.
ConclusionsInconclusion,thepresentstudysuggeststhatdeterminingthespermmotilityofnormospermicindividualsafterpro-cessingandincubationfor24hat37°Cin5%CO2,withacutoffvalueof56.
5%isabletopredictIUIsuccess.
AbbreviationsART:Assistedreproductiontechniques;CI:Confidenceinterval;COH:Controlledovarianhyperstimulation;CP:Clinicalpregnancy;hCG:Humanchorionicgonadotropin;hMG:Humanmenopausalgonadotropin;IUI:Intrauterineinsemination;IVF:invitrofertilization;mHTF:Modifiedhumantubalfluid;npv:Negativepredictivevalue;ppv:Positivepredictivevalue;r-FSH:Recombinantfolliclestimulatinghormone;r-hCG:Recombinanthumanchorionicgonadotropin;ROC:Receiveroperatingcharacteristiccurve;SSS:Syntheticserumsubstitute;TMC:Totalmotilespermcount.
CompetinginterestsTheauthorsdeclarethattheyhavenocompetinginterests.
Authors'contributionsLFPAwasresponsiblefordesigningandcoordinatingthestudy,thecollection,analysisandinterpretationofthedata,andforwritingthemanuscript.
EAFwasresponsibleforthecollection,analysisandinterpretationofthedata.
CLFandMCOBwereresponsiblefordatacollection.
LAM-Pwasresponsiblefortheanalysisandinterpretationofthedataandrevisingthemanuscript.
JECwasresponsibleforthestatisticalanalyses.
MCandPCSMwereresponsibleforrevisingthemanuscript.
APwasresponsiblefordesigningandcoordinatingthestudy.
Allauthorsreadandapprovedthefinalmanuscript.
AcknowledgementsTheauthorswishtothanktheElsevierLanguageEditinghttp://webshop.
elsevier.
com/languageediting/forrevisingtheEnglishtext.
Authordetails1CenterofHumanReproductionofSoJosédoRioPreto,SoJosédoRioPreto,SP,Brazil.
2DepartmentofGynaecologyandObstetrics,BotucatuMedicalSchool,SoPauloStateUniversity-UNESP,Botucatu,SP,Brazil.
3DepartmentofBioestatistics,InstituteofBiosciencesBotucatu,SoPauloStateUniversity-UNESP,Botucatu,SP,Brazil.
4CenterforHumanReproductionProf.
FrancoJr,RibeiroPreto,SP,Brazil.
5PaulistaCenterforDiagnosis,ResearchandTraining,RibeiroPreto,SP,Brazil.
6GERAR-FertilityClinic,Recife,PE,Brazil.
Received:22May2013Accepted:18October2013Published:22October2013References1.
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doi:10.
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:Efficacyofspermmotilityafterprocessingandincubationtopredictpregnancyafterintrauterineinseminationinnormospermicindividuals.
ReproductiveBiologyandEndocrinology201311:101.
SubmityournextmanuscripttoBioMedCentralandtakefulladvantageof:ConvenientonlinesubmissionThoroughpeerreviewNospaceconstraintsorcolorgurechargesImmediatepublicationonacceptanceInclusioninPubMed,CAS,ScopusandGoogleScholarResearchwhichisfreelyavailableforredistributionSubmityourmanuscriptatwww.
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