No abstract

This retrospective study aimed to evaluate the prognostic value of the inseminating motile count (IMC) and sperm morphology (using strict criteria) on success rates after homologous intrauterine insemination (IUI) combined with clomiphene citrate (CC) stimulation. A total of 373 couples underwent 792 IUI cycles in a predominantly (87.4%) male subfertility group. The overall cycle fecundity (CF) and baby take-home rate (BTH) was 14.6 and 9.9% respectively. The cumulative CF and BTH (per couple) after three cycles were 30.6 and 21.1% respectively. Overall, sperm morphology and IMC were of no prognostic value using receiver operating characteristic (ROC) curve analysis, but after classifying the study population into different subgroups according to IMC, sperm morphology turned out to be a valuable prognostic parameter in subgroup 1, i.e. IMC <1 x 10(6). In this subgroup, no pregnancies were seen when the morphology score was <4% and the mean value of sperm morphology was significantly different in the pregnant (8.3%) versus non-pregnant group (5.0%; P <0.05). The cumulative CF and BTH after three IUI cycles were comparable for all couples with the exception of those cases in which the IMC was <1 x 10(6) with a morphology score of <4% normal forms. We recorded only two twin pregnancies (2.5%) and no moderate or severe ovarian hyperstimulation syndrome. We conclude that in a selected group of patients without CC resistance and normal ovarian response following CC stimulation [maximum of three follicles with a diameter of >16 mm at the time of administration of human chorionic gonadotrophin (HCG)], IUI combined with CC-HCG can be offered as a very safe and non-expensive first-line treatment, at least with an IMC of >1 x 10(6) spermatozoa. In cases with <1 x 10(6) spermatozoa, CC-IUI remains important as a first-choice therapy provided the morphology score is > or =4%.

Zusammenfassung Vorbeugung von Fertilitätsstörungen durch frühzeitige Diagnostik und Behandlung der Varikocele bei Schülern und Studenten 4,067 Schüler und Studenten (12 ‐ 15 Jahre) wurden auf das Vorhandensein einer linksseitigen Varikozele untersucht. Mit dem Einsetzen der Pubertät steigt die Häufigkeit von Varikozelen stufenweise an und bleibt danach konstant. In der gesamten Gruppe liegt die Frequenz bei 14.7%. Nur die Gruppen mit Varikozelen zweiten und dritten Grades können als “Risikogruppe” bezeichnet werden in Bezug auf eine spätere Unfruchtbarkeit; letztere wurde bei 5.3% aller Fälle beobachtet. Allerdings entstehen schon bei einem Crittel der Jugendlichen mit einer Varikozele zweiten Grades und bei fast alien mit einer Varikozele dritten Grades anatomische Veränderungen (Volumen und Konsistenz) an den Hoden während der Pubertät. Um einer eventuellen späteren Unfruchtbarkeit vorzubeugen, kann ein operativer Eingriff erwogen werden; jedoch muß man die psychologischen Reaktionen in diesem Alter mit besonderer Aufmerksamkeit berücksichtigen. Ein Eingriff im jugendlichen Alter zur Vorbeugung einer „möglichen” späteren Unfruchtbarkeit kann eine psychogene Impotenz auslösen. Resumen Prevención de alteraciones de la fertilidad mediante detectión y tratamiento del varicocele en la edad escolar Se examinaron 4.067 estudiantes entre 12 y 15 años para ver si tenian varicocele izquierdo. Con el inicio de la pubertad la incidencia del varicocele aumenta gradualmente hasta que se completa la pubertad. Después de la — adolescencia la incidencia de varicocele permanece constante. Para el grupo completo la incidencia de varicocele al‐canzó el 14′7%. Puesto que solo los grupos con varicocele grados II o III, deben ser considerados como “grupos — riesgo”, en cuanto concierne a una infertilidad posterior, podemos establecer que el 5′3% de todos los estudiantes — pertenecen a este grupo. Por tanto un tercio de los sujetos con varicocele grado II y casi todos los sujetos con varicocele grado III, ya presentan en la adolescencia una influencia anatómica sobre el testicu‐lo (volumen y/o consistencia). Puede considerarse la prevención de una posible alteration posterior de la fertilidad, mediante tratamiento quirúrgico del varicocele, pero es necesario una cuidadosa atención por la reactión psicológica a esta — edad. La prevención en la adolescencia de una posible alteratión de la fertilidad en la edad adulta tiene el ries go de provocar reacciones psicológicas de inferioridad sexual y genital.

Careful analysis of sperm morphology has always been an important part of a routine semen examination. However, the usefulness of sperm morphology assessment as a predictor of a man's fertilizing potential has often been challenged due to different classification systems, various slide preparation techniques and inconsistency of analyses within and between laboratories. Automated sperm morphology analysis instruments may overcome the subjective nature of visual assessments of sperm morphology, but the technical problems are numerous and the validity of these instruments has still to be proven. Having reviewed the literature, it seems clear that there is general agreement concerning the clinical relevance and predictive value of this single semen parameter in vivo and in vitro. Nevertheless, even in cases of severe teratozoospermia, fertilization may be possible. Studies on the acrosome reaction are very promising for patients with severe sperm morphology abnormalities that do not have major effects on the fertilizing potential. Most promising is the development of intracytoplasmic sperm injection (ICSI) as the treatment of first choice in cases of severe teratozoospermia with failed fertilization in vitro. Normal fertilization and pregnancy rates can be obtained with ICSI in the presence of extreme teratozoospermia, suggesting that sperm morphology may be important in spermatozoa-zona binding, penetration and spermatozoon-oocyte fusion but fails to be of any predictive value once the spermatozoon reaches the cytoplasm of the oocyte. To conclude, accurate and strict sperm morphology assessment is very useful in evaluating a patient's fertilizing potential, with the main advantage that the methods used to examine this parameter are easy to learn on equipment found in most laboratories.