Artificial insemination has been used to treat
infertile couples for almost 200 years. Intrauterine
insemination (IUI) is now performed for
several reasons. The cut-off level of semen parameters
in predicting the likelihood of successful
IUI is still unequivocal (
Some pregnancy will occur after IUI even with
sever male factor. Clinicians need tests that identify
which sub-fertile couples are likely to benefit
from IUI (
The effectiveness of IUI depends mainly on semen quality, which is assessed by the total motile sperm count (TMSC) and sperm morphology.
TMSC in the ejaculate is the product of multiplying
the semen volume by the sperm concentration
by the percentage of progressively motile sperms.
The best results are achieved when the number of
TMSC exceeds a threshold of approximately 10
Sperm morphology is another factor that may
influence the IUI result. Most studies have
found a strong correlation between sperm
morphology and the IUI result. In assessing
sperms morphology by strict criteria, success
rates with IUI are highest when 14% or more
of the sperm have normal morphology, like the
results observed in
The post-wash total motile count (TMC) has
been proposed as a test to help distinguish the couples
who would benefit from IUI, but it could not
distinguish between the couples who are likely
to benefit from IUI and those more likely to benefit
from IVF or intracytoplasmic sperm injection
The aim of our study was to assess the threshold of TMSC, sperm morphology and NMSI on the IUI outcome.
This study was a cross sectional. Four hundred forty five couples completed 820 IUI cycles in the infertility department of Imam khomieni Hospital in Ahvaz, Iran from May 2004 to May 2006. They were candidates for IUI because of male factor infertility or unexplained infertility. Informed consent forms were signed by all patients. This study was approved by the Ethics Committee of Ahvaz Jundishapour University Medical Sciences.
Inclusion criteria were normal thyroid stimulating hormone (TSH), prolactin levels and hysterosalpingography. Laparoscopy was performed for suspicious tubal and peritoneal factors before any treatment.
Serological tests human immunodeficiency virus (HIV) antibody, hepatitis B surface antigen (HbsAg) and hepatitis C virus (HCV) antibody were conducted for all the couples.
At first, all women were examined by the vaginal ultrasound (Honda 2000, 7.5 MHZ Transducer, Japan) on 1-5th days of their menstrual period to ensure that ovarian follicles were smaller than 15 mm.Then they underwent controlled ovarian hyperstimulation and received clomiphen citrate100 to 150 mg on the 3-5th day of cycle for 5days and at least 75IU HMG after the last dose of clomiphen citrate irrespective of whether they were ovulatory or anovulatory. Ovarian response was monitored by the vaginal ultrasound;when the follicular size of the leading follicle was 18- 22 mm, human chorionic gonadotropin (HCG) (5000 IU) was administered. All semen samples were collected in the laboratory after 2-3 days of sexual abstinence.
After liquefaction, the sperm volume, pH, count,
motility and morphology were evaluated according
to the WHO guidelines 1999 (
Raw semen was processed for IUI using swimup technique. The sampls were liquidated at 37°C and centrifuged at 300-500 g for 5-10 minutes. Then the supernants were discarded, the pellets were resuspended in 2 ml of medium (Ham’s F10 media, Steinheim, Germany) and centrifuged two times. In each time, the supernants were discarded. Finally, the pellets were resuspended in 0.5-1 ml of medium and the tubes were left at 37°C for 30-60 minutes in a humidified incubator to allow sperm to swimp up. Then the washed sperms were inseminated with an IUI catheter. No drug was used for luteal phase support.
Serum HCG levels were determined two weeks after the HCG injection in the absence of menstruation for diagnosis of pregnancy. A clinical pregnancy was defined as serum positive β-HCG.
The principal assessment criterion consists of the pregnancy rate per cycle according to TMSC, sperm morphology and NMSI.
Statistical analysis of the data was done by the SPSS software (version 13, SPSS, Chicago,USA). The data were expressed as the mean standard deviation, independent t test and χ2 test. Odd ratios were calculated using the Logistic regression model for comparison of categorical variables. Significance was set at p<0.05.
In this study, 445 couples, who underwent 820 IUI treatment procedures ,were recruited. Demographic characteristics of the couples are listed in table 1.
Profile of patients (distribution of variables)
|27.58 ± 5.1||28.58 ± 5.2||0.105|
|33.96 ± 7.8||33.65 ± 6.2||0.675|
|62.83 ± 39||74.73 ± 50||0.042|
Values are mean ± SD (95% confidence interval).
The range of female and male age were between "16 to 46" and "21 to 63" years and duration of infertility was 12-456 months.
The results of IUI according to the age of women, kind of infertility and ovulation
|54 (10.5)||458 (89.5)|
|18 (9.9)||163 (90.1)|
|9 (7.2)||116 (92.8)|
|56 (6.89)||546 (67.24)|
|24 (2.95)||189 (23.27)|
|43 (5.4)||523 (65.7)|
|35 (4.39)||195 (24.49)|
Parentheses indicate the percentage
The results of IUI according to TMSC , Normal sperm morphology and NMSI
|3 (5.6)||51 (94.4)|
|14 (5.1)||258 (94.9)|
|25 (10.8)||206 (89.2)|
|2 (2.1)||94 (97.9)|
|54 (10.1)||482 (89.9)|
|23 (12.6)||160 (87.4)|
|65 (11.2)||516 (88.8)|
Parentheses indicate the percentage
Seventy -three point eighty six percent and 26.13% of the couples had primary and secondary infertility, respectively.
Eighty one pregnancies followed 820 IUI cycles,
and the total pregnancy rate per cycle was 9.9 %.
There was a statistically significant difference between
the clinical pregnancy rate and duration of
infertility and ovulatory cycles (p=0.042, p=0.001,
respectively) , but not with age of women and men
and kind of infertility (
Table 3 shows the results of IUI with TMSC.
When the TMSC is 5×106 to < 10×106 , pregnancy
rate is significantly higher than the subgroups
with <1×106, 1×106 to <5×106 and ≥10×106 (15%,
5.6%, 5.1% and 10.8%, respectively) (p=0.001).
By considering the clinical pregnancy rate according
to normal sperm morphology, the most positive
IUI cycles were observed in the subgroups
with normal sperm morphology (5% or more) and the most difference of the results was in the subgroups
with normal sperm morphology<%5 (2.1% vs. 97.9 %) (p=0.017), (
Table 3 also indicates the results of IUI with the number of motile sperms inseminated. The PR per cycle was significantly higher when the number of motile sperms inseminated (NMSI) ≥10×106 in comparable with the subgroups <5×106 and 5×106 to <10×106 (11.2%, 4.1% and 5.2%, respectively). The difference is statistically significant (p =0.026).
On the other hand when the NMIS was divided into two groups of ≥10×106 and <10×106, according to Logistic regression model, the rate of pregnancy was higher in the first group (p=0.001, OR=2.86; CI, 1.57-5.21).
According to the findings of the present study, 81
clinical pregnancies were achieved after 820 IUI
cycles for a total pregnancy rate per cycle of 9.9%.
This rate is within the range of the previous studies
Overall, most of the previous studies have indicated
that the female age, duration of infertility
and ovulation are prognostic factors for
IUI success (
In the current study, we found that the most of IUI success when the range of total motile count was 5×106 to <10×106. Also, the findings of this study showed that TMC<1×106 was not justified for IUI treatment.
In accordance with the present results, some
previous studies have suggested that using the
total number of motile spermatozoa of semen
was a criteria for choosing between IUI and IVF
and have recommended the threshold values of
5 to 10×106 (
Sperm morphology is another factor that may
influence the IUI results. It is worth mentioning
that morphological assessment may vary
substantially according to the condition of
observation, and the kind of sperm morphology
assessment, but like the results observed
in IVF cycles, the probability of IUI success
rises with the percentage of morphologically
normal sperms. A number of prior studies
have reported that IUI success rates are
higher when 14% or more of the sperms have
normal morphology and inseminated with the
values between 4% and 14% and generally
quite poor when fewer than 4% of sperms are
In agreement with the above studies, the results of the present study also showed that when sperm morphology is more than 5%, the likelihood of IUI success is higher than when it is less than 5%.
Regarding the NMIS, as a factor that may
influence on the IUI success, our finding
showed that 11.2 % of the positive results
were in the group that their NIMS was 10×106
or more. On the other hand, rate of pregnancy
after IUI was 2.86 times when NMIS ≥10×106.
This finding is in agreement with the study of
Miller et al. (
Berg et al. also found a nonlinear increase in
the PR per cycle with the increasing of NMIS
in the uterine. They observed that insemination
with <0.8×106 motile sperms after swim-up resulted
in a PR of <1% per treatment cycle. But
when the motile sperm count was above this level,
the PR per cycle reached a plateau of 6.9%
to 10.2% (
Van weert et al. listed 16 studies reporting that
at cut-off levels of 0.8 to 5 million motile spermatozoa,
the post wash TMC provided a substantial
discriminative performance. At these cut-off levels,
the specificity of the post wash TMC was as
high as 100% and the sensitivity of the test was
Tay et al. (
Dadkhah et al. (
However, Motazedian et al. (
The results of the present study identified a statistically significant difference in the TMSC, sperm morphology and the NMSI on the outcome of intra uterine insemination.