Study of Prognostic Factors affecting on the IUI Outcome of Infertile Patients

 

Mohsin K. Al- Murshdi¹, Yahya K. Al – Sultani²

¹University of Kufa, Faculty of Science Department of Biology, Najaf-Iraq

²Department of Drugs and Toxins – College of Pharmacy–Kufa University-Iraq

*Corresponding Author E-mail: mohsin.almurshidi@uokufa.edu.iq

ABSTRACT:

Objective: The main objective of the study is to determine of prognostic factors on the pregnancy rate after intrauterine insemination (IUI) of infertile patients. Methods: The study was carried out between January 2014 and October 2014 including one hundred and fifty five infertile men who attended the Fertility Center in Al – Sadr Medical City. Results: The of the study showed that there was statistically significant (p<0.01) increase in pregnancy rate with couples that had sperm concentration ≥20 × 10⁶/ml, progressive motility (A +B) ≥ 50 % and normal morphology ≥ 30% as well as couples with leukocyte concentration < 1×10⁶ /ml, MDA concentration < 4 µmol/L and sperm chromatin maturity < 30%. This results also appeared higher significant (p<0.01) with couples that had age <30 years, infertility duration < 6 years and with couples non – smokers compared to smokers. While no significant difference (p> 0.01) was showed with type of infertility. Conclusion: Many factors may influence success rate after IUI treatment procedures such as potential sperm parameters, leukocyte concentration, MDA concentration and sperm chromatin maturity as well as age, infertility duration and smoking. Recommendation: Advance study to determine of the effect female factors on the IUI outcome.

 

 

 

INTRODUCTION:

Most couples seeking infertility treatment are subfertile and IUI is the first effective treatment chosen for suitably selected patients. IUI is the mode of treatment in infertility due to cervical factors, ovulatory dysfunction, endometriosis, immunological causes, male factor and unexplained infertility(1).

 

IUI is easy to perform, inexpensive and offers particular advantages such as the minimal equipment required, an easy technique to learn, being less invasive with reduced psychological burden on the couple when compared to IVF / ICSI.(2).

 

 

 

 

Pregnancy rates after IUI differ from one study to another depending on the patient selection criteria, the presence of various infertility factors, the methods of ovarian stimulation, the numbers of cycles performed, the different sperm parameters and technique of activation(3). Predictive sperm parameters and threshold values with respect to the semen characteristics, for successful IUI have been controversial. Apositive correlation between pregnancy rate and the total number of motile sperm count inseminated has been challenged in study by (4). But other have reported no such correlation(5).

 

Many different methods of isolation and concentration of sperm for IUI have been develoloped. The separation of spermatozoa and expression of their intrinsic fertilizing ability is a fundamental prerequisite for assisted reproduction technology ( 6 )

 

 

 

 

MATERIALS AND METHODS:

Subjects:

The study was carried in the Fertility Center in AL-Sadr Medical City. Semen samples were obtained from one hundred and fifty five infertile men, were collected by masturbation in to wide –mouth containers after 3-5 days of sexual abstinence in room near the laboratory, immediately placed in an incubator at 37C˚ till complete liquefaction. After liquefaction time, the liquefied semen was then carefully mixed for few second and the semen was analyzed by macroscopic and microscopic examination using standardization (7). Both before and after sperm activation: concentration, progressive motility (A+B) and normal morphology as well as leukocyte concentration, MDA concentration and sperm chromatin maturity were evaluated. Also, the information of demographic and medical history including: age, type of infertility, infertility duration and smoking was taken from the patients before starting the evaluation of patients before starting the evaluation of semen analysis.

 

Sperm activation:

After liquefaction and intail sperm analysis. Two method of IUI sperm activation have been used in this study to separate the motile spermatozoa from seminal plasma. The main IUI outcome measure was the pregnancy rate.

 

Swim –up technique:

Dilute the semen sample 1:1 with ferticult medium to promote removal of seminal plasma, then transfer the diluted suspension in to centrifuge tubes, centrifuge at 2500 rpm for 5 minutes. The supernatant was discarded, the final pellet was gently covered with 1 ml of medium and incubated for 60 minutes at 37 c˚ in an incubator until used in IUI procedure.

 

Density gradient centrifugation technique:

A two gradients 45% and 90% sil select stock medium were used for the procedure. All procedures were conducted under sterile conditions. Media were brought to 37c˚ temperature. Using sterile pipette 2.0 ml of the lower layer (90%) was transferred in to a conical centrifuge tube. Using anew sterile pipette 2.0 ml of the upper Layer (45%) was gently dispensed on top of the Lower Layer. 1 ml of Liquefied semen sample was then placed on top of the upper Layer and the tube was centrifuge at 3000 rpm for 10 min . The supernatant was discarded and the sperm pellet was suspended in volume 3 ml of ferticult medium , centrifuge for 10 minutes at 3000 rpm. The supernatant was then removed and the final pellet suspended in a volume of 0.5 ml of ferticult medium which used in IUI procedure.

 

 

RESULTS:

Pregnancy rate according to sperm concentration shown in figure (1) the highest pregnancy rate was achived among couples with sperm concentration more than 40 million (10.9%) followed by those with sperm concentration between 20-40 million (7.5%), while the pregnancy rate was observed in those with sperm concentration of less than 20 million (5%).

 

Figure (1) Effect of the sperm concentration on the IUI outcome for infertile patients.

Different letters means significant difference (P < 0.01)

 

Our results in the figure (2) showed that the pregnancy rate increased with couples that had 50% or greter of progressive motility percent (A + B) (10%) compared to less than 50% (5.8%).

 

Figure (2) Effect of the progressive motility percent on the IUI outcome of infertile patients.

Different letters means significant difference (P < 0.01)

 

In the figure (3) there was statistically significant (P < 0.01) increase in pregnancy rate among couples in whom normal morphology percent was > 30% (10%) as compared to those with < 30% (5.3%).

 

Figure (3) Effect of the normal morphology percent on the IUI outcome of infertile patients.

Different letters means significant difference (P < 0.01)

 

Figure (4) The pregnancy rate was better in couples with leukocyte concentration less than 1 million (16.6%) followed by those with leukocyte concentration between 1-2 million (10%) and more than 2-5 million (5.5%), while the pregnancy rate was showed higher decline in those with leukocyte concentration more than 5 million (3.6%).

 

 

Figure (4) Effect of the leukocyte concentration on the IUI outcome of infertile patients .

Different letters means significant difference (P < 0.01)

 

The pregnancy rate according to the MDA concentration was observed in figure (5) The pregnancy rate with couples have less than 4 µmol/L was significantly higher than 4 µmol/L or greter (11.4% versus 4.7%).

 

 

Figure (5) Effect of the MDA concentration on the IUI outcome of infertile patients.

Different letters means significant difference (P < 0.01)

 

In the figure (6) The pregnancy rate was much higher in the couples that have less than 30% of sperm chromatin maturity percent (10.7%), while the couples that have 30% or greter had the lowest pregnancy rate (5.5%).

 

 

Figure (6) Effect sperm chromatin maturity percent on the IUI outcome of infertile patients.

Different letters means significant difference (P < 0.01)

 

Figure (7) The pregnancy rate was reduced when the couples age increased. For less than 30 years, the pregnancy rate higher significant (16.6%) followed by those with age between 30-34 years (8%) and age between 35-39 years (5.2%), while the pregnancy rate significantly reduced with age more than 40 years (4.8%) .

 

 

Figure (7) Effect of the age on the IUI outcome of infertile patients.

Different letters means significant difference (P < 0.01)

 

Figure (8) showed no statistical significant was observed in the pregnancy rate for type of infertility between secondary infertility (7.8%) and primary infertility (7.5%).

 

 

Figure (8) Effect type of infertility on the IUI outcome of infertile patients

NS: no significant difference (P > 0.01)

 

Difference was statistically a significant at (P < 0.01). in the figure (9) we found that 4-6 years duration of infertility had the highest pregnancy rate (10%). The pregnancy rate for duration between 1-3 years was (8%). The pregnancy rate reduced to (4%) after 6 years of infertility.

 

 

Figure (9) Effect duration of infertility on the IUI outcome of infertile patients .

Different letters means significant difference (P < 0.01)

 

Figure (10) the pregnancy rate of the non – smoker was showed a significantly (P < 0.01) higher than those of the smoker (9.2% versus 5.8%) .

 

 

Figure (10) Effect smoking on the IUI outcome of infertile patients.

Different letters means significant difference (P < 0.01).

 

DISCUSSION:

The rates of pregnancy following IUI vary among studies may be due to various in sperm quality and quantity, activation methods, selection patients, different factors of infertility and ovarian stimulation techniques (8)Moreover, sperm parameters of male partners' using in IUI is generally play a predictor factors and enhance the possibility of pregnancy(9).

 

The number of motile sperm, progressive motility and sperm count in both pre – activation and post – activation were significantly elevation in IUI outcome (10). The best pregnancy rats were appeared significantly higher when fresh semen specimen ≥ 20 million /ml spermatozoa, lower this concentration the correlation between fertilization capacity and sperm concentration may lead to be less predictable (11).

Defective of sperm morphology (teratozoospermia ) is a diagnosis by site, including the head, mid – pice and tail. Sperm morphology is the better factor of fertilization capacity (12). Therefore, the alteration of sperm form establish a significantly decrease IUI outcome (13). Our study by (9) was reported to the sperm morphology of less than 30% given a pregnancy rate of 5.43% compared to 18.42% of pregnancy with normal morphology.

 

The success of pregnancy rates in IUI are elevation when the sperm morphology was ≥ 30% while quite lower when sperm morphology < 30% (9).

 

The impacts of increase leukocytes on sperm may be lead to high livels of DNA damage by increase ROS production which may be attributed ART particularly in infertile couples (14). Therefore, increase pregnancy rate following in vitro activation may be resulted from improvement in semen parameters because reduce sperm DNA damage and oxidative stress by elimination of seminal leukocytes (15). Many studies proposed that sperm DWA chromatin damage is associated with decrease pregnancy rates in IUI and suggested that sperm DNA damage is related with long time to pregnancy and very poor possibility of achieving a spontaneous pregnancy (16,17).

 

Moreover, studies was appeared that males where showed greatly damage of sperm DNA have decrease values of natural fecundity. Above 30% of sperm DNA damage, approximately 10% of males achieved pregnancy during one year ( 18,19), Also, sperm DNA damage is a correlated with decrease IVF and IUI out comes but not with intracytoplasmic sperm injection outcomes (20).

 

MDA may be used as a parameter of oxidative stress and prognostic factor for expecting assiste reproduction techniques out comes (21). Because the lipid per oxidation effects the potential sperm parameters (count, motility and morphology) and related with decrease sperm quality (22). High levels of oxidative stress have been related with decrease sperm function during failure of sperm metabolism, sperm motion, impairment of plasma membrane and failed intiated fertilization as well as abnormal chromatin structure and break strands of DNA (23). Moreover, oxidative stress have been appositive correlation with sperm DNA damage but negative association with sperm quality, fertilization and development of embryo and finally effects on ART outcomes (24).

 

Advance male age also negative effects on sperm quality (sperm count, sperm motility and morphology) and function of testicle as well as increased levels of DNA damage and chromatin defective (25).(26) was suggested the fertilization rate after assisted reproductive technologies were reduce significantly with male age more than 50 years old. Some studies have proposed no correlation found between advance age and successful of pregnancy rate (27,28).

 

On the other hand, the duration of infertility was important predicator factor for successful rate of pregnancy. This study found that with 2 to 4 years of infertility, the percentage of IUI outcome begins to reduce (29). Our study was found the longer duration more than 6 years has been significantly decline with success rate of IUI outcome (30).

 

Other study was found no significant effect on IUI outcome with advance duration of infertility (31).

 

Furthermore, many studies was showed that smoking is related with decrease semen volume, sperm concentration, progressive motility and normal morphology as well as delayed Liquefaction time and increase viscosity. Also it was proposed that elevated Levels of DNA damge and then decrease IUI outcome compared with nonsmokers. (32,33). The metabolism of smoking substances may cause inflammatory reaction in the accessory glands and then release chemical mediators may have increased Leukocytes (34). The study by (35)was concluded the pregnancy rate after IUI decrease significantly with men smokers because negative effect of smoking cigarette compared with nonsmokers.

 

CONCLUSION:

The pregnancy rate following IUI was positively affected by increase sperm concentration, progressive motility (A+B) and normal morphology, also by decrease Leukocyte concentration, MDA concentration and sperm chromatin maturity. The pregnancy rate in IUI was negatively affected by increase patients age, infertility duration and Smoking.

 

RECOMMENDATION:

A comprehensive study to the determine of effect female factors on the IUI outcome.

 

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Accepted on 24.11.2018        © RJPT All right reserved

Research J. Pharm. and Tech 2019; 12(1): 161-166.