Prediction of unexpectedly poor fertilization and pregnancy outcome using the strict criteria for sperm morphology before and after sperm separation in IVF-ET.

This study was performed to investigate if unexpectedly poor fertilization and in-vitro fertilization (IVF) outcome could be predicted using sperm morphology as diagnosed by the strict criteria. Sperm morphology was assessed in 137 IVF-ET cycles with at least three oocytes collected. The lowest amount of normal forms was 5% in 137 samples, indicating there were no patients belonging to 'poor prognosis' (<5% normal forms). Treatment using intracytoplasmic sperm injection (ICSI) was also excluded. Before sperm separation by the swim-up method, sperm morphology demonstrated a significant correlation with the fertilization rate (p < 0.0001). The fertilization rate (80.5%) in 110 'normal' samples (>14% normal forms) was significantly higher (p < 0.01) than that (55.4%) in 27 samples with 'good prognosis' (those with 5--14% normal forms). No embryo was available for transfer (ET) in 4 (3.6%) of 110 'normal' cycles and in 3 (11.1%) of 27 'good prognosis' cycles (not significant). Fresh ET was intentionally cancelled to avoid severe ovarian hyperstimulation syndrome (OHSS) in six of 110 'normal' cycles as well as in one of 27 'good prognosis' cycles. The pregnancy rate per ET was 31.0% (31/100) in the former group, while it was 26.1% (6/23) in the latter group. There was no difference between the two groups. In the post swim-up evaluation of sperm characteristics, morphology was significantly correlated with the fertilization rate in IVF-ET (p < 0.05) while other sperm parameters were not. When the cut off level for the post swim-up sperm morphology was set at 25%, there was a significant difference in the fertilization rates between patients (78.6%) with post-swim-up >25% and those (55.0%) with post-swim-up < or =25% (p < 0.01). Taken together, a relative indication for ICSI using sperm morphology before and after swim-up was established. Category A includes < or =14% normal forms in the ejaculate and post-swim-up < or =25%, while Category B includes < or =14% in the ejaculate and post-swim-up >25%. There was a significant difference in the fertilization rates between patients (47.2%) in Category A and those (60.2%) in Category B (p < 0.05). The clinical pregnancy rate was 11.1% for patients in Category A compared with 35.7% for patients in Category B. However, there was no significant difference between the two categories. These results indicate that the strict criteria provide a reliable estimation of the fertilizing ability of human spermatozoa. ICSI might be considered in Category A patients to avoid poor fertilization and pregnancy outcome.