1 IVF and Fertility Laboratory and 2 Department of Obstetrics and Gynecology, Bikur Cholim Hospital, 5 Strauss Street, Jerusalem 91004, Israel
Dear Sir,
Spontaneous pregnancies have been reported in couples with severe male and female reproductive disorders waiting for IVF/intracytoplasmic sperm injection (ICSI) treatments (Matorras et al., 1996; Snick et al.1997
; Evers et al.1998
) and after discontinuation of therapy (Osmanagaoglu et al.1999
). However, in severe oligoasthenozoospermia (fresh sperm concentration <1x106/ml, motility <30%), only few cases of spontaneous pregnancies have been described and sperm quality after achieving conception was not always evaluated (Matorras et al.1996
).
We studied the rate of spontaneous pregnancies among 85 married couples who between mid-1996 and December 1997 underwent 119 ICSI treatment cycles due to severe idiopathic oligoasthenozoospermia.
All male spouses had sperm counts and motility <1x106/ml and <30% respectively. They did not receive any medication for infertility and had no surgical treatments. Exclusion criteria included: sperm count and motility >1x106/ml and >30% respectively, ICSI cycles in which testicular sperm extraction was performed, cycles with frozen spermatazoa, psychogenic anejaculation, mechanical infertility and endometriosis.
The majority of couples (81, 95%) were Jews belonging to orthodox communities, and four couples (5%) were Arab- Muslims. All resided in Jerusalem. We have kept continuous contacts with our patients during the two year follow-up period (July 1998December 1999), and none were lost to the follow-up.
In our study group, 27 clinical pregnancies were obtained following 119 ICSI treatment cycles (pregnancy rate per cycle 22.7%, delivery rate 11%). The mean sperm counts ± SD were (0.45 ± 0.32)x106/ml, and sperm motility was 17 ± 15%. Normal sperm morphology was <10%. The women's age was 28.6 ± 6.3 years.
During the follow-up period, five out of the 85 couples (5.9%) achieved seven singleton spontaneous pregnancies without any medical intervention (three couples once and two couples twice). In the spontaneous conception group, pregnancy rate per month was 0.34%. The women's average age was 27 ± 5.3 years, and the male partners' age was 30 ± 6.5 years (Table I). All spontaneous pregnancies were normal singletons and resulted in the birth of seven healthy babies (four girls, three boys). Two couples (nos 1 and 4) each succeeded in obtaining two consecutive spontaneous conceptions (Table I
) within two years. It is noteworthy that the two couples were also successful in their ICSI treatments (Table I
). Couple no. 4 started assisted reproduction therapy 6 months after they were married since the husband's infertility problem had already been recognized from his previous marriage.
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We did not perform paternity testing in our study group because all couples belong to ultra-orthodox communities in which even accidental contact between non-family members of the other sex is utterly unacceptable. The slightest insinuation at the possibility of extra-marital relations would be extremely offensive, with devastating impact on all family members.
The 5.9% rate of spontaneous pregnancies in our study is concordant with previous reports; In a two year follow-up of couples with male infertility waiting for artificial donor insemination, spontaneous pregnancy rates among non- azoospermic cases were 7.6% (Matorras et al.1996). In a 5 year follow-up study (Osmanagaoglu et al.1999
), 23 spontaneous pregnancies were recorded among 149 couples (4.6%) after discontinuation of ICSI therapy.
In-vivo conception requires successful penetration of spermatazoa through the cervical mucus and its arrival at the fertilization site. Yet, the threshold levels of motile spermatazoa needed to achieve in-vivo fertilization are not known. Our observations indicate that even 50x103 ejaculated poorly motile spermatozoa (patients 3 and 4) may induce in-vivo conception in young couples when the female partner has no fertility problems.
It is suggested that although the probability of achieving conception is low (0.34% per month), even severe cases of oligoasthenozoospermia are not necessarily indicative of reproductive failure in vivo.
Notes
3 To whom correspondence should be addressed. E-mail: almagors{at}hotmail.com
References
Evers, J.L.H., De Haas, H.W., Land, J.A. et al. (1998) Treatment independent pregnancy rate in patients with severe reproductive disorders. Hum. Reprod., 13, 12061209.[Abstract]
Matorras, R., Diez, J., Corcostegui, B. et al. (1996) Spontaneous pregnancies in couples waiting for artificial insemination donor because of severe male infertility. Eur. J. Obstet. Gynecol., 70, 175178.[ISI][Medline]
Osmanagaoglu, K., Tournaye, H., Camus, M. et al. (1999) Cumulative delivery rates after intracytoplasmic sperm injection: 5 year follow up of 498 patients. Hum. Reprod., 14, 26512655.
Snick, H.K.A., Snick, T.S., Evers, J.L.H. and Collins, J.A. (1997) The spontaneous pregnancy prognosis in untreated subfertile couples: the Walcheren primary care study. Hum. Reprod., 12, 15821587.[Abstract]