Objective: To design a reproductive treatment algorithm based on the sperm DNA fragmentation (SDF) for couples with unexplained infertility following a poor intrauterine insemination (IUI) outcome.
Design: Couples that failed IUI with no apparent reproductive issue in both partners were allocated to diverse reproductive treatments on the basis of SDF.
Setting: Reproductive medical center in an academic setting.
Patient(s): Over 4 years, couples with an unexpected poor IUI outcome and no apparent female or male partner reproductive issues were recruited.
Intervention(s): IUI, IVF, and ICSI were performed in the standard fashion following sperm SDF assays.
Main outcomes measure(s): Fertilization rate, implantation rate, pregnancy characteristics, and delivery rates.
Result(s): A total of 354 couples with unexplained infertility and normal semen parameters underwent 1133 IUI cycles. Clinical pregnancy rate (CPR) with IUI at our center in an age-matched cohort is 23.9% while the study cohort had 1.8%. Following SDF assessment, couples with failed IUI attempts but normal SDF (SCSA 9.8 ± 4.6%; TUNEL 11.8 ± 6.2%) underwent IVF with a CPR of 12.7%; those with abnormal SDF underwent ICSI with ejaculated spermatozoa, resulting in a CPR of 18.7%. This group included couples with normal SDF that had failed IVF. Couples with abnormal SDF that failed ICSI with ejaculated spermatozoa achieved a CPR of 31.0% with surgically retrieved spermatozoa.
Conclusion(s): Couples with unexplained infertility that present with unexpectedly poor IUI outcomes can be funneled into a treatment algorithm guided by the integrity of the sperm genome for higher chances of pregnancy using an alternate method of insemination.
Keywords: ICSI; IVF; Sperm DNA fragmentation; TESE; Unexplained infertility.