What is the recommended fertility treatment approach for a couple with the husband having moderate to good motility and count but poor sperm morphology (1-2%)?

Management of Male Infertility with Poor Sperm Morphology (1-2%)

For couples where the male partner has moderate to good motility and count but poor morphology (1-2%), intrauterine insemination (IUI) remains a viable treatment option and should not be excluded based on morphology alone.

Impact of Poor Morphology on Treatment Approach

• Poor sperm morphology (1-2%) alone should not exclude couples from attempting IUI when other parameters (motility and count) are adequate 1
• There appears to be no clinical difference in IUI pregnancy success among men with normal and abnormal sperm morphology when total motile sperm count and female age are favorable 1
• Current guidelines do not recommend either for or against the use of IUI in couples with solely poor sperm quality in the male partner 2

Recommended Treatment Algorithm

1. Initial Assessment:

   • Evaluate total motile sperm count (TMSC) as the primary determinant for treatment approach 2
   • For TMSC >10 million: IUI with ovarian stimulation is recommended despite poor morphology 2
   • For TMSC between 3-10 million: IUI in natural cycles may be considered 2

2. Treatment Protocol:

   • Perform at least three consecutive IUI cycles before considering other options 2
   • Time insemination 24-40 hours after hCG trigger or 1 day after LH surge 2
   • Apply bed rest for 10-15 minutes after insemination 2
   • Single insemination per cycle is sufficient 2

Evidence on Morphology and IUI Success

• Studies show that when TMSC is adequate (>5 million), poor morphology (<30%) may be compensated by the quantity of motile sperm 3
• A systematic review of 41,018 IUI cycles found no statistical or clinical differences in pregnancy rates between men with normal (>4%) and abnormal (≤4%) morphology 1
• Even with very poor morphology (<1%), pregnancy rates per IUI cycle were comparable (14.0% vs 13.9%) to those with morphology ≥1% 1

Important Considerations and Caveats

• Sperm motility appears to be a more significant determinant of IUI success than morphology 4
• If TMSC is <5 million combined with poor morphology (<30%), success rates decrease significantly (5.43% vs 18.42% when TMSC ≥5 million) 3
• For couples with failed IUI attempts, progression to IVF with ICSI should be considered as the next step 2, 5
• There is no established threshold for sperm parameters below which IUI should be withheld, making it difficult to exclude patients based solely on morphology 2

Alternative Approaches

• For couples with severe oligoasthenoteratozoospermia (OAT) syndrome where all parameters are poor, IVF with ICSI may be more appropriate as the first-line treatment 5, 6
• Medical interventions such as FSH analogues may be considered to improve sperm parameters before attempting IUI, though evidence is limited 2, 5
• Avoid testosterone monotherapy as it suppresses spermatogenesis and should not be prescribed for men interested in fertility 2

Monitoring and Follow-up

• Regular semen analysis should be performed to monitor any changes in sperm parameters 2
• If no pregnancy occurs after three IUI cycles, consider moving to more advanced assisted reproductive technologies 2, 6
• Sperm cryopreservation should be considered if any improvement in parameters is achieved 6