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Zhu DL, Zhang HG, Wang RX, Jiang YT, Liu RZ. (2019) Re-evaluation of the value of sperm morphology in classical in vitro fertilization in a Northeastern Chinese population. J Int Med Res. 2019 Jul 7:300060519860324. doi: 10.1177/0300060519860324
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  Re-evaluation of the value of sperm morphology in classical in vitro fertilization in a Northeastern Chinese population
  Conclusions: This study suggests that infertile patients with an NSMR ::< ::4% are more likely to have a poor normal fertilization status in IVF.
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  Comment # 1  
  Does 4% normal sperm morphology have any predictive value in IVF  
    In a study from a Chinese IVF clinic, sperm with <4%normal forms performed poorer in standard IVF inseminations.  
    In a small study from a Chinese IVF clinic, cases for day 3 IVF cycles are partitioned by sperm morphology of either above or below 4%, the WHO benchmark value for normal. Since ICSI has been introduced, few clinics provide IVF only services and allow such a comparison to be made. The 4% cut-off for normal sperm morphology was largely based upon a normal distribution of a large number of samples and consequentially is largely epidemiologically based. It represents only the lower end of a normal distribution. However, for many reasons, the WHO standard is applied to IVF cycles to determine the probability of poor fertilisation. A lot of activity is based upon the results of one semen sample assessed by experienced (and others) the most important is whether the doctor should recommend IVF or ICSI insemination. Clearly, it is a very loose parameter for such a decision and since most clinics offer IVF and ICSI, review of the 4% rule is difficult to justify. This is one reason why this small study is of interest.  
    The authors looked 375 IVF cycles of which 188 proceeded to day 3 transfer. There is no description of why the transfer rate was so low. Notwithstanding this feature, the authors reported that semen samples with less than 4% normal forms had sa statistically lower fertilisation rate and a lower normal (2PN) fertilisation rate. However, the difference in the fertilisation rate was 80% x 84% and for normal fertilisation was 62% x 70%. There was a small effect on the cleavage rate. There was no difference in any pregnancy related parameter.  
    So even though this was a small study with all the limitations such a study has, the observation was that sperm samples with less than 4% normal forms may have performed slightly poorer but it had no impact of outcome. Note, there was no data on failed fertilisation, etc so there may have been some other non-described significant risks. The reason why this paper aroused interest is that this data should be collected and the normal range for IVF samples should be unequivocally applied rather than a 4% epidemiologically based standard.  

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