Effect of Sperm Morphology on Pregnancy Success via Intrauterine Insemination: A Systematic Review and Meta-Analysis

Kohn, Taylor P.; Kohn, Jaden R.; Ramasamy, Ranjith

doi:10.1016/j.juro.2017.11.045

Cited by 56Sperm and Testicular FunctionReproductive Health and TechnologiesMale Reproductive Health Studies

Effect of Sperm Morphology on Pregnancy Success via Intrauterine Insemination: A Systematic Review and Meta-Analysis

Kohn, Taylor P., Kohn, Jaden R., Ramasamy, Ranjith·2018·Journal of Urology

DOI 10.1016/j.juro.2017.11.045

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Abstract

PURPOSE: Men with abnormal sperm morphology are often counseled that natural conception and intrauterine insemination are ineffective, and in vitro fertilization is the only option. Our objective was to determine the effect of sperm morphology on the pregnancy success of intrauterine insemination. MATERIALS AND METHODS: We systematically searched for studies published prior to January 2017 that 1) reported ultrasound verified clinical pregnancies per intrauterine insemination cycle, 2) assessed sperm morphology using the Kruger strict criteria and 3) described morphology at the greater than 4% and 4% or less and/or the 1% or greater and less than 1% thresholds. In all studies mean female age was between 25 and 40 years and mean total motile sperm count was greater than 10 million. Estimates were pooled using random effects meta-analysis. RESULTS: Data were extracted from 20 observational studies involving a total of 41,018 cycles. When comparing men at the greater than 4% and 4% or less thresholds, the rate of ultrasound verified pregnancy per intrauterine insemination cycle was not statistically or clinically different (14.2% vs 12.1%, p = 0.06) and the risk difference was 3.0% (95% CI 1.4-4.6), indicating 3.0 additional pregnancies per 100 intrauterine insemination cycles. When comparing men at the 1% or greater and the less than 1% thresholds, there were no statistical or clinical differences in the rate of ultrasound verified pregnancy per cycle of intrauterine insemination (14.0% vs 13.9%, p = 0.97) or in the risk difference (1.6%, 95% CI -4.5-7.6). CONCLUSIONS: There appears to be no clinical difference in intrauterine insemination pregnancy success among men with normal and abnormal sperm morphology when accounting for total motile sperm count and female age. Abnormal sperm morphology alone should not exclude couples from attempting intrauterine insemination.

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BackgroundInfluential
Evaluation of technicians’ ability to accurately identify sperm morphology through EQA programs in China: a 5-year nationwide study (2019–2024)
Zheng, Y., Wu, Y.-B., Yu, L., Liu, Y., Yuan, J.-T., Diao, C.-C., Ma, Y., Jia, Y. A. N. G., & Li, F.-P. (2026) · Asian Journal of Andrology · doi:10.4103/aja202582 · Cited by 1 · see citing works
Post-wash total progressively motile sperm count thresholds and clinical pregnancy after intrauterine insemination: a systematic review and meta-analysis
Wan, B., Ma, N., Zhou, Z., Lu, W., & Fu, Y. (2026) · European journal of medical research · doi:10.1186/s40001-026-04474-x · Cited by 1 · see citing works
“Where available, integrating functional assays with TPMSC should be considered in future predictive models [21, 24].”
Sperm morphology by strict criteria does not predict clinical pregnancy rate following intra-uterine insemination
Sayegh, L., Shah, R. S., Shmoury, M., Depret-Bixio, L., & Fakih, M. H. (2024) · Arab Journal of Urology · doi:10.1080/20905998.2024.2327194 · Cited by 1 · see citing works
“These results demonstrating no difference in pregnancy rate irrespective of morphology severity, are similar to those of Kohn et al. [9] Patel et al. [14] and Stanhiser et al. [11] however, they are contrary to the relatively old publications reporting that normal morphology is associated with…”
Result
Sperm Morphology of Post-wash Sample and Its Association with Clinical Pregnancy among the Couples Undergoing Intrauterine Insemination: A Cohort Study
Prathyusha, S., Kubera, N. S., Murugesan, S., Sharma, J. K., Venkatraman, S., & Ram, A. (2024) · Journal of Human Reproductive Sciences · doi:10.4103/jhrs.jhrs_158_24 · Cited by 2 · see citing works
Impacto de la morfología espermática en las tasas de embarazo con inseminación intrauterina
Orrego, J. G., Antonio Mackenna, I., Meza, J. E. S., Parraguez, V. O., Rojas, J. C., & Ceppi, C. P. (2022) · Revista Internacional de Andrología · doi:10.1016/j.androl.2021.04.007 · Cited by 1 · see citing works
Rethinking the role of sperm morphology in clinical practice
Dubin, J. M., & Halpern, J. A. (2022) · F&S Reports · doi:10.1016/j.xfre.2022.04.001 · Cited by 1 · see citing works
“In addition, for couples who do proceed to intrauterine insemination or in vitro fertilization, sperm morphology is not associated with clinical pregnancy (3, 4).”
Background
Re: Normal Ranges: Normal for Whom?
Niederberger, C. (2018) · The Journal of Urology · doi:10.1016/j.juro.2018.04.043
Resultados de la inseminación artificial conyugal en un centro hospitalario no especializado durante los años 2001 y 2017
Cantó, J. G., Burriel, P. L. E., Catena, M. R. E., la Puerta, F. N. D., Bolufer, A. B. F., & Garcia, J. (2018) · Medicina Reproductiva y Embriología Clínica · doi:10.1016/j.medre.2018.10.002
The Time Interval between Insemination and Ovulation as Given by Ultrasound Predicts Live Birth Rate After Intrauterine Insemination with Donor Sperm (IUI-D)Preprint
Mu, X. L., Wang, H., Zhang, N., Wen, W., Wu, Q., Liu, P., & Shi, J.-Z. (2020) · doi:10.21203/rs.3.rs-44759/v1
“Many factors have been veri ed to in uence the outcome of IUI-D, including the women’s age [7,8], an extreme body mass index, decreased ovarian reserve, primary infertility, unilateral tubal occlusion, pelvic adhesions and mild endometriosis [9-13], insemination times in a cycle [14] and semen factors (volume, motilit…”
Background
Reproduktionsmedizinische Techniken: Indikationen, Durchführung und Chancen (VZO, IUI, IVF, ICSI)
Germeyer, A. (2021) · Springer Reference Medizin · doi:10.1007/978-3-662-47329-0_27-1
Estudio de la pareja infértil
Danny Mendoza, G., Catalina Hitchfeld, B., María Inés Luco, M., Francisco Vargas, B., & Rodrigo Carvajal, G. (2022) · Revista Hospital Clínico Universidad de Chile · doi:10.5354/2735-7996.2022.69351
SPERM PARAMETERS' PREDICTIVE VALUE IN INTRAUTERINE INSEMINATION SUCCESS: A SINGLE-CENTER EXPERIENCE
Afşin, M., Nursal, A. F., OTCU, S. M. Ö., Yavuz, D., & Ege, S. (2023) · Middle East Journal of Science · doi:10.51477/mejs.1367866
Sperm Morphology
Zenoaga-Barbăroşie, C., & Martinez, M. P. (2024) · Springer eBooks · doi:10.1007/978-3-031-55337-0_7 · Cited by 2 · see citing works
Predictive Value of Teratospermia During Initial Sperm Analysis on the Success of Intrauterine Insemination Cycles
Pavlovic, Z. J., Nemov, V. C., Sarkar, P., Jahandideh, S. S., Devine, K., & Imudia, A. N. (2024) · Urology · doi:10.1016/j.urology.2024.07.043
Editorial Comment on “Predictive Value of Teratospermia During Initial Sperm Analysis on the Success of Intrauterine Insemination Cycles”
Panken, E. J., & Halpern, J. A. (2024) · Urology · doi:10.1016/j.urology.2024.08.047
Low morphology does not lower success after intrauterine insemination unless inseminating motile sperm count is low
Burks, H. R., Peck, J. D., Hansen, K. R., Stoner, J. A., & Craig, L. B. (2025) · PLoS ONE · doi:10.1371/journal.pone.0317521
“A systematic review and meta-analysis did not demonstrate a relationship between morphology alone and IUI success and likely reflects this change over time [5].”
Retrospective Study of Analysis of Sperm Parameters in Patients with Positive Intrauterine Insemination Outcome in a Tertiary Care Hospital in North India
Bajaj, B., Narayan, R., Negi, R., Singh, L., Chauhan, S., & Kalita, B. (2025) · International Journal of Infertility & Fetal Medicine · doi:10.5005/jp-journals-10016-1378
Light exposure-induced circadian rhythm disruption impairs male reproductive health through oxidative stress and apoptosis
Liu, G., Zhang, Y., Gao, H., Wu, X., Li, F., Zhang, W., Jiang, H., & Zhang, X. (2026) · Life Sciences · doi:10.1016/j.lfs.2026.124222
A retrospective cohort study: predictive nomogram for clinical pregnancy outcomes after intrauterine insemination
Feng, K., Yin, H., Xu, Y., Wang, W., & Zhou, Y. (2026) · Frontiers in Medicine · doi:10.3389/fmed.2026.1912464
“However, other studies have shown that these factors have no significant prognostic value (11).”
Two-Stage Probabilistic Classification of Sperm Identity and Morphology
Zayman, E., & İnceoğlu, F. (2026) · Diagnostics · doi:10.3390/diagnostics16203390
“The meta-analysis by Kohn et al. [47] supports not restricting IUI options solely on the basis of morphology under appropriate clinical conditions.”

Pregnancy Success via Intrauterine Insemination and Effect of Sperm Morphology: Systematic Review & Meta-Analysis [10E]
Kohn, J. R., Kohn, T. P., & Ramasamy, R. (2018) · Obstetrics and Gynecology · doi:10.1097/01.aog.0000533029.76503.f4
Self-citation
PD68-10 THE EFFECT OF SPERM MORPHOLOGY ON INTRAUTERINE INSEMINATION PREGNANCY SUCCESS RATE: A SYSTEMATIC REVIEW AND META-ANALYSIS
Kohn, T. P., Kohn, J. R., Shabtaie, S. A., Brackett, N. L., Lynne, C. M., & Ramasamy, R. (2017) · The Journal of Urology · doi:10.1016/j.juro.2017.02.3138
Self-citation
Effect of strict sperm morphology on intrauterine insemination pregnancy success: a systematic review and meta-analysis
Kohn, T. P., Shabtaie, S. A., & Ramasamy, R. (2016) · Fertility and Sterility · doi:10.1016/j.fertnstert.2016.07.267 · Cited by 2 · see citing works
Self-citation
The influence of sperm morphology on the pregnancy rate of intrauterine insemination
Wen-jin, L. (2014) · China Medicine and Pharmacy
The impact of sperm morphology evaluated by strict criteria on intrauterine insemination success
Karabinus, D. S., & Gelety, T. J. (1997) · Fertility and Sterility · doi:10.1016/s0015-0282(97)80082-9 · Cited by 66 · see citing works

Authors: Kohn, T. P., Kohn, J. R., & Ramasamy, R.
Affiliations: University of Miami (US)
ORCID: Kohn, Taylor P.
Kohn, Jaden R.
Ramasamy, Ranjith
Venue: Journal of Urology
Publisher: Ovid Technologies (Wolters Kluwer Health)
Published: 2018-03
Volume: 199
Issue: 3
Pages: 812-822
ISSN: 0022-5347 (ISSN-L)
1527-3792
DOI: 10.1016/j.juro.2017.11.045
OpenAlex: W2767913496
Cited by: 56
References: 31
Citations by year: 2026: 5 · 2025: 6 · 2024: 11 · 2023: 5 · 2022: 6 · 2021: 9 · 2020: 8 · 2019: 2 · 2018: 4
FWCI: 0.79
Type: journal article
Language: en
Open access: closed
Licence: www.elsevier.com/tdm/userlicense/1.0/ (tdm)
Locations: The Journal of Urology (publishedVersion)
PubMed (publishedVersion)
Topics: Health Sciences › Medicine › Reproductive Medicine › Sperm and Testicular Function
Health Sciences › Medicine › Reproductive Medicine › Reproductive Health and Technologies
Health Sciences › Health Professions › General Health Professions › Male Reproductive Health Studies
Keywords: sperm morphology, intrauterine insemination, pregnancy success, abnormal sperm morphology, male infertility, motile sperm count, assisted reproduction
MeSH terms: Female, Fertilization in Vitro, Humans, Infertility, Male, Insemination, Male, Pregnancy, Sperm Count, Sperm Motility, Pregnancy Rate

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Effect of Sperm Morphology on Pregnancy Success via Intrauterine Insemination: A Systematic Review and Meta-Analysis

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