Sperm Quality and FSH Therapy? To the Editor: In the October issue we read with interest the article by Ashkenazi et al. (1) concerning the impact of long-term FSH therapy in male partners before intracytoplasmic sperm in- jection (ICSI). The prospective, randomized, controlled study included 78 patients (study and control group with 39 patients each) exhibiting severe male factor infertility. In the study group the male partners received FSH over a period of 50 days before oocyte retrieval. Although the authors detect an increase in fertilization and pregnancy rates due to FSH treatment, they report that this difference did not reach statistical significance. Electron microscopy and statistical analysis proved to be crucial to assess the effect of FSH therapy on human sperm structure (2). In our opinion it is not advisable to classify severe male factor infertility into a single category, because the therapeutic effect of FSH depends on the sperm defect. The largest submicroscopic examination was performed by Baccetti et al. (3). They demonstrated that at least five categories of major sperm defects could be distinguished before therapy. These categories were defined as immaturity, infection, apoptosis, autoantibodies, and azoospermia due to spermatogenetic arrest. Each responded differently to FSH therapy. In their experience, positive responses have been obtained mainly in immature or apoptotic spermatozoa. It is unfortunate that Ashkenazi et al. (1) does not refer to the important findings of Baccetti et al. (3). Especially in studies with few patients, these aspects should be mentioned. The different results reported in the FSH studies may be due to a lack of relevant discrimination between the different defects present in the spermatozoa of patients, without as- sessing the likelihood of their response. Erwin Strehler, M.D. Karl Sterzik, M.D. Institute for Reproductive Medicine Ulm, Germany November 9, 1999 References 1. Ashkenazi J, Bar-Hava I, Farhi J, Levy T, Feldberg D, Orvieto R, et al. The role of purified follicle stimulating hormone therapy in the male partner before intracytoplasmic sperm injection. Fertil Steril 1999;72: 670 –3. 2. Strehler E, Sterzik K, DeSanto M, Abt M, Wiedemann R, Bellati U, et al. The effect of follicle-stimulating hormone therapy on sperm quality: an ultrastructural evaluation. J Androl 1997;18:439 – 47. 3. Baccetti B, Strehler E, Capitani S, Collodel G, DeSanto M, Moretti E, et al. The effect of follicle stimulating hormone therapy on human sperm structure (Notulae seminologicae 11). Hum Reprod 1997;12:1955– 68. PII S0015-0282(99)00595-6 Reply of the Authors: We thank Dr. Strehler and his colleagues for their interest in our study (1). We agree that to assess the prognosis of long-term FSH administration to the male partner, it would be beneficial to stratify patients according to Baccetti’s clas- sification (2). However, in a previous study by our group that was recently accepted for publication (3), we investigated a group of normogonadotropic normogonadal patients with oligoteratoasthenospermia. Our results were in accordance with Baccetti et al., showing that long-term FSH adminis- tration caused a significant increase in the normal appear- ance of the acrosomes, nucleoli, and axonema on electron microscopy (3). We attributed our positive results to our restriction of the sample to patients in the apoptosis and immaturity-related defect group of Baccetti’s classification. Furthermore, sperm quality improved after long-term FSH therapy, leading to better embryo quality and a higher im- plantation rate per embryo. This finding points to a possible paternal contribution to embryonic development. Jacob Ashkenazi, M.D. Raoul Orvieto, M.D. Ital Bar-Hava, M.D. Dov Feldberg, M.D. Zion Ben-Rafael, M.D. Department of Obstetrics and Gynecology Rabin Medical Center Petah Tikva, Israel November 24, 1999 References 1. Ashkenazi J, Bar-Hava I, Farhi J, Levy T, Feldberg D, Orvieto R, et al. The role of purified follicle stimulating hormone therapy in the male partner before intracytoplasmic sperm injection. Fertil Steril 1999;72: 670 –3. 2. Baccetti B, Strehler E, Capitani S, Collodel G, DeSanto M, Moretti E, et al. The effect of follicle stimulating hormone therapy on human sperm structure (Notulae seminologicae 11). Hum Reprod 1997;12:1955– 68. 3. Ben-Rafael Z, Farhi J, Feldberg D, Bartoov B, Kovo M, Eltes F, et al. Follicle-stimulating hormone treatment for men with idiopathic oligo- teratoasthenozoospermia before in vitro fertilization: its impact on sperm microstructure and fertilization potential. Fertil Steril 2000;73:24 –30. PII S0015-0282(99)00596-8 LETTERS TO THE EDITOR FERTILITY AND STERILITY VOL. 73, NO. 4, APRIL 2000 Copyright ©2000 American Society for Reproductive Medicine Published by Elsevier Science Inc. Printed on acid-free paper in U.S.A. 867