A one year study was carried out to determine the outcome of the seminal fluid parameters collected via masturbation and coitus interruptus in 151 patients who were undergoing intrauterine insermination (IUI) and patients who came for seminal analysis. There were no statistically significant difference in terms of volume, concentration, progressive motility and normal morphology from specimens collected via coitus interruptus compared to specimens collected via masturbation. Pregnancy outcomes were also comparable

Abd. Wahab, Noraziana

Awang, Mokhtar

Idris, Ghazali

Mustafa, Kamarul Bahyah

Omar, Mohd Hashim

Ramli, Roszaman

Zainuddin, Ahmad Murad

English

The International Islamic University Malaysia Repository

Med J Malaysia Vol 65 No 1 March 2010 23SUMMARYA one year study was carried out to determine the outcomeof the seminal fluid parameters collected via masturbationand coitus interruptus in 151 patients who were undergoingintrauterine insemination (IUI) and patients who came forseminal analysis.  There were no statistically significantdifferences in terms of volume, concentration, progressivemotility and normal morphology from specimens collectedvia coitus interruptus compared to specimens collected viamasturbation.  Pregnancy outcomes were also comparable.KEY WORDS:Semen analysis, Masturbation, Coitus InterruptusINTRODUCTIONHarvesting the maximum quantity and quality ofspermatozoa is of extreme importance in an intrauterineinsemination (IUI) program for infertility treatmentpurposes1-2. The most widely accepted method of semen collection inhumans for the purpose of semen analysis or artificialinsemination is via masturbation 1-6.  However some Muslimshave a reserved view regarding this method of seminalcollection because of views held by some Islamic scholarsespecially Shafi’i school of Fiqh who feel that masturbationfalls into the forbidden categories of sexual fulfillment 7.These scholars anyhow stated that masturbation may bepermissible under certain conditions such as avoidingpremarital sex. One may therefore view that collection ofsemen by masturbation in assisted reproduction is acceptable. Coitus interruptus on the other hand is a known andpermitted practice for contraception in Islam8 even thoughthis may not be the most effective method.  PracticingMuslims therefore would not hesitate in using this spermcollection method.  This is an important considerationbecause the majority of Malaysians where this study wascarried out are Muslims.Various studies support the view that seminal collectionobtained through collection devices have better quantitativeand qualitative characteristics compared to that obtainedthrough masturbation9.  The method of collection usingcollection devices also closely resembles the semen producednaturally.  It has been shown that seminal characteristics can besignificantly improved by the extent of sexual stimulation 1-3, 5, 10.Considering coitus interruptus is a more natural methodcompared to masturbation, and the extent of sexual stimulationis therefore assumed to be superior, we would expect theseminal characteristics to be better using this method.Unfortunately published data on seminal fluid collectioncomparing coitus interruptus and masturbation is limited.Masturbation is still the preferred method for spermcollection in almost all fertility centres across Malaysia.  It isusually performed in private in the institute or at home.  Ourcentre in International Islamic University Malaysia provides asuitable room for couples who wish to obtain the seminalsample via coitus interruptus and masturbation since 2004.The aim of this study is to determine if there is a differencebetween the seminal parameters obtained via coitusinterruptus versus masturbation – two methods which arecurrently employed by our centre to obtain seminal fluidsamples.MATERIALS AND METHODSOne hundred and fifty one men who were referred to theinfertility centre participated in this study. Conveniencesampling was used. All patients who attended the centrewithin the study period were included. The study period wasfrom June 2005 until May 2006. If the same patient came forrepeat intrauterine insemination (IUI) or seminal fluidanalysis (SFA), they would be excluded from the study if theyuse the same method of semen collection.  There were noother exclusion criteria.  All patients were recruited if theycome for the first time.  A proforma was used to get thepatients’ details and their comments after the procedure.  Thesemen analysis results were then entered into the sameproforma before data analysis. In order to collect the seminal sample, patients wereinstructed to produce one semen specimen via eithermasturbation or coitus interruptus (patients’s own choice)after a period of abstinence of 3 to 5 days.  The specimen wascollected into a sterile, wide-mouthed container. Semenspecimens were assessed according to the WHO standards forvolume, sperm concentration, progressive and non-progressive motility and normal morphology12.  Twolaboratory embryologist were involved in the seminal fluidassessment.The Outcome of the Seminal Fluid Parameters Collected viaCoitus Interruptus versus Masturbation M Kamarul Bahyah, MOG*, Z Ahmad Murad, MOG*, I Ghazali, MOG**, R Roszaman, MMed(O&G)*, A WNoraziana, MMed(O&G)*, A Mokhtar, FRCOG*, M H Omar, (MOG)*** *Department of Obstetric & Gynaecology, International Islamic University Malaysia, Kuantan, Pahang, Malaysia, **HospitalTengku Ampuan Afzan, Kuantan, Pahang, ***University Kebangsaan Malaysia Medical Centre, Kuala Lumpur.ORIGINAL ARTICLEThis article was accepted: 5 March 2010Corresponding Author: Kamarul Bahyah Mustafa, Specialist & Lecturer, Department of Obstetric & Gynaecology, International Islamic University Malaysia,Jalan Sultan Ahmad Shah, Bandar Indera Mahkota, 25200 Kuantan, Pahang     Email: drkamarulbahyah@yahoo.co.uk001519 NV-7-OUTCOME:3-PRIMARY.qxd  4/12/10  1:30 PM  Page 23Original Article 24 Med J Malaysia Vol 65 No 1 March 2010The patients were then followed up until the end of theirpregnancy if they were found to be pregnant.   A clinicalpregnancy is defined when fetal heart activity is documentedby ultrasound evaluation.  Take home baby is defined aspregnancy ending in a delivery of a live baby.Statistical data analysis was performed using SPSS 12.0 usingthe Mann Whitney U-Test and Independent-t-Test.Differences were considered statistically significant whenp<0.05.RESULTSOne hundred and fifty one patients were included during theone year study period.  One hundred and one (66.9%)attended the clinic for IUI, and the remaining fifty (33.1%)for SFA as part of infertility investigations. The majority of thepatients were Malays (n=134)(88.7%), followed by Chinese(n=11)(7.3%), Indian (n=5) (3.3%), and other(s) (n=1)(0.7%).These tallies with their religions of which 137 (90.7%) areMuslims; Buddhist, Hindu, and other(s), 9 (6%), 3(2%), 2 (1.3%), respectively (Figure 1). Of the patients enrolled into the study, 45.7% (n=69) werenon smokers, and the rest were either smokers or ex-smokers.Most of the patients did not consume alcohol(98.7%)(n=149), and the other 1.3%(n=2) was only socialdrinker. There was no statistically significant differencebetween the two study groups.There was also no statistical difference of age between the twogroups (Table I).  The results obtained from this study arereported in Table II.  No significant differences were seen interms of volume, concentration, progressive motility andnormal morphology from specimens collected via coitusinterruptus compared to specimens collected viamasturbation.  Only two patients had male factor attributedto the infertility with sperm counts of less than 20 millions –one in the ‘masturbation’ group, and the other one in the‘coitus interruptus’ group. There were higher clinicalpregnancy rate for IUI using semen collected from coitusinterruptus compared to those collected via masturbation –19% (6/31) versus 11.4% (8/70) respectively.  The take homebaby rate was also higher (12.9%) (4/31) for semen collectedvia coitus interruptus versus 7.1% (5/70) for semen collectedPatients’ Characteristics Coitus Interruptus Masturbation p(n= 39 (25.8%)) (n=112 (74.2%))IUI* n= 31 n= 70SFA# n=8 n=42Age of patient (years)Median (IQR) 36 (10) 35 (7) 0.611 (>0.05)Age of female spouse (years)Median (IQR) 31 (4) 31 (6) 0.786 (>0.05)SmokingNo 18 (46.2%) 51 (45.5%)Yes 14 (35.9 %) 46 (41.1%)Ex-smoker 7 (17.9 %) 15 (13.4%) 0.737 (>0.05)Drinking StatusNon-alcoholic n=39 (100%) n=110 (98.2% )Alcoholic n=0 n=2(1.8 % ) 0.478 (>0.05)*IUI=patient come for intrauterine insemination, #SFA=patient come for seminal fluid analysis only, IQR=interquartile rangeTable I: Study population characteristics for each method of semen collectionSemen parameters Coitus Interruptus Masturbation p(n=39) (n=112)Volume(ml)Median(IQR)* 2.5 ( 1) 3 ( 2) 0.491 (>0.05)Concentration (x106/ml)Median (IQR) 96 (98) 106 (112) 0.779 (>0.05)Progressive motility (%)Mean ± SD# 56.37 ± 19.81 54.46 ± 20.87 0.619 (>0.05)Normal morphology (%)Median(IQR) 94.5 (7.5) 94.3 (10.1) 0.722 (>0.05)Clinical Pregnancy 6/31 patients (19.4%) 8/70 patients (11.4%) 0.288 (>0.05)Take home baby rate 4/31 patients (12.9%) 5/70 patients (7.1%) 0.349 (>0.05)*IQR = interquartile range.  #SD = standard deviationTable II: Comparison of Semen Analysis for Ejaculates Collected Via Masturbation and Coitus InterruptusCoitus Interruptus group Masturbation group(n= 39 (25.8%)) (n=112 (74.2%))Choice for future semen collectiona. Coitus Interruptus n=39 (100%) n=74 (66.1% )b. Masturbation n=0 (0%) n=38 (33.9%)Table III: Method of seminal collection opted by patient for future semen collection 001519 NV-7-OUTCOME:3-PRIMARY.qxd  4/12/10  1:30 PM  Page 24The Outcome of the Seminal Fluid Parameters Collected via Coitus Interruptus versus Masturbation Med J Malaysia Vol 65 No 1 March 2010 25via masturbation.  The differences however were notstatistically significant.  The total clinical pregnancy ratefollowing IUI using both methods during this period was13.8%. Another interesting finding from this study is that the initialmethod of seminal fluid collection, 25.8% (n=39) of patientsused coitus interruptus, and 74.2% (n=112) usedmasturbation.  However after explaining the availability ofsuitable room in the infertility clinic that can be used forcoitus interruptus, the percentage was almost reversed with74.8%(n=113) wanted to use coitus interruptus method in thefuture and 25.2%(n=38) wanted to use masturbation.  All whohad adopted coitus interruptus wanted to continue with thesame method (Table III, Figure 2).DISCUSSIONThe most widely accepted method of semen collection for thepurpose of semen analysis or assisted reproductive technique(ART) is by masturbation 2, 11, 12.  Published data on seminalfluid collection comparing coitus interruptus andmasturbation is very limited even on international basis atthe time of study initiation. Dehghani et al (2004) comparingbetween semen parameters of ejaculates collected viamasturbation versus coitus interruptus from the same 30patients showed that collection of ejaculates via masturbationis superior to coitus interruptus 13.This study however aimed to look at the seminal parametersfrom semen collected from different patients. Even thoughdifferent patients were allocated to the two groups, there wereno significant difference statistically in terms of smoking,drinking and age, that could have affect the reading.  Eventhough male factors were not excluded, there were only twopatients with sperm counts of less than 20 millions, and theywere in the two different groups.Ideally the patients should be randomly allocated into thestudy groups.  In our setting however, it is not possible due tothe sensitivity involved in the process especially due to thefact that the majority of our patients were Malays andMuslims. It was difficult to ask the same patients to produceseminal sample using both methods due to various reasons,either social, psychological, or religious issues, thuspreventing us from performing direct comparative study. The result from this study did not show any significantdifferences in terms of volume, concentration, progressivemotility and normal morphology from semen collected viacoitus interruptus compared to semen collected viamasturbation. So offering coitus interruptus for those whowish or prefer this method could be a non disadvantageousoption.  However, our study must still be interpreted withcaution as this is not a randomized study, and is just aconvenience sampling.  Bigger sample sizes would definitelyprovide better picture and might give a statistically significantdifferences. Another important finding from this study is that thepregnancy rate for IUI from semen collected via coitusinterruptus is higher than those via masturbation – 19.4 %versus 11.4% though not statistically significant. The sameapplies to the take home baby (12.9% versus 7.1%).  Theclinical pregnancy rate following IUI using both methodsduring this period was 13.8%.  This is comparable withfindings from HUKM (Hospital Universiti KebangsaanMalaysia)- another well known fertility centre in Malaysia,which has a clinical pregnancy rate of 12.7% following IUI 14.These findings will undoubtly make a significant impact onpatients in Malaysia who due to psychological status orreligious belief decline to collect ejaculates via masturbation.However, as mentioned above, bigger sample size is requiredwith more patients enrolled into the study especially into thecoitus group in order to achieve better and morerepresentative result.From this study also, 66.1% of patients who use masturbationin the initial semen collection wish to use coitus interruptusin the future if another cycle of IUI or if further semensamples are required. All who had used coitus interruptushowever wanted to continue with the same method.  Thislocal preference (most likely due to the fact that majority ofour patients were Malays and Muslims) must be taken intoconsideration to ensure patients’ satisfaction when they areFig. 1: Distribution of patients by religion. Fig. 2: Method of Seminal Fluid Collection and future preferredmethod.001519 NV-7-OUTCOME:3-PRIMARY.qxd  4/12/10  1:30 PM  Page 25Original Article 26 Med J Malaysia Vol 65 No 1 March 2010undergoing infertility treatment15.  Patients’ wives commentand opinion regarding the methods are also important to takenote of. However it was not included into this study. With the availability of a special room at our infertilitycentre, couples who are living far away who wished to obtainthe specimen using coitus interruptus will be able to do so,instead of having the only option of masturbation.Apart from lack of randomization and small sample size,other limitations of this study include the fact that themajority of our patients were Malays, all of whom wereMuslims.  This could affect the result especially whenpatients’ preferences of the two methods were considered.Ideally, a multicentre randomized study with mixed ethnicityin equal proportion would give a much better result.CONCLUSIONOur results are encouraging for patients who due to variousreasons wish to use coitus interruptus instead of masturbationfor seminal fluid collection prior to IUI, as both methods areshown to produce sperms which are not different statisticallyin terms of quality. REFERENCES1. Zavos PM. Seminal parameters of ejaculates collected from oligospermicand normospermic patients via masturbation and at intercourse with theuse of a Silastic seminal fluid collection device. Fertil Steril 1985; 44: 517-20.2. Zavos PM. Parameters and improvements in ejaculates collected atintercourse and the use of a silastic seminal collection device vsmasturbation. Infertility 1986; 9: 57-64.3. Zavos PM. Seminal parameters of ejaculates collected at intercourse andthe use of a seminal collection device versus masturbation. Proc FifthWorld Congr Hum Reprod 1986; 387-9.4. Karagouinis CS, Zavos PM, Prapas J et al. Clinical use and experience witha new silastic seminal fluid collection device. Infertility 1988; 11: 281-7.5. Zavos PM, Goodpasture JC. Clinical improvements of specific seminaldeficiencies via intercourse with a seminal collection device versusmasturbation. Fertil Steril 1989; 51: 190-3.6. Sofikitis NV. Miyagawa I. Endocrinological, biophysical and biochemicalparameters of semen collected via masturbation versus sexual intercourse.J Androl 1993; 14: 366-73.7. http://www.islamonline.net/fatwa/english8. http://muslim-canada.org/family9. Zarmakoupis Zavos PN, Correa JR, Zarmakoupis CN et al. Multiple ejaculatecollection via the use of a semen collection device at intercourse versusmasturbation. Middle East Fertil Soc J 1999; 4(3): 228-32.10. Zavos PM, Kofinas GD, Sofikitis NV et al. Differences in seminal parametersin specimens collected via intercourse and incomplete intercourse (coitusinterruptus). Fertil.Steril 1994; 61: 1174-6.11. Sofitikis NV, Miyagawa I. Endocrinological, biophysical and biochemicalparameters of semen collected via masturbation versus sexual intercourse.J Androl 1993; 14: 366-73.12. World Health Organization. WHO laboratory manual for the examinationof human semen and semen-cervical mucus interaction. Cambridge.Cambridge University Press 1999; 4-5.13. Dehghani VA, Khalili MA, Zamani N et al. Comparison between semenparameters of ejaculates collected via masturbation versus coitusinterruptus. Iranian J Reprod Med 2004; 2(1): 9-11.http://docs.google.com/viewer?a=v&q=cache:SAqWNRHIAWIJ:www.bioline.org.br/pdf%3Frm04002+dehghani+khalili&hl=en&gl=my&pid=bl&srcid=ADGEEShJuD6VTD3-  14. Aris S, Zain M, Omar MH et al. Outcome of intrauterine insemination inpatients with single patent tube: a 3 year review. Malaysian J ObstetGynecoL 2006; 8(10): 48-57. 15. Inhorn MC. Religion and Reproductive Technologies – IVF and GameteDonation in the Muslim World. Anthropology News 2005; 46(2):14.http://www.aaanet.org/press/an/0502Inhorn.htm. Accessed on 3rd July2007.001519 NV-7-OUTCOME:3-PRIMARY.qxd  4/12/10  1:30 PM  Page 26

The outcome of the seminal fluid parameter collected via coitus interruptus versus mastubation

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The outcome of the seminal fluid parameter collected via coitus interruptus versus mastubation

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