Effect of Ejaculatory Abstinence on Semen Parameters in Male Factor Infertility Patients: a Randomized Controlled Study
Phase: NA
Conditions: Infertility, Male
Sponsor: Boston IVF

(CCI) Committee on Clinical Investigations 
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Study Description – Part B 
 
 
Date:12/11/2019 
 
Title: Effect of ejaculatory abstinence on semen parameters in male factor infertility patients: a 
randomized controlled study 
 
NCT #: NCT04206800 
 
Document date: 12/11/2019 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

(CCI) Committee on Clinical Investigations 
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Study Description – Part B 
 
 
Date:12/11/2019 
 
PART B 
STUDY DESCRIPTION 
 
Title of Protocol 
Effect of ejaculatory abstinence on semen parameters in male factor infertility 
patients: a randomized controlled study 
Principal 
Investigator 
Alan Penzias, MD 
 
B1. 
PURPOSE OF PROTOCOL 
The purpose of this study is to compare semen parameters with in vitro fertilization 
(IVF)/intracytoplasmic sperm injection (ICSI) when male factor infertility patients abstain from 
ejaculation more than 48 hours (routine care) or less than 24 hours. We hypothesize that total motile 
sperm will be improved with EA less than 24 hours. Information from this trial could allow us to 
optimize chances for a successful pregnancy in patients who need IVF/ICSI.  
 
B2. 
SIGNIFICANCE AND BACKGROUND FOR THE STUDY 
The semen analysis is currently one of the main tests in diagnosing male factor infertility but does not 
measure fertilization potential (1,2). There are numerous parameters in a semen analysis that are affected 
by different factors with one being ejaculatory abstinence (EA) prior to artificial reproductive technology 
(ART). Current guidelines from the World Health Organization (WHO) recommend between 2 to 7 days 
of EA while the European Society of Human Reproduction and Embryology advises 3 to 4 days of EA 
prior to a semen sample (3,4). This EA period has been utilized for diagnostic purposes and was 
inherited in IVF/ICSI treatment procedures with minimal investigation.  
 
Two prior studies showed optimal semen parameters when following the current WHO guidelines on EA 
(5,6). Conversely, other studies suggest shorter EA periods may provide benefit on certain semen 
parameters (7–13). Furthermore, a shorter EA may result in a reduced exposure to reactive oxygen species 
which leads to improved sperm quality (14,15). ROS may be a contributory factor to a male’s infertility 
(16). 
 
Two prior systematic reviews evaluated EA periods and correlations to semen quality in fertile and 
infertile males (17,18). Ayad et al reported despite the varied quality of studies, there may be enough 
evidence to favor a shorter EA period and guidelines should be revisited (17). Hanson et al reported that 
certain semen parameters improved with longer or shorter EA periods and no clear recommendations 
could be given (18). Both of these systematic reviews demonstrated conflicting results when evaluating 
total motile sperm. 
 
To our knowledge, this is the first randomized control trial to evaluate semen parameters with varying 
EA periods in male factor infertility patients when IVF/ICSI is utilized for first time IVF patients. In 
addition, we will survey patients’ ejaculatory mode and frequency during the IVF cycle. This will 
provide useful and practical information for physicians and patients when determining how to optimize 
chances for a successful pregnancy.  
 
B3. 
DESCRIPTION OF RESEARCH PROTOCOL 
A. Study Design – Overview, Methods, Procedures 
 

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Study Description – Part B 
 
 
Date:12/11/2019 
 
Overview 
This will be a randomized controlled trial to compare semen parameters following EA for either more 
than 48 hours (routine care) or less than 24 hours among male factor infertility patients who receive 
IVF/ICSI. 
 
Methods 
Study participation will not influence any element of IVF treatment and all patients will be receiving 
the standard of care at Boston IVF. For participants who meet eligibility criteria and provide informed 
verbal consent, baseline demographic data will be obtained from their medical record including for 
example; age, race, education level, height, weight, baseline semen analysis, testosterone level, follicle 
stimulating hormone (FSH) level. Demographic data on the female partner will include parameters such 
as: age, race, education level, height, weight, gravidity, parity, anti-mullerian hormone (AMH) level, 
and day 3 FSH. 
 
Eligible participants will have the study introduced by the medical care team. Eligible participants will 
be given information on study details (see study details for participants) as well as an ejaculatory 
calendar/survey (see survey and calendar) that can be used if the participant enrolls in the study (see 
study timeline). The medical care team will inform eligible participants that they will receive a 
recruitment email from the research team at Bivfresearch@bostonivf.com followed by a phone call 
from the research team to see if eligible participants are willing to participate (see recruitment email). 
Eligible participants who meet inclusion and exclusion criteria whom do not get information regarding 
the study from the medical care team will also receive a recruitment email. If so, the research member 
will call the eligible participant to obtain verbal consent to enroll in the study (see verbal consent). If 
the participant does not answer, a voicemail will be recorded followed by a second phone call the 
following day. The recruitment email and verbal consent will occur between the pre-IVF period and 
before stimulation day 4 of the IVF cycle. If a participant consents to enrollment, we will make a note 
in the treatment plan for their cycle. Enrolled participants will receive a phone call from a member of 
the research team during stimulation day 6 to 8 to randomize the participant to EA > 48 hours (routine 
care) or EA < 24 hours (see randomization call).  If the participant does not answer, a voicemail will be 
recorded followed by a second phone call the following day.  
 
The semen sample provided on day of oocyte retrieval will be analyzed with a basic and advanced 
semen panel. Any remaining samples will be discarded per routine practice. Prior to providing the 
semen sample, participants turn in the completed survey/ejaculation history calendar to a member of the 
research team. Blank copies will be available for participants the day of egg retrieval if needed.  
 
There is no clinical risk to your IVF cycle as the procedures followed are standard clinical 
practice. Study participation will not influence any element of the IVF treatment except for EA 
counseling. Currently there is no set protocol on how EA counseling is performed. Counseling on EA 
varies among the medical care teams at Boston IVF as some patients may or may not receive explicit 
EA instructions. Patients may be counseled by the medical care team with recommendations to abstain 
for > 48 hours at the time of their consult. All patients in this study are using ICSI to fertilize eggs and 
the number of sperm needed for treatment will not be compromised by ejaculatory abstinence < 24 
hours. Participants who crossover to the alternate treatment arm will continue their participation in the 
study so that we can collect cycle outcome data. IVF stimulation protocols will be according to standard 
practice. ICSI and embryology practice will follow standard practice. Selection of embryos will be 
based on the current embryology laboratory selection protocols or by preimplantation genetic testing for 
aneuploidy (PGT-A). The number of embryos transferred will be based on the usual American Society 
of Reproductive Medicine guidelines. Any unused embryos will be disposed of or cryopreserved per 

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Study Description – Part B 
 
 
Date:12/11/2019 
 
standard clinical protocols.   
 
Outcomes 
Primary: Total motile sperm (motility x concentration x volume) 
 
Secondary: 
Clinical data from the IVF cycle randomized to intervention or control condition, will include but not 
be limited to the following: fertilization rate; blastocyst rate; number of morphologically normal 
blastocysts; number of euploid and aneuploid embryos (if preimplantation genetic testing-aneuploidy 
[PGT-A] performed); number of embryos transferred; implantation rate; biochemical pregnancy rate 
(defined as positive beta-hCG but no gestational sac visualized); clinical pregnancy rate (defined as 
confirmation of gestational sac on ultrasound); ongoing pregnancy rate (defined as confirmation of a 
gestational sac with at least one fetal pole with a fetal heartbeat); live birth rate (defined as delivery > 
23 weeks gestation); Cumulative pregnancy rate; Miscarriage rate; Multiple pregnancy, defined as 
twins or higher-order gestations 
 
Semen characteristics will be examined in relation to:  
Changes in semen analysis from baseline diagnostic sample 
An advanced semen analysis panel  
Time from last ejaculation to oocyte retrieval 
 
All data that is collected for the trial is clinical data that would be collected and stored in the electronic 
medical record as part of routine clinical care. In addition to collecting outcome data from this initial 
IVF cycle, we will collect data regarding subsequent IVF cycles and outcomes for any of the frozen 
embryos created but not transferred in this cycle. 
 
Procedure 
Intervention 
Participants will be randomized to EA more than 48 hours (routine care) or less than 24 hours from the 
day of their partner’s oocyte retrieval.  
 
Randomization 
We will use computer-generated block randomization in REDCap to randomize participants in a 1:1 
ratio to the EA period more than 48 hours (routine care) or less than 24 hours. Randomization will be 
stratified by whether the patients receive PGT-A. Research staff will call participants on stimulation 
day 6 to 8 to notify participants which treatment arm they were randomized to. The participant can 
withdraw from the study at any time if desired or will have an opportunity to not continue with the 
treatment arm they were randomized to. We anticipate that most of the crossovers will occur due to 
participants wishing to be in the alternate EA period or not being able to produce a sample in the 
window assigned.  
 
The purpose of this study is to examine semen parameters with IVF/ICSI when male factor infertility 
patients abstain from ejaculation more than 48 hours (routine care) or less than 24 hours. Information 
from this study would allow us to provide evidence-based recommendations to future patients who need 
IVF/ICSI.  
 
B. Statistical Considerations 
Sample Size Justification  
Our sample size calculation is based on data from Boston IVF from 2013 to 2018 for patients with less 

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Study Description – Part B 
 
 
Date:12/11/2019 
 
than 3 million total motile sperm post prep for IVF/ICSI patients. The mean number of total motile 
sperm is 38 million ± 24 which will be our control group. We hypothesize that the mean number of 
total motile sperm at the time of retrieval will increase to 48 million. In order to achieve 80% power to 
detect the specified difference using a two-sided alpha of 0.05, we will need 90 evaluable participants 
per arm. We anticipate that approximately 15% of participants will drop out or crossover, and we will 
inflate the sample size by another 15% to account for a non-normal distribution. Thus, we aim to 
randomize 117 participants per arm for a total of 234 participants.   
 
Data Analysis  
We will conduct both intention-to-treat and per-protocol analysis. Both intention-to-treat and per-
protocol analyses are noted in the RCT reporting guidelines (CONSORT) as valid approaches. For this 
study, we will perform an intention-to-treat analysis because it is the gold standard for RCTs, even with 
crossover or withdraw. We also will perform a per-protocol analysis. While this analysis can introduce 
bias, it is a valid statistical approach. 
 
Descriptive data will be presented as a proportion, mean with standard deviation or median with 
interquartile range. Comparisons will be made using Chi-square or Fisher’s exact test for categorical 
variables and parametric or non-parametric tests for continuous variables based on data distribution. 
Log-binomial regression will be used to estimate risk ratios and 95% confidence intervals for the 
primary and secondary outcomes. While we anticipate that randomization will balance the distribution 
of measured and unmeasured potential confounders in the two study arms, if this is not the case, we will 
assess the influence of potential confounders as needed. All data will be analyzed with SAS 9.4 (SAS 
Institute Inc., Cary, NC, USA). All tests will be two sided and a P value <0.05 will be required to 
confer significance.  
 
C. 
Subject Selection 
Inclusion Criteria 
• 
Male Age 18 – 50 years and female age < 38 years 
• 
First IVF cycle  
• 
Abnormal semen parameters (at least 1 of the following on 2 semen analysis with at least one 
being in the past 12 months) 
• 
sperm concentration < 10 million/mL  
• 
unprocessed semen analysis with < 10 million motile sperm or processed semen 
analysis with < 3 million motile sperm 
• 
< 2 % normal forms (strict Kruger morphology) 
• 
Female AMH > 0.7 and/or and day 2-4 FSH < 12  
 
Exclusion Criteria 
• 
Donor sperm 
• 
Males with sperm concentration < 200,000/mL 
• 
Utilization of a gestational carrier 
• 
Frozen donor egg 
• 
Female morbid obesity: BMI > 40 
• 
History of recurrent pregnancy loss (≥2 spontaneous abortions) 
• 
Preimplantation genetic testing – (M or SR) Monogenetic disorders or chromosomal 
rearrangement 
• 
The use of non-ejaculated sperm (testicular sperm extraction) 
 

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Study Description – Part B 
 
 
Date:12/11/2019 
 
  
B4. POSSIBLE BENEFITS 
We do not know whether participants in the study will gain any direct benefit from participation. 
However, we hope that this study will provide data to inform how we can improve treatment for future 
patients with male factor infertility. 
 
The potential benefits to the field, as a whole, are enormous. This is a clinical conundrum that is 
encountered daily by infertility physicians and the results of this study have the potential to change 
clinical practice. 
 
B5. 
POSSIBLE RISKS AND ANALYSIS OF RISK/BENEFIT RATIO 
There is no clinical risk to the patient as the procedures followed are standard clinical practice.  
 
EA > 48 hours is routine care. 
 
The risks of EA < 24 hours: 
• 
Lower semen volume 
• 
Less total sperm 
 
As there is no good evidence to guide clinical practice and these patients constitute a large volume of 
our practice, potential benefits far outweigh the potential risks. Given that all patients in the RCT are to 
be treated by ICSI, the number of sperm needed for treatment will not be compromised by EA less than  
24 hours. 
 
B6. 
RECRUITMENT AND CONSENT PROCEDURES 
Recruitment 
This study will utilize an opt-out recruitment method. First-time IVF/ICSI patients will be identified, 
and eligibility will be determined per the study inclusion and exclusion criteria prior to the start of the 
IVF cycle. All eligible participants will be patients of Boston IVF physicians. All Boston IVF 
physicians will have the option to exclude any of their patients from the study.  
 
Eligible participants will have the study introduced by the medical care team (see script for medical 
care team). The medical care team will also have access to general study information (see handout for 
medical care team). Eligible participants will be given information on study details (see study details 
for participants) as well as an ejaculatory calendar/survey (see survey and calendar) that can be used if 
the participant enrolls in the study (see study timeline). The standard of practice for patients at Boston 
IVF is to receive communication via email, access many online documents, and enter the information 
into the online patient portal. To be consistent with this method of patient contact, participants will 
receive a recruitment email from the research team. The medical care team will inform eligible 
participants that they will receive a recruitment email from the research team at 
Bivfresearch@bostonivf.com that explains the study followed by a phone call from the research team to 
see if eligible participants are willing to participate. Eligible participants can choose to reply back to 
Bivfresearch@bostonivf.com to opt-out from receiving any more contact in regards to this 
study. Eligible participants who meet inclusion and exclusion criteria whom do not get information 
regarding the study from the medical care team will also receive a recruitment email. 
 
Consent 
We are requesting a HIPAA waiver for pre-screening and recruitment. For the study intervention, we 
are requesting a waiver of documentation of consent. Participants will be informed in the recruitment 

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Study Description – Part B 
 
 
Date:12/11/2019 
 
email the study is completely voluntary. The day following the recruitment email, eligible participants 
will receive a phone call from a member of the research team to discuss the study and obtain verbal 
consent if the eligible participant is interested in participating in the study (see verbal consent). If the 
participant does not answer, a voicemail will be recorded followed by a second phone call the following 
day. The recruitment and consent process will occur between the pre-IVF period and before stimulation 
day 4 of the IVF cycle. If a participant consents to enrollment, we will make a note in the treatment 
plan for their IVF cycle. Throughout the study, we will let participants know that they have the option 
to stop participating at any time and that their care would not be affected by that decision. 
 
We anticipate that a proportion of participants may desire to crossover to the other assigned EA period. 
If this occurs, participants will be instructed to email or call the research team. These patients would be 
included in the per protocol analysis. The study team will access the patients’ medical records for up to 
24 months following randomization in order to follow the clinical/pregnancy outcomes. These 
outcomes are recorded as part of routine clinical care.  
 
Subject Protection 
This is a completely voluntary study. Participants may withdraw from the study at any point; they also 
may choose to not continue with their randomized EA period. Participants will be advised that if they 
withdraw or choose to cross over to the other treatment arm their clinical care will not be influenced in 
any way.    
 
B7. 
STUDY LOCATION 
Privacy  
Verbal, informed consent will be obtained at a location of their choosing.  
 
Physical Setting 
All patient recruitment will occur at Boston IVF and through email and phone. Participants will be 
notified of their intervention via phone during the randomization process. Participants will complete a 
survey at a location of their choosing or at Boston IVF.  
 
 
B8. 
DATA SECURITY 
All electronic data will be kept in a restricted-access folder on the Boston IVF secure server behind the 
firewall. Any paper generated as a result of this study will be kept in a locked office belonging to a 
member of the study team. 
 
 
B9 
Multi-Site Studies 
 
Is the BIDMC the coordinating site?       ☐ Yes ☐ No  
 
Is the BIDMC PI the lead investigator of the multi-site study?     ☐ Yes ☐ No  
 
 

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Study Description – Part B 
 
 
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B10 
Dissemination of Research Results 
 
We will share the final results of the study to participants who would like the results and provide their 
email in the survey. 
 
Study results will be presented nationally and internationally at conferences and submitted for peer 
review publication. We will acknowledge the patients in future publications. 
 
References: 
1.  
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Assisted Reproductive Technology. Diagnostic evaluation of the infertile male: A committee 
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