Improved in vitro fertilization embryo quality and pregnancy rates with intracytoplasmic sperm injection of sperm from fresh testicular biopsy samples vs. frozen biopsy samples

Male Infertility and the Future of In Vitro Fertilization

The male contribution to infertility has traditionally been overlooked, or at best oversimplified. In recent years efforts have been made to optimize diagnostic and therapeutic techniques to maximize fertility outcomes. A renewed focus on the male partner has resulted in an increased understanding of both genetic and epigenetic changes within the male germline. Furthermore, single-nucleotide polymorphisms, copy-number variants, DNA damage, sperm cryopreservation, obesity, and paternal age have recently been recognized as important factors that play a role in male fertility. Developing a deeper knowledge of these issues could potentially lead to improved success with assisted reproductive technology.

Intracytoplasmic sperm injection with fresh versus cryopreserved testicular sperm in azoospermic patients

Background

The purpose of this study is to compare the outcome of intracytoplasmic sperm injection (ICSI) using fresh sperm versus frozen-thawed sperm in both obstructed and non-obstructed azoospermias. This retrospective study included 159 ICSI cycles from 126 couples. In 91 obstructed azoospermia cases, 66 cycles were treated with fresh testicular sperm and 25 cycles were treated with frozen-thawed testicular samples. In 68 non-obstructed azoospermia cases, 32 cycles were treated with fresh testicular sperm and 36 cycles were treated with frozen-thawed testicular sperm, and the main measure and outcomes calculated are fertilization rate, clinical pregnancy, and live birth rate.

Results

In case of obstructed azoospermia, there were no statistically significant differences between fresh sperm and frozen-thawed testicular sperm used for ICSI regarding fertilization rate, clinical pregnancy rate, and live birth rate as shown (57%, 47%, 0.093 p value; 23.7%, 17.4%, 0.54 p value; and 11.9%, 8.7%, 0.68 p value, respectively). Non-obstructed azoospermia cases also show no significant differences in fertilization rate (37%, 36%, 0.91 p value), clinical pregnancy rate (20%, 14.3%, 0.58 p value), and live birth rate (4%, 3.6%, 0.93 p value).

Conclusion

Cryopreservation of testicular sperm is reliable if carried out before ovulation induction especially in cases with non-obstructive azoospermia

The Role of the Urologist in the Era of In Vitro Fertilization-Intracytoplasmic Sperm Injection

The use of in vitro fertilization and intracytoplasmic sperm injection has dramatically increased. In spite of this, the male partner in the couple is often not evaluated for fertility status or other general health conditions associated with male infertility. Such an approach goes against established guidelines recommending dual partner evaluations and does not address longer term male health risks. In this review, we discuss the urologist's role in the era of in vitro fertilization-intracytoplasmic sperm injection, which includes diagnosing serious conditions associated with infertility, treating reversible causes of infertility, defining untreatable causes of testis failure, and, when appropriate, facilitating sperm retrieval.

Validation-verification of a highly effective, practical human testicular tissue in vitro culture-cryopreservation procedure aimed to optimize pre-freeze and post-thaw motility

PURPOSE

The aim of our paper was to validate a testicular biopsy procedure that simplifies handling, processing, and cryopreservation, while at the same time optimizes sperm motility before freezing and after thawing.

METHODS

Two prospective studies were conducted to verify, optimize, and understand the virtues of pre-freeze testicular tissue IVC at different temperatures (21, 30, or 37 °C). Testicular tissue was obtained from clinical specimens designated for whole tissue cryopreservation (i.e., intact mass of tubules) and/or for fresh use in IVF-ICSI cycles. Whole testicular biopsy pieces (1-3 mm(3)) were diluted in glycerol containing freeze solutions, slow cooled to 4 °C and then rapidly frozen in LN2 vapor. Fresh and post-thaw testicular biopsy tissue were evaluated for changes in the quantity (%) and pattern of motility (I-IV: twitching to rapid progression, respectively) over a 1 week duration. The clinical effectiveness of IVC-cryopreserved whole testicular biopsy tissue was also validated analyzing fresh embryo transfers.

RESULTS

More reliable recovery of motile testicular sperm was achieved using whole tissue freeze preservation combined with IVC (24-96 h) post-acquisition at an incubation temperature of 30 °C compared to ambient temperature (21 °C) or 37 °C. Up to 85 % of the pre-freeze motility was conserved post-thaw (+3 h) for easy ICSI selection. Sperm longevity was optimized to fresh tissue levels by implementing testicular biopsy sucrose dilution post-thaw. Favorable clinical outcomes were proven using frozen-thawed testicular biopsy sperm for ICSI.

CONCLUSIONS

By employing minimal tissue manipulation, integrating pre-freeze IVC processing at 30 °C and the freezing of whole testicular biopsy tissue, we have reduced the labor and improved the efficacy of processing testicular tissue for freeze-preservation and subsequent ICSI use.

Impact on ICSI outcomes of adding 24 h of in vitro culture before testicular sperm freezing: a retrospective study

Purpose

To compare sperm parameters and intracytoplasmic sperm injection (ICSI) outcomes for testicular spermatozoa frozen on the day of the biopsy (DO) with those frozen after 24 h of in vitro culture (D1).

Methods

In this retrospective study, from 1999 to 2012, forty-nine azoospermic patients were included to compare sperm (motility and viability) and outcomes (fertilization (FR), implantation (IR), pregnancy (PR) and delivery rates (DR)).

Results

The in vitro culture increased total motility (+2.8 %, p = 0.0161) but decreased viability (−8.3 %, p = 0.007). After 24 h of culture, the post-thaw changes in motility and viability were not significant. Twenty-six couples underwent ICSI: thirty–four ICSI were performed with spermatozoa cryopreserved at D0 and eighteen with spermatozoa frozen at D1. Cumulated IR and DR were lower for ICSI with D1 spermatozoa than with D0 spermatozoa (IR: 21.6 % with D0 vs. 9.8 % with D1, p = 0.102; DR: 27.5 % with D0 vs. 8.3 % with D1, p = 0.049).

Conclusion

Despite improving motility, freezing spermatozoa 24 h after testicular biopsy had a potential negative effect on ICSI outcomes, notably on delivery rates. These results may be related to the detrimental impact of the additional culture on the nuclear integrity of sperm.

Surgical management of nonobstructive azoospermia

Nonobstructive azoospermia (NOA) is characterized by the complete absence of sperm in the ejaculate due to testicular failure. The evaluation and management of patients with NOA offer a challenge to the reproductive urologist. In the era of in vitro fertilization with intracytoplasmic sperm injection, surgical sperm extraction techniques can afford men with NOA biologic paternity. To provide a comprehensive review of surgical sperm retrieval approaches in the patient with NOA emphasizing complications, success rates and outcome optimization, a Medline search was conducted querying surgical approaches used to manage NOA. Four sperm extraction techniques are described including: testicular sperm aspiration, testicular sperm extraction, fine needle aspiration mapping and microdissection testicular sperm extraction. In addition, the roles for pre-extraction varicocelectomy and sperm cryopreservation are discussed. The management of NOA continues to evolve as newer tools become available. Several modalities of sperm acquisition exist. An understanding of their complications and success rates is fundamental to the treatment of NOA.

Sperm recovery and IVF after testicular sperm extraction (TESE): effect of male diagnosis and use of off-site surgical centers on sperm recovery and IVF

Objective

Determine whether testicular sperm extractions and pregnancy outcomes are influenced by male and female infertility diagnoses, location of surgical center and time to cryopreservation.

Patients

One hundred and thirty men undergoing testicular sperm extraction and 76 couples undergoing 123 in vitro fertilization cycles with testicular sperm.

Outcome Measures

Successful sperm recovery defined as 1–2 sperm/0.5 mL by diagnosis including obstructive azoospermia (n = 60), non-obstructive azoospermia (n = 39), cancer (n = 14), paralysis (n = 7) and other (n = 10). Obstructive azoospermia was analyzed as congenital absence of the vas deferens (n = 22), vasectomy or failed vasectomy reversal (n = 37) and “other”(n = 1). Sperm recovery was also evaluated by surgical site including infertility clinic (n = 54), hospital operating room (n = 67) and physician’s office (n = 11). Treatment cycles were evaluated for number of oocytes, fertilization, embryo quality, implantation rate and clinical/ongoing pregnancies as related to male diagnosis, female diagnosis, and use of fresh or cryopreserved testicular sperm.

Results

Testicular sperm recovery from azoospermic males with all diagnoses was high (70 to 100%) except non-obstructive azoospermia (31%) and was not influenced by distance from surgical center to laboratory. Following in vitro fertilization, rate of fertilization was significantly lower with non-obstructive azoospermia (43%, p = <0.0001) compared to other male diagnoses (66%, p = <0.0001, 59% p = 0.015). No differences were noted in clinical pregnancy rate by male diagnosis; however, the delivery rate per cycle was significantly higher with obstructive azoospermia (38% p = 0.0371) compared to diagnoses of cancer, paralysis or other (16.7%). Women diagnosed with diminished ovarian reserve had a reduced clinical pregnancy rate (7.4% p = 0.007) compared to those with other diagnoses (44%).

Conclusion

Testicular sperm extraction is a safe and effective option regardless of the etiology of the azoospermia. The type of surgical center and/or its distance from the laboratory was not related to success. Men with non-obstructive azoospermia have a lower chance of successful sperm retrieval and fertilization.

Different sperm sources and parameters can influence intracytoplasmic sperm injection outcomes before embryo implantation

To evaluate the effects of sperm with different parameters and sources on the outcomes of intracytoplasmic sperm injection (ICSI), 1972 ICSI cycles were analyzed retrospectively. Groups 1 to 5 were composed of cycles using ejaculated sperm and were grouped according to sperm quantity, quality, and morphology into normal (288 cycles), or mild (329 cycles), moderate (522 cycles), severe (332 cycles), and extremely severe (171 cycles) oligozoospermia and/or asthenozoospermia and/or teratozoospermia (OAT) groups. Group 6 was composed of 250 cycles using testicular or epididymal sperm, and Group 7 consisted of 80 cycles using frozen-thawed sperm. We found that fertilization rates were gradually reduced from Groups 1 to 6, and reached statistical difference in Groups 5 and 6 (P<0.05). The high-quality embryo rate was higher in Group 1 than in Groups 2, 3, 5, 6, and 7 (P<0.05). No statistical differences were observed in the rates of embryo cleavage, clinical pregnancy, miscarriage, live-birth, premature birth, low birth weight, weeks of premature birth, average birth weight, or sex ratio for all seven groups (P>0.05). A total of nine cases of malformation were observed, with a malformation rate of 1.25% (9/719). In conclusion, different sperm sources and parameters can affect ICSI outcomes before embryo implantation. A full assessment of offspring malformation will require further study using a larger sample size.

The human sperm epigenome and its potential role in embryonic development

Along with many of the genome-wide transitions in chromatin composition throughout spermatogenesis, epigenetic modifications on histone tails and DNA are continuously modified to ensure stage specific gene expression in the maturing spermatid. Recent findings have suggested that the repertoire of epigenetic modifications in the mature sperm may have a potential role in the developing embryo and alterations in the epigenetic profile have been associated with infertility. These changes include DNA demethylation and the retention of modified histones at important developmental, signaling and micro-RNA genes, which resemble the epigenetic state of an embryonic stem cell. This review assesses the significance of epigenetic changes during spermatogenesis, and provides insight on recent associations made between altered epigenetic profiles in the mature sperm and its relationship to infertility.

[Management of azoospermias]

An oral assessment and thorough clinical examination are an essential prerequisite in the presence of azoospermia (varicocele? absence of vas deferens?). Examination of the volume and pH of the ejaculate must also be included in the assessment, together with measurement of the FSH and testosterone required and a scrotal and prostatic endorectal ultrasound (particularly helpful in the diagnosis of obstructions, testicular nodules etc.). In terms of second-line treatment, the assessment can be completed by prescription of plasma inhibin B, seminal biochemistry and genetic assessment (blood karyotype, diagnosis of microdeletion of the Y chromosome and diagnosis of mutation of the CFTR gene in the case of bilateral absence of the vas deferens). On completion of this assessment, the azoospermia is either obstructive or non-obstructive, even if it is not always this simple. Obstructive azoospermia can be overcome by reconstructive surgery (vasovasostomy, vasoepididymostomy and transurethral resection of the ejaculatory ducts), thus avoiding the need for ICSI. In the case of azoospermia with varicocele, treatment of the varicocele can achieve certain results. Finally, in the case of non-obstructive azoospermia, it is difficult to draw a conclusion between the use of fresh or frozen spermatozoa although many teams favour frozen spermatozoa.

Optimal use of fresh and frozen-thawed testicular sperm for intracytoplasmic sperm injection in azoospermic patients

PURPOSE

To optimize the use of fresh and frozen-thawed testicular biopsy specimens from patients with azoospermia.

METHODS

Fifty-one patients suffering from obstructive and non-obstructive azoospermia underwent testicular sperm extraction (TESE). The specimens were divided and used for either in vitro maturation or freezing for a future intracytoplasmic sperm injection (ICSI) cycle.

RESULTS

At initial testicular sperm extraction, very few motile spermatozoa were seen. After 24 h of in vitro maturation, sperm motility increased remarkably, with a maximum motility rate seen between 48 and 72 h of culture. Motile spermatozoa were observed up to 120 h in culture. In the 22 fresh ICSI cycles, a total of 294 oocytes were injected using motile sperm and 212 oocytes demonstrated normal 2PN formation (fertilization rate, 72.1%). In 36 frozen-thawed ICSI cycles, a total of 454 oocytes were injected and 302 oocytes became 2PN (66.5%). On day 3, high quality embryos were observed in 54.2% of fresh cycles and 54.1% of frozen cycles (P > 0.05). The clinical pregnancy rate did not show a significant difference between using fresh (59%) and frozen (55.5%) testicular biopsy sperm for ICSI (P > 0.05), but the embryo implantation rates did differ significantly between fresh (29.5%) and frozen-thawed (22.2%) cycles (P < 0.05). A total of 33 healthy babies have been born from 22 women, giving birth after 58 embryo transfer attempts (38%).

CONCLUSION

The freezing and in vitro culturing of testicular biopsy tissue is a very reliable approach for the management of testicular biopsy specimens from azoospermic patients, and offers the possibility of several treatments of IVF/ICSI from a single sample.