Intracytoplasmic sperm injection facilitates fertilization even in the most severe forms of male infertility: pregnancy outcome correlates with maternal age and number of eggs available

Effect of sperm treatment with lysolecithin on in vitro outcomes of equine intracytoplasmic sperm injection

Intracytoplasmic sperm injection (ICSI) in horses is currently employed for clinical and commercial uses, but the protocol could be optimized to improve its efficiency. We have hypothesized that destabilization of plasma and acrosomal membranes prior to injection would positively impact the developmental potential of equine zygotes generated by ICSI. This study evaluated effects of the sperm treatment with lysolecithin on plasma and acrosomal membranes and on oocyte activation ability, initially following heterologous ICSI on bovine oocytes and subsequently employing equine oocytes. The effects of the lysolecithin -treatment on the efficiency of conventional and piezo-assisted equine ICSI were evaluated. To do this, the equine sperm were treated with different concentrations of lysolecithin and the sperm plasma membrane, acrosome and DNA integrity were evaluated by flow cytometry. The results showed that a lysolecithin concentration of 0.08 % destabilized the membranes of all sperm and affected DNA integrity within the range described for the species (8-30 %). In addition, the heterologous ICSI assay showed that lysolecithin treatment was detrimental to the sperm's ability to activate the oocyte, therefore, chemical oocyte activation was used after equine ICSI after injection with lysolecithin -treated sperm. This group showed similar developmental rate to the control group with and without exogenous activation. In conclusion, lysolecithin pre-treatment is not necessary when using ICSI to produce equine embryos in vitro. The results from the current study provide additional insight regarding the factors impacting ICSI in horses.

Clinical Andrologists: Do We Really Need Them in the Era of ART?

Infertility is on a rise, and so is the availability of assisted reproductive technique (ART) centres. The sole aim of these centers is to help these unfortunate couples achieve pregnancy. Hence, the concentration of the treatment is on the female partner, while the male is relegated to just being a source for sperm. In the era of intracytoplasmic sperm injection, when pregnancy is possible even with a single mature sperm, evaluation and management of male factor infertility (MFI) is often neglected. MFI and poor semen parameters are markers of male health. He could be suffering from erectile or ejaculatory issues or with correctable obstructive azoospermia. A simple timely varicocele correction may help resolve the issue. It is important to understand that MFI is not a disease but may be a symptom of major underlying clinical condition like testicular or brain tumors. Infertility treatment could be the only occasion when a male seeks health-care evaluation. India has a large pool of qualified urologists trained in andrological care. In contrast, gynecologists may not be trained in the management of male patients, hence there is an important place for andrological services to be an integral part of ART centers. Andrologists would offer minimal andrological evaluation and condition-specific treatment. This could avoid or reduce the need for invasive and expensive ART. Andrologists could also choose the most appropriate mode of sperm retrieval. Undoubtedly, availability of andrological services would improve the overall quality of care, reduce the costs and complications, and would also be medicolegally safe.

Use of intracytoplasmic sperm injection (ICSI) in normospermic men may result in lower clinical pregnancy and live birth rates

BACKGROUND

While intracytoplasmic sperm injection (ICSI) was developed for overcoming male infertility, it is increasingly being used for non-male factor indications, without consensus regarding the safety and efficacy of this approach.

AIMS

To determine whether ICSI offers any benefit compared to standard in vitro fertilisation (IVF), in the setting of normal semen parameters.

MATERIALS AND METHODS

Retrospective analysis of reproductive outcomes in 3363 stimulated cycles (IVF = 1661; ICSI = 1702), in patients treated between 2009-2015, was performed. Selected couples had no male factor infertility. Couples with abnormal semen parameters (based on WHO 2010 guidelines), presence of anti-sperm antibodies and low oocyte yield of ≤4 oocytes, were excluded. The outcomes analysed included: (1) fertilisation rate (FR); (2) clinical pregnancy rate (CPR); and (3) live birth rate (LBR), by method of fertilisation used (IVF vs ICSI) and controlling for significant confounders.

RESULTS

FR, CPR and LBR were significantly higher in the IVF group compared with ICSI (67.1% vs 62.3%, 23.06% vs 16.8%, 17.22% vs 13.2%, respectively). Pregnancy rate with ICSI was approximately 30% lower than with IVF, even when controlling for significant factors such as day of embryo transfer and number of embryos transferred. This translates to one less pregnancy in every 15 cycles where ICSI was used without clear indication.

CONCLUSIONS

Our data suggest that ICSI may be detrimental to clinical outcomes and contributes to the wider understanding of use of ICSI in normospermic men.

Lower blastocyst quality after conventional vs. Piezo ICSI in the horse reflects delayed sperm component remodeling and oocyte activation

PURPOSE

The aim of this study was to evaluate the differential effects of conventional and Piezo-driven ICSI on blastocyst development, and on sperm component remodeling and oocyte activation, in an equine model.

METHODS

In vitro-matured equine oocytes underwent conventional (Conv) or Piezo ICSI, the latter utilizing fluorocarbon ballast. Blastocyst development was compared between treatments to validate the model. Then, oocytes were fixed at 0, 6, or 18 h after injection, and stained for the sperm tail, acrosome, oocyte cortical granules, and chromatin. These parameters were compared between injection techniques and between sham-injected and sperm-injected oocytes among time periods.

RESULTS

Blastocyst rates were 39 and 40%. The nucleus number was lower, and the nuclear fragmentation rate was higher, in blastocysts produced by Conv. Cortical granule loss started at 0H after both sperm and sham injection. The acrosome was present at 0H in both ICSI treatments, and persisted to 18H in significantly more Conv than Piezo oocytes (72 vs. 21%). Sperm head area was unchanged at 6H in Conv but significantly increased at this time in Piezo; correspondingly, at 6H significantly more Conv than Piezo oocytes remained at MII (80 vs. 9.5%). Sham injection did not induce significant meiotic resumption.

CONCLUSIONS

These data show that Piezo ICSI is associated with more rapid sperm component remodeling and oocyte meiotic resumption after sperm injection than is conventional ICSI, and with higher embryo quality at the blastocyst stage. This suggests that there is value in exploring the Piezo technique, utilized with a non-toxic fluorocarbon ballast, for use in clinical human ICSI.

ICSI treatment of severe male infertility can achieve prospective embryo quality compared with IVF of fertile donor sperm on sibling oocytes

Azoospermia, cryptozoospermia and necrospermia can markedly decrease the ability of males to achieve pregnancy in fertile females. However, patients with these severe conditions still have the option to be treated by intracytoplasmic sperm injection (ICSI) to become biological fathers. This study analyzed the fertilization ability and the developmental viabilities of the derived embryos after ICSI treatment of the sperm from these patients compared with in vitro fertilization (IVF) treatment of the proven-fertile donor sperm on sibling oocytes as a control. On the day of oocyte retrieval, the number of sperm suitable for ICSI collected from two ejaculates or testicular sperm extraction was lower than the oocytes, and therefore, excess sibling oocytes were treated by IVF with donor sperm. From 72 couples (73 cycles), 1117 metaphase II oocytes were divided into 512 for ICSI and 605 for IVF. Compared with the control, husbands’ sperm produced a lower fertilization rate in nonobstructive azoospermia (65.4% vs 83.2%; P < 0.001), crytozoospermia (68.8% vs 75.5%; P < 0.05) and necrospermia (65.0% vs 85.2%; P < 0.05). The zygotes derived in nonobstructive azoospermia had a lower cleavage rate (96.4% vs 99.4%; P < 0.05), but the rate of resultant good-quality embryos was not different. Analysis of the rates of cleaved and good-quality embryos in crytozoospermia and necrospermia did not exhibit a significant difference from the control. In conclusion, although the sperm from severe male infertility reduced the fertilization ability, the derived embryos had potential developmental viabilities that might be predictive for the expected clinical outcomes.

The epigenetic lorax: gene-environment interactions in human health

Over the last decade, we have witnessed an explosion of information on genetic factors underlying common human diseases and disorders. This 'human genomics' information revolution has occurred as a backdrop to a rapid increase in the rates of many human disorders and diseases. For example, obesity, Type 2 diabetes, asthma, autism spectrum disorder and attention deficit hyperactivity disorder have increased at rates that cannot be due to changes in the genetic structure of the population, and are difficult to ascribe to changes in diagnostic criteria or ascertainment. A likely cause of the increased incidence of these disorders is increased exposure to environmental factors that modify gene function. Many environmental factors that have epidemiological association with common human disorders are likely to exert their effects through epigenetic alterations. This general mechanism of gene-environment interaction poses special challenges for individuals, educators, scientists and public policy makers in defining, monitoring and mitigating exposures.

Male reproductive health and prostate cancer risk

PURPOSE OF REVIEW

Male infertility impacts a substantial proportion of men and has serious implication for a man's quality of life. Advances in reproductive technology may allow men to bypass urologic care in order to achieve their family planning goals. Recent data suggests that male reproductive failure may be a harbinger of future urologic diseases, including prostate cancer (CaP), thus emphasizing the importance of dedicated urologic evaluation and care for all male infertility patients.

RECENT FINDINGS

We will review the epidemiologic data that explores an association between male reproductive health and CaP. We will review the potential biologic mechanisms that may underlie this association, and explore possible reasons for inconsistencies in study findings.

SUMMARY

Studies of the association between male infertility and CaP are inconsistent. Despite this, the association between reproductive health in a man's fourth decade (30s) and his development of aggressive CaP in his sixth decade (50s) should not be ignored. These findings, combined with the robustness of the potential common underlying mechanisms, provide a foundation for future studies of male reproductive health that are more specific in their approach to answering questions about the association between male reproductive failure and future systemic disease.

Should ICSI be recommended routinely in patients with four or fewer oocytes retrieved?

PURPOSE

To determine if patients with a low response to controlled ovarian hyperstimulation during IVF benefit from intracytoplasmic sperm injection (ICSI) METHODS: Retrospective analysis of 350 IVF cycles in which four or fewer oocytes were retrieved. Severe male factor cases were excluded from analysis. Conventional insemination (CI) and ICSI were compared, with primary outcome measures of fertilization rate, implantation rate, clinical pregnancy rate per embryo transfer, and pregnancy loss rate.

RESULT(S)

Fertilization rates per oocyte retrieved for CI and ICSI were comparable (51.5% vs. 51.8%). Parallel implantation rates (22% vs. 25%), clinical pregnancy rates (32.8% vs. 33.3%), and loss rates (26.7% vs. 39.5%) were also noted. No difference in cancelled cycles was reported.

CONCLUSION(S)

Our results demonstrate that in the presence of normal semen parameters, low egg number is not an indication to perform ICSI.

Intracytoplasmic injection of morphologically selected spermatozoa (IMSI) improves outcome after assisted reproduction by deselecting physiologically poor quality spermatozoa

PURPOSE

We used computer assisted sperm selection (MSOME) during cycles of intracytoplasmic sperm injection to test whether this technique improves results over traditional ICSI protocols. We also used the TUNEL assay to test whether MSOME could deselect physiologically abnormal spermatozoa.

METHODS

Individual spermatozoa were examined with MSOME. Normal and abnormal spermatozoa were tested for the level of DNA fragmentation using TUNEL assay. In a prospective, randomized trial, patients were selected for standard ICSI, or IMSI techniques. We tested the two groups for biological and clinical parameters.

RESULTS

64.8% of spermatozoa, otherwise selectable for ICSI, were characterized by abnormalities after computer-assisted sperm analysis. These sperm were also characterized by an increase in the level of DNA fragmentation. We noted an increase in embryo quality, pregnancy and implantation rates after computerized sperm selection during ICSI procedures.

CONCLUSIONS

Computerised selection of spermatozoa during ICSI procedures deselects physiological abnormal spermatozoa and improves clinical results.

Large P body-like RNPs form in C. elegans oocytes in response to arrested ovulation, heat shock, osmotic stress, and anoxia and are regulated by the major sperm protein pathway

As Caenorhabditis elegans hermaphrodites age, sperm become depleted, ovulation arrests, and oocytes accumulate in the gonad arm. Large ribonucleoprotein (RNP) foci form in these arrested oocytes that contain RNA-binding proteins and translationally masked maternal mRNAs. Within 65 min of mating, the RNP foci dissociate and fertilization proceeds. The majority of arrested oocytes with foci result in viable embryos upon fertilization, suggesting that foci are not deleterious to oocyte function. We have determined that foci formation is not strictly a function of aging, and the somatic, ceh-18, branch of the major sperm protein pathway regulates the formation and dissociation of oocyte foci. Our hypothesis for the function of oocyte RNP foci is similar to the RNA-related functions of processing bodies (P bodies) and stress granules; here, we show three orthologs of P body proteins, DCP-2, CAR-1 and CGH-1, and two markers of stress granules, poly (A) binding protein (PABP) and TIA-1, appear to be present in the oocyte RNP foci. Our results are the first in vivo demonstration linking components of P bodies and stress granules in the germ line of a metazoan. Furthermore, our data demonstrate that formation of oocyte RNP foci is inducible in non-arrested oocytes by heat shock, osmotic stress, or anoxia, similar to the induction of stress granules in mammalian cells and P bodies in yeast. These data suggest commonalities between oocytes undergoing delayed fertilization and cells that are stressed environmentally, as to how they modulate mRNAs and regulate translation.

Sperm banking for adolescent and young adult cancer patients: sperm quality, patient, and parent perspectives

BACKGROUND

Infertility is often a complication for adolescent and young adult males who receive cancer therapy, a problem that might be averted through using cryopreserved sperm. We aim to evaluate feasibility of offering newly diagnosed patients the opportunity to bank sperm and, to determine the beliefs and decision-making processes of patients and their parents who considered sperm banking.

PROCEDURE

Eligible patients and parents were approached and offered sperm cryopreservation. Semen samples from patients who sequentially attempted sperm banking were analyzed. Questionnaires were then administered to patients and parents who had been approached about sperm banking.

RESULTS

Semen samples from 68 patients were analyzed. Nine patients were azoospermic; all had been pre-treated with chemotherapy. Fifty patients completed the questionnaire. Parent and patient made the decision together to bank 80% of the time. All sons who attempted to bank and their parents felt they had made the right decision, including those who attempted but failed.

CONCLUSIONS

Viable sperm can be collected successfully from adolescent and young adults who are newly diagnosed with cancer. Semen quality was dramatically reduced by one course of gonadotoxic therapy. Parents and patients want information regarding sperm cryopreservation early. Parents appear to play an important role in the decision to sperm bank. We recommend sperm banking be offered to all eligible patients.

Necrospermia, antisperm antibodies, and vasectomy

OBJECTIVE

To present a case of necrospermia and antisperm antibodies after vasectomy reversal and in which motile sperm, subsequently used in intracytoplasmic sperm injection (ICSI) treatment, was found after testicular sperm retrieval.

DESIGN

Case report and literature review.

SETTING

Reproductive medicine unit based in a women's hospital in the United Kingdom.

PATIENT(S)

A 36-year-old man with secondary infertility who presented with necrospermia and antisperm antibodies after vasectomy reversal.

INTERVENTION(S)

Testicular sperm retrieval and IVF with ICSI.

MAIN OUTCOME MEASURE(S)

Presence of motile sperm in testicular sperm extraction biopsies.

RESULT(S)

Motile sperm found after testicular sperm retrieval successfully fertilized oocytes in an ICSI cycle.

CONCLUSION(S)

It appears difficult to dissociate the presence of antisperm antibodies from the necrospermia in our patient. Testicular sperm retrieval appeared to partially overcome the effect of the antisperm antibodies by retrieving sperm before they reach seminal plasma, where they would be exposed to the antibodies.

Use and outcomes of intracytoplasmic sperm injection for non-male factor infertility

OBJECTIVE

To determine whether intracytoplasmic sperm injection (ICSI) is associated with improved outcomes for non-male factor infertility.

DESIGN

We examined the patient characteristics associated with treatment choice-ICSI and conventional in vitro fertilization (IVF)-among patients without a diagnosis of male factor infertility and compared outcomes between the two groups, adjusting for patient characteristics using multivariate regression models.

SETTING

Academic fertility center.

PATIENT(S)

We evaluated 696 consecutive assisted reproductive technology (ART) cycles performed for couples with normal semen analysis at the Stanford Reproductive Endocrinology and Infertility Center between 2002 and 2003. We compared patient characteristics, cycle details, and outcomes for ICSI and IVF.

MAIN OUTCOME MEASURE(S)

Fertilization, pregnancy, and live birth rates.

RESULT(S)

Patient characteristics were similar between the two groups, except the proportion of patients with unexplained infertility (IVF 15.1% vs. ICSI 23.5%), previous fertility (IVF 62.6% vs. ICSI 45.5%), and previous ART cycle (IVF 41.2% vs. ICSI 67.7%). More oocytes were fertilized per cycle for the IVF group (6.6 oocytes versus 5.1 oocytes). Fertilization failure, pregnancy, and live birth rates did not differ between IVF and ICSI. Using logistic regressions, having had previous ART was found to be positively associated with ICSI. Treatment choice of ICSI was not associated with fertilization, pregnancy, or live birth rates.

CONCLUSION(S)

No clear evidence of improved outcomes with ICSI was demonstrated for non-male factor infertility.

Sperm retrieval for obstructive azoospermia

Advances in the treatment of male infertility now routinely allow men with obstructive azoospermia to have fertility treatment without microsurgical reconstruction. A variety of methods for retrieving sperm from men with obstructive azoospermia have been described. The goals of sperm retrieval are to obtain the best quality sperm possible, to retrieve adequate numbers of sperm for immediate use and for cryopreservation, and to minimize damage to the reproductive tract.

What factors affect intracytoplasmic sperm injection outcomes?

Within the last decade, intracytoplasmic sperm injection (ICSI), a new assisted reproductive technique that allows for the direct injection of spermatozoa into the oocyte, has become available to infertile couples. While most studies indicate that ICSI has success rates similar to those of traditional in vitro fertilization, there are many concerns about the safety of the procedure, including increased risks of chromosomal and developmental abnormalities in children conceived by ICSI. Factors that contribute to these increased risks have not been well elucidated. The purpose of this paper is to review the latest literature concerning 1) the adverse outcomes associated with ICSI; and 2) factors that affect the success rates of ICSI (with emphasis on paternal factors).

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to explain the procedure, intracytoplasmic sperm injection (ICSI), to outline the data surrounding chromosomal and developmental outcomes after ICSI, and to list and explain the potential factors that influence ICSI.

Non-disclosing preimplantation genetic diagnosis for Huntington disease

OBJECTIVES

Individuals at risk for Huntington disease face difficult decisions regarding their reproductive options. Most do not wish to pass on the gene for Huntington disease to their children, but may not be prepared themselves to undergo presymptomatic testing and learn their genetic status. For these reasons, many at-risk individuals with a family history of HD would choose a method of genetic diagnosis that would assure them that they can have children unaffected with HD without revealing their own genetic status (non-disclosing). We have shown that, with a carefully designed and executed programme of non-disclosing preimplantation genetic testing, one can successfully assist at-risk couples to have their own biological children who are free from Huntington disease, without forcing parents to confront knowledge of their own genetic status.

METHODS

Couples where one partner was at 50% risk for Huntington disease underwent in vitro fertilization with preimplantation embryo biopsy and molecular analysis for Huntington disease where appropriate.

RESULTS

After extensive counselling and informed consent, 10 couples underwent 13 in vitro fertilization and two frozen embryo transfer cycles in a programme for non-disclosing preimplantation genetic diagnosis for Huntington disease. In 11 cycles, embryos determined to be free of Huntington disease were transferred, resulting in five clinical pregnancies. One set of twins and three singleton pregnancies have delivered. One pregnancy resulted in a first-trimester loss.

CONCLUSIONS

The option of non-disclosing preimplantation genetic diagnosis should be reviewed, along with other relevant medical options, when counselling at-risk Huntington disease families.

Novel approach to the molecular diagnosis of Marfan syndrome: application to sporadic cases and in prenatal diagnosis

Marfan syndrome is an autosomal dominant disorder affecting the skeletal, ocular, and cardiovascular systems. Defects in the gene that encodes fibrillin-1 (FBN1), the main structural component of the elastin-associated microfibrils, are responsible for the disorder. Molecular diagnosis in families with Marfan syndrome can be undertaken by using intragenic FBN1 gene markers to identify and track the disease allele. However, in sporadic cases, which constitute up to 30% of the total, DNA-based diagnosis cannot be performed using linked markers but rather requires the identification of the specific FBN1 gene mutation. Due to the size and complexity of the FBN1 gene, identification of a causative Marfan syndrome mutation is not a trivial undertaking. Herein, we describe a comprehensive approach to the molecular diagnosis of Marfan syndrome that relies on the direct analysis of the FBN1 gene at the cDNA level and detects both coding sequence mutations and those leading to exon-skipping, which are often missed by analysis at the genomic DNA level. The ability to consistently determine the specific FBN1 gene mutation responsible for a particular case of Marfan syndrome allows both prenatal and pre-implantation diagnosis, even in sporadic instances of the disease.

Characteristics of cryopreserved semen from men with lymphoma

PURPOSE

This study compared the pretreatment semen quality in patients with Hodgkin's disease and non-Hodgkin's lymphoma with a group of healthy donors. We also examined the differences in prefreeze and postthaw semen quality among the different stages of Hodgkin's disease.

METHODS

The study included 89 patients with Hodgkin's disease, 18 with non-Hodgkin's lymphoma, and 50 healthy sperm donors.

RESULTS

In patients with Hodgkin's disease, the prefreeze and postthaw semen characteristics were significantly lower than those of the healthy donors. Similar results also were seen in patients with non-Hodgkin's lymphoma. No significant differences in the prefreeze semen quality were seen in patients with different stages of cancer.

CONCLUSION

Patients with Hodgkin's disease and non-Hodgkin's lymphoma in our study had poor semen quality when compared with healthy donors both before and after cryopreservation. As cancer therapy significantly impairs reproductive potential, sperm banking should be offered to these men before the start of their therapy.

The effects of cryopreservation on semen from men with sarcoma or carcinoma

PURPOSE

This study evaluated prefreeze and postthaw semen quality before treatment in patients with different types of sarcomas and carcinomas to determine whether cryopreservation would be of value for these patients.

METHODS

Semen specimens were obtained from 50 normal donors and from 21 patients with carcinoma and from 14 patients with sarcoma. The specimens were cryopreserved by a standard freezing procedure using TEST-Yolk buffer. Prefreeze and postthaw sperm motion characteristics were measured.

RESULTS

Prefreeze total motile sperm count was significantly higher in donors (median: 129.6 x 10(6)/ml) than in men with carcinoma (46.9 x 10(6)/ml, P < .001) or sarcoma (66.3 10(6)/ml, P = .04). The percent motility and percent linearity were significantly lower in patients with carcinoma. In postthaw specimens, total motile sperm count, curvilinear velocity, and linearity were significantly lower in patients with carcinoma.

CONCLUSIONS

The two patient groups in this study had poor semen quality when compared with healthy donors both before and after cryopreservation. Sarcoma patients had better semen quality than carcinoma patients. As cancer therapy in these men could significantly impair their reproductive potential, these men should be advised to preserve their semen before starting treatment.

Intracytoplasmic sperm injection increases embryo fragmentation without affecting clinical outcome

PURPOSE

To examine the effect of intracytoplasmic sperm injection (ICSI) on embryo fragmentation and implantation rates in those embryos chosen for transfer compared to conventional in vitro fertilization (IVF).

METHODS

We compared 253 infertility patients (71 ICSI and 182 IVF) with respect to age, semen analysis, number of embryos transferred, embryo fragmentation, implantation rate, and pregnancy rate. Embryo fragmentation was determined by one observer at the same laboratory over the entire study period.

RESULTS

A statistically significant difference was observed in mean embryo grade between IVF (2.2 +/- 0.84) and ICSI (2.5 +/- 0.77), P = 0.01. Additionally, the IVF patients had significantly more nonfragmented (grade I) embryos compared to the ICSI group, P < 0.01.

CONCLUSIONS

These data suggest that ICSI, irrespective of semen parameters, may increase embryo fragmentation and produce fewer nonfragmented grade I embryos while maintaining implantation and pregnancy rates similar to conventional IVF.

Influence of female age on pregnancy outcome in in vitro fertilization and embryo transfer patients undergoing intracytoplasmic sperm injection

PURPOSE

To determine the influence of female age on the outcomes of ICSI in IVF-ET patients.

METHODS

One hundred and seventy-five couples underwent 352 cycles of ICSI. The quality of oocytes and embryos, fertilization rate, and pregnancy outcomes were retrospectively evaluated according to female age; < 30 years in Group A (49 cycles), 30-34 in Group B (177 cycles), 35-39 in Group C (97 cycles), and > or = 40 in Group D (29 cycles).

RESULTS

The fertilization rates were not significantly different among the age groups. Significant negative linear correlations were observed between female age and the numbers of oocytes retrieved and embryos transferred, and cumulative embryo score. Clinical pregnancy rates were significantly decreased and spontaneous abortion rate increased with advancing age.

CONCLUSIONS

Female age may be a prognostic indicator in ICSI program.

Does female age affect embryo morphology?

Deteriorating oocyte quality is commonly believed to be the primary determinant of the decreased implantation potential in older women. We assessed the influence of age on embryo morphology in standard in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) modalities. All 6350 consecutive embryos (2990 IVF, 3360 ICSI) obtained in our Assisted Reproductive Technology Unit from January 1996 through June 1997 were included. High quality embryos were defined as those with equal-sized blastomeres and < 10% fragmentations and a cleavage rate of four cells on day 2 or eight cells on day 3 transfers. The results were analyzed for the standard IVF group, the ICSI group, and the ICSI subgroup with severe male factor infertility (< or = 1 x 10(6) total motile spermatozoa in the ejaculate). For standard IVF, a positive association was observed between female age and increased proportion of good quality embryos. No such association was detected for the ICSI cycles (whole group or subgroup). We conclude that in standard IVF, embryo quality, as reflected by embryo morphology, does not deteriorate with increased maternal age.

Intracytoplasmic sperm injection is not associated with poor outcome in couples with normal semen parameters and previous idiopathic fertilization failure in conventional in vitro fertilization

In this study, we compared the results of intracytoplasmic sperm injection (ICSI) in patients with normal semen parameters and a history of failed fertilization with conventional IVF (study group) and in patients with male factor infertility (control group). Patient and cycle characteristics were similar in both groups. The mean number of retrieved and metaphase II oocytes, fertilized oocytes, embryos developed, embryos transferred and the number of cycles with fertilization failure also did not differ between groups. Although differences were not statistically significant, pregnancy rate (56.3% vs. 31.5%), implantation rate (14.2% vs. 12%) and ongoing pregnancy rate (37.5% vs. 17.7%) per embryo transfer were higher in the study group than the ones in the control group. We concluded that previous idiopathic fertilization failure with conventional IVF is not associated with poor outcome in subsequent ICSI treatment.

Sperm cryopreservation in patients with testicular cancer

OBJECTIVES

To review a large experience with sperm cryopreservation in patients with testicular cancer and determine the effect of clinical stage and tumor histologic features on semen quality.

METHODS

The prefreeze and post-thaw sperm quality of 157 patients with testicular cancer was compared with that of 50 normal donors. The impact of tumor stage and histologic features (pure seminoma, pure embryonal, or mixed germ cell) was also determined. A computer-assisted semen analysis was performed before and after cryopreservation. The motile sperm count (MSC), motility, and motion characteristics were measured before and after cryopreservation and compared between groups.

RESULTS

Patients with testicular cancer had lower prefreeze and post-thaw MSC and motility compared with normal donors (P = 0.0001 for both). The curvilinear velocity and linearity were also significantly less in patients with testicular cancer (P <0.05 for both). The percentage of change in the semen characteristics did not differ between patients and donors, indicating that sperm from both patients and donors withstood the cryopreservation process equally well. Tumor stage (n = 143) and histologic features (n = 136) did not significantly influence semen quality. No individual histologic component significantly influenced MSC or motility.

CONCLUSIONS

The effect of cryopreservation on sperm was similar in patients with testicular cancer and donors. Patients with poor prefreeze semen quality have poor post-thaw semen quality, and the effects of cryopreservation were not significantly affected by histologic features or stage. Our results indicate that routine sperm banking should be recommended for men with a diagnosis of testicular cancer to preserve future fertility potential.

A survey of oncologists regarding sperm cryopreservation and assisted reproductive techniques for male cancer patients

BACKGROUND

The authors surveyed the current knowledge, opinions, and clinical practices of oncologists regarding pretherapy cryopreservation of semen from male cancer patients since the introduction of intracytoplasmic sperm injection (ICSI).

METHODS

A survey was sent to all members of the American Society of Clinical Oncology in Minnesota.

RESULTS

Forty-six of 165 oncologists (28%) responded. Factors considered important in how strongly to recommend cryopreservation were patient age at the time of diagnosis (94%), type of treatment (83%), type of cancer (65%), urgency to initiate treatment (63%), and preexisting infertility (57%). Oncologists perceived patients to be significantly more concerned about cryopreservation than they were themselves during pretherapy counseling (P = 0.0005). Oncologists estimated that 27% of their patients chose to cryopreserve sperm. However, only 26% of the oncologists knew about ICSI. The cancers perceived to warrant cryopreservation the most were lymphomas, leukemias, and testicular carcinomas. The treatment modalities perceived to warrant cryopreservation the most were distributed among various chemotherapy and radiation regimens. A majority of respondents to the survey knew where patients could go to cryopreserve sperm (89%), but less than half of the respondents gave accurate information about the cost.

CONCLUSIONS

Most of the oncologists surveyed were unaware of recent advances in reproductive technology in which only a few sperm are needed for successful in vitro fertilization with ICSI. This lack of awareness may be contributing to underutilization of sperm cryopreservation by male cancer patients. Currently, all male cancer patients of reproductive age who will have treatment that may affect testicular function and who may desire children in the future should cryopreserve sperm before the initiation of therapy.

Developmental capacity of damaged spermatozoa

We report the first detailed and systematic study in a mammalian system to unravel the mystery of the beginnings of life. The fertilizing ability of damaged spermatozoa at various levels of disintegration (cellular and molecular) has been investigated in homologous (mouse) and heterologous (human spermatozoon, hamster oocyte) models. Live pups were produced after destruction of spermatozoa at various cellular and molecular levels followed by injection into oocytes. We demonstrate that with damaged spermatozoa, the key point in the fertilization process is the activation of the oocyte by injection of cytosolic sperm factor. A similar fertilization rate as that using live intact spermatozoa can be achieved following activation. However, the integrity of the genetic material influenced in-vitro development of the embryos and live fetuses. This study contributes to a better understanding of the fertilizing ability of damaged spermatozoa. These findings can be applied clinically to patients with necrozoospermia or very severe oligozoospermia and in wildlife research where damaged spermatozoa from rare species can be used to regenerate young, and hence propagate the species. Also implied is the possible contribution of sperm DNA strand breakage to early pregnancy loss.

The outcome of clinical pregnancies following intracytoplasmic sperm injection is not affected by semen quality

The objective of this study was to investigate the impact of severe oligoasthenoteratozoospermia (OAT) on pregnancy outcome. For this purpose 279 consecutive intracytoplasmic sperm injection (i.c.s.i) cycles were retrospectively evaluated and compared to 436 consecutive IVF cycles performed during the same time frame. Group A (n = 62) included ICSI patients with severe OAT; group B (n = 217) included patients who underwent ICSI for other indications; and group C (n = 436) included couples who underwent standard IVF. The mean age of female patients and mean number of embryos transferred were comparable in all groups. No difference was observed regarding implantation, clinical pregnancy, delivery and miscarriage rates between all three groups, but fertilization rate was significantly lower in group A than in groups B and C. It is concluded that couples undergoing ICSI with severe male infertility (OAT) have a slightly reduced fertilization rate but their chances of delivery and pregnancy loss are similar to those of other patients undergoing clinical ICSI and IVF with non-male infertility.

Previous fertilization failure with conventional in vitro fertilization is associated with poor outcome of intracytoplasmic sperm injection

OBJECTIVE

To evaluate the outcome of intracytoplasmic sperm injection (ICSI) in patients with a history of fertilization failure with conventional IVF.

DESIGN

Retrospective analysis of 2 years of clinical experience with ICSI.

SETTING

Clinical IVF-ET program in a tertiary care referral center.

PATIENT(S)

The results of ICSI performed between January 1995 and December 1996 were compared between patients with normal semen parameters and a history of fertilization failure (< 20% of oocytes) with conventional IVF and patients with male factor infertility.

INTERVENTION(S)

In vitro fertilization with ICSI.

MAIN OUTCOME MEASURE(S)

Parameters examined included oocyte survival, fertilization, embryo cleavage, implantation rates, and clinical pregnancy rates.

RESULT(S)

Fertilization was achieved with ICSI for all patients during the study period. Although oocyte survival and fertilization did not differ between groups, the pregnancy and implantation rates for patients with a history of idiopathic fertilization failure (20% and 6%, respectively) were significantly lower than those for other patients undergoing ICSI (47% and 22%, respectively).

CONCLUSION(S)

The outcome of ICSI varied depending on the indication for treatment. Patients who had a history of failed or poor fertilization in vitro with apparently normal semen parameters had significantly lower pregnancy and implantation rates than did patients with either obstructive azoospermia or impaired semen quality.

Advances in the evaluation and treatment of the infertile man

Numerous advances in technology have been made in the last several years in the diagnosis and treatment of the infertile man. Using case presentations, this article highlights these important new developments and reviews the basics of a comprehensive male infertility evaluation. The use of ultrasound as a critical, indispensable, yet noninvasive tool in the evaluation of possible male reproductive tract obstruction is discussed. Since assisted reproductive techniques (ARTs) have become increasingly important in the management of the otherwise untreatable infertile man, specialized testing of sperm function, e.g., the sperm penetration assay (SPA), and strict morphology assessment are often useful prior to the initiation of some of these assisted reproductive procedures such as intrauterine insemination (IUI) or in vitro fertilization (IVF). Testicular touch preparation cytology and image analysis are also important additions to routine testicular biopsy for quantifying the extent of spermatogenesis. Finally, the revolutionary micromanipulation procedure of intracytoplasmic sperm injection (ICSI) has forever changed the practice of andrology by enabling men previously thought to be irreversibly infertile the chance to initiate their own biologic pregnancy.

Impact of fertilization history and semen parameters on ICSI outcome

PURPOSE

The objectives of this study were (1) to investigate intracytoplasmic sperm injection (ICSI) outcome according to its indications, i.e., a history of failed or poor fertilization and unsuitable sperm parameters for conventional IVF, and (2) to examine the impact of a female's age, sperm concentration, motility, morphology, presence of antisperm antibodies, and hemizona assay (HZA) results on overall outcome.

METHODS

Two hundred seventy-nine ICSI cycles performed in 207 couples were retrospectively evaluated.

RESULTS

Clinical pregnancy and delivery rates were 36.8 and 29.8% for patients with prior failed fertilization, 23.2 and 17.8% for patients who had prior poor fertilization, and 28.6 and 21.3% for patients with unsuitable sperm parameters. The differences among all groups were found to be insignificant. There was a significant, negative correlation between a female's age and pregnancy results. No difference was found in the three basic sperm parameters between those patients who produced and those who did not produce a pregnancy, but the fertilization rate was significantly higher in patients with more adequate sperm parameters. Although there was a trend toward a better fertilization rate in patients with a hemizona index (HZI) greater than 30 (indicative of a superior sperm-zona pellucida binding capacity) than in those with a HZI less than 30, the difference was not significant. There were no differences in fertilization rate according to the presence or absence of antisperm antibodies.

CONCLUSIONS

Fertilization history in a conventional IVF cycle has no effect on success rates following ICSI, and there is no correlation among the basic sperm parameters, the presence of antisperm antibodies, and pregnancy rates.

Approaches for obtaining sperm in patients with male factor infertility

OBJECTIVE

To describe methods of sperm retrieval for intracytoplasmic sperm injection (ICSI) in patients with male factor infertility and to review the clinical results using sperm from the different sources.

DESIGN

The literature on sperm-obtaining methods and ICSI was reviewed. Studies related to this topic were identified through MEDLINE.

RESULTS(S)

This review describes the evolution of sperm retrieval methods. Sperm can be obtained by microepididymal sperm aspiration (MESA), percutaneous sperm aspiration (PESA), and testicular sperm extraction (TESE), from patients with congenital absence of the vas deferens or acquired vas obstruction. When ICSI is performed with ejaculated, epididymal, or testicular sperm, good fertilization and pregnancy rates are achieved without significant differences among the various sperm sources. The original percutaneous sperm aspiration method has been modified slightly and yields successful results.

CONCLUSION(S)

Viable pregnancies can be achieved with ICSI by using not only ejaculated sperm, but also epididymal and testicular sperm. Microepididymal sperm aspiration, percutaneous sperm aspiration, modified percutaneous sperm aspiration, and testicular sperm extraction can be considered standard procedures to treat male factor infertility.

Results of intracytoplasmic sperm injection in relation to indication

BACKGROUND

Intracytoplasmic sperm injection (ICSI) was first introduced as a treatment to couples that were infertile due to severe male factors. Later, the ICSI technic has also been used on other indications like low or no fertilization in previous IVF cycles.

METHODS

A total of 262 ICSI cycles performed in 180 patients were reviewed and the results related to the indications. The indications were severely impaired semen quality (182 cycles) or absent or low fertilization in previous IVF attempts (80 cycles).

RESULTS

A total of 2298 oocytes were aspirated and 1939 oocytes were injected resulting in 1172 fertilized (60%) and 995 cleaved oocytes (51%). Of these, 547 preembryos were transferred in 240 cycles and 287 preembryos were cryopreserved. We obtained 99 pregnancies (41%/transfer) of which 63 were ongoing pregnancies (26%/transfer). The pregnancy rate was significantly lower (p = 0.025) in couples referred for ICSI due to previously failed IVF (29%/ transfer) compared to couples with impaired semen quality (46%/transfer). Seventy-seven children have been born. Forty-eight healthy children were born from singleton pregnancies with a mean gestational age of 39.8 weeks and an average birthweight of 3561 g. Thirteen sets of healthy twins and one set of healthy triplets were born. In 29 of the 63 ongoing pregnancies amniocenteses were performed and all karyotypes were normal.

CONCLUSION

IVF with ICSI gave good clinical results in couples with severe male factor infertility. The technic can also be used in couples with unexplained fertilization failure, but the pregnancy rate may be lower.

Use of electroejaculation in the treatment of ejaculatory failure secondary to diabetes mellitus

OBJECTIVES

To describe the experience of two male fertility programs using electroejaculation (EEJ) in the management of men with ejaculatory failure secondary to diabetes mellitus.

METHODS

Twenty-nine EEJ procedures were performed in 7 diabetic men with ejaculatory failure. Results were reviewed with attention paid to sperm characteristics in both antegrade and retrograde specimens as well as pregnancy rates.

RESULTS

Retrograde semen specimens retrieved from the bladder following EEJ contained a mean of 3444.5 million sperm (range 269.2 to 4996 million). Antegrade specimens contained a mean of 698.8 million sperm (range 226.8 to 1961 million). Mean sperm motility was 4% for retrograde specimens (range 0% to 11%) and 7% for antegrade specimens (1% to 15%). In all but 1 case, semen specimens were used for intrauterine insemination. The total number of motile sperm contained in the processed, inseminated specimens ranged from 1 to 87.2 million. In 1 case, the sperm obtained through EEJ was used in an in vitro fertilization procedure.

CONCLUSIONS

EEJ can be successfully used to obtain sperm from men with ejaculatory failure due to diabetes mellitus. The procedure requires general anesthesia, and pregnancy rates after intrauterine insemination with the processed sperm are low. Advanced reproductive technologies may offer a feasible alternative, providing higher success rates with fewer procedures.