Intracytoplasmic sperm injection: achievement of high pregnancy rates in couples with severe male factor infertility is dependent primarily upon female and not male factors

Effect of ovarian reserve on pregnancy outcomes in patients undergoing IVF treatment due to azoospermia

PURPOSE

Infertility is an increasingly common condition that has demographic, psychological, economic, and medical consequences for society. Although many studies have examined azoospermia (AZO) and diminished ovarian reserve (DOR), few have investigated these two groups together. In this study, we aimed to contribute to the literature by comparing these conditions, which can be challenging for physicians and patients.

METHODS

The study included couples with AZO and/or DOR who underwent intracytoplasmic sperm injection (ICSI) at Tepecik Training and Research Hospital Gynecology and Obstetrics Clinic In Vitro Fertilization (IVF) Center between 01 January 2017 and 30 June 2023. A total of 100 couples meeting the inclusion criteria were divided into 3 groups according to treatment indication: AZO (n = 34), DOR (n = 34), and AZO + DOR (n = 32). The women's ages, basal hormone levels (follicle-stimulating hormone, estradiol, progesterone, anti-Müllerian hormone), treatment indications, day of embryo transfer, and clinical pregnancy outcomes were documented.

RESULTS

Clinical pregnancy rates were 64.7% in the AZO group, 50% in the DOR group, and 34.4% in the DOR + AZO group. In pairwise comparisons, the clinical pregnancy rate was significantly higher in the AZO group than in the DOR + AZO group (p = 0.014). The live birth rate was also significantly lower in the DOR + AZO group than in the AZO group (p = 0.022). In the DOR group, 70.6% of achieved pregnancies resulted in live birth and 29.4% in missed abortion.

CONCLUSION

Clinical pregnancy and live birth rates were found to be significantly higher in couples with AZO compared to those with both DOR and AZO. This suggests that the woman's ovarian reserve is more decisive than sperm quality in the success of IVF/ICSI.

Novel insights into necrozoospermia from a single-center study: reference ranges, possible etiology, and impact on male fertility

ABSTRACT

Necrozoospermia is a poorly documented condition with a low incidence, and its definition and clinical significance are unclear. Herein, we provide a reference range for necrozoospermia and discuss its possible etiology and impact on male fertility and assisted reproductive outcomes. We extracted relevant information from 650 Chinese male partners of infertile couples and statistically analyzed sperm vitality. Necrozoospermia was present in 3.4% (22/650) of our study population, and the lower cut-off value for sperm vitality was 75.3%. We compared two methods for assessing sperm vitality (eosin-nigrosin head staining and hypo-osmotic swelling test [HOST]), for which the percentage in the eosin-nigrosin group (mean ± standard deviation [s.d.]: 77.5% ± 10.5%) was significantly higher than that in the HOST group (mean ± s.d.: 58.1% ± 6.7% [5-10 min after incubation] and 55.6% ± 8.2% [25-30 min after incubation]; both P < 0.001). The incidence of necrozoospermia increased with age (odds ratio [OR] = 1.116, 95% confidence interval [CI]: 1.048-1.189, P = 0.001), while the percentage of normal sperm morphology and DNA fragmentation index (DFI) were significantly associated with necrozoospermia, with ORs of 0.691 (95% CI: 0.511-0.935, P = 0.017) and 1.281 (95% CI: 1.180-1.390, P < 0.001), respectively. In the following 6 months, we recruited 166 patients in the nonnecrozoospermia group and 87 patients in the necrozoospermia group to compare intracytoplasmic sperm injection (ICSI) and pregnancy outcomes between the two groups. The necrozoospermia group had a significantly lower normal fertilization rate (74.7% vs 78.2%, P = 0.041; OR = 0.822; 95% CI: 0.682-0.992) than that in the nonnecrozoospermia group. This study presents substantial information on necrozoospermia to establish comprehensive and applicable reference values for sperm vitality for spontaneous conception and artificially assisted reproductive management.

Embryo selection through non-invasive preimplantation genetic testing with cell-free DNA in spent culture media: a protocol for a multicentre, double-blind, randomised controlled trial

INTRODUCTION

Morphological evaluation is used to select embryos for in vitro fertilisation. However, it does not fully reflect the implantation potential. Preimplantation genetic testing for aneuploidies (PGT-A) can detect embryonic aneuploidy, but biopsy procedure is invasive. Currently, a non-invasive PGT (ni-PGT) approach using spent medium is being evaluated. However, the clinical benefit of ni-PGT has not been clearly demonstrated. A multicentre randomised trial is needed to verify whether ni-PGT can be an new effective tool for evaluating embryos.

METHODS AND ANALYSIS

Overall, 1148 couples aged 35~42 (women) receiving in vitro fertilization-intracytoplasmic sperm injection are planned to be enrolled. Couples will be digitally randomised to (1) ni-PGT and (2) conventional morphology groups at a 1:1 treatment ratio. The primary outcome will be the ongoing pregnancy rate related to the first transfer cycle within 6 months after oocyte retrieval.

ETHICS AND DISSEMINATION

The study protocol is approved by the Ethics Committee of Peking University Third Hospital and the participating hospitals. The results will be disseminated through international conferences and scientific journals.

TRIAL REGISTRATION NUMBER

NCT04339166.

Preimplantation genetic testing for aneuploidy in severe male factor infertility: protocol for a multicenter randomised controlled trial

INTRODUCTION

Conventional intracytoplasmic sperm injection (ICSI) is a widely used treatment for couples with severe male infertility. However, there are controversies regarding the selection and the damage to gametes during the ICSI procedure. Although preimplantation genetic testing for aneuploidies (PGT-A) can give genetic information about embryos for transfer and improve fertility rate, and it is widely used in women with recurrent spontaneous abortion or advanced age, PGT-A is not only more expensive but also has unclear effectiveness with respect to the improvement of fertility rate among couples with severe male infertility. High-quality, well-powered randomised clinical trials (RCTs) comparing ICSI+PGT-A and ICSI are lacking.

METHODS AND ANALYSIS

This is a protocol for a multicenter, open-label RCT in four reproductive medical centers qualified for PGT technique in China. We will study couples with severe male infertility scheduled for their fertility treatment. After the blastocyst culture, eligible participants are randomised to the ICSI+PGT-A group or the conventional ICSI group in a 1:1 ratio. Other assisted reproductive procedures are similar and parallel between the two groups. The primary outcome will be live birth rate and cumulative live-birth rate . Secondary outcomes will be embryo implantation rate, biochemical pregnancy rate, clinical pregnancy rate, spontaneous abortion rate, ongoing pregnancy rate, preterm birth rate, fetal chromosomal abnormality rate, birth defect rate and treatment complications. To demonstrate or refute a difference between the two groups, we plan to include 188 participants in each group; taking consideration of 20% of dropout, the total target sample size is 450.

ETHICS AND DISSEMINATION

Ethical approval was obtained from International Peace Maternity and Child Health Hospital of Shanghai Jiao Tong University Medical Science Research Ethics Committee (GKLW2016-16). Informed consent will be obtained from each participant. The findings will be disseminated to the public through conference presentations and publication in peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov, NCT02941965.

The association of impaired semen quality and pregnancy rates in assisted reproduction technology cycles: Systematic review and meta-analysis

Some studies suggest a relationship between semen quality and pregnancy rates of assisted reproduction technologies (ART). Others have questioned the utility of semen quality as proxy for fertility in couples attempting to conceive with or without assistance. We aimed to investigate the current body of evidence which correlates semen parameters and clinical pregnancy among couples utilizing ART (i.e. in vitro fertilization [IVF], intracytoplasmic sperm injection [ICSI]) through a systematic review and meta‐analysis of cross‐sectional and retrospective cohort studies. Pooled Odd Ratio (OR) for oligo‐, astheno‐ and teratospermic compared to normospermic number of ART cycles were calculated among. Meta‐regression and sub‐group analysis were implemented to model the contribution of clinical/demographic and laboratory standards differences among the studies. Overall, 17 studies were analysed representing 17,348 cycles were analysed. Pooled OR for impaired sperm concentration, motility and morphology was 1 (95%Confidence Interval [CI]: 0.97–1.03), 0.88 (95%CI: 0.73–1.03) and 0.88 (95%CI: 0.75–1) respectively. Further analysis on sperm morphology showed no differences with regard of IVF versus ICSI (p = 0.14) nor a significant correlation with rising reference thresholds (Coeff: −0.02, p = 0.38). A temporal trend towards a null association between semen parameters and clinical pregnancy was observed over the 20‐year observation period (Coeff: 0.01, p = 0.014). The current analysis found no association between semen quality (as measured by concentration, motility or morphology) and clinical pregnancy rates utilizing ART. Future investigations are necessary to explore the association between semen parameters and other ART outcomes (e.g. fertilization, implantation, birth and perinatal health).

The outcome of intra-cytoplasmic sperm injection (ICSI): do the sperm concentration and motility matter?

OBJECTIVES

The male-factor subfertility was reported to be 30% globally; thus, the intracytoplasmic sperm injection (ICSI) procedure was implemented to improve the overall in vitro fertilization (IVF) rates. Nevertheless, at least 10% of fertilization failure still occurs. Concerning this issue, we explored the association of sperm concentration and motility with the quality of embryo development and pregnancy outcome in IVF-ICSI cycles.

METHODS

Retrospective analysis of 109 couples with male factor were done over 14 months in a tertiary university hospital in Malaysia. The data were divided into four groups; Group I: normal sperm parameters, Group II: normal sperm concentration but reduced total sperm motility, Group III: reduced sperm concentration and motility, Group IV: reduced sperm concentration but normal sperm motility. Only fresh semen samples and fresh embryo transfers were included. The fertilization, cleavage rate, embryo quality and pregnancy outcome were assessed.

RESULTS

Overall, group I had the highest oocytes yield and ICSI attempted; (10.12 + 6.50), whereas the lowest was in group IV; (7.00 + 2.82). Group II revealed the highest fertilization and cleavage rates; (54.14 + 25.36), (55.16 + 26.06), thus not surprisingly resulting in the highest number of good embryos and highest clinical pregnancy rates. The lowest cleavage and pregnancy rates were seen in group IV. However, all the outcomes were not statically significant (p>0.05).

CONCLUSIONS

Similar fertilization rate and comparable pregnancy outcome was seen among couples with normal and reduced sperm concentration and motility.

Is Intracytoplasmic Sperm Injection the Solution for all in Unexplained Infertility?

Intracytoplasmic sperm injection (ICSI) was first introduced as a supplemental method to conventional in vitro fertilization (c-IVF) for couples with severe male factor infertility to overcome the poor fertilization rate, while its indications expanded in current clinical practice and gained worldwide popularity. However, ICSI is invasive and crosses all natural barriers, raising several unresolved concerns regarding procedure-dependent and procedure-independent risks, as well as the characteristic of being labor-intensive and more expensive than c-IVF. This review is aimed to draw readers' attention, to the widespread use of ICSI worldwide, with its effectiveness in different indications of infertility, especially in those with unexplained infertility, as well as the cost-effectiveness of the ICSI-for-all strategy. Also, we covered current evidence on the short- and long-term safety of children born thanks to ICSI-aided conception. Further well-designed, adequately powered, and randomized controlled clinical trials are absolutely needed to arrive at a consensus on the use of ICSI over c-IVF in different populations.

Relationship between male age, semen parameters and assisted reproductive technology outcomes

BACKGROUND

Low semen quality often obligates the use of assisted reproductive technology; however, the association between semen quality and assisted reproductive technology outcomes is uncertain.

OBJECTIVES

To further assess the impact of semen quality on assisted reproductive technology outcomes.

MATERIALS AND METHODS

A retrospective cohort study was carried out at a single academic reproductive medicine center (January 2012-December 2018). Patients undergoing at least one assisted reproductive technology cycle utilizing freshly ejaculated spermatozoa from the male partner were included. We assessed the association between semen quality (as stratified based on WHO 5th edition criteria), paternal age (< or ≥40), and reproductive/perinatal outcomes. To evaluate the differences in assisted reproductive technology outcomes by semen parameters and age, generalized estimating equations were applied for rates of fertilization, pregnancy, implantation, miscarriage, live birth, blast formation, gestational age, and normal embryo biopsy.

RESULTS

A total of 2063 couples were identified who underwent 4517 assisted reproductive technology cycles. Average ages of the male and female partners were 39.8 and 37.7, respectively. Lower pregnancy rates were observed in cycles with lower sperm motility (ie <40%; 39.9% vs 44.1%) and total motile count (ie <9 million; 38.3% vs 43.5%). When examining only cycles utilizing Intracytoplasmic Sperm Injection, only a lower motility count was associated with a decline in pregnancy rate (39.1% vs 44.9%). No association was identified between semen quality and gestational age or birth weight. Paternal age was not associated with ART outcomes. However, among assisted reproductive technology cycles in women <40, aneuploidy rate was higher for older men (P < .001). In cycles with women >40, no association between aneuploidy and male age was identified.

DISCUSSION

Sperm motility is associated with pregnancy rates, while other semen parameters are not. In cycles in women <40, paternal age is associated with embryo aneuploidy rate.

CONCLUSION

Paternal factors are associated with assisted reproductive technology outcomes, and future studies should explore mechanisms by which semen quality is associated with assisted reproductive technology outcomes.

Diagnostic value of routine semen analysis in clinical andrology

Infertility is a major health issue affecting over 48.5 million couples around the world, with the male factor accounting for about 50% of the cases. The conventional semen analysis recommended by the World Health Organization (WHO) is the cornerstone in the evaluation of male fertility status. It includes macroscopic and microscopic evaluation of the ejaculate, which reflects the production of spermatozoa in the testes, the patency of the duct system and the glandular secretory activity. Evaluation of seminal fructose, sperm vitality and leucocytes (Endtz test) are useful adjuncts to semen analysis that provide information on specific clinical conditions. Though several computer-assisted sperm analysis (CASA) systems have been developed, conventional methods for semen analysis are still widely accepted in clinical practice. This review summarises the conventional techniques used in routine semen analysis and their diagnostic value in clinical andrology.

Intracytoplasmic sperm injection (ICSI) versus conventional in vitro fertilisation (IVF) in couples with non-severe male infertility (NSMI-ICSI): protocol for a multicentre randomised controlled trial

INTRODUCTION

Intracytoplasmic sperm injection (ICSI), originally introduced as add-on to in vitro fertilisation (IVF) for couples with severe male infertility, is in current clinical practice also used in couples with mild male or even unexplained infertility. However, ICSI has involved unresolved concerns regarding the selection and damage to gametes and the health conditions of the offspring, and it is also labour intensive and therefore more expensive than conventional IVF. High-quality well-powered randomised clinical trials (RCTs) comparing ICSI and IVF are lacking.

METHODS AND ANALYSIS

We propose a multicentre, open-label RCT in 10 reproductive medical centres across China. We will study couples with non-severe male infertility (defined as a semen concentrate 5-15×106/mL or sperm with a progressive motility 10%-32%) scheduled for their first or second ICSI or IVF cycle, as low fertility rate after fertilisation are more frequent in this population, which could lead to controversy about ICSI or conventional IVF for fertilisation. On the day of oocyte retrieval, eligible participants are after informed consent be randomised to undergo either ICSI or conventional IVF in a 1:1 treatment ratio. Other standard assisted reproductive treatments are similar and parallel between two groups. Our primary outcome is ongoing pregnancy leading to live birth after the first cycle with embryo transfer. To demonstrate or refute a difference of 7% between ICSI and conventional IVF, we need to include 2346 women (1173 in each intervention arm). In addition, we will follow-up neonatal outcomes after delivery to identify the influence of ICSI on offspring.

ETHICS AND DISSEMINATION

Ethical approval was obtained from Peking University Third Hospital medical science research ethics committee. The findings will be disseminated to the public through conference presentations and peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov registry (NCT03298633).

Intracytoplasmic morphologically selected sperm injection, but for whom?

Intracytoplasmic sperm injection (ICSI) is performed in cases of infertility by injecting a motile and morphologically normal sperm cell under a routine ×400 magnification at which is hard to distinguish morphologically healthy sperm. Recently, the use of high-powered differential interference contrast optics gave the opportunity to select a sperm under ultra-high magnification of ×10,160. The aim of the present study was to evaluate the efficacy of the intracytoplasmic morphologically selected sperm injection (IMSI) technique in different infertility populations undergoing ICSI. Main outcome measures of routine ICSI were compared with IMSI in three different groups of patients (1, non-selected; 2, male infertility; and 3, repeated implantation failure group). Results were analysed to evaluate the effects of the IMSI procedure and to find the most suitable group of patients who may benefit from the procedure. IMSI caused a significant increase in the fertilization and top quality embryo rates in the male infertility group and a significant increase in fertilization and pregnancy rates in the repeated implantation failure group, whereas no effect was observed in the non-selected group with patients of various indications. A positive effect of IMSI on the outcome of male factor infertility and repeated implantation failure patients was observed. Data observed confirmed that the application of IMSI was beneficial for a selected group of patients with male factor infertility and repeated implantation failure.

Effect of low sperm quality on progeny: a study on zebrafish as model species

Nowadays a decrease tendency in human sperm quality has been reported mainly in developed countries. Reproductive technologies have been very valuable in achieving successful pregnancies with low quality sperm samples. However, considering that spermatozoa molecular contribution is increasingly important in recent studies, it is crucial to study whether fertilization with low sperm quality could leave a molecular mark on progeny. This study explores the consequences that fertilization with low sperm quality may have on progeny, using zebrafish as a model. Good and bad breeders were established attending to sperm quality analyses and were individually tracked. Significant differences in fertilization and malformation rates were obtained in progenies between high and low quality sperm samples. Moreover an altered miR profile was found in the progenies of bad zebrafish breeders (upregulation of miR-141 and miR -122 in 24 hpf embryos) and as a consequence, some of their targets involved in male sex development such as dmrt1, suffered downregulation. Our results indicate that fertilizing with high sperm quality samples becomes relevant from a new perspective: to avoid molecular alterations in the progeny that could remain masked and therefore produce unexpected consequences in it.

Abnormal sperm concentration and motility as well as advanced paternal age compromise early embryonic development but not pregnancy outcomes: a retrospective study of 1266 ICSI cycles

PURPOSE

To investigate the effect of sperm concentration, motility and advanced paternal age on reproductive outcomes.

METHODS

A retrospective analysis of 1266 intracytoplasmic sperm injection (ICSI) cycles between 2013 and 2017. The cohort was divided into four groups according to semen concentration based on the WHO criteria (2010): group A (conc. <1 M/ml), group B (1 ≤ conc. <5 M/ml), group C (5 ≤ conc. < 15 M/ml) and the control group D (conc. ≥15 M/ml). The primary outcome investigated was the blastulation rate. Secondary outcomes were fertilization rate, top quality blastocyst formation rate and ongoing pregnancy rate.

RESULTS

After adjustment for maternal age and number of oocytes recovered, a significant difference was observed between group A and group D on the rate of fertilized oocytes [66.7 (40.0-80.0) vs 75.0 (57.1-90.2), adjusted p < 0.001] and the blastocyst formation rate [50.0 (33.3-66.3) vs 55.6 (40.0-75.0), adjusted p < 0.05]. However, the male factor did not affect the top quality blastocyst formation rate nor the ongoing pregnancy rate. Considering the age of the male partner as confounding factor, at the increase of each year of age, a reduction of 0.3% on the fertilization rate was observed but no other outcome was impacted. A negative correlation was also observed between sperm motility and fertilization rate in the group with a motility <5%.

CONCLUSION

Male factor infertility and advanced paternal age may compromise fertilization and blastulation rates but not top quality blastocyst formation rate or the establishment of pregnancy in ICSI cycles.

Clinical outcomes following ICSI cycles using surgically recovered sperm and the impact of maternal age: 2004-2015 SART CORS registry

PURPOSE

The aims of this study were (1) to evaluate clinical outcomes after ICSI cycles using surgically recovered sperm and (2) to assess the influence of maternal age on those outcomes.

METHODS

A retrospective cohort study of 24,763 IVF cycles of fresh autologous oocytes and ICSI using surgically recovered sperm reported to the SART CORS database from 2004 to 2015.

RESULTS AND CONCLUSIONS

Older women had significantly longer stimulation (p < 0.001), a lower number of oocytes retrieved (p < 0.001), a lower number of 2PN zygotes (p < 0.001), a lower chance of having a blastocyst transferred (p < 0.001), and a higher number of fresh embryos transferred (p < 0.001). There was no significant association between the number of 2PNs per oocyte retrieved and maternal age (p = 0.214). Both clinical pregnancy rates and live birth rates (LBR) decreased with advanced maternal age (p < 0.001). LBR ranged from 50.4% in women < 30 to 7.2% in women > 42 years, and for cleavage-stage transfers, the LBR ranged from 47.3% in women< 30 to 6.3% in women > 42 years. There were no differences in gestational age at delivery, proportion of term deliveries, preterm deliveries, neonatal birth weight < 2500 g, neonatal birth weight > 4000 g and average birthweight of neonates for singleton pregnancies according to age. For twin pregnancies, women < 30 years had significantly higher number of live births, term deliveries, and lower preterm deliveries than older women. There was a similar number of female (6051) and male neonates (5858; p = 0.2). Overall, pregnancy outcomes with ICSI using surgically recovered sperm are reassuring and comparable to those of ICSI with ejaculated sperm.

Long-term clinical outcomes of testicular sperm extraction and intracytoplasmic sperm injection for infertile men

Purpose

To find the best methods to achieve the highest pregnancy and birth rates for couples needing testicular sperm extraction (TESE)‐intracytoplasmic sperm injection (ICSI).

Methods

Retrospectively studied were 801 patients with male factor infertility who had undergone TESE‐ICSI between April, 1996 and July, 2016 and who had been categorized into four groups: obstructive azoospermia (OA); non‐obstructive azoospermia (NOA); Klinefelter syndrome (KS); and cryptozoospermia (Crypt). The sperm retrieval rate, hormone levels, fertilization rate (FR), pregnancy rate (PR), and birth rate (BR) after ICSI among three groups were compared: fresh testicular sperm (FS)‐fresh oocytes (FO) (Group I); frozen‐thawed testicular sperm‐FO (Group II); and FS‐vitrified‐warmed oocytes (Group III).

Results

The testicular sperm recovery rate was 57.8% (463/801): 89.6% in the Crypt, 97.1% in the OA, 28.9% in the NOA, and 42.2% in the KS groups. The follicle‐stimulating hormone levels were significantly higher in the NOA and KS groups and the testosterone levels were significantly lower in the KS group. The FR, PR, and BR were: 65.2%, 43.2%, and 28.5% in group I; 59.2%, 33.4%, and 18.7% in group II; and 56.4%, 33.8%, and 22.1% in group III.

Conclusion

Intracytoplasmic sperm injection with FS‐FO achieved the best PR and BR. It should be considered what to do in cases with no testicular sperm by TESE. The authors hope that ICSI with donor sperm will be allowed in Japan in the near future.

The influence of semen quality on male pronucleus demethylation process during ICSI cycle

There is growing evidence that the spermatozoon's epigenetic structure is of the utmost importance in the health of the future embryo. Following fertilization, sperm chromatin undergoes epigenetic reprogramming including DNA demethylation and remethylation, which resets gene expression. In some infertile patients, it is inevitable that sperm cells that are not within the range of normal human sperm parameters will be used for intracytoplasmic sperm injection. Understanding the relationship between the human sperm parameters and male pronucleus DNA demethylation seems necessary. We hypothesized that demethylation of the male pronucleus might be altered in zygotes conceived from a spermatozoa obtained from a sample exhibiting an abnormal semen analysis profile. To test the hypothesis, sperm cells from normal and abnormal human semen samples were injected into mouse oocytes. A group of cultured zygotes was fixed before the onset of DNA demethylation and the other group was fixed after DNA demethylation. Both groups were then labeled with a 5 methylcytosine antibody and the level of pronuclei methylation was detected as a function of fluorescent intensity. The level of demethylation was then determined as the difference between 5 methylcytosine fluorescent intensity before and after DNA demethylation. A negative correlation (p<0.05) was observed between sperm motility, morphology, percentage of head defects, protamine deficiency, and DNA demethylation level. However, no correlation was found between the demethylation level and sperm count. In conclusion, these observations suggest that demethylation is altered in the male pronucleus when low quality sperm samples are used.

A. Overcoming male factor infertility with intracytoplasmic sperm injection

Summary Objective: To evaluate the effect of male factor infertility on intracytoplasmic sperm injection (ICSI) outcomes compared with a control group presenting isolated tubal factor. Method: This retrospective study included 743 couples undergoing ICSI as a result of isolated male factor and a control group consisting of 179 couples undergoing ICSI as a result of isolated tubal factor, performed in a private university- -affiliated in vitro fertilization center, between January/2010 and December/2016. Patients were divided into two groups according to maternal age: women ≤35 years old and >35 years old. The effects of infertility causes on laboratorial and clinical ICSI outcomes were evaluated using Student's t-test and (2 test. Results: No differences in controlled ovarian stimulation outcomes were observed between male factor cycles and tubal factor cycles in the two age groups. Implantation (male factor 35.5% vs. tubal factor 32.0%, p=0.340), pregnancy (male factor 46.9% vs. tubal factor 40.9%, p=0.184) and miscarriage (male factor 10.3% vs. tubal factor 10.6%, p=0.572) rates were similar between the infertility groups, irrespective of female age. Considering maternal age, the cancelation rate was higher in older women (>35 years old) undergoing ICSI as a result of male factor infertility (17.4% vs. 8.9%, p=0.013). Conclusion: Our results showed that there is no difference in the outcomes of pregnancy between couples with male or tubal factor infertility, which indicates that ICSI surpasses the worse specific outcomes associated with male factor.

ICSI outcomes in men undergoing TESE for azoospermia and impact of maternal age

This retrospective study compared clinical outcomes in men with obstructive and nonobstructive azoospermia after ICSI following testicular sperm extraction and the influence of maternal age. Fertilisation rates, embryo quality, pregnancy rates, miscarriage rates and live birth rates were evaluated. Men with obstructive azoospermia (OA) had significantly higher rates of diploid fertilisation and clinical pregnancy than men with nonobstructive azoospermia (NOA), but miscarriage rates and live birth rates were not significantly different. The higher rates of fertilisation, embryo quality and clinical pregnancy in men with OA were statistically significant when their female partners were <35 years but results were similar in both groups when female partners ≥35 years. Although the OA group had better overall quality embryos than the NOA group when maternal age was <35 years, embryologists can select the morphologically better embryos for transfer, eliminating the effect of embryo quality differences present in these two groups. Understanding more about factors that affect TESE/ICSI outcomes will not only help us predict patients' outcomes but it can help us educate and better counsel our patients.

Can intra cytoplasmatic morphologically selected sperm injection (IMSI) technique improve outcome in patients with repeated IVF-ICSI failure? a comparative study

OBJECTIVE

Spermatozoal morphology was reported to effect fertilization, embryo quality and pregnancy results in spontaneous conception and ART. Intracytoplasmic morphologically selected sperm injection (IMSI) is an innovative, not invasive technique, which examines the sperm with no harm at a magnification of 6000 × in order to obtain optimal sperm to perform IVF-ICSI. We evaluated the efficiency of IMSI technique in patients with repeated IVF-ICSI failure of at least three cycles with no viable pregnancy and/or very poor sperm quality.

STUDY DESIGN AND METHODS

All couples who performed IMSI between the years 2009 to 2012 were enrolled retrospectively to the study. Couples with male infertility who were treated with IMSI were included in the study. All their treatments were evaluated and divided into two subgroups: conventional IVF-ICSI treatment and their subsequent IMSI treatment. Demographic data, clinical parameters and outcome were recorded. The IMSI treatments were compared to previous non-IMSI treatments in terms of fertilization rates, cleavage rates, number of embryos and their quality, number of embryos transferred and pregnancy outcome.

MAIN RESULTS

Forty-two couples were reviewed. Basic characteristics of the groups were comparable. Fertilization and cleavage rates of the two groups were comparable. The embryos quality demonstrated a trend toward superior quality (grade 1-2) embryos in the IMSI versus ICSI (60% versus 47%; p = 0.07 and 53% versus 40%; p = 0.07), respectively. Implantation and clinical pregnancy rates were significantly superior in IMSI group (19.2% versus 7.8%; p = 0.042 and 41.3% versus 10.5%; p = 0.02, respectively). Miscarriage rate was significantly higher in conventional IVF-ICSI group (100% versus 15.8%; p = 0.04), and live birth rate was significantly higher in IMSI group (0 in conventional IVF-ICSI and 34.7% per transfer in IMSI group; p = 0.003).

CONCLUSION

IVF outcome of IMSI resulted in a higher implantation rate, pregnancy rate and most importantly delivery rate compare to non IMSI treated cycles.

Can intracytoplasmic sperm injection prevent total fertilization failure and enhance embryo quality in patients with non-male factor infertility?

OBJECTIVE

To determine whether intracytoplasmic sperm injection (ICSI) could prevent total fertilization failure (TFF) and enhance the embryo quality in patients with non-male factor infertility.

STUDY DESIGN

A total of 296 in vitro fertilization (IVF) cycles performed in patients with non-male factor infertility between April 2009 and March 2013 were included in this retrospective study. During the period, ICSI and conventional IVF were performed in 142 and 154 cycles, respectively. The usual indications for ICSI were in the cycles of patients with (1) known low fertilization rate, (2) repetitive implantation failure, (3) advanced maternal age, (4) presence of endometrioma, (5) low oocyte yield (number of oocytes ≤3), or (6) poor quality oocytes. The rate of TFF, normal fertilization, abnormal pronuclei (PN) formation, embryo quality, and pregnancy outcomes between the patients treated with ICSI and conventional IVF cycles were compared.

RESULTS

The patients treated with ICSI (ICSI group, n=142) presented fewer number of oocytes than patients treated with conventional IVF cycles (n=154). The TFF rate was not different (4.2% vs. 0.6%, P=0.059), but the ICSI group presented a significantly higher rate of normal fertilization (83.4% vs. 79.1%, P=0.04) and lower rate of abnormal PN formation (3.9% vs. 13.3%, P<0.01). The cleavage stage embryo quality was better in the ICSI group (grade A: 31.1% vs. 21.3%, P=0.001; grade A+B: 65.1% vs. 47.6%, P<0.001).

CONCLUSION

The result of this study does not support the use of ICSI to prevent TFF in patients with non-male factor infertility. However, ICSI improved the fertilization rate and the embryo quality.

The Kunming mouse: as a model for age-related decline in female fertility in human

To ascertain whether the Kunming (KM) mouse is an available model for age-related decline in female fertility in human or not, oocytes from young (6–8 weeks), middle-aged (9 months) and aged (12 months) female mice were compared with respect to number of oocytes, frequency of in-vitro maturation (IVM) and in-vitro fertilization (IVF), and meiotic chromosome segregation and alignment. The mean number of pups born per mouse decreased significantly from the young to the middle-aged and the aged mice. The mean number of ovarian follicles, ovarian germinal vesicle oocytes and ovulated MII oocytes decreased significantly with maternal age. The rate of IVM in oocytes from young mice (73.9%) was less significantly than that in oocytes from middle-aged and aged mice (86.1% and 84.4%, respectively). Immunocytochemical analysis showed that ageing caused a significantly higher rate (49.3%) of chromosome misalignment than that (15.7%) of the young mice. The presence of premature chromatids was also significantly higher in MII oocytes of aged mice as compared with young mice (37.8 versus 8.3%). Pronuclear formation was delayed in oocytes of middle-aged and aged females (35.5 and 42.3% respectively in 5 h of IVF) as compared with young mice (88.1%). The study suggests that KM mouse exhibits an age-related decline in female fertility. Significant reduction of germinal vesicle (GV) and MII oocytes and significant increase of metaphase chromosome misalignment and premature chromatid segregation after meiotic maturation of oocytes, similar to human, presumably contribute to the decline in aged KM mice.

Is ICSI Risky?

As assisted reproductive technology (ART) methods become the mainstream of infertility treatment, it has become even more critical to reassess its safety. Following the results of a study published by the Robinson Institute in the New England Journal of Medicine, the risk of ART, especially intracytoplasmic sperm injection (ICSI), has never been so closely scrutinized. This paper traces the origins and development of ICSI, assesses the risks documented in the literature, and finally interprets the implications of the study for couples contemplating therapy. We support the need for continued vigilance towards ICSI and the importance in investigating male-factor infertility as a prequel to its use.

Clinical management of male infertility in assisted reproduction: ICSI and beyond

The advent of in vitro fertilization and its augmentation with intracytoplasmic sperm injection (ICSI) has allowed a large number of couples suffering from moderate to severe male infertility, and also presenting with female pathologies, to achieve their reproductive dreams. Notwithstanding the existence of fundamental questions about the pathophysiological mechanisms leading to sperm dysfunction, and still unanswered concerns about health risks following ICSI, it appears that overall ICSI is safe and here to stay. Although on one hand ICSI possibly hampered advances of the knowledge in some areas of gamete biology and interaction, on the other it definitely gave impulse to studies designed to unveil the sperm contributions during and beyond fertilization, including the normalcy of the DNA/chromatin as well as molecular mechanisms of genetic/epigenetic control and nuclear organization status. In all, almost entering the fourth decade of assisted reproductive technologies, we should continue monitoring the safety of the technique and long-term development of offspring, whereas at the same time prioritizing areas of research addressing these fundamental questions.

Impact of assisted hatching on the outcome of intracytoplasmic sperm injection: a prospective, randomized clinical trial and pregnancy follow-up

OBJECTIVE

To evaluate the overall effect of assisted hatching (AH) on the implantation, pregnancy, and live birth rates in women undergoing intracytoplasmic sperm injection (ICSI) cycles; and to determine the effect of AH on the cytogenetic outcome (chromosomal constitution) of pregnancy.

DESIGN

Prospective, randomized study.

SETTING

Academic research environment.

PATIENT(S)

A total of 172 couples were enrolled in the study.

INTERVENTION(S)

Assisted hatching was carried out on day-3 ICSI embryos.

MAIN OUTCOME MEASURE(S)

Implantation, clinical pregnancy, and live birth rates; cytogenetic analysis of abortuses and umbilical cord blood samples from newborns.

RESULT(S)

Biochemical, clinical, and ongoing pregnancy rates were not significantly different between the AH and control groups. The implantation rate was higher in the AH group than in the control group (16% vs. 8%), especially in women aged > or =35 years. Postnatal umbilical cord blood samples were collected and cytogenetically analyzed from 39 live births (20 from the AH group, 19 from the control group). Two abnormal karyotypes were found (one AH, one control). There were seven spontaneous losses during the study interval. Six of the abortuses underwent cytogenetic study (five AH, one control), and four were found to have an abnormal karyotype (three AH, one control).

CONCLUSION

We found that AH improves implantation rates of ICSI cycles and seems to be most effective in women aged > or =35 years. A larger sample size is needed to determine whether AH improves the take-home-baby rate. Assisted hatching did not affect the rate of chromosomal abnormalities in live births in this study.

Comparison of the outcome of intracytoplasmic sperm injection in obstructive and non-obstructive azoospermia in the first cycle: a report of case series and meta-analysis

To investigate the outcome of intracytoplasmic sperm injection with fresh and cryopreserved-thawed testicular spermatozoa in the first cycle in patients with obstructive azoospermia (OA) and non-obstructive azoospermia (NOA), a total of 90 cases, 48 OA and 42 NOA were studied. All patients underwent sperm retrieval by testicular sperm extraction (TESE) while their wives received conventional ovarian hyperstimulation. The hormone levels, testicular histology, the rates of sperm retrieval, fertilization, implantation and pregnancy were analysed and evaluated. This study and other four similar studies were subjected to meta-analysis. Sperm retrieval was successful in 100% OA and 61% NOA. Fresh spermatozoa were used in 87.5% and 92.4% of OA and NOA cases respectively; while cryopreserved-thawed spermatozoa were used in 12.5% and 7.6% of OA and NOA, respectively. The fertilization, implantation and clinical pregnancy rates were 65.5%, 15% and 25% respectively in OA group, and 54.2%, 5% and 23.1% respectively in NOA group. Sperm status (fresh or thawed), male partner's age, female age and male serum follicle-stimulating hormone had no significant effect upon fertilization rate, implantation rate, or pregnancy rate per embryo transfer. The results of meta-analysis indicate that there is no statistically significant difference in clinical pregnancy rates between the two groups. There was a significantly higher fertilization rate among OA patients in all analysed studies (95% CI = 14.29-15.71, d.f. 832, T = 1.96). In conclusion, although the fertilization rate was significantly higher in the OA group in our study and from the given meta-analysis, there were some differences as regards pregnancy rates. Although the overall effect was more or less similar pregnancy rates in both subtypes of azoospermia, this may not be true if non-male infertility variables were controlled for in all studies.

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.

Should ICSI be used in non-male factor infertility?

There is general agreement that intracytoplasmic sperm injection (ICSI) should be used in male factor infertility cases, such as oligoasthenoteratozoospermia, presence of anti-sperm antibodies, or azoospermia, these cases being diagnosed through abnormal semen analysis. There are no randomized clinical trials comparing ICSI with IVF (or other interventions) where semen quality is so poor that IVF would not achieve fertilization. It is accepted that ICSI is the only treatment option in those circumstances. The role of ICSI where IVF can be expected to give a reasonable fertilization rate is the question that needs to be answered. The argument is whether or not ICSI should be used for all cases of infertility. This paper proposes and strongly supports the use of ICSI for all indications. Considerations of fertilization and embryo development, cost effectiveness and safety will be clearly discussed.

Role of the nonhuman primate for research related to women's health

This overview of the current status of medical problems that affect women is related to current studies on pathophysiology and therapeutic interventions using nonhuman primates to demonstrate the utility of the primate model for the study of disease processes in women. The current medical literature on women's health is compared with the literature on nonhuman primate research. The findings reviewed in the articles of ILAR Journal Volume 45 Issue 2 of 2004 are evaluated in the context of the scope and problems associated with disease entities in women. Nonhuman primate research with known information regarding women's disease is discussed, and the utility of the animal model for the study of human disease is highlighted, based on its significant relevance due to similarities of nonhuman primate and human subjects' physiology, metabolism, and responses to therapeutic interventions. Additional advantages of the animal model include the ability to control the experimental environment and the capacity to perform chronic study procedures. These findings allow us to utilize the nonhuman primate as the most relevant model in the animal world for the study of human disease processes.

Factors associated with an optimal pregnancy outcome in an oocyte donation program

PURPOSE

To identify donor and recipient variables that may have a significant impact on pregnancy outcome in order to optimize results of an oocyte donation program.

METHOD

Retrospective analysis through a Generalized Estimating Equation (GEE) approach to clustered and binary clustered data, linear mixed effects model, scatter plot smoothing functions, and receiving operator characteristics (ROC) curves.

SETTING

University-based center.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURES

Pregnancy and implantation rates.

PATIENTS

257 donation and transfer cycles.

RESULT(S)

Overall results were as follows: clinical pregnancy rate, 47%; implantation rate, 22%; abortion rate, 19%; and overall multiple pregnancy rate, 35%. The total reproductive potential was 60%. Implantation and pregnancy rates were not significantly related to any variable from donors or recipients. Abortion rate increased significantly with donors' increased basal serum LH. Pregnancy rate was significantly enhanced with improved embryo quality. In donors stimulated more than once, the pregnancy rate was 84%.

CONCLUSION(S)

Although no single or combined donor or recipient variable(s) could be identified as predictor(s) of pregnancy, the data suggest that donors < or = 33 years of age with basal cycle day 3 serum levels of FSH 4-8 IU/L, LH < 8 IU/L, and E2 < 70 pg/mL had an optimal outcome. Transfer of two selected embryos on day 3 yields a favorable pregnancy outcome while significantly decreasing the occurrence of multiple pregnancies. These policies, in addition to embryo cryopreservation, were associated with optimal pregnancy outcome in oocyte donation.

Impact of transabdominal ultrasound guidance on performance and outcome of transcervical uterine embryo transfer

PURPOSE

To determine the impact of transabdominal ultrasound guidance on embryo transfer during IVF therapy.

METHODS

Retrospective analysis of 823 consecutive embryo transfers. Three hundred and sixty-seven procedures performed with transabdominal ultrasound guidance were compared to 456 cases performed with the "clinical touch" method.

RESULTS

Ultrasound-guided embryo transfer yielded higher, but not statistically significant, clinical pregnancy (48% vs. 44%) and implantation rates (22% vs. 20%). The incidence of multiple pregnancies, ectopic and multiple pregnancy rates were similar. The frequency of negative factors typically associated with difficult transfers, such as requirement of use of tenaculum, and presence of blood or mucus in the catheter tip, were significantly lower in the ultrasound-guided group in comparison with the clinical touch group. Ultrasound-guided embryo transfer was associated with a significantly increased easiness of transfer performance; 95% of the transfers were rated as very easy in the ultrasound-guidance group compared to 87% in the clinical touch group. The use of a soft pass catheter was the only variable independently and significantly associated with pregnancy success (odds ratio = 2.74).

CONCLUSION(S)

Ultrasound-guidance facilitates embryo transfer and in combination with the use of a soft catheter should be implemented to optimize embryo transfer results.

Failed fertilization: is it predictable?

PURPOSE OF REVIEW

The purpose of this review is to critically examine the ability of screening tests to predict fertilization failure.

RECENT FINDINGS

Failed fertilization occurs in 5-10% of in-vitro fertilization cycles and 2-3% of intracytoplasmic sperm injection cycles. Failed fertilization may result from impaired spermatozoa, oocyte deficiencies or defects in the in-vitro sperm/oocyte medium. In the in-vitro fertilization setting most cases are caused by male factor deficiencies, whereas failure of oocyte activation is the most common cause of failed fertilization after intracytoplasmic sperm injection. Although the standard semen analysis has limited ability to predict fertilization failure, strict sperm morphology criteria, sperm-zona binding ratios and zona pellucida induced acrosome reaction tests provide increased capacity to avoid this outcome. The quality of the semen sample on the day of oocyte retrieval and fertilization performance in previous in-vitro fertilization cycles may also guide the appropriate use of intracytoplasmic sperm injection. However, the routine use of the latter technique in cases of non-male factor infertility is contraindicated.

SUMMARY

The ever improving techniques highlighted in this analysis offer improved ability to predict failed fertilization.

Comparison of sibling oocyte outcomes after intracytoplasmic sperm injection and in vitro fertilization in severe teratozoospermic patients in the first cycle

To follow up the outcome of sibling oocytes subjected to both conventional in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) in the first cycles of severe teratozoospermic patients with normal sperm morphology (NSM)<or=4%, a total of 1193 sibling metaphase II oocytes (MII) in 85 cycles were randomly allocated into two groups: 588 underwent IVF and 605 ICSI and the embryo outcomes between the two groups were compared. The fertilization rate was significantly higher in the ICSI groups than in the IVF group (p < 0.05) and fertilization failure rate in the ICSI group (2.3%) was lower than in the IVF group (28.2%). Subsequently, the rates of embryo arrest as well as grade 1 and 2 embryo formation before day 3, >or=6 cell embryos on day 3 and blastocyst formation on days 5 and 6, did not differ significantly between the two groups. There was a trend towards a high pregnancy rate cycle in mixed ICSI/IVF embryo transfer (ET) (49.1%). In conclusion, this study showed that in couples with only severe teratozoospermia, there was a benefit in subjecting sibling oocytes to both IVF and ICSI in the first cycle because 24 (28.2%) cycles of total fertilization failure were avoided. Furthermore, despite initially significant higher fertilization rates in ICSI than IVF oocytes, subsequent rates of development from >or=6 cells up to blastocyst stage were the same suggesting that ICSI should be used with caution, as after day 3, ICSI-derived embryo development was compromised compared with IVF.

Analysis of intracytoplasmic sperm injection procedures related to delayed insemination and ejaculated, epididymal and testicular spermatozoa

In all, 1210 treatment cycles were divided into three categories for retrospective analysis according to the period of delay between oocyte retrieval (occurring at a fixed time after human chorionic gonadotrophin) and intracytoplasmic sperm injection (ICSI) of <3 h, 3-5 h, >5 h (referred to as 'delayed ICSI'). Three stages from oocyte to the birth of a live baby were identified for statistical analysis, (i) fertilization (2PN zygotes), (ii) cleavage of 2PN zygotes, (iii) transferred embryo to live birth. Stages 1, 2 and 3 were analysed statistically for the three time periods. Chi-square analysis showed no significant effect of delayed ICSI on fertilization (chi(2) = 3.615, P = 0.65), and embryo transfer to birth (chi(2) = 1.840, P = 0.399). The effect on cleavage was significant (chi(2) = 9.625, P = 0.008). However, shorter incubation times produced results which were better than the traditional longer ones. The success rate at the cleavage stage was so high that the marginal advantage had very little effect on the overall process. This study of a substantial patient sample establishes that ICSI on a peri-ovulatory oocyte (<3 h after oocyte retrieval) does not compromise outcome parameters, and that longer periods of incubation (>5 h) do not offer a statistically significant advantage.

Five years experiences with microinjection of testicular spermatozoa into oocytes in Hungary

The aim of the study was to summarize our five years experience (1996-2000) of testicular spermatozoa for intracytoplasmic sperm injection in Hungary. The influence of sperm count, maternal age, number of transferred embryos, and application of assisted hatching on outcome was investigated. Testicular spermatozoa were retrieved by microsurgical testicular sperm extraction. Samples were classified depending on the number of spermatozoa. Indication for testicular sperm extraction in conjunction with intracytoplasmic sperm injection was severe azoospermia or azoospermia combined with tubal origin infertility. Ovarian stimulation was carried out using an ultrashort protocol with GnRH agonist and gonadotrophin. Intracytoplasmic sperm injection was performed without PVP. Embryos were cultured for 48 or 72 h before embryo transfer. Indications for assisted hatching included elevated maternal age, increased zona thickness or at least two previous unsuccessful IVF cycles. Testicular spermatozoa were successfully retrieved in 218 out of 273 cases. Extreme low sperm count was found more frequently in cases of nonobstructive azoospermia. No significant differences were observed in fertilization rate (61.1% vs. 51.7%) or clinical pregnancy rate (29.0% vs. 26.7%) between patients with obstructive or nonobstructive azoospermia. Maternal age, number of transferred embryos and application of assisted hatching had a significant effect on outcome. A total of 55 clinical pregnancies were achieved, including 14 sets of twins, three sets of triplets and two sets of quadruplets. It is concluded that testicular sperm extraction is an efficient way of obtaining testicular spermatozoa, allowing not only successful fertilization by ICSI, but also freezing of testicular spermatozoa for use in subsequent cycles.