In-vitro fertilisation of oocytes from women with serum antisperm antibodies

Effects of in vivo exposure to eggs with sperm-immobilizing antibodies in follicular fluid on subsequent fertilization and embryo development in vitro

Aims:  It has been shown that supplementation of patients' sera that contains sperm-immobilizing antibodies results in failure of fertilization and embryo development in vitro. The present study was carried out to investigate if exposing retrieved eggs to a high number of sperm-immobilizing antibodies in the follicular fluid (FF) in vivo affected subsequent fertilization and embryo development in vitro, even if they were washed with an antibody-free culture medium. Methods:  Patients' sera and their FF were collected in 15 in vitro fertilization-embryo transfer (IVF-ET) or intracytoplasmic sperm injection-embryo transfer (ICSI-ET) treatment cycles from 11 infertile women with sperm-immobilizing antibodies in their sera. Quantitative sperm-immobilizing antibody titers (SI₅₀ titers) in the sera and FF were evaluated. The fertilization rate, good-quality embryo rate and implantation rate by IVF-ET were compared between infertile patients having higher (10≤) SI₅₀ titers and lower (<10) SI₅₀ titers in their FF. Results:  There was a significant correlation in the SI₅₀ titers between the patients' sera and their FF (P < 0.0001). After thoroughly washing the collected eggs in culture medium without the patient's serum before IVF, there was no difference in the fertilization rate in the patients with high (10≤) and low (<10) SI₅₀ titers in their FF (P = 0.62). However, the good-quality embryo rate in the patients with a high SI₅₀ titer was significantly lower than patients with a low antibody titer (P < 0.05). There was no significant difference in the implantation rate between the two groups (P = 0.33). Conclusions:  Similar amounts of sperm-immobilizing antibodies existed in the patients' FF and in their sera. ICSI did not seem to be necessary in patients having the antibodies if their sera were not supplemented in the culture media. Even with careful manipulation of eggs, it might be suggested that the harmful effects of sperm-immobilizing antibodies on embryo development cannot be completely avoided, especially in patients with high SI₅₀ titers in the FF. (Reprod Med Biol 2006; 5: 137-143).

Effects of in vivo exposure to eggs with sperm-immobilizing antibodies in follicular fluid on subsequent fertilization and embryo development in vitro

Aims:  It has been shown that supplementation of patients' sera that contains sperm-immobilizing antibodies results in failure of fertilization and embryo development in vitro. The present study was carried out to investigate if exposing retrieved eggs to a high number of sperm-immobilizing antibodies in the follicular fluid (FF) in vivo affected subsequent fertilization and embryo development in vitro, even if they were washed with an antibody-free culture medium. Methods:  Patients' sera and their FF were collected in 15 in vitro fertilization-embryo transfer (IVF-ET) or intracytoplasmic sperm injection-embryo transfer (ICSI-ET) treatment cycles from 11 infertile women with sperm-immobilizing antibodies in their sera. Quantitative sperm-immobilizing antibody titers (SI₅₀ titers) in the sera and FF were evaluated. The fertilization rate, good-quality embryo rate and implantation rate by IVF-ET were compared between infertile patients having higher (10≤) SI₅₀ titers and lower (<10) SI₅₀ titers in their FF. Results:  There was a significant correlation in the SI₅₀ titers between the patients' sera and their FF (P < 0.0001). After thoroughly washing the collected eggs in culture medium without the patient's serum before IVF, there was no difference in the fertilization rate in the patients with high (10≤) and low (<10) SI₅₀ titers in their FF (P = 0.62). However, the good-quality embryo rate in the patients with a high SI₅₀ titer was significantly lower than patients with a low antibody titer (P < 0.05). There was no significant difference in the implantation rate between the two groups (P = 0.33). Conclusions:  Similar amounts of sperm-immobilizing antibodies existed in the patients' FF and in their sera. ICSI did not seem to be necessary in patients having the antibodies if their sera were not supplemented in the culture media. Even with careful manipulation of eggs, it might be suggested that the harmful effects of sperm-immobilizing antibodies on embryo development cannot be completely avoided, especially in patients with high SI₅₀ titers in the FF. (Reprod Med Biol 2006; 5: 137-143).

Effects of sera from infertile women with sperm immobilizing antibodies on fertilization and embryo development in vitro in mice

PROBLEM

This study was performed to investigate if patients' sera with anti-human sperm antibodies show inhibitory effects on in vitro fertilization (IVF) and embryo development in mice.

METHOD OF STUDY

Patients' sera were collected from eight infertile women having sperm immobilizing antibodies and 17 infertile women without the antibodies. Male ICR mice and female F1 mice (BALB/c X C57BL/6J) were used. In mouse IVF, pre-incubated sperm were cultured in the medium containing patient's serum with or without sperm immobilizing antibodies, or bovine serum albumin (BSA) as a control. The fertilization rates and the incidences of blastocyst formation were compared.

RESULTS

A mouse sperm immobilization test was established. Five (62.5%) of eight serum samples with sperm immobilizing antibodies and nine (52.9%) of 17 serum samples without the antibodies showed sperm immobilizing activities in mice. There was no significant difference between the two groups. Five sera with sperm immobilizing activities in human and mice, and five sera without sperm immobilizing activities in human or mice were used for the further experiments. The fertilization rates in BSA, patient's serum with sperm immobilizing antibodies, and that without the antibodies were 82.5% (746/904), 43.6% (508/1165), and 64.5% (669/1037), respectively. There were significant differences between the groups. The incidences of blastocyst formation were 59.9% (447/746), 31.7% (161/508), and 47.7% (319/669), respectively. There were also significant differences between the groups.

CONCLUSIONS

Some of the patient's serum with and without sperm immobilizing antibodies could immobilize sperm with complement. However, as compared with control, sera with sperm immobilizing activities against human and mouse sperm significantly blocked IVF and inhibited embryo development in mice. Further studies are required to investigate the mechanisms of the blocking effects of antisperm antibodies on fertilization and embryo development using the mouse model.

Clinical assessment of male infertility in the era of intracytoplasmic sperm injection

This communication outlines the major causes of infertility in the male and, where indicated, the application of in vitro fertilization and intracytoplasmic sperm injection in their treatment. It also points out that there are many types of infertility in the male where other methods of treatment are also successful and where reproductive technology is unnecessary.

High implantation rate and consequently high pregnancy rate by in vitro fertilization-embryo transfer treatment in infertile women with antisperm antibody

OBJECTIVE

To examine the effect of antisperm immunity on postfertilization steps, such as implantation of embryos and fetal growth in IVF-ET treatment of women with sperm-immobilizing antibodies.

DESIGN

Retrospective analysis of clinical laboratory data.

SETTING

The IVF-ET program of the Department of Obstetrics and Gynecology. The University of Tokushima, School of Medicine.

PATIENTS

Eighteen women with sperm-immobilizing antibodies and 122 infertile patients with nonimmune etiology as controls. Infertile couples due to a male factor and with unknown etiology were excluded.

INTERVENTIONS

All patients received the same IVF-ET program with GnRH agonist.

MAIN OUTCOME MEASURES

Rates of fertilization and cleavage, implantation rate per embryo transferred and pregnancy rate (PR) in both test and comparison groups.

RESULTS

The rate of fertilization in the antisperm group (61.3%) was significantly lower than that in the comparison group (76.8%). But the implantation rate per embryo transferred (23.5%) and consequently the modified PR per oocyte recovery procedure (34.4%) in immunologically infertile women were significantly higher than those in the comparison group (7.9% and 17.8%, respectively).

CONCLUSIONS

Although sperm-immobilizing antibodies prevent sperm-egg interaction, they do not seem to have any adverse effects on achievement of pregnancy. Moreover, the existence of antisperm immunity in woman with antisperm antibodies is suggested to be favorable for successful pregnancy by the IVF-ET procedure.

Relationship of sperm antibodies in women and men to human in vitro fertilization, cleavage, and pregnancy rate

PROBLEM

The presence of anti-sperm antibodies (ASA) in female serum has been correlated with decreased fertilization in the in vitro fertilization (IVF) program; however, the impact of each type of ASA (IgG, IgA, IgM) is not known.

METHOD

To clarify the role of each ASA subtype, the immunobead binding technique was used to identify IgG, IgA, and IgM ASA in the female sera and on the spermatozoa from 137 couples undergoing the IVF program.

RESULTS

Couples with ASA on spermatozoa had a lower fertilization rate and lower number of transferred embryos: and IgG was the major immunoglobin involved. Couples with ASA in female sera showed significant decreases in the rates of fertilization, cleavage, and number of transferred embryos only when IgM was detected, but not IgG or IgA. However, the presence of IgA ASA in female sera was only associated with a decrease in pregnancy rate, although the number of transferred embryos was not reduced.

CONCLUSION

These findings suggest that ASA can influence the results of IVF and that the specific effect is dependent upon the subtypes of ASA.

The detection of antisperm antibodies in serum: a comparison of the tray agglutination test, indirect immunobead test and indirect SpermCheck assay

Testing for antisperm antibodies (ASAs) is an important part of the work-up of the sub-fertile couple, yet there is little consensus regarding the most appropriate methods. The SpermCheck assay (GSC; Bio-Rad Laboratories Inc., Diagnostics Division, Hercules, CA, U.S.A.) is supplied with wash buffer, controls and bead reagent which detects all three major classes of ASAs (IgA, IgG and IgM) in a single test. This study compared results on a bank of samples using the tray agglutination test (TAT), immunobead test (IBT), GSC and a modified SpermCheck assay to detect a single isotype in each test (SISC). The IBT and SISC showed excellent correlation, with 127/141 (90.1%) tests agreeing. There was an apparent lack of sensitivity to IgM with GSC as 8/15 (53.3%) samples testing positive with IBT and 7/15 (46.7%) testing positive with SISC were negative with GSC. Of the 24 IBT-negatives, seven (29.2%) were positive for TAT, indicating a high incidence of non-immunological agglutination, though this decreased as the TAT titre increased. The proportion of samples testing positive for IBT increased with TAT titre: 3/20 (15.0%) for TAT-negative samples, 6/10 (60.0%) for low titres and 21/24 (87.5%) for high titres. This was also observed when comparing the GSC with TAT. The TAT therefore appears useful as a first-line screen, whilst the inability of the GSC to adequately detect IgM limits its use as an indirect test. Both the IBT and SISC can be used to further investigate the type and class of ASA present.

The effect of female antisperm antibodies on in vitro fertilization, early embryonic development, and pregnancy outcome

STUDY OBJECTIVE

To evaluate the extent to which human in vitro fertilization-embryo transfer (IVF-ET) alleviates immunological infertility.

DESIGN

Retrospective.

SETTING

In vitro fertilization program.

PATIENTS

Thirty-three patients with positive antisperm antibodies undergoing 50 cycles of IVF-ET in which maternal serum was replaced by 5 mg/mL of bovine serum albumin (BSA) comprised the study group. Seventy-one patients with tubal infertility served as controls. In 50 of these, medium was supplemented with 7.5% maternal serum, and 21 were assigned to BSA substitution.

RESULTS

Percentage of fertilization in the study group was significantly lower (41 +/- 31; mean +/- SD) than that of controls with maternal serum (77 +/- 15) and BSA (76 +/- 22). Early embryonic quality, as assessed by percentage of cleavage and morphological grading, was found to be inferior in patients with antisperm antibodies. The percentage of advanced embryos (greater than or equal to 4 blastomeres) at the time of transfer was 42 +/- 39 in the study group, compared with 65 +/- 23 and 75 +/- 35 for maternal serum and BSA controls, respectively. Percentage of morphologically favorable embryos (grades 1 and 2 in a 1 to 5 grading system) was 49 +/- 31 in the study group, compared with 78 +/- 35 and 74 +/- 23 for the controls. Percentage of clinical pregnancy was somewhat lower in the study group (12.5%) than in controls with either maternal serum (18%) or BSA (19%).

CONCLUSIONS

Antisperm antibodies may have an adverse effect on fertilization and early embryonic development. Female immunological infertility may not be completely alleviated by IVF-ET.

The role of superovulation with menotropins in ovulatory infertility: a review

The risks of menotropin therapy (ovarian hyperstimulation syndrome, multiple gestation, adnexal torsion) are well known and have been previously described. Superovulation should not be considered for the indications described herein until more traditional therapies for infertility have been tried and found unsuccessful and sufficient time has elapsed for conception to occur. The cost of superovulation is high: the medications are expensive, frequent E2 monitoring and US studies are costly, and pregnancy complications relating to the higher rate of pregnancy loss and multiple gestation may add substantially to the overall cost. Yet, compared with IVF and GIFT, superovulation cycles combined with IUI cost between one third to one sixth that of an IVF cycle. Protocols involving combined CC/hMG/hCG, which reduce the total number of ampules of Pergonal needed per cycle and still provide multiple follicular development, may further reduce costs. There is a growing consensus that superovulation-IUI protocols should be attempted before GIFT and IVF in couples with normal pelvic viscera. There is little doubt that IVF and GIFT cycles are more costly, stressful, and complex. No comparative data have clearly shown IVF and GIFT to be superior to superovulation protocols in ovulatory women with normal pelvic anatomy. In the only study examining this issue published to date, Kaplan et al. retrospectively analyzed all GIFT and superovulation/IUI cycles at a single university center and found GIFT to be three times more efficient. However, the inherent limitations of a nonrandomized, nonprospective study of this kind are obvious as these authors have suggested. Therefore, it may be wise to consider the use of superovulation before assisted reproductive technologies until this issue is settled. It would be interesting to determine if the high PRs reported for couples with unexplained infertility or mild endometriosis in IVF and GIFT cycles in some centers not incorporating superovulation/IUI protocols would hold up if such an approach was routinely followed. Despite the increasing acceptance of superovulation protocols, we must be aware that many of the studies suggesting a role of hMG in treating ovulatory infertile women with normal pelvic anatomy suffer from deficiencies in experimental design. In a payor-driven system, such as in the United States, the difficulties in designing and carrying out scientifically sound clinical studies examining infertility therapies are obvious. The lack of federal or outside funding for the study of infertility issues contributes to the problem. It is our hope that better designed studies examining the role of superovulation in the treatment of ovulatory infertile women with normal pelvic anatomy will be forthcoming.

Correlation between quantitative antibody titers of sperm immobilizing antibodies and pregnancy rates by treatments

Immunological infertility in women who possessed sperm immobilizing (SI) antibodies made it very difficult to conceive using the usual treatments. We examined SI antibodies by the quantitative Sperm Immobilization Test and found the antibody titers (50% sperm immobilization unit: SI50 unit) associated with pregnancy rates. Patients with high SI50 titers (greater than 10 units) did not conceive by ordinary or repeated artificial inseminations with husband's semen (AIH) except when treated with in vitro fertilization (IVF) and embryo replacement. Patients with relatively low SI50 titers (less than 10 units) could conceive either by repeated or ordinary AIH, though the success rates were lower than by IVF-embryo replacement. It is important to assess the SI50 titers by the quantitative method to select treatments for infertile women with SI antibodies. In follow-up studies of the patients who conceived successfully, it was found that SI50 titers tended to decline as pregnancy proceeded.

Fertilization of human oocytes in vitro by spermatozoa from oligozoospermic and normospermic men

Sperm were isolated from the semen of oligozoospermic (less than 20 x 10(6) sperm/ml) and normospermic (greater than or equal to 20 x 10(6) sperm/ml) men in an in-vitro fertilization (IVF) programme. Oocytes from the female partners were inseminated with either 75 or 100 x 10(3) motile sperm and checked for fertilization after 16-20 h. A significant reduction in the overall fertilization rate of oocytes was seen for the oligozoospermic group compared to the normospermic group, at both insemination concentrations. In the oligozoospermic group, a fertilization rate of 31% (19/61) was achieved when oocytes were inseminated with 75 x 10(3) sperm, and 38% (9/24) when inseminated with 100 x 10(3) sperm. This compared with rates of 57% (397/696) and 64% (650/1018), respectively, for normospermic cases at both insemination concentrations. No evidence of fertilization was seen in 36% (4/11) and 67% (4/6) of oligozoospermic cases when 75 or 100 x 10(3) sperm were used, compared with values of 13% (17/133) and 9% (20/212), respectively, in normospermic cases. After excluding zero cases, the fertilization rate of oocytes for the oligozoospermic group (75%; 9/12) was similar to the normospermic group (70% 650/935) when 100 x 10(3) sperm were used. However, when 75 x 10(3) sperm were used, the fertilization rate for the oligozoospermic group (41%; 19/46) was significantly lower than that of the normospermic group (62%; 397/645). Following the transfer of embryos into the female partner, clinical pregnancies were diagnosed in 2/7 (29%) oligozoospermic cases and 27/267 (10%) normospermic cases.(ABSTRACT TRUNCATED AT 250 WORDS)

The effects of antibody sperm-egg interaction

Previous studies have shown that high titers of antisperm antibodies are correlated with low fertility. Furthermore, immunosuppressive therapy enhances pregnancy in some individuals. Serum tests, however, provide only an indirect measure of a potential pool of antisperm antibodies. When men have antibodies, direct measurement of the percent of sperm that are entirely antibody bound is a more appropriate approach. Antibodies can affect fertilization at many sites. Since sperm are composed of numerous antigens, many antibodies can develop but not all of them will interfere with infertility. Better tests are necessary to define which antibodies may affect fertility. To do that requires the development of better antigens. Use of monoclonal antibodies allows a framework for such further modifications.

Intrauterine insemination as treatment for antisperm antibodies in the female

Ninety-one women with long-standing infertility in the presence of humoral antisperm antibodies (ASA) underwent 473 cycles of intrauterine insemination of washed sperm (IUI), resulting in 26 pregnancies. Nine pregnancies were achieved in 67 women who underwent 285 IUI during unstimulated cycles (13% pregnancy rate; 3% pregnancy/cycles of treatment). Twenty women underwent 86 IUI after clomiphene citrate (CC) stimulation, resulting in 6 pregnancies (30%; 7% per cycle), while 28 underwent 102 cycles of IUI after human menopausal gonadotropins (hMG) stimulation, resulting in 11 pregnancies (39%; 11% per cycle). Twenty-one of the 26 pregnancies (81%) were achieved in the first 2 IUI cycles. During unstimulated and CC IUI cycles, all pregnancies occurred in the first two cycles of treatment, while with hMG stimulation pregnancies also occurred in the third, fourth, and fifth IUI cycles. Nine of these 91 women subsequently conceived spontaneously, and three others conceived through in vitro fertilization. Only 6 of the 38 pregnancies resulted in spontaneous abortion (16%). Thus, pregnancies achieved in women with ASA have no increased risk of abortion.

Results of in vitro fertilization in women with antisperm antibodies in serum, cervical mucus, and follicular fluid

This study was undertaken to investigate the presence of antisperm antibodies (ASA) in serum, cervical mucus, and follicular fluid (FF) of women undergoing in vitro fertilization and embryo transfer (IVF-ET). IgG and IgA ASA directed mostly against sperm head were found at similar concentrations in serum, cervical mucus, and FF of 2 of 34 patients. Ninety-one percent fertilization and 100% cleavage rates, respectively, were observed in one of the two patients. No fertilization occurred in the second patient. In both women, in vitro sperm penetration tests revealed hostile mucus and repeated postcoital tests were poor. It is concluded that the sperm-cervical mucus penetration test and mucus ASA measurements are useful in establishing the diagnosis of immunological infertility.

The reproductive autoimmune failure syndrome

The association between reproductive failure and abnormal autoimmune function has been recognized for decades in association with such established autoimmune diseases as systemic lupus erythematosus. Recent investigations have expanded this association to women who demonstrate similar humoral abnormalities as patients with defined autoimmune diseases but do not express any of the clinical symptoms required for the diagnosis of an autoimmune disease. The observation that abnormal autoimmune function in clinically asymptomatic patients can lead to reproductive failure has led us to define the reproductive autoimmune failure syndrome as a diagnostic entity. The present article summarizes evidence suggesting that the occurrence of reproductive autoimmune failure syndrome may be teleologically related to the woman's need for increased self-tolerance in face of antigenic exposure to the maternal haplotype of the fetus during normal pregnancy. This need for increased self-tolerance is documented by higher normal autoantibody levels in women than in men and may also be responsible for the highly increased incidence of autoimmune diseases in women in comparison with men. Under this concept, abnormal autoimmune function may lead to reproductive failure at different stages of the reproductive process, depending on the quality and possibly quantity of the abnormal autoimmune response.

Blocking effect of sperm immobilizing antibodies on sperm penetration of human zonae pellucidae

To investigate the mechanism of the blocking effect of sperm immobilizing antibodies on human fertilization, an in vitro zona penetration test was carried out using media containing the IgG fraction extracted from sperm immobilizing antibody-negative or -positive serum. The sperm penetration rate of the test was 100% (6/6) when spermatozoa were treated with the IgG fraction derived from sperm immobilizing antibody-negative serum, whereas it was only 17% (1/6) when spermatozoa were treated with the IgG fraction derived from sperm immobilizing antibody-positive serum. Electron microscopic observation of the sperm immobilizing antibody-negative and -positive serum-treated spermatozoa showed that the number of acrosome-reacted spermatozoa was significantly greater in the sperm immobilizing antibody-negative serum than in the antibody-positive serum. Therefore, it appears that one of the blocking mechanisms of the spermatozoal penetration of the zona pellucida by sperm immobilizing antibodies may be due to inhibition of the acrosome reaction in the spermatozoa.

Sperm antibodies and human fertilization

Previous investigations using zona-free hamster oocytes and salt-stored human zonae pellucidae, and retrospective analysis of routine human in vitro fertilization (IVF) results have suggested that sperm antibodies can impair the fertilizing capacity of human spermatozoa. The results of our investigations using viable human oocytes confirm that human antispermatozoal antibodies can inhibit fertilization by human spermatozoa. In the future we plan to examine the mechanism of fertilization inhibition, including characterization of the sperm antigens involved. These studies may facilitate the development of immunocontraceptive vaccines and of new treatments for immunological infertility.

Autoantibodies and common idiotypes in men and women with sperm antibodies

Antisperm antibodies have been implicated as a causative factor of infertility and pregnancy wastage. Since concomitant autoimmune phenomena were reported in men with antisperm antibodies, we investigated known antisperm antibody-positive sera from 25 women, 27 men, and the respective seminal plasma samples. The investigated autoimmune panel included a search for antinuclear antibodies, autoantibodies (in IgG, IgM and IgA isotypes) to seven phospholipids (cardiolipin, phosphatidylserine, phosphatidylglycerol, phosphatidylcholine, phosphatidylethanolamine, phosphatidylinositol, and phosphatidic acid), to four histone subfractions (H1, H2A, H3, H4), and to four polynucleotides [ssDNA, dsDNA, poly(I), and poly(dT)], total immunoglobulin levels, and sperm antibody titers. The sera were also evaluated for the presence of a common anti-deoxyribonucleic acid antibody, and anticardiolipin antibody idiotypes. Levels of sperm antibody titers were significantly lower in women than in men. Both men and women with antisperm antibodies demonstrated elevated total IgG levels compared with those of normal control subjects. Only women showed elevated levels of total IgM. Sera from 24% of women and 11% of men with antisperm antibodies demonstrated antinuclear antibody titers greater than 1:40. The most striking autoantibody abnormalities were found among antiphospholipid antibodies. Sera from women with antisperm antibodies demonstrated higher autoantibody production than was found in their male counterparts. A significant correlation was found between antisperm antibodies and IgM anticardiolipin and IgA anti-phosphatidylinositol in women and between sperm antibodies and IgA phosphatidylserine antibodies in men. The presence of anticardiolipin and anti-deoxyribonucleic acid antibody idiotypes was significantly more frequent in women than in men. By means of discriminant analysis and variables selected by this mathematical model, the identification of 24 of 25 women and 26 of 27 men with antisperm antibodies was correctly predicted. These results suggest that women and men respond differently to sperm antigens. The apparent cross-reactivity between sperm antibodies and other autoantibodies, usually associated with autoimmune disease, suggests that a polyclonal B cell activation, similar to that seen in autoimmune diseases, occurs in patients with sperm antibodies.

Pregnancies following pronuclear stage tubal transfer

Pronuclear stage tubal transfer (PROST) is a technique that involves in vitro fertilization (IVF) of oocytes, followed by the transfer of pronuclear oocytes into the fallopian tubes. It has been developed for its prognostic value of confirming fertilization in couples with oligospermia or asthenospermia and enabling fertilization in cases with antispermatozoal antibodies (ASAB). PROST has provided useful diagnostic information in the management of couples who have failed to conceive in other treatment programs and has particular advantages over IVF for those receiving fresh donated oocytes for ovarian failure. Fourteen pregnancies resulted from 52 transfers, providing a pregnancy rate of 27% per transfer. The pregnancy rates were higher than a matched IVF series in the male factor and female ASAB groups and reached statistical significance for the ovum donation group. It is anticipated that both pregnancy rates and fetal wastage will be improved over conventional IVF and embryo transfer for the described infertility groups.

How should sperm antibody tests be used clinically?

Immunoglobulin-specific assays are currently available for detection of patients with antibody-mediated infertility. Care must be taken in insuring that the correct immunoglobulin class is assayed, the assay is directed to the possible interaction of antibodies and sperm in the male or female genital tract, and the antigen employed will not detect antibodies against antigens not found on the plasma membrane of living sperm.

Cytotoxic sperm antibodies and in vitro fertilization of mature oocytes: a preliminary report

The fertilization rates of mature oocytes during in vitro fertilization and embryo transfer (IVF-ET) using fetal cord serum-supplemented insemination media were greater than or equal to 57% for five infertile couples without sperm antibodies (group 1). But they were less than or equal to 50% for four of nine infertile couples (group 2) with cytotoxic sperm antibodies in both partners (n = 6) or the husband alone (n = 3). Two women in group 1 were successful in achieving normal, full-term pregnancies with the delivery of normal infants (chi2 = 4.2, P less than 0.05, by chi-square analysis). One of them consistently tested negative for sperm antibodies, while her husband was previously treated with antibiotics for infection and transient sperm antibodies in the seminal plasma. Subsequently, antibody titers in the husband were in the normal range when the successful IVF-ET was performed. One woman in group 2, with antibodies to her autoimmune husband's sperm but not control sperm and with a long-standing poor postcoital test sperm motility, conceived through artificial insemination with donor sperm (AID) after failing to conceive with her husband through IVF-ET. These data suggest that the presence of cytotoxic sperm antibodies in the serum and/or secretions of both partners reduces the rates of fertilization of mature oocytes in spite of using fetal cord serum in the IVF media. Pregnancy achievement is impaired in this group.

Effect of sperm antibodies in females on human in vitro fertilization

The effect of sperm antibodies derived from the female partner's serum on fertilization and embryo cleavage was evaluated by analyzing the Royal Women's Hospital in vitro fertilization (IVF) data. The results suggest that antispermatozoal isoantibodies detected by the immunobead test (IBT) can interfere with IVF. Thus, in a group of patients with IBT-IgG and IBT-IgA sperm antibody titers of greater than or equal to 10 in serum, a low fertilization rate (15%) was obtained when the wife's serum was used as serum supplement in the IVF culture medium. Where replacement (antibody-negative donor or cord) serum was used in the culture medium, a higher fertilization rate (69%) was obtained (P less than 0.01). These results underline the importance of using replacement serum in cases where the wife has significant sperm antibody levels in her serum. Six pregnancies were obtained in the antibody-positive group (n = 20), five of which occurred in patients with IBT-IgG and IBT-IgA-titers less than 10, for a pregnancy rate of 5/9 in this subgroup. Four of these patients delivered (4/9). Analysis of larger groups of antibody-positive patients is required for further evaluation of these results and ascertainment of the likelihood of occurrence of posttransfer effects of sperm antibodies on the embryo.

Ultrasonically guided oocyte collection under local anesthesia: the first choice method for in vitro fertilization--a comparative study with laparoscopy

Ultrasonically guided oocyte collection gradually replaces laparoscopy in many in vitro fertilization (IVF) centers. In the present study we compare the efficacy of both methods in our IVF program. One hundred twenty patients were prospectively randomized into two groups. Sixty women underwent oocyte collection during laparoscopy under general anesthesia, and 60 women under ultrasound guidance with local anesthesia. Superovulation was induced with human menopausal gonadotropin/human chorionic gonadotropin. For the oocyte collection a cannula with a trocar was used for single percutaneous puncture, through which both ovaries could be reached by the aspiration needle. The number of aspirated oocytes and transferred embryos was higher in the laparoscopy group as compared with the ultrasound group (5.3 versus 4.0 per woman and 3.0 versus 2.3 per woman, respectively); but the clinical pregnancy rate per cycle was similar in both groups (12.5% versus 14.5%). Ultrasound aspiration seems to be as effective as laparoscopy in terms of oocyte retrieval and conception rates. Because the procedure is simple and inexpensive, we believe that it may replace laparoscopy as a method for oocyte collection in most patients who undergo IVF.

Antisperm antibodies and in vitro fertilization failure

A new enzyme-linked immunosorbent assay (ELISA)-based test (Zer, Jerusalem) has allowed us to show the presence of antisperm antibodies (1:32 to 1:64) in the blood of 14 (33%) of 32 patients undergoing in vitro fertilization and embryo transfer (IVF-ET) under gonadotropin stimulation. Observation of the morphology of fertilization in eight patients with and seven patients without antisperm antibodies has shown a significant association (P less than or equal to 0.025, Fisher exact probability test) among the cumulus/corona coagulation, the absence of fertilization, and the presence of these antibodies. Cumulus/oocyte complex washing and/or enzymatic cumulus removal are considered as elective interventions in the case of antisperm immunity. Each patient entering an IVF-ET program should have the antisperm antibody assay performed as a preliminary screening.

In vitro fertilization results for women with sperm antibodies in plasma and follicular fluid

In vitro fertilization (IVF) and embryo transfer results were analyzed for three women with sperm antibodies in their plasma and follicular fluid. These preliminary results suggest that substitution of the patients' serum by replacement serum in the fertilization and embryo growth media may prove to be an effective means of improving IVF treatment for women with sperm immunity.

The management of oligospermic infertility by in vitro fertilization

The fertilization rates of mature preovulatory oocytes aspirated from 156 women treated by in vitro fertilization were analyzed as a function of spermatozoal density and motility and the findings were correlated with the category of infertility (chronic oligospermia, tubal disease, endometriosis, serum antibodies to spermatozoa in the female, and unexplained infertility). Overall reduced fertilization rates were found in all cases if the semen sample presented on the day of fertilization demonstrated less than or equal to 5 million motile spermatozoa per milliliter, less than 40% motile forms, or the combined findings of less than 20 million per ml and less than or equal to 60% motile forms. Where the husband was known to have chronic oligospermia, reduced fertilization was found if the semen on the day of fertilization contained less than 20 million spermatozoa per ml and less than 12 million motile spermatozoa per milliliter. For cases of unexplained infertility, a poor fertilization rate was noted if the semen demonstrated less than 60% progressively motile forms regardless of the overall spermatozoal density, implying that a proportion of unexplained infertility is due to a disorder of spermatozoa reflected by reduced motility. Pregnancies were achieved in 5 of 26 cases with chronic oligospermia, including 2 where oligospermia was very pronounced (less than or equal to 5 million motile spermatozoa per milliliter).

Successful in vitro fertilization with sperm cells from a man with immune infertility

In vitro fertilization and embryo transfer was carried out in a couple that has been infertile for 7 years. High titers of antisperm autoantibodies in the husband's serum are (table, see text) believed to be the main cause of their infertility. Prolonged methylprednisolone treatment of the man combined with artificial insemination remained unsuccessful. In two IVF attempts embryos were obtained and replaced using capacitated sperm of the husband. A pregnancy was established in the second IVF cycle, but a spontaneous abortion followed after 6 weeks of amenorrhea.

Hormonal profiles in the follicular phase, luteal phase and first trimester of pregnancies arising from in-vitro fertilization

The hormonal profiles for oestradiol-17 beta, progesterone, prolactin and beta-human chorionic gonadotrophin (beta-hCG) are documented for the first 24 pregnancies arising from in-vitro fertilization during a collaborative project between the University of Western Australia and PIVET Laboratory. All patients had ovarian follicle stimulation with clomiphene citrate, sometimes combined with human menopausal gonadotrophin and all had oocyte recovery undertaken 36 h after injection of 5000 i.u. hCG. The follicular phase profile indicated that patients were admitted for the hCG injection when oestradiol-17 beta levels were around 1500 pmol/l per follicle with a dimension of greater than or equal to 1.6 cm on ultrasound. Luteal phase data indicated that oestradiol-17 beta and progesterone levels were two to three times higher than that expected during spontaneous conception cycles and those pregnancies which subsequently aborted had significantly lower levels in the late luteal phase. During pregnancy elevated oestradiol-17 beta and progesterone levels were maintained through the early weeks during organogenesis while the beta-hCG profile was similar to that reported for spontaneous pregnancies arising without ovarian stimulation. Six women aborted and the other 18 pregnancies have generated 22 infants.

Antispermatozoal antibodies in human follicular fluid

The possibility of antispermatozoal antibodies in women having significant effects in the higher regions of the female reproductive tract has been investigated. Follicular fluids (FF) and sera taken at the time of oocyte recovery from women undergoing in vitro fertilisation and embryo transfer (IVF-ET) were tested for the presence of antispermatozoal antibodies, and the concentrations of IgM, IgG, IgA, and complement C3 were determined. The concentrations of immunoglobulins and C3 in FF were consistent with transudation from serum inversely proportional to molecular weight. Titres of agglutinating and immobilizing antibodies in FF were usually one or two dilution steps below those of serum except where immobilizing activity was associated with IgM. IgG:IgA ratios were lower in FF from women with antispermatozoal antibodies, suggesting local production or enhanced transudation of IgA; however, a secretory component could not be detected in any of the follicular fluids in this study. Two women with antispermatozoal antibodies and infertility in excess of 5 years had successful IVF-ET and have delivered healthy infants.

The limitations of in vitro fertilization from males with severe oligospermia and abnormal sperm morphology

Thirty-one patients whose infertility was attributed to oligospermia were included for treatment by in vitro fertilization and embryo transfer. Three subgroups were defined: severe oligospermia (less than or equal to 5 million motile sperm/ml), moderate oligospermia (6 to less than 12 million motile sperm/ml), and abnormal sperm morphology (greater than 60% atypical). The fertilization rates were compared to those of a normospermic group managed concurrently. A modified overlay technique of sperm preparation is described for oligospermic samples so that the number of motile spermatozoa inseminated into each tube or culture dish containing a mature preovulatory oocyte was similar in each category, within the range 0.5 to 2 X 10(5)/ml. Significantly fewer oocytes were fertilized in the severe oligospermic group (P less than 0.001), suggesting a reduced capacity for fertilization by spermatozoa from severely oligospermic males. The fertilization rate of oocytes was normal in the moderate oligospermic group and those with abnormal morphology, although in the latter there was a significant delay noted in reaching the pronuclear stage (P less than 0.001), and the embryos were at a less advanced stage of cleavage at the time of transfer (0.001 less than P less than 0.01). Pregnancies were achieved in both the severe and the moderate oligospermic groups, with healthy infants delivered from each.

Human in-vitro fertilisation, in-vivo sperm penetration of cervical mucus, and unexplained infertility

Oocytes were recovered at routine diagnostic laparoscopy for infertility after stimulation with clomiphene and human chorionic gonadotropin. The results of in-vitro fertilisation (IVF) with the husband's semen were compared in 3 distinct groups of fully investigated infertile couples. Those with bilateral tubal occlusion (36) were combined with fertile controls undergoing sterilisation (6) to form a "tubal" group for normal reference. In this tubal group 48/88 (55%) oocytes were fertilised, at least one oocyte being fertilised in each of 33/42 couples (79%). In couples with a negative or poor postcoital test (PCT), despite mostly normal semen analysis, 8/50 (16%) oocytes were fertilised in 6/21 (29%) couples. In couples with unexplained infertility and a positive PCT, 22/61 (36%) oocytes were fertilised in 17/25 (68%) couples. The results show that spermatozoa unable to penetrate preovulatory cervical mucus are generally also unable to fertilise the human oocyte. They emphasise the biological and prognostic importance of the PCT, and the hidden frequency of defective sperm function as a cause of unexplained infertility. Human IVF is likely to be a more helpful diagnostic investigation than hamster egg penetration testing because it is specific for individual couples. If IVF is to offer therapeutic hope to couples with impaired sperm/mucus penetration the fertilisation rates and the numbers of mature oocytes stimulated for recovery will both have to be high.