Comparison of the ICSI outcome of ejaculated sperm with normal, abnormal parameters and testicular sperm

Intracytoplasmic sperm injection cycle success in patients under 35 years old with diminished ovarian reserve plus severe male factor

OBJECTIVE

We aimed to evaluate intracytoplasmic sperm injection (ICSI) outcomes in young patients with diminished ovarian reserve (DOR) plus severe male factor (SMF) compared with age-matched controls with DOR.

STUDY DESIGN

A total of 189 infertile women under 35 years with DOR undergoing ICSI procedures were included retrospectively. Participants whose partners' sperm analysis was normal considered as the DOR group (n = 154) and whose partners' had SMF considered as the DOR + SMF group (n = 35). The two groups were compared regarding cycle characteristics and pregnancy outcomes.

RESULTS

Demographic features except infertility duration were similar between two groups. The duration of infertility was significantly longer in the DOR + SMF group compared to the DOR group (p = 0.02). Ovarian stimulation characteristics, oocyte retrieval parameters, fertilization rate, quality of embryos, embryo cancellation rate, and development up to blastocyst stage were found similar between two groups. Implantation, clinical pregnancy, abortion, and live birth rate, multiple pregnancy rate per cycle were distributed homogenously between the DOR and DOR + SMF groups. Regarding perinatal and neonatal outcomes of groups, fetal height and weight were significantly lower in DOR + SMF group than in DOR group (p = 0.001 and 0.01, respectively). Gestational week at delivery was lower in the DOR + SMF group compared to the DOR group (p < 0.0001).

CONCLUSION

Fetal anthropometric measures were lower regarding to preterm delivery in the DOR + SMF group than the DOR group. Large sample-sized studies should be performed to explain the decreased gestational week at the time of delivery in the DOR + SMF group.

Reproductive Chances of Men with Azoospermia Due to Spermatogenic Dysfunction

Non-obstructive azoospermia (NOA), or lack of sperm in the ejaculate due to spermatogenic dysfunction, is the most severe form of infertility. Men with this form of infertility should be evaluated prior to treatment, as there are various underlying etiologies for NOA. While a significant proportion of NOA men have idiopathic spermatogenic dysfunction, known etiologies including genetic disorders, hormonal anomalies, structural abnormalities, chemotherapy or radiation treatment, infection and inflammation may substantively affect the prognosis for successful treatment. Despite the underlying etiology for NOA, most of these infertile men are candidates for surgical sperm retrieval and subsequent use in intracytoplasmic sperm injection (ICSI). In this review, we describe common etiologies of NOA and clinical outcomes following surgical sperm retrieval and ICSI.

Potential of testicular sperm to support embryonic development to the blastocyst stage is comparable to that of ejaculated sperm

PURPOSE

Recent studies have shown that improved clinical outcomes can be achieved by transferring blastocysts rather than cleavage-stage embryos. However, blastocyst transfer is not performed in all patients. The aim of this study was to compare clinical outcomes of intracytoplasmic sperm injection (ICSI) cycles using testicular sperm (TE) with those of ICSI cycles using ejaculated sperm (EJ).

METHODS

ICSI was performed using EJ in 141 cycles and TE in 37 cycles. Embryos were cultured for 5 days. The quality of embryos was assessed on days 3 and 5 before embryo transfer.

RESULTS

Fertilization rate was 77.3% in the EJ group and 69.6% in the TE group (p < 0.05). The good-quality embryos on day 3 and 5 were not different between the EJ and TE groups. Embryos did not develop to blastocyst stage in 7 cycles of the EJ group (5.0%) and 2 cycles of the TE group (5.4%). There were no significant differences in blastocyst formation and blastocyst quality (46.1% vs. 47.5% and 5.7% vs 5.8%, respectively) on day 5 between both groups. Embryos were transferred in all cycles. Implantation (22.8 vs. 24.7%), clinical pregnancy (44.7 vs. 43.2%), miscarriage (21.7 vs. 33.3%), and delivery (76.5 vs. 66.7%) did not differ between EJ group and TE group. Clinical outcomes of ICSI were not different between the EJ and TE groups.

CONCLUSIONS

In conclusion, the potential of testicular sperm supporting embryonic development to blastocysts is comparable to that of ejaculated sperm. Therefore, this study suggests that blastocyst transfer can be a very useful assisted reproductive technique in the ICSI cycles that require the use of testicular sperm, and the clinical outcomes of the cycles are comparable to those of ICSI cycles using ejaculated sperm.

Extreme spermatogenesis failure: andrological phenotype and intracytoplasmic sperm injection outcomes

Patients with very low sperm count through direct sperm examination can exhibit extreme oligozoospermia or cryptozoospermia (after centrifugation). The management of these patients is a real challenge for both clinicians and biologists. In this retrospective and comparative cohort study, we compared the andrological phenotype of patients with extreme alterations of spermatogenesis and assessed whether the origin of spermatozoa (testicular or ejaculate) had any influence on intracytoplasmic sperm injection (ICSI) outcomes. A total of 161 ICSI cycles were performed using ejaculated spermatozoa from 75 patients with extreme oligozoospermia (EOS) or cryptozoospermia (CS) and 150 ICSI cycles using extracted testicular spermatozoa from 74 patients with non-obstructive azoospermia (NOA). Physical, hormonal, ultrasound assessments, and ICSI outcomes were performed in each group. Cryptorchidism was significantly more frequent in the NOA group (60.8% vs. 22.6%, p = 0.001). FSH levels were significantly higher [18.9 IU/L (5.9-27.0) vs. 15.3 IU/L (9.0-46.5), p = 0.001] and the majority of inhibin B levels measured were found mostly undetectable in the NOA group as compared to EOS/CS group (31.1% vs. 10.7%, p = 0.0004). Moreover, we found no significant differences in the respect to the fertilization rates (48.9% and 43.3%, p = 0.43), implantation rates (17.4% and 15.9%, p = 0.77), and percentage of top quality embryo (22.4% and 20.4%, p = 0.73) between the two groups. The clinical pregnancy rates per embryo transferred were comparable in both groups (28.3% and 27.4%, p = 0.89). In this study, we showed for the first time a different andrological phenotype between EOS/CS and NOA groups. Indeed, cryptorchidism was significantly more frequent with more severe endocrine parameters found in the NOA group. These results reflect a more profound alteration in spermatogenesis in NOA patients. However, there was no difference in ICSI outcomes between NOA and EOS/CS groups.

Use of testicular versus ejaculated sperm for intracytoplasmic sperm injection among men with cryptozoospermia: a meta-analysis

OBJECTIVE

To examine outcomes of intracytoplasmic sperm injection (ICSI) using testicular versus ejaculated sperm among men with cryptozoospermia.

DESIGN

Meta-analysis.

SETTING

Not applicable.

PATIENT(S)

Men with cryptozoospermia undergoing consecutive ICSI cycles using ejaculated or testicular sperm.

INTERVENTION(S)

A systematic search was performed using PubMed (inception to August 2015). Inclusion criteria were studies comparing ICSI outcomes among men with cryptozoospermia using ejaculated and testicular sperm.

MAIN OUTCOME MEASURE(S)

Primary outcomes included ICSI fertilization or pregnancy rates (PRs). Secondary analysis included number of retrieved oocytes, maternal and paternal ages. Meta-analysis of weighted data using a random effects model was performed. Results are reported as relative risk or weighted mean differences (WMD) with 95% confidence intervals (CI).

RESULT(S)

Five cohort studies were included, encompassing 272 ICSI cycles and 4,596 injected oocytes. There were no differences in ICSI PRs (relative risk [RR] 0.53, 95% CI 0.19-1.42, I(2) = 67%) or fertilization rates (RR 0.91, 95% CI 0.78-1.06, I(2) = 73%) between testicular and ejaculated sperm groups. There was a significant trend toward increasing maternal age (WMD 1.69 years, 95% CI -2.71 to -0.66) and paternal age (WMD 2.61 years, 95% CI -4.73 to -0.48) with testicular sperm. There was no difference between numbers of oocytes retrieved (WMD 0.95, 95% CI -0.15 to 2.05). Post-hoc power analysis revealed pβ <20% for PR analysis and pβ <10% for fertilization rate analysis.

CONCLUSION(S)

The existing literature does not support a recommendation for men with cryptozoospermia to use testicular sperm in preference over ejaculated sperm for ICSI.

Follicular steroid hormones as markers of oocyte quality and oocyte development potential

CONTEXT:

Various components of follicular fluid are suggested as biochemical predictors of oocyte quality. Previous studies of follicular steroid hormone levels have shown disparate results when related with fertilization outcomes.

AIM:

The objective of the study was to relate the levels of steroid hormones of each individual follicle with oocyte maturation, fertilization results, embryo quality, and pregnancy rates.

SETTINGS AND DESIGN:

Prospective cohort study in a university hospital.

METHODS:

In 31 patients, who underwent intracytoplasmic sperm injection, it was performed an ultrasound guided aspiration of follicular fluid of the first two mature follicles from each ovary. Follicular levels of estradiol, progesterone, testosterone, and dehydroepiandrosterone sulfate were measured by chemiluminescent immunoassay.

STATISTICAL ANALYSIS:

Generalized estimating equation model.

RESULTS:

In follicular fluids with mature oocyte presence, in normal as well as in failed fertilization, there was a positive correlation between follicular testosterone and progesterone (r = 0.794, P = 0.0001 and r = 0.829, P = 0.0001). Progesterone levels were higher in cases of normal fertilization compared to failed fertilization (P = 0.003). B quality embryos came from oocytes immersed in follicular fluids with higher estradiol values and higher estradiol/progesterone and estradiol/testosterone ratios than those of C quality (P = 0.01; P = 0.0009; P = 0.001). Estradiol levels were higher in patients who achieved pregnancy (P = 0.02).

CONCLUSION:

The analysis of follicular hormone composition could be considered as an additional tool in oocyte selection.

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

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

Effect of Helicobacter pylori infection on pregnancy rates and early pregnancy loss after intracytoplasmic sperm injection

BACKGROUND

There is a need to elucidate what affects the implantation and early pregnancy course in pregnancies conceived with assisted reproductive technology (ART) so that pregnancy rates and outcomes can be improved. Our aim was to determine the role of maternal Helicobacter pylori infection.

MATERIAL AND METHODS

We did a prospective study of 187 infertile couples undergoing intracytoplasmic sperm injection (ICSI) and segregated those according to underlying infertility etiology. We assessed the status of H. pylori IgG antibodies and anti-CagA IgG antibodies by ELISA assay. All pregnancies were followed for early pregnancy loss (EPL, first 12 weeks).

RESULTS

The likelihood of H. pylori infection increased with age (1.01, 95% confidence interval [CI]: 1.0-1.13; P = 0.040) but there was no association with EPL. Women infected with CagA-positive strains were more likely to have EPL (19.39, 95% CI: 1.8-208.4; P = 0.014). Women with tubal factor or ovulatory disorder infertility were more likely to abort early (12.95, 95% CI: 1.28-131.11; P = 0.030, 10.84, 95% CI: 1.47-80.03; P = 0.020, respectively). There was no association between EPL and age, number of embryos formed or transferred, or number of oocytes retrieved.

CONCLUSION

Our findings suggest that infection with CagA-positive H. pylori strains is linked to an increase in women's potential to abort early (possibly through increased release of inflammatory cytokines). In addition, tubal factor and ovulatory disorder infertility are linked to EPL after ICSI due to unknown mechanisms. Proposals to eradicate H. pylori infection prior to ICSI could lead to a decrease in EPL after ART.

Fresh MESA improved embryo fertilization, cleavage, blastula formation and implantation rates after failed TESA in couples with obstructive azoospermia

PURPOSE

To determine whether our use of fresh MESA cycles improved outcomes in patients with obstructive azoospermia who had failed IVF with TESA.

METHODS

A prospective observational trial of couples undergoing IVF for obstructive azoospermia was performed at an academic IVF center.

RESULTS

When TESA resulted in poor embryo cleavage, implantation and ongoing pregnancy rates, subsequent fresh MESA cycles in these same couples, demonstrated dramatic improvement in cleavage, blastulation, implantation and live birth rates.

CONCLUSIONS

In patients undergoing IVF-TESA-ICSI with obstructive azoospermia resulting in poor cleavage rates, blastulation rates and cycle failure, a repeat cycle with MESA may result in marked improvement in outcome.

Sperm defect severity rather than sperm Source is associated with lower fertilization rates after intracytoplasmic sperm injection

OBJECTIVE

To evaluate the impact of sperm defect severity and the type of azoospermia on the outcomes of intracytoplasmic sperm injection (ICSI).

MATERIALS AND METHODS

This study included 313 ICSI cycles that were divided into two major groups according to the source of spermatozoa used for ICSI: 1) Ejaculated (group 1; n = 220) and 2) Testicular/Epididymal (group 2; n = 93). Group 1 was subdivided into four subgroups according to the results of the semen analysis: 1) single defect (oligo-[O] or astheno-[A] or teratozoospermia-[T], n = 41), 2) double defect (a combination of two single defects, n = 45), 3) triple defect (OAT, n = 48), and 4) control (no sperm defects; n = 86). Group 2 was subdivided according to the type of azoospermia: 1) obstructive (OA: n = 39) and 2) non-obstructive (NOA: n = 54). Fertilization (2PN), cleavage, embryo quality, clinical pregnancy and miscarriage rates were statistically compared using one-way ANOVA and Chi-square analyses.

RESULTS

Significantly lower fertilization rates were obtained when either ejaculated sperm with triple defect or testicular sperm from NOA patients (63.4 +/- 25.9% and 52.2 +/- 29.3%, respectively) were used for ICSI as compared to other groups ( approximately 73%; P < 0.05). Epididymal and testicular spermatozoa from OA patients fertilized as well as normal or mild/moderate deficient ejaculated sperm. Cleavage, embryo quality, pregnancy and miscarriage rates did not differ statistically between ejaculated and obstructive azoospermia groups. However, fertilization, cleavage and pregnancy rates were significantly lower for NOA patients.

CONCLUSION

Lower fertilization rates are achieved when ICSI is performed with sperm from men with oligoasthenoteratozoospermic and non-obstructive azoospermic, and embryo development and pregnancy rates are significantly lower when testicular spermatozoa from NOA men are used.

The levels of steroid hormones and cytokines in individual follicles are not associated with the fertilization outcome after intracytoplasmic sperm injection

OBJECTIVE

To investigate the association between the levels of two steroid hormones and eight cytokines in fluids from individual follicles and the fertilization outcome of the oocytes derived from the same follicles.

DESIGN

Prospective study.

SETTING

University hospital.

PATIENT(S)

Forty-three women participating in intracytoplasmic sperm injection (ICSI)/ET cycles.

INTERVENTION(S)

The ovarian stimulation followed the multidose GnRH antagonist protocol. ICSI was performed in mature oocytes. The concentrations of estradiol, progesterone, tumor necrosis factor-alpha, interleukin (IL) -1beta, IL-6, vascular endothelial growth factor, leptin, basic fibroblast growth factor, epidermal growth factor, and insulin-like growth factor-I were measured by immunoassay methods in the follicles from which the mature oocytes were derived.

MAIN OUTCOME MEASURE(S)

The concentrations of the above hormones and cytokines in individual follicles and the fertilization outcome of the oocytes derived from the same follicles.

RESULT(S)

The intrafollicular concentrations of the above factors were not significantly associated with the fertilization outcome. These factors were not correlated with embryo quality, with the exception of leptin, which was weakly associated with embryo score (R = 0.276).

CONCLUSION(S)

The intrafollicular concentrations of the above factors cannot predict the fertilization outcome after ICSI.

Donor oocyte dysmorphisms and their influence on fertilization and embryo quality

The aim of this study was to identify predictors of fertilization rate (FR) and embryo quality (EQ) in 126 donor women who underwent 160 intracytoplasmic sperm injection (ICSI) cycles. Main outcome measures were oocyte dysmorphisms (OD) [perivitelline space (normal/large), perivitelline debris (no/yes), oocyte shape (spherical/non-spherical), zona pellucida (normal/abnormal), first polar body morphology (normal/fragmented or irregular), cytoplasmic granularity (normal/excessive), cytoplasmic vacuoles (no/yes) and colour of cytoplasm (normal/dark)], semen source (ejaculated or testicular), donor age, number of days of stimulation, plasma oestradiol concentration (pg/ml) on the day of human chorionic gonadotrophin administration, FR and day 2 EQ. No significant predictors of fertilization were identified. However, the presence of a dark cytoplasm decreased by 83% the likelihood of obtaining good quality embryos (OR=0.17; 95% CI: 0.04-0.74). Oocytes with a larger than normal perivitelline space were associated with 1.8 times higher chance of having good quality embryos (OR=1.80; 95% CI: 1.15-2.80). Patients and ovarian stimulation characteristics evaluated here did not affect FR and EQ. ICSI technique may guarantee good FR in spite of OD; however, certain cytoplasmic anomalies at the oocyte level, such as a dark cytoplasm, could compromise subsequent embryo development.

The effects of sperm quality on embryo development after intracytoplasmic sperm injection

PURPOSE

To explore the possible relationship between sperm quality and embryo development, pregnancy and implantation rates, in patients undergoing intracytoplasmic sperm injection (ICSI).

METHODS

Fertilization and cleavage rates, quality of embryos, blastocyst development, pregnancy and implantation rates were analyzed in 1020 embryos from 219 couples undergoing first ICSI treatment cycle. The couples were allocated in five groups, according to semen parameters: Group 1: patients with normal semen parameters, Group 2: patients with mild oligo-astheno-teratozoospermia, Group 3: patients with severe oligo-astheno-teratozoospermia, Group 4: patients with obstructive azoospermia, Group 5: patients with non-obstructive azoospermia.

RESULTS

Fertilization and cleavage rates, quality of embryos as well as blastocyst development rates were significantly reduced, as semen quality decreased. However, no significant differences were observed in clinical pregnancy and implantation rates.

CONCLUSION

Overall, a negative relationship was observed between semen quality and embryo development, even before activation of the embryonic genome, suggesting that sperm can affect embryogenesis from a very early stage.

Cytogenetic analysis of azoospermic patients: karyotype comparison of peripheral blood lymphocytes and testicular tissue

OBJECTIVE

The objective was to compare the results of a complete chromosomal, genetic and histological investigation in 13 azoospermic men with the results of the intracytoplasmic sperm injection (ICSI) procedure.

STUDY DESIGN

Peripheral blood samples were used for the measurement of follicle-stimulating hormone (FSH) levels, chromosomal analysis, microdeletions in the azoospermia factor (AZF) region of the Y chromosome and cystic fibrosis transmembrane conductance regulator (CFTR) mutation analysis. Testicular tissue was used for histological scoring and cytogenetic evaluation.

RESULTS

Peripheral blood cytogenetic analysis revealed a normal male karyotype in all cases. Chromosomal analysis from testicular tissue revealed a mosaicism for the terminal deletion of chromosome 22 with a breakpoint site at 22q13 in one patient with congenital bilateral absence of the vas deferens (CBAVD). Deletions in the AZFa, ATFb, and AZFc regions were not detected. The CFTR mutational analysis showed normal results in all patients.

CONCLUSIONS

Cytogenetic evaluation of testicular tissue should be performed in non-obstructive and obstructive azoospermic patients as well as in patients with multiple failed IVF and recurrent spontaneous abortion.

Does underlying infertility aetiology impact on first trimester miscarriage rate following ICSI? A preliminary report from 1244 singleton gestations

BACKGROUND

We evaluated the impact of using ICSI for assisted fertilization on first trimester survival rates of singleton gestations among an unselected infertile population.

METHODS

The 1244 singleton gestations achieved by ICSI were segregated according to underlying infertility aetiology, with 55.0% having male factor, 3.6% endometriosis, 4.3% polycystic ovarian disease, 9.1% tubal factor, 24.3% unexplained and 3.3% other. None of the patients had coexisting infertility factor.

RESULTS

The survival rate of all ICSI singleton gestations during the first trimester was 72.2%. There were no differences in early pregnancy loss (EPL) rate by infertility factor. Among patients undergoing ICSI because of male factor, there were no differences in EPL using ejaculated or non-ejaculated sperm. Regardless of aetiology, women aged >40 years had significantly higher EPL (42.1%).

CONCLUSION

Our preliminary results demonstrate that first trimester miscarriage rates of ICSI gestations are not affected by underlying infertility aetiology but are affected by maternal age.

Complete down-regulation is not mandatory for good assisted reproductive treatment cycle outcomes

OBJECTIVE

To determine the implications and predictive value of estradiol concentrations following pituitary down-regulation with gonadotrophin releasing hormone agonists in women undergoing controlled ovarian hyperstimulation for assisted reproductive technology.

STUDY DESIGN

A total of 277 patients undergoing ovarian hyperstimulation for intracytoplasmic sperm injection (ICSI) were enrolled into the study and the patients were divided into four groups according to estradiol levels on the initial day of stimulation of which group-A consisted of the patients who had < or =25 pg/ml (n=90), group-B with levels between 26 and 50 pg/ml (n=104), group-C with levels between 51 and 75 pg/ml (n=67) and group-D with levels > or =76-90 pg/ml (n=16) and the results were compared. The primary outcome measures included ovarian response and the clinical pregnancy rates.

RESULTS

The clinical pregnancy rates in groups-A, B, C and D were 33.3% (30/90), 26.0% (27/104), 35.8% (24/67), and 25.0% (4/16), respectively, and there was no statistically significant difference (P=0.482). The mean number of oocytes retrieved in groups were (9.7+/-5.8, 10.3+/-6.5, 11.0+/-6.8, and 12.1+/-6.6), respectively (P=0.453) and the fertilization rates in groups-A, B, C and D were found to be similar (75, 80, 73 and 79%, respectively; P=0.658).

CONCLUSION

Complete and deep desensitization obviously seems not to be mandatory for successful stimulation in assisted reproductive technology cycles.