A strategy for treatment of couples with unexplained infertility who failed to conceive after intrauterine insemination

Early cumulus cell removal increases cumulative live birth rate while having no negative effect on the malformation rate in in vitro fertilization: a propensity score-matched cohort study

PURPOSE

The aim of this study was to investigate the efficacy and safety of early cumulus cell removal (ECCR) during human in vitro fertilization (IVF).

METHODS

A retrospective analysis was performed between January 2011 and December 2019. The study enrolled 1131 couples who underwent IVF treatment with ECCR. After propensity score matching at a 1:1 ratio, 1131 couples who underwent overnight coincubation of gametes were selected. The main outcome measure was the cumulative live birth rate. Secondary outcome measures included the cumulative pregnancy rate, polyspermy rate, available embryo rate, miscarriage rate, malformation rate, time to live birth, and oocyte-to-baby rate.

RESULTS

There were no significant differences found between the two groups in the polyspermy rate, available embryo rate, miscarriage rate, time to live birth, oocyte-to-baby rate, and neonatal congenital anomalies rate. The results of the study showed that ECCR was associated with a significantly higher cumulative live birth rate and cumulative pregnancy rate, along with a significantly lower fertilization rate.

CONCLUSIONS

ECCR tended to confer increased cumulative live birth rate and had no negative effect on the neonatal malformation rate.

Intracytoplasmic sperm injection vs. in-vitro fertilization in couples in whom the male partners had a semen analysis within normal reference ranges: An open debate

During recent decades, the application of intracytoplasmic sperm injection has increased considerably worldwide, especially in couples with non-male factor infertility. However, several studies analyzing the broad use of intracytoplasmic sperm injection, even in cases with a normal semen analysis, have collectively demonstrated no benefits compared to conventional in-vitro fertilization. Currently, there is insufficient evidence to support the intracytoplasmic sperm injection technique vs. in-vitro fertilization in cases of poor ovarian response or a low number of oocytes collected, or in patients with advanced maternal age. Since the intracytoplasmic sperm injection technique is more operator-dependent and invasive, its use should only be recommended in cases of male-factor infertility. There is some evidence showing that intracytoplasmic sperm injection is linked with an increased risk of birth defects. Albeit this evidence is limited, and currently it is not possible to draw a firm conclusion on these concerns, we do believe that these risks should be rigorously investigated. Thus, this review aims to clarify the debate on the application of the intracytoplasmic sperm injection procedure, as compared to standard in-vitro fertilization, in those assisted reproductive technology cycles without a clear male factor infertility. Furthermore, we try to clarify whether intracytoplasmic sperm injection would result in a higher live birth rate than in-vitro fertilization, in couples with non-male factor infertility.

The definition of unexplained infertility: A systematic review

BACKGROUND

There is no consensus on tests required to either diagnose unexplained infertility or use for research inclusion criteria. This leads to heterogeneity and bias affecting meta-analysis and best practice advice.

OBJECTIVES

This systematic review analyses the variability of inclusion criteria applied to couples with unexplained infertility. We propose standardised criteria for use both in future research studies and clinical diagnosis.

SEARCH STRATEGY

CINAHL and MEDLINE online databases were searched up to November 2022 for all published studies recruiting couples with unexplained infertility, available in full text in the English language.

DATA COLLECTION AND ANALYSIS

Data were collected in an Excel spreadsheet. Results were analysed per category and methodology or reference range.

MAIN RESULTS

Of 375 relevant studies, only 258 defined their inclusion criteria. The most commonly applied inclusion criteria were semen analysis, tubal patency and assessment of ovulation in 220 (85%), 232 (90%), 205 (79.5%) respectively. Only 87/220 (39.5%) studies reporting semen analysis used the World Health Organization (WHO) limits. Tubal patency was accepted if bilateral in 145/232 (62.5%) and if unilateral in 24/232 (10.3%). Ovulation was assessed using mid-luteal serum progesterone in 115/205 (56.1%) and by a history of regular cycles in 87/205 (42.4%). Other criteria, including uterine cavity assessment and hormone profile, were applied in less than 50% of included studies.

CONCLUSIONS

This review highlights the heterogeneity among studied populations with unexplained infertility. Development and application of internationally accepted criteria will improve the quality of research and future clinical care.

Is It Time for Andrology and Endocrinology Professionals in Assisted Reproduction Centers?

Epidemiologists indicate that about half of the couple's infertility cases are due to a male factor. Despite this, the role of andrologists or endocrinologists in assisted reproductive technique (ART) centers is still underestimated. According to our literature review, this reduces the chance of a thorough clinical evaluation of the male partners, which, sometimes consists only in a mere semen analysis, usually performed by laboratory technicians. A more complete diagnostic process could lead to the identification of potentially treatable causes of infertility, the recognition of diseases that require immediate treatment, and to the discovery of genetic diseases and, therefore, transmissible to the offspring. It can also increase the success rate of ART resulting in less psychological and financial burden for both public health resources and infertile couples. The presence of medical personnel with andrological and endocrinological skills in the ART centers represents the first step in creating 'precision medicine'. We hope that the guidelines of the various scientific societies will clearly contemplate this possibility.

Contemporary Use of ICSI and Epigenetic Risks to Future Generations

Since the birth of Louise Brown in 1978 via IVF, reproductive specialists have acquired enormous knowledge and refined several procedures, which are nowadays applied in assisted reproductive technology (ART). One of the most critical steps in this practice is the fertilization process. In the early days of IVF, a remarkable concern was the unpleasant outcomes of failed fertilization, overtaken by introducing intracytoplasmic sperm injection (ICSI), delineating a real breakthrough in modern ART. ICSI became standard practice and was soon used as the most common method to fertilize oocytes. It has been used for severe male factor infertility and non-male factors, such as unexplained infertility or advanced maternal age, without robust scientific evidence. However, applying ICSI blindly is not free of potential detrimental consequences since novel studies report possible health consequences to offspring. DNA methylation and epigenetic alterations in sperm cells of infertile men might help explain some of the adverse effects reported in ICSI studies on reproductive health in future generations. Collected data concerning the health of ICSI children over the past thirty years seems to support the notion that there might be an increased risk of epigenetic disorders, congenital malformations, chromosomal alterations, and subfertility in babies born following ICSI compared to naturally conceived children. However, it is still to be elucidated to what level these data are associated with the cause of infertility or the ICSI technique. This review provides an overview of epigenetic mechanisms and possible imprinting alterations following the use of ART, in particular ICSI. It also highlights the sperm contribution to embryo epigenetic regulation and the risks of in vitro culture conditions on epigenetic dysregulation. Lastly, it summarizes the literature concerning the possible epigenetic disorders in children born after ART.

Fertilization and neonatal outcomes after early rescue intracytoplasmic sperm injection: a retrospective analysis of 16,769 patients

Purpose

To evaluate the efficacy and safety of short-term insemination and early-rescue intracytoplasmic sperm injection (ICSI), an approach that rescued oocytes with unclear second polar body 6 h after initial insemination by ICSI (early R-ICSI) to avoid total or near-total fertilization failure in conventional in vitro fertilization (IVF).

Methods

We performed a retrospective study in 16,769 patients (short-term IVF, n = 12,094; ICSI, n = 3452; early R-ICSI, n = 1223) who received IVF/ICSI treatment in our hospital from January 2009 to October 2018. Fertilization and clinical outcomes were compared among those three groups.

Results

When considering the R-ICSI embryos in the early R-ICSI group independently, the rates of fertilization and day-3 cleaved embryos in 2PN oocytes were comparable, the rates of fertilization (2PN) and high-quality embryos were lower, whereas the multi-PN fertilization rate (3.27%) was significantly higher than the ICSI group (1.26%). The difference of clinical pregnancy rate between the part of transferred R-ICSI embryos (40.81%) and the ICSI group (44.73%) remained nonsignificant. Furthermore, the rate of congenital birth defects in the early R-ICSI group (0.99%) was not significantly different from those in the short-term IVF (0.76%) and ICSI groups (1.07%).

Conclusion

Despite the multi-PN fertilization rate, our study highlights early R-ICSI as a safe and effective alternative in assisted reproduction to decrease complete IVF fertilization failure and reduce ICSI utilization. Additional large amount and long-term follow-up studies are needed to further validate the use of early R-ICSI.

[Systematic karyotyping before ICSI: A necessary procedure? Analysis of case studies in the Nancy University Hospital Fertility Centre]

INTRODUCTION

A constitutional karyotype is often assayed for the couple before ICSI management. The objective of this study was to assess the prevalence of chromosomal abnormality in an infertile population, the impact on the care of couples and its cost.

METHODS

A single-center retrospective study was carried out at the Fertility Center of the University Hospital of Nancy, including all infertile couples who underwent a karyotype analysis from June 2009 to December 2016.

RESULTS

1252 couples were included. 7.9% had at least one abnormal karyotype. A change in care affected 22% of these couples, i.e. 1.7% of the total population. 9% of couples with karyotype abnormality underwent PGD. In the male population, the percentage of abnormal spermograms is significantly higher in the group with karyotype abnormality compared to the control group (85.7% vs. 46.5%, P<0.001).

DISCUSSION

The constitutional karyotype, due to its high economic and human cost, and limited interest, is a screening method for chromosomal abnormalities that has no place systematically before performing IVF. The future lies in the restriction of the indications for prescribing the karyotype as well as in the realization of PGS in targeted situations.

Should intrauterine inseminations still be proposed in cases of unexplained infertility? Retrospective study and literature review

OBJECTIVE

Unexplained infertility is defined by the absence of identifiable causes of infertility. The results of randomized studies and meta-analysis regarding the treatment of unexplained infertility are discordant due to methodological problems.

DESIGN

The aim of this study is to compare the clinical pregnancy rate per cycle (CPR/c) in IUI and IVF/ICSI in cases of unexplained infertility, according to the woman's age group and to identify the factors which predict success.

INTERVENTIONS

We performed a retrospective study in two ART centers, comparing overall clinical pregnancy, ongoing pregnancy and live birth rates in IVF/ICSI and IUI. We also compared pregnancy and birth rates according to different female age groups.

RESULTS

855 IVF/ICSI and 804 IUI cycles were compared. We found a significant difference (p < 0.001) in the pregnancy and live birth rates per cycle between IUI and IVF/ICSI, overall and in the different female age groups, except in women aged 40 and over. The greatest chances of pregnancy with IUI are found in women with secondary unexplained infertility, during the first two cycles and with a bi-follicular response to stimulation. In IVF/ICSI, pregnancy rates are higher in women with secondary unexplained infertility, in the first two cycles, in IVF and in women receiving a transfer of two embryos regardless of the embryonic stage.

CONCLUSION

We recommend IVF/ICSI treatment rather than IUI for unexplained infertility (OR CPR/c 4.20 with 95% CI [3.72-4.68]). This is in accordance with NICE, which advises the use of IVF after 2 years.

Effects of Early Cumulus Cell Removal on Treatment Outcomes in Patients Undergoing In Vitro Fertilization: A Retrospective Cohort Study

BACKGROUND

Early cumulus cell removal combined with early rescue intracytoplasmic sperm injection (ICSI) has been widely practiced in many in vitro fertilization (IVF) centers in China in order to avoid total fertilization failure. However, uncertainty remains whether the pregnancy and neonatal outcomes are associated with early cumulus cell removal.

OBJECTIVES

To investigate if early cumulus cell removal alone after 4 hours co-incubation of gametes (4 h group), has detrimental effect on the pregnancy and neonatal outcomes in patients undergoing IVF, through a comparison with conventional cumulus cell removal after 20 hours of insemination (20 h group).

METHODS

This retrospective cohort study included 1784 patients who underwent their first fresh cleavage stage embryo transfer at the Centre for Assisted Reproduction of Shanghai First Maternity and Infant Hospital from June 2016 to December 2018 (4 h group, n=570; 20 h group, n=1214). A logistic regression analysis was performed to examine the independent association between early cumulus cell removal and pregnancy outcomes after adjustment for potential confounders. The neonatal outcomes between the two groups were compared.

RESULTS

When compared with the 20 h group, the 4 h group had similar pregnancy outcomes, including rates for biochemical pregnancy, clinical pregnancy, ongoing pregnancy, miscarriage, ectopic pregnancy, multiple pregnancy, live birth. There were 1073 infants delivered after embryo transfer (4 h group, n=337; 20 h group, n=736). Outcomes in both groups were similar for both singleton and twin gestations, including preterm birth rate and very preterm birth rate, mean birth weight, mean gestational age, sex ratio at birth and rate of congenital birth defects. In addition, findings pertaining to singleton gestations were also similar in the two groups for Z-scores (gestational age- and sex-adjusted birth weight), rates of small for gestational age, very small for gestational age, large for gestational age and very large for gestational age infants.

CONCLUSIONS

In this study early cumulus cell removal alone was not associated with adverse pregnancy and neonatal outcomes. From this perspective, early cumulus cell removal to assess for a potential early rescue ICSI is therefore considered to be a safe option in patients undergoing IVF.

Thoughts on the popularity of ICSI

Purpose

Intracytoplasmic sperm injection (ICSI) is the most widely utilized assisted reproductive technique (ART) worldwide. In this feature, we review the early assisted fertilization attempts that eventually led to the development of ICSI, and discuss its current utilization in cases of male and non-male factor infertility.

Methods

We researched the literature related to the development, indications, and current use of ICSI, such as sperm structural abnormalities, male genetic indications, surgically retrieved sperm, high sperm chromatin fragmentation, oocyte dysmorphism, and preimplantation genetic testing (PGT). We also describe the potential future applications of ICSI.

Results

This review summarizes the early micromanipulation techniques that led to the inception of ICSI. We also explore its current indications, including non-male factor infertility, where its use is more controversial. Finally, we consider the benefits of future advancements in reproductive biology that may incorporate ICSI, such as in vitro spermatogenesis, neogametogenesis, and heritable genome editing.

Conclusion

The versatility, consistency, and reliability of ICSI have made it the most prevalently utilized ART procedure worldwide.

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.

ALWAYS ICSI? A SWOT analysis

PURPOSE

Intracytroplasmatic sperm injection (ICSI) is a common procedure used to improve reproductive results, even among couples without male factor infertility. However, the evidence available is still uncertain on the possible advantages and deficiencies that this procedure may have in patients with no formal indication for ICSI.

METHODS

A SWOT (strengths, weaknesses, opportunities, threats) analysis examines the possible advantages and deficiencies of performing ICSI in these patients with no formal indication.

RESULTS

The evidence suggests that ICSI is not justified for non-male factor infertile couples requiring in vitro conception. One of the major strengths associated to the procedure is the virtual elimination of cases further complicated by total fertilization failure and a combination between IVF and ICSI on sibling oocytes has been advised in the literature. Greater technical difficulties, higher costs and performing an unnecessary invasive technique in some cases represent some of the weaknesses of the procedure, and questions regarding safety issues should not be ruled out.

CONCLUSION

Despite the widespread use of ICSI in patients without a formal diagnosis of male factor infertility, evidence demonstrating its effectiveness in this population is still lacking. Additional large and well-designed randomized controlled trials are needed to clarify definitive indications for ICSI in non-male factor infertility.

Evidence-based treatments for couples with unexplained infertility: a guideline

OBJECTIVE

To provide evidence-based recommendations to practicing physicians and others regarding the effectiveness and safety of therapies for unexplained infertility.

METHODS

ASRM conducted a literature search, which included systematic reviews, meta-analyses, randomized controlled trials, and prospective and retrospective comparative observational studies published from 1968 through 2019. The ASRM Practice Committee and a task force of experts used available evidence and informal consensus to develop evidence-based guideline recommendations.

MAIN OUTCOME MEASURE(S)

Outcomes of interest included: live-birth rate, clinical pregnancy rate, implantation rate, fertilization rate, multiple pregnancy rate, dose of treatment, rate of ovarian hyperstimulation, abortion rate, and ectopic pregnancy rate.

RESULT(S)

The literature search identified 88 relevant studies to inform the evidence base for this guideline.

RECOMMENDATION(S)

Evidence-based recommendations were developed for the following treatments for couples with unexplained infertility: natural cycle with intrauterine insemination (IUI); clomiphene citrate with intercourse; aromatase inhibitors with intercourse; gonadotropins with intercourse; clomiphene citrate with IUI; aromatase inhibitors with IUI; combination of clomiphene citrate or letrozole and gonadotropins (low dose and conventional dose) with IUI; low-dose gonadotropins with IUI; conventional-dose gonadotropins with IUI; timing of IUI; and in vitro fertilization and treatment paradigms.

CONCLUSION(S)

The treatment of unexplained infertility is by necessity empiric. For most couples, the best initial therapy is a course (typically 3 or 4 cycles) of ovarian stimulation with oral medications and intrauterine insemination (OS-IUI) followed by in vitro fertilization for those unsuccessful with OS-IUI treatments.

Intracytoplasmic sperm injection (ICSI) for non-male factor indications: a committee opinion

Intracytoplasmic sperm injection, while typically effective for overcoming low or absent fertilization in couples with a clear abnormality of semen parameters, is frequently used in combination with assisted reproductive technologies for other etiologies of infertility in the presence of semen parameters that meet the World Health Organization 2010 normative reference values. This committee opinion provides a critical review of the literature, where available, to identify situations where this may or may not be of benefit. This document replaces the previously published document of the same name, last published in 2012 (Fertil Steril 2012;98:1395-9).

Multicentric, prospective observational data show sperm capacitation predicts male fertility, and cohort comparison reveals a high prevalence of impaired capacitation in men questioning their fertility

RESEARCH QUESTIONS

Can a previously defined relationship between sperm capacitation and the probability of a man generating pregnancy within three cycles, prospectively predict male fertility in diverse clinical settings? A second study asked, what is the prevalence of impaired sperm fertilizing ability in men questioning their fertility (MQF), and does this relate to traditional semen analysis metrics?

DESIGN

In the multicentric, prospective observational study, data (n = 128; six clinics) were analysed to test a published relationship between the percentage of fertilization-competent, capacitated spermatozoa (Cap-Score) and probability of generating pregnancy (PGP) within three cycles of intrauterine insemination. Logistic regression of total pregnancy outcomes (n = 252) assessed fit. In the cohort comparison, Cap-Scores of MQF (n = 2155; 22 clinics) were compared with those of 76 fertile men.

RESULTS

New outcomes (n = 128) were rank-ordered by Cap-Score and divided into quintiles (25-26 per group); chi-squared testing revealed no difference between predicted and observed pregnancies (P = 0.809). Total outcomes (n = 252; 128 new + 124 previous) were pooled and the model recalculated, yielding an improved fit (P < 0.001). Applying the Akaike information criterion found that the optimal model used Cap-Score alone. Cap-Scores were performed on 2155 men (with semen analysis data available for 1948). To compare fertilizing ability, men were binned by PGP (≤19%, 20-29%, 30-39%, 40-49%, 50-59%, ≥60%). Distributions of PGP and the corresponding Cap-Scores were significantly lower in MQF versus fertile men (P < 0.001). Notably, 64% of MQF with normal volume, concentration and motility (757/1183) had PGP of 39% or less (Cap-Scores ≤31), versus 25% of fertile men.

CONCLUSIONS

Sperm capacitation prospectively predicted male fertility. Impaired capacitation affects many MQF with normal semen analysis results, informing diagnosis versus idiopathic infertility.

Comparison of the assisted reproductive technology outcomes between conventional IVF and ICSI with donor oocytes in normozoospermic patients

There is no evidence for the superiority of conventional in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) using donor oocytes. This retrospective descriptive study aimed to compare the outcomes of conventional IVF (n = 506) and ICSI (n = 613) with donor oocytes in (n = 968) normozoospermic patients. Although the fertilization rate was statistically higher in the ICSI group (p < 0.001), conventional IVF provided better results than ICSI with respect to embryo quality (number of grade A embryos, p < 0.001). In addition, we observed more blastocysts in the conventional IVF group (p < 0.001) and more good quality embryos were obtained for cryopreservation compared to ICSI (p < 0.001). Regarding clinical results, there were no statistical significant differences in the positive pregnancy test, clinical pregnancy and clinical miscarriage rates between IVF and ICSI. However, the implantation rate was statistically higher when IVF was performed (50.4% vs. 43.0%, p = 0.031, OR (95% CI): 1.185 (1.050-2.530)). In conclusion, with the use of normozoospermic samples in our oocyte donation programme, IVF offers more embryo efficiency and increased implantation rates than ICSI.

Intracytoplasmic sperm injection for male infertility and consequences for offspring

Intracytoplasmic sperm injection (ICSI) has become the most commonly used method of fertilization in assisted reproductive technology. The primary reasons for its popularity stem from its effectiveness, the standardization of the procedure, which means that it can easily be incorporated into the routine practice of fertility centres worldwide, and the fact that it can be used to treat virtually all forms of infertility. ICSI is the clear method of choice for overcoming untreatable severe male factor infertility, but its (over)use in other male and non-male factor infertility scenarios is not evidence-based. Despite all efforts to increase ICSI efficacy and safety through the application of advanced sperm retrieval and cryopreservation techniques, as well as methods for selecting sperm with better chromatin integrity, the overall pregnancy rates from infertile men remain suboptimal. Treating the underlying male infertility factor before ICSI seems to be a promising way to improve ICSI outcomes, but data remain limited. Information regarding the health of ICSI offspring has accumulated over the past 25 years, and there are reasons for concern as risks of congenital malformations, epigenetic disorders, chromosomal abnormalities, subfertility, cancer, delayed psychological and neurological development, and impaired cardiometabolic profile have been observed to be greater in infants born as a result of ICSI than in naturally conceived children. However, as subfertility probably influences the risk estimates, it remains to be determined to what extent the observed adverse outcomes are related to parental factors or associated with ICSI.

The management of unexplained infertility: an evidence-based guideline from the Canadian Fertility and Andrology Society

Unexplained infertility is a common diagnosis affecting as many as 50% of couples seeking infertility care. As a diagnosis of exclusion, its treatment remains largely empirical. Historically, a step-wise progression in treatment has been initiated with the least invasive, least expensive option followed by a gradual progression to therapies using assisted reproductive technology. In recent years there have been advocates for more rapid-progression IVF. This guideline from the Canadian Fertility and Andrology Society (CFAS) provides comprehensive, evidence-based recommendations for the treatment of unexplained infertility, including expectant management, laparoscopy, intrauterine insemination (IUI) alone, ovarian stimulation with oral agents or gonadotropins alone, ovarian stimulation + IUI, and IVF. The quality of supporting evidence for each recommendation is evaluated using the framework outlined by the Canadian Task Force on Preventive Health Care. This guideline recognizes that the therapeutic approach should be individualized taking into account patient age and duration of infertility, and emphasizes those strategies that are most likely to result in a healthy live birth.

Effect of early cumulus cells removal and early rescue ICSI on pregnancy outcomes in high-risk patients of fertilization failure

OBJECTIVE

The objective of this retrospective study was to evaluate clinical outcomes of early cumulus cells removal and early rescue intracytoplasmic sperm injection (ICSI) in high-risk patients of fertilization failure during human in vitro fertilization (IVF).

METHODS

A total of 5,518 patients were enrolled between January 2014 to December 2016. Of which 505 couples performed short insemination with >30% fertilization rate were included in short-term IVF group, 102 patients detected total fertilization failure (TFF) were treated with early rescue ICSI (R-ICSI group), and 4911 couples underwent conventional IVF with overnight co-incubation of gametes (traditional IVF group). The clinical outcomes were analyzed among the three groups.

RESULTS

The embryo implantation rates (40.34%, 39.78% and 42.42% for traditional, short-term IVF and R-ICSI groups, respectively) were comparable in the three groups. The clinical pregnancy rates among traditional IVF group, short-term IVF group and R-ICSI group were 57.95%, 57.03% and 60.78%, respectively, and the difference among three groups didn't reach significance.

CONCLUSION

The present study indicated that short insemination had no detrimental effects on clinical outcomes in human IVF and could prevent the occurrence of TFF combined with early rescue ICSI for high-risk patients of fertilization failure, which attained acceptable pregnancy outcomes.

Human sperm handling in intracytoplasmic sperm injection processes: In vitro studies on mouse oocyte activation, embryo development competence and sperm oxidation-reduction potential

Polyvinylpyrrolidone (PVP) and hyaluronic acid (HA) are routinely used in handling spermatozoa for intracytoplasmic sperm injection (ICSI). As there are still concerns about possible adverse effects on the embryo, this study investigated sperm handling in a mouse ICSI model to (i) evaluate oocyte activation after injection of spermatozoa selected for rotational or linear motion in PVP; (ii) assess the effect of sperm selection in PVP, HA and medium on oocyte activation; (iii) examine the effects of PVP and HA on parthenogenetic oocyte activation and embryo development; and (iv) assess the oxidation-reduction potential (ORP) of spermatozoa exposed to PVP, HA or medium. Oocyte activation was higher when spermatozoa exhibited rotational motion rather than linear motion (79% vs. 52%; p = .05). There was no difference in oocyte activation and embryo development after parthenogenetic oocyte activation after sperm injection using PVP, HA or medium-incubated spermatozoa. PVP-selected spermatozoa exhibited lower (p < .0001) ORP levels than using HA. Thus, results indicate that the sperm handling method and the type of medium used impact ICSI outcomes. Overall, sperm incubation in PVP, HA and medium yields similar outcomes with regard to oocyte activation and embryo development. However, PVP provides more antioxidative protection than HA and should therefore be preferred for sperm manipulation.

Percentage of motile spermatozoa at 22 hours after swim-up procedure: An indicator for intracytoplasmic sperm injection?

Objective

Methods

Results

Conclusion

Association between etiologic factors in infertile couples and fertilization failure in conventional in vitro fertilization cycles

The aim of this study was to investigate the relationship between the etiology of the couples and risk of fertilization failure (FF) in conventional in vitro fertilization (IVF) cycles and the effect of rescue intracytoplasmic sperm injection (ICSI) technique to offspring. A total of 2542 IVF cycles were divided into four groups according to infertile etiology: Group A - primary infertility with normal semen parameters; Group B - secondary infertility with oligoasthenozoospermia; Group C - primary infertility with oligoasthenozoospermia; and Group D - secondary infertility with normal semen parameters. The results showed that there were significant differences in incidence of FF among Group A (16.8%), Group B (20.9%), Group C (48.7%), and Group D (0.9%) (p < 0.001). Logistic regression models demonstrated that primary infertility (OR: 10.898, 95% CI: 4.651-25.583, p < 0.001) and oligoasthenozoospermia (OR: 12.215, 95% CI: 5.903-25.276, p < 0.001) were independent risk factors for FF. There were no significant differences in main outcomes between conventional ICSI and rescue ICSI. In conclusion, the patients with primary infertility and oligoasthenozoospermia might be at higher risk of FF. The rescue ICSI technique is safe and helpful for IVF cycles of FF.

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.

Office-based sperm retrieval for treatment of infertility

This article describes sperm retrieval procedures that may be performed in an office setting. Indications for sperm retrieval, preprocedural preparation, and anesthetic considerations are discussed. Vasal sperm aspiration, percutaneous epididymal sperm aspiration, microsurgical epididymal sperm aspiration, testicular sperm aspiration, conventional, and microdissection testicular sperm extraction are reviewed. Success and complication rates as well as factors that may influence success (histopathology, cancerous cause, Klinefelter syndrome, Y microdeletions, varicocele, and hormone administration) are reviewed.

Intracytoplasmic sperm injection (ICSI) for non-male factor infertility: a committee opinion

Intracytoplasmic sperm injection, while typically effective for overcoming low or absent fertilization in couples with a clear abnormality of semen parameters, is frequently utilized in combination with assisted reproductive technologies for other etiologies of infertility in the presence of normal semen parameters. This committee opinion provides a critical review of the literature, where available, to identify situations where this may or may not be of benefit.

[Assisted reproductive technologies place]

There are three kinds of infertility treatment: medical treatment, surgical treatment and assisted reproductive technology (ART). ART includes intra uterine insemination (IUI), in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). ART technologies made a lot of progress last years and their field of applications extended. Through literature reviews, IUI is recommended for unexplained infertility and discussed for male or cervical infertility. IVF is recommended for tubal and unexplained infertility. Limits between IVF and ICSI in case of male infertility remains unclear. In non mal infertility ICSI is not recommended.

The role of hyaluronic acid binding assay in choosing the fertilization method for patients undergoing IVF for unexplained infertility

PURPOSE

Patients with unexplained infertility may have fertilization problems. Split fertilization (ICSI and conventional IVF on sibling oocytes) is often used to avoid poor fertilization. Our aim was to assess the ability of hyaluronic acid binding (HA-binding) assay to predict spontaneous fertilization during IVF.

METHODS

Prospective, blinded, controlled trial. Patients undergoing their first IVF cycle for unexplained infertility were eligible. Split fertilization was used. IVF and ICSI fertilization rates and embryo development based on 3 HA-binding cut-offs (< 60%; 60-80%; >80%) were compared.

RESULTS

ICSI fertilization was higher than IVF, but none of the HA-binding cut-off levels predicted those cases where IVF was less effective, therefore ICSI only would have lead to improved outcome. Embryo development and morphology were similar in all cut-off groups.

CONCLUSIONS

HA-binding did not predict spontaneous fertilization in patients with unexplained infertility undergoing IVF treatment. When it was used for "screening" it did not help to select the method of fertilization.

[A prospective auto-controlled study to evaluate the interest of selected sperm morphology to inseminate oocytes during IVF]

OBJECTIVES

Since we observed in our laboratory a significant decrease of the fertilization rate in the classical IVF procedure compared to ICSI, we wanted to evaluate a new insemination procedure, using sperm morphology of selected semen as a criterion taken into account to calculate the number of mobile sperm to inseminate.

PATIENTS AND METHODS

Therefore, we designed a prospective autocontrolled study which took place from September 2006 to May 2007. All IVF attempts resulting from infertile couples were included in the study if a previous analysis (lesser than one year) of sperm parameters performed in our laboratory was assessed as normal. The retrieved oocytes were separated into two groups (sibling ovocytes), inseminated randomly either with the usual procedure (control group) or with the tested protocol (tested group). Fertilization rate was the primary end point to evaluate this assay. Polyspermy rates were also compared. Subsequently, embryonic quality and development were assessed to eliminate an oxidative stress impact. Paired Student t-test was applied for statistical analysis.

RESULTS

In all, 130 couples were included. The diploid fertilization rate was significantly increased in the tested group compared to the control group (66.9% vs 61.3%; p=0.017). No statistically significant difference was showed between the polyspermy rate and numbers of (i) good quality embryos and (ii) blastomeres per embryo into the two groups.

DISCUSSION AND CONCLUSION

Compared with the conventional insemination procedure, the fertilization rate benefited from the tested insemination method in our laboratory without damaging embryonic growth. In the limit of our procedure, selected sperm morphology should be used to inseminate an appropriate number of spermatozoa within oocytes, even in case of normal semen values.

Trends in the use of intracytoplasmic sperm injection in the United States

BACKGROUND

Intracytoplasmic sperm injection (ICSI) was initially developed as part of in vitro fertilization (IVF) to treat male-factor infertility. However, despite the added cost, uncertain efficacy, and potential risks of ICSI, its use has been extended to include some patients without documented male-factor infertility.

METHODS

We analyzed national data on assisted reproductive technology reported to the Centers for Disease Control and Prevention, to determine temporal trends in the use of ICSI and IVF in the United States, and we examined differences in the use of ICSI between states with and those without mandated insurance coverage.

RESULTS

From 1995 to 2004, the number of fertility clinics and fresh-embryo cycles and the rates of IVF-related pregnancies and live births increased. The percentage of IVF cycles with the use of ICSI also increased dramatically (from 11.0% to 57.5%), while the percentage of diagnoses of infertility attributed to male-factor conditions remained stable. The ratio of ICSI procedures to diagnoses of male-factor infertility steadily increased each year, suggesting an increasing use of ICSI for conditions other than male-factor infertility. From 1999 to 2004, there was an increasing use of ICSI relative to the percentage of patients with male-factor infertility in states with and those without mandated insurance coverage. For any given year, however, states with insurance coverage had a higher ratio of ICSI use to diagnoses of male-factor infertility than did states without insurance coverage (P<0.001).

CONCLUSIONS

Since 1995, the use of ICSI in the United States has increased dramatically, while the proportion of patients receiving treatment for male-factor infertility has remained stable. State-mandated health insurance coverage for IVF services is associated with greater use of ICSI for infertility that is not attributed to male-factor conditions.

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

OBJECTIVE

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

DESIGN

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

SETTING

Academic fertility center.

PATIENT(S)

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

MAIN OUTCOME MEASURE(S)

Fertilization, pregnancy, and live birth rates.

RESULT(S)

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

CONCLUSION(S)

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

Rational diagnosis and treatment in infertility

Subfertility is a statistical concept. When a pregnancy has not been achieved within a year of unprotected intercourse, the odds are that an underlying pathological mechanism is at play. Advanced female age, longer duration and primary infertility, are important prognostic factors, suggestive of low fecundity and indicating a need for further diagnosis and treatment. Many diagnostic tests only have screening value and the only gold standards are hysteroscopy and laparoscopy. Severely impaired semen quality should lead to andrological work-up. Postcoital test and endometrial biopsy are obsolete. Treatment should preferably be aetiological, such as in anovulation, and sometimes also in endometriosis and tubal infertility. Primary treatment of male infertility is not proven to be advantageous. Conception-enhancing techniques such as intrauterine insemination (IUI), in vitro fertilisation (IVF) with or without intracytoplasmic sperm injection (ICSI), have shown to be effective. As a rule, and where possible, IUI is preferred and only if four to six cycles have failed should IVF be offered.

IUI in male subfertility: are we able to select the proper patients?

There is at this time no indication as to which semen parameters from the fertility work-up discriminate between couples with male subfertility who will and will not benefit from intrauterine insemination (IUI). This study evaluated the predictive capacity of semen parameters (both pre- and post-wash) and antisperm antibodies (ASA) obtained during the fertility workup on IUI outcome in couples with male subfertility in a retrospective cohort study. It included 290 couples, who underwent 722 IUI cycles. The overall ongoing pregnancy rate was 9% per cycle. Model I, with female age, duration of subfertility, secondary subfertility, the presence of anovulation, cervical hostility and cycle number had an area under the curve (AUC) of 0.59. Adding the presence of ASA to this model improved the AUC to 0.65 (model II). Further addition of the post-wash total motile count (TMC) to the model with ASA (model III) improved the AUC to 0.67. Using the models to exclude couples from IUI due to low expected pregnancy rates would increase the pregnancy rate to 11% per cycle with model I, and to 14% per cycle for model II and for model III. In conclusion, in the selection of patients with male subfertility for IUI, the use of prediction models including ASA can increase the efficiency of IUI.

Clomiphene citrate challenge test predicts outcome of intrauterine insemination in women aged under 37 years

The clomiphene citrate challenge test is a tool to predict ovarian reserve and fertility. It has mainly been used as a predictor of success of IVF/intracytoplasmic sperm injection (ICSI) cycles. Infertile young women with diminished ovarian reserve have a worse prognosis than women with adequate ovarian reserve attempting IVF/ICSI cycles. Nothing is known regarding the outcome of young women with diminished ovarian reserve undergoing low-complexity assisted reproductive treatment such as ovulation induction plus intrauterine insemination (IUI). This study included all women under 37 years who consulted in the authors' centre between May 2004 and August 2005 who underwent ovulation induction and IUI. Ninety-six women younger than 37 years with adequate ovarian reserve, and 50 women with diminished ovarian reserve were found. The pregnancy rate and pregnancy rate per cycle in the adequate ovarian reserve group were significantly higher than those of the diminished ovarian reserve group (46.7% versus 25%, P < 0.02 ; 15.9% versus 7.6%, P < 0.02 respectively). It is concluded that the clomiphene citrate challenge test is a good predictor of low-complexity infertility intervention outcome, and represents an effective tool to establish a prognosis. Therefore, it is very useful in planning therapy, and advising the infertile couple.