Failure of fertilization after intracytoplasmic sperm injection in a patient with Kartagener's syndrome and totally immotile spermatozoa: case report

Live birth after Laser Assisted Viability Assessment (LAVA) to detect pentoxifylline resistant ejaculated immotile spermatozoa during ICSI in a couple with male Kartagener's syndrome

Primary ciliary dyskinesia (PCD) is a rare, autosomal recessive disease with abnormalities in the structure of cilia, causing impairment of muco-ciliary clearance with respiratory tract infections, heterotaxia and abnormal sperm motility with male infertility. Here, with a comprehensive literature review, we report a couple with an infertility history of 9 years and three unsuccessful IVF treatments, where male partner has Kartagener's Syndrome, a subtype of PCD, displaying recurrent respiratory infections, dextrocardia and total asthenozoospermia. His diagnosis was verified with transmission electron microscopy and genetic mutation screening, revealing total absence of dynein arms in sperm tails and homozygous mutation in the ZMYND10, heterozygous mutations in the ARMC4 and DNAH5 genes. Laser assisted viability assay (LAVA) was performed by shooting the sperm tails during sperm retrieval for microinjection, following detection of pentoxifylline resistant immotile sperm. Live births of healthy triplets, one boy and two monozygotic girls, was achieved after double blastocyst transfer.

A case of primary ciliary dyskinesia treated with ICSI using testicular spermatozoa: case report and a review of the literature

Purpose

To investigate whether or not intracytoplasmic sperm injection (ICSI) using spermatozoa extracted from testis (TESE-ICSI) is a more effective treatment than ICSI with ejaculated spermatozoa (EJ-ICSI) for primary ciliary dyskinesia (PCD).

Methods

We reported a case of PCD in which we performed TESE-ICSI after repeated failure of EJ-ICSI. Together with data from previous case reports, we compared the fertilization rate and pregnancy outcome of TESE-ICSI and EJ-ICSI.

Results

In our case, TESE-ICSI improved the morphology of spermatozoa and fertilization rate. However, the outcome was only a biochemical pregnancy. According to the analysis combined with previous reports, there was no difference in the fertilization rate and pregnancy outcome parameters between TESE-ICSI and EJ-ICSI.

Conclusions

TESE-ICSI for PCD may improve the fertilization rate compared to EJ-ICSI. However, it does not necessarily improve the pregnancy outcome for a patient with primary ciliary dyskinesia.

Healthy twin live-birth after ionophore treatment in a case of theophylline-resistant Kartagener syndrome

PURPOSE

To evaluate whether it is a feasible option to target the oocyte (with Ca(2+)-ionophore) in case that sperm motility cannot be restored in Kartagener syndrome.

METHODS

A case of a male Kartagener syndrome with exclusively immotile spermatozoa that did not react to the dimethylxanthine theophylline. Thus, half of the associated oocytes were treated for 15 min with the ready-to-use- ionophore CultActive immediately after ICSI whereas the other 50 % were injected with routine ICSI without artificial oocyte activation. Rates of fertilization, blastulation, pregnancy and live birth were evaluated.

RESULTS

Fertilization check revealed that none of the conventionally injected but 4/6 (66.7 %) of the artificially activated oocytes showed two pronuclei. Three embryos were of good and one of fair quality. Corresponding blastocyst formation rate was 3 out of 4 (75 %). A double embryo transfer led to a healthy twin birth in the 34th week of gestation (two boys with a birth weight of 1724 g and 2199 g).

CONCLUSIONS

This case indicates that Ca(2+)-ionophore treatment in cycles from theophylline-resistant Kartagener syndrome patients is a feasible option. The future will show if routine application of A23187 in Kartagener or primary cilia dyskinesis patients will be of benefit.

Normal live birth after vitrified/warmed oocytes intracytoplasmic sperm injection with immotile spermatozoa in a patient with Kartagener's syndrome

The present article is a report on two cases of male Kartagener's syndrome enrolled in intraconjugal IVF programme due to akinetospermia. Viable spermatozoa were selected using a hypo-osmotic swelling test (HOST) and pentoxifylline activation and subsequently microinjected into vitrified/warmed oocytes. The treatment enabled one of these two couples to achieve a pregnancy and to give birth to a healthy baby girl.

Management of primary ciliary dyskinesia/Kartagener's syndrome in infertile male patients and current progress in defining the underlying genetic mechanism

Kartagener's syndrome (KS) is an autosomal recessive genetic disease accounting for approximately 50% of the cases of primary ciliary dyskinesia (PCD). As it is accompanied by many complications, PCD/KS severely affects the patient's quality of life. Therapeutic approaches for PCD/KS aim to enhance prevention, facilitate rapid definitive diagnosis, avoid misdiagnosis, maintain active treatment, control infection and postpone the development of lesions. In male patients, sperm flagella may show impairment in or complete absence of the ability to swing, which ultimately results in male infertility. Assisted reproductive technology will certainly benefit such patients. For PCD/KS patients with completely immotile sperm, intracytoplasmic sperm injection may be very important and even indispensable. Considering the number of PCD/KS susceptibility genes and mutations that are being identified, more extensive genetic screening is indispensable in patients with these diseases. Moreover, further studies into the potential molecular mechanisms of these diseases are required. In this review, we summarize the available information on various aspects of this disease in order to delineate the therapeutic objectives more clearly, and clarify the efficacy of assisted reproductive technology as a means of treatment for patients with PCD/KS-associated infertility.

Auditory processing disorders associated with a case of Kartagner's syndrome

Kartagner's syndrome is a rare autosomal recessive disorder characterized by sinusitis, bronchiectasis and situs inversus. Otitis media is seen in 95% of the individuals with this syndrome due to recurrent respiratory infections and dysfunctional cilia in the middle ear. Earlier research reported the presence of structural and functional deficits in the auditory brainstem following long standing otitis media. However, no such findings have been reported in individuals with this syndrome. Thus, the present case report highlights the results of various audiological tests with special emphasis on investigating the auditory processing abilities in a known case of Kartagner's syndrome. In order to accomplish the aim, the audiological test battery was carried out on a 42 year old male patient diagnosed as having Kartagner's syndrome. The basic audiological tests, including immittance audiometry, pure tone audiometry, otoacoustic emission and auditory brainstem response (using click stimulus) results indicated the presence of mild to moderate mixed hearing loss in both ears. However, results of the auditory brainstem response (using speech stimulus) pointed toward abnormal speech processing skills. Thus, the behavioral test battery approach (including speech perception in noise test, gap detection test, temporal modulation transfer function test and duration pattern test) was followed and the findings suggested presence of auditory closure and temporal processing deficit. The outcome of the case study recommends that a complete test battery approach involving psychoacoustic tests should be used to assess such cases and auditory rehabilitation should be suggested accordingly.

Normal live birth after testicular sperm extraction and intracytoplasmic sperm injection in variant primary ciliary dyskinesia with completely immotile sperm and structurally abnormal sperm tails

OBJECTIVE

To report on the investigation and fertility management of variant primary ciliary dyskinesia (PCD).

DESIGN

Case report.

SETTING

University-affiliated assisted reproductive technologies practice.

PATIENT(S)

A 40 year-old man presenting with 12 months' primary infertility, complete sperm immotility, severe morphologic defects, and moderate sinopulmonary disease.

INTERVENTION(S)

Electron microscopy (EM) of sperm, nasal cilial function studies, open testis biopsy, and sperm extraction for intracytoplasmic sperm injection (ICSI).

MAIN OUTCOME MEASURE(S)

Outcome of ICSI treatment using immotile testicular sperm.

RESULT(S)

EM revealed abnormal connecting pieces, shortened midpieces with attenuated mitochondrial sheaths, poorly developed annulus, abnormal outer dense fibers, and axonemes missing the two central mircotubules. Nasal ciliary beat frequency was subnormal and dyssynchronous. Immotile testicular sperm were selected for ICSI based on physical characteristics and fertilized 12 of 18 eggs. A single day-5 blastocyst achieved a normal pregnancy and delivery of a healthy 3,840-g girl at 38 weeks' gestation.

CONCLUSION(S)

Nonclassic PCD may present with structurally abnormal completely immotile sperm, with seemingly little prospect of fertility, and moderate respiratory dysfunction supporting the presence of an underlying ciliopathy. Despite testicular sperm also being immotile and showing profound structural defects that would seem to preclude fertilization, more morphologically normal sperm are capable of establishing a normal pregnancy.

The cardiac malpositions

Dextrocardia was known in the 17th century and was 1 of the first congenital malformations of the heart to be recognized. Fifty years elapsed before Matthew Baillie published his account of complete transposition in a human of the thoracic and abdominal viscera to the opposite side from what is natural. In 1858, Thomas Peacock stated that "the heart may be congenitally misplaced in various ways, occupying either an unusual position within the thorax, or being situated external to that cavity." In 1915, Maude Abbott described ectopia cordis, and Richard Paltauf's remarkable illustrations distinguished the various types of dextrocardia. In 1928, the first useful classification of the cardiac malpositions was proposed, and in 1966, Elliott et al's radiologic classification set the stage for clinical recognition. The first section of this review deals with the 3 basic cardiac malpositions in the presence of bilateral asymmetry. The second section deals with cardiac malpositions in the presence of bilateral left-sidedness or right-sidedness. Previous publications on cardiac malpositions are replete with an arcane vocabulary that confounds rather than clarifies. Even if the terms themselves are understood, inherent complexity weighs against clarity. This review was designed as a guided tour of an unfamiliar subject.

Successful twin birth following blastocyst culture of embryos derived from the immotile ejaculated spermatozoa from a patient with primary ciliary dyskinesia: a case report

PURPOSE

To describe the ultrastructure of spermatozoa from a patient with complete asthenozoospermia that resulted in live births following blastocyst culture.

MATERIALS AND METHODS

Analyses of spermatozoa from a 36 year old patient were performed using light and electron microscopy. The hypo-osmotic swelling test was used to select spermatozoa for intracytoplasmic sperm injection. Embryos were cultured to the blastocyst stage.

RESULTS

100% of the spermatozoa had dynein arm deficiency with secondary defects varying from 3-17%. Six oocytes were injected; five fertilized normally and one was digynic. All five zygotes formed good quality blastocysts. Three blastocysts were cryopreserved and two blastocysts were transferred. Twin females were born at 37 weeks.

CONCLUSIONS

The hypo-osmotic swelling test can be used to select viable immotile ejaculated spermatozoa from a patient with dynein arm deficiency and can produce excellent fertilization rates and blastocyst development resulting in live births.

Pregnancy after laser-assisted selection of viable spermatozoa before intracytoplasmatic sperm injection in a couple with male primary cilia dyskinesia

OBJECTIVE

To report an intracytoplasmatic sperm injection (ICSI) pregnancy achieved in a couple with male primary cilia dyskinesia (PCD) with viable sperm that were detected using a 1.48 microm wavelength diode laser.

DESIGN

Case report.

SETTING

University hospital.

PATIENT(S)

A 37-year-old man with infertility due to primary cilia dyskinesia; semen analysis revealed a severe oligoasthenoteratozoospermia with absence of motile spermatozoa. A 34-year-old healthy woman with a 10-year history of primary infertility.

INTERVENTION(S)

Selection of viable spermatozoa using the hypo-osmotic swelling (HOS) test or a 1.48 microm wavelength diode laser and subsequent ICSI.

MAIN OUTCOME MEASURE(S)

Sperm analysis. Fertilization and cleavage rates and pregnancy.

RESULT(S)

Semen samples showed no motile spermatozoa and high percentages of spermatozoa with curled flagella resembling HOS-reactive spermatozoa. To identify viable spermatozoa we used the HOS test or a 1.48 microm diode laser. The ICSI using HOS-selected spermatozoa resulted in two fertilized out of four oocytes (50%), and injection of laser-selected spermatozoa resulted in four fertilized out of seven oocytes (57%). The transfer of two frozen/thawed oocytes of the laser group led to a singleton pregnancy.

CONCLUSION(S)

Use of a noncontact diode laser for sperm viability assessment may be a useful alternative, especially in cases where the HOS test is not informative.

Outcome of ICSI with ejaculated spermatozoa in a series of men with distinct ultrastructural flagellar abnormalities

BACKGROUND

Severe sperm motility impairment results in human infertility, which can be overcome by ICSI. Whether some particular, possibly genetic, flagellar abnormalities can influence embryonic development is a matter of debate.

METHODS

Analysis of ultrastructural flagellar abnormalities and ICSI outcomes with ejaculated spermatozoa in a series of 21 infertile patients with asthenozoospermic or dyskinetic spermatozoa due to a primary and specific flagellar abnormality was carried out.

RESULTS

Patients were sorted into six categories according to flagellar ultrastructural defects. Oocyte fertilization occurred in the 21 couples with a mean 2PN fertilization rate reaching 61.85%. No difference was observed in the kinetics of in vitro development or in the morphological quality of the embryos between the different types of flagellar abnormalities. Pregnancy occurred in 12 couples (57.1%) and delivery in nine couples (42.86%). Both the implantation rate and the clinical pregnancy rate per cycle were lower in type III abnormalities and in patients with an initial sperm motility less than 5%.

CONCLUSIONS

The rate of ICSI success may be influenced by the type of flagellar abnormality. ICSI provides a suitable solution for patients with sperm flagellar defects but raises the question of the consequences of a specific (and primary flagellar) abnormality on oocyte fertilization, on embryo and fetal development as well as on live birth.

The use of the modified hypo-osmotic swelling test for the selection of immotile testicular spermatozoa in patients treated with ICSI: a randomized controlled study

BACKGROUND

Various methods for the selection of viable sperm from among immotile testicular spermatozoa for use in ICSI have been described in non-randomized studies. We have conducted a randomized controlled study to compare the use of the modified hypo-osmotic swelling (HOS) test (50% culture medium + 50% Milli-Q grade water) with that of sperm selection on the basis of their morphology alone.

METHODS

A total of 79 couples with immotile testicular spermatozoa treated with ICSI were randomly assigned into two groups. In the first group, spermatozoa used for injection were selected using the modified HOS test, while in the second group spermatozoa were selected on the basis of their morphology.

RESULTS

The fertilization rate was significantly higher in the HOS test group (43.6%) compared with the no-HOS test group (28.2%) [odds ratio (OR) 2.494; 95% confidence interval (CI) 1.606-3.872]. The pregnancy and ongoing pregnancy rates were also higher in the HOS test group (27.3% versus 20.5%) compared with the no-HOS test group (5.7% versus 2.9%) (OR 6.188, 95% CI 1.282-29.860; and OR 8.743, 95% CI 1.050-72.783, respectively).

CONCLUSIONS

The use of the modified HOS test for the selection of viable sperm from among immotile testicular spermatozoa for ICSI results in higher fertilization, pregnancy and ongoing pregnancy rates compared with morphological selection.

[Kartagener's syndrome and infertility: observation, diagnosis and treatment]

Primary ciliary dyskinesia is a rare etiology of sterility in man (prevalence between 1/6000 and 1/40000). Kartagener's syndrome is an autosomal recessive disorder, characterized by total or partial dysfunction of the ciliary or flagellated cells. This syndrome associates situs inversus, sinusitis, bronchiectasis and occasionally sterility in males. We report a case of immotile cilia syndrome with male infertility and compare the data with four other couples reported in the literature (two couples in Germany, two in the United States). The difficulty is to select an alive sperm cell for ICSI.

Pregnancy after ICSI with ejaculated immotile spermatozoa from a patient with immotile cilia syndrome: a case report and review of the literature

This study presents a case of intracytoplasmic sperm injection (ICSI) with ejaculated immotile spermatozoa from a patient with immotile cilia syndrome. Semen analysis of the patient suffering from immotile cilia syndrome revealed an extreme oligoasthenoteratozoospermia (OAT: count <1.4 x 10(6)/ml, 0% motility and 3% normal morphology). Electron microscopy of sperm flagella showed the absence of inner and outer dynein arms. During the ICSI cycle, the hypo-osmotic swelling test (HOS) was used for the identification of viable spermatozoa in the pool of immotile spermatozoa for ICSI. A normal fertilization rate was found in eight out of the 12 oocytes. A first fresh double embryo transfer resulted in a late miscarriage at 21 weeks. A second healthy singleton pregnancy occurred after transfer of two frozen-thawed embryos from the same ICSI procedure. Although only one successful ICSI case of the immotile cilia syndrome combined with HOS is described here, HOS might be a simple but valuable tool to obtain normal fertilization and pregnancy for patients suffering from immotile spermatozoa.