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Stein DM, Victorson DE, Choy JT, Waimey KE, Pearman TP, Smith K, Dreyfuss J, Kinahan KE, Sadhwani D, Woodruff TK, Brannigan RE. Fertility Preservation Preferences and Perspectives Among Adult Male Survivors of Pediatric Cancer and Their Parents. J Adolesc Young Adult Oncol 2014; 3:75-82. [PMID: 24940531 DOI: 10.1089/jayao.2014.0007] [Citation(s) in RCA: 113] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Purpose: In this study, we set out to determine the preferences, concerns, and attitudes toward fertility preservation of adult male survivors of pediatric cancer and their parents. Methods: We conducted 3 focus groups with a total of 15 male survivors of pediatric cancer (age at diagnosis: mean=14, range: 10-20; age at study: mean=35, range: 25-47) and 2 groups with a total of 7 parents of survivors. Grounded theory methodology was used for the identification and analysis of recurrent themes expressed by survivors and their parents in the course of focus group discussions. Results: Themes most frequently expressed by survivors included concern regarding long-term treatment effects and a retrospective desire for fertility impairment to have been discussed when they were originally diagnosed with cancer. Parental themes included the same hindsight desire, as well as reliance upon the treating oncologist for direction in selecting the course of treatment, and an acknowledgment that input from a specialist in fertility preservation would have been beneficial. Conclusions: Although future reproductive potential was not consistently reported as a source of apprehension when diagnosed with cancer, both survivors and their parents noted it to be a paramount concern later in life. Parents and survivors both reported that fertility preservation discussions should be routinely incorporated in the clinical context of a pediatric cancer diagnosis.
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Affiliation(s)
- Daniel M Stein
- Department of Urology, Feinberg School of Medicine, Northwestern University , Chicago, Illinois. ; Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University , Chicago, Illinois
| | - David E Victorson
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University , Chicago, Illinois. ; The Robert H. Lurie Comprehensive Cancer Center of Northwestern University , Chicago, Illinois
| | - Jeremy T Choy
- Department of Urology, Feinberg School of Medicine, Northwestern University , Chicago, Illinois
| | - Kate E Waimey
- The Oncofertility Consortium at Northwestern University , Chicago, Illinois
| | - Timothy P Pearman
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University , Chicago, Illinois. ; The Robert H. Lurie Comprehensive Cancer Center of Northwestern University , Chicago, Illinois
| | - Kristin Smith
- The Oncofertility Consortium at Northwestern University , Chicago, Illinois
| | - Justin Dreyfuss
- Department of Urology, Feinberg School of Medicine, Northwestern University , Chicago, Illinois
| | - Karen E Kinahan
- The Robert H. Lurie Comprehensive Cancer Center of Northwestern University , Chicago, Illinois
| | - Divya Sadhwani
- College of Medicine, University of Central Florida , Orlando, Florida
| | - Teresa K Woodruff
- The Oncofertility Consortium at Northwestern University , Chicago, Illinois
| | - Robert E Brannigan
- Department of Urology, Feinberg School of Medicine, Northwestern University , Chicago, Illinois. ; The Oncofertility Consortium at Northwestern University , Chicago, Illinois
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Bringer-Deutsch S, Belaisch-Allart J, Delvigne A. Préservation de la fertilité en cas de traitement stérilisant. ACTA ACUST UNITED AC 2010; 39:S53-66. [DOI: 10.1016/s0368-2315(10)70031-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Bonetti TCS, Pasqualotto FF, Queiroz P, Iaconelli A, Borges E. Sperm banking for male cancer patients: social and semen profiles. Int Braz J Urol 2010; 35:190-7; discussion 197-8. [PMID: 19409123 DOI: 10.1590/s1677-55382009000200009] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2008] [Indexed: 11/22/2022] Open
Abstract
PURPOSE Report the characteristics of cryopreserved semen from a cohort of male cancer patients, attitudes towards cryopreservation and outcomes of semen samples based on a 12-year cryopreservation program. MATERIAL AND METHODS Data from 98 male cancer patients whose sperm samples were banked were evaluated. Demographic parameters, semen characteristics, destination of sperm banked samples and questionnaires answered by the patients regarding cryopreservation time were evaluated. RESULTS The cancer diagnoses were testicle (56.1%), prostate (15.3%), Hodgkin's lymphomas (9.2%), non-Hodgkin's lymphomas (7.1%), leukemia (3.1%) and other malignancies (9.2%). The patients with testicular cancer presented lower sperm concentration (p < 0.001); however, there were no differences with the percentage of normozoospermic patients among cancer type groups (p = 0.185). A shorter time between cancer diagnosis and sperm banking was observed for testicular and prostate cancer patients (p < 0.001). Most of the patients (89.5%) favored sperm banking as a fertility preservation method. CONCLUSIONS Although less than 20% of banked sperm samples were disposed of, the majority of patients related sperm banking with safe for fertility preservation. Our results show that all male cancer patients of reproductive age facing cancer treatment could be offered sperm banking.
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Leonard M, Hammelef K, Smith GD. Fertility Considerations, Counseling, and Semen Cryopreservation for Males Prior to the Initiation of Cancer Therapy. Clin J Oncol Nurs 2007; 8:127-31, 145. [PMID: 15108413 DOI: 10.1188/04.cjon.127-131] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
An innovative program jointly sponsored by members of the departments of obstetrics and urology and the Comprehensive Cancer Center at the University of Michigan began in 2002. The Fertility Counseling and Gamete Cryopreservation Program (FCGCP) was created to provide counseling and education about therapy-induced infertility to newly diagnosed patients with cancer as well as facilitating the semen cryopreservation process. Unlike most sperm banking facilities in this country, this program is coordinated by an oncology nurse practitioner whose understanding of cancer and cancer treatments provides patients and staff with a unique perspective. Oncology staff misconceptions about sperm banking were addressed through intensive staff education programs. Patient education materials covering all aspects of infertility and sperm banking were developed and made available in patient care areas and on the Internet. Material aimed at young adolescents and their parents is prominent. Developmentally appropriate discussions are held with adolescent patients and their parents, both individually and together. Communication among patients and their families, the oncology team, and the sperm bank is maintained, permitting efficient and timely service. FCGCP provides an important service by affording all males with cancer the potential to father a child in the future.
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Cho SW, Lee SH, Chung MK, Kim HA, Chung HM, Lee YJ, Kwon H, Yoon TK, Cha KY. Successful spouse pregnancy of male patients with severe aplastic anemia and chronic myelogenous leukemia using spermatozoa banked prior to bone marrow transplantation and using the ICSI procedure: case reports. J Assist Reprod Genet 2005; 21:59-61. [PMID: 15186024 PMCID: PMC3455444 DOI: 10.1023/b:jarg.0000025940.98249.85] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE To report two cases of successful spouse pregnancies which were conceived with long-term cryopreserved spermatozoa that had been collected prior to the male patients receiving a bone marrow transplant. METHODS The first case is the pregnant wife of a 25-year-old man with chronic myelogenous leukemia, whose semen was collected before bone marrow transplant and then cryopreserved, thawed, and then injected into the wife's eggs via ICSI. The second case is a 28-year-old man with severe aplastic anemia who became a father after his wife's eggs were fertilized via ICSI with thawed spermatozoa. RESULTS These two cases were achieved pregnancies. CONCLUSIONS These cases support research that men with malignancy have the chance of fathering their own genetic children. Therefore, it is important to increase the awareness of clinicians, oncologists, and patients to the new developments in preserving fertility for cancer patients.
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Affiliation(s)
- Sung-Won Cho
- Genome Research Center for Reproductive Medicine and Infertility of Korea Ministry of Health and Welfare, CHA General Hospital, College of Medicine, Pochon CHA University, 606-5 Yeoksam-dong, Kangnam-ku, Seoul, 135-081 Korea
| | - Sook-Hwan Lee
- Genome Research Center for Reproductive Medicine and Infertility of Korea Ministry of Health and Welfare, CHA General Hospital, College of Medicine, Pochon CHA University, 606-5 Yeoksam-dong, Kangnam-ku, Seoul, 135-081 Korea
| | - Mi-Kyung Chung
- Genome Research Center for Reproductive Medicine and Infertility of Korea Ministry of Health and Welfare, CHA General Hospital, College of Medicine, Pochon CHA University, 606-5 Yeoksam-dong, Kangnam-ku, Seoul, 135-081 Korea
| | - Hyun-Ah Kim
- Genome Research Center for Reproductive Medicine and Infertility of Korea Ministry of Health and Welfare, CHA General Hospital, College of Medicine, Pochon CHA University, 606-5 Yeoksam-dong, Kangnam-ku, Seoul, 135-081 Korea
| | - Hyung-Min Chung
- Cell and Gene Therapy Research Institute, Pochon CHA University, Seoul, Korea
| | - Yun-Jung Lee
- Department of Obstetrics and Gynecology, Infertility Medical Center, CHA General Hospital, College of Medicine, Pochon CHA University, 606-5 Yeoksam-dong, Kangnam-ku, Seoul, Korea
| | - Hwang Kwon
- Department of Obstetrics and Gynecology, Infertility Medical Center, CHA General Hospital, College of Medicine, Pochon CHA University, 606-5 Yeoksam-dong, Kangnam-ku, Seoul, Korea
| | - Tae-Ki Yoon
- Department of Obstetrics and Gynecology, Infertility Medical Center, CHA General Hospital, College of Medicine, Pochon CHA University, 606-5 Yeoksam-dong, Kangnam-ku, Seoul, Korea
| | - Kwang-Yul Cha
- Department of Obstetrics and Gynecology, Infertility Medical Center, CHA General Hospital, College of Medicine, Pochon CHA University, 606-5 Yeoksam-dong, Kangnam-ku, Seoul, Korea
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Revel A, Haimov-Kochman R, Porat A, Lewin A, Simon A, Laufer N, Gino H, Meirow D. In vitro fertilization-intracytoplasmic sperm injection success rates with cryopreserved sperm from patients with malignant disease. Fertil Steril 2005; 84:118-22. [PMID: 16009166 DOI: 10.1016/j.fertnstert.2005.01.121] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2004] [Revised: 01/13/2005] [Accepted: 01/13/2005] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To describe the success rate of intracytoplasmic sperm injection (ICSI) using thawed cryopreserved sperm in male cancer patients. DESIGN Retrospective consecutive study. SETTING IVF unit in a tertiary university hospital. PATIENT(S) Twenty-one couples treated by ICSI using the frozen-thawed sperm of husbands treated for cancer. INTERVENTION(S) Follow-up of all treatments by ICSI. MAIN OUTCOME MEASURE(S) Pregnancy rate, sperm count, and fertilization rate. RESULT(S) Male patients being treated for cancer froze between one and 29 sperm samples. Post-thaw sperm count ranged from 1 x 10(5) to 106 x 10(6). The mean fertilization rate by ICSI was 60% (range, 33%-100%), and the pregnancy rate was 42%. Twenty-six pregnancies were obtained resulting in 23 children (13 singleton and 10 twins) and eight spontaneous abortions (31%). Delivery was obtained in 12 of the 21 treated couples (57%). The lowest total motile sperm count that resulted in a pregnancy was 1 x 10(5). CONCLUSION(S) Male cancer patients should be encouraged to freeze numerous sperm samples even when sperm count and motility are poor. In these cases, ICSI is a powerful technique compared with intrauterine injection since thawed sperm samples with poor parameters can produce relatively high fertilization rates resulting in normal pregnancies and deliveries. The possibility to repeat treatments even in the face of a limited number of sperm samples appears to be of importance.
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Affiliation(s)
- Ariel Revel
- IVF Unit, Hadassah University Hospital, Jerusalem, Israel.
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Tournaye H, Goossens E, Verheyen G, Frederickx V, De Block G, Devroey P, Van Steirteghem A. Preserving the reproductive potential of men and boys with cancer: current concepts and future prospects. Hum Reprod Update 2004; 10:525-32. [PMID: 15319377 DOI: 10.1093/humupd/dmh038] [Citation(s) in RCA: 125] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
The introduction of ICSI has totally changed the reproductive prospects for boys and men who are treated for cancer. With post-pubertal boys and adult men, semen cryopreservation should be offered to every patient undergoing a cancer treatment since preservation of fertility cannot be guaranteed for an individual patient and treatment may shift to a more sterilizing regimen. In the ICSI era, all semen samples, even those containing only a few motile sperm, should be accepted for cryopreservation. Patients who are azoospermic at the time cancer is diagnosed may be offered testicular sperm extraction and cryopreservation of testicular tissue. With pre-pubertal boys, no prevention of sterility by sperm banking is possible since no active spermatogenesis is present. However, in the next decade, prevention of sterility in childhood cancer survivors will become a major challenge for reproductive medicine. In theory, testicular stem cell banking is the only way of preserving the future fertility of boys undergoing a sterilizing chemotherapy. In animal models, testicular stem cell transplantation has proved to be effective; however, it remains to be shown that this technique is clinically efficient as well, especially when frozen-thawed cells are to be transplanted. Malignancy recurrence prevention is an important prerequisite for any clinical application of testicular stem cell transplantation. Although still at the experimental stage, cryobanking of testicular tissue from pre-pubertal boys may now be considered an acceptable strategy.
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Affiliation(s)
- Herman Tournaye
- Centre for Reproductive Medicine, Dutch-speaking Free University Brussels, Brussels, Belgium.
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Agarwal A, Ranganathan P, Kattal N, Pasqualotto F, Hallak J, Khayal S, Mascha E. Fertility after cancer: a prospective review of assisted reproductive outcome with banked semen specimens. Fertil Steril 2004; 81:342-8. [PMID: 14967371 DOI: 10.1016/j.fertnstert.2003.07.021] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2003] [Revised: 07/08/2003] [Accepted: 07/08/2003] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To examine the outcome of assisted reproduction techniques (ART) using cryopreserved semen from patients with cancer. DESIGN Prospective. SETTING Therapeutic semen banking program at a tertiary healthcare center. PATIENT(S) Twenty-nine men with cancer who cryopreserved their sperm before treatment at our facility from 1982 to 2001 and withdrew their samples for assisted reproduction (IUI, IVF, or intracytoplasmic sperm injection [ICSI]). INTERVENTION(S) Sperm bank records were used to identify the patients. Information on fertility potential indices was obtained from medical records and through interviews. Of the 29 patients, 9 had testicular cancer, 12 had Hodgkin's disease, and 8 had other types of cancer. MAIN OUTCOME MEASURE(S) Pregnancy and live births. RESULT(S) A total of 87 ART cycles (42 IUI, 26 IVF, and 19 ICSI) was performed. Of those cycles, 18.3% resulted in pregnancy (7% IUI, 23% IVF, and 37% ICSI), and 75% of the pregnancies resulted in a live birth (100% IUI, 83% IVF, and 57% ICSI). There was no significant difference in the outcomes when the results were stratified by type of ART and malignancy. None of the 11 infants who were born had congenital anomalies. CONCLUSION(S) Our findings emphasize the need for physicians to discuss the issue of semen cryopreservation with all men of reproductive age who have cancer before antineoplastic therapy is started.
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Affiliation(s)
- Ashok Agarwal
- Center for Advanced Research in Human Reproduction, Infertility and Sexual Function, Glickman Urological Institute, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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Schr??der AK, Diedrich K, Ludwig M. Strategies for Preventing Chemotherapy- and Radiotherapy-Induced Gonadal Damage. ACTA ACUST UNITED AC 2004. [DOI: 10.2165/00024669-200403020-00003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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10
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Schuffner A, Stockler S, Costa S, Centa L. Long-term cryopreserved semen results in a live birth 12 years later. J Urol 2003; 171:358. [PMID: 14665928 DOI: 10.1097/01.ju.0000100089.85955.9d] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Alessandro Schuffner
- Androlab-Clínica e Laboratorio de Reprodução Humana e Andrologia and Department of Human Reproduction, Federal University of Paraná, Curitaba, Brazil.
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Blackhall FH, Atkinson AD, Maaya MB, Ryder WDJ, Horne G, Brison DR, Lieberman BA, Radford JA. Semen cryopreservation, utilisation and reproductive outcome in men treated for Hodgkin's disease. Br J Cancer 2002; 87:381-4. [PMID: 12177773 PMCID: PMC2376135 DOI: 10.1038/sj.bjc.6600483] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2001] [Revised: 05/16/2002] [Accepted: 06/15/2002] [Indexed: 12/03/2022] Open
Abstract
Between 1978 and 1990, 122 men underwent semen analysis before starting sterilising chemotherapy for Hodgkin's disease. Eighty-one (66%) had semen quality within the normal range, 25 were oligospermic (<20 x 10(6) sperm per ml) and five were azoospermic (no sperm in the ejaculate). Semen from 115 men was cryopreserved and after a median follow-up time of 10.1 years, 33 men have utilised stored semen (actuarial rate 27%) and nine partners have become pregnant resulting in 11 live births and one termination for foetal malformation. Actuarial 10 year rates of destruction of semen before death or utilisation and death before utilisation are 19% and 13% respectively. This retrospective cohort study demonstrates that approximately one-quarter of men utilising cryopreserved semen after treatment for Hodgkin's disease obtain a live birth. The high non-utilisation rate is intriguing and warrants further investigation.
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Affiliation(s)
- F H Blackhall
- Cancer Research UK Department of Medical Oncology, Christie Hospital NHS Trust, Wilmslow Road, Manchester M20 4BX, UK
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Aguilar-Mahecha A, Hales BF, Robaire B. Chronic cyclophosphamide treatment alters the expression of stress response genes in rat male germ cells. Biol Reprod 2002; 66:1024-32. [PMID: 11906922 DOI: 10.1095/biolreprod66.4.1024] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Increases in the survival rate of men treated with chemotherapeutic drugs and their desire to have children precipitate concerns about the effects of these drugs on germ cells. Azoospermia, oligospermia, and infertility are common outcomes resulting from treatment with cyclophosphamide, an alkylating agent. Exposure of male rats to cyclophosphamide results in dose-dependent and time-specific adverse effects on progeny outcome. Elucidation of the effects of chronic low-dose cyclophosphamide treatment on the expression of stress response genes in male germ cells may provide insight into the mechanisms underlying such adverse effects. Male rats were gavaged with saline or cyclophosphamide (6 mg/kg) for 4-5 wk; pachytene spermatocytes, round spermatids, and elongating spermatids were isolated; RNA was extracted and probed on cDNA arrays containing 216 cDNAs. After saline treatment, 125 stress response genes were expressed in pachytene spermatocytes (57% of genes studied), 122 in round spermatids (56%), and 83 in elongating spermatids (38%). Cyclophosphamide treatment reduced the number of genes detected in all germ cell types. The predominant effect of chronic cyclophosphamide exposure was to decrease the expression level of genes in pachytene spermatocytes (34% of genes studied), round spermatids (29%), and elongating spermatids (4%). In elongating spermatids only, drug treatment increased the expression of 8% of the genes studied. The expression profiles of genes involved in DNA repair, posttranslational modification, and antioxidant defense in male germ cells were altered by chronic cyclophosphamide treatment. We hypothesize that the effects of cyclophosphamide exposure on germ cell gene expression during spermatogenesis may have adverse consequences on male fertility and progeny outcome.
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Affiliation(s)
- Adriana Aguilar-Mahecha
- Department of Pharmacology and Therapeutics, McGill University, 3655 Promenade Sir-William-Osler, Montreal, Quebec, Canada H3G 1Y6
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McLaughlin EA. Cryopreservation, screening and storage of sperm the challenges for the twenty-first century. HUM FERTIL 2002; 5:S61-5. [PMID: 11897918 DOI: 10.1080/1464727022000199941] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The advent of HIV and the serious nature of the sequelae resulted in a major reassessment of artificial insemination practices in the UK. The development of human semen cryopreservation had enormous impact on reproductive medicine and the availability of cryopreserved quarantined donor semen became a mainstay for the treatment of male infertility in the UK. The regulation and accreditation of assisted reproductive technologies and the introduction of peer-reviewed guidelines have largely standardized clinical and laboratory practice. The introduction of assisted fertilization techniques such as intracytoplasmic sperm injection, testicular sperm retrieval and improved oncology treatments have placed pressure on reproductive biologists and cryobiologists to design and use cryopreservation protocols for the optimum survival of sperm.
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Affiliation(s)
- Eileen A McLaughlin
- University of Bristol Department of Obstetrics and Gynaecology, St Michael's Hospital, Bristol BS2 8EG, UK
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Ola B, Afnan M, Sharif K, Papaioannou S, Hammadieh N, Barratt CL. Should ICSI be the treatment of choice for all cases of in-vitro conception? Considerations of fertilization and embryo development, cost effectiveness and safety. Hum Reprod 2001; 16:2485-90. [PMID: 11726563 DOI: 10.1093/humrep/16.12.2485] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
There is now considerable discussion whether intracytoplasmic sperm injection (ICSI) should be used in all cases of IVF. A critical and balanced view of the current literature is presented. The difficult question is how to identify men with apparently normal semen who are likely to fail to achieve a pregnancy using IVF. In conclusion, from both the safety and scientific viewpoint, ICSI should only be used in cases where success at IVF is regarded as unlikely.
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Affiliation(s)
- B Ola
- Assisted Conception Unit, Birmingham Women's Hospital, Edgbaston, Birmingham B15 T2G, UK
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