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Izadi M, Khalili MA, Rezvani ME, Anbari F, Maleki B, Woodward B, Aflatoonian B. Sperm Selection Using Zona Pellucida-Binding Enhanced Embryo Morphokinetic and Clinical Outcomes in ICSI: A Sibling Oocytes Study. Am J Mens Health 2024; 18:15579883241228236. [PMID: 38279800 PMCID: PMC10822090 DOI: 10.1177/15579883241228236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/07/2024] [Accepted: 01/08/2024] [Indexed: 01/29/2024] Open
Abstract
The objective was to investigate the embryo morphokinitics using a time-lapse monitoring (TLM) system and assessment of clinical outcomes following intracytoplasmic sperm injection (ICSI) with zona pellucida (ZP)-bound sperm selection and conventional methods. A total of 371 metaphase II (MII) oocytes from 50 ICSI cycles were studied. Sibling oocytes were randomly divided into control (n = 199) and ZP-bound group (n = 172). All resulting zygotes were cultured and monitored in the TLM system up to Day 3 after ICSI. Fertilization rate, early embryo development, and clinical outcomes were evaluated. No significant differences were found in fertilization rate, time-lapse qualitative and quantitative measures, pronuclear fading time (PNF) t2, t3, t4, t5, t6, and t7 (times of cleavage to 2, 3, 4, 5, 6, and 7 cells), respectively. However, the t8 (time of cleavage to eight cells) and cc3 (duration of third cell cycle) revealed a significant difference between control and ZP-bound groups (p < .05). A significant difference between the two groups (p < .05) in the rates of Grade A embryos (according to Basile algorithm), chemical pregnancy, clinical pregnancy, and implantation was observed. Sperm selection using biological materials, such as ZP, improved both embryo quality and pregnancy outcomes, despite not affecting the early embryo development and morphokinetic parameters up to t8. This prospective randomized sibling oocyte trial was registered in October 2020 to January 2022 (IRCT20200705048021N1).
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Affiliation(s)
- Mahin Izadi
- Research and Clinical Center for Infertility, Yazd Reproductive Sciences Institute, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
- Department of Reproductive Biology, School of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Mohammad Ali Khalili
- Research and Clinical Center for Infertility, Yazd Reproductive Sciences Institute, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
- Department of Reproductive Biology, School of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Mohammad Ebrahim Rezvani
- Department of Physiology, School of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Fatemeh Anbari
- Research and Clinical Center for Infertility, Yazd Reproductive Sciences Institute, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
- Department of Reproductive Biology, School of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Behnam Maleki
- Research and Clinical Center for Infertility, Yazd Reproductive Sciences Institute, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
- Infertility Center, Department of Obstetrics and Gynecology, Mazandaran University of Medical Sciences, Sari, Iran
| | | | - Behrouz Aflatoonian
- Research and Clinical Center for Infertility, Yazd Reproductive Sciences Institute, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
- Department of Reproductive Biology, School of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
- Stem Cell Biology Research Center, Yazd Reproductive Sciences Institute, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
- Department of Advanced Medical Sciences and Technologies, School of Paramedicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
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What Does Intracytoplasmic Sperm Injection Change in Embryonic Development? The Spermatozoon Contribution. J Clin Med 2023; 12:jcm12020671. [PMID: 36675600 PMCID: PMC9867417 DOI: 10.3390/jcm12020671] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 12/30/2022] [Accepted: 01/11/2023] [Indexed: 01/19/2023] Open
Abstract
The intracytoplasmic sperm injection (ICSI) technique was invented to solve severe male infertility due to altered sperm parameters. Nowadays, it is applied worldwide for the treatment of couple infertility. ICSI is performed with any available spermatozoon from surgery or ejaculated samples, whatever are the sperm motility, morphology or quantity. The aim of the present review was to study if embryo development and kinetics would be modified by (1) ICSI under the technical aspects, (2) the micro-injected spermatozoa in connection with male infertility. From published data, it can be seen that ICSI anticipates the zygote kinetics Furthermore, because fertilization rate is higher in ICSI compared to conventional in vitro fertilization (IVF), more blastocysts are obtained for clinical use in ICSI. Sperm and spermatozoa characteristics, such as sperm parameters, morphology and vitality, DNA content (levels of sperm DNA fragmentation, microdeletions, and chromosomal abnormalities), RNA content, epigenetics, and sperm recovery site (testicular, epididymis, and ejaculated), have an impact on fertilization and blastocyst rates and embryo kinetics in different ways. Even though ICSI is the most common solution to solve couples' infertility, the causes of male infertility are crucial in building a competent spermatozoa that will contribute to normal embryonic development and healthy offspring.
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Jumeau F, Rives N, Lechevallier P, Boniou C, Letailleur M, Réal-Lhommet A, Feraille A. Sperm Chromatin Condensation Defect Accelerates the Kinetics of Early Embryonic Development but Does Not Modify ICSI Outcome. Int J Mol Sci 2022; 24:ijms24010393. [PMID: 36613835 PMCID: PMC9820555 DOI: 10.3390/ijms24010393] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/05/2022] [Accepted: 12/14/2022] [Indexed: 12/28/2022] Open
Abstract
The origin and quality of gametes are likely to influence the kinetics of embryonic development. The purpose of the study was to assess the impact of sperm nuclear quality, and in particular sperm chromatin condensation, on the kinetics of early embryo development after intracytoplasmic sperm injection (ICSI). Our study included 157 couples who benefitted from ICSI for male factor infertility. Chromatin condensation and DNA fragmentation were assessed in spermatozoa prior to ICSI. Above the 20% threshold of sperm condensation defect, patients were included in the abnormal sperm chromatin condensation (ASCC) group; below the 20% threshold, patients were included in the normal sperm chromatin condensation (NSCC) group. After ICSI, the oocytes were placed in the time-lapse incubator. The kinetics of the cohort's embryonic development have been modeled. The fading times of pronuclei and the time to two blastomeres (t2, first cleavage) and four blastomeres (t4, third cleavage) differed significantly between the NSCC and ASCC groups, with earlier events occurring in the ASCC group. On the other hand, the state of sperm chromatin condensation did not seem to have an impact on live birth rates or the occurrence of miscarriages. The kinetics of early embryonic development was accelerated in males with a sperm chromatin condensation defect without compromising the chances of pregnancy or promoting miscarriage. However, our study highlights the paternal contribution to early embryonic events and potentially to the future health of the conceptus.
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Affiliation(s)
- Fanny Jumeau
- Team Adrenal and Gonadal Pathophysiology, Reproductive Biology Laboratory—CECOS, Rouen University Hospital, University Rouen Normandie, Inserm, U1239 NorDIC, F-76000 Rouen, France
| | - Nathalie Rives
- Team Adrenal and Gonadal Pathophysiology, Reproductive Biology Laboratory—CECOS, Rouen University Hospital, University Rouen Normandie, Inserm, U1239 NorDIC, F-76000 Rouen, France
- Correspondence: ; Tel.: +33-02-32-88-82-25
| | - Pauline Lechevallier
- Team Adrenal and Gonadal Pathophysiology, Reproductive Biology Laboratory—CECOS, Rouen University Hospital, University Rouen Normandie, Inserm, U1239 NorDIC, F-76000 Rouen, France
| | - Coline Boniou
- Team Adrenal and Gonadal Pathophysiology, Reproductive Biology Laboratory—CECOS, Rouen University Hospital, University Rouen Normandie, Inserm, U1239 NorDIC, F-76000 Rouen, France
| | - Maria Letailleur
- Assisted Reproductive Center, Department of Gynaecology and Obstetrics, Rouen Normandy University Hospital, F-76000 Rouen, France
| | - Audrey Réal-Lhommet
- Assisted Reproductive Center, Department of Gynaecology and Obstetrics, Rouen Normandy University Hospital, F-76000 Rouen, France
| | - Aurélie Feraille
- Team Adrenal and Gonadal Pathophysiology, Reproductive Biology Laboratory—CECOS, Rouen University Hospital, University Rouen Normandie, Inserm, U1239 NorDIC, F-76000 Rouen, France
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Rahmawati P, Wiweko B, Boediono A. Mitochondrial DNA copy number in cumulus granulosa cells as a predictor for embryo morphokinetics and chromosome status. Syst Biol Reprod Med 2022; 69:101-111. [PMID: 36426586 DOI: 10.1080/19396368.2022.2145248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
While morphokinetic evaluation of embryos has become the most commonly used technique in IVF to select embryos for transfer, studies have demonstrated that mitochondrial DNA (mtDNA) copy number is correlated with embryo viability and transfer outcomes. Correspondingly, this cohort study aims to evaluate the association between the mtDNA copy number in cumulus granulosa cells (CGCs) with embryo morphokinetic parameters and chromosomal status. Real-time PCR was employed to measure the mtDNA copy number of the 129 CGCs in samples obtained from 30 patients undergoing the IVF-IMSI program at Morula IVF Jakarta between July and October 2020. Bivariate and multiple analyses were utilized to determine its relationship with embryo morphokinetics, blastocyst yield, and chromosomal status. According to the analysis, there was a significant correlation between the mtDNA copy number and the blastocyst status after adjusting for the maternal age and sperm morphology (coefficient 0.832, p value = 0.032, RR value 2.299). Moreover, a significant link was observed between mtDNA copy number in CGC and early embryo developmental phase M1 (t2-t8), using the equation of M1 is 5.702-0.271 mtDNA copy number of CGCs + 0.017 maternal age + 0.013 sperm motility -0.115 sperm morphology (p value = 0.032). However, no correlation was found between the mtDNA copy number in CGCs with the other morphokinetic parameters (M2: tC-tEB, M3: t2-tEB, DC, RC, MN with p > 0.05), or the chromosomal status of the embryos (euploid: 139.44 ± 133.12, aneuploid: 142.40 ± 111.30, p = 0.806). In conclusion, our study suggests that mtDNA copy number in CGCs can serve as a useful biomarker for blastocyst status and early embryo developmental phase but not for chromosomal status.
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Affiliation(s)
- Pitra Rahmawati
- Master Program in Biomedical Science, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
- Morula IVF Jakarta, IVF Center, Jakarta, Indonesia
| | - Budi Wiweko
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
- Yasmin IVF Clinic, Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
- Human Reproductive, Infertility and Family Planning Research Center, Indonesia Medical Education and Research Institute (IMERI), Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Arief Boediono
- Morula IVF Jakarta, IVF Center, Jakarta, Indonesia
- Department of Anatomy, Physiology and Pharmacology, IPB University, Bogor, Indonesia
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Méndez M, Guimerà M, Corral J, Cívico S. Sperm origin impact on early human embryo kinetics. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2022. [DOI: 10.1016/j.gine.2022.100750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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van Marion ES, Chavli EA, Laven JSE, Steegers-Theunissen RPM, Koster MPH, Baart EB. Longitudinal surface measurements of human blastocysts show that the dynamics of blastocoel expansion are associated with fertilization method and ongoing pregnancy. Reprod Biol Endocrinol 2022; 20:53. [PMID: 35305653 PMCID: PMC8933899 DOI: 10.1186/s12958-022-00917-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 02/23/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite all research efforts during this era of novel time-lapse morphokinetic parameters, a morphological grading system is still routinely being used for embryo selection at the blastocyst stage. The blastocyst expansion grade, as evaluated during morphological assessment, is associated with clinical pregnancy. However, this assessment is performed without taking the dynamics of blastocoel expansion into account. Here, we studied the dynamics of blastocoel expansion by comparing longitudinal blastocoel surface measurements using time-lapse embryo culture. Our aim was to first assess if this is impacted by fertilization method and second, to study if an association exists between these measurement and ongoing pregnancy. METHODS This was a retrospective cohort study including 225 couples undergoing 225 cycles of in vitro fertilization (IVF) treatment with time-lapse embryo culture. The fertilization method was either conventional IVF, intracytoplasmic sperm injection (ICSI) with ejaculated sperm or ICSI with sperm derived from testicular sperm extraction (TESE-ICSI). This resulted in 289 IVF embryos, 218 ICSI embryos and 259 TESE-ICSI embryos that reached at least the full blastocyst stage. Blastocoel surface measurements were performed on time-lapse images every hour, starting from full blastocyst formation (tB). Linear mixed model analysis was performed to study the association between blastocoel expansion, the calculated expansion rate (µm2/hour) and both fertilization method and ongoing pregnancy. RESULTS The blastocoel of both ICSI embryos and TESE-ICSI embryos was significantly smaller than the blastocoel of IVF embryos (beta -1121.6 µm2; 95% CI: -1606.1 to -637.1, beta -646.8 µm2; 95% CI: -1118.7 to 174.8, respectively). Still, the blastocoel of transferred embryos resulting in an ongoing pregnancy was significantly larger (beta 795.4 µm2; 95% CI: 15.4 to 1575.4) and expanded significantly faster (beta 100.9 µm2/hour; 95% CI: 5.7 to 196.2) than the blastocoel of transferred embryos that did not, regardless of the fertilization method. CONCLUSION Longitudinal blastocyst surface measurements and expansion rates are promising non-invasive quantitative markers that can aid embryo selection for transfer and cryopreservation. TRIAL REGISTRATION Our study is a retrospective observational study, therefore trial registration is not applicable.
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Affiliation(s)
- Eva S van Marion
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Effrosyni A Chavli
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Joop S E Laven
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | | | - Maria P H Koster
- Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Esther B Baart
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
- Department of Developmental Biology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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Kashir J, Ganesh D, Jones C, Coward K. OUP accepted manuscript. Hum Reprod Open 2022; 2022:hoac003. [PMID: 35261925 PMCID: PMC8894871 DOI: 10.1093/hropen/hoac003] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 01/16/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Oocyte activation deficiency (OAD) is attributed to the majority of cases underlying failure of ICSI cycles, the standard treatment for male factor infertility. Oocyte activation encompasses a series of concerted events, triggered by sperm-specific phospholipase C zeta (PLCζ), which elicits increases in free cytoplasmic calcium (Ca2+) in spatially and temporally specific oscillations. Defects in this specific pattern of Ca2+ release are directly attributable to most cases of OAD. Ca2+ release can be clinically mediated via assisted oocyte activation (AOA), a combination of mechanical, electrical and/or chemical stimuli which artificially promote an increase in the levels of intra-cytoplasmic Ca2+. However, concerns regarding safety and efficacy underlie potential risks that must be addressed before such methods can be safely widely used. OBJECTIVE AND RATIONALE Recent advances in current AOA techniques warrant a review of the safety and efficacy of these practices, to determine the extent to which AOA may be implemented in the clinic. Importantly, the primary challenges to obtaining data on the safety and efficacy of AOA must be determined. Such questions require urgent attention before widespread clinical utilization of such protocols can be advocated. SEARCH METHODS A literature review was performed using databases including PubMed, Web of Science, Medline, etc. using AOA, OAD, calcium ionophores, ICSI, PLCζ, oocyte activation, failed fertilization and fertilization failure as keywords. Relevant articles published until June 2019 were analysed and included in the review, with an emphasis on studies assessing large-scale efficacy and safety. OUTCOMES Contradictory studies on the safety and efficacy of AOA do not yet allow for the establishment of AOA as standard practice in the clinic. Heterogeneity in study methodology, inconsistent sample inclusion criteria, non-standardized outcome assessments, restricted sample size and animal model limitations render AOA strictly experimental. The main scientific concern impeding AOA utilization in the clinic is the non-physiological method of Ca2+ release mediated by most AOA agents, coupled with a lack of holistic understanding regarding the physiological mechanism(s) underlying Ca2+ release at oocyte activation. LIMITATIONS, REASONS FOR CAUTION The number of studies with clinical relevance using AOA remains significantly low. A much wider range of studies examining outcomes using multiple AOA agents are required. WIDER IMPLICATIONS In addition to addressing the five main challenges of studies assessing AOA safety and efficacy, more standardized, large-scale, multi-centre studies of AOA, as well as long-term follow-up studies of children born from AOA, would provide evidence for establishing AOA as a treatment for infertility. The delivery of an activating agent that can more accurately recapitulate physiological fertilization, such as recombinant PLCζ, is a promising prospect for the future of AOA. Further to PLCζ, many other avenues of physiological oocyte activation also require urgent investigation to assess other potential physiological avenues of AOA. STUDY FUNDING/COMPETING INTERESTS D.G. was supported by Stanford University’s Bing Overseas Study Program. J.K. was supported by a Healthcare Research Fellowship Award (HF-14-16) made by Health and Care Research Wales (HCRW), alongside a National Science, Technology, and Innovation plan (NSTIP) project grant (15-MED4186-20) awarded by the King Abdulaziz City for Science and Technology (KACST). The authors have no competing interests to declare.
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Affiliation(s)
| | | | - Celine Jones
- Nuffield Department of Women’s & Reproductive Health, University of Oxford, Level 3, Women’s Centre, John Radcliffe Hospital, Oxford, UK
| | - Kevin Coward
- Correspondence address. Nuffield Department of Women’s & Reproductive Health, University of Oxford, Level 3, Women’s Centre, John Radcliffe Hospital, Oxford, OS3 9DU, UK. E-mail: https://orcid.org/0000-0003-3577-4041
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Bruno C, Bourredjem A, Barry F, Frappier J, Martinaud A, Chamoy B, Hance I, Ginod P, Cavalieri M, Amblot C, Binquet C, Barberet J, Fauque P. Analysis and quantification of female and male contributions to the first stages of embryonic kinetics: study from a time-lapse system. J Assist Reprod Genet 2022; 39:85-95. [PMID: 34674102 PMCID: PMC8866590 DOI: 10.1007/s10815-021-02336-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 09/28/2021] [Indexed: 01/03/2023] Open
Abstract
PURPOSE The few studies that examined the effect of male and/or female features on early embryo development, notably using the time-lapse system (TL), reported conflicting results. This can be explained by the small number of studies using an adapted model. METHODS We used two original designs to study the female and male effects on embryo development: (1) based on embryos from donor oocytes (TL-DO), and (2) from donor sperm (TL-DS). Firstly, we analyzed the female and male similarities using an ad hoc intraclass correlation coefficient (ICC), then we completed the analysis with a multivariable model to assess the association between both male and female factors, and early embryo kinetics. A total of 572 mature oocytes (TL-DO: 293; TL-DS: 279), fertilized by intracytoplasmic sperm injection (ICSI) and incubated in a TL (Embryoscope®) were included from March 2013 to April 2019; 429 fertilized oocytes (TL-DO: 212; TL-DS: 217) were assessed. The timings of the first 48 h have been analyzed. RESULTS The similarities in the timings thought to be related to the female component were significant: (ICC in both DO-DS designs respectively: tPB2: 9-18%; tPNa: 16-21%; tPNf: 40-26%; t2: 38-24%; t3: 15-20%; t4: 21-32%). Comparatively, those related to male were lower. Surprisingly after multivariable analyses, no intrinsic female factors were clearly identified. However, in TL-DO design, oligozoospermia was associated with a tendency to longer timings, notably for tPB2 (p = 0.026). CONCLUSION This study quantifies the role of the oocyte in the first embryo cleavages, but without identified specific female factors. However, it also highlights that sperm may have an early embryonic effect.
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Affiliation(s)
- Céline Bruno
- Laboratoire de Biologie de La Reproduction, Hôpital François Mitterrand, Université de Bourgogne, Dijon, France.
| | - Abderrahmane Bourredjem
- Inserm, CIC1432, Module Epidémiologie Clinique, F-21000, Dijon, France
- CHU Dijon-Bourgogne, Centre d'Investigation Clinique, Module Epidémiologie Clinique/Essais Clinique, 21000, Dijon, France
| | - Fatima Barry
- Laboratoire de Biologie de La Reproduction, Hôpital François Mitterrand, Université de Bourgogne, Dijon, France
| | - Jean Frappier
- Laboratoire de Biologie de La Reproduction, Hôpital François Mitterrand, Université de Bourgogne, Dijon, France
| | - Aurélie Martinaud
- Laboratoire de Biologie de La Reproduction, Hôpital François Mitterrand, Université de Bourgogne, Dijon, France
| | - Bruno Chamoy
- Laboratoire de Biologie de La Reproduction, Hôpital François Mitterrand, Université de Bourgogne, Dijon, France
| | - Isabelle Hance
- Service de Gynécologie-Obstétrique, Hôpital François Mitterrand, Université de Bourgogne, Dijon, France
| | - Perrine Ginod
- Service de Gynécologie-Obstétrique, Hôpital François Mitterrand, Université de Bourgogne, Dijon, France
| | - Mathilde Cavalieri
- Service de Gynécologie-Obstétrique, Hôpital François Mitterrand, Université de Bourgogne, Dijon, France
| | - Céline Amblot
- Service de Gynécologie-Obstétrique, Hôpital François Mitterrand, Université de Bourgogne, Dijon, France
| | - Christine Binquet
- Inserm, CIC1432, Module Epidémiologie Clinique, F-21000, Dijon, France
- CHU Dijon-Bourgogne, Centre d'Investigation Clinique, Module Epidémiologie Clinique/Essais Clinique, 21000, Dijon, France
| | - Julie Barberet
- Laboratoire de Biologie de La Reproduction, Hôpital François Mitterrand, Université de Bourgogne, Dijon, France
| | - Patricia Fauque
- Laboratoire de Biologie de La Reproduction, Hôpital François Mitterrand, Université de Bourgogne, Dijon, France
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Peer A, Atzmon Y, Aslih N, Bilgory A, Estrada D, Raya YSA, Shalom-Paz E. Male genome influences embryonic development as early as pronuclear stage. Andrology 2021; 10:525-533. [PMID: 34842361 DOI: 10.1111/andr.13133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 10/20/2021] [Accepted: 11/21/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Impaired paternal genome expression may cause poor embryonic development after in vitro fertilization (IVF). OBJECTIVE To evaluate the expression of male infertility on embryo morphokinetics using a time-lapse incubator and its impact on IVF cycles. MATERIALS AND METHODS This retrospective cohort study followed patients from January 2017 to August 2019. Patients were divided according to the cause of infertility to male factor (study group) and unexplained infertility (control group) and further subdivided according to the severity of male infertility. RESULTS A cohort of 462 patients who underwent IVF cycles, with a total of 3,252 embryos was evaluated. Intracytoplasmic sperm injection (ICSI) was conducted more often in the study group compared to the control group (94% vs. 47%, p < 0.0001) and more embryos were discarded (47% vs. 43%, p = 0.016). Treatment outcomes were comparable in both groups regardless of the severity of male infertility. T3-T5 had a significant impact on embryo quality and more transfer and freeze compared to discard. Maternal age, number of aspirated oocytes, BMI, protocol used, and faster time to T3, T6 were significant in increasing chances of achieving pregnancy. CONCLUSION The paternal genome may have an earlier impact on embryo development than previously surmised and may also account for faster morphokinetics. Faster embryo cleavage in male infertility IVF-ICSI cycles may contribute to outcomes comparable to other causes of infertility, in terms of embryo quality and clinical pregnancy rate, despite lower sperm quality, even in cases of severe Oligo-terato-Astheno spermia (OTA).
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Affiliation(s)
- Aviv Peer
- Department of Obstetrics & Gynecology, IVF Unit, Hillel Yaffe Medical Center, Hadera, Israel.,Ruth and Bruce Rappaport School of Medicine, The Technion-Institute of Technology, Haifa, Israel
| | - Yuval Atzmon
- Department of Obstetrics & Gynecology, IVF Unit, Hillel Yaffe Medical Center, Hadera, Israel
| | - Nardin Aslih
- Department of Obstetrics & Gynecology, IVF Unit, Hillel Yaffe Medical Center, Hadera, Israel
| | - Asaf Bilgory
- Department of Obstetrics & Gynecology, IVF Unit, Hillel Yaffe Medical Center, Hadera, Israel
| | - Daniela Estrada
- Department of Obstetrics & Gynecology, IVF Unit, Hillel Yaffe Medical Center, Hadera, Israel
| | - Yasmin Shibli Abu Raya
- Department of Obstetrics & Gynecology, IVF Unit, Hillel Yaffe Medical Center, Hadera, Israel
| | - Einat Shalom-Paz
- Department of Obstetrics & Gynecology, IVF Unit, Hillel Yaffe Medical Center, Hadera, Israel.,Ruth and Bruce Rappaport School of Medicine, The Technion-Institute of Technology, Haifa, Israel
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Setti AS, Braga DPDAF, Vingris L, Iaconelli A, Borges E. Early and late paternal contribution to cell division of embryos in a time-lapse imaging incubation system. Andrologia 2021; 53:e14211. [PMID: 34437729 DOI: 10.1111/and.14211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 07/29/2021] [Accepted: 07/30/2021] [Indexed: 11/28/2022] Open
Abstract
The objective of this study was to investigate the impact of male age, semen quality and days of ejaculatory abstinence on embryo morphokinetics. A total of 1,220 zygotes obtained from 139 couples in a private in vitro fertilisation centre were analysed. The timing of specific events from the point of insemination, such as timings to pronuclei appearance and fading, to two, three, four, five, six, seven and eight cells and to blastulation were recorded. Multivariate linear regression analysis was used to evaluate the influence of paternal factors on embryo morphokinetic events. Paternal age was positively correlated with delayed cell cleavage and blastulation, and negatively associated with implantation rate, and clinical pregnancy and live-birth chances. The ejaculatory abstinence was inversely correlated with the implantation rate. Inverse relationships were observed between semen parameters (sperm count, progressive sperm motility, total motile sperm count and morphology) and the timing of specific events during embryo development. Sperm morphology was also positively associated with implantation rate and pregnancy and live-birth chances. Increased paternal age and ejaculatory abstinence, and poor semen quality correlate with delayed cell cleavage and blastulation and negatively impact intracytoplasmic sperm injection outcomes.
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Affiliation(s)
- Amanda Souza Setti
- Scientific Research Department, Fertility Medical Group, São Paulo, Brazil.,Scientific Research Department, Sapientiae Institute - Centro de Estudos e Pesquisa em Reprodução Humana Assistida, São Paulo, Brazil
| | - Daniela Paes de Almeida Ferreira Braga
- Scientific Research Department, Fertility Medical Group, São Paulo, Brazil.,Scientific Research Department, Sapientiae Institute - Centro de Estudos e Pesquisa em Reprodução Humana Assistida, São Paulo, Brazil
| | | | - Assumpto Iaconelli
- Scientific Research Department, Sapientiae Institute - Centro de Estudos e Pesquisa em Reprodução Humana Assistida, São Paulo, Brazil.,Clinical Department, Fertility Medical Group, São Paulo, Brazil
| | - Edson Borges
- Scientific Research Department, Sapientiae Institute - Centro de Estudos e Pesquisa em Reprodução Humana Assistida, São Paulo, Brazil.,Clinical Department, Fertility Medical Group, São Paulo, Brazil
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11
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van Marion ES, Speksnijder JP, Hoek J, Boellaard WPA, Dinkelman-Smit M, Chavli EA, Steegers-Theunissen RPM, Laven JSE, Baart EB. Time-lapse imaging of human embryos fertilized with testicular sperm reveals an impact on the first embryonic cell cycle. Biol Reprod 2021; 104:1218-1227. [PMID: 33690817 PMCID: PMC8181962 DOI: 10.1093/biolre/ioab031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 02/08/2021] [Accepted: 02/18/2021] [Indexed: 11/14/2022] Open
Abstract
Testicular sperm is increasingly used during in vitro fertilization treatment. Testicular sperm has the ability to fertilize the oocyte after intracytoplasmic sperm injection (ICSI), but they have not undergone maturation during epididymal transport. Testicular sperm differs from ejaculated sperm in terms of chromatin maturity, incidence of DNA damage, and RNA content. It is not fully understood what the biological impact is of using testicular sperm, on fertilization, preimplantation embryo development, and postimplantation development. Our goal was to investigate differences in human preimplantation embryo development after ICSI using testicular sperm (TESE-ICSI) and ejaculated sperm. We used time-lapse embryo culture to study these possible differences. Embryos (n = 639) originating from 208 couples undergoing TESE-ICSI treatment were studied and compared to embryos (n = 866) originating from 243 couples undergoing ICSI treatment with ejaculated sperm. Using statistical analysis with linear mixed models, we observed that pronuclei appeared 0.55 h earlier in TESE-ICSI embryos, after which the pronuclear stage lasted 0.55 h longer. Also, significantly more TESE-ICSI embryos showed direct unequal cleavage from the 1-cell stage to the 3-cell stage. TESE-ICSI embryos proceeded faster through the cleavage divisions to the 5- and the 6-cell stage, but this effect disappeared when we adjusted our model for maternal factors. In conclusion, sperm origin affects embryo development during the first embryonic cell cycle, but not developmental kinetics to the 8-cell stage. Our results provide insight into the biological differences between testicular and ejaculated sperm and their impact during human fertilization.
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Affiliation(s)
- E S van Marion
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - J P Speksnijder
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - J Hoek
- Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - W P A Boellaard
- Department of Urology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - M Dinkelman-Smit
- Department of Urology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - E A Chavli
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - R P M Steegers-Theunissen
- Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - J S E Laven
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - E B Baart
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.,Department of Developmental Biology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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12
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Boediono A, Handayani N, Sari HN, Yusup N, Indrasari W, Polim AA, Sini I. Morphokinetics of embryos after IMSI versus ICSI in couples with sub-optimal sperm quality: A time-lapse study. Andrologia 2021; 53:e14002. [PMID: 33606295 DOI: 10.1111/and.14002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 01/06/2021] [Accepted: 01/17/2021] [Indexed: 11/30/2022] Open
Abstract
An investigation was conducted to determine the influence of two sperm selection modalities, IMSI and ICSI, on the morphokinetics, dynamic development and ploidy status of embryos derived from males with sub-optimal sperm profiles during IVF program. A total of 209 PGTA-tested top-quality blastocysts (IMSI = 129, ICSI = 80) from 84 couples (IMSI = 51, ICSI = 33) were assessed retrospectively. This study found that both IMSI and ICSI yielded comparable embryo morphokinetics, except for the T7, TEB and CC3 parameters (p < 0.05). A significant lower incidence of multinucleation was observed in the IMSI group when compared to the ICSI group (48.8% vs. 71.3%, p = 0.002), while other parameters of embryo development such as direct cleavage, distorted cytoplasmic movement, reverse cleavage and vacuole(s) appearance did not differ (p > 0.05). No differences were noticed in the proportion of generating chromosomally euploid embryos (44.2% vs. 51.3%, p = 0.394, respectively, for IMSI and ICSI). The implementation of IMSI or ICSI in couples with sub-optimal sperm profiles resulted in embryos with comparatively similar morphokinetics. Furthermore, the incidence of multinucleation at the two- to four-cell stage was lower following the practice of IMSI, although the method did not improve the proportion of gaining euploid embryos.
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Affiliation(s)
- Arief Boediono
- Morula IVF Jakarta Clinic, Jakarta, Indonesia.,IRSI Research and Training Centre, Jakarta, Indonesia.,Department of Anatomy, Physiology and Pharmacology, IPB University, Bogor, Indonesia
| | - Nining Handayani
- Morula IVF Jakarta Clinic, Jakarta, Indonesia.,IRSI Research and Training Centre, Jakarta, Indonesia
| | | | - Nuraeni Yusup
- IRSI Research and Training Centre, Jakarta, Indonesia
| | | | - Arie A Polim
- Morula IVF Jakarta Clinic, Jakarta, Indonesia.,IRSI Research and Training Centre, Jakarta, Indonesia.,Department of Obstetrics and Gynecology, School of Medicine and Health Sciences, Atmajaya Catholic University of Indonesia, Jakarta, Indonesia
| | - Ivan Sini
- Morula IVF Jakarta Clinic, Jakarta, Indonesia.,IRSI Research and Training Centre, Jakarta, Indonesia
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13
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Montjean D, Geoffroy-Siraudin C, Gervoise-Boyer MJ, Boyer P. Competence of embryos showing transient developmental arrest during in vitro culture. J Assist Reprod Genet 2021; 38:857-863. [PMID: 33532884 DOI: 10.1007/s10815-021-02090-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 01/25/2021] [Indexed: 11/30/2022] Open
Abstract
PURPOSE In vitro developing embryos may apparently show no developmental progress during 24 h and resume their development up to the blastocyst stage. The present study was conducted to assess their ability to implant and to give rise to a live birth when replaced at day 5 (fresh or vitrified/warmed) as compared to continuously developing embryos. METHODS Embryo development follow-up and grade were prospectively recorded in a photo database. The studied period was from April 2011 to July 2017. The studied embryos included transient arrested embryos (TAE) that showed the same developmental stage at two subsequent observations, i.e. between day 2 and day 3 (d2 and d3), between day 3 and day 4 (d3 and d4) and between day 4 and day 5 (d4 and d5). TAE were compared to continuously developing embryos (CDE). Elective day 5 embryo transfers were performed. RESULTS Woman age was higher in TAE (34.3±3.9) than in CDE (32.9±4.8) (p<0.01). TAE were more frequently (63.1%) observed after ICSI than after conventional IVF (55.9%) (p<0.01). Implantation rate was reduced in TAE as compared to CDE, after both fresh (10.0% vs 23.8% [p<0.01]) and vitrified/warmed (12.9% vs 19.0% [p<0.01]) embryo transfers. Delivery rate was also lower after the transfer of fresh (8.3% vs 19.4% [p<0.01]) and vitrified/warmed (8.5% vs 14.1% [p<0.01]) TAE as compared to CDE. Implantation and delivery rates were not statistically different whether embryo arrested between day 2 and day 3 (d2 and d3), between day 3 and day 4 (d3 and d4) or between day 4 and day 5 (d4 and d5). CONCLUSION TAE may be considered for transfer at a lower priority than CDE and associated with inferior prognosis than CDE.
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Affiliation(s)
- Debbie Montjean
- Service de Médecine et Biologie de la Reproduction, Centre Ste Colette, Hôpital Saint-Joseph, 26 boulevard de Louvain, 13008, Marseille, France.
| | - Cendrine Geoffroy-Siraudin
- Service de Médecine et Biologie de la Reproduction, Centre Ste Colette, Hôpital Saint-Joseph, 26 boulevard de Louvain, 13008, Marseille, France
| | - Marie-José Gervoise-Boyer
- Service de Médecine et Biologie de la Reproduction, Centre Ste Colette, Hôpital Saint-Joseph, 26 boulevard de Louvain, 13008, Marseille, France
| | - Pierre Boyer
- Service de Médecine et Biologie de la Reproduction, Centre Ste Colette, Hôpital Saint-Joseph, 26 boulevard de Louvain, 13008, Marseille, France
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14
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Karavani G, Kan-Tor Y, Schachter-Safrai N, Levitas E, Or Y, Ben-Meir A, Buxboim A, Har-Vardi I. Does sperm origin-Ejaculated or testicular-Affect embryo morphokinetic parameters? Andrology 2020; 9:632-639. [PMID: 33251758 DOI: 10.1111/andr.12952] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 11/04/2020] [Accepted: 11/23/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND It is unclear whether sperm origin, either ejaculated or testicular, in couples diagnosed with male factor infertility, affects the timing of the embryo's developmental events evaluated by time-lapse monitoring and implantation rates. OBJECTIVE To examine the effect of sperm origin on embryo morphokinetics in couples diagnosed with male factor infertility. MATERIALS AND METHODS This study included a retrospective analysis of morphokinetic parameters performed by time-lapse monitoring between 2013 and 2017. The developmental processes and morphokinetic parameters of 419 embryos obtained from couples with male factor infertility attributed to oligo-astheno-teratozoospermia, 158 embryos derived from surgically extracted testicular spermatozoa from couples diagnosed with non-obstructive azoospermia, and 190 embryos from couples with normal ejaculated spermatozoa and female mechanical factor-related infertility, were evaluated. A comparison of morphokinetic parameters, implantation, and clinical pregnancy rates was performed between the groups with additional analysis in accordance with implantation status. RESULTS Embryos from the normal ejaculated spermatozoa and oligo-astheno-teratozoospermia patients reached the later morphokinetic milestones-synchronous division (S3) and time to morula (tM)-faster than embryos obtained from testicular spermatozoa. Implantation rate was similar in the normal ejaculated spermatozoa and oligo-astheno-teratozoospermia groups (41.9% vs. 45.8%, NS), with higher implantation rate in the oligo-astheno-teratozoospermia group compared to the testicular spermatozoa group (45.8% vs. 33.6%, p = 0.02). Comparison of Known Implantation Data (KID) positive (KIDp) and KID negative (KIDn) embryos in each group revealed more rapid development in KIDp embryos in the normal ejaculated spermatozoa and the oligo-astheno-teratozoospermia groups, while in the testicular spermatozoa group implanted embryos reached the late morphokinetic milestones (time to 8 cell stage-t8, ECC3, S3, and tM) significantly faster than embryos that failed to implant. In a multivariate logistic regression analysis of the male factor infertility population, (oligo-astheno-teratospermia) (OR = 2.54, p = 0.003) and t8 (OR = 0.95, p = 0.027) were predictive of successful implantation. Male factor infertility embryos that reached the t8 milestone within 48-56 h had favorable implantation rates (p < 0.001). DISCUSSION The study results may highlight another pathophysiology by means of which sperm origin affects embryo developmental kinetics. Selecting embryos demonstrating a faster developmental rate at t8 and specifically the 48- to 56 h interval following time of pronuclei fading (tPNf) may improve implantation rates in cases of male factor infertility. CONCLUSION This study showed that ejaculated spermatozoa is associated with faster late cell divisions, more rapid compaction, and higher implantation rates compared to testicular spermatozoa. Additionally, t8 is an important predictor for implantation in the male factor infertility population.
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Affiliation(s)
- Gilad Karavani
- Department of Obstetrics and Gynecology, Hadassah Medical Center-Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yoav Kan-Tor
- Alexander Grass Center for Bioengineering, The Hebrew University of Jerusalem, Jerusalem, Israel.,School of Computer Science and Engineering, The Hebrew University of Jerusalem, Jerusalem, Israel.,Institute of Life Sciences, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Natali Schachter-Safrai
- Department of Obstetrics and Gynecology, Hadassah Medical Center-Hebrew University of Jerusalem, Jerusalem, Israel
| | - Eliahu Levitas
- Fertility and IVF Unit, Department of Obstetrics and Gynecology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Yuval Or
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Kaplan Hospital, Rehovot, Israel
| | - Assaf Ben-Meir
- Department of Obstetrics and Gynecology, Hadassah Medical Center-Hebrew University of Jerusalem, Jerusalem, Israel.,Infertility and IVF Unit, Hadassah Medical Center-Hebrew University of Jerusalem, Jerusalem, Israel
| | - Amnon Buxboim
- Alexander Grass Center for Bioengineering, The Hebrew University of Jerusalem, Jerusalem, Israel.,School of Computer Science and Engineering, The Hebrew University of Jerusalem, Jerusalem, Israel.,Institute of Life Sciences, The Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Cell and Developmental Biology, Institute of Life Sciences, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Iris Har-Vardi
- Fertility and IVF Unit, Department of Obstetrics and Gynecology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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15
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Asoglu MR, Celik C, Serefoglu EC, Findikli N, Bahceci M. Preimplantation genetic testing for aneuploidy in severe male factor infertility. Reprod Biomed Online 2020; 41:595-603. [PMID: 32763130 DOI: 10.1016/j.rbmo.2020.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 05/17/2020] [Accepted: 06/19/2020] [Indexed: 11/30/2022]
Abstract
RESEARCH QUESTION Does the use of preimplantation genetic testing for aneuploidies (PGT-A) improve outcomes in couples with severe male factor infertility (SMFI)? DESIGN This retrospective cohort study included SMFI cases that underwent blastocyst transfer with/without PGT-A. Inclusion criteria were SMFI (azoospermia and sperm count <1 million/ml), women aged 25-39 years, single vitrified-warmed blastocyst transfer, and no intracavitary pathologies. Patients were divided into PGT-A and non-PGT-A groups. The primary outcome was live birth rate (live birth of an infant after 24 weeks of gestation); secondary outcomes were implantation and clinical pregnancy rates. RESULTS The study included 266 SMFI cases (90 and 176 in the PGT-A and non-PGT-A groups, respectively). Men and women in the PGT-A group were significantly older than those in the non-PGT-A group. The groups did not differ in terms of male factor categories, sperm collection methods or additional female factors. Live birth rates in the PGT-A and non-PGT-A groups were 55.6% and 51.1%, respectively (odds ratio [OR] 1.19, 95% confidence interval [CI] 0.71-1.98, P = 0.495). The implantation rates were 65.6% and 64.2%, respectively (OR 1.06, 95% CI 0.62-1.80, P = 0.827). The clinical pregnancy rates were 62.2% and 58.0%, respectively (OR 1.19, 95% CI 0.71-2.01, P = 0.502). The use of PGT-A was not an independent factor for live birth (aOR 1.33, 95% CI 0.66-2.70, P = 0.421). Advanced age in women was the only independent factor associated with live birth (aOR 0.46, 95% CI 0.22-0.96, P = 0.041). CONCLUSIONS The use of PGT-A does not seem to be an independent factor associated with live birth per transfer in couples with SMFI.
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Affiliation(s)
| | - Cem Celik
- Bahceci Umut Assisted Reproduction Center Istanbul, Turkey; Uskudar University, School of Medicine, Department of Obstetrics and Gynecology Istanbul, Turkey
| | - Ege Can Serefoglu
- Bahceci Fulya Assisted Reproduction Center Istanbul, Turkey; Biruni University, School of Medicine, Department of Urology Istanbul, Turkey
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