The ESHRE Capri Workshop Group. Intracytoplasmic sperm injection (ICSI) in 2006: Evidence and Evolution

A method for determining potential parental contamination: linkage disequilibrium-based log-likelihood ratio analysis for IVF-PGT

BACKGROUND

At present, embryologists are attempting to use conventional in vitro fertilization (cIVF) as an alternative to intracytoplasmic sperm injection (ICSI) for preimplantation genetic testing (PGT). However, the potential parental contamination origin of sperm cells and cumulus cells is considered the main limiting factor in the inability of cIVF embryos to undergo PGT.

METHODS

In this study, we established an IVF-PGTA assay for parental contamination tests with a contamination prediction model based on allele frequencies and linkage disequilibrium (LD) to compute the log-likelihood ratio (LLR) under competing ploidy hypotheses, and then verified its sensitivity and accuracy. Finally, comparisons of the effectiveness of SNP-based analysis and LLR-based IVF-PGTA among 40 cIVF embryos was performed, based on both statistical analysis of the parental contamination rate and chromosomal ploidy concordance rate between TE biopsy and ICM isolations.

RESULTS

With IVF-PGTA assay, biopsies with 10% maternal contamination could be detected accurately, and contamination caused by sperm cells could be eliminated completely. Utilizing LLR-based or single Nucleotide Polymorphism (SNP) -based analyses, our comprehensive examination of 40 clinically discarded fresh cIVF embryos revealed an absence of paternal contamination. Strikingly, the LLR-based analysis uniquely revealed a mere instance of 24% maternal contamination within the trophectoderm cell (TE) biopsy of 5* embryo. Furthermore, it was solely through this analysis that embryo (9-F) was identified as a triploid of paternal origin.

CONCLUSIONS

In this study, we developed a new bioinformatics analysis method for identifying parental contamination during IVF-PGT, especially for couples with nonmale factor infertility.

Application of conventional IVF during preimplantation genetic testing for aneuploidies: a feasibility study

RESEARCH QUESTION

Is it feasible to apply conventional IVF to couples undergoing preimplantation genetic testing for aneuploidies (PGT-A) with non-severe male infertility?

DESIGN

The last wash fluid of biopsied trophectoderm (TE) cells was collected for whole genome amplification (WGA). A method was developed to determine parental contamination. Using single-nucleotide polymorphism (SNP) analysis, two standard curves were established; further mixtures were used for verification. Finally, 29 WGA products from couples undergoing conventional IVF were used to evaluate parental contamination.

RESULTS

The WGA results of the last wash fluid of biopsied TE cells revealed almost no free DNA. By adopting two strategies based on maternally and paternally biased SNP in the mixture, data from bioinformatics analysis were analysed to determine the relationship between maternal (Index M) and paternal (Index F) bias statistics. Two standard curves were successfully established based on these indices that allowed the prediction of maternal and parental contamination, which correlated well with actual ratios of known composition mixtures during validation. The average contamination level was 10.6% determined from 10 WGA products that featured maternal contamination, whereas that of the other 19 products that featured paternal contamination was less than 10%.

CONCLUSIONS

This study confirmed the feasibility of applying conventional IVF to couples undergoing PGT-A with non-severe male infertility.

Preimplantation genetic testing for human blastocysts with potential parental contamination using a quantitative parental contamination test (qPCT): an evidence-based study

RESEARCH QUESTION

Is it possible to develop a quantitative method for detecting parental DNA contamination in conventional IVF using preimplantation genetic testing for aneuploidy (PGT-A)?

DESIGN

In this study, a quantification method was established for the parental contamination test (qPCT), which ensured more reliable results, and then verified its effectiveness for vitrified conventional IVF embryos. A total of 120 surplus vitrified blastocysts from patients who underwent prior routine IVF cycles were available for study.

RESULTS

The results of the prospective clinical study of qPCT-PGT-A showed that the maternal contamination rate was 0.83% (1/120) and that the risk of paternal contamination was negligible. The 24 frozen embryo transfer cycles resulted in 16 clinical pregnancies, including 13 live births, one late inevitable miscarriage and two ongoing pregnancies.

CONCLUSIONS

The risk of PGT in embryos with potential parental contamination is relatively low, and PGT-A is applicable for vitrified conventional IVF embryos.

Opportunities and Limits of Conventional IVF versus ICSI: It Is Time to Come off the Fence

Conventional IVF (c-IVF) is one of the most practiced assisted reproductive technology (ART) approaches used worldwide. However, in the last years, the number of c-IVF procedures has dropped dramatically in favor of intracytoplasmic sperm injection (ICSI) in cases of non-male-related infertility. In this review, we have outlined advantages and disadvantages associated with c-IVF, highlighting the essential steps governing its success, its limitations, the methodology differences among laboratories and the technical progress. In addition, we have debated recent insights into fundamental questions, including indications regarding maternal age, decreased ovarian reserve, endometriosis, autoimmunity, single oocyte retrieval-cases as well as preimplantation genetic testing cycles. The “overuse” of ICSI procedures in several clinical situations of ART has been critically discussed. These insights will provide a framework for a better understanding of opportunities associated with human c-IVF and for best practice guidelines applicability in the reproductive medicine field.

Non-invasive preimplantation genetic testing for conventional IVF blastocysts

BACKGROUND

Previous studies suggested that non-invasive preimplantation genetic testing (niPGT) for intracytoplasmic sperm injection (ICSI) blastocysts can be used to identify chromosomal ploidy and chromosomal abnormalities. Here, we report the feasibility and performance of niPGT for conventional in vitro fertilization (IVF) blastocysts.

METHODS

This was a prospective observational study. In the preclinical stage, whole genome amplification and NGS were performed using the sperm spent culture medium (SCM). Then, trophectoderm (TE) biopsies and corresponding SCM derived from 27 conventional IVF monopronuclear embryos were collected. In the clinical stage, samples from 25 conventional IVF cycles and 37 ICSI cycles from April 2020-August 2021 were collected for performance evaluation.

RESULTS

Preclinically, we confirmed failed sperm DNA amplification under the current amplification system. Subsequent niPGT from the 27 monopronuclear blastocysts showed 69.2% concordance with PGT results of corresponding TE biopsies. In the clinical stage, no paternal contamination was observed in any of the 161 SCM samples from conventional IVF. While maternal contamination was observed in 29.8% (48/161) SCM samples, only 2.5% (4/161) samples had a contamination ratio ≥ 50%. Compared with that of TE biopsy, the performances of NiPGT from 161 conventional IVF embryos and 122 ICSI embryos were not significantly different (P > 0.05), with ploidy concordance rates of 75% and 74.6% for IVF and ICSI methods, respectively. Finally, evaluation of the euploid probability of embryos with different types of niPGT results showed prediction probabilities of 82.8%, 77.8%, 62.5%, 50.0%, 40.9% and 18.4% for euploidy, sex-chromosome mosaics only, low-level mosaics, multiple abnormal chromosomes, high-level mosaics and aneuploidy, respectively.

CONCLUSIONS

Our research results preliminarily confirm that the niPGT approach using SCM from conventional IVF has comparable performance with ICSI and might broadening the application scope of niPGT.

The effect of oocyte denudation time and intracytoplasmic sperm injection time on embryo quality at assisted reproductive technology clinic – A cross-sectional study

Background

This study aims to determine whether there is an effect of oocyte denudation time and ICSI time on embryo quality at assisted reproductive Technology clinic.

Methods

An observational analytic retrospective study was conduct using cross-sectional study. The subject were oocytes from in-vitro fertilization procedures using the ICSI method at the assisted reproductive technology clinic in a private hospital in Bandung for the period 2017 - 2019. Three variables were oocyte denudation time, ICSI time and embryo quality collected from samples that met the research criteria. Data will be grouped based on denudation time (T₁) and Intracytoplasmic Sperm Injection time (T₂).

Result

From the 5 groups of denudation time; 3–4 hours, 4–5 hours, 5–6 hours, 6–7 hours and more than 7 hours group, the denudation time of 3–4 hours group showed the highest number (66.7%) for excellent embryo quality results, while denudation time of more than 7 hours showed the lowest number (29.2%) for excellent embryo quality results with p < 0.001. From these figures, it shows that the ICSI time of 3–4 hours is superior to the ICSI time of 2–3 hours because the outcome of excellent embryo quality is higher while the outcome of poor embryo quality is lower, although the difference is not significant (p = 0.140).

Conclusion

This study shows there was a significant difference in the effect of oocyte denudation time on embryo quality at assisted reproductive technology clinic. There was no significant difference in the effect of intracytoplasmic sperm injection (ICSI) time on embryo quality at assisted reproductive technology clinic.

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Oocyte denudation time is a vital parameter in IVF.

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Oocyte denudation time plays a vital role in improving embryo quality.

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Intracytoplasmic sperm injection may not exert a significant role on embryo quality.

Non-contact ultrasound oocyte denudation

Cumulus removal (CR) is a central prerequisite step for many protocols involved in the assisted reproductive technology (ART) such as intracytoplasmic sperm injection (ICSI) and preimplantation genetic testing (PGT). The most prevalent CR technique is based upon laborious manual pipetting, which suffers from inter-operator variability and therefore a lack of standardization. Automating CR procedures would alleviate many of these challenges, improving the odds of a successful ART or PGT outcome. In this study, a chip-scale ultrasonic device consisting of four interdigitated transducers (IDT) on a lithium niobate substrate has been engineered to deliver megahertz (MHz) range ultrasound to perform denudation. The acoustic streaming and acoustic radiation force agitate COCs inside a microwell placed on top of the LiNbO₃ substrate to remove the cumulus cells from the oocytes. This paper demonstrates the capability and safety of the denudation procedure utilizing surface acoustic wave (SAW), achieving automation of this delicate manual procedure and paving the steps toward improved and standardized oocyte manipulation.

Intracytoplasmic sperm injection is not superior to conventional IVF in couples with non-male factor infertility and preimplantation genetic testing for aneuploidies (PGT-A)

STUDY QUESTION

Does the insemination method impact the euploidy outcome in couples with non-male factor infertility?

SUMMARY ANSWER

Conventional IVF can be applied in cycles with preimplantation genetic testing for aneuploidies (PGT-A), as both IVF and ICSI generate equal numbers of euploid blastocysts.

WHAT IS KNOWN ALREADY

Ever since its introduction, the popularity of ICSI has increased tremendously, even in couples with non-male factor infertility. The use of conventional IVF is a contraindication for couples undergoing PGT to ensure monospermic fertilisation and to eliminate potential paternal contamination from extraneous sperm attached to the zona pellucida. Despite this, it has recently been shown that sperm DNA fails to amplify under the conditions used for trophectoderm biopsy samples.

STUDY DESIGN, SIZE, DURATION

This single-centre prospective pilot study included 30 couples between November 2018 and April 2019.

PARTICIPANTS/MATERIALS, SETTING, METHOD

Arab couples, with a female age between 18-40 years, body mass index ≤30 kg/m2, at least 10 cumulus oocyte complexes (COCs) following oocyte retrieval (OR) and normal semen concentration and motility (WHO) in the fresh ejaculate on the day of OR, were eligible for the study. Half of the sibling oocytes were assigned to conventional IVF, and the other half were assigned to ICSI. All embryos were cultured in a time-lapse imaging system in Global Total LP media. Blastocysts were subjected to trophectoderm biopsy on Day 5, 6 or 7 and next-generation sequencing (NGS) to determine blastocyst ploidy status. The primary objective was to determine the euploid rate in blastocysts from sibling oocytes.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 568 COCs were randomly allocated between IVF (n = 283; 9.4 ± 4.0) and ICSI (n = 285; 9.5 ± 4.1). While the incidence of normal fertilisation per cycle (6.1 ± 3.8 (64.0%) vs 6.3 ± 3.5 (65.4%); P = 0.609) was distributed equally between IVF and ICSI, the degeneration rate (0.1 ± 0.3 vs 0.7 ± 0.8; P = 0.0003) was significantly higher after ICSI and the incidence of abnormal fertilisation (≥3 pronuclei) was significantly higher after IVF (0.9 ± 1.2 vs 0.2 ± 0.4; P = 0.005). For all fertilised oocytes, there were no differences in the number of good-quality embryos on Day 3 (74% vs 78%; P = 0.467), nor in the blastulation rate on Day 5 (80.4% vs 70.8%; P = 0.076). The total number of blastocysts biopsied per cycle on Days 5, 6 and 7 was not significantly different between IVF or ICSI (4.0 ± 2.8 vs 3.9 ± 2.5; P = 0.774). With euploid rates of 49.8 and 44.1% (P = 0.755; OR: 1.05664 [0.75188-1.48494), respectively, there was no significant difference identified between IVF and ICSI (2.0 ± 1.8 vs 1.9 ± 1.7; P = 0.808) and all couples had at least one euploid blastocyst available for transfer. When considering only euploid blastocysts, the male/female ratio was 61/39 in IVF and 43/57 in ICSI (P = 0.063).

LIMITATIONS, REASON FOR CAUTION

This is a pilot study with a limited patient population of 30 couples (and 568 COCs) with a normal ovarian response. The results of our study should not be extrapolated to other patient populations.

WIDER IMPLICATIONS OF THE FINDINGS

It is safe to apply conventional IVF in couples with non-male factor infertility undergoing PGT-A.

STUDY FUNDING/COMPETING INTEREST(S)

No funding was obtained. There are no competing interests.

TRIAL REGISTRATION NUMBER

NCT03708991.

Comparison of preimplantation genetic testing for aneuploidy versus intracytoplasmic sperm injection in severe male infertility

The retrospective cohort study was conducted to evaluate the effectiveness of preimplantation genetic testing for aneuploidy (PGT-A) for severe male factor (SMF) infertility on pregnancy outcomes in comparison with intracytoplasmic sperm injection (ICSI). A total of 206 couples with SMF were included in the study, among which, 102 couples underwent ICSI with next-generation sequencing (NGS)-based PGT-A (the PGT-A group), while 104 underwent ICSI only (the control group). Results showed while no differences were noted in clinical pregnancy rate (CPR) (66.7% versus. 69.9%, p = .64) and ongoing pregnancy rate (OPR) (62.2% versus. 54.7%, p = .29) per transfer between groups, early miscarriage rate (EMR) per transfer was significantly lower (6.7% versus. 21.6%, p = .02) in the PGT-A group. Cumulative OPR per patient remained similar between groups (54.9% versus. 55.8%, p = .90). Results of multivariable logistic regression also demonstrated the use of PGT-A was significantly associated with lower EMR (adjusted OR 0.17, 95%CI 0.05-0.55) in SMF, while it was not related to cumulative OPR. In conclusion, our results showed that NGS-based PGT-A can improve pregnancy outcomes for couples with SMF by significantly decreasing EMR without compromising cumulative OPR, indicating that NGS-based PGT-A could be offered as an appropriate approach for couples with SMF.

Obstetric and Perinatal Outcomes in Pregnancies Conceived After Preimplantation Genetic Testing for Monogenetic Diseases

OBJECTIVE

To investigate whether the addition of embryo biopsy performed during preimplantation genetic testing for monogenic diseases is associated with a higher risk of obstetric and neonatal complications compared with in vitro fertilization (IVF) without preimplantation genetic testing or spontaneously conceived pregnancies.

METHODS

This is a cohort study of all pregnancies conceived after preimplantation genetic testing for monogenic diseases (PGT-M group) from 2006 to 2018 at Sheba Medical Center, Israel. The control groups included patients who had conceived spontaneously (spontaneous conception group) or by IVF without preimplantation genetic testing (IVF group) and delivered at Sheba Medical Center. The obstetrics outcomes were compared among the groups. Multivariable regression modeling was performed, focusing on the relationship between preimplantation genetic testing and adverse outcomes.

RESULTS

Final analysis included 345 singleton and 76 twin deliveries in the PGT-M group. The spontaneous conception group included 5,290 singleton and 92 twin deliveries. The IVF group included 422 singleton and 101 twin deliveries. Among singleton pregnancies, patients in the PGT-M group had a higher rate of hypertensive disorders (6.9%) compared with those in the spontaneous conception group (2.3%; odds ratio [OR] 3.3; 95% CI 1.9-4.8; adjusted odds ratio [aOR] 14.8; 95% CI 7.4-29.8) and the IVF group (4.7%; OR 1.5; 95% CI 0.8-2.7; aOR 5.9; 95% CI 1.9-18.2). Likewise, patients in the PGT-M group had a higher rate of small-for-gestational age neonates (12.4%) compared with those in the spontaneous conception group (3.9%; OR 3.4; 95% CI 2.4-4.9; aOR 2.3; 95% CI 1.5-3.4) and the IVF group (4.5%; OR 3; 95% CI 1.7-5.2; aOR 2.5; 95% CI 1.7-5.2). Among twin pregnancies, patients in the PGT-M group also had an increased rate of hypertensive disorders compared with those in the spontaneous conception group (4.3%; OR 4.1; 95% CI 1.2-13.3; aOR 10.9; 95% CI 2.3-50) and the IVF group (4%; OR 4.5; 95% CI 1.4-14.7; aOR 3.7; 95% CI 1.1-12.8).

CONCLUSION

Pregnancies conceived after preimplantation genetic testing for monogenic disorders were associated with an increased risk of obstetric complications compared with pregnancies conceived spontaneously or by IVF without preimplantation genetic testing.

Proposition of Belief and Practice Theory for Men Undergoing Infertility Treatment: A Hospital Based Study in Mumbai, India

The paper aims to understand the treatment seeking behavior and the experiences of men with male factor infertility. A cross-sectional study was conducted at consented hospitals/infertility centers in Mumbai, India in purview of the fact that men are not considered as important as a part of infertility treatment as women. An infertile man is defined here as one who is diagnosed with primary or secondary infertility, undergoing infertility treatment, irrespective of the fertility status of his wife. Primary data of 150 men undergoing infertility treatment from a variety of socioeconomic backgrounds was collected through semi-structured interviews. The initial effect of the infertility status led the men to feel depressed, guilty, shocked, and isolated. A large proportion of the respondents never discussed the problem with anyone except their wives. More than one third of the respondents consulted with Ayurvedic, Unani, Siddha, and Homeopathy (AYUSH) practitioners. Changes of doctors or clinics were more attributed to unsuccessful treatment cycles and success rate of other clinics than the referral by doctors. Destiny, bad luck, lifestyle, medical reasons, and late marriage are found as perceived causes of male infertility. Age above 40, younger age at marriage, marriage duration for 6 and more years, secondary infertility, self-employment, and higher income have significant association with longer time gap between marriage and initiation of infertility treatment. Based on study findings, we propose Belief and Practice theory where we elaborate the progression in treatment for male infertility. Men should be given due consideration in infertility treatment. They must be taken into consideration at an early stage of fertility evaluation due to the fact that minor problems of male infertility can be cured with modest medication. Proper Information Education and Communication (IEC) is essential for creating awareness in society on male infertility. Better counseling services during treatment and standardization of cost can help infertile men to manage treatment-related stress. Since infertility treatment is a time-consuming and exhaustive process, considering the timing for patient's income generating work, evening out patient department, and comprehensive knowledge dissemination at health centers can be improve male factor infertility treatment.

A treatment approach for couples with disrupted sperm DNA integrity and recurrent ART failure

OBJECTIVE

To test a novel method to select spermatozoa with high chromatin integrity.

DESIGN

Specimens with high sperm chromatin fragmentation (SCF) were selected by density gradient selection (DGS) and microfluidic sperm sorting (MSS).

SETTING

Academic medical center.

PATIENT(S)

Ejaculates from consenting men were processed by DGS/MSS. Couples underwent ICSI cycles with spermatozoa processed by DGS/MSS. Clinical outcomes were evaluated after embryo transfer.

INTERVENTION(S)

SCF was measured by TUNEL. ICSI with spermatozoa selected by DGS and MSS was performed.

MAIN OUTCOME MEASURE(S)

Fertilization, embryo implantation, and pregnancy outcomes were compared between DGS and MSS.

RESULT(S)

A total of 23 men had an average SCF of 20.7 ± 10%. After DGS and MSS, the SCF was 12.5 ± 5% and 1.8 ± 1%, respectively. In couples who underwent ICSI, the average SCF was 28.8 ± 9%, which fell to 21.0 ± 9% after DGS and 1.3 ± 0.7% after MSS. Four couples underwent 11 ICSI cycles with DGS and achieved one (25%) pregnancy that resulted in pregnancy loss. In four subsequent ICSI cycles with MSS, an ongoing clinical pregnancy rate of 50% was achieved. Five additional couples underwent 12 cycles of ICSI with DGS. After preimplantation genetic testing for aneuploidy, 30.3% of the embryos were euploid. One pregnancy was achieved, resulting in pregnancy loss. With MSS, 31.5% of the embryos were euploid and 4 couples obtained a pregnancy. Finally, sixteen couples underwent 20 ICSI cycles solely with MSS at our center. Of these couples, 8 had failed 13 ICSI cycles with DGS elsewhere. These couples achieved an overall implantation of 34.5% (10/29) and a pregnancy rate of 58.8% (10/17).

CONCLUSION(S)

Microfluidic selection yielded spermatozoa with optimal genomic integrity and improved chances of obtaining a euploid conceptus.

Preimplantation Genetic Testing for Breast Cancer

Breast cancer (BC), a malignant tumor characterized mainly by a lump in the breast and a change in breast shape, has plagued many women of childbearing age in Nigeria today. This has thus propelled many to find both prophylactic and curative agents to combat BC in affected persons. This article extensively reviews a method of preventing BC in the offspring of affected parents, known as preimplantation genetic testing (PGT) – an assisted reproductive technique that selects genetically unaffected embryo(s) to be transferred to the uterus of a mother upon in vitro fertilization and standard genetic analysis. The present study also seeks to present the techniques involved in PGT that have been reported to prevent the inheritance of BC, its benefits and risks, related case studies in Africa and other continents, and ethical issues surrounding the application of assisted reproduction for BC testing. To achieve these, a thorough search was conducted in reputable scientific journals of reproduction and cancer, and expert knowledge was consulted with regard to these aspects of health and reproduction. Upon reviewing this very important subject, it was confirmed that the beneficial role of assisted reproduction in the field of science and the homes of many cannot be overestimated. This review of the role of PGT in BC prevention will enlighten the understanding of many – creating awareness that with PGT, BC-affected women can have not only children, but also healthy and genetically unaffected children.

Minimizing mosaicism: assessing the impact of fertilization method on rate of mosaicism after next-generation sequencing (NGS) preimplantation genetic testing for aneuploidy (PGT-A)

PURPOSE

Advances in preimplantation genetic testing (PGT) have led to practice changes in assisted reproductive technologies (ART), enabling fertility centers to transfer single embryos while maintaining excellent ongoing pregnancy rates, reducing miscarriage rates, and dramatically reducing ART-associated multiple pregnancies. The introduction of next-generation sequencing (NGS) allows PGT laboratories to assess for embryo mosaicism-although the true incidence and reproductive potential of predicted mosaic embryos are controversial. Due to concern for genetic contamination from other spermatozoa, most reference laboratories require use of intracytoplasmic sperm injection (ICSI) for single gene preimplantation genetic diagnosis (PGT-M). However, in PGT for aneuploidy (PGT-A), conventional insemination (IVF) is typically permissible. The purpose of this study was to evaluate rates of euploid, aneuploid, and mosaic in trophectoderm biopsy samples from embryos in IVF versus ICSI PGT-A cycles. Secondary aims were to assess sex ratio, and subtypes of aneuploidy and mosaicism in IVF versus ICSI PGT-A cycles.

METHODS

We performed a retrospective review of women undergoing PGT-A at a single academic fertility center from July 1, 2015, to September 1, 2017. In all cycles, PGT-A was performed via trophectoderm biopsy on day 5 or 6 and analyzed using NGS at a single reference lab. We collected and compared patient demographics, fertility testing, cycle characteristics, and PGT-A outcomes between IVF and ICSI cycles.

RESULTS

Three hundred two PGT-A cycles were included for analysis: 75 IVF and 227 ICSI cycles, resulting in 251 IVF and 724 ICSI biopsied blastocysts. Mean oocyte age of included cycles was 38.6 years (IVF) and 38.5 years (ICSI), p = 0.85. Baseline characteristics of IVF and ICSI PGT-A cycles were similar with the exception of semen parameters: IVF cycles had higher sperm concentration and total motility compared to ICSI cycles. PGT-A outcomes did not differ between IVF and ICSI cycles: euploid 27.9% (IVF) versus 30% (ICSI); aneuploid 45.4% (IVF) versus 43.1% (ICSI); no result 4.4% (IVF) versus 6.2% (ICSI). Though not significant, we identified a trend toward higher rate of mosaicism in IVF (25.9%) versus ICSI (20.9%). Among mosaic embryos, a lower percentage of simple mosaic embryos resulted from IVF (53.8%) versus ICSI (70.2%). Among aneuploid embryos, a non-significant higher percentage of complex aneuploidy resulted from IVF (16.3%) versus ICSI (9%). IVF resulted in a non-significant higher proportion of cycles with no transferrable embryos (42.7%) versus ICSI (36.6%). Numerical and sex chromosome involvement in mosaicism and aneuploidy were similar between IVF and ICSI cycles.

CONCLUSION

IVF and ICSI NGS PGT-A have similar rates of euploid, aneuploid, and no result embryos, though IVF may result in higher rates of mosaicism and demonstrates differences in proportions of mosaic and aneuploid subtypes compared to ICSI. ICSI may be preferable to conventional insemination to minimize the rate of mosaic results in NGS PGT-A cycles.

Comparison of semen quality between university-based and private assisted reproductive technology laboratories

OBJECTIVE

Obtaining a semen analysis (SA) is an essential step in evaluating infertile men. Despite using standardized procedures for analysis semen quality in the same individual often varies on repeated tests. The objective of this study was to investigate inter-laboratory variation in semen quality between private- and university-based assisted reproductive technology (ART) laboratories.

MATERIALS AND METHODS

IRB approval was obtained to retrospectively evaluate men with a SA at both the private- and university-based ART laboratories. When more than one SA was available from either laboratory, the first at each laboratory was selected for analysis. Comparison of major semen parameters was performed using descriptive statistics and Bland-Altman plots, with differences tested using Wilcoxon-signed rank test.

RESULTS

Twenty-eight men aged 33 ± 5 (mean ± SD) years were included in the study. Motility was higher at the private laboratories compared to the university-based laboratory (Median difference -12.5%, 95% confidence interval -20.3%; -5.5%). Percent normal morphology was higher at the university-based laboratory compared to private laboratories (5.0%, 3.6%; 6.9%). No significant differences were found in volume, concentration and total motile sperm count although the Bland-Altman plot bias for concentration was clinically significant (15.9 × 10⁶/ml).

CONCLUSIONS

In this small series, motility was significantly higher at private laboratories compared to a university-based laboratory but was above WHO reference limits at both places. Normal sperm morphology was significantly lower in semen analyses performed at private laboratories compared to a university-based laboratory and was below WHO reference limits.

Effect of the initiation of progesterone supplementation in in vitro fertilization-embryo transfer outcomes: a prospective randomized controlled trial

OBJECTIVE

To analyze the influence of the start point of luteal support on clinical pregnancy rate, implantation rate, and live birth rate of in vitro fertilization and embryo transfer (IVF-ET) cycles.

DESIGN

Single-center prospective randomized controlled trial.

SETTING

University-affiliated IVF unit.

PATIENT(S)

Women ≤35 years of age with day 3 FSH levels <15 mIU/mL, who were undergoing their first IVF-ET cycles and received ovarian stimulation with the use of a GnRH agonist long protocol.

INTERVENTION(S)

The patients were randomized on the day of hCG trigger to receive luteal phase support either 1 day after oocyte retrieval (group A) or on the day of oocyte retrieval (group B).

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rate, implantation rate, miscarriage rate in the first trimester of pregnancy, and live birth rate per embryo transfer cycle.

RESULT(S)

Two hundred thirty-three patients were enrolled in this study: 117 were assigned to group A and 116 to group B. The clinical pregnancy rate (group A vs. group B: 55.3% vs. 51.5%), implantation rate (38.4% vs. 38.0%), and miscarriage rate (7.7% vs. 7.5%) were similar between the two groups. The live birth rate also did not significantly differ between the two groups (45.7% vs. 46.6%).

CONCLUSION(S)

Our study indicated that the initiation of progesterone supplementation 1 day after oocyte retrieval did not decrease the clinical pregnancy rate, implantation rate, or live birth rate in women undergoing IVF-ET cycles with the use of the GnRH agonist long protocol.

CLINICAL TRIAL REGISTRATION NUMBER

ChiCTR-IPR-14005293.

Preimplantation genetic diagnosis for cystic fibrosis: a case report

Cystic fibrosis is an autosomal recessive disorder caused by mutations in the cystic fibrosis transmembrane conductance regulator gene. This disorder produces a variable phenotype including lung disease, pancreatic insufficiency, and meconium ileus plus bilateral agenesis of the vas deferens causing obstructive azoospermia and male infertility. Preimplantation genetic diagnosis is an alternative that allows identification of embryos affected by this or other genetic diseases. We report a case of couple with cystic fibrosis; the woman had the I148 T mutation and the man had the Delta F508 gene mutation. The couple underwent in vitro fertilization, associated with preimplantation genetic diagnosis, and with subsequent selection of healthy embryos for uterine transfer. The result was an uneventful pregnancy and delivery of a healthy male baby.

Self-control study on reduced-dose depot versus daily administration of gonadotrophin-releasing hormone agonists for pituitary desensitization in in vitro fertilization cycles

AIM

Our aim was to analyze the effect of reducing the dose of depot gonadotrophin-regulating hormone-agonist (GnRH-a) to 1.0 mg on pituitary desensitization and clinical outcome of in vitro fertilization and embryo transfer cycles.

MATERIAL AND METHODS

This retrospective self-control study was conducted on 143 patients who underwent repeated long-protocol treatment from 1 January 2011 to 31 May 2012 at our hospital. Of the 143 patients, 64 received reduced-dose depot (1.0 mg diphereline depot) GnRH-a for the first cycle and short-acting GnRH-a (0.05 mg diphereline) for the second cycle, while 79 patients received short-acting GnRH-a for the first cycle and reduced-dose depot GnRH-a for the second cycle.

RESULTS

The serum follicle-stimulating hormone, luteinizing hormone and estradiol levels on the day of gonadotrophin initiation were significantly higher in the short-acting group compared with the long-acting group. Both number of days of gonadotrophin stimulation and gonadotrophin doses were significantly higher in the short-acting group. On the day of human chorionic gonadotrophin administration, the serum estradiol level was significantly higher while the progesterone level was significantly lower in the short-acting group. There were no significant differences with regard to the number of retrieved oocytes, fertilization rate, number of transferred embryos, clinical pregnancy rate, implantation rate, and early pregnancy loss rate between the two groups. However, the oocyte maturation rate was significantly higher in the long-acting group.

CONCLUSION

Reduced-dose depot GnRH-a can be successfully used for pituitary desensitization in in vitro fertilization and embryo transfer. Deeper downregulation with reduced-dose depot GnRH-a indicates that the optimal dose of GnRH-a warrants future study.

The effect of complementary and alternative medicine on subfertile women with in vitro fertilization

About 10-15% of couples have difficulty conceiving at some point in their reproductive lives and thus have to seek specialist fertility care. One of the most commonly used treatment options is in vitro fertilization (IVF) and its related expansions. Despite many recent technological advances, the average IVF live birth rate per single initiated cycle is still only 30%. Consequently, there is a need to find new therapies to promote the efficiency of the procedure. Many patients have turned to complementary and alternative medical (CAM) treatments as an adjuvant therapy to improve their chances of success when they undergo IVF treatment. At present, several CAM methods have been used in infertile couples with IVF, which has achieved obvious effects. However, biologically plausible mechanisms of the action of CAM for IVF have not been systematically reviewed. This review briefly summarizes the current progress of the impact of CAM on the outcomes of IVF and introduces the mechanisms.

The effects of acupuncture on rates of clinical pregnancy among women undergoing in vitro fertilization: a systematic review and meta-analysis

BACKGROUND Recent systematic reviews of adjuvant acupuncture for IVF have pooled heterogeneous trials, without examining variables that might explain the heterogeneity. The aims of our meta-analysis were to quantify the overall pooled effects of adjuvant acupuncture on IVF clinical pregnancy success rates, and evaluate whether study design-, treatment- and population-related factors influence effect estimates. METHODS We included randomized controlled trials that compared needle acupuncture administered within 1 day of embryo transfer, versus sham acupuncture or no adjuvant treatment. Our primary outcome was clinical pregnancy rates. We obtained from all investigators additional methodological details and outcome data not included in their original publications. We analysed sham-controlled and no adjuvant treatment-controlled trials separately, but since there were no large or significant differences between these two subsets, we pooled all trials for subgroup analyses. We prespecified 11 subgroup variables (5 clinical and 6 methodological) to investigate sources of heterogeneity, using single covariate meta-regressions. RESULTS Sixteen trials (4021 participants) were included in the meta-analyses. There was no statistically significant difference between acupuncture and controls when combining all trials [risk ratio (RR) 1.12, 95% confidence interval (CI), 0.96-1.31; I(2) = 68%; 16 trials; 4021 participants], or when restricting to sham-controlled (RR 1.02, 0.83-1.26; I(2) = 66%; 7 trials; 2044 participants) or no adjuvant treatment-controlled trials (RR 1.22, 0.97-1.52; I(2) = 67%; 9 trials; 1977 participants). The type of control used did not significantly explain the statistical heterogeneity (interaction P = 0.27). Baseline pregnancy rate, measured as the observed rate of clinical pregnancy in the control group of each trial, was a statistically significant effect modifier (interaction P < 0.001), and this covariate explained most of the heterogeneity of the effects of adjuvant acupuncture across all trials (adjusted R(2) = 93%; I(2) residual = 9%). Trials with lower control group rates of clinical pregnancy showed larger effects of adjuvant acupuncture (RR 1.53, 1.28-1.84; 7 trials; 1732 participants) than trials with higher control group rates of clinical pregnancy (RR 0.90, 0.80-1.01; 9 trials; 2289 participants). The asymmetric funnel plot showed a tendency for the intervention effects to be more beneficial in smaller trials. CONCLUSIONS We found no pooled benefit of adjuvant acupuncture for IVF. The subgroup finding of a benefit in trials with lower, but not higher, baseline pregnancy rates (the only statistically significant subgroup finding in our earlier review) has been confirmed in this update, and was not explained by any confounding variables evaluated. However, this baseline pregnancy rate subgroup finding among published trials requires further confirmation and exploration in additional studies because of the multiple subgroup tests conducted, the risk of unidentified confounders, the multiple different factors that determine baseline rates, and the possibility of publication bias.

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

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

A comparison of ejaculated and testicular spermatozoa aneuploidy rates in patients with high sperm DNA damage

Testicular spermatozoa are utilized to achieve pregnancy in couples with severe male factor infertility. Several studies suggest that aneuploidy rates in spermatozoa are elevated at the testicular level in infertile patients compared to ejaculates of normal controls. However, essential data regarding aneuploidy rates between ejaculated and testicular spermatozoa in the same individuals is lacking. The purpose of our study was to compare aneuploidy rates at the testicular and post-testicular level from the same patients with persistently high sperm DNA damage. Ejaculates and testicular biopsies were obtained from eight patients with persistently high DNA damage (>30%). Both ejaculated and testicular samples were analyzed for sperm DNA damage and sperm aneuploidy for chromosomes 13, 18, 21, X, and Y. In addition, semen samples from ten normozoospermic men presenting for fertility evaluation served as a control group. A strong correlation between the alteration of spermatogenesis and chromatin deterioration was observed in our study. In the same individuals, testicular samples showed a significantly lower DNA damage compared to ejaculated spermatozoa (14.9% ± 5.0 vs. 40.6% ± 14.8, P<0.05), but significantly higher aneuploidy rates for the five analyzed chromosomes (12.41% ± 3.7 vs. 5.77% ± 1.2, P<0.05). While testicular spermatozoa appear favourable for ICSI in terms of lower DNA damage, this potential advantage could be offset by the higher aneuploidy rates in testicular spermatozoa.

In vitro fertilization/intracytoplasmic sperm injection for male infertility

Progress in the field of assisted reproduction, and particularly micromanipulation, now heralds a new era in the management of severe male factor infertility, not amenable to medical or surgical correction. By overcoming natural barriers to conception, in vitro fertilization and embryo transfer (IVF-ET), subzonal sperm insemination, partial zona dissection, and intracytoplasmatic injection of sperm (ICSI) now offer couples considered irreversibly infertile, the option of parenting a genetically related child. However, unlike IVF, which necessitates an optimal sperm number and function to successfully complete the sequence of events leading to fertilization, micromanipulation techniques, such as ICSI, involving the direct injection of a spermatozoon into the oocyte, obviate all these requirements and may be used to alleviate severe male factor infertility due to the lack of sperm in the ejaculate due to severely impaired spermatogenesis (non-obstructive azoospermia) or non-reconstructable reproductive tract obstruction (obstructive azoospermia). ICSI may be performed with fresh or cryopreserved ejaculate sperm where available, microsurgically extracted epididymal or testicular sperm with satisfactory fertilization, clinical pregnancy, and ongoing pregnancy rates. However, despite a lack of consensus regarding the genetic implications of ICSI or the application and efficacy of preimplantation genetic diagnosis prior to assisted reproductive technology (ART), the widespread use of ICSI, increasing evidence of the involvement of genetic factors in male infertility and the potential risk of transmission of genetic disorders to the offspring, generate major concerns with regard to the safety of the technique, necessitating a thorough genetic evaluation of the couple, classification of infertility and adequate counseling of the implications and associated risks prior to embarking on the procedure. The objective of this review is to highlight the indications, advantages, limitations, outcomes, implications and safety of using IVF/ICSI for male factor infertility to enable a more judicious use of these techniques and maximize their potential benefits while minimizing foreseen complications.

What to do when ICSI fails

The refinement of gamete micromanipulation techniques has made conception possible for couples with male factor infertility who otherwise would remain childless. Moreover, intracytoplasmic sperm injection (ICSI) has ensured that such refractory cases can now generate offspring as successfully as in couples that merely require in vitro insemination. However, despite the now sterling record of ICSI it does not assure a successful outcome for every patient. This can be due, for instance, to the inability of the spermatozoon to activate the oocyte, and applies obviously in cases where spermatozoa are absent from the ejaculate or testicular biopsy. In the present paper we describe in detail the reasons for such failure and review the options that may help overcome it. In particular, we outline the treatment protocol for the situation in which spermatozoa are unable to induce oocyte activation. Further, we report on the clinical outcome achieved with spermatozoa retrieved from the testis, and in cases of extreme oligozoospermia we also explore the option of replicating a single spermatozoon while gaining information on its genomic content. For the most extreme situation in which men have no identifiable germ cells, we will discuss the current status of efforts to accomplish neo-gametogenesis through embryonic stem cell differentiation.

CD9 Expression by Human Granulosa Cells and Platelets as a Predictor of Fertilization Success during IVF

Objective. To determine whether CD9 expression on human granulosa cells (GCs) and platelets could predict the success of conventional fertilization of human oocytes during in vitro fertilization (IVF). Methods. Thirty women undergoing IVF for nonmale factor infertility participated. Platelets from venous blood and GCs separated from retrieved oocytes were prepared for immunofluorescence. Flow cytometry quantified the percent of GCs expressing CD9, and CD9 surface density on GCs and platelets. Fertilization rate was determined for the total number of oocytes, and the number of mature oocytes per patient. Correlations tested for significant relationships (P < .05) between fertilization rates and CD9 expression. Results. CD9 surface density on human GCs is inversely correlated with fertilization rate of oocytes (P = .04), but the relationship was weak. Conclusion. More studies are needed to determine if CD9 expression on GCs would be useful for predicting conventional fertilization success during IVF.

Oocyte activation, phospholipase C zeta and human infertility

BACKGROUND

Mammalian oocytes are activated by intracellular calcium (Ca(2+)) oscillations following gamete fusion. Recent evidence implicates a sperm-specific phospholipase C zeta, PLCζ, which is introduced into the oocyte following membrane fusion, as the responsible factor. This review summarizes the current understanding of human oocyte activation failure and describes recent discoveries linking certain cases of male infertility with defects in PLCζ expression and activity. How these latest findings may influence future diagnosis and treatment options are also discussed.

METHODS

Systematic literature searches were performed using PubMed, ISI-Web of Knowledge and The Cochrane Library. We also scrutinized material from the United Nations and World Health Organization databases (UNWHO) and the Human Fertilization and Embryology Authority (HFEA).

RESULTS AND CONCLUSIONS

Although ICSI results in average fertilization rates of 70%, complete or virtually complete fertilization failure still occurs in 1-5% of ICSI cycles. While oocyte activation failure can, in some cases, be overcome by artificial oocyte activators such as calcium ionophores, a more physiological oocyte activation agent might release Ca(2+) within the oocyte in a more efficient and controlled manner. As PLCζ is now widely considered to be the physiological agent responsible for activating mammalian oocytes, it represents both a novel diagnostic biomarker of oocyte activation capability and a possible mode of treatment for certain types of male infertility.

Infertility in Australia circa 1980: an historical population perspective on the uptake of fertility treatment by Australian women born in 1946-51

OBJECTIVE

To estimate the prevalence of lifetime infertility in Australian women born in 1946-51 and examine their uptake of treatment.

METHODS

Participants in the Australian Longitudinal Study on Women's Health born in 1946-51 (n=13,715) completed up to four mailed surveys from 1996 to 2004. The odds of infertility were estimated using logistic regression with adjustment for socio-demographic and reproductive factors.

RESULTS

Among participants, 92.1% had been pregnant. For women who had been pregnant (n=12738): 56.5% had at least one birth but no pregnancy loss (miscarriage and/or termination); 39.9% experienced both birth and loss; and 3.6% had a loss only. The lifetime prevalence of infertility was 11.0%. Among women who reported infertility (n=1511), 41.7% used treatment. Women had higher odds of infertility when they had reproductive histories of losses only (OR range 9.0-43.5) or had never been pregnant (OR=15.7, 95%CI 11.8-20.8); and higher odds for treatment: losses only (OR range 2.5-9.8); or never pregnant (1.96, 1.28-3.00). Women who delayed their first birth until aged 30+ years had higher odds of treatment (OR range 3.2-4.3).

CONCLUSIONS

About one in ten women experienced infertility and almost half used some form of treatment, especially those attempting pregnancy after 1980. Older first time mothers had an increased uptake of treatment as assisted reproductive technologies (ART) developed.

IMPLICATIONS

This study provided evidence of the early uptake of treatment prior to 1979 when the national register of invasive ART was developed and later uptake prior to 1998 when data on non-invasive ART were first collected.

Rare presentation of ectopic pregnancy following IVF-ET: live twin gestation in the same fallopian tube

We report a case of a twin ectopic pregnancy (EP) after in vitro fertilization and embryo transfer (IVF-ET). A 24-year-old nulligravida presented with lower abdominal pain and vaginal bleeding 4 weeks after embryo transfer. Serum beta-HCG levels were 40 IU/mL, 90 IU/mL, and 1970 IU/mL on ET days 12, 14, and 23, respectively. Ultrasound examination revealed two ectopic gestational sacs with fetal heart beats in the left adnexa, without evidence of intrauterine pregnancy. At laparoscopy, one isthmic and another ampullary sac were detected in the left tube and left salpingectomy was performed. The patient was discharged healthy on postoperative day 2. Albeit extremely rare, ectopic pregnancies with abnormal presentation can be encountered following IVF-ET. Single embryo transfer may be advised to protect from ectopic pregnancies after IVF-ET.

Congenital anomalies and other perinatal outcomes in ICSI vs. naturally conceived pregnancies: a comparative study

BACKGROUND

Intracytoplasmic sperm injection (ICSI) procedures have become accepted worldwide and their effect on society is well-known. However, the full extent of the possible complications of these procedures on maternal and neonatal outcome is still unclear.

MATERIALS AND METHODS

This is a retrospective case controlled study from January 2003 to December 2007 which compared 253 women that had conceived using assisted reproduction (ICSI) and delivered 327 children at our center (study group) with a matched group of 349 women who naturally conceived and delivered 354 children at Abha General Hospital (control group) during the same period. The obstetrical and neonatal characteristics of the women and their children were assessed to determine any significant differences between the groups.

RESULTS

The number of gestations per pregnancy (1.34 +/- 0.57 vs. 1.01 +/- 0.12) and number of children born per woman (1.28 +/- 0.49 vs. 1.01 +/- 0.12) was significantly higher in the ICSI group (p < 0.001). In addition, the gestational age at delivery (37.23 +/- 2.68 vs. 38.56 +/- 1.89) was significantly shorter in the ICSI group (p < 0.001) and this led to an increased number of obstetrical interventions, as well as the incidence of cesarean deliveries. Examination of the new-born children revealed similar incidence of congenital anomalies in both groups.

CONCLUSION

ICSI conceived pregnancies were characterized by an increased number of gestations and live-born, and there was no increase in congenital malformations compared to naturally conceived pregnancies.

Does assisted reproductive technology cause birth defects?

PURPOSE OF REVIEW

Observational studies have reported small but increased risk of birth defects associated with assisted reproductive technology (ART) pregnancies. We intend to review the current data on this issue to provide essential information for patient counseling.

RECENT FINDINGS

There is lack of consensus on whether ART per se increases the risk of birth defects, genetic and imprinting disorders, mostly due to the bias inherent to the observational studies, which suggest 30-40% increased risk of birth defects with ART. Recent reports suggest that apparent risks for adverse outcome following ART may be largely related to parental infertility-linked factors. Criteria used to define birth defects bring challenges as well.

SUMMARY

All couples undergoing these procedures should be counseled about the current information suggesting elevated risks of birth defects, genetic abnormalities and imprinting disorders associated with infertility and the infertility treatment with ART. In order to elucidate the controversy whether ART is associated with adverse outcome in the offspring, a multinational collaborative effort is needed, as the required sample size is between 10 000 and 84 000 or more.

Male gamete survival at stake: causes and solutions

Over the years, the development of assisted reproductive technology to bypass male factor infertility has improved drastically. Considered one of the most perplexing disorders in the reproductive field, male factor infertility is prevalent and may be on the rise. Unfortunately, its aetiology remains elusive. One of the main reasons lies in the complex machinery and structure of the hydrodynamic sperm cell. Its polyunsaturated fatty acid cell membrane, the protamines in its genetic material and the absence of antioxidants in its cytoplasm ensure that the spermatozoon is highly susceptible to environmental effects. The spermatozoon's genesis, storage, and transport through the male reproductive tract are also susceptible, genetically and pathologically, to environmental effects. This review aims to include all the possible causes of disruption to this unique cell and their probable solutions, in the hope of clearing up the ambiguity that surrounds male factor infertility.