In vitro fertilization/intracytoplasmic sperm injection for male infertility

Quantifying the association of sperm DNA fragmentation with assisted reproductive technology outcomes: An umbrella review

BACKGROUND

Systematic reviews and meta-analyses are instrumental in shaping clinical practice. However, their findings can sometimes be marred by discrepancies and potential biases, thereby diluting the strength of the evidence presented. Umbrella reviews serve to comprehensively assess and synthesise these reviews, offering a clearer insight into the quality of the evidence presented. In the context of the relationship between sperm DNA fragmentation (SDF) and assisted conception outcomes, there is a divergence in the literature. Some reviews suggest a clear cause-and-effect linkage, whereas others present conflicting or inconclusive results.

OBJECTIVES

In this umbrella review we aimed to synthesise the evidence collated in systematic reviews and meta-analyses summarising the association of SDF with assisted reproductive technology (ART) outcomes.

SEARCH STRATEGY

After preregistration (https://doi.org/10.17605/OSF.IO/6JHDP), we performed a comprehensive search of the PubMed, Scopus, Cochrane Library, Web of Science and Embase databases. We conducted a search for systematic reviews on the association between SDF and ART without any restrictions on language or publication date.

SELECTION CRITERIA

Systematic reviews and meta-analyses assessing the association between SDF and ART outcomes were eligible.

DATA COLLECTION AND ANALYSIS

We assessed the quality of the included reviews using AMSTAR 2 and ROBIS, and determined the degree of overlap of primary studies between reviews estimating the corrected covered area (CCA), adjusted for structural missingness. We evaluated the most recent reviews assessing the association of SDF with live birth, pregnancy, miscarriage, implantation, blastulation and fertilisation. The synthesis of evidence was harmonised across all included quantitative syntheses, re-estimating the odds ratio (eOR) in random-effects meta-analyses with 95% confidence intervals (95% CIs) and 95% prediction intervals (95% PIs). We categorised the evidence strength into convincing, highly suggestive, suggestive, weak or nonsignificant, according to the meta-analysis re-estimated P-value, total sample size, I2 statistic for heterogeneity, small study effect, excess significance bias and the largest study significance.

MAIN RESULTS

We initially captured and screened 49 332 records. After excluding duplicate and ineligible articles, 22 systematic reviews, 15 of which were meta-analyses, were selected. The 22 reviews showed a moderate degree of overlap (adjusted CCA 9.2%) in their included studies (overall n = 428, with 180 unique studies). The 15 meta-analyses exhibited a high degree of overlap (adjusted CCA = 13.6%) in their included studies (overall n = 274, with 118 unique studies). AMSTAR 2 categorised the quality of evidence in 18 reviews as critically low and the quality of evidence in four reviews as low. ROBIS categorised all the reviews as having a high risk of bias. The re-estimated results showed that the association of SDF with live birth was weak in one and nonsignificant in four meta-analyses. Similarly, the association of SDF with pregnancy, miscarriage, implantation, blastulation and fertilisation was also weak or nonsignificant. The association of high SDF with different ART outcomes was also weak or nonsignificant for different interventions (IVF, ICSI and IUI) and tests.

CONCLUSIONS

This umbrella review did not find convincing or suggestive evidence linking SDF with ART outcomes. Caution should be exercised in making any claims, policies or recommendations concerning SDF.

In cases with raised sperm DNA fragmentation, can sperm selection by magnetic-activated cell sorting or testicular sperm aspiration help improve reproductive outcomes?

PURPOSE

To evaluate the efficacy of magnetic-activated cell sorting (MACS) or testicular sperm aspiration (TESA) to improve reproductive outcomes in cases with elevated sperm DNA fragmentation undergoing assisted reproduction.

METHODS

This randomized controlled trial included couples with failed IVF cycles and sperm DNA fragmentation > 30%. Sperm DNA fragmentation was assessed using the sperm chromatin structure assay (SCSA) method. Participants were randomly assigned to either the MACS or TESA group. Testicular sperm retrieval was performed for the TESA group, while MACS involved sperm selection using magnetic beads. Extended blastocyst culture, freeze all policy of blastocysts by vitrification, and frozen embryo transfer were undertaken as per clinic's standard operating protocols. Blastocyst formation rate, implantation rate, miscarriage rate, multiple pregnancy rate, and live birth rate were analyzed and compared between MACS and TESA groups.

RESULTS

There were no significant differences in female age, male age, or sperm DNA fragmentation index (DFI) between the MACS and TESA groups. The blastocyst conversion rate was slightly higher in the TESA group (39%) compared to the MACS group (32%). However, the MACS group had a higher implantation rate (50%) than the TESA group (35%). Miscarriage rates, multiple pregnancy rates, and live birth rates did not show statistically significant differences between the groups. A chi-squared test was conducted to compare categorical variables, and t-tests were done to compare continuous variables.

CONCLUSION

In cases with raised sperm DNA fragmentation, sperm selection by MACS or TESA seems to offer comparable reproductive outcomes. There seems no superiority of one intervention over the other in cases with raised sperm DNA fragmentation undergoing assisted reproduction. Both interventions seem to be beneficial for couples seeking assisted reproduction with raised sperm DNA fragmentation.

Preimplantation genetic testing in the current era, a review

BACKGROUND

Preimplantation genetic testing (PGT), also referred to as preimplantation genetic diagnosis (PGD), is an advanced reproductive technology used during in vitro fertilization (IVF) cycles to identify genetic abnormalities in embryos prior to their implantation. PGT is used to screen embryos for chromosomal abnormalities, monogenic disorders, and structural rearrangements.

DEVELOPMENT OF PGT

Over the past few decades, PGT has undergone tremendous development, resulting in three primary forms: PGT-A, PGT-M, and PGT-SR. PGT-A is utilized for screening embryos for aneuploidies, PGT-M is used to detect disorders caused by a single gene, and PGT-SR is used to detect chromosomal abnormalities caused by structural rearrangements in the genome.

PURPOSE OF REVIEW

In this review, we thoroughly summarized and reviewed PGT and discussed its pros and cons down to the minutest aspects. Additionally, recent studies that highlight the advancements of PGT in the current era, including their future perspectives, were reviewed.

CONCLUSIONS

This comprehensive review aims to provide new insights into the understanding of techniques used in PGT, thereby contributing to the field of reproductive genetics.

Analyzing Blood Cells of High-Risk Myelodysplastic Syndrome Patients Using Interferometric Phase Microscopy and Fluorescent Flow Cytometry

Myelodysplastic syndromes (MDSs) are a group of potentially deadly diseases that affect the morphology and function of neutrophils. Rapid diagnosis of MDS is crucial for the initiation of treatment that can vastly improve disease outcome. In this work, we present a new approach for detecting morphological differences between neutrophils isolated from blood samples of high-risk MDS patients and blood bank donors (BBDs). Using fluorescent flow cytometry, neutrophils were stained with 2',7'-dichlorofluorescin diacetate (DCF), which reacts with reactive oxygen species (ROS), and Hoechst, which binds to DNA. We observed that BBDs possessed two cell clusters (designated H and L), whereas MDS patients possessed a single cluster (L). Later, we used FACS to sort the H and the L cells and used interferometric phase microscopy (IPM) to image the cells without utilizing cell staining. IPM images showed that H cells are characterized by low optical path delay (OPD) in the nucleus relative to the cytoplasm, especially in cell vesicles containing ROS, whereas L cells are characterized by low OPD in the cytoplasm relative to the nucleus and no ROS-containing vesicles. Moreover, L cells present a higher average OPD and dry mass compared to H cells. When examining neutrophils from MDS patients and BBDs by IPM during flow, we identified ~20% of cells as H cells in BBDs in contrast to ~4% in MDS patients. These results indicate that IPM can be utilized for the diagnosis of complex hematological pathologies such as MDS.

Causes and Risk Factors for Male Infertility: A Scoping Review of Published Studies

Background

Despite the evidence of declining sperm counts worldwide and the increasing prevalence of male infertility, there has been limited documentation of the potential causes and risk factors for male infertility. With limited methods of primary treatment of male infertility, understanding the causes and risk factors will pinpoint specific lines of prevention.

Objective

We reviewed published studies on causes and risk factors for male infertility and identify gaps in the literature enabling more focused research and innovations.

Design/Setting

The study was a scoping review. The review included studies on the causes and risk factors of male infertility published in scientific/academic publications. It was not limited to any region or date. The following databases were searched: Cumulative Index to Nursing and Allied Health Literature, Wiley online, HINARI, Science Direct, PubMed/Medline, Google Scholar, African Journals Online, and the WHO Repository. In total, 1295 articles were identified. After removing 357 duplicates, 938 articles were screened, and 71 articles were identified for inclusion, while 60 articles met the inclusion criteria.

Results

Four broad causes and risk factors of male infertility identified were 1) biological/physiological/genetic causes, 2) behavioral/lifestyle risk factors, 3) environmental factors, and 4) socio-demographic risk factors. However, no substantive results on actual causes under each category were identified, leaving gaps for further research and experimentation.

Conclusion

The results indicate limited knowledge of the actual causes of male infertility in published studies. The gaps in knowledge that need to be bridged to enable a fuller understanding of the actual causes of male infertility were highlighted.

Impact of paternal body mass index on assisted reproduction treatment outcomes: An updated systematic review and meta-analysis

AIM

The aim was to provide updated evidence on the association of male body mass index (BMI) with outcomes of assisted reproduction technology (ART).

METHODS

PubMed, Embase, and Scopus databases were systematically searched. The review included observational studies in patients undergoing ART, that is, either in-vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) and compared rate of clinical pregnancy and live birth based on different categories of male BMI. Quality of the pooled findings was assessed using the GRADE criteria.

RESULTS

A total of 19 studies were included in the review. Among subjects undergoing IVF, there were no significant differences in the rates of clinical pregnancy among overweight (odds ratio [OR] 1.38, 95% confidence interval [CI]: 0.65, 2.96) and obese (OR 1.86, 95% CI: 0.75, 4.58) BMI, compared to normal male BMI. Similarly, there were no significant differences in the rates of live birth among overweight (OR 1.04, 95% CI: 0.97, 1.13) and obese BMI (OR 0.90, 95% CI: 0.69, 1.18) when compared to males with normal BMI. Further, among those undergoing ICSI, there were no significant differences in the odds of clinical pregnancy among overweight (OR 0.98, 95% CI: 0.73, 1.33) and obese (OR 0.89, 95% CI: 0.62, 1.29). The odds of live births among overweight (OR 0.97, 95% CI: 0.89, 1.05) and obese (OR 0.95, 95% CI: 0.84, 1.07) male BMI were statistically similar to males with normal BMI undergoing ICSI.

CONCLUSIONS

The low to very low-quality findings suggest no significant association of overweight and obese BMI with clinical pregnancy and live birth rates among couples undergoing either IVF or ICSI.

Infertility cell therapy and epigenetic insights

Recent advances in assisted reproductive technology (ART) have allowed couples with severe infertility to conceive, but the methods are not effective for all cases. Stem cells as undifferentiated cells which are found in different stages of embryonic, fetal and adult life are known to be capable of forming different cell types, tissues, and organs. Due to their unlimited resources and the incredible power of differentiation are considered as potential new therapeutic biological tools for treatment of infertility. For reproductive medicine, stem cells are stimulated in vitro to develop various specialized functional cells including male and female gametes. The epigenetic patterns can be modified in the genome under certain drugs exposure or lifestyle alterations. Therefore, epigenetics-related disorders may be treated if the nature of the modifications is completely admissible. It is proved that our understanding of epigenetic processes and its association with infertility would help us not only to understand the etiological factors but also to treat some type of male infertilities. Exploration of both genetic and epigenetic variations in the disease development could help in the identification of the interaction patterns between these two phenomena and possible improvement of therapeutic methods.

Clinical implications of Y chromosome microdeletions among infertile men

Male factor infertility contributes significantly to couples facing difficulty achieving a pregnancy. Genetic factors, and specifically those related to the Y chromosome, may occur in up to 15% of men with oligozoospermia or azoospermia. A subset of loci within the Y chromosome, known as the azoospermia factors (AZFa, AZFb, and AZFc), have been associated with male infertility. Emerging evidence has demonstrated that microdeletions of at least a subset of these regions may also have impacts on systemic conditions. This review provides a brief review of male infertility and the structure of the Y chromosome, and further highlights the role of Y chromosome microdeletions in male infertility and other systemic disease.

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.

Single nucleotide polymorphisms in Renalase and KCNQ1 genes and female infertility: A cross-sectional study in Pakistan

A global increase in the incidence of subfertility is observed, and research suggests strong genetic influences that might restrict fertility directly or indirectly. It therefore becomes important to rule out the existence of genetic causes and counsel infertile couples before offering "Advanced Infertility Treatment Techniques." This cross-sectional study aimed to explore the association of KCNQ1 (rs2237895) and Renalase (rs2576178 and rs10887800) single nucleotide polymorphisms with different causes of infertility by analysing 508 fertile and 164 infertile women. Gene variant (AC/CC) of KCNQ1 rs2237895 showed a slight difference in the endometriosis group compared to the fertile group (p = .049), with the C allele showing a significant association with infertility overall (OR = 1.42 [1.100-1.833]; p < .0069). The variant AG/GG of Renalase rs2576178 was significantly associated with overall infertility (OR = 2.266; p < .001), with a strong G allele association with unexplained infertility OR = 2.796 (p = .002) that remained significant after adjusting for age and body mass index. Similarly, Renalase rs10887800 AG/GG and G allele showed significant association with both infertility due to polycystic ovarian syndrome and unexplained infertility. Expression of single nucleotide polymorphism rs2237895 and rs2576178 in both KCNQ1 and Renalase genes might be responsible for altering reproductive potential, hence leading to infertility in women.

The outcomes of intracytoplasmic sperm injection and laser assisted hatching in women undergoing in vitro fertilization are affected by the cause of infertility

Background

We sought to determine the association between factors that affected clini- cal pregnancy and live birth rates in patients who underwent in vitro fertilization (IVF) and received intracytoplasmic sperm injection (ICSI) and/or laser assisted hatching (LAH), or neither.

Materials and Methods

In this retrospective cohort study, the records of women who underwent IVF with or without ICSI and/or LAH at the Far Eastern Memorial Hospital, Taipei, Taiwan between January 2007 and December 2010 were reviewed. We divided patients into four groups: 1. those that did not receive ICSI or LAH, 2. those that received ICSI only, 3. those that received LAH only and 4. those that received both ICSI and LAH. Univariate and multivariate analyses were performed to determine factors associated with clinical pregnancy rate and live birth rate in each group.

Results

A total of 375 women were included in the analysis. Oocyte number (OR=1.07) affected the live birth rate in patients that did not receive either ICSI or LAH. Mater- nal age (OR=0.89) and embryo transfer (ET) number (OR=1.59) affected the rate in those that received ICSI only. Female infertility factors other than tubal affected the rate (OR=5.92) in patients that received both ICSI and LAH. No factors were found to affect the live birth rate in patients that received LAH only.

Conclusion

Oocyte number, maternal age and ET number and female infertility fac- tors other than tubal affected the live birth rate in patients that did not receive ICSI or LAH, those that received ICSI only, and those that received both ICSI and LAH, respectively. No factors affected the live birth rate in patients that received LAH only. These data might assist in advising patients on the appropriateness of ICSI and LAH after failed IVF.

Estradiol progesterone ratio on ovulation induction day: a determinant of successful pregnancy outcome after intra cytoplasmic sperm injection

BACKGROUND

Intracytoplasmic sperm injection (ICSI) is an advanced technique employed in assisted reproductive clinics for treatment of infertile couples. The reproductive endocrinologists try their level best to identify factors that enhance success rate after ICSI.

OBJECTIVE

To compare estradiol progesterone ratio on ovulation induction day amongst pregnancy outcome groups following ICSI.

MATERIALS AND METHODS

A cross sectional study was conducted on 323 couples of Assisted Reproductive Clinic in Islamabad from June 2010 till August 2011. Down regulation of females aged 18-40 years with gonadotrophin releasing hormone agonist was followed by calculated stimulation with gonadotrophin injections (COS). Oocytes pickup was done 36 hours after ovulation induction by 16G adapter and double lumen oocyte aspiration needle under general anesthesia. Oocytes were fertilized in vitro, graded and only blastocysts were transferred seven days after ovulation induction. Serum estradiol and progesterone were measured by enzyme linked immuno sorbent assay on ovulation induction day, ratio was compared in three groups of females; no conception with βhCG 5-25 mIU/ml, preclinical abortion with βhCG >25 mIU/ml and no cardiac activity on transvaginal scan and clinical pregnancy with βhCG >25mIU/ml and cardiac activity on transvaginal scan.

RESULTS

Females having high estradiol/ progesterone ratio were able to achieve clinical pregnancy shown by a positive βhCG and cardiac activity on transvaginal scan. These females also had significantly high number of oocytes, endometrial thickness and implantation rate.

CONCLUSION

A high estradiol/progesterone ratio on the day of ovulation induction predicts the success of intra cytoplasmic sperm injection.

Preimplantation embryo metabolism and culture systems: experience from domestic animals and clinical implications

Despite advantages of in vitro embryo production in many species, widespread use of this technology is limited by generally lower developmental competence of in vitro derived embryos compared to in vivo counterparts. Regardless, in vivo or in vitro gametes and embryos face and must adjust to multiple microenvironments especially at preimplantation stages. Moreover, the embryo has to be able to further adapt to environmental cues in utero to result in the birth of live and healthy offspring. Enormous strides have been made in understanding and meeting stage-specific requirements of preimplantation embryos, but interpretation of the data is made difficult due to the complexity of the wide array of culture systems and the remarkable plasticity of developing embryos that seem able to develop under a variety of conditions. Nevertheless, a primary objective remains meeting, as closely as possible, the preimplantation embryo requirements as provided in vivo. In general, oocytes and embryos develop more satisfactorily when cultured in groups. However, optimization of individual culture of oocytes and embryos is an important goal and area of intensive current research for both animal and human clinical application. Successful culture of individual embryos is of primary importance in order to avoid ovarian superstimulation and the associated physiological and psychological disadvantages for patients. This review emphasizes stage specific shifts in embryo metabolism and requirements and research to optimize in vitro embryo culture conditions and supplementation, with a view to optimizing embryo culture in general, and culture of single embryos in particular.