Considerations for future modification of The Association for the Study of Reproductive Biology embryo grading system incorporating time-lapse observations

The Association for the Study of Reproductive Biology (ASEBIR) Interest Group in Embryology (in Spanish 'Grupo de Interés de Embriología') reviewed key morphokinetic parameters to assess the contribution of time-lapse technology (TLT) to the ASEBIR grading system. Embryo grading based on morphological characteristics is the most widely used method in human assisted reproduction laboratories. The introduction and implementation of TLT has provided a large amount of information that can be used as a complementary tool for morphological embryo evaluation and selection. As part of IVF treatments, embryologists grade embryos to decide which embryos to transfer or freeze. At the present, the embryo grading system developed by ASEBIR does not consider dynamic events observed through TLT. Laboratories that are using TLT consider those parameters as complementary data for embryo selection. The aim of this review was to evaluate review time-specific morphological changes during embryo development that are not included in the ASEBIR scoring system, and to consider them as candidates to add to the scoring system.

Predicting the likelihood of live birth: an objective and user-friendly blastocyst grading system

RESEARCH QUESTION

Can day-5 blastocysts be ranked according to their likelihood of live birth using an objective and user-friendly grading system?

DESIGN

A retrospective multicentre study conducted between 2017 and 2019, including 1044 day-5 blastocysts. Blastocyst expansion degree, trophectoderm and inner cell mass quality were assessed morphologically and morphometrically. Several analyses were conducted: the association between the qualitative and quantitative assessment for the blastocyst expansion degree and the number of trophectoderm cells; the effect of the embryo quality on day 3 and the contribution of the three blastocyst parameters to live birth, with logistic regression; and a decision tree with the most significant variables to create the new scoring system.

RESULTS

Cut-off points were found to discriminate between expanding and expanded blastocysts (165 µm for blastocyst diameter) and between trophectoderm grades (A: ≥14 cells; B: 11-13 cells; C: ≤10 cells). When the embryos reached the blastocyst stage, their quality on day 3 did not add predictive value for implantation and live birth. In the logistic regression analysis, the only parameter capable of significantly predicting the live birth likelihood was the trophectoderm grade: A versus C (OR 1.95, 95% CI 1.26 to 3.0); B versus C (OR 1.71, 95% CI 1.22 to 2.4). The decision tree supported the finding that the trophectoderm grade had the highest predictive value for a live birth, followed by the blastocyst expansion degree in a second step.

CONCLUSIONS

This new method makes objective blastocyst assessment feasible, allowing for standardization and exportation to other laboratories worldwide.

Motivations and personality characteristics of candidate sperm and oocyte donors according to parenthood status: a national study from the french CECOS network

STUDY QUESTION

In a non-commercial national gamete donation programme, do the motivations and personality characteristics of candidate sperm and oocyte donors differ according to their parenthood status?

SUMMARY ANSWER

Moderate differences exist between non-parent and parent candidate donors in motivations for gamete donation and representations as well as in personality characteristics.

WHAT IS KNOWN ALREADY

Several studies have analysed the motivations and experiences of oocyte or sperm donors, but mainly in countries where gamete donation is a commercial transaction, and very few studies have reported results of personality traits using personality inventory tests. No study has specifically investigated the motivations and personality characteristics of candidate gamete donors according to parenthood status.

STUDY DESIGN, SIZE, DURATION

A prospective study was carried out including 1021 candidate donors from 21 centres (in university hospitals) of the national sperm and egg banking network in France between November 2016 and December 2018.

PARTICIPANTS/MATERIALS, SETTING, METHODS

In total, 1021 candidate gamete donors were included in the study. During their first visit, male (n = 488) and female candidate donors (n = 533) completed a questionnaire on sociodemographic characteristics, their motivations for donation and their representations of donation, infertility and family. Secondly, a NEO Personality Inventory (NEO-PI-R) exploring the Big Five personality traits was completed online. Results were compared between parent and non-parent candidate donors.

MAIN RESULTS AND THE ROLE OF CHANCE

Altruistic values were the principal motive for donation irrespective of parenthood status. Reassurance about their fertility or preservation of sperm for future use was more often reported in non-parent than in parent candidate donors. With regard to representation of gamete donation or of the family, independently of their parenthood status, candidate donors more frequently selected social rather than biological representations. Mean personality characteristics were in the normal range. Non-parent candidate donors had higher scores on openness and depression than parents, while parent candidate donors appeared more social than non-parents.

LIMITATIONS, REASONS FOR CAUTION

The personality characteristics inventory was not completed by all candidate donors included in the study. However, family status did not differ between the two groups (NEO-PI-R completed (n = 525) or not), while the group who completed the NEO-PI-R had a higher educational level. This national study was performed in a country where gamete donation is subject to strict legislation.

WIDER IMPLICATIONS OF THE FINDINGS

In a global context where reproductive medicine is commercialized and gamete donor resources are limited, this study found that altruism and social representations of gamete donation and family are the main motivations for gamete donation in a country which prohibits financial incentive. These findings are relevant for health policy and for gamete donation information campaigns.

STUDY FUNDING/COMPETING INTEREST(S)

Grant from the Agence de la Biomédecine, France. The authors have nothing to disclose related to this study.

TRIAL REGISTRATION NUMBER

N/A.

O-262 Impact of the cancer treatment received on the quality of the human (pre)pubertal testicular tissue prior to testicular tissue freezing (TTF)

Study question

What is the impact of the cancer treatment received prior to TTF and the disease on spermatogonia quantity in testicular tissue from (pre)pubertal boys?

Summary answer

A decrease in spermatogonia number was observed in testicular tissue after cancer treatment when cyclophosphamide equivalente dose (CED) is above 4000 mg/m2.

What is known already

The improved survival rates associated with the development of sperm and testicular tissue freezing (TTF) renders difficult not to offer fertility preservation to children or adolescents before cancer. Several studies exploring cancer patients have examined the number of spermatogonia per seminiferous tubular cross-section (S/T) or tubular fertility index (TFI, percentage of tubular cross-sections containing spermatogonia) in testicular biopsies. All studies, demonstrated that the S/T and TFI always decreased after the introduction of chemotherapy and more specifically in case of highly gonadotoxic risk such as alkylating agents.

Study design, size, duration

Testicular tissue samples from 79 (pre)pubertal boys diagnosed with cancer (ranging from 6 month to 16 years of age) were cryopreserved between May 2009 and June 2014. Medical diagnosis and previous chemotherapy exposure were recorded. We examined histological sections of (pre)pubertal testicular tissue to elucidate whether chemotherapy, doses or primary diagnosis affects the quality of testicular tissue.

Participants/materials, setting, methods

(Pre)pubertal boys with cancer diagnosis who benefitted from TTF prior to conditioning treatment for hematopoietic stem cell transplantation. All the patients included had previously received chemotherapy with moderate risk for future fertility. We have selected patients for whom data on chemotherapy received were complete. The quantity of spermatogonia and quality of testicular tissue were assessed by both morphological and immunohistochemical analysis.

Main results and the role of chance

The main finding was a significant reduction in spermatogonial cell counts in boys treated with alkylating agents. The mean S/T values in boys exposed to alkylating agents was significantly lower than in a group exposed to non-alkylating agents (p = 0.018). In contrast, no difference was observed for patients treated with carboplatin as the only alkylating agent compared to the group of patients exposed to non-alkylating agents. We observed an increase of S/T with age in the group of patients who did not receive alkylating agents and a decrease of S/T with age when patients received alkylating agents included in the CED formula (r = 0.6166, p = 0.0434; r= -0.3759, p = 0.0036, respectively). The TFI and S/T were decreased in the group of patients who received vincristine (p = 0.0049; p < 0.0001, respectively), but the CED was also significantly increased (p < 0.0001). Multivariate analysis, adjusted for CED, showed the persistence of a decrease in TFI correlated with vincristine administration (-0.5 [-0.96; 0.09], p = 0.02).

Limitations, reasons for caution

This is a descriptive study of testicular tissues obtained from patients who were at risk of infertility. Spermatognia functionanlity could not be tested by transplantation due limited sample size.

Wider implications of the findings

This study summarizes spermatogonia quantity and quality of testicular tissue of (pre)pubertal boys after potentially sterilizing treatments. We confirmed a negative correlation between the cumulative exposure to alkylating agents and the spermatogonial quantity. For patients in whom fertility preservation is indicated, TTF should be performed before initiation of alkylating agents.

Trial registration number

N/A

P-454 Less than half of men with testicular cancer or lymphomas banked sperm before gonadotoxic treatment in France in 2018

Study question

What is the proportion of men treated for testicular cancer or lymphoma who banked sperm before gonadotoxic treatment in France?

Summary answer

In 2018, 41% of men with testicular cancer and 28% of men with lymphoma banked sperm before gonadotoxic treatment in France.

What is known already

Cancer treatments significantly improved survival rates in men. In Europe, the 5-year survival rate is above 90% for testicular cancer (TC) and Hodgkin lymphoma (HL), which, with Non Hodgkin Lymphoma (NHL), are the most frequent cancers in men of reproductive age. However, surgery, chemotherapy and/or radiotherapy may damage male fertility: between 15% and 30% of men remain permanently infertile after treatment. Since 2011, the French bioethics law recommends and guarantees free access to fertility preservation for all patients needing gonadotoxic treatments. Few international data are available about the rate of male cancer patients who receive sperm cryopreservation before cancer treatment.

Study design, size, duration

We analyzed the data of male cancer incidence in 2018 published by the French National Institute of Cancer (INCa), only available and latest French national data, estimated from cancer registers of selected metropolitan departments (Defossez et al. 2019). We organized a survey among the 27 metropolitan centers of the CECOS network (public centers for study and conservation of human eggs and sperm) to collect the annual number of sperm cryopreservations for TC, HL or NHL.

Participants/materials, setting, methods

We compared the number of 0-59 years-old men with TC, HL or NHL in metropolitan France (extracted from 2018 INCa data) and the number of sperm banking for TC, HL or NHL in metropolitan centers of the CECOS network.

Main results and the role of chance

INCa estimated that 38,048 new cancers were diagnosed in metropolitan France in 2018 in men aged 0-59 years. TC accounted for 2,630 new cases and lymphomas for 3,913 new cases (943 HL and 2,970 NHL).

Twenty-six out of 27 metropolitan CECOS centers answered the survey (96% participation rate): in 2018, 1,079 men banked sperm for TC, 375 for HL and 211 for NHL.

In 2018, the fertility preservation rate in metropolitan France was 41% for TC and 28% for lymphomas (51% for HL, and 15% for NHL). The results of our national study are in accordance with Uçar et al. 2020, a monocentric study on 110 TC patients showing a 43% fertility preservation rate, but differ from those of Abdel-Razek et al. 2020, a monocentric study on 59 NHL and 26 HL patients, showing respectively 32% and 14% fertility preservation rates.

A limit of our study is to be based on estimated cancer incidence from INCa reports without stratification on age and parenthood; sperm banking activity was measured in the CECOS network, which performs 90% of French male fertility preservation (French Biomedicine Agency 2018 data). This design may induce an underestimation of cancer incidence and of sperm banking activity.

Limitations, reasons for caution

Our study did not consider patients who were informed of fertility preservation but did not want to/could not bank ejaculated sperm (azoospermia, sperm collection failure, no-show). In CECOS network, the estimated rate of such patients is 10%.

French overseas regions were not studied (lack of INCa data).

Wider implications of the findings

Our results suggest that despite the recommendations and facilities offered by the French bioethics law, the male patients’ pathway for fertility preservation before cancer treatments could be improved. Further study should evaluate if this suboptimal rate of fertility preservation is homogeneous on French territory or related to postal code.

Trial registration number

Not applicable

P–447 Challenging cases in Oncofertility: Insights from a national specialized e-meeting for fertility preservation specialists

Study question

How a new specialized e-meeting for complex cases in oncofertility is used by fertility preservation specialists (FPS)?

Summary answer

The e-meeting for complex oncofertility cases is an innovative tool that fulfils the needs of FPS and could help them to improve their oncofertility practice.

What is known already

Little is known about the management of fertility preservation (FP) in rare cancer that could be challenging for FPS due to lack of experience and scientific data. To our knowledge, there is no specially dedicated meeting reported in published literature to provide highly specialized advices to FPS in these challenging situations of FP.

Study design, size, duration

We present three years of activity of a national French e-meeting dedicated to the management of challenging oncofertility cases. We conducted a retrospective analysis of all submitted cases. Second, a survey was conducted to evaluate the use of this e-meeting at participating FPS.

Participants/materials, setting, methods

The E-meeting for Complex Cases in Oncofertility was created in 2016 September in France, allowing for National oncofertility experts to share viewpoints about challenging cases for which they do not have experience and/or no sufficient data available in published literature. Demographic and clinical data, number of replies and proposal for each case were collected retrospectively. A survey to investigate the use and the interest of FPS for this tool was sent to its members. Main results and the role of chance: One hundred and four experts have joined the e-meeting since its set-up and 109 challenging cases have been submitted. Mean age of patients was 22.0 ± 8.9 years old and 87% were female. Most of cases were hematological cancers (n = 32/109; 29%), gynecologic cancers (n = 30/109; 27%) and neurological cancers (n = 12/109; 10.9%). Each submitted case received on average 2 ± 1 different strategy for FP and the opinion of 7 ± 2 experts. Among the FPS who submitted cases, seeking the opinions from others FPS allowed them to confirm their care plan (N = 49; 84%), to offer different options to their patient (N = 34; 58%) and to compare their practices with other specialists (N = 23; 39%). All respondents reported a self-perceived improvement in their practice of oncologic FP (n = 80; 100%).

Limitations, reasons for caution

Although this study showed a perceived improvement at FPS in the management of challenging oncofertility cases, we did not study in details their adherence to the e-meeting’s proposals. The value of this new tool has also not been assessed regarding patient’s quality of life and further fertility.

Wider implications of the findings: Specific attention should be paid for challenging cases in oncofertility for which only experiences of individual exist. Enhancing communication between FPS through national and international networks, pooling experiences and collecting the most complex cases are required in order to improve the management of these patients.

Trial registration number

Not applicable

[Onco-TESE and testicular cancer]

INTRODUCTION

Fertility preservation is essential before cancer treatment. When ejaculated sperm preservation is not possible, testicular tissue can be surgically collected by Onco-TESE technic (Oncological Testicular Sperm Extraction) to isolate sperm. We report on our experience with Onco-TESE in testicular cancer patients at the Rouen University Hospital.

MATERIAL AND METHOD

Retrospective study including all pubescent men, treated for testicular cancer, uni- or bilateral, before any carcinological therapy, who have undergone Onco-TESE at the Rouen University Hospital. Fragment weight, detection of sperm or its precursors were analysed. A histological interpretation of the testicular tumor was carried out. For each positive sample, straws were kept at the French Sperm Bank.

RESULTS

Twenty-four patients had an Onco-TESE: 58.34% severe sperm alteration (SSA) and 41.36% sperm collection failure (SCF), between 1996 and 2019. The mean age was 26.6 (±5.29) years. The mean procedure and length of stay were 71minutes (±30.7) and 3.75 days (±2.83), respectively. The rate of positive testicular biopsies (TB) was 58.33% overall and 66,67% in the case of TB on tumour testis. One patient had a Clavian-Dindo III complication. The mean number of straws preserved per patient was 14.28 (±15.34) for 7.14% use.

CONCLUSION

Our results seem to confirm that Onco-TESE is an effective solution for preserving fertility in men with testicular cancer in cases of SSA or SCF.

LEVEL OF EVIDENCE

III.

Fertility preservation in boys: recent developments and new insights †

BACKGROUND

Infertility is an important side effect of treatments used for cancer and other non-malignant conditions in males. This may be due to the loss of spermatogonial stem cells (SSCs) and/or altered functionality of testicular somatic cells (e.g. Sertoli cells, Leydig cells). Whereas sperm cryopreservation is the first-line procedure to preserve fertility in post-pubertal males, this option does not exist for prepubertal boys. For patients unable to produce sperm and at high risk of losing their fertility, testicular tissue freezing is now proposed as an alternative experimental option to safeguard their fertility.

OBJECTIVE AND RATIONALE

With this review, we aim to provide an update on clinical practices and experimental methods, as well as to describe patient management inclusion strategies used to preserve and restore the fertility of prepubertal boys at high risk of fertility loss.

SEARCH METHODS

Based on the expertise of the participating centres and a literature search of the progress in clinical practices, patient management strategies and experimental methods used to preserve and restore the fertility of prepubertal boys at high risk of fertility loss were identified. In addition, a survey was conducted amongst European and North American centres/networks that have published papers on their testicular tissue banking activity.

OUTCOMES

Since the first publication on murine SSC transplantation in 1994, remarkable progress has been made towards clinical application: cryopreservation protocols for testicular tissue have been developed in animal models and are now offered to patients in clinics as a still experimental procedure. Transplantation methods have been adapted for human testis, and the efficiency and safety of the technique are being evaluated in mouse and primate models. However, important practical, medical and ethical issues must be resolved before fertility restoration can be applied in the clinic.Since the previous survey conducted in 2012, the implementation of testicular tissue cryopreservation as a means to preserve the fertility of prepubertal boys has increased. Data have been collected from 24 co-ordinating centres worldwide, which are actively offering testis tissue cryobanking to safeguard the future fertility of boys. More than 1033 young patients (age range 3 months to 18 years) have already undergone testicular tissue retrieval and storage for fertility preservation.

LIMITATIONS REASONS FOR CAUTION

The review does not include the data of all reproductive centres worldwide. Other centres might be offering testicular tissue cryopreservation. Therefore, the numbers might be not representative for the entire field in reproductive medicine and biology worldwide. The key ethical issue regarding fertility preservation in prepubertal boys remains the experimental nature of the intervention.

WIDER IMPLICATIONS

The revised procedures can be implemented by the multi-disciplinary teams offering and/or developing treatment strategies to preserve the fertility of prepubertal boys who have a high risk of fertility loss.

STUDY FUNDING/COMPETING INTERESTS

The work was funded by ESHRE. None of the authors has a conflict of interest.

Establishment, maintenance and functional integrity of the blood-testis barrier in organotypic cultures of fresh and frozen/thawed prepubertal mouse testes

STUDY QUESTION

Can the spatio-temporal formation of an intact blood-testis barrier (BTB), which is essential for the progression of spermatogenesis, be reproduced in cultures of fresh or frozen/thawed prepubertal mouse testes?

SUMMARY ANSWER

Organotypic cultures allow the establishment and maintenance of major BTB components and the formation of a functional BTB in mouse testicular tissues.

WHAT IS KNOWN ALREADY

In vitro maturation of prepubertal testicular tissues is a promising approach to restore fertility in adult survivors of childhood cancer. Although gametes can be successfully obtained from prepubertal mouse testes in organotypic cultures, the spermatogenic yield remains low compared to in vivo controls.

STUDY DESIGN, SIZE, DURATION

Mouse testicular tissues were frozen using controlled slow freezing (CSF) or solid surface vitrification (SSV) procedures. A total of 158 testes (fresh n = 58, CSF n = 58 or SSV n = 42) from 6 to 7 days postpartum (dpp) mice were cultured at 34°C in basal medium (α-MEM, 10% KnockOut Serum Replacement, 5 μg/ml gentamicin) at a gas-liquid interphase (under 20% O2), with or without 10-6 M retinol, for 9, 16 and 30 days. In addition, 32 testes from 6-7, 15-16, 22-23 and 36-37 dpp mice were used as in vivo controls.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The mRNA levels of BTB genes (Claudin 3, Claudin 11, Zonula occludens 1 and Connexin-43), germ cell-specific genes (Sal-like protein 4, Kit oncogene, Stimulated by retinoic acid gene 8, Synaptonemal complex protein 3, Transition protein 1 and Protamine 2), markers of Sertoli cell immaturity/maturity (anti-Mullerian hormone, androgen receptor, cyclin-dependent kinase inhibitor 1b) and the androgen-regulated gene Reproductive homeobox 5 (Rhox5) were measured by quantitative RT-PCR (RT-qPCR). The localization of BTB proteins in seminiferous tubules was studied by immunohistochemistry and spermatogenic progression was evaluated histologically. The integrity of the BTB was assessed using a biotin tracer.

MAIN RESULTS AND THE ROLE OF CHANCE

Modest differences in Claudin 11 (Cldn11), Zonula occludens 1 (Zo-1), Connexin-43 (Cx43) transcript levels and in the localization of the corresponding proteins were found between in vitro cultures of fresh or frozen/thawed testes and in vivo controls (P < 0.05). However, a 32-77-fold decrease in Claudin 3 (Cldn3) mRNA levels and a lack of CLDN3 immunolabelling in 36-44% of seminiferous tubules were observed in 30-day organotypic cultures (P < 0.05). Although Sertoli cell maturation and the completion of a full spermatogenic cycle were achieved after 30 days of culture, meiotic and postmeiotic progression was altered in cultured testicular tissues (P < 0.05). Moreover, an increased BTB permeability and a decreased expression of Rhox5 were observed at the end of the culture period in comparison with in vivo controls (P < 0.05). Completion of spermatogenesis occurred in vitro in seminiferous tubules with an intact BTB, and in those expressing or lacking CLDN3.

LARGE SCALE DATA

None.

LIMITATIONS, REASONS FOR CAUTION

Further studies will be needed to determine whether the expression of other BTB components is altered and to decipher the reason for lower Cldn3 and Rhox5 mRNA levels in organotypic cultures.

WIDER IMPLICATIONS OF THE FINDINGS

This work contributes to a better understanding of the molecular mechanisms occurring in in vitro matured prepubertal testes. The organotypic culture system will have to be developed further and optimized for human tissue, before potential clinical applications can be envisaged.

STUDY FUNDING AND COMPETING INTEREST(S)

This work was supported by Rouen University Hospital, Ligue contre le Cancer (to L.D.), and co-supported by European Union and Région Normandie (to A.O.). Europe gets involved in Normandie with European Régional Development Fund (ERDF). The authors declare that they have no conflict of interest.

Vitamin A prevents round spermatid nuclear damage and promotes the production of motile sperm during in vitro maturation of vitrified pre-pubertal mouse testicular tissue

STUDY QUESTION

Does vitamin A (retinol, Rol) prevent round spermatid nuclear damage and increase the production of motile sperm during in vitro maturation of vitrified pre-pubertal mouse testicular tissue?

SUMMARY ANSWER

The supplementation of an in vitro culture of ~0.75 mm³ testicular explants from pre-pubertal mice with Rol enhances spermatogenesis progression during the first spermatogenic wave.

WHAT IS KNOWN ALREADY

The production of functional spermatozoa in vitro has only been achieved in the mouse model and remains a rare event. Establishing an efficient culture medium for vitrified pre-pubertal testicular tissue is now a crucial step to improve the spermatic yield obtained in vitro. The role of Rol in promoting the differentiation of spermatogonia and their entry into meiosis is well established; however, it has been postulated that Rol is also required to support their full development into elongated spermatids.

STUDY DESIGN, SIZE, DURATION

A total of 60 testes from 6.5 days post-partum (dpp) mice were vitrified/warmed, cut into fragments and cultured for 30 days: 20 testes were used for light microscopy and histological analyses, 20 testes for DNA fragmentation assessment in round spermatids and 20 testes for induced sperm motility assessment. Overall, 16 testes of 6.5 dpp were used as in vitro fresh tissue controls and 12 testes of 36.5 dpp mice as in vivo controls. Testes were vitrified with the optimal solid surface vitrification procedure and cultured with an in vitro organ culture system until Day 30 (D30). Histological analysis, cell death, degenerating round spermatids, DNA fragmentation in round spermatids and induced sperm motility were assessed. Testosterone levels were measured in media throughout the culture by radioimmunoassay.

MAIN RESULTS AND THE ROLE OF CHANCE

At D30, better tissue development together with higher differentiation of spermatogonial stem cells, and higher global cell division ability were observed for vitrified/warmed testicular fragments of ~0.75 mm³ with a culture medium supplemented with Rol compared to controls. During in vitro culture of vitrified pre-pubertal testicular tissue, Rol enhanced and maintained the entry of spermatogonia into meiosis and promoted a higher spermatic yield. Furthermore, decreased round spermatid nuclear alterations and DNA damage combined with induced sperm motility comparable to in vivo highlight the crucial role of Rol in the progression of spermatogenesis during the first wave.

LIMITATIONS, REASONS FOR CAUTION

Despite our promising results, the culture media will have to be further improved and adapted within the context of a human application.

WIDER IMPLICATIONS OF THE FINDINGS

The results have potential implications for the handling of human pre-pubertal testicular tissues cryopreserved for fertility preservation. However, because some alterations in round spermatids persist after in vitro culture with Rol, the procedure needs to be optimized before human application, bearing in mind that the murine and human spermatogenic processes differ in many respects.

LARGE SCALE DATA

None.

STUDY FUNDING AND COMPETING INTERESTS

This study was supported by a Ph.D. grant from the Normandy University and a financial support from 'la Ligue nationale contre le cancer' (both awarded to L.D.), funding from Rouen University Hospital, Institute for Research and Innovation in Biomedicine (IRIB) and Agence de la Biomédecine. The authors declare that there is no conflict of interest.

Light microscopy morphological characteristics of the sperm flagellum may be related to axonemal abnormalities

Although electron microscopy provides a detailed analysis of ultrastructural abnormalities, this technique is not available in all laboratories. We sought to determine whether certain characteristics of the flagellum as assessed by light microscopy were related to axonemal abnormalities. Forty-one patients with an absence of outer dynein arms (type I), a lack of a central complex (type III) and an absence of peripheral doublets (type IV) were studied. Sperm morphology was scored according to David's modified classification. Flagella with an irregular thickness were classified as being of normal length, short or broken. There were correlations between missing outer dynein arms and abnormal, short or coiled flagellum. Type III patients showed the highest flagellar defects (a short (P = 0.0027) or an absent flagellum (P = 0.011)). Just over 68% of the irregular flagella were short in Type III patients, whereas this value was only 34.5% in type I and 26.4% in type IV (P = 0.002). There was a negative correlation between misassembly and spermatozoa of irregular flagella (r = -0.79; P = 0.019). It is concluded that light microscopy analysis of flagellum abnormalities may help provide a correct diagnosis, identify sperm abnormalities with fertility potentials and outcomes in assisted reproduction technologies and assess the genetic risk.

[In vitro spermatogenesis… new horizon to restore fertility?]

The survival of the young boy after cancer has considerably progressed in recent years due to the efficiency of chemo/radiotherapy against the tumor cells. However, this treatment causes adverse effects on healthy tissues, including fertility. Freezing testicular tissue before highly gonadotoxic treatment is a prerequisite for preserving fertility in prepubertal boys that do not produce sperm yet. But which strategy proposes to restore fertility from frozen-thawed testicular tissue? One potential solution would be to consider an in vitro maturation of spermatogonial stem cells. In this article we trace the chronological development of in vitro spermatogenesis that resulted in mouse sperm production in vitro and give an overview of new challenges for the future.

Emergency IVF for embryo freezing to preserve female fertility: a French multicentre cohort study

STUDY QUESTION

What are the outcomes of French emergency IVF procedures involving embryo freezing for fertility preservation before gonadotoxic treatment?

SUMMARY ANSWER

Pregnancy rates after emergency IVF, cryopreservation of embryos, storage, thawing and embryo transfer (embryo transfer), in the specific context of the preservation of female fertility, seem to be similar to those reported for infertile couples undergoing ART.

STUDY DESIGN, SIZE, DURATION

A French retrospective multicentre cohort study initiated by the GRECOT network-the French Study Group for Ovarian and Testicular Cryopreservation. We sent an e-mail survey to the 97 French centres performing the assisted reproduction technique in 2011, asking whether the centre performed emergency IVF and requesting information about the patients' characteristics, indications, IVF cycles and laboratory and follow-up data. The response rate was 53.6% (52/97).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Fourteen French centres reported that they performed emergency IVF (56 cycles in total) before gonadotoxic treatment, between 1999 and July 2011, in 52 patients.

MAIN RESULTS AND THE ROLE OF CHANCE

The patients had a mean age of 28.9 ± 4.3 years, and a median length of relationship of 3 years (1 month-15 years). Emergency IVF was indicated for haematological cancer (42%), brain tumour (23%), sarcoma (3.8%), mesothelioma (n = 1) and bowel cancer (n = 1). Gynaecological problems accounted for 17% of indications. In 7.7% of cases, emergency IVF was performed for autoimmune diseases. Among the 52 patients concerned, 28% (n = 14) had undergone previous courses of chemotherapy before beginning controlled ovarian stimulation (COS). The initiation of gonadotoxic treatment had to be delayed in 34% of the patients (n = 19). In total, 56 cycles were initiated. The mean duration of stimulation was 11.2 ± 2.5 days, with a mean peak estradiol concentration on the day on which ovulation was triggered of 1640 ± 1028 pg/ml. Three cycles were cancelled due to ovarian hyperstimulation syndrome (n = 1), poor response (n = 1) and treatment error (n = 1). A mean of 8.2 ± 4.8 oocytes were retrieved, with 6.1 ± 4.2 mature oocytes and 4.4 ± 3.3 pronuclear-stage embryos per cycle. The mean number of embryos frozen per cycle was 4.2 ± 3.1. During follow-up, three patients died from the consequences of their disease. For the 49 surviving patients, 22.5% of the couples concerned (n = 11) requested embryo replacement. A total of 33 embryos were thawed with a post-thawing survival rate of 76%. Embryo replacement was finally performed for 10 couples with a total of 25 embryos transferred, leading to one biochemical pregnancy, one miscarriage and three live births. Clinical pregnancy rate and live birth per couple who wanted a pregnancy after cancer were, respectively, 36% (95% CI = 10.9-69.2%) and 27% (95% CI = 6.0-61%).

LIMITATIONS, REASONS FOR CAUTION

The overall response rate for clinics was 53.6%. Therefore, it is not only that patients may not have been included, but also that those that were included were biased towards the University sector with a response rate of 83% (25/30) for a small number of patients.

WIDER IMPLICATIONS OF THE FINDINGS

According to literature, malignant disease is a risk factor for a poor response to COS. However, patients having emergency IVF before gonadotoxic treatment have a reasonable chance of pregnancy after embryo replacement. Embryo freezing is a valuable approach that should be included among the strategies used to preserve fertility.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was sought for this study. None of the authors has any conflict of interest to declare.

The feasibility of fertility preservation in adolescents with Klinefelter syndrome

STUDY QUESTION

Is fertility preservation feasible after the onset of puberty in adolescents with Klinefelter syndrome (KS)?

SUMMARY ANSWER

Fertility preservation counseling should be an integral part of the care of XXY adolescents. Frozen ejaculated or testicular spermatozoa and even frozen immature germ cells can give them the potential to conceive their genetic progeny. However, no biological or clinical parameters were predictive of mature or immature germ cell retrieval.

WHAT IS KNOWN ALREADY

KS is the commonest sex chromosome disorder observed in azoospermic infertile males. Testicular sperm extraction success decreases with age and after testosterone therapy. Arguably, spermatozoa should be retrieved from KS males at the onset of puberty and before testosterone therapy to increase the chance of success.

STUDY DESIGN, SIZE, DURATION

A retrospective study was performed in eight KS adolescents, aged between 15 and 17 years, who were referred for counseling about their future fertility to the center CECOS (Centre d'Etude et de Conservation des Oeufs et du Sperme humain) at Rouen University Hospital between October 2008 and December 2011.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The patients were first seen with their parents and then separately. It was proposed to them that they should provide a semen sample, if this was azoospermic, two other semen samples spaced by 3 months were collected. If azoospermia was confirmed, a bilateral testicular biopsy was proposed for sperm retrieval and testicular tissue preservation. Each adolescent met the psychologist before undergoing testicular biopsy. Paraffin-embedded testicular tissue was evaluated after staining with hematoxylin-eosin and saffron and immunostaining using vimentin, anti-Müllerian hormone, androgen receptor and MAGE-A4 antibodies. Sertoli cell maturity, germ cell identification and lamina propria alteration were assessed on seminiferous tubules.

MAIN RESULTS AND THE ROLE OF CHANCE

KS adolescents were not deeply concerned about their future fertility and only became involved in the process of fertility preservation after at least three medical consultations. The parents agreed immediately that fertility preservation should be attempted. Seven non-mosaic XXY adolescents presented with azoospermia and one XXY/XY adolescent had oligozoospermia. Increased plasma levels of FSH and LH as well as bilateral testicular hypotrophy were observed in all patients. The XXY/XY adolescent banked four semen samples before testosterone replacement therapy. Two patients refused testicular biopsy. Five patients accepted a bilateral testicular biopsy. Spermatozoa were retrieved in one patient, elongated spermatids and spermatocytes I in a second patient.

LIMITATIONS, REASONS FOR CAUTION

The number of patients enrolled in our study was low because the diagnosis of KS is only rarely made before or at the onset of puberty. Most XXY males are diagnosed in adulthood within the context of male infertility.

WIDER IMPLICATIONS OF THE FINDINGS

Spermatozoa can be retrieved in semen sample and in testicular tissue of adolescent Klinefelter patients. Furthermore, the testis may also harbor spermatogonia and incompletely differentiated germ cells. However, the physician should discuss with the patient and his parents over a period of several months before collecting a semen sample and performing bilateral testicular biopsy. Fertility preservation might best be proposed to adolescent Klinefelter patients just after the onset of puberty when it is possible to collect a semen sample and when the patient is able to consider alternative options to achieve fatherhood and also to accept the failure of spermatozoa or immature germ cell retrieval.

[ICSI treatment in severe asthenozoospermia]

In the management of asthenozoospermia, the spermogram-spermocytogram plays an important role during diagnosis. It is of major importance to distinguish between necrozoospermia and sperm vitality. An ultrastructural study of spermatozoa is processed in the case of primary infertility without female implication, severe, unexplained and irreversible asthenozoospermia, sperm vitality at least 50 % and normal concentration of spermatozoa. Ultrastructural flagellar abnormalities are numerous and involve most spermatozoa. ICSI provides a suitable solution for patients with sperm flagellar defects to conceive children with their own gametes but the rate of ICSI success may be influenced by the type of flagellar abnormality. Some fertilization and birth rate failures which are related to some flagellar abnormalities might occur.

[Assisted reproductive technologies with sperm donation]

INTRODUCTION

The purpose of this review is to relate to the operating rules of CECOS in France and the legal, medical and ethical issues raised by sperm donation.

MATERIAL AND METHODS

Review of articles and consensus conferences on this subject published in Medline (PubMed) selected from 1973 and 2011 according to their relevance and Acts recorded on official legislative French websites.

RESULTS

The operating rules of CECOS were established by the Act of July 29, 2004, revised 6 August 2004 and July 7, 2011. Of the 21,759 children born of ART in France in 2009, 5.1% are from a sperm donation. From 1973 to 2006, 44,045 children are born after a sperm donation. Between 1973 and 2006, 16,971 donors are presented in the CECOS and only 10,347 donors have completely made their donation process. The main indication for use of donor sperm (75% of applications) is represented by men of infertile couples with nonobstructive azoospermia, the second indication is infertile men with oligospermia. In azoospermia, the application is usually performed after failure of testicular or epididymal surgical specimen. In oligozoospermia, claims made most often after several failures of intraconjugal ART.

CONCLUSION

Many questions are still present around the conception of children by sperm donation. The legitimacy of maintaining anonymity in the gift remains widely debated.

Management of male infertility due to congenital bilateral absence of vas deferens should not ignore the diagnosis of cystic fibrosis

Microsurgical or percutaneous epididymal sperm aspiration and intracytoplasmic sperm injection (ICSI) are proposed to overcome male infertility due to congenital bilateral absence of vas deferens (CBAVD). CBAVD has been associated with mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene and consequently, genetic counselling has to be addressed before beginning ICSI procedure. However, management of male infertility due to CBAVD should not ignore a mild form of cystic fibrosis. We describe the case of cystic fibrosis late diagnosis performed in a 49-year-old infertile men with CBAVD. CFTR molecular testing detected two mutations F508del and A455E corresponding to a cystic fibrosis genotype. Pneumological evaluation revealed a severe obstructive respiratory disease, bronchiectasis and high sweat chloride levels. Symptoms consistent with a cystic fibrosis have to be identified in infertile men with CBAVD before beginning assisted reproductive procedures.

Assessment of freezing procedures for rat immature testicular tissue

Fertility preservation has been included in the management of childhood cancer treatment. Cryopreservation of immature testicular tissue is the only available solution for pre-pubertal boys. Different freezing protocols have been developed in several species but without a clearly identified procedure. We tried to evaluate several protocols for cryopreservation of rat immature testicular tissue. Twelve different freezing protocols using different (i) cryoprotectant (dimethylsulphoxide [DMSO] or 1,2-propanediol [PROH]), (ii) cryoprotectant concentration (1.5M or 3M), (iii) equilibration time (30 or 60 min), (iv) equilibration temperature (4 °C or room temperature), (v) size of testicular fragment (7.5mg or 15 mg), (vi) package (straws or cryovials), were compared using cord morphological damage evaluation. A testicular tissue piece of 7.5mg cryopreserved in cryovial using 1.5M DMSO, an equilibration time of 30 min at 4 °C showed fewer morphological alterations than the other protocols tested. The selected freezing protocol was able to maintain rat immature testicular tissue architecture, functionality after testicular pieces organotypic culture, and could be proposed in a human application.

Rapid screening of cryopreservation protocols for murine prepubertal testicular tissue by histology and PCNA immunostaining

Numerous parameters have to be tested to identify optimal conditions for prepubertal testicular tissue banking. Our study evaluated 19 different cryopreservation conditions for immature testicular tissue using a rapid screening method. Immature mice testes were cryopreserved using either 1,2-propanediol (PROH) or dimethyl sulfoxide (DMSO) at a concentration of 0.75 or 1.5 M using a controlled slow-cooling rate protocol with (S+) or without seeding (S+). Equilibration was performed either at room temperature or at 4°C for 15 or 30 minutes. Seminiferous cord cryodamage was determined by scoring morphologic alterations. Cell proliferation ability was evaluated using a proliferating cell nuclear antigen (PCNA) antibody. Testes cryopreserved with optimal conditions were grafted into immunodeficient mice. The highest proportions of PCNA-positive nuclei and lowest morphologic alterations were observed with 1.5 M DMSO. Tissues were more altered with 0.75 M DMSO or PROH. Complete germ cell maturation was observed after allografting of testicular pieces previously frozen with 1.5 M DMSO, S+, 30 minutes. The 1.5 M DMSO, S+ or S+ protocol preserved prepubertal mice testicular tissue architecture and germ cell and Sertoli cell proliferation potential. Allografting of thawed testis fragments into immunodeficient mice confirmed that the 1.5 M DMSO, S+, 30 minutes protocol maintained testicular somatic and germ cell functions. Postthaw histologic evaluation and PCNA immunostaining are useful to rapidly test numerous freeze-thaw parameters. They may also be efficient tools to control human prepubertal frozen testis quality, within the context of a clinical application.

[Laser assisted hatching: Rouen University Hospital outcomes]

OBJECTIVE

Despite technical progress in In Vitro Fertilisation (IVF) procedure, embryo implantation rate remains low. Assisted hatching has been proposed to facilitate natural embryo hatching and implantation.

PATIENTS AND METHODS

Our study has evaluated whether laser assisted hatching improves implantation, pregnancy and live birth rates in different cases. We studied retrospectively 143 IVF cycles concerning more than 38 years old women, 166 IVF cycles after two previous implantation failures and 180 frozen-thawed embryo transfers.

RESULTS

Population characteristics were comparable in hatched and control groups. Implantation, pregnancy and live birth rates in women more than 38 years old were comparable with or without assisted hatching. Concerning repeated implantation failures, even if implantation, pregnancy and live birth rates were higher in assisted hatching group (FIV or ICSI), the differences were not significant. After frozen-thawed embryo transfers, implantation rate was significantly better with assisted hatching (19.14% vs 8.84% [p=0.02]).

DISCUSSION AND CONCLUSION

Assisted hatching improves embryo implantation rate after frozen-thawed embryo transfer.

Transposition ovarienne par cœlioscopie et cryopréservation de tissu ovarien avant radiochimiothérapie d'un cancer du rectum

We report a case of laparoscopic ovarian transposition and ovarian cryopreservation in a nulliparous 25-year-old woman with rectal cancer. The authors focus on the surgical technique and the importance of preserving ovarian function.

Complex chromosomal rearrangement and intracytoplasmic sperm injection: a case report

Complex chromosomal rearrangements (CCRs) are rare events in human pathology and are usually considered to induce severe reproductive impairment by disturbing the meiotic process and producing unbalanced gametes responsible for high reproductive risk. One-third of all CCRs are familial and tend to implicate fewer breakpoints and fewer chromosomes than de novo cases. CCRs are rarely transmitted through spermatogenesis and are primarily ascertained by male infertility. We report a familial balanced CCR, with seven breakpoints involving three chromosomes, which was detected prenatally in a female fetus conceived after intracytoplasmic sperm injection (ICSI) in a couple initially thought to be a carrier of a paternal reciprocal translocation involving two chromosomal breakpoints. Fluorescent in-situ hybridization (FISH) was used to elucidate the complexity of this CCR. The karyotype of the female CCR carrier was balanced and determined as 46,XX.ish t(1;4)(q42;q32)(WCP1+, D1Z5+, WCP4+, D1S3738-, D4S2930+; WCP4+, D4Z1+, WCP1+, D4S2930-, D1S3738+), ins(1;11)(q41;q23q24)(WCP1+,WCP11+, D11S2071-, MLL+; WCP11+, D11S2071+, WCP1-, MLL-), ins(4;11)(q23;q14q23)(WCP4+,WCP11+; WCP11+,WCP4-). The same balanced CCR was confirmed in her oligozoospermic father. We report, to our knowledge, the first case of ICSI performed in an infertile male with CCR, resulting in a balanced CCR carrier female with a normal clinical follow-up at 4 years of age. This particular case stresses the point of the relevance and feasibility of ICSI procedure in cases of balanced CCRs.

Chromosome constitution and apoptosis of immature germ cells present in sperm of two 47,XYY infertile males

BACKGROUND

In order to assess sperm alterations observed in some XYY males, we analysed the chromosome constitution as well as apoptosis expression in germ cells from two oligozoospermic males with high count of immature germ cells in their semen.

METHODS

Sex chromosome number and distribution were assessed at pachytene stage by fluorescence in situ hybridization (FISH). Immature germ cells and spermatozoa were examined by FISH and TdT (terminal deoxynucleotidyl transferase)-mediated dUDP nick-end (TUNEL) assay, combined with immunocytochemistry using the proacrosin-specific monoclonal antibody (mAb 4D4).

RESULTS

For patients 1 and 2, two Y chromosomes were present in respectively 60.0 and 39.6% of pachytenes. The three sex chromosomes were always in close proximity and partially or totally condensed in a sex body. XYY spermatocytes I escape the pachytene checkpoint and achieve meiosis. Nevertheless, nuclear division and/or cytokinesis were often impaired during meiosis leading to diploid (mainly 47,XYY cells) and tetraploid (94,XXYYYY) meiocytes. The presence of binucleated (23,Y)(24,XY) immature germ cells resulting from cytokinesis failure agree with a preferential segregation of the two Y chromosomes during meiosis I. In addition, 69.6% (patient 1) and 53.12% (patient 2) of post-reductional round germ cells were XY. However, high level of apoptotic round germ cells (94.9% for patient 1 and 93.3% for patient 2) was detected and may explain the moderate increase of hyperhaploid XY spermatozoa. Segregation errors also occurred in the XY cell line responsible for disomic 18 and X, as well as 46,XY diploid spermatozoa.

CONCLUSIONS

Our data are in agreement with the persistence of the extra Y chromosome during meiosis in XYY oligozoospermic males responsible for spermatogenesis impairment and a probable elimination via apoptosis of most XYY germ cells not solely during but also after meiosis.

[Cryopreservation of immature testicular tissue]

An increased incidence of cancer is observed in the population of adolescents and young adults since thirty years. Major progress in cancer diagnosis and therapy is unfortunately associated to high degree of toxicity on gonad function. Cryopreservation of ovarian tissue is performed in girls and women before cancer treatment with high risk of infertility. Procedures for ejaculated or testicular extracted spermatozoa are well defined. However, for prepubertal boys or after ejaculated sperm collection failure, mature or immature testicular tissue banking should be proposed. Still, an optimal cryopreservation protocol is a prerequisite for clinical application and does not exist for the moment. Furthermore, the future applications of immature testicular tissue banking should be developed, not solely germ cell in vitro maturation but also autologous testicular tissue grafting.

[Chromosome abnormalities of spermatozoa]

Chromosome meiotic pairing during male meiosis is a major event for chromosome segregation during anaphase I and spermatogenesis normal process. Chromosome non-disjunctions responsible for aneuploidy in male gametes can be observed during the first and the second meiotic divisions. The analysis of sperm nuclei chromosome constitution is a major and indirect tool for assessing male meiotic non-disjunctions and the genesis of chromosomal abnormalities. This evaluation has been performed initially by the human sperm/hamster oocyte fusion assay and more recently by fluorescence in situ hybridisation (FISH). Therefore, male populations with increased risk of aneuploidy for their progeny could be identified before entering an in vitro fertilization procedure, and depending on the potential risk a preimplantation or prenatal genetic diagnosis could be performed. For males with constitutional chromosome abnormalities, a specific genetic counselling could also be proposed.

Reversible meiotic abnormalities in azoospermic men with bilateral varicocele after microsurgical correction

Because of a possible relationship between microenvironmental disturbances and meiotic abnormalities and of a straight relationship between lower-quality semen in patient carrying a varicocele and first meiotic non-disjunction, bilateral bipolar testicular biopsies are realized according the thermic differential gradient described in varicocele. Systematic meiotic studies of multiple testicular biopsies from 65 azoospermic men with bilateral varicocele were done in a multi-centric study on microsurgical correction of bilateral varicocele with microthermic intra-operative evaluation using minimally invasive thermal microsensors (Betatherm 10K3MCD2). In the present study abnormal temperature raising, histomorphometric abnormalities (spermatocyte arrest) and meiotic abnormalities (class IIC) are strongly correlated. In the ten patients submitted to another testicular biopsy procedure six months after surgery for TESE, normal thermal differential is registered and no meiotic abnormalities recurrences are found.

Meiotic segregation of sex chromosomes in mosaic and non-mosaic XYY males: case reports and review of the literature

The aim of this study was to determine the incidence of sex chromosome aneuploidy in spermatozoa of two males with a 47,XYY karyotype and one male with a 46,XY/47,XYY constitution. Spermatozoa obtained from two oligospermic patients and one volunteer semen donor were studied by multicolour fluorescence in situ hybridization. In the XY/XYY male, the frequencies of X-bearing to Y-bearing sperm were significantly different from the 1 : 1 expected ratio. Significantly increased frequencies were found in the mosaic and non-mosaic males for 24,XX and 24,YY sperm when compared with control donors. The number of 24,XY sperm was significantly different from the controls in the XYY males, but not in the mosaic male. The incidence of disomy 18 and the rate of diploidy also increased in the three patients. However, the mosaic male had the lowest cumulative rate of disomic and diploid spermatozoa when compared with the two XYY patients. Our data suggest that: (i) chromosome abnormalities observed in spermatozoa of the two XYY oligoasthenoteratospermic (OAT) males arise through segregation errors in XY germ cells rather than normal meiosis of XYY germ cells, (ii) mosaic XYY males with normal semen parameters have a lower risk of producing offspring with a sex chromosomal abnormality than OAT males with XYY karyotype.