Era Of Intracytoplasmic Sperm Injection Research Articles

Role of DNase Activity in Human Sperm DNA Fragmentation.

In this clinical era of intracytoplasmic sperm injection (ICSI), where a single spermatozoon is chosen for fertilization, the diagnostic functionality of the classical parameters typically associated with fertilization, such as sperm concentration, sperm motility, acrosome integrity, and mitochondria, is perhaps becoming less critical. In contrast, the contribution of sperm DNA quality to our understanding of the impact of male fertility within the context of ICSI is gaining increasing interest and importance. Even with respect to natural conception, high levels of sperm DNA fragmentation (SDF) in the ejaculate can adversely affect reproductive outcomes. However, the precise origin of SDF pathology in sperm cells is often ambiguous and most likely to be multifactorial. Hence, the genetic makeup of an individual, unbalanced REDOX processes, enzymatic activity, environmental and lifestyle factors, and even damage during sperm handling in the laboratory all operate in a unique and often synergistic manner to produce or induce sperm DNA damage. Surprisingly, the contribution of active enzymes as potential agents of SDF has received much less attention and, therefore, is likely to be underrated. This review highlights the roles of different enzymes related to the degradation of sperm DNA as possible effectors of DNA molecules in spermatozoa.

Clinical Andrologists: Do We Really Need Them in the Era of ART?

Infertility is on a rise, and so is the availability of assisted reproductive technique (ART) centres. The sole aim of these centers is to help these unfortunate couples achieve pregnancy. Hence, the concentration of the treatment is on the female partner, while the male is relegated to just being a source for sperm. In the era of intracytoplasmic sperm injection, when pregnancy is possible even with a single mature sperm, evaluation and management of male factor infertility (MFI) is often neglected. MFI and poor semen parameters are markers of male health. He could be suffering from erectile or ejaculatory issues or with correctable obstructive azoospermia. A simple timely varicocele correction may help resolve the issue. It is important to understand that MFI is not a disease but may be a symptom of major underlying clinical condition like testicular or brain tumors. Infertility treatment could be the only occasion when a male seeks health-care evaluation. India has a large pool of qualified urologists trained in andrological care. In contrast, gynecologists may not be trained in the management of male patients, hence there is an important place for andrological services to be an integral part of ART centers. Andrologists would offer minimal andrological evaluation and condition-specific treatment. This could avoid or reduce the need for invasive and expensive ART. Andrologists could also choose the most appropriate mode of sperm retrieval. Undoubtedly, availability of andrological services would improve the overall quality of care, reduce the costs and complications, and would also be medicolegally safe.

Sperm Morphology Assessment in the Era of Intracytoplasmic Sperm Injection: Reliable Results Require Focus on Standardization, Quality Control, and Training.

Semen analysis is the first, and frequently, the only step in the evaluation of male fertility. Although the laboratory procedures are conducted according to the World Health Organization (WHO) guidelines, semen analysis and especially sperm morphology assessment is very difficult to standardize and obtain reproducible results. This is mainly due to the highly subjective nature of their evaluation. ICSI is the choice of treatment when sperm morphology is severely abnormal (teratozoospermic). Hence, the standardization of laboratory protocols for sperm morphology evaluation represents a fundamental step to ensure reliable, accurate and consistent laboratory results that avoid misdiagnoses and inadequate treatment of the infertile patient. This article aims to promote standardized laboratory procedures for an accurate evaluation of sperm morphology, including the establishment of quality control and quality assurance policies. Additionally, the clinical importance of sperm morphology results in assisted reproductive outcomes is discussed, along with the clinical management of teratozoospermic patients.

448 - Pregnancy and live birth rates of microsurgical vasoepididymostomy for azoospermic patients with epididymal obstruction in the era of intracytoplasmic sperm injection and possible factors affecting the outcomes

448 - Pregnancy and live birth rates of microsurgical vasoepididymostomy for azoospermic patients with epididymal obstruction in the era of intracytoplasmic sperm injection and possible factors affecting the outcomes

The effect of varicocele on embryo development and IVF outcomes

The treatment of male factor infertility secondary to varicocele is controversial in the era of Intracytoplasmic Sperm Injection. Utilizing this technique, all but the most severe male factor can be overcome. In some patients, treatment of varicoceles can help a couple avoid IVF, but for those who require it, the impact of a varicocele on outcomes is not well defined. We evaluated the influence of a clinically relevant varicocele on IVF.

Early Versus Late Maturation Arrest: Reproductive Outcomes of Testicular Failure

There is a paucity of data characterizing infertile men with maturation arrest. We hypothesized that men with early stage maturation arrest could be clinically distinguished from men with late maturation arrest and would have worse reproductive outcomes. We retrospectively reviewed the records of all patients with nonobstructive azoospermia and cryptozoospermia who underwent testis mapping and sperm extraction from 2002 to 2009 and for whom histopathological findings were available. Patients had uniform maturation arrest if multiple biopsies revealed maturation arrest at the spermatogonia/spermatocyte (early maturation arrest) or the spermatid (late maturation arrest) stage. Clinical parameters and pregnancy outcomes of in vitro fertilization/intracytoplasmic sperm injection were examined. Statistical analysis consisted of univariate and multivariate analysis. Uniform maturation arrest was identified in 49 of 219 men (22.3%) undergoing testicular sperm extraction. On multivariate analysis men with maturation arrest had significantly larger testes (p=0.01), decreased follicle-stimulating hormone (p=0.05) and more detectable genetic abnormalities (p=0.01) than men with other histopathological conditions. Men with late maturation arrest had decreased follicle-stimulating hormone (p=0.02), increased testosterone (p=0.03) and a higher sperm retrieval rate at testicular sperm extraction (p=0.01) than men with early maturation arrest. Predictors of successful sperm retrieval were larger testes, cryptozoospermia, late maturation arrest and hypospermatogenesis (each p≤0.05). Pregnancy outcomes for men with maturation arrest were not significantly different from those for men with other histopathological conditions. Maturation arrest is a common, diverse histopathological subtype of severe male infertility. Compared to men with late maturation arrest those with early maturation arrest have increased follicle-stimulating hormone, decreased testosterone and a decreased probability of mature spermatozoa. In vitro fertilization/intracytoplasmic sperm injection outcomes were similar when spermatozoa were discovered during testicular sperm extraction.

DNA Fragmentation in Morphologically Normal Spermatozoa: How Much Should We Be Concerned in the ICSI Era?

Intracytoplasmic sperm injection (ICSI) has revolutionized the treatment of male infertility. However, there are still unanswered questions about the safety of this technique. During ICSI, only morphologically normal and motile spermatozoa are typically used to fertilize an oocyte. We recently reported that in infertile men, spermatozoa with apparently normal morphology may have DNA fragmentation. This finding consequently raised the possibility that spermatozoa with normal-shaped appearance but with DNA fragmentation could be mistakenly selected to fertilize oocytes during ICSI. This concern became more clinically significant following the subsequent finding that the presence of an increased proportion of normal spermatozoa with damaged DNA was negatively associated with embryo quality and pregnancy outcome after ICSI. Herein, we propose and discuss the hypothesis that the examination of DNA integrity in the subpopulation of highly motile (hence viable) and morphologically normal cells (and not in the total sperm population) may provide optimized information in prediction of ICSI success. More importantly, this new way of evaluation may provide reassurance about genomic normalcy and minimal risk of transmission of genetic disease and guide the development of improved methods of selection of spermatozoa with intact DNA to be used in assisted reproduction.

Natural history of varicocele management in the era of intracytoplasmic sperm injection

To evaluate the outcomes of infertile couples with varicocele. Retrospective study. University infertility clinic. Six hundred ten consecutive infertile couples in whom the man was found to have a clinical varicocele. Microsurgical varicocelectomy and assisted reproductive technologies (ARTs; intrauterine insemination and intracytoplasmic sperm injection). Clinical characteristics, pregnancy rates, and ART utilization in two subgroups of couples (those who elected to undergo varicocelectomy and those who did not). Sixty percent of the couples (363/610) opted for varicocele repair. The surgical and nonsurgical groups had comparable ages and duration of infertility. However, sperm concentration and motility were significantly lower in the surgical group, compared with in the observation one. As well, the surgical group had a significantly higher prevalence of primary infertility (80% vs. 71%) and had significantly smaller testicles bilaterally. Utilization of ART was significantly higher in the observation group compared with the surgical group (54% vs. 38%). Overall pregnancy rates (spontaneous + assisted pregnancies) in the observation and surgical group were not significantly different. This study suggests that men with poorer baseline characteristics are more likely to opt for varicocele repair. Furthermore, couples electing not to repair the varicocele are more likely to undergo ART procedures to improve their chances of conception.

Variability in testis biopsy interpretation: implications for male infertility care in the era of intracytoplasmic sperm injection

To determine whether center to center discrepancies in the ability to locate sperm in infertile testes with abnormal histology stems in part from inconsistencies in pathologists' readings of testis biopsies. Prospective cohort study. Academic male infertility practice. Consecutive series of azoospermic men referred with testis biopsy slides between 1998 and 2003. Testis biopsy histologies on azoospermic patients referred for infertility care were re-reviewed by a single pathologist blinded to the original reading. Subsequent infertility care was guided by the findings from the second histologic reading. Agreement between the outside and in-house review of testis biopsy readings was assessed with the kappa statistic. Pregnancy outcomes that resulted from clinical decisions informed by the second histologic readings were also assessed. Among 113 histologic specimens, re-review was complicated by fixation artifacts in 18 cases (16%) and insufficient biopsy sample size in 13 cases (12%). The kappa score for interobserver agreement in readings was 0.43 (95% CI 0.32-0.054). Mixed histology patterns in particular were underappreciated by outside pathologists (13% of cases on original reading, 36% of cases on review). In 27% of all cases, the differences in biopsy readings had a significant impact on clinical management. A correlation between independent testis histology readings in azoospermic men demonstrates frequent inconsistencies. These differences contribute to inaccurate phenotyping of male infertility and can significantly impact the direction of infertility care. These findings highlight the need for a standardized approach to testis histologic review.

VASOVASOSTOMY IN THE CONVOLUTED VAS DEFERENS: INDICATIONS AND OUTCOMES

We examined the indications for vasovasostomy (VV) in the convoluted vas deferens as well as the outcome of this procedure. We retrospectively analyzed the indications and outcomes of all vasectomy reversals performed in the convoluted vas deferens (CVV). Indications for CVV were clear fluid with or without sperm, motile or nonmotile sperm, or sperm parts. Patency was defined as motile sperm in the ejaculate postoperatively. Pregnancy data were calculated based on natural pregnancy occurring within year 1 postoperatively. A total of 48 patients underwent bilateral CVV (42) or unilateral CVV (6) when there was an unreconstructable/atrophic contralateral side. Average patient age was 39 years. Average age of the female partner was 30 years. The average obstructive interval was 10 years. The patency rate was 88% (38 of 43 cases). The natural pregnancy rate was 48% (15 of 31 cases). There was a significant difference in the patency rate in patients with sperm or sperm parts compared to those with clear fluid alone (p = 0.015). There was no difference in the pregnancy rate. Vasovasostomy in the CVV is a technically more difficult procedure than standard VV. Nevertheless, postoperative results are typically comparable to those obtained via VV and superior to those of epididymovasostomy in many cases. Therefore, we recommend CVV using the same indications as for standard VV in the straight portion of the vas deferens. However, consideration for epididymovasostomy should be given when no sperm are seen in the vasal fluid intraoperatively.

PREDICTION OF SUCCESSFUL OUTCOME OF MICRODISSECTION TESTICULAR SPERM EXTRACTION IN MEN WITH IDIOPATHIC NONOBSTRUCTIVE AZOOSPERMIA

Microsurgical techniques in testicular sperm extraction can improve sperm retrieval in patients with nonobstructive azoospermia (NOA). However, spermatozoa retrieval rates have still been reported to be around 50% for patients with NOA. Thus, a reliable prediction method for successful outcome is needed to avoid unnecessary surgery. In this retrospective study we determined the diagnostic and predictive values of noninvasive parameters used in the treatment of patients with NOA. We analyzed 9 preoperative factors including patient age, testicular volume and endocrinological data of 100 patients with NOA using multivariate logistic modeling. Testicular spermatozoa were retrieved successfully in 41 of the 100 patients (41%). We found that the concentrations of follicle-stimulating hormone (FSH), total testosterone (TT) and inhibin B were considered the most influential preoperative factors. We developed a formula to calculate the probability of successful outcome, P = [1 + exp(5.201 - 0.048 x FSH - 0.449 x TT - 0.021 x inhibin B)](-1). Association of predicted probabilities and observed responses was 0.77. A predicted probability of more than 15.7% was found to be the best cutoff. Sensitivity was 71.0% and specificity was 71.4% as determined by receiver operating characteristic analysis. We concluded that our formula should be useful for doctors considering microdissection testicular sperm extraction for patients with NOA because our equation uses noninvasive parameters without a preoperative testicular biopsy, which is a relatively invasive examination.

A study of conditions required for prolonged storage of human spermatozoa preserved by air-drying technique

This study was carried out to evaluate the effect of different conditions of storage on the long-term storage of sperm samples that had been preserved by air-drying. Our observations indicate that storage at 0 °C provide the optimum storage condition for recovery of intact sperms after prolonged storage. Storage in ambient (room temperature) condition lead to sample deterioration due to excessive drying over prolonged period leading to complete deterioration of the sample and complete disintegration of the sperms on re-suspension. Sample storage at 8 °C in the short term up to 6 weeks does not adversely affect recovery of intact sperms; however, longer-term storage duration under this condition appears to lead to progressive deterioration of the sample and the sperm content although to a lesser degree compared to storage in ambient condition. Our observations indicate that prolonged storage of air-dried sperm require maintenance of a certain degree of moisture content if recovery of intact sperms is to be achieved. Storage at 0 °C provide optimal condition for such prolonged preservation. In an era of intra-cytoplasmic sperm injection (ICSI), the technique of air-drying preservation of sperm provides a cheap and attractive alternative to current cryo-preservation technique.

Diagnosis and Treatment of Male Infertility

As a result of the technological advance provided by intracytoplasmic sperm injection (ICSI) in 1992, the evaluation and treatment of the infertile male has changed significantly. Many men who were previously thought to be irreversibly infertile have the potential to initiate their own biologic pregnancy. However, not all men having impaired semen parameter are ideal candidates for ICSI for numerous reasons including a lack of addressing the underlying problem causing the male infertility, unknown genetic consequences, and cost-effectiveness issues. In this era of ICSI, the fundamental approach to the male with suspected subfertility is unchanged and is based on a history, physical examination, and focused laboratory testing. The urologist should approach the patient with an intent to identify remediable causes of subfertility given the specific clinical situation. For instance, should a gentleman have his varicocele repaired or vasectomy reversed, or should he proceed directly with ICSI? If no factors can be improved in a timely manner, then ICSI should be considered using the available sperm. Examples of recent advances include the diagnosis and treatment of ejaculatory duct obstruction, indications and techniques for performing test is biopsy, and technique for sperm harvesting. In addition, potential genetic causes of male subfertility should be diagnosed and discussed with the patient. Cystic fibrosis gene mutation, karyotype abnormalities, and Y-chromosome microdeletions all have recently been identified as causative for male infertility in otherwise phenotypically normal men. With recently evolved diagnostic and therapeutic techniques now available for the infertile couple, even the most severe male factor problems in patients previously considered irreversibly infertile are now potentially treatable. The physician should be aware of the availability and limitations of these new and exciting reproductive technologies because they will allow him to provide timely and more effective therapy for the infertile couple. An understanding of these advances by all physicians is important as we progress into the 21st century.

Is microsurgical reconstruction following failed vasectomy reversal cost effective in the era of intracytoplasmic sperm injection?

Objective: Due to the high fertilization rates of intracytoplasmic sperm injection (ICSI), it has been proposed that men with failed vasectomy reversals who desire fertility go directly to this form of assisted reproduction. We compared the cost-effectiveness of assisted reproduction with testicular sperm extraction (TESE) and ICSI to microsurgical reconstruction in men following failed vasectomy reversal.

Vasectomy and its reversal

A vasectomy is the contraceptive method of choice for 7% of American couples. With more than 500,000 vasectomies performed yearly in the United States, it is a procedure that is shared by several fields of medicine. The variety of techniques, their successes and their complication rates make the vasectomy anything but a basic procedure. Considering this, the common goal of a vasectomy is male sterilization. The vasectomy reversal is a highly specialized procedure that requires considerable microsurgical training. There are several preoperative, intraoperative and postoperative decisions that may affect the overall success of the procedure and the main goal, which is pregnancy. Urologists may find themselves at either end of the fertility spectrum. The present review discusses the vasectomy procedure, surgical techniques and how to manage the outcomes. In addition, vasectomy reversal and its increasing success in the era of intracytoplasmic sperm injection are discussed.

Microsurgical single tubular epididymovasostomy: assessment in the era of intracytoplasmic sperm injection

Objective: To reevaluate the role of microsurgical single tubular epididymovasostomy for the treatment of obstructive azoospermia in the era of intracytoplasmic sperm injection (ICSI). Design: Retrospective clinical study. Setting: University infertility clinic. Patient(s): Sixty-one patients with obstructive azoospermia who underwent microsurgical single tubular epididymovasostomy. Intervention(s): Microsurgical single tubular epididymovasostomy. Main Outcome Measure(s): The overall patency and live-birth rates and factors that influenced the surgical outcome. Result(s): The overall patency rate after surgery was 68.9% (42/61) and the live-birth rate 31.1% (19/61). Of the 19 live-birth cases, 11 were achieved by natural means and 2 were achieved by conventional IVF soon after the operation, then subsequently by natural conception. The remaining 6 were the result of conventional IVF after surgery. An analysis of the potential prognostic factors previously associated with epididymovasostomy indicated that none had a statistically significant correlation with surgical outcome. In cases of patency, the partners were stratified into a younger group (21–30 years; n = 12) and an older group (31–36 years; n = 30). There was no statistically significant difference between the groups in the live-birth rate regardless of the means of conception (natural versus conventional IVF). Conclusion(s): This study demonstrates that the results obtained by microsurgical single tubular epididymovasostomy are comparable to those obtained with the use of IVF and ICSI. Even in this era of ICSI, the option of microsurgical single tubular epididymovasostomy should be considered because ICSI involves surgery to retrieve sperm and complex invasive treatment of the wife.

Vasectomy reversal.

Vasectomy reversal.

Microsurgical Vasovasostomy versus Microsurgical Epididymal Sperm Aspiration/Testicular Extraction of Sperm Combined with Intracytoplasmic Sperm Injection

Purpose: Vasovasostomy (VVS) represents the standard therapy of choice for the treatment of obstructive azoospermia following vasectomy. However, recently, intracytoplasmic sperm injection (ICSI) has been suggested by some to represent the solution for all cases of malefactor infertility regardless of its etiology based on its success rates. Therefore, we compared VVS to microsurgical epididymal sperm aspiration (MESA)/testicular extraction of sperm (TESE) and ICSI in terms of pregnancy, complications, and costs.Patients and Methods: Between 1/93 and 6/98, 157 VVS were performed microsurgically using the double–layer technique. Between 9/94 and 9/97, 69 and 42 couples underwent MESA/ICSI and TESE/ICSI, respectively, for epididymal obstruction and azoospermia of testicular origin. Results: The mean interval of vasal obstruction was 7.6 (0.5–18) years; patency after VVS was 77%, pregnancy rate was 52%. Local complication rate was 4.7%, no major complications were observed. Costs per life birth after VVS were 5,447 DM or 2,793 Euro. Pregnancy rates after MESA/TESE and ICSI were 22.5 and 19.5%, respectively, with 16 singletons, 3 twins and 3 abortions; local complications occurred in 3.9% of the men. Multiple births were noticed in 15.8% following ICSI, but in only 0.7% following VVS. 5.7 and 1.4% of the female partners experienced serious complications (mild or severe ovarian hyperstimulation syndrome, respectively). Costs per life birth after a MESA/TESE cycle amounted to 28,804 DM or 14,547 Euro.Conclusions: Even in the era of ICSI, microsurgical VVS represents the standard approach for obstructive azoospermia following vasectomy. Based on a cost–benefit analysis, VVS is more successful in terms of pregnancy rates (52 vs. 22.5%). VVS does not expose the female partners to complications following treatment of male infertility. In contrast to ICSI, multiple birth rates do not increase after VVS. We conclude that MESA/ICSI should be reversed for patients who are not amenable for microsurgical reconstruction.

Genetic concerns for the subfertile male in the era of ICSI

The treatment of severe male factor infertility has seen remarkable advances in the last five years with the introduction and widespread use of intracytoplasmic sperm injection (ICSI). Although ICSI represents one of the most important advances in the treatment of the subfertile male, significant concerns exist regarding the potential for transmission of abnormal genes to the offspring because many of the natural barriers to conception have been bypassed. Because these couples were not able to conceive prior to ICSI, the long-term genetic consequences in these offspring are largely undefined at this time. Genetic abnormalities related to male infertility need to be considered in terms of being (1) causative for male infertility and (2) potentially transmissible to the offspring. Reasons for pursuing a genetic evaluation include (1) establishing a diagnosis, (2) establishing a possible genetic origin, (3) clarifying the pattern of inheritance, and (4) providing information on natural history, variation and expression. The three most common known genetic factors related to male infertility are cystic fibrosis gene mutations leading to congenital absence of the vas deferens, Y-chromosome microdeletions leading to spermatogenic impairment, and karyotype abnormalities. When congenital bilateral absence of the vas deferens with azoospermia is encountered, cystic fibrosis transmembrane conductance regulator (CFTR) gene mutations are commonly the underlying cause. When testicular failure is manifest by azoospermia or severe oligoszoospermia, Y-chromosome microdeletions may be present in approximately 10-15 per cent of otherwise normal appearing men. Karyotyping can uncover potentially transmissible genetic abnormalities in the infertile male including structural chromosomal disorders such as Klinefelter's (classic 47,XXY), mixed gonadal dysgenesis, chromosomal translocations and XYY syndromes. Finally, potential male infertility genes in animal models are reviewed. Without question, advances in clinical and basic research raise scientific and social issues that must be addressed.

Triplet pregnancy after intracytoplasmic sperm injection of cryopreserved oocytes: case report

Objective: To report a triplet pregnancy that occurred after intracytoplasmic injection of sperm into cryopreserved oocytes. Design: Case report. Setting: Instituto de Ginecologı́a y Fertilidad (IFER), Buenos Aires, Argentina. Patient: A 36-year-old infertile patient with premature ovarian failure and a previous term pregnancy with fresh donated oocytes. Intervention(s): We administered leuprolide acetate for pituitary down-regulation followed by E 2 valerianate in incremental doses until an endometrial lining of >8 mm was observed by ultrasound. Thawing of frozen donated oocytes, intracytoplasmic sperm injection (ICSI), and translaparoscopic fallopian tube ET also were performed. Natural micronized progesterone was administered intravaginally (600 mg/d) before ET. Main Outcome Measure(s): Ultrasound at the 8th week of gestation revealed a triplet pregnancy with active fetal heartbeats. Result(s): A triple intrauterine gestation was achieved with the use of microinjection into cryopreserved oocytes. Conclusion(s): This case illustrates the feasibility of oocyte cryopreservation for clinical use in the era of ICSI.