Treatment Of Severe Male Infertility Research Articles

A brief history of technical developments in intracytoplasmic sperm injection (ICSI). Dedicated to the memory of J.M. Cummins.

Intracytoplasmic sperm injection (ICSI) is an assisted reproductive technology for treatment of severe male infertility introduced into clinical practice in 1992. This review provides a brief history of the development of ICSI by acknowledging major developments in the field. The review addresses key developments in pre-clinical and early studies, how ICSI compares with in vitro fertilisation, long-term consequences, how the mechanistic approach to ICSI has changed in both manual and semi-automated approaches, and how sperm selection procedures are integrated into ICSI. From the beginnings using animal models in the 1960-1970s, the development of ICSI is a remarkable and transformative success story. Indeed, its broad use (70% of cycles globally) exceeds the need required for treating infertile males, and this remains a controversial issue. There remain questions around the long-term health impacts of ICSI. Furthermore, advances in automation of the ICSI procedure are occurring. An estimated 6million children have been born from the ICSI procedure. With further automation of sperm selection technologies, coupled with automation of the injection procedure, it is likely that the proportion of children born from ICSI will further increase.

Human Spermatogenesis: Insights From the Clinical Care of Men With Infertility.

Human spermatogenesis is a qualitatively and quantitatively different process than that observed for most other mammals. In contrast with most other mammals, human spermatogenesis is characterized by reduced quantitative production and more abnormal sperm morphology. Until recently, direct evaluation and observations of human sperm production has been limited and the majority of scientific knowledge regarding spermatogenesis was derived from rodent models of study. Unique opportunities to observe human spermatogenesis have occurred as a consequence of the treatment of severe male infertility. These patients have sperm production so limited that no sperm reach the ejaculate so their fertility treatment involves surgical sperm retrieval from the testis, coupled with use of those sperm with advanced assisted reproductive techniques. Treatment of men with severe male infertility has enhanced identification of new genetic abnormalities that may cause this condition, since they now seek medical care. Three key novel concepts have resulted: (a) spermatogenesis is spatially heterogeneous in the human male, especially when sperm production is compromised, (b) genetic abnormalities are common in men with severe male infertility, particularly in men with diffuse maturation arrest and (c) rodent studies may not be an ideal model for understanding human male infertility. Scientific understanding of human spermatogenesis has been enhanced by these clinical observations.

Clinical success of IUI cycles with donor sperm is not affected by total inseminated volume: a RCT.

STUDY QUESTIONWhat is the impact on live birth rates (LBR) when a donor IUI (dIUI) cycle is performed with an insemination volume of 0.5 mL versus the usual 0.2 mL?SUMMARY ANSWERLBR after a dIUI cycle is no different when performed with 0.5 versus 0.2 mL.WHAT IS ALREADY KNOWNAn IUI has an important role in the treatment of severe male infertility, and is often used in same-sex female couples and single parents. Different variables have been studied to determine factors correlated with clinical outcomes (IUI scheduling, ovarian stimulation, sperm parameters) but little is known about the inseminated volume. The use of conical bottom test tubes could contribute substantially to the loss of inseminated spermatozoa because it precludes the total recovery of the sample. Additionally, the insemination catheter could uphold this reduction causing sperm adhesion on the inner walls of the insemination catheter, decreasing even more the total inseminated volume. It is expected that utilizing an IUI approach that increases sperm volume in the fallopian tubes (0.5 mL rather than 0.2 mL) at the time of ovulation will lead to higher LBRs. To avoid bias related to sperm quality, the study population was restricted to dIUI cycles.STUDY DESIGN, SIZE, AND DURATIONA parallel-group, double-blinded, RCT, including patients undergoing natural or stimulated dIUI, was performed between March 2013 and April 2015. dIUI cycles (n = 293) were randomized through a computer-generated list to undergo insemination with 0.2 mL (control group) or 0.5 mL (study group), of which 24 were excluded (protocol deviation) and 269 received the allocated intervention. Patients with the presence of tubal factor infertility, grades III–IV endometriosis, >3 previous dIUI cycles or with ≥3 follicles >14 mm were excluded. The study was designed with 80% power to detect a 5% difference in LBR with a reference of 15% and a two-tailed 5% significance level. The required sample size was 118 per group.PARTICIPANTS/MATERIALS, SETTING AND METHODThere were 143 cycles (0.2 mL group) and 126 cycles (0.5 mL group). The primary end-point of the trial was LBR per dIUI cycle in both treatment groups. Clinical pregnancy rate and miscarriage rate were evaluated as secondary outcomes.MAIN RESULTS AND THE ROLE OF CHANCENo adverse events were reported during the study trial. Study groups (0.2 versus 0.5 mL, respectively) were similar in age (35.8 ± 3.9 versus 35.4 ± 4.0 years: mean±SD), and had similar anti-Mullerian hormone levels (2.2 ± 1.8 versus 2.0 ± 1.5 ng/mL), basal antral follicle count (13.2 ± 6.4 versus 13.6 ± 6.0), BMI (23.5 ± 3.9 versus 23.7 ± 4.1 kg/m2), number of follicles >17 mm (1.1 ± 0.5 versus 1.1 ± 0.5), total gonadotrophin dose (553.1 ± 366.3 versus 494.6 ± 237.1 IU), and total motile sperm count (8.22 ± 7.1 versus 7.7 ± 5.7 million). Similar clinical pregnancy rates (18.9% (27/143) versus 19.8% (25/126), NS), LBRs (15.4% (22/143) versus 19.0% (24/126), NS) and miscarriage rates (18.5% (5/27) versus 4.0% (1/25), NS) were observed between groups.LIMITATIONS REASONS FOR CAUTIONThe study was not powered to detect differences in the secondary outcomes, clinical pregnancy and miscarriage rates. The randomization was performed at the dIUI cycle level, therefore, the results are reported as success rate per dIUI cycle rather than per patient.WIDER IMPLICATIONS OF THE FINDINGSThis is the first RCT to show that the inseminated volume is not correlated with the probability of a live birth. The miscarriage rate was higher in the 0.2 mL group, although this difference was not statistically significant. If the lower miscarriage rate observed in the 0.5 mL group is confirmed, this could be related to the presence of uterine contractions similar of those generated during sexual intercourse, which may be implicated in the inception of early biochemical embryo–endometrium communication.STUDY FUNDING/COMPETING INTERESTSAll authors declare having no conflict of interest with regard to this trial. No funding was received for this study. This research was performed under the auspices of ‘Càtedra d’Investigació en Obstetrícia I Ginecologia’ of the Department of Obstetrics, Gynaecology and Reproductive Medicine, Hospital Universitari Quiron-Dexeus, Universitat Autònoma de Barcelona.TRIAL REGISTRATION NUMBERThe trial was registered at clinicaltrials.gov (Identifier: NCT03006523).

Risk of chromosomal aberration in spermatozoa during intracytoplasmic sperm injection.

Intracytoplasmic sperm injection (ICSI) has become critical for the treatment of severe male infertility. The principal feature of ICSI is the direct injection of spermatozoon into an oocyte, which facilitates the production of fertilized embryos regardless of semen characteristics, such as sperm concentration and motility. However, the chromosomal integrity of ICSI zygotes is degraded compared to that of zygotes obtained via in vitro fertilization. This chromosomal damage may occur due to the injection of non-capacitated, acrosome-intact spermatozoa, which never enter the oocytes under natural fertilization. Furthermore, it is possible that the in vitro incubation and pre-treatment of spermatozoa during ICSI results in DNA damage. Chromosomal aberrations in embryos induce early pregnancy losses. However, these issues may be overcome by embryo production using gametes with guaranteed chromosomal integrity. Because conventional chromosome analysis requires fixing cells to obtain the chromosome spreads, embryos cannot be produced using the nucleus that has been analyzed. On the other hand, genome cloning using androgenic or gynogenic embryos provides an additional nucleus for chromosome analysis following embryo production. Thus, this review aims to highlight the hazardous nature of chromosomal aberrations in sperm during ICSI and to introduce a method for the prezygotic examination for chromosomal aberrations.

ICSI treatment of severe male infertility can achieve prospective embryo quality compared with IVF of fertile donor sperm on sibling oocytes.

Azoospermia, cryptozoospermia and necrospermia can markedly decrease the ability of males to achieve pregnancy in fertile females. However, patients with these severe conditions still have the option to be treated by intracytoplasmic sperm injection (ICSI) to become biological fathers. This study analyzed the fertilization ability and the developmental viabilities of the derived embryos after ICSI treatment of the sperm from these patients compared with in vitro fertilization (IVF) treatment of the proven-fertile donor sperm on sibling oocytes as a control. On the day of oocyte retrieval, the number of sperm suitable for ICSI collected from two ejaculates or testicular sperm extraction was lower than the oocytes, and therefore, excess sibling oocytes were treated by IVF with donor sperm. From 72 couples (73 cycles), 1117 metaphase II oocytes were divided into 512 for ICSI and 605 for IVF. Compared with the control, husbands’ sperm produced a lower fertilization rate in nonobstructive azoospermia (65.4% vs 83.2%; P < 0.001), crytozoospermia (68.8% vs 75.5%; P < 0.05) and necrospermia (65.0% vs 85.2%; P < 0.05). The zygotes derived in nonobstructive azoospermia had a lower cleavage rate (96.4% vs 99.4%; P < 0.05), but the rate of resultant good-quality embryos was not different. Analysis of the rates of cleaved and good-quality embryos in crytozoospermia and necrospermia did not exhibit a significant difference from the control. In conclusion, although the sperm from severe male infertility reduced the fertilization ability, the derived embryos had potential developmental viabilities that might be predictive for the expected clinical outcomes.

Comparison of ART outcome between non-obstructive azoospermia and obstructive azoospermia: 15 years experiences

Comparison of ART outcome between non-obstructive azoospermia and obstructive azoospermia: 15 years experiences

Genetic Diagnosis in Infertile Men with Numerical and Constitutional Sperm Abnormalities

Infertile men having numerical or structural sperm defects may carry several genetic abnormalities (karyotype abnormalities, Y chromosome microdeletions, cystic fibrosis transmembrane conductance regulator (CFTR) gene mutations, androgen receptor gene mutations, and abnormalities seen in sperm cells) leading to this situation. First we aimed to investigate the relationship between the numerical and constitutional (morphological) sperm anomalies and the genetic disorders that can be seen in infertile males. Our other aim was to compare two different kinds of kits that we use for the detection of Y chromosome microdeletions. Sixty-three infertile males [44 nonobstructive azoospermic, 8 severe oligozoospermic, and 11 oligoasthenoteratozoospermic] were investigated in terms of somatic chromosomal constitutions and microdeletions of the Y chromosome. Sperm aneuploidy levels were analyzed by fluorescence in situ hybridization (FISH) in sperm cells obtained from the semen of six OAT patients. Microdeletion and sex chromosome aneuploidy (47,XXY) rates in somatic cells were found to be approximately 3.2% and 4.7%, respectively. Sperm aneuploidy rates were determined as 9%, 22%, and 47% in three patients out of six. Two of these three patients also had high rates of head anomalies in semen samples. High correlation was found between sperm aneuploidy rates and sperm head anomalies. Since the introduction of the assisted reproductive techniques for the treatment of severe male infertility, genetic tests and genetic counseling became very important due to the transmission of genetic abnormalities to the next generation. Thus in a very near future, for a comprehensive male infertility panel, it will be essential to include additional genetic tests, such as CFTR gene mutations, sperm mitochondrial DNA mutations, and androgen receptor gene mutations, besides the conventional chromosomal analyses, Y chromosome microdeletion detection, and sperm-FISH analyses.

The Birth of Mice from Testicular Spermatozoa Retrieved from Frozen Testicular Sections1

Male gamete cryopreservation has been widely used for both human reproduction and animal breeding. We investigated whether testicular spermatozoa retrieved from frozen testicular sections (10 or 25 mum thick) could support the full-term development of normal progeny. For this purpose, frozen testicular sections were prepared from two genetic backgrounds (BDF1 or B6 GFP transgenic mice), and the functional ability of testicular spermatozoa after preservation for 1 day, 1 mo, and 3 mo was assessed by intracytoplasmic sperm injection (ICSI). Testicular spermatozoa were successfully retrieved from frozen testicular sections for the use of ICSI, regardless of the preservation period. The ICSI technique revealed that oocytes (BDF1 or B6 background) injected with testicular spermatozoa prepared from frozen testicular sections developed into normal progeny, even though the sections had been cryopreserved for 3 mo at -30 degrees C. Approximately 15% and 5% of the embryos preserved for 3 mo developed to full term if the testicular spermatozoa were prepared from the 25- and 10-mum sections, respectively. These results clearly indicate that male gametes can be viably preserved in frozen testicular sections. The technique described herein will allow the preservation of male gametes in the form of a "book" or "file" by mounting the sections on a paper-thin sheet. Furthermore, this technique may be of value in the clinical treatment of severe male infertility, since testicular spermatozoa can easily be found through examination of testicular cross sections rather than by attempts to identify them in testicular cell suspension.

Treatment of severe male infertility by micromanipulation-assisted fertilization: an update

In the past 5-10 years the evolution of micromanipulation-assisted fertilization for the treatment of severe male infertility was marked by the introduction of new technical support, refinement of diagnostic methods for the evaluation of sperm developmental potential, and development of new treatment regimens for the newly discovered abnormalities. The new technical support involves the use of non-contact laser technology to assist micromanipulation for fertilization, the evolution of polarized microscopy-based optical systems to non-invasively detect the position of the meiotic spindle in living human oocytes, and the development of high-magnification optical systems for a better morphological selection of spermatozoa to be used for fertilization. Diagnostic approaches were enriched by commercial availability of kits for the analysis of sperm DNA integrity, leading to the definition of sperm nuclear DNA damage as a distinct cause of male infertility, and by the development of tests, based on heterologous ICSI, for detection of sperm failure to activate oocytes. Several treatment options for these conditions have been proposed and are currently being tested in larger-scale trials. Some technical improvement was also achieved in the field of in vitro maturation of germ cells from men with in vivo maturation arrest, but only a modest clinical improvement resulted from their application. As to the risk for the offspring, recent data are rather reassuring. Except for the risk of transmission of genetically based infertility, no straightforward evidence for a health risk derived from these techniques has been provided. Nevertheless, caution is necessary, particularly concerning the eventual increase in genomic-imprinting abnormalities.

Rescue of spermatogenesis arrest in azoospermic men after long-term gonadotropin treatment

Several studies have shown that FSH treatment can improve sperm production quantitatively and increase the spermatogonial population in oligozoospermic men with normal hormonal profiles. In this study, we describe the results of long-term gonadotropin therapy of normogonadotropic patients with nonobstructive azoospermia.

Computational models for prediction of IVF/ICSI outcomes with surgically retrieved spermatozoa

IVF/intracytoplasmic sperm injection (ICSI) using surgically retrieved spermatozoa (SRS) is a key option in the treatment of severe male infertility. It was aimed to develop a computational model for the prediction of this modality's outcome. A dataset of 113 exemplars, derived from patients who underwent IVF/ICSI with SRS, was retrospectively analysed. The dataset, containing input features maternal age, sperm retrieval technique, type of spermatozoa used, type of male factor and output intrauterine pregnancy, was randomized into a modelling (‘training’) set of 83 and cross-validation (‘test’) set of 30. neUROn++, a set of C++ programs, was used to model the dataset using linear and quadratic discriminant function analysis, logistic regression, and neural computation. A 4-hidden node neural network was found to have the highest accuracy, with a test set receiver operator characteristic (ROC) curve area of 0.783. Reverse regression of this neural network showed maternal age to be the most significant feature in predicting pregnancy ( P = 0.025), followed by sperm type ( P = 0.076). Type of male factor ( P = 0.47) and sperm retrieval technique ( P = 0.88) did not predict outcome. In summary, a neural network of clinical relevance was found to be superior in terms of IVF/ICSI outcome prediction. Future media deployment is planned.

New Reproductive Technologies and Infertility Treatment in Africa / Les Nouvelles Technologies Reproductives et le Traitement de la Stérilité en Afrique

New Reproductive Technologies and Infertility Treatment in Africa / Les Nouvelles Technologies Reproductives et le Traitement de la Stérilité en Afrique

223 Cases of Microinjection and Fallopian Transfer (MIFT) for Treatment of Severe Male Infertility in a Private IVF Center

Objectives: Although GIFT lost popularity because of its requirement of a fully equipped operation theatre and improvements in in-vitro embryo culture system, it consistently reported higher pregnancy rates than IVF as reported by the Society for Assisted Reproductive Technology (SART) Fertil Steril71(5):798–807;1999. The advent of ICSI added a new dimension in ART. We endeavor to show that tubal gamete transfer after ICSI is technically feasible and a successful treatment for even the most severe male factor cases.

Status of genomic imprinting in mouse spermatids.

The advent of human round spermatid microinjection (ROSI) into oocytes as a treatment for severe male infertility raises the question of whether spermatids have undergone all of the maturation processes necessary for normal development. It is particularly important to know whether spermatids have undergone correct genomic imprinting, which results in the parent-of-origin-specific expression of only one allele of a gene. We assessed the imprinting status of three maternally and three paternally expressed genes in interspecific hybrid embryos generated by injecting Mus castaneus spermatids into Mus musculus oocytes. We used the single nucleotide primer extension (SNuPE) assay to measure the relative expression of maternal and paternal alleles on the basis of sequence polymorphisms in the transcripts. Expression of imprinted genes in mouse embryos derived by ROSI did not differ from controls, indicating that paternal genes have undergone proper imprinting by the round spermatid stage.

Treatment of severe male infertility by micromanipulation-assisted fertilization: news and views.

Recent progress in cell micromanipulation has made it possible to achieve fertilization even with highly deficient male gametes, by injecting them directly to oocyte cytoplasm. This technique, known as intracytoplasmic sperm injection (ICSI), has proved efficient in most types of sperm pathology. However, ICSI fails when injected spermatozoa are not capable of supporting the process of oocyte activation or when they carry genetic abnormalities incompatible with normal embryonic development. Abnormalities of oocyte activation and the transmission of genetic anomalies to the progeny are also two major concerns relating to the clinical use of ICSI. The use of micromanipulation-assisted fertilization in cases of male germ cell maturation arrest, namely fertilization by round spermatid injection (ROSI), has brought preliminary clinical results, and the improvement of ROSI clinical efficacy remains a major challenge for future research.

Clinical Application of Microfertilization for the Treatment of Severe Male Infertility

Clinical Application of Microfertilization for the Treatment of Severe Male Infertility

Fertilization of oocytes by injecting spermatozoa, spermatids and spermatocytes.

The feasibility of fertilization by injecting spermatozoa into oocytes has increased significantly the possibilities for treatment of severe male infertility. However, the rapidity of human application has raised some concern about potential health hazards for the progeny. Human pregnancies and births have also occurred with the use of immature spermatozoa and spermatids, and normal offspring have been born after the injection of secondary spermatocytes into mouse oocytes. This short review deals with the problems that may arise from the injection technique and from the use of deficient or immature sperm cells for fertilization, with particular attention to human applications. Tests for screening parents and follow-up of children are suggested to control the main suspected risk factors.

Intracytoplasmic sperm injection facilitates fertilization even in the most severe forms of male infertility: pregnancy outcome correlates with maternal age and number of eggs available

To evaluate, in a prospective study, the fertilization and pregnancy rates after intracytoplasmic sperm injection (ICSI) in infertile couples with severe male infertility. Intracytoplasmic sperm injection was performed in 229 consecutive IVF cycles on 190 couples with rigorously defined severe male infertility or proven failure of fertilization in prior IVF cycles. Neither male nor female partners were chosen from a waiting list or on any other selective basis, including age, prior or anticipated ovarian response, or oocyte number or quality. There were no upper age limits, in no instance was donor sperm used for ICSI, and cycle cancellation rate was minimal. Private genetics and fertility center in Fairfax, Virginia. Fertilization, transfer, and pregnancy rates were measured in ICSI-treated couples, and comparisons were made regarding both female age and strictly defined semen categories. Two hundred six cycles (90%) resulted in ETs, with initiation of 52 pregnancies (25% per transfer, 23% per cycle). Thirty-eight of 52 (18% per transfer) were clinical pregnancies with established gestational sacs or were ongoing or delivered. Pregnancies were achieved even in older women but were more readily established in younger women producing larger numbers of metaphase II oocytes. The severity of semen abnormalities had some small effect on fertilization rate, but only actual necrospermia was associated with markedly decreased frequency of embryo formation. Pregnancy per transfer was similar across groups. In some cases, pregnancy was initiated with fewer than 100 viable sperm in the ejaculate. Intracytoplasmic sperm injection is a very powerful new treatment for severe male infertility. Paradoxically, egg number and probably egg quality are now the main determinants of success in treating male infertility.

Local experience with zona drilling, zona cutting and sperm microinjection

Clinical trials were performed between 1987 and 1992 on the use of zona drilling (ZD), zona cutting (ZC) and subzonal sperm microinjection (SZI) for the treatment of severe male infertility. ZD significantly improved the fertilization rate, but embryo morphology was poor and no pregnancies were achieved, so it was abandoned in favour of ZC. The fertilization rate was acceptable in the first trial of ZC but embryo morphology was still poor and no pregnancies were achieved, so a number of protocol changes were instigated. Shrinkage of oocytes in hypertonic sucrose prior to ZC markedly improved embryo quality, whereas transfer of embryos on Day 3 after oocyte retrieval enhanced the pregnancy rate. However, despite these improvements, the overall pregnancy rate in the third ZC trial was still low (16.6% per transfer), so a trial of SZI was initiated in 1992. The overall fertilization rate in 82 SZI cycles was 34.4% and, although the polyspermy rate was high, a clinical pregnancy rate of 30.8% per transfer and an implantation rate of 18.4% per embryo were achieved. These trials demonstrate that SZI is a successful treatment for severe male infertility; under the trial conditions, at least, it was superior to ZD or ZC.

Zona-free sperm penetration assay and inducers of the acrosome reaction: a model for sperm microinjection under the zona pellucida.

In order to minimize the percentage of false-negative results in the zona-free sperm penetration assay (SPA), a wide range of substances and/or physical agents capable of inducing the acrosome reaction (AR) have been incorporated in the incubation medium. These agents can also be used for treatment of severe male infertility using the technique of sperm microinjection under the zona pellucida (SMUZ). In the present review, the percentages of acrosome-reacted spermatozoa induced by several physiological, biochemical or physical agents published in the literature are compared in order to find the most efficient method(s) of inducing the AR in human sperm as a previous requirement of optimizing the technique of SMUZ. A working estimate of the level of efficiency of a given AR inducer is calculated by adding up its range score in each of three different arrangements from the highest to the lowest value of percentages of AR and differences in percentages of AR and penetration indexes between treated and control groups in SPA. The agents able to induce the AR by nonphysiological (electropermeabilization, lysophosphatidyl choline, and freezing-thawing) have better positions in this hierarchical system than those ones which require the active participation of sperm membrane receptors or second messenger systems (progesterone, zona pellucida, and stimulators of protein kinase A). Electropermeabilization appears to be the most efficient AR inducer. However, more possibilities need to be explored to enhance the relatively low percentages of acrosome-reacted spermatozoa shown by infertile men.