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The treatment of human infertility has changed enormously since the introduction of IVF and GIFT. GIFT can be offered as a reduced-cost technique compared with IVF, but the same methods of ovarian stimulation, oocyte retrieval and sperm preparation have to be used as for IVF. Recently even more simplified methods have been suggested.
The aim of this comparative clinical study was to examine whether the fertilizing potential of frozen-thawed testicular sperm in the most severe cases of hypospermatogenesis is reduced compared with fresh testicular sperm. The results could determine the necessity of using fresh testicular sperm cells, which mandates involving the spouse by performing simultaneous in vitro fertilization intracytoplasmic sperm injection (IVF-ICSI) treatment in this subgroup of nonobstructive azoospermia (NOA) patients. We studied 13 couples in which the husband was diagnosed as having NOA and few motile testicular sperm cells or only immotile testicular sperm cells were isolated by testicular sperm extraction (TESE). Each couple underwent both an ICSI cycle, in which fresh testicular sperm that were retrieved shortly beforehand were injected, and a consecutive cycle, which used frozen-thawed sperm that were retrieved in the original TESE procedure but were cryopreserved and stored until use. We found that motility was lost during the freezing and thawing process in some cases, which resulted in significantly more cycles with only immotile sperm cells for injection in the frozen-thawed sperm group (38.5%) than in the fresh sperm group (7.7%; P < .05). Availability of only immotile sperm cells significantly reduced fertilization rates in both fresh and frozen-thawed groups, but the respective overall fertilization rate (44.9% vs 41.1%) and quality of embryos and pregnancy rate (18.2% vs 15.4%) were not significantly different between groups. Implantation rates were more favorable in the fresh sperm group (10.5% vs 5.9%), but not significantly so. We conclude that, although cryopreservation does impair motility, which results in significantly more cycles with only immotile sperm cells for ICSI in the most severe forms of hypospermatogenesis, fertilization and pregnancy rates are not significantly compromised.
The advent of intracytoplasmic sperm injection (ICSI) has offered new solutions for the management of patients with azoospermia. Surgical sperm recovery combined with ICSI has allowed many men with azoospermia to father their own biological children. Azoospermia can be classified as obstructive and non-obstructive, with investigations, management and success rates varying markedly between the two forms. In certain cases of obstructive azoospermia surgical reconstruction remains a viable option, whereas cases with congenital obstruction need to be screened for mutations of the cystic fibrosis gene. In most cases of obstruction sperm can be retrieved from the epididymis using percutaneous epididymal sperm aspiration (PESA). If PESA is unsuccessful, testicular sperm extraction (TESE) is successful in all cases. With non-obstructive azoospermia, the genetic basis has been investigated intensely. Screening for karyotypic abnormalities as well as Y microdeletions is recommended. Irrespective of the histological diagnosis, focal spermatogenesis can be observed in 40-50% of cases using multiple testicular biopsies.
Among the most popular techniques of assisted reproduction for the treatment of male subfertility and infertility are intrauterine insemination, in vitro fertilization and intracytoplasmic sperm injection. The objective of these techniques is to bring more functional spermatozoa closer to the oocyte in order to promote fertilization. These techniques are thus not a cure per se and are only indicated when no specific or effective treatment is available for the male partner, when this treatment has failed or when the improvement of the female fertility status has also failed. While for moderate oligoasthenozoospermia, intrauterine insemination has proved to be a valid treatment, the outcome after conventional in vitro fertilization is limited because of a high incidence of complete fertilization failure. Since the introduction of intracytoplasmic sperm injection, a reliable method has become available in order to achieve fertilization in vitro. Apart from well from ejaculated spermatozoa, epididymal or testicular spermatozoa too can be used successfully for intracytoplasmic sperm injection. The surgical retrieval of spermatozoa for intracytoplasmic sperm injection has therefore become a routine technique in clinical andrology. Although these techniques have been implemented in everyday infertility practice within a few years of their introduction, many concerns about safety continue to exist. Intracytoplasmic sperm injection must be applied with caution, only when no other treatment option is available and when an appropriate prospective follow-up of the offspring is available.
In-vitro fertilization (IVF) by intracytoplasmic sperm injection (ICSI) with spermatozoa retrieved by percutaneous epididymal sperm aspiration (PESA) is a novel, simple and effective treatment for azoospermic men. In all, 38 azoospermic men had an IVF/PESA/ICSI cycle. A total of 42 cycles were performed. The aetiology of azoospermia was classified as failed vasectomy reversal (12 patients/16 cycles), inflammatory obstruction (five patients/five cycles), partial testicular failure (five patients/five cycles) and bilateral congenital absence of vas (16 patients/16 cycles). Adequate sperm preparations for ICSI were obtained from 38 of the 42 treatment cycles (90%). The mean fertilization rate was 32.7%, and fertilization occurred in 35 cycles (92.0%). Embryo transfer was performed in 13 out of 14 cycles (93%) in men with a failed vasectomy reversal, four out of five cycles in men with an inflammatory obstruction (80%), four out of four cycles in men with a partial testicular failure (100%), and 14 out of 15 cycles in men with a bilateral congenital absence of vas (93%). The overall pregnancy rate per two or three embryos transferred was 28.6 and 26.3% per treatment cycle respectively. The sperm parameters of the final pooled sperm aspirate preparations varied widely among the four aetiological groups. These parameters were of no value in predicting the fertilization or pregnancy rates (P > 0.05), and neither was the embryo cleavage rate.
OBJECTIVE: To evaluate 2 methods of processing testicular tissue for the retrieval of viable sperm from men with nonobstructive azoospermia. STUDY DESIGN: Fresh testicular tissue was obtained from nonobstructive azoospermia patients using a biopsy needle. The specimens were divided into 2 fractions. All specimens were minced and immersed in human tubal fluid (HTF). The first fraction was filtered through a nylon filter and incubated for 3 hours. The supernatant was centrifuged, resuspended in HTF and analyzed. The second fraction was immediately vortexed for 5 minutes and filtered through a nylon filter. The supernatant was centrifuged, resuspended in HTF and analyzed. RESULTS: Spermatozoa were obtained in 13 of 24 cases (54.2%) using the vortex method and in 5 of 24 cases (20.8%) with the nylon filter method. CONCLUSION: The vortex mixing method may be a better option than the conventional method for processing testicular tissue for sperm collection.
The measurement of serum FSH is useful in the diagnostic workup of the infertile male, but fails to predict the presence of sperm in testicular tissue. We investigated whether inhibin B reflects testicular morphology and the presence of sperm more accurately than FSH. Serum inhibin B and gonadotropin levels were determined in 91 infertile men undergoing diagnostic bilateral testicular biopsy. In 52 of the 91 patients multiple samples were taken for testicular sperm extraction (TESE). Inhibin B levels were (mean +/- SEM) 238+/-32 pg/mL in men with normal spermatogenesis (n = 9), 102+/-18 pg/mL in men with spermatogenetic arrest (n = 15), 98+/-16 pg/mL in hypospermatogenesis (n = 23), 41+/-6 pg/mL in focal Sertoli cell-only syndrome (SCO; n = 26), and 27+/-8 pg/mL in complete SCO (n = 18). The percentage of SCO tubuli was more strongly correlated to serum inhibin B (r = -0.58; P<0.01) than to FSH (r = 0.34; P<0.05). Similarly, the percentage of tubules with elongated spermatids was significantly (P<0.05) more strongly correlated to serum inhibin B (r = 0.65; P<0.01) than to FSH (r = -0.4; P<0.01). Thus, inhibin B is slightly more sensitive than FSH as an index of the spermatogenic status. Neither FSH nor inhibin B alone, however, could predict the type of spermatogenetic damage exactly. The combination of FSH and inhibin B had high diagnostic sensitivity (88%) and specificity (83%) for the presence of elongated spermatids in testicular biopsies. Sperm could be retrieved in 34 (65%) of the TESE patients. The combination of inhibin B and FSH measurement showed a sensitivity of 75% and a specificity of 73% when identifying patients in whom sperm could possibly be retrieved by TESE. We conclude that although the measurement of serum inhibin B improves the sensitivity of predictive tests for the presence of sperm in histology or for TESE, this parameter cannot accurately predict TESE outcome.
For men with uncorrectable obstructive azoospermia, their only hope of fathering a child is microsurgical epididymal sperm aspiration (MESA) combined with in vitro fertilization (IVF). In 1988, proximal epididymal sperm were demonstrated to have better motility than senescent sperm in the distal epididymis, and it was thought that retrieval of motile sperm from the proximal epididymis would yield reliable fertilization and pregnancy rates after conventional IVF. However, the results to date have been poor, and although a minority of patients achieved good fertilization rates with IVF, the vast majority (81%) had consistently poor or no fertilization and the pregnancy rate averaged only 9%. Recently, intracytoplasmic sperm injection (ICSI) has been successfully used to achieve fertilization and pregnancies for patients with extreme oligoasthenozoospermia. ICSI has therefore been applied to cases of obstructive azoospermia and, in this report, 67 MESA-IVF cases are compared with 72 MESA-ICSI cases. The principle that motile sperm from the proximal segments of the epididymis should be used for ICSI was followed, although in the most severe cases in which there was an absence of the epididymis (or absence of sperm in the epididymis), testicular sperm were obtained from macerated testicular biopsies. These sperm only exhibited a weak, twitching motion. In 72 consecutive MESA cases, ICSI resulted in fertilization and normal embryos for transfer in 90% of the cases, with an overall fertilization rate of 46%, a cleavage rate of 68%, and ongoing or delivered pregnancy rates of 46% per transfer and 42% per cycle. The pregnancy and take-home baby rates increased from 9% and 4.5% with IVF to 53% and 42% with ICSI. There were no differences between the results for fresh epididymal, frozen epididymal or testicular sperm, and the number of eggs collected did not affect the outcome. The results were also unaffected by the aetiology of the obstruction such as congenital absence of the vas deferens or failed vasoepididymostomy. The only significant factor which affected the pregnancy rate was female age. It is concluded that although complex mechanisms involving epididymal transport may be beneficial for conventional fertilization of human oocytes (in vivo or in vitro), none of these mechanisms are required for fertilization after ICSI. Given the excellent results with epididymal and testicular sperm, ICSI is obligatory for all future MESA patients. Finally, the use of ICSI with testicular sperm from men with non-obstructive azoospermia is also discussed.
The purpose of this study was to determine whether sulfogalactosylglycerolipid (SGG) was desulfated during mouse sperm capacitation. Levels of [35S]SGG were determined in freshly retrieved caudal epididymal sperm, motile capacitated sperm, and immotile sperm, after feeding mature male mice with [35S]sulfate-laced chow for 32 days. Caudal epididymal sperm and coisolated epididymal cells were separated into pellet and interphase fractions by centrifugation through a two-step Percoll gradient (45 and 90%). Upon resuspension in Krebs-Ringer bicarbonate medium supplemented with 0.4% bovine serum albumin, the Percoll-gradient pellet fraction consisted mainly of motile capacitated sperm, whereas the interphase fraction comprised largely immotile sperm and fragmented epididymal epithelial cells. The level of [35S]SGG in the Percoll-gradient-pelleted sperm appeared to be much higher than that in the Percoll-gradient interphase sperm. Percoll-gradient-pelleted sperm were further incubated in the culture medium for 2 h. The level of [35S]SGG showed little or no change after 1 h, but was reduced appreciably after 2 h. At this time point, sperm motility was also decreased. Reduction of sperm SGG is correlated with sperm immotility and (or) senescence and may have no direct relation to the capacitation process.
OBJECTIVE: To compare the efficacy of intracytoplasmic sperm injection (ICSI) and conventional IVF in patients with favorable and poor sperm parameters in which only a single oocyte was available for insemination. DESIGN: Retrospective analysis. SETTING: University-affiliated IVF center. PATIENT(S): A total of 311 patients (425 cycles) who underwent either stimulated or spontaneous IVF cycles that resulted in single oocyte retrieval. INTERVENTION(S): The ICSI was indicated when fertilization failure was anticipated because of sperm quality or other confounding female factors. MAIN OUTCOME MEASURE(S): Fertilization rates and pregnancy rates (PRs) were analyzed according to the woman's age (< or =39 or >39 years), sperm quality, and mode of insemination. RESULT(S): In patients <39 years old with favorable semen quality, ICSI and standard insemination produced similar fertilization rates (67.1% vs. 75.0%) and PRs (0.0 vs. 8.2%). Conversely, in cases with apparent lower semen quality, ICSI gave a significantly higher fertilization rate (85.4% vs. 44.2%) but no significant difference in PRs (14.6% vs. 4.7%). In patients >39 years old and with favorable semen quality, ICSI and standard insemination produced similar fertilization rates (82.4% vs. 68.4%) and PRs (0.0 vs. 1.1%). The ICSI for lower semen quality, however, produced both higher fertilization rates (84.0% vs. 52%) and higher PRs (8.0% vs. 0). CONCLUSION(S): Our results suggest that in poorly responding patients, semen quality should remain the most important determinant when considering whether to perform ICSI. We have found that the values of 20 x 10(6)/mL and 35% motility are good predictors of success in such patients.
Cystic fibrosis is a life-threatening disease. Only recently has the prognosis improved. In the male patient there is an almost invariable absence or maldevelopment of the vas deferens, creating a situation of obstructive azoospermia. Consequently, their fertility potential has been considered nonexistent. Having gained experience in microscopic epididymal sperm aspiration coupled with the advanced reproductive technologies for the treatment of congenital absence of the vasa, we sought to extend this treatment option to the male cystic fibrosis population. An Indian male with clinically evident and genetically confirmed cystic fibrosis underwent microscopic retrieval of epididymal sperm. The anatomy of the epididymis and the quality of sperm obtained were similar to those patients with congenital absence of the vas deferens. After appropriate spousal genetic testing, superovulation, and transvaginal oocyte retrieval, in vitro insemination of sperm was performed. Fifty percent of the oocytes were subjected to partial zona dissection and a single embryo resulted. Subsequent to transfer, no conception was realized but the effort expanded the clinical usefulness of microscopic epididymal sperm aspiration. This should open up an avenue of treatment for couples in whom only the most dire predictions for fertility have been made to date.
Sperm cells can be retrieved directly from the testis (testicular sperm extraction [TESE] procedure) and used for intracytoplasmic sperm injection (ICSI), circumventing underlying spermatogenetic defects. Thus, it is important that added information be available on the genetic defects in men undergoing TESE for the ICSI procedure and on the transmission of genetic factors associated with infertility to the offspring. We report a three-generation genetic analysis of a family with a case of male factor infertility. The proband, previously diagnosed as infertile, was physically examined and laboratory tested for gonadotrophic hormones, semen analysis, karyotype and Y-chromosome microdeletion screening in the blood and testis. The Y-chromosome microdeletion screening was performed by multiplex polymerase chain reaction with 20 Y-chromosome sequenced, tagged sites located at the Y chromosome. A microdeletion including the AZF-c region was detected in the azoospermic patient. His father, four brothers, and three offspring born after ICSI also underwent Y-chromosome microdeletion screening. The genetic analysis of the male members of the patient's family did not reveal similar microdeletions. The newborn male was found to bear a Y-chromosome microdeletion similar to that of his father. The fertilization capacity of the proband testicular microdeleted spermatozoa by the ICSI procedure is described. The transfer of the genetic defect raises the possibility that the son will have the same fertility problem as his father.
OBJECTIVE: To compare semen parameters and intracytoplasmic sperm injection (ICSI) outcome in spinal cord-injured subjects who underwent single (group 1) or multiple (group 2) electroejaculations before ICSI. DESIGN: Prospective, randomized, controlled study. SETTING: Department of gynecology, obstetrics, and pediatric science in a reproductive medicine unit at a major Italian university. PATIENT(S): Thirty-four healthy women with a male partner with SCI who were seeking assisted reproduction services. INTERVENTION(S): Transrectal electroejaculation, controlled ovarian hyperstimulation, and ICSI. MAIN OUTCOME MEASURE(S): Sperm concentration, morphology, and motility and fertilization and pregnancy rates after ICSI. RESULT(S): Sperm was successfully retrieved in 94.1% of cases. In male subjects who underwent multiple electroejaculations, statistically significant improvements in sperm concentration and total sperm motility rate were observed. The overall fertilization rate was 63.6%. The number of oocytes retrieved and injected was comparable between the two groups. A total of nine clinical pregnancies were achieved. The pregnancy rate was statistically significantly higher in group 2 (n = 6/16; 37.5%) than in group 1 (n = 3/16; 18.75%). CONCLUSION(S): These data suggest that multiple electroejaculation has a positive effect on semen parameters and ICSI outcome.
BACKGROUND: The aim of the present study is to investigate cryopreservation of oocytes in patients refusing embryo cryopreservation for ethical reasons, patients from whom no sperm could be retrieved and patients with enough oocytes to yield a number of fresh and cryopreserved embryos to transfer. METHODS: A total of 2900 oocytes out of 6216 retrieved were cryopreserved in 286 patients undergoing 303 cycles. The reasons for cryopreservation were because no sperm was found in 16 cycles, for ethical or personal reasons in 80, and in 207 only supernumerary oocytes were frozen. In 159 cycles, the oocytes were thawed and the surviving metaphase II oocytes microinjected. RESULTS: A total of 1087 oocytes were thawed, 760 (69.9%) survived and 687 were microinjected. We obtained 368 (53.5%) normally cleaved embryos, 331 were transferred and 37 were cryopreserved. One hundred and forty-five transfers (range 1-3 embryos/patient) were performed and 18 (12.4%) pregnancies were obtained. Twelve patients delivered 13 healthy children, and six first trimester abortions were observed (33.3%). CONCLUSION: Although a low implantation rate was observed and a higher abortion rate than in fresh cycles, our results show that in sibling oocytes, the process of cryopreservation apparently does not affect the fertilization and cleavage rate. In this group of patients, producing a large number of mature gametes, oocyte cryopreservation gives the couple extra chances to achieve a pregnancy within a single retrieval and is a good effort towards reducing the number of embryos cryopreserved and enhancing our experience in this new technology.
BACKGROUND: Pregnancy following frozen thawed embryo transfer in a patient with nonmosaic Klinefelter's syndrome is extremely rare. A healthy ongoing pregnancy achieved with frozen thawed embryo transfer in a patient with nonmosaic Klinefelter's syndrome was described. METHOD: A case report from a tertiary center for assisted reproductive technologies. A 34-year-old man with azoospermia and nonmosaic Klinefelter's syndrome and his 26-year-old wife presented with primary infertility of 8 years' duration. Frozen thawed embryo transfer following intracytoplasmic sperm injection using surgically retrieved spermatozoa was performed. RESULTS: A healthy ongoing pregnancy with a normal 46,XY karyotype was achieved with day 3 frozen thawed embryo transfer. CONCLUSION: Frozen thawed embryo transfer may be a viable option to achieve pregnancy in patients with Klinefelter's syndrome.
This study was conducted to assess the outcomes of TESA in women undergoing oocyte donation. Descriptive reports from a university IVF practice were reviewed to evaluate the outcomes of women (n = 10) who underwent 12 cycles of ovum donation and required testicular sperm aspiration due to obstructive azoospermia (n = 6) and nonobstructive azoospermia (n = 4). Percutaneous needle aspiration of the testes was performed prior to oocyte retrieval to recover sperm, and intracytoplasmic sperm injection was subsequently performed on the donated oocytes. Fertilization was documented 16-18 h later and transcervical embryo transfer performed 72 h postretrieval. Successful retrieval of testicular spermatozoa utilizing the percutaneous technique was achieved in all 12 cycles. All cycles resulted in an ET with the achievement of 7 (58%) pregnancies, of which 5 (42%) are ongoing or delivered. The individual embryo implantation rate was 18.4% (9/49). Two cycles (16.6%) produced supernumerary embryos for cryopreservation. TESA represents a simple procurement technique associated with minimal morbidity. It may be offered even in cases of nondestructive azoospermia.
PURPOSE: Testicular biopsy specimens contain large amounts of debris that makes sperm pick-up for ICSI more difficult than with epididymal aspirates. We sought to develop improved processing techniques for testicular sperm extraction (TESE). METHODS: Retrievals were with azoospermic male partner scheduled to undergo percutaneous epididymal sperm aspiration (PESA) and TESE. The study group consisted of 9 retrievals with a new TESE technique (TESE-N). The control group was 21 retrievals with PESA and 3 retrievals with a previous TESE technique (TESE-P). RESULTS: TESE-N eliminated almost all debris, which made ICSI sperm pick-up more rapid. TESE-N, PESA, and TESE-P fertilization (77, 75, and 72%) and ongoing/delivered pregnancy rates per retrieval (67, 76, and 67%) were similar. CONCLUSIONS: Our new technique provides for easy removal of debris from TESE specimens and fertilization and pregnancy rates equal to epididymal sperm's. Eliminating debris from TESE specimens allows for rapid sperm pick-up for ICSI, making the procedure more efficient for embryology staff.
PURPOSE: Our aim was to examine the potential of the uterine cavity to affect fertilization and early embryo development. DESIGN: A prospective IRB-approved protocol for patients fulfilling study eligibility criteria was used. METHODS: Patients studied included those with primary or secondary infertility, aged less than 38 years, with no history of severe male-factor infertility, and with hysterosalpingogram- and laparoscopic-confirmed bilateral proximal tubal occlusion. Superovulation induction was accomplished with a combination of GnRH agonist and menotropins, with serum hormonal and sonographic monitoring. Within 24 hr prior to, and again at the time of, ovulatory hCG administration, progesterone (P4) was given. Sonographic-guided transvaginal retrieval was performed 35 hr after hCG. Between four and six oocytes were returned to the uterine cavity, admixed with sperm, immediately following retrieval. Luteal support consisted of daily P4 administration. RESULTS: Of the 20 patients recruited for the study, all completed the retrieval and transfer procedure. A total of four clinical pregnancies was achieved, with one early first-trimester loss, one late first-trimester loss (Trisomy 14), and two healthy term infants delivered. IVF of surplus oocytes demonstrated a 82.5% fertilization rate and 66.7% cleavage following cryopreservation. CONCLUSIONS: Human fertilization can be achieved through direct uterine transfer of gametes. Furthermore, administration of P4 prior to the ovulatory dose of hCG is compatible with in vitro or in vivo fertilization and implantation.