Prognostic value of male diagnostic profiles in intracytoplasmic sperm injection (ICSI)

This reported investigation was designed to determine the role of a new synthetic conduit-expanded polytetrafluoroethylene (ePTFE) tube--in clinical repair of median and ulnar nerves in the upper extremities. The main goals of this study were: to determine the effectiveness of the ePTFE conduit in clinical nerve reconstruction; to evaluate the potential of this technique in reconstruction of various nerve gaps (1.5 to 6 cm); and to analyze the results of repair with the ePTFE tube regarding different mechanisms of injury. Forty-three patients were evaluated. They had upper-extremity peripheral-nerve injuries (21 injuries to the median nerve, and 22 ulnar nerve injuries) located at the various levels of the upper extremities. All surgical procedures described in the study were secondary reconstructions, and the average delay from injury to repair was 4.2 months. With regard to the nerve-gap lengths, patients were categorized in two groups. Group 1 (gaps from 1.5 to 4 cm) included 28 patients (17 median nerve injuries and 11 ulnar nerve injuries), and Group 2 (gaps from 4.1 to 6 cm) comprised 15 patients (4 median nerve injuries and 11 ulnar nerve injuries). Results showed that 78.6 percent of patients from Group 1 demonstrated functional motor and sensory recovery, while reconstruction of only 13.3 percent of peripheral nerves from Group 2 resulted in useful reinnervation. According to published results, ePTFE conduit is a reliable and successful surgical procedure for nerve repair in reconstruction of nerve gaps up to 4 cm between the ends of median and ulnar nerves in various levels of the upper extremity. Because of its properties, ePTFE conduit has the advantages of promoting better nerve regeneration, compared to other synthetic tubes, especially in reconstruction of proximal nerve injuries, larger nerve gaps, and in cases with unfavorable mechanisms of nerve injury.     

The heparin-glutathione test: an alternative to the hypo-osmotic swelling test to select viable sperm for intracytoplasmic sperm injection

OBJECTIVE: To evaluate the heparin-glutathione test (HEGLUT) for the selection of viable sperm for intracytoplasmic sperm injection (ICSI). DESIGN: A prospective study. SETTING: Department of Pediatrics, Obstetrics and Gynecology, University of Valencia and Instituto Valenciano de Infertilidad. PATIENT(S): Semen samples from healthy donors and patients with infertility. INTERVENTION(S): Sperm samples were kept in culture for different periods in Ham's F-10 medium supplemented or not supplemented with heparin, reduced glutathione (GSH), or a heparin-GSH mixture. Control and heparin-GSH-treated spermatozoa were injected into hamster oocytes. The HEGLUT and ICSI were performed. MAIN OUTCOME MEASURE(S): Sperm nuclear decondensation, progressive and nonprogressive motility, and male pronucleus formation. RESULT(S): The maximum proportion of sperm nuclear decondensation (28.7%+/-2.1% versus 2.6%+/-0.5% in the control group) was reached after 60 minutes of incubation in the presence of a heparin-GSH mixture. Differences in the percentages of progressive and nonprogressive motility among treatments and times of incubation, although statistically significant, were biologically negligible. No statistically significant differences were observed in the rate of sperm head decondensation (8.2% [4/49] versus 11.1% [6/54]) and male pronucleus formation (18.4% [9/49] versus 22.2% [12/541) after the injection of control and treated spermatozoa into hamster oocytes. CONCLUSION(S): The HEGLUT may offer an alternative to the hypo-osmotic swelling test for the selection of viable sperm for ICSI.     

The outcome of intracytoplasmic sperm injection is unrelated to 'strict criteria' sperm morphology

Sperm morphology was assessed according to the 'strict criteria' established for in-vitro fertilization treatment in the semen samples used for 354 consecutive treatment cycles for intracytoplasmic sperm injection (ICSI). The semen samples were classified according to the three predictive categories of the Tygerberg strict criteria: excellent prognosis (>14% morphologically normal spermatozoa), good prognosis (4-14%) and poor prognosis (<4%). It was found that 37 (10.5%) of the ICSI cycles belonged to the excellent prognosis category, 197 (55.6%) to the good prognosis category, and 120 (33.9%) to the poor prognosis category. The outcomes of the ICSI treatments were evaluated and compared with the sperm morphology classification in order to determine whether the strict criteria could aid in predicting the outcome of ICSI. The fertilization rates in the three categories were 61.6, 66.8, and 61.9%, the pregnancy rates per oocyte retrieval 18.9, 24.9, and 28.3%, and the implantation rates 9.9, 13.0, and 14.9% respectively. No significant differences were found in fertilization, pregnancy, or implantation rates between the three prognosis categories, i.e. the poor prognosis category had an equal chance of obtaining pregnancy compared with the good prognosis category. The results indicate that strict sperm morphology is not related to the outcome of ICSI.     

Relevance of genetic counselling in couples prior to intracytoplasmic sperm injection

Since the first reports of successful pregnancies after treatment with intracytoplasmic sperm injection (ICSI) in humans numerous attempts have been made to assess the genetic risks of this highly invasive technique. During the study period (February 1995-November 96), 142 couples were referred to our genetic counselling unit prior to ICSI. In three couples, genetic counselling revealed a high recurrence risk for a monogenic disease (myotonic dystrophy, hereditary ataxia and polycystic kidney disease). In nine out of 128 men (7%) an abnormal karyotype was identified, including three Robertsonian translocations, two reciprocal translocations, three sex chromosome aberrations and one case with centric fission of chromosome no. 7. A total of 14 men refused chromosomal analysis. Only one of the 122 women examined had an abnormal karyotype (47, XXX). Five out of six men with congenital bilateral absence of the vas deferens (CBAVD) had at least one mutation in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. Three had mutations in both CFTR alleles, including one case in which the second mutation was the 5T allele. One patient with CBAVD and a single Delta F508 CFTR mutation also had left renal agenesis. In conclusion, we strongly recommend that genetic counselling, chromosomal analysis and, in the case of CBAVD, screening for CFTR mutations should be offered to all couples with a diagnosis of male or idiopathic infertility.     

The result of intracytoplasmic sperm injection is not related to any of the three basic sperm parameters

High success rates have been reported for the use of intracytoplasmic sperm injection (ICSI) in alleviating essentially andrological infertility. However, neither the relationship between any of the sperm parameters and the result of ICSI nor the minimal sperm requirements for ICSI have been investigated so far. In this paper, our objective was therefore to study the relationship between three basic sperm parameters (total sperm count, sperm motility and morphology) and the outcome of ICSI by retrospective analyses of fertilization, embryo development and pregnancy rates in 966 micro-injection cycles, performed with ejaculated semen. The results showed that there was no important influence from either the type or the extent of sperm impairment on the outcome of ICSI. Even in the most extreme cases of male-factor infertility, where cryptozoospermia or total astheno- or total teratozoospermia was diagnosed in the initial semen sample, high fertilization and pregnancy rates were obtained by ICSI. Only one condition had a strongly negative influence on the result of ICSI: where an immotile (presumably dead) spermatozoon was injected into the oocyte. Thus the only ultimate criterion for successful ICSI is the presence of at least one living spermatozoon per oocyte in the pellet of the treated semen sample used for micro-injection.     

The relationship between sperm morphology and rates of fertilization, pregnancy and spontaneous abortion in an in-vitro fertilization/intracytoplasmic sperm injection programme

The morphological normality of a spermatozoon is considered to be an important factor in relation to its ability to fertilize an oocyte. We examined the influence of morphology (strict criteria) on the rates of fertilization, pregnancy and spontaneous abortion obtained following conventional in-vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) in our clinical programme. We found our fertilization cut-off values for conventional IVF to be slightly different from those of the Kruger group (10 and 5%, compared to 14 and 5%). We also found the pregnancy rate per transfer to be as good or better in the groups with < 5% normal forms: 36% of these men had a fertilization rate > 50% using conventional IVF, showing that fertilization capacity is not necessarily impaired even in this 'poor prognosis' group. With the exception of the ICSI group with 5-9% normal forms, the rate of spontaneous abortion in this study was similar to or lower than in our IVF/ICSI programme overall. When the 5-9% normal spermatozoa group was divided into those with teratozoospermia as the only factor and those with additional sperm factors, the increased abortion rate was found in the group with multiple sperm factors (67% spontaneous abortions).     

Prevalence of Y chromosome microdeletions in oligospermic and azoospermic candidates for intracytoplasmic sperm injection

OBJECTIVE: To determine the prevalence and type of Y chromosome microdeletions in 136 consecutively seen intracytoplasmic sperm injection (ICSI) candidates and in 50 consecutively seen azoospermic men attending an infertility clinic. DESIGN: Controlled clinical study. SETTING: Genetics laboratory and infertility clinic at a University hospital. PATIENT(S): One hundred eighty-six men who were seen at an infertility clinic and who were referred to a genetics counseling service for genetic assessment before ICSI. INTERVENTION(S): Collection of semen and blood samples. MAIN OUTCOME MEASURE(S): Semen analysis; serum FSH, LH, and T levels; karyotype analysis; and presence or absence of several single tagged site markers along the Y chromosome (sY274, sY238, sY276, sY84, sY102, sY143, sY153, sY254, sY269, sY202, sY158, sY160). RESULT(S): Yq chromosome microdeletions were detected in 10 (5.4%) of 186 consecutively seen ICSI candidates. The number of microdeletions was much higher in azoospermic patients (16%; 8 of 50) than in oligospermic patients (1.5%; 2 of 136). Two of the azoospermic patients with a Yq microdeletion also had sex chromosome aneuploidy mosaicism. No microdeletions were detected in 100 consecutively seen fathers who were included as controls. CONCLUSION(S): The prevalence of Yq microdeletions in the azoospermic group was much higher than in the oligospermic group and was consistent with the prevalence of Yq microdeletions detected in other series of azoospermic men in different geographic areas. All Yq microdeletions found in our patients belong to the AZFc region, indicating that microdeletions of the AZFa and AZFb regions are infrequent among oligospermic ICSI candidates or azoospermic males in our population.     

Clinical assessment of male infertility in the era of intracytoplasmic sperm injection

This communication outlines the major causes of infertility in the male and, where indicated, the application of in vitro fertilization and intracytoplasmic sperm injection in their treatment. It also points out that there are many types of infertility in the male where other methods of treatment are also successful and where reproductive technology is unnecessary.     

The usefulness of MESA-ICSI (microsurgical epididymal sperm aspiration and intracytoplasmic sperm injection) in cases of obstructive azoospermia]

Till the end of March 1998 first seven trials of MESA-ICSI (microsurgical epididymal sperm aspiration and intracytoplasmic sperm injection) in the Ist Chair and Clinics of Obstetrics and Gynecology of the Silesian Medical Academy in Bytom were performed in cooperation with an urologist from the IInd Chair and Clinics of Urology in Zabrze in couples suffering from sterility caused by obstructive azoospermia. In all the cases both contraindications and conditions of MESA-ICSI were respected. Fertilization rate of the MII oocytes was on average 62% and cleavage rate of the fertilized oocytes 76.9%. After embryo transfer at least two pregnancies occurred, from them one is ongoing well. The result of the last procedure is not known yet. The data obtained permit to conclude, that MESA-ICSI makes a real chance to possess their own children by couples with sterility caused by obstructive azoospermia.     

The effects of a copper-intrauterine device on the uterine artery blood flow in regularly menstruating women

The aim of the study was to evaluate the effect of a copper-intrauterine device (IUD) on uterine artery blood flow during the midluteal phase and on the first day of the menstrual cycle using pulsed colour Doppler ultrasonography. Twenty-one regularly menstruating women (18-45 years) who were willing to use copper-IUD contraception participated in the study. The patients were first examined without the IUD in the midluteal phase 6-9 days before the expected onset of menstruation and on the first day of menstruation, after which the IUD was inserted. Three months later the patients were examined again on the corresponding cycle days. The patients estimated the level of dysmenorrhoeic pain with a scoring system. Transvaginal ultrasonography with colour flow imaging was used to measure the pulsatility index (PI) in the uterine arteries. There were no significant changes in the uterine artery blood flow after the insertion of the IUD during menstruation or in the midluteal phase. In patients with increased IUD-related pain during menstruation (n = 5), however, there was a decrease in PI (2.87 +/- 0.52 versus 2.41 +/- 0.23, P = 0.05) after IUD insertion. The decrease in the mean PI was present in all five patients. In conclusion, copper-IUD does not induce any major changes in the resistance of the uterine artery blood flow, although during menstruation in patients with increased menstrual pain after IUD insertion there seems to be a decrease in the uterine artery PI.     

Screening male intracytoplasmic sperm injection candidates for mutations of the follicle stimulating hormone receptor gene

Follicle stimulating hormone (FSH) is considered to be essential for spermatogenesis. Therefore, genetic abnormalities of FSH signalling on testicular Sertoli cells would be expected to affect sperm production negatively in males. Inactivating FSH receptor mutations have been reported earlier in both males and females. All affected males had elevated FSH serum concentrations and abnormal sperm parameters. We postulated that inactivating FSH receptor mutations might be a cause of oligozoospermia or azoospermia and reviewed the clinical data of 151 male intracytoplasmic sperm injection (ICSI) candidates with special attention to FSH serum concentrations. The exclusion criteria for mutation screening of the FSH receptor gene were: a history of operative sterilization or testicular malignancy, congenital abnormality other than cryptorchidism, and a chromosomal aberration or a Y-chromosome microdeletion. The inclusion criteria were: male (ICSI candidate) with azoospermia or oligoasthenoteratozoospermia (OAT) and elevated FSH serum concentrations. In total, 23 males with OAT and five males with azoospermia were tested for mutations of the coding sequences and the intron-exon boundaries of the FSH receptor gene by polymerase chain reaction (PCR) followed by single strand conformation polymorphism analysis (SSCP). Neutral polymorphisms were readily detected using this technique in both probands and controls. None of the 28 selected patients showed a pathogenic FSH receptor mutation. Mutations in the FSH receptor gene are not a common cause of infertility in ICSI candidates.     

Implications of complete fertilization failure after intracytoplasmic sperm injection for subsequent fertilization and reproductive outcome

With the introduction of intracytoplasmic sperm injection (ICSI), couples with severe male factor infertility have achieved fertilization and clinical pregnancy rates comparable to other in-vitro fertilization (IVF) patients. However, failure of fertilization still occurs in some patients despite the utilization of microsurgical sperm injection techniques. How such fertilization failure after ICSI might impact later ICSI treatment(s) is unknown. In this investigation, couples with complete fertilization failure after ICSI treated from August 1993 to August 1996 were identified (index cycle, n = 21). Additionally, fertilization data from any previous or subsequent infertility treatments were evaluated. Seven patients (33%) had at least one IVF treatment before the index cycle, although no deliveries occurred. Of patients with complete fertilization failure in the index cycle, 48% (n = 10) underwent at least one subsequent ICSI cycle which proceeded to oocyte retrieval. The remainder (n = 11) elected to discontinue treatment. Although six subsequent cycles were cancelled due to poor follicular response (< or = 2 mature oocytes), all patients electing to continue treatment eventually achieved a subsequent embryo transfer. The clinical pregnancy rate per transfer was 45.4% for this group; the delivery and ongoing pregnancy rate per transfer was 36.3%. Review of semen parameters, superovulation characteristics or other clinical parameters during the three study cycles (pre-index, index, and post-index) was not prognostic of fertilization success or reproductive outcomes in later treatments. Fertilization failure with ICSI therefore could not be predicted by prior cycle performance, although total immotility of spermatozoa at time of oocyte retrieval, total teratozoospermia, and low oocyte yield were common characteristics of couples experiencing complete fertilization failure with ICSI. These findings suggest that fertilization failure in one ICSI cycle does not preclude successful fertilization and delivery in a later ICSI treatment.     

Strong preference for non-invasive prenatal diagnosis in women pregnant through intracytoplasmic sperm injection (ICSI)

Intracytoplasmic sperm injection (ICSI) is a new and most powerful technique to treat severe forms of human infertility. While the follow-up studies have not shown an increased malformation risk so far, the genetic implications of ICSI are still not fully understood. For this reason, many institutions routinely recommend or even enforce invasive prenatal tests after successful intracytoplasmic sperm injection. We have counselled 107 women pregnant through ICSI about prenatal diagnosis. Sixty-five had already received genetic counselling prior to the treatment (group 1), while 42 had not attended our clinic before (group 2). They were free to choose between invasive and non-invasive diagnosis or no prenatal tests at all. Fifty-four per cent of these patients had an indication for prenatal karyotyping or other invasive procedures independent of ICSI. Only 17 per cent of the total cohort made use of amniocentesis or fetal blood sampling, 82 per cent opted for non-invasive tests (ultrasound, serum screening), and one couple did not wish any prenatal studies. The preference for non-invasive procedures was stronger in group 1 (94 per cent) than in group 2 (65 per cent). We suggest that if patients pregnant through ICSI have the option to choose freely between invasive and non-invasive prenatal tests, they strongly favour the latter.     

Transport in vitro fertilization and intracytoplasmic sperm injection: results of a collaborative trial

An arteriovenous vasodilator, flosequinan, has been shown to be effective for the treatment of acute heart failure. However, little is known as to its effect on aortic impedance, which is known to be a proper and precise expression of left ventricular (LV) afterload. To evaluate the acute cardiovascular effect of flosequinan in failing heart, we administered flosequinan intravenously to seven dogs with cardiac failure produced by an infusion of carbon powder (20-50 microm in diameter) into left main trunks of coronary artery. The LV-pump function was severely impaired after intracoronary injection of carbon powder, as evidenced by the findings that cardiac output, circumferential shortening velocity (mean Vcf), and peak +dP/dt of LV pressure were all decreased, associated with a significant increase in LV end-diastolic pressure. Flosequinan (0.9 mg/kg, i.v.) increased cardiac output by 28%, mean Vcf by 44%, and peak +dP/dt by 24%, whereas it decreased total systemic resistance by 32%, time constant of LV pressure decay by 22%, and LV end-diastolic pressure by 18%. Moreover, flosequinan substantially decreased the pulsatile components of LV afterload (i.e., characteristic impedance by 11% and arterial wave reflection coefficient by 45%). Thus flosequinan exerted not only positive inotropic but also positive lusitropic effects, in association with a significant reduction of both pulsatile and steady components of LV afterload, contributing to an improvement of LV-pump function in acute cardiac failure.     

Preferences for intracytoplasmic sperm injection versus donor insemination in severe male factor infertility: a preliminary report

With the advent of intracytoplasmic sperm injection (ICSI), our programme noted a drop in the number of couples using donor insemination (DI) for severe male factor infertility. Over the first 8 months in which our infertility programme offered both treatments, 27 consecutive couples scheduled for ICSI and 15 consecutive couples scheduled for DI were evaluated Since all patients in our infertility programme beginning in-vitro fertilization (IVF) with planned ICSI or starting DI undergo a semi-structured psychological interview, the psychologist's clinical notes as well as the medical chart were reviewed and coded retrospectively to determine factors related to a couple's treatment choice. Couples who chose IVF-ICSI over DI had a higher occupational status and included husbands with higher educational levels. Their most common motivation was to have the husband's biological child (93% of couples in the ICSI group). The most common motivation for choosing DI (60% of DI couples) was that IVF was not financially affordable. Choice of treatment was not related to psychological adjustment, the husband having prior biological children, or his risk of passing on a genetic defect to offspring. These preliminary data raise the concern that, with the success of ICSI, DI may change in the USA from being an option dictated by semen quality to a second choice treatment utilized for economic reasons.     

Success of intracytoplasmic sperm injection in couples with male and/or female chromosome aberrations

This paper reports on results of intracytoplasmic sperm injection (ICSI) in patients in whom constitutional or secondary chromosome aberrations were detected in the male and/or female partner. Out of 434 couples treated by ICSI (590 cycles), 16 couples (3.7%) were affected by constitutional chromosome aberrations and 96 (22.1%) by secondary chromosome aberrations. Constitutional chromosome aberrations were found in eight male and eight female patients. Couples with the aberration in the male showed significantly lower fertilization, implantation and pregnancy rates (P < 0.05). The occurrence of female constitutional chromosome aberrations led to lower fertilization rates but implantation and pregnancy rates were similar to a control group; however, a higher abortion rate was noted. In the group with secondary chromosome aberrations, 22 males and 59 females carried an abnormality and in 15 couples, both partners. Compared to the remaining (unaffected) 322 couples, fertilization and embryo transfer rates were reduced but implantation rates and pregnancy rates were not different. In all couples where an abortion occurred, mainly parental autosomal aberrations were involved (six out of eight). Our retrospective analysis shows that an unexpectedly high number of infertile couples in an ICSI programme are affected by chromosome aberrations, which in turn may explain the reduced fertilization rates observed in this subgroup of patients.     

Perivitelline space granularity: a sign of human menopausal gonadotrophin overdose in intracytoplasmic sperm injection

The significance of the presence of coarse dark granules in the perivitelline space of oocytes has not been studied before. The study included 2288 intact oocytes [2063 in metaphase II (MII), 136 in metaphase I (MI), and 89 in germinal vesicle (GV)] retrieved in 206 intracytoplasmic sperm injection cycles stimulated by a long agonist protocol. The incidence of granules varied with oocyte maturity. It was detected in 34.3% and 4% of the MII and MI oocytes respectively, while none of the GV oocytes contained granules. The woman's age, hormonal values (oestradiol and progesterone), human chorionic gonadotrophin/oocyte retrieval interval, number of oocytes retrieved, and oocyte retrieval/injection interval were not related to the percentage of granular oocytes. Moreover, there was no correlation between the percentage of granular oocytes and the fertilization and cleavage rates, pregnancy outcome, as well as the implantation rate. Patients were divided into three groups according to the total human menopausal gonadotrophin (HMG) dose they received. There was a statistically significant difference between the three groups in the percentage of granular oocytes [17.4 +/- 5.2% versus 26.7 +/- 3.2% versus 45.4 +/- 4.2% in the low-dose (< 30 ampoules), intermediate dose (31-45 ampoules), and high-dose (> 45 ampoules) groups respectively]. We conclude that granularity in the perivitelline space is probably a physiological phenomenon related to the maturational events in oocytes and enhanced by exposure to high dosages of HMG.     

Fertilization and pregnancy using intentionally cryopreserved testicular tissue as the sperm source for intracytoplasmic sperm injection in 10 men with non-obstructive azoospermia

Testicular tissue extraction (TESE) to obtain spermatozoa for use with intracytoplasmic sperm injection (ICSI) has recently been employed in patients with non-obstructive azoospermia. Standard protocol is to retrieve a new sample of testis tissue on the day of oocyte recovery. Unfortunately, approximately 30% of men will possess no spermatozoa in their tissue, making ICSI an impossibility. We investigated whether testicular tissue that was intentionally obtained well before any planned ICSI cycle and cryopreserved could then serve as an efficacious sperm source in a subsequent ICSI cycle. This study reports on 10 men with non-obstructive azoospermia who did have spermatozoa found within their testis tissue at the time of TESE and who chose to use their frozen samples as the source of spermatozoa for a later cycle of ICSI. In 19 cycles the overall fertilization rate was 48%. Embryo transfer occurred in 89% of cycles. Two couples have achieved pregnancy (one ongoing, one delivered). All patients except one had multiple vials of frozen tissue remaining following their first cycle. This approach is offered as an alternative to repeated testicular tissue sampling, as the availability of spermatozoa is assured prior to the initiation of ovulation induction. This tissue can be harvested at the same time as diagnostic biopsy, thereby minimizing the number of surgical procedures.