Failure of pregnancy after intracytoplasmic sperm injection with decapitated spermatozoa: case report.

The case of a couple with a history of long standing primary infertility is reported in which the man presented with a decapitated sperm defect. The woman had a normal history and presented with normal clinical characteristics. The couple underwent one unsuccessful conventional in-vitro fertilization (IVF). Subsequently, embryos were obtained and transferred after assisted fertilization attempts: in all, three subzonal inseminations and four intracytoplasmic sperm injections. A total of 49 mature oocytes was injected in both studies, 25 embryos obtained and 20 embryos transferred, three of them after freezing and thawing. Despite the good embryo morphology, implantation was unsuccessful and no pregnancy occurred. The failure of implantation may have resulted from an arrest in early embryonic development related to the sperm anomaly. One hypothesis is that transferred embryos may carry a chromosomal imbalance that prevents them from progressing to the blastocyst stage. Nevertheless, we cannot exclude the possibility that the woman is responsible for the implantation failure. Co-culture associated with a further attempt could provide information regarding the ability of embryos to progress to the blastocyst stage and implant.     

High fertilization and pregnancy rate after intracytoplasmic sperm injection with spermatozoa obtained from testicle biopsy

In cases requiring microsurgical epididymal sperm aspiration(MESA) for congenital absence of the vas deferens (CAVD) orirreparable obstructive azoospermia, often no spermatozoa canbe retrieved from the epididymis, or there may even be no epididymispresent. We wished to see whether testicular biopsy with testicularsperm extraction (TESE) in such cases could yield spermatozoathat would result in successful fertilization and pregnancy(despite the absence of epididymal spermatozoa) using intracytoplasmicsperm injection (ICSI). In the same setting during the same2-week period, 28 patients with CAVD or irreparable obstructionwere treated; 16 consecutive fresh MESA—ICSI cycles and12 cycles which required testicular biopsy with testicular spermextraction (TESE—ICSI) were performed. Normal two-pronuclearfertilization rates were similar in both groups: 45% for epididymalspermatozoa and 46% for testicular biopsy-extracted spermatozoa.Cleavage rates were also similar (68% for epididymal and 65%for testicular spermatozoa). The ongoing pregnancy rates inthis series were 50 and 43% respectively. We conclude that epididymalspermatozoa and testicular spermatozoa yield similar fertilization,cleavage and ongoing pregnancy rates using ICSI. When epididymalspermatozoa cannot be retrieved, a testicular biopsy can beperformed and the few barely motile spermatozoa thus obtainedcan be used for ICSI. It appears that all cases of obstructiveazoospermia can now be successfully treated.     

Full-term delivery following intracytoplasmic sperm injection with frozen-thawed immotile testicular spermatozoa

We present one of the very few deliveries occurring following intracytoplasmic sperm injection of thawed immotile testicular spermatozoa from a testicular biopsy of a man with bilateral congenital absence of the vas deferens. A first attempt in the 33 year old woman with fresh testicular biopsy extracted spermatozoa was unsuccessful. The supernumerary spermatozoa were cryopreserved for later use. After thawing, testicular spermatozoa were immotile. From 11 intact oocytes injected with frozen-thawed immotile testicular spermatozoa, a two pronuclear fertilization rate of 27% and a cleavage rate of 100% were obtained. A total of three embryos was transferred resulting in a singleton pregnancy and the birth of a normal female baby.      

Ongoing pregnancies after intracytoplasmic injection using cryopreserved testicular spermatozoa

We report two clinical pregnancies occurring after intracytoplasmic sperm injection (ICSI) using cryopreserved spermatozoa obtained from testicular biopsy, made in two different infertility situations in our clinic. The first patient showed a secretory azoospermia associated with elevated serum follicular stimulating hormone (FSH) level and spermiogenesis maturation arrest. The second patient was affected by azoospermia resulting from bilateral epididymal obstruction. Spermatozoa present in the wet preparation of testicular biopsy made on the day of scrotal exploration were cryopreserved within the testicular tissue for both men. Intracytoplasmic injections were performed at a later date, using spermatozoa prepared from frozen-thawed tissues. In each case, three embryos were obtained and transferred in utero. The transfers resulted in a twin pregnancy for the first case, and in a singleton pregnancy for the second. Living foetuses were seen in the ultrasound scan at the 7th week and both pregnancies are proceeding to date beyond 30 weeks without complications.      

Pregnancies after intracytoplasmic sperm injection with cryopreserved testicular spermatozoa

In 25 patients (14 suffering from obstructive azoospermia, sixfrom non-obstructive azoospermia, three from astheno-azoospermiaand two from absence of ejaculation) spermatozoa were extractedfrom testicular biopsies. Intracytoplasmic sperm injection (ICSI)with fresh testicular spermatozoa was performed in 18 cases;spermatozoa in excess were cryopreserved in pills. No pregnancieswere achieved. In the remaining seven patients, testicular spermatozoawere retrieved and cryopreserved during a diagnostic testicularbiopsy. After thawing, sperm motility was assessed in 17 cases(68%), and 18 ICSI with cryopreserved testicular spermatozoawere performed. The mean two-pronuclear (2PN) fertilizationrate was 59%, the mean cleavage rate was 92%, and six clinicalpregnancies were achieved, all of them still ongoing (pregnancyrate 33%). A comparison of the results of ICSI carried out withfresh or cryopreserved testicular spermatozoa showed that themean 2PN fertilization rates per cycle (53 compared with 55%),mean cleavage rates per cycle (99 compared with 96%) and embryoquality were not significantly different In conclusion, cryopreservationof testicular spermatozoa is feasible, even in patients withnon-obstructive azoospermia, and the results of ICSI with frozen-thawedtesticular spermatozoa are similar to those obtained using freshtesticular spermatozoa. Cryopreservation of testicular spermatozoamay avoid repetition of testicular biopsies to retrieve spermatozoafor successive ICSI cycles in patients in whom the only sourceof motile spermatozoa is the testicle.     

Triplet pregnancy achieved through intracytoplasmic sperm injection with spermatozoa obtained by prostatic massage of a paraplegic patient: case report.

Spinal cord-injured men with ejaculation disorders can have children thanks to assisted reproduction techniques. Spermatozoa from these patients are usually obtained through vibratory stimulation, electroejaculation or by puncturing the seminal duct or the testicle. We present the first published case, as far as we are aware, of spermatozoa obtained through prostatic massage of a paraplegic patient. Penile vibratory stimulation was unsuccessful in this patient. In-vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) with spermatozoa obtained through electroejaculation was performed at another centre but pregnancy was not achieved. Through prostatic massage, we obtained a total semen volume of 6 ml containing a total count of 12.32x10(6) spermatozoa (6.24x10(6) with tails), 8% of which had motility (graded + and ++); and 16% of which had normal morphology. The spermatozoa obtained were then used to perform IVF with ICSI and a triplet pregnancy was achieved. Prostatic massage appears to be an easy, non-traumatic and risk-free method to obtain spermatozoa from paraplegic patients.     

Simultaneous bilateral tubal pregnancy after intracytoplasmic sperm injection

Since the advent of assisted reproductive technology, the concernabout ectopic implantation of embryos has increased dramatically.Simultaneous bilateral tubal pregnancy is the least common typeof ectopic implantation of two embryos. In this report we presentthe first case of simultaneous bilateral tubal pregnancy afterintracytoplasmic sperm injection (ICSI) and embryo transfertreatment. The present case had no risk factor for ectopic pregnancy.Therefore, for early diagnosis and management of such cases,close clinical follow-up and routine ultrasonography followingICSI are necessary.     

Andrology: Fertilizing ability of immotile spermatozoa after intracytoplasmic sperm injection

Sometimes spermatozoa from ejaculate, epididymis or testis showa total absence of motility. For some patients, however, veryfew spermatozoa with very poor motility can be found after severalhours of incubation (initially immotile spermatozoa). Othersamples show no motility at all even after extended culture(totally immotile spermatozoa). Intracytoplasmic sperm injection(ICSI) is the only method available to select and retrieve asingle immotile or initially immotile spermatozoon and injectit into the oocyte. A total of 103 patients with asthenozoospermiaunderwent ICSI in this study. It was shown that initially immotileand totally immotile spermatozoa, whatever their origin, havethe capacity to fertilize an oocyte after ICSI. No significantdifference could be observed between the fertilizing capacityof testicular or epididymal spermatozoa. Totally immotile ejaculatedspermatozoa, however, fertilized significantly fewer oocytesafter ICSI when compared with initially immotile ejaculatedspermatozoa. Embryos of lower quality tended to be producedwhen totally immotile spermatozoa of any origin were used, comparedwith embryos resulting from initially immotile spermatozoa.Ongoing pregnancies were conceived after ICSI with initiallyimmotile spermatozoa from any origin and totally immotile spermatozoaretrieved from testis only. One biochemical pregnancy was theresult of embryo transfer after ICSI with totally immotile ejaculatedspermatozoa. No supernumerary embryos could be cryo-preservedfor patients with totally immotile spermatozoa from ejaculateor epididymis. For a Kartagener patient, subzonal insemination(SUZI) seemed to be a better approach for obtaining fertilizationand pregnancy than ICSI because no fertilization occurred afterICSI on sibling oocytes. Hence a healthy pregnancy was obtainedafter SUZI.     

Comparison of pregnancy outcome after intracytoplasmic sperm injection and in-vitro fertilization

The aim of this study was to compare pregnancy characteristics and perinatal outcome of intracytoplasmic sperm injection (ICSI) pregnancies with pregnancies obtained after in-vitro fertilization (IVF). Retrospectively, 145 ICSI pregnancies were matched with 145 IVF pregnancies using the last menstruation data. The main outcome measures were preclinical and clinical abortions, ectopic pregnancies, multiple gestations, prenatal morbidity, prematurity, Caesarean section, birthweight, perinatal mortality and malformations for singletons, twins and triplets. Although patients were significantly younger (P < 0.001) in ICSI (31 years) than in IVF (33 years), their infertility duration (5 years) was similar. The mean number of transferred embryos (2.7 embryos per transfer) was similar in IVF and ICSI. The rates of preclinical (15%) and clinical abortions (11% in ICSI versus 15% in IVF) were not different. Four ectopic pregnancies were observed in the IVF group and none in the ICSI group. In ICSI, two minor malformations were detected and two therapeutic abortions were performed respectively for polymalformations and suspicion of cystic fibrosis. The rate of congenital malformation was 2.8% in ICSI and 2.2% in IVF. In this last group, one therapeutic abortion for malformation of neural tube was performed and two minor malformations were detected. The rate of aborted embryonic sacs before 16 weeks of gestation was not significantly lower in ICSI compared with IVF (13.7% versus 20%). The rate of multiple gestations was similar in both groups (31% in IVF and 35% in ICSI). The number of Caesarean sections was similar in IVF and in ICSI and was twice as frequent for twins versus singletons. The number of singletons born by Caesarean section was 21% after ICSI and 17% after IVF. Mean birthweights and gestational ages at birth for twins were significantly higher (P < 0.05) in ICSI than in IVF (2488 versus 2281 g and 36.5 versus 35.5 weeks). This difference was not observed for singletons. In conclusion, pregnancy characteristics and perinatal outcome after ICSI showed no increase in the number of pathologies in comparison with IVF.      

Pregnancy with spermatozoa from a globozoospermic man after intracytoplasmic sperm injection treatment

We present a case of third trimester pregnancy occurring ina 29 year old woman after intracytoplasmic sperm injection (ICSI)treatment with spermatozoa from a globozoospermic man. We believethis is the first reported case. A 37 year old man was diagnosedwith globozoospermia with normal sperm count and motility. In-vitrofertilization and subzonal insemination treatments failed toachieve fertilization of any eggs. The ICSI method produced50% fertilization, 75% cleavage rate and a singleton pregnancywith a female fetus. No pregnancy or fetal abnormalities havebeen noted after >7 months of gestation.     

Correlation between testicular histology and outcome after intracytoplasmic sperm injection using testicular spermatozoa

A comprehensive study is presented of a series of 124 infertilemen undergoing testicular sperm retrieval for intracytoplasmicsperm injection (ICSI). In this study we correlated the histologicalchanges observed in the testicular tissue with the results ofthe wet preparation and the outcome after ICSI using testicularspermatozoa. In all patients with normal spermatogenesis andhypospermatogenesis spermatozoa were recovered from the wetpreparation. The sperm recovery rate was 84% in patients withincomplete germ-cell aplasia and maturation arrest, while inpatients with complete germ-cell aplasia or maturation arrestthis figure was 76%. In these patients more specimens were sampledand fewer spermatozoa were recovered. Since no spermatozoa wererecovered in only 10 patients, ICSI with testicular sperm wasperformed in the remaining 114 couples (91.9%). The normal fertilizationrate was 57.8%. The fertilization rate was significantly lowerin couples among whom the husband showed germ-cell aplasia andmaturation arrest. Overall, 55.2% of normally fertilized oocytesdeveloped into embryos showing 50% of anucleate fragments. Therewere no major differences between the different histologicalcategories in terms of embryonic development in vitro. The overallpregnancy rates per testicular sperm extraction (TESE) procedure,per ICSI procedure and per transfer were respectively 36.3,39.5 and 43.7%. The overall implantation rate per embryo (sacs/embryosreplaced) was 20.3%. A lower implantation rate was observedin couples among whom the husband had maturation arrest (notstatistically significant). The above data show that testicularbiopsies may have an important therapeutic role in the managementof infertility in azoospermic patients.     

In-vitro culture of spermatozoa induces motility and increases implantation and pregnancy rates after testicular sperm extraction and intracytoplasmic sperm injection.

The aim of this study was to determine the effect of 24-h in-vitro culture of testicular spermatozoa in recombinant follicle stimulating hormone (recFSH) supplemented medium versus simple medium on sperm motility, and to analyse the outcome of intracytoplasmic sperm injection (ICSI) of such spermatozoa. A total of 143 positive testicular sperm extraction procedures in men with non-obstructive azoospermia was evaluated prospectively. Extracted testicular tissue samples were randomized to be cultured in vitro for 24 h in simple medium or recFSH supplemented media. ICSI was performed with spermatozoa cultured in recFSH (n = 73) or in simple medium (n = 70). Sperm motility following in-vitro culture, embryo quality after ICSI, and implantation and pregnancy rates were assessed. Of the 898 MII oocytes available in the recFSH group, 646 (71.9%) were injected with spermatozoa showing either twitching or progressive motility. However, only 29.1% of the oocytes in the simple medium group (245/841) were injected with motile spermatozoa (P < 0.05). Fertilization rate (68.8 versus 42.1%), implantation rate per embryo (20.1 versus 13.2%), and clinical pregnancy rate (47. 9 versus 30%) were significantly increased in the recFSH group compared with the simple medium group respectively (P < 0.05). In conclusion, in-vitro culture with recFSH appears to increase the motility of testicular spermatozoa, thus increasing the success of ICSI.     

Patients with absolutely immotile spermatozoa and intracytoplasmic sperm injection

The microinjection of completely immotile spermatozoa may impair the outcome of intracytoplasmic sperm injection (ICSI). Eleven couples underwent an initial ICSI cycle with 100% immotile freshly ejaculated spermatozoa. Two-pronuclear fertilization ensued in 18 of 145 (12.4%) successfully injected oocytes. None of these cycles resulted in a pregnancy. Nine couples underwent ICSI in subsequent cycles (n = 16). Ejaculated spermatozoa were injected in 15 cycles and testicular spermatozoa in one cycle. In 10 of the 15 cycles, motile spermatozoa were available at the time of injection. Motile testicular spermatozoa could also be injected. In the subsequent cycles, 91 of 176 (51.7%) successfully injected oocytes fertilized normally and four patients became pregnant. In the subsequent cycles where again immotile spermatozoa had to be injected no pregnancies occurred. In four subsequent cycles embryo cryopreservation was carried out. After replacement of two frozen-thawed embryos one additional pregnancy was obtained. In all, five healthy infants were born. It has been ascertained that motile spermatozoa can be detected either in repeated ejaculates or after testicular biopsy. The causes of total asthenozoospermia are variable and the problem is a sporadic rather than a permanent condition.      

Aggressive sperm immobilization prior to intracytoplasmic sperm injection with immature spermatozoa improves fertilization and pregnancy rates

This study was conducted to determine whether the mode of spermimmobilization prior to intracytoplasmic sperm injection (ICSI)influences fertilization by immature spermatozoa. Of the 837ICSI cycles evaluated, 81 were performed with epididymal ortesticular spermatozoa; 35 cycles with epididymal spermatozoaimmobilized in the standard fashion resulted in fertilizationand pregnancy rates of 48.3 and 51.4% respectively. When a moreaggressive sperm immobilization technique (i.e. permanentlycrimping the sperm fiagellum between the midpiece and the restof the tail) was applied in 17 cycles, the resultant fertilizationand pregnancy rates were significantly (P < 0.05) higher:82.0 and 82.4% respectively. Similar increases in fertilizationand ensuing pregnancy rates were also observed in ICSI cycleswith the aggressive immobilization of frozen-thawed epididymalspermatozoa (eight cycles) versus standard immobilization (16cycles). However, the fertilization rates for ICSI using testicularspermatozoa (five cycles) were basically the same, regardlessof the immobilization technique. Furthermore, for ejaculatedspermatozoa (756 cycles), the fertilization rates followingaggressive sperm immobilization were also positively affected(73.4%), although no statistical differences in the clinicalpregnancy rates were found. Because aggressive immobilizationappears to affect sperm membrane pennea-bilization, the enhancedfertilization patterns observed in immature spermatozoa followingaggressive immobilization may suggest a different membrane constitutionin these spermatozoa. These findings indicate that immaturegametes may require additional manipulation to enhance the post-ICSIevents essential for adequate nuclear decon-densation.     

Fertility of ejaculated and testicular megalohead spermatozoa with intracytoplasmic sperm injection

In this study the fertility and outcome of intracytoplasmic sperm injection (ICSI) using megalohead spermatozoa from the ejaculates and testicles was evaluated. Seventeen males with megalohead and pinhead sperm forms in their ejaculate were studied in 22 cycles. A high number of sperm heads without tails and abundant round spermatid forms were commonly observed. Round-headed spermatozoa were seldom accompanied by these severely abnormal spermatozoa. The majority of megalohead spermatozoa were observed to have multiple tails, were predominant in the sample, and were used for ICSI. Ejaculated megalohead spermatozoa were used for ICSI in 15 cycles, while testicular spermatozoa were used in seven cycles where there were no vital spermatozoa or spermatozoa of low vitality in the ejaculate. The same abnormal morphology was observed in the testicles as in the ejaculated spermatozoa in the same males. Mean (+/- SD) low motility 4.7 +/- 5.6% and sperm count (3.8 +/- 4.19 x 10(6)) were common findings in these severely teratozoospermic patients. A low fertilization rate (43.2%) was achieved by using megalohead sperm forms (group I, n = 17) in comparison with the control group (60.2%) which had zero normal sperm morphology according to strict criteria (group II, n = 30) (P <0.01). Furthermore, a low pregnancy rate (9.1%) was obtained in the megalohead sperm group in comparison with the control group (40%) (P <0.05). Low fertilization and pregnancy rates may be due to a high incidence of chromosomal abnormalities from severely defective spermatozoa in the ejaculate. Couples should be counselled and warned about possible low fertilization and pregnancy rates with ICSI when only pinhead and megalohead forms with a high number of sperm heads without tails are present in the ejaculate.     

Efficacy of intracytoplasmic sperm injection using intentionally cryopreserved epididymal spermatozoa

Microsurgical epididymal sperm aspiration was a great advancein the therapy of patients with non-recon-structable, obstructiveazoospermia, most notably congenital bilateral absence of thevas deferens. Using conventional in-vitro fertilization, pregnancieswere rarely achieved because the rate of oocyte fertilizationwas extremely poor. However, the use of retrieved spermatozoain conjunction with intracytoplasmic sperm injection (ICSI)has dramatically increased the likelihood of embryo formation.Typically, sperm and oocyte harvesting are performed simultaneously.We have investigated whether frozen-thawed spermatozoa workas well as fresh spermatozoa. When we had concluded from ourown population of patients (groups I and II) that they did,we adopted a policy of aspirating spermatozoa, primarily cryopreservingthem and using them for ICSI at a later date. We found the fertilizationrates of this latter cohort of patients (group III) to be excellent(37% per oocyte), and the ongoing pregnancy rate is quite satisfactory(40 % per couple, 29% per cycle). We offer this approach asan alternative to the traditional scheme because it markedlyeases the burden of partner scheduling on both the couple andthe clinicians involved. In addition, assurance of the availabilityof male partner spermatozoa can be attained prior to beginningovulation induction.     

Pregnancy and birth after intracytoplasmic sperm injection with spermatozoa from a patient with tail stump syndrome

Tail stump syndrome, which may be associated with primary ciliarydyskinesia, is also associated with morphological defects ofthe flagellum resulting in severe asthenozoospermia. Until recently,these morphological anomalies caused definite male infertility.Today, however, new methods such as micromanipulation techniquesprovide a rational therapy for this patient group. A pregnancyfollowed by living offspring was achieved following the intracytoplasmicinjection of immotile spermatozoa from a patient with tail stumpsyndrome.     

Dizygotic twin pregnancy after intracytoplasmic sperm injection of 1 day old unfertilized oocytes

We report on a case where late intracytoplasmic sperm injection (ICSI) on unfertilized oocytes after standard in-vitro fertilization (IVF) cycles resulted in a dizygotic twin pregnancy. Fifteen oocytes were harvested from a patient with a history of salpingotomy. After a single cycle of IVF, only one oocyte showed two pronuclei. Subsequently ICSI was performed on six unfertilized metaphase II oocytes, and three of these oocytes showed two pronuclei. Three fertilized embryos were transferred (two derived from ICSI and one from IVF). A normal twin pregnancy resulted, and after delivery of two healthy boys the twins were confirmed to be dizygotic by DNA analysis of several loci. We conclude that at least one of the embryos was derived from the reinsemination by 'second day ICSI'.      

Andrology: CASE REPORT Pregnancy after intracytoplasmic sperm injection of spermatozoa extracted from frozen-thawed testicular biopsy

The case report illustrates the successful application of anew method of sperm extraction from a frozen-thawed testicularbiopsy specimen within an established programme of intracytoplasmicsperm injection.