A review of ten years experience of ICSI

This review summarizes the introduction of ICSI in the early 1990s as an assisted fertilization procedure in couples with severe male factor infertility, who could not be helped by conventional IVF. As for current practice, the indications for ICSI using fresh or frozen-thawed ejaculated, epididymal or testicular sperm are reviewed as well as some reports on the use of ICSI in non-male infertility. The main steps in an ICSI cycle are well standardized by now; it is rare that ICSI cannot be carried out and the results in terms of fertilization, embryo transfer and clinical pregnancy rate have been consistent for many years, indicating that a substantial number of couples can now have their own genetic child instead of having to use artificial insemination with donor sperm. This review also emphasizes the importance of assessing the risk of ICSI for the children: there is a slight increase in de novo chromosomal abnormalities, the major congenital malformation rate is similar for IVF and ICSI (between 3 and 4%), and at approximately 2 years of age the developmental outcome as assessed by the Bayley scale is similar for IVF and ICSI. Recent publications mention that a few children are affected by diseases caused by imprinting disorders. Future studies are needed to assess the association between assisted reproductive technologies and imprinting disorders. ICSI is frequently used in couples undergoing preimplantation genetic diagnosis. PGD stricto sensu as well as PGD for aneuploidy screening and for Klinefelter patients are reviewed using the ESHRE PGD Consortium data.     

Subfertile men with constitutive chromosome abnormalities do not necessarily refrain from intracytoplasmic sperm injection treatment: a follow-up study on 75 Dutch patients

A follow-up study was performed to investigate the impact of the detection of a chromosome abnormality in infertile men who are candidates for intracytoplasmic sperm injection (ICSI) treatment. In this collaborative study between clinical genetics centres and fertility clinics in the Netherlands, 75 ICSI couples of which the male partners had a chromosome abnormality were included. All couples were extensively counselled on the risk of having a chromosomally unbalanced child. Forty-two out of 75 couples chose to proceed with the ICSI treatment. So far, treatment has resulted in a pregnancy in 11 cases. Four of them opted to have invasive prenatal diagnosis. Despite the genetic risks related to a chromosome abnormality in infertile men, a small majority (56%) of the couples did not refrain from the ICSI treatment.     

Intracytoplasmic sperm injection (ICSI) in 2006: evidence and evolution

The introduction of intracytoplasmic sperm injection (ICSI)in 1992 has dramatically changed the management of severe maleinfertility. In severe male infertility, live birth rates withICSI are superior to those with other non-donor treatments.In non-male infertility, however, pregnancy rates are not betterwith ICSI than with in vitro fertilization (IVF). With obstructiveor non-obstructive azoospermia, reasonable pregnancy rates arenow possible with ICSI after recovery of sperm from the testesfollowed by ICSI. Genetic counselling is indicated for severemale infertility, whether or not ICSI is considered. ICSI isindicated in preimplantation genetic diagnosis (PGD) to avoidcontamination by extraneous DNA in the case of PCR-based testingand to increase the number of embryos available for testing.In turn, PGD may be indicated in pregnancies that are at highrisk of aneuploidy because of genetic factors associated withazoospermia. As with IVF, not all couples succeed, but 2% ofcouples with failed ICSI cycles will conceive without treatment.ICSI outcome studies indicate that there is a significant increasein prematurity, low birthweight, and perinatal mortality associatedwith single and multiple births, similar to the outcomes ofconventional IVF. However, as evidenced in long-term follow-upstudies, the higher rates of urogenital abnormalities and increaseduse of healthcare may be associated with paternal characteristics.     

Genetic risk factors in infertile men with severe oligozoospermia and azoospermia.

BACKGROUND: Male infertility due to severe oligozoospermia and azoospermia has been associated with a number of genetic risk factors. METHODS: In this study 150 men from couples requesting ICSI were investigated for genetic abnormalities, such as constitutive chromosome abnormalities, microdeletions of the Y chromosome (AZF region) and mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. RESULTS: Genetic analysis identified 16/150 (10.6%) abnormal karyotypes, 8/150 (5.3%) AZFc deletions and 14/150 (9.3%) CFTR gene mutations. An abnormal karyotype was found both in men with oligozoospermia and azoospermia: 9 men had a sex-chromosomal aneuploidy, 6 translocations were identified and one marker chromosome was found. Y chromosomal microdeletions were mainly associated with male infertility, due to testicular insufficiency. All deletions identified comprised the AZFc region, containing the Deleted in Azoospermia (DAZ) gene. CFTR gene mutations were commonly seen in men with congenital absence of the vas deferens, but also in 16% of men with azoospermia without any apparent abnormality of the vas deferens. CONCLUSIONS: A genetic abnormality was identified in 36/150 (24%) men with extreme oligozoospermia and azoospermia. Application of ICSI in these couples can result in offspring with an enhanced risk of unbalanced chromosome complement, male infertility due to the transmission of a Y-chromosomal microdeletion, and cystic fibrosis if both partners are CFTR gene mutation carriers. Genetic testing and counselling is clearly indicated for these couples before ICSI is considered.     

Embryo donation: outcome and attitudes among embryo donors and recipients

The outcome of an embryo donation programme was evaluated and attitudes among donors and recipients studied by means of a questionnaire survey. A total of 27 couples went through 54 treatment cycles with frozen-thawed embryos donated by other infertile couples. The indications for treatment were premature or incipient ovarian failure in combination with severe male factor infertility. The mean age of the recipient women was 36 years, and that of the recipient men was 35 years. The mean duration of infertility was 8 years (range 2-19 years). Forty-six couples donated 209 excess frozen embryos to the programme. The clinical pregnancy rate in the recipients was 27.8% (15/54) per embryo transfer. An average of 1.9 embryos were transferred on each occasion. The response rate to the questionnaire was high (80-91%). Significantly more recipients (69%) than donors (47%) considered that the child should be informed about the manner of conception (P < 0.05). Some 29% of recipients and 42% of donors thought that the child should receive identifying information concerning the donor couple. The interest of the offspring, not only as regards knowing his/her genetic origin but also knowing full-blood genetic siblings, should be kept in mind in embryo donation programmes.     

Sterilitätsbehandlung mit donogener Insemination

Donor inseminations (DI) have been performed for decades. Most of the publications on this topic deal only with problems of tolerance and acceptance of this treatment for sterility. We already reported on them in parts I and II. In the present third and last part, we discuss the indications for DI: male infertility, genetic disorders, and unsuccessful assisted reproduction therapy. Which conditions do affect the success of therapy? Which methods are recommended? Our treatment results verify realistically that in effect DI only produces the desired child in about 50 % of the couples. As a complementary therapy, in vitro fertilization (IVF) with donor spermatozoa offers a real chance for pregnancy even for women whose husbands are infertile and who themselves suffer from impaired fertility such as pathological conditions of the fallopian tube or when simple inseminations have not resulted in pregnancy. After receiving consent from the State Physicians’ Chamber, we treated 19 women by donor IVF in our group practice and fulfilled their desire to bear their own child.     

Patients' attitudes towards donation of surplus cryopreserved embryos for treatment or research

BACKGROUND: The aim of the study was 2-fold: first, to investigate couples' reasons for not using cryopreserved embryos within the maximum storage period; second, to study their attitudes towards potential embryo donation for specific purposes. METHODS: A questionnaire was sent to 284 IVF/ICSI couples who experienced destruction of their cryopreserved embryos (n=1180) because the cryopreservation period exceeded the Danish legislative limit of 24 months. RESULTS: Seventy-four per cent of the couples responded. The main reasons for not utilizing surplus embryos was 'successful delivery' (85%), 'consider family completed' (61%) and 'too short legislative limit for cryopreservation' (59%). Sixty per cent of the couples agreed to the concept of donation of cryopreserved embryos for infertility research, 57% responded affirmatively to donation for stem cell research and 49% for stem cell treatment, but only 29% agreed to the concept of donation to infertile couples. Multiple logistic regression analysis showed that delivery of a child after IVF treatment (OR 3.8, 95% CI 1.4-10.2) and female age <35 years (OR 2.2, 95% CI 1.3-6.0) were predictive of agreement to the idea of donation for stem cell research and stem cell treatment respectively; however, male age, duration of infertility, mode of conception (IVF or ICSI) and having IVF children were not significant predictors. The following predictive variables were entered into the analysis: female and male age, duration of infertility, IVF versus ICSI, donor semen and +/- IVF children. CONCLUSIONS: This study shows that 23% of all couples having cryopreserved embryos do not utilize them for further treatment within the legislative storage period of 2 years. A major reason is successful delivery. More than half of these patients agreed to the concept of donation of surplus outdated embryos for research, whereas less than one-third agreed to donation to other infertile couples. Based on these figures, an alternative utilization of surplus embryos for stem cell research would require a 100-fold larger pool of available embryos to provide a realistic basis for this purpose.     

The psychological influence of gender infertility diagnoses among men about to start IVF or ICSI treatment using their own sperm

BACKGROUND: The aim of the present study was to investigate the psychological influence of gender infertility diagnoses among men in couples about to start their first IVF or ICSI treatment. METHODS: The study was a part of a prospective study of 65 men with male infertility diagnosis and 101 men in couples with female, mixed and unexplained infertility diagnoses. Of the 200 men invited, 166 agreed to participate (83% response rate). The men answered questionnaires concerning psychological and social factors on three occasions, at the information meeting held 2-4 weeks prior to first treatment, 1 h before oocyte retrieval and 2 weeks after the pregnancy test. RESULTS: The main findings of this study gave no indication that male infertility influenced men negatively concerning their experience of infertility, view of life and relationships and psychological well-being. We found that men with a male factor infertility diagnosis reacted in a similar way as compared with men in couples where the diagnosis was female, mixed or unexplained infertility. CONCLUSIONS: In general, men are well adjusted with regard to a first IVF/ICSI treatment cycle, independent of gender infertility diagnoses.     

The use of intracytoplasmic sperm injection with electroejaculates from anejaculatory men

Electroejaculation has been successfully used for sperm procurement in anejaculatory men desiring fertility. However, electroejaculates typically have normal sperm numbers but poor motility, morphology, and functional deficiencies. Here we report the pregnancy outcome of a series of couples undergoing combined electroejaculation and in-vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI). In all, 13 couples underwent a total of 18 cycles. The aetiologies of anejaculation included history of retroperitoneal lymph node dissection for testicular cancers, spinal cord injury and psychogenic causes. ICSI was performed on 192 oocytes, resulting in a fertilization rate of 75.5%. A total of 15 embryo transfers were performed using a total of 51 embryos. Clinical pregnancy rate, as defined by positive fetal heart rate(s) using vaginal sonography, was 55.6% per retrieval; implantation rate was 33.3% per embryo. These rates appear to be similar to those obtained in standard IVF for non-male factor infertility, or ICSI for male factor infertility. The use of ICSI for electroejaculates undoubtedly provides these couples with the highest chance of pregnancy.      

Possibilities and limitations of techniques of assisted reproduction for the treatment of male infertility

Since relatively few spermatozoa are needed for oocyte fertilization during gamete intra-Fallopian transfer (GIFT) or in-vitro fertilization (IVF), these methods have been applied in couples with infertility due to male causes. Forty-six couples with male factor infertility were enrolled in this study and results were compared with those attained in 48 couples treated with the same techniques for other than male causes. Overall, GIFT resulted in 26% ongoing pregnancies. GIFT seems to be particularly successful when the sperm concentration is 20 x 10(6)/ml or more, but sperm motility and/or morphology are poor. Nine pregnancies occurred out of 26 GIFT cycles in 18 cases selected on this basis. The ongoing pregnancy rate after IVF was 16% per patient. The latter treatment should be attempted in male immune infertility and in cases with a low sperm concentration, with or without abnormal sperm motility and/or morphology. In these circumstances, five pregnancies were attained out of 28 cycles in 14 cases. For similar sperm concentrations, the conception rate per cycle attained with techniques of assisted reproduction was more than twice that attained with conventional treatment of male infertility.     

Relationship between human in-vitro fertilization and intracytoplasmic sperm injection and the zona-free hamster egg penetration test

The zona-free hamster egg penetration test (HEPT) is widely used for evaluating the fertilizing ability of human spermatozoa. However, the relationship between the HEPT and microassisted fertilization has yet to be determined. To evaluate the efficiency of HEPT in selecting the most appropriate method of in-vitro fertilization (IVF), including intracytoplasmic sperm injection (ICSI) in couples with male factor infertility, clinical laboratory data was analysed retrospectively. The patients were divided into groups according to the sperm penetration index as determined by the HEPT: group A (sperm penetration index = 0), group B (sperm penetration index < 15) and group C (sperm penetration index > or = 15). A total of 405 oocytes were collected and inseminated by conventional methods in 69 couples with male factor infertility. In all, 31 out of 148 (20.9%) oocytes fertilized in group A; 35 out of 117 (29.9%) in group B; and 73 of 140 (52.1%) in group C. The clinical pregnancy rates per transfer in groups A, B and C were 0% (0/13), 0% (0/14) and 25.9% (7/27) respectively. Both the fertilization rate and pregnancy rate in group C was significantly higher than in groups A and B. ICSI was carried out in a total of 57 couples and 334 oocytes in metaphase II stage were manipulated. The normal fertilization (2 pronuclear) rate per oocyte was 65.6 +/- 26.0% (mean +/- SD). Out of 127 oocytes, 76 (59.8%) fertilized in group A, 57 out of 87 oocytes (65.5%) in group B and 86 out of 120 oocytes (71.7%) in group C. Of the 56 transfers, 17 clinical pregnancies were obtained, giving an average pregnancy rate of 30.4% per transfer. The clinical pregnancy rates per transfer in groups A, B and C were 17.4% (4/23), 40.0% (4/10) and 39.1% (9/23) respectively. No significant differences were observed in the fertilization rates or in the pregnancy rates between the three groups. In addition, there were no differences in the fertilization and pregnancy rates between the ICSI and IVF patients in group C. These findings suggest that the results of the HEPT are well correlated with the fertilizing ability of human spermatozoa in the patients treated by conventional IVF. Couples suffering from male factor infertility with a sperm penetration index of < 15 (as determined by HEPT) should consider treatment with ICSI, while those with a sperm penetration index of > or = 15 should attempt conventional IVF.      

Prognostic value of Y deletion analysis: How reliable is the outcome of Y deletion analysis in providing a sound prognosis?

Y chromosomal microdeletions at the azoospermia factor (AZF) locus have been implicated as one of the major causes of idiopathic male infertility. The availability of intracytoplasmic sperm injection (ICSI) in treating a variety of male infertility has raised the risk of the transmission of Y microdeletions from father to son. In many IVF centres, Y microdeletion analysis has been used as a diagnostic tool for genetic counselling of infertile couples. Presently, the only prognosis that can be derived from Y microdeletion analysis is that the affected male offspring would benefit from proper clinical management of their infertility. Prognoses based on the pattern of Y microdeletions in relation to phenotype are rather subjective and inconclusive because of insufficient data to derive a definitive correlation whose significance can be determined by statistical analysis. Standardization of the number and choice of sequence-tagged sites (STS), whose deletions result in defective spermatogenesis, for the polymerase chain reaction (PCR) analysis of Y microdeletions would enhance its reliability in the interpretation of the results which is crucial for therapeutic decision-making. Furthermore, in-depth understanding of the gene functions in male infertility, especially at the AZF locus, would contribute greatly to the quality of the prognostic value of Y microdeletion analysis.     

Andrology: 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 donorinsemination (DI) for severe male factor infertility. Over thefirst 8 months in which our infertility programme offered bothtreatments, 27 consecutive couples scheduled for ICSI and 15consecutive couples scheduled for DI were evaluated Since allpatients in our infertility programme beginning in-vitro fertilization(TVF) with planned ICSI or starting DI undergo a semi-structuredpsychological interview, the psychologist's clinical notes aswell as the medical chart were reviewed and coded retrospectivelyto determine factors related to a couple's treatment choice.Couples who chose IVF-ICSI over DI had a higher occupationalstatus and included husbands with higher educational levels.Their most common motivation was to have the husband's biologicalchild (93% of couples in the ICSI group). The most common motivationfor choosing DI (60% of DI couples) was that IVF was not financiallyaffordable. Choice of treatment was not related to psychologicaladjustment, the husband having prior biological children, orhis risk of passing on a genetic defect to offspring. Thesepreliminary data raise the concern that, with the success ofICSI, DI may change in the USA from being an option dictatedby semen quality to a second choice treatment utilized for economicreasons.     

男性不育因素分析

目的:分析不孕不育中的男性因素。方法:收集3 777对不孕夫妇的孕产史及不孕不育病因检查结果,对男性不育患者资料进行分析,包括男性生殖专科体格检查、精液常规分析、遗传学检查等。结果:单纯男性因素不育患者1 406例,占总数的37.23％。其中无精子症在男性不育患者中占57.99％,少弱精子症及严重少弱精子症占37.34％。在无精子症及严重少弱精子症患者中,染色体异常表现有数目异常和涉及大多数染色体在内的结构异常。结论:男性因素是不孕症病因中重要的组成部分,影响男性生育的相关基因可能存在于性染色体和大部分常染色体上。     

Treatment of male infertility due to sperm surface antibodies: IUI or IVF?

This prospectively designed study was aimed at comparing the results of two different treatment protocols in 29 infertile couples with proven male immunological infertility, i.e. a positive (>50%) mixed antiglobulin reaction (MAR) test (IgG and/or IgA). In the first protocol (group I, n = 14) couples were treated with ovarian stimulation/ intrauterine insemination (IUI), followed by in-vitro fertilization (IVF) if no pregnancy occurred after three IUI cycles. In the second protocol (group II, n = 15), patients were treated with IVF as a first choice procedure. The decision to follow protocol 1 or 2 was made by the couples after information about financial costs and expected success rates (according to the literature) for both treatment options. In group I, nine patients (64.3%) conceived after a maximum of three IUI cycles whereas seven patients (46.6%) of group II became pregnant during the first IVF cycle. The take-home baby rate per started IUI or IVF cycle was 27.3% (9/33) and 44.4% (16/36) respectively with a take-home baby rate of 64.3% after three IUI cycles and 93.3% after three IVF attempts. To conclude, both IUI and IVF yielded unexpectedly high pregnancy rates in this selected group of patients with long-standing infertility due to sperm surface (predominantly IgG) antibodies. Since cost benefit analysis comparing superovulation IUI with IVF may favour a course of four IUI cycles, we advocate superovulation IUI as the first line therapy in male immunological infertility.      

Is the male involved in the aetiology of ectopic pregnancy?

We have previously observed a low incidence of ectopic pregnancies in couples having gamete intra-Fallopian transfer (GIFT) with donated spermatozoa. Based on findings in both animal and human models, we proposed the hypothesis that sperm defects may be associated with the expression of paternal genes which cause abnormal early embryo development and predispose the embryos to interact inappropriately with the genital tract epithelium, and so increase the risk of an ectopic implantation. To both confirm and extend the initial observation, GIFT and in-vitro fertilization (IVF) pregnancies entered on the Australian and New Zealand national database between 1979 and 1993 were analysed with regard to the incidence of ectopic pregnancy. There was an increased risk of ectopic pregnancy for IVF relative to GIFT and when spermatozoa from the male partner were used rather than donor spermatozoa. However, when couples were categorized with respect to the aetiology of their infertility, we were unable to show a significant association between ectopic pregnancy and whether spermatozoa from the male partner or a donor were used. We have therefore been unable to confirm a direct association between the source of spermatozoa and ectopic pregnancy.      

Oocyte donation programme: results obtained with intracytoplasmic sperm injection in cases of severe male factor infertility or previous failed fertilization

Intracytoplasmic sperm injection was carried out in 15 oocytedonation cycles of 15 infertile couples where oocytes had failedto fertilize after in-vitro fertilization (IVF) procedures orwhere the male partner had severe male factor infertility. Atotal of 62 oocytes were donated, but only 46 of these, in metaphaseEl, were injected. Of the injected oocytes, 31 (673%) had twopronuclei the morning after the injection procedure. On thefollowing day, 29 embryos were obtained (93% of the fertilizedoocytes) and 25 were transferred. Two patients were not successfuland consequently did not undergo embryo transfer. A total offive clinical pregnancies were obtained, giving pregnancy ratesof 333 and 38.4% per started cycle and embryo transfer respectively.     

从不同角度探讨男性不育的原因

全世界有10％-15％的夫妻在结婚一年内未孕。这些病例中,男性因素不育至少占一半。男性不育的原因很多,包括身体发育异常、免疫原因、精子畸形、染色体异常、Y染色体微缺失、基因缺失、基因单核苷酸多态性以及其他原因。本文综述男性不育的每一种因素,其目的是为了帮助临床医师对不育男性病人诊断、遗传咨询以及进一步开展辅助生殖工作。     

特发性男性不育症的遗传学分析

不孕症指夫妇同居生活两年、未避孕而未怀孕者。大约15%育龄夫妇患不孕症,其中男性因素占一半。造成男性不育的因素很多,比如内分泌、感染、生殖器畸形、免疫、遗传等原因,然而多半男性不育症患者找不到明确原因,我们称之为特发性男性不育症。生精障碍是男性不育的主要原因,多数男性不育症患者最初通过精液常规检查被确诊。精液常规检查可发现多种异常,比如无精子症、少精子症、弱精子症、畸精子症、死精症以及脓精症等,大约30%前来遗传咨询的男性不育患者患有特发性无精子或少精子症。已确定与特发性无精子症或少精子症有关的遗传异常包括染色体异常、精子mtDNA突变、单基因遗传病、多基因遗传病以及遗传因素引起的内分泌异常等,本文就特发性男性不育症的以上遗传学因素作一综述。     

Cancer and male infertility: Gamete intra-Fallopian transfer or in-vitro fertilization after failed ovarian stimulation and intrauterine insemination in unexplained infertility?

A prospective randomized study was designed to compare gameteintra-Fallopian transfer (GIFT) and in-vitro fertilization (IVF)and embryo transfer in the treatment of couples who have failedto conceive after at least three cycles of ovarian stimulationand intrauterine insemination (IUI). A total of 69 couples withprimary unexplained infertility of at least 2 years' durationplus at least three failed cycles of ovarian stimulation andIUI were randomly allocated to either GIFT or IVF/embryo transfer.The clinical pregnancy rate was 34% after GIFT treatment and50% after IVF/embryo transfer. This difference was not statisticallysignificant. The twin rate in the IVF/embryo transfer groupwas higher than in the GIFT group (53 versus 17%, P = 0.005).We conclude that patients with unexplained infertility and failedovarian stimulation and IUI can still achieve encouraging pregnancyrates with IVF/embryo transfer or GIFT. Since IVF/embryo transferis the least invasive of the two procedures and may yield diagnosticinformation, we would favour this therapy; however, the numberof embryos transferred should be reduced to two to reduce therisk of twin pregnancy.