Cumulative experience of percutaneous epididymal sperm aspiration (PESA) with intracytoplasmic sperm injection

Relationship of sperm motility with clinical outcome of percutaneous epididymal sperm aspiration-intracytoplasmic sperm injection in infertile males with congenital domestic absence of vas deferens: a retrospective study

Congenital domestic absence of vas deferens (CBAVD) is a common factor in male infertility, and percutaneous epididymal sperm aspiration (PESA) combined with intracytoplasmic sperm injection (ICSI) is a primary clinical treatment, but the effect of the sperm obtained on pregnancy outcome remains to be explored. This study aimed to investigate the relationship between sperm motility with clinical outcome of PESA-ICSI in infertile males with CBAVD. A cohort of 110 couples was enrolled. In total, 76 infertile males were included in the high motility group, while the remaining 34 males were placed in the low motility group. Clinical pregnancy, embryo implantation rate and live birth rate were included as the primary outcome. After all follow-ups, we found that the high motility group achieved higher normal fertilization rates, cleavage rates, transplantable embryo rates and high-quality embryo rates than those in low motility group (normal fertilization rate, 78.2 ± 11.7% vs. 70.5 ± 10.2%, P = 0.003; cleavage rate, 97.1 ± 2.9% vs. 92.3 ± 3.0%, P = 0.000; transplantable embryo rate, 66.8 ± 14.9% vs. 58.6 ± 12.6%, P = 0.009 and high-quality embryo rate, 49.9 ± 10.5% vs. 40.5 ± 11.2%, P = 0.000). Additionally, compared with the low motility group, the clinical pregnancy rates, embryo implantation rates, and live birth rates in the high motility group were significantly increased (pregnancy rate, 61.8% vs. 26.5%, P = 0.009; embryo implantation rate, 36.5% vs. 18.0%, P = 0.044; live birth rate, 55.3% vs. 17.6%, P = 0.000). We concluded that the motility of sperm obtained by PESA affected the clinical outcome of ICSI in infertile males with CBAVD.

Advances in the management of infertility in men with spinal cord injury

Couples with a spinal cord injured male partner require assisted ejaculation techniques to collect semen that can then be further used in various assisted reproductive technology methods to achieve a pregnancy. The majority of men sustaining a spinal cord injury regardless of the cause or the level of injury cannot ejaculate during sexual intercourse. Only a small minority can ejaculate by masturbation. Penile vibratory stimulation and electroejaculation are the two most common methods used to retrieve sperm. Other techniques such as prostatic massage and the adjunct application of other medications can be used, but the results are inconsistent. Surgical sperm retrieval should be considered as a last resort if all other methods fail. Special attention must be paid to patients with T6 and rostral levels of injury due to the risk of autonomic dysreflexia resulting from stimulation below the level of injury. Bladder preparation should be performed before stimulation if retrograde ejaculation is anticipated. Erectile dysfunction is ubiquitous in the spinal cord injured population but is usually easily managed and does not pose a barrier to semen retrieval in these men. Semen analysis parameters of men with spinal cord injury are unique for this population regardless of the method of retrieval, generally presenting as normal sperm concentration but abnormally low sperm motility and viability. When sperm retrieval is desired in this population, emphasis should be placed on initially trying the simple methods of penile vibratory stimulation or electroejaculation before resorting to more advanced and invasive surgical procedures.

Infertility in men with spinal cord injury: research and treatment

Spinal cord injury (SCI) occurs most often to young men. Following SCI, most men are infertile due to a combination of erectile dysfunction, ejaculatory dysfunction and semen abnormalities. Erectile dysfunction may be treated by the same therapies that are used in the general population. Similarly, the same treatments that are effective to assist conception in couples with non-SCI male factor patients are effective in assisting conception in SCI male-factor patients. The most apparent differences in male-factor symptoms between SCI and non-SCI patients are the high occurrences of anejaculation and atypical semen profiles in men with SCI. Methods available to assist ejaculation in men with SCI include penile vibratory stimulation and EEJ. Use of surgical sperm retrieval as the first line of treatment for anejaculation in men with SCI is controversial. Most men with SCI have a unique semen profile characterized by normal sperm concentration, but abnormally low sperm motility. Toxic substances in the semen contribute to this problem. Despite impaired sperm parameters, pregnancy outcomes using sperm from men with SCI are similar to pregnancy outcomes using sperm from non-SCI men. Future studies should focus on improving natural ejaculation and improving semen quality in these men.

Measurement of sexual functioning after spinal cord injury: preferred instruments

BACKGROUND/OBJECTIVE

To determine the utility of certain instruments to assess sexuality and fertility after SCI, an expert panel identified key areas to study and evaluated available instruments. These were rated according to certain predefined criteria.

METHODS

The authors divided sexual issues into male and female sexual function, male reproductive function, and female reproductive function. The instruments that have been used most frequently to measure these aspects of sexual function over the past 5 years were identified by expert consensus. Finally, these instruments were subjected to a critical review.

RESULTS

The Female Sexual Function Index (FSFI), measurement of vaginal pulse amplitude (VPA), the International Index of Erectile Function (IIEF), and the measurement of ejaculatory function and semen quality were considered appropriate measures to assess sexual responses and reproductive function after SCI. There were no measures identified to assess female reproductive function.

CONCLUSIONS

For clinical trials aiming to improve sexual function after SCI, the FSFI or the IIEF is currently preferred. Although VPA is an appropriate means to assess female sexual responses, it is only useful for laboratory studies and is too invasive for use in clinical trials. For assessment of male fertility potential, assessment of ejaculatory capacity and semen analysis are recommended.

Current trends in the treatment of infertility in men with spinal cord injury

OBJECTIVE

To determine current use of penile vibratory stimulation (PVS), electroejaculation (EEJ), and intrauterine insemination (IUI) in treatment of infertility in men with spinal cord injury (SCI).

DESIGN

Prospective survey, retrospective chart review, and literature review.

SETTING

Major university medical center.

PATIENT(S)

Male SCI patients and female partners.

INTERVENTION(S)

A survey administered to professionals determined current treatment methods for infertility in couples with SCI male partners.

MAIN OUTCOME MEASURE(S)

Sperm retrieval methods, ejaculation success rates, total motile sperm (TMS), IUI application, and IUI outcomes.

RESULT(S)

Twenty-eight percent of surveyed professionals do not retrieve sperm from ejaculates of SCI patients, relying instead on retrieval from reproductive tissues. Reasons for not offering PVS or EEJ were lack of familiarity, training, or equipment. Thirty-four percent do not offer IUI to these couples. Chart review showed that semen could be retrieved by PVS or EEJ in 95% of patients. Fifty-three percent and 43% of trials had TMS >5 and >10 x 10(6), respectively. Of survey respondents performing IUI, 42% lacked enough data to estimate pregnancy rates (PRs) in these couples. Literature review showed IUI PRs between 9% and 18% per cycle and 30% and 60% per couple.

CONCLUSION(S)

Based on ejaculation success rates, TMS yields, and IUI outcomes, the methods of PVS, EEJ, and IUI warrant consideration in centers not currently offering these options for couples with SCI male partners.

Intracytoplasmic sperm injection--an assisted reproduction technique that should make us cautious about imprinting deregulation

OBJECTIVE

Due to the extensive use of intracytoplasmic sperm injection (ICSI) in assisted reproduction, not only among couples with severe male factor infertility problems, but to a broader scale, a lot of concern has been raised regarding the safety of the method and its implications in epigenetic control and imprinting dysregulation. This review means to provide a comprehensive report of the published scientific data, outline putative associations between ICSI and epigenetic control, and suggest measures to improve the current state of affairs and reach more scientifically consolidated results.

METHODS

This review was conducted by studying a broad spectrum of articles dealing with the subject of epigenetic control and its relation with ICSI. We tried to view the two subjects as parallel procedures that occur in the organism and by delineating the molecular and biochemical steps that comprise them make suggestions about putative associations between ICSI and epigenetic control.

CONCLUSIONS

No hard evidence presented at the moment can prove or disapprove ICSI's implications in epigenetic control. Nevertheless, we take the view that more comprehensive, long-term, and properly designed studies are imperative to be applied on a large-scale basis. We urge cautiousness, since the welfare of our progeny is what is at stake.

Intracytoplasmic injection of frozen-thawed epididymal spermatozoa in a nonhuman primate model, the cynomolgus monkey (Macaca fascicularis)

Intracytoplasmic sperm injection (ICSI) with frozen-thawed epididymal spermatozoa was performed in the cynomolgus monkey (Macacafascicularis) to produce embryos in vitro. Eleven sexually mature females were hyperstimulated with an GnRH agonist (1.8 mg active triptorelin per 2 kg body weight), followed (2 weeks later) by rFSH (37.5 IU per 2 kg daily) for 12 days, and finally 1000 IU of hCG. Epididymal spermatozoa were collected from a single adult male monkey. The first stimulation cycle resulted in 90 oocytes; 70% of which were metaphase II (MII). Sixty-four percent of these MII oocytes were fertilized. Comparing ovarian response of five monkeys that underwent a second stimulation cycle there was an increase in oocyte quantity (13.2 versus 9.2 oocytes per monkey) but the percentage of MII oocytes remained the same at 58%. Fertilization and cleavage rates were also reduced but there was an increase in the number of embryos available for transfer. Overall, four monkeys became pregnant resulting in the birth of two healthy infants and two abortions. These findings show that ovarian stimulation by GnRH-rFSH did not compromise the developmental competence of the oocytes; effective combination of cryopreservation of epididymal spermatozoa and ICSI is possible in nonhuman primate reproduction, and thus has potential application in the conservation of highly endangered nonhuman primate species, and the cynomolgus monkey is a reliable biomedical research model to study the potential risks and benefits associated with assisted reproductive techniques prior to approval for clinical trials on humans.

A comparison of ICSI outcomes with fresh and cryopreserved epididymal spermatozoa from the same couples

The published experience with frozen-thawed epididymal spermatozoa and intracytoplasmic sperm injection (ICSI) suggests that fertilization and pregnancy success rates are comparable to those achieved with freshly retrieved spermatozoa. However, no study has exactly compared clinical outcomes between the two IVF/ICSI cycles in the same couples. To formally address this issue, we assessed ICSI outcomes in couples each of whom had had two IVF/ICSI cycles: one using fresh and the second using frozen-thawed epididymal spermatozoa obtained from a single aspiration procedure. From a pool of 101 consecutive patients undergoing IVF/ICSI with epididymal spermatozoa, 19 couples initially used fresh epididymal spermatozoa and subsequently underwent a second IVF/ICSI procedure with frozen-thawed spermatozoa from the same aspiration. Normal (2PN) oocyte fertilization rates, embryo quality and pregnancy rates were compared between the two IVF/ICSI cycles for each couple. In the fresh epididymal sperm group, 58.4% of the injected oocytes fertilized normally compared with 62.0% of the injected oocytes in the frozen-thawed epididymal sperm group, revealing no statistically significant difference. Graded embryo quality also did not differ significantly between the paired IVF/ICSI cycles. The clinical pregnancy rates were 31.6% (6/19) and 36.8% (7/19) in the first and second cycles respectively. All but one pregnancy were singletons. In summary, this study provides strong evidence to support the notion that motile, cryopreserved and thawed epididymal spermatozoa are equal to freshly retrieved spermatozoa for ICSI in couples with obstructive azoospermia.

Reproductive capacity of spermatozoa from men with testicular failure

Controversial reports have been published about the influence of sperm source and of the underlying testicular pathology on success rates of intracytoplasmic sperm injection (ICSI). In this controlled study, ICSI treatment cycles with testicular spermatozoa from men with obstructive and non-obstructive azoospermia were compared with ICSI ejaculated sperm cycles with semen parameters < or = 5 x 10(6)/ml and < or = 10% progressive motility. The control cases were matched for female age, rank of trial, female basal follicle-stimulating hormone serum concentrations and close proximity to the study group's procedure. The fertilization, cleavage, pregnancy and abortion rates were similar in matched groups irrespective of the type of azoospermia. However, the implantation rate in the non-obstructive azoospermic patient group was significantly lower than that in the matched ejaculated sperm group (13.4% versus 26%, P = 0.05). On the other hand, no impairment of the implantation rate was observed in the obstructive azoospermic patient group. These data show that testicular pathology has a negative impact on reproductive performance of testicular spermatozoa, resulting in a decreased implantation potential without any apparent effect on fertilization and early preimplantation development.

Intracytoplasmic sperm injection

Intracytoplasmic sperm injection (ICSI) can now alleviate infertility in couples who could not conceive by other means. Most patients with obstructive azoospermia and some patients with non-obstructive azoospermia can now be treated. The practice of five years of ICSI (1991-1995) is reviewed in terms of patients selection and counselling, controlled ovarian stimulation and oocyte handling, semen evaluation and preparation, ICSI procedure, oocyte damage and pronuclear status after ICSI, embryo development, embryo transfer, freezing of supernumerary embryos, obstetrical outcome, prenatal diagnosis and follow-up study of the children resulting from ICSI.