The impact of intracytoplasmic sperm injection versus conventional in vitro fertilization on the reproductive outcomes of couples with non-male factor infertility and frozen-thawed embryo transfer cycles

This study was aimed to investigate the impact of intracytoplasmic sperm injection (ICSI) on reproductive outcomes in couples with non-male factor infertility and frozen-thawed embryo transfer (FET) treatment. This retrospective cohort study involved a total of 10,143 cycles from 6206 couples who underwent FET at the Third Affiliated Hospital of Zhengzhou University between January 2016 and September 2022. Patients were categorized into two groups based on the insemination methods of transferred embryos. Clinical and neonatal outcomes were compared between ICSI and conventional in vitro fertilization (cIVF) groups. The results showed that ICSI was not associated with improved clinical outcomes compared to cIVF. However, ICSI was associated with lower birthweight when twins were born. In conclusion, although subgroup analysis showed that ICSI was associated with slightly improved live birth rate for infertile couples with non-male factor infertility compared to cIVF, the regression analysis showed that ICSI did not demonstrate any improvement of the reproductive outcomes. The infertile women with twin pregnancies should be further informed of the lower birthweight and lower birth length when their oocytes were inseminated with ICSI. The findings of this study provide valuable insights for clinicians when discussing the benefits and risks of ICSI in patients with non-male factor infertility.

Comparisons of conventional in vitro fertilization versus intracytoplasmic sperm injection in women with thyroid autoimmunity and non-male factor infertility, a propensity score matching analysis

The aim of the study is to compare the outcomes between the insemination methods of conventional in vitro fertilization and intracytoplasmic sperm injection in infertile women with thyroid autoimmunity and non-male factor infertility. This was a retrospective cohort study which included women with thyroid autoimmunity and non-male factor infertility. Reproductive outcomes such as embryo development parameters and clinical outcomes were compared between the two groups. The propensity score matching was applied to balance the general characteristics with significant differences between the two groups. Generalized estimating equations were used to explore the impact of ICSI on the embryo development potential of the inseminated oocytes. Sensitivity analysis using E-values was used to account for unknown confounders. After 1:2 propensity score matching, the general characteristics were all comparable. The good cleavage embryo rate, blastocyst utilization rate, and good blastocyst rate were significantly lower in the intracytoplasmic sperm injection group than those in the conventional in vitro fertilization group. After controlling for the confounding factors, intracytoplasmic sperm injection was significantly negatively associated with development of usable blastocysts and good blastocysts, while showed no impact on fertilized oocytes, usable cleavage embryos and good cleavage embryos. Although limited by the limited sample size, there were comparable clinical and obstetrical outcomes between conventional in vitro fertilization and intracytoplasmic sperm injection groups. Intracytoplasmic sperm injection neither improved the embryo development potential nor increased the clinical pregnancy and live birth rates compared to conventional in vitro fertilization in the studied population. Prospective studies that randomly divide the studied population in two the two groups and compare the reproductive outcomes are warranted.

Associations between Urinary Concentrations of Disinfection Byproducts and in Vitro Fertilization Outcomes: A Prospective Cohort Study in China

BACKGROUND

Experimental studies show that disinfection byproducts (DBPs) can inhibit oocyte maturation, decrease fertilization capacity, and impair embryo development, but human evidence is lacking.

OBJECTIVES

We aimed to evaluate the associations between exposure to drinking water DBPs and in vitro fertilization (IVF) outcomes.

METHODS

The study included 1,048 women undergoing assisted reproductive technology (ART) treatment between December 2018 and January 2020 from a prospective cohort study, the Tongji Reproductive and Environmental study in Wuhan, China. Exposure to DBPs was assessed by dichloroacetic acid (DCAA) and trichloroacetic acid (TCAA) in up to four urine samples, which were collected on the day of both enrollment and oocyte retrieval. Multivariable generalized linear mixed models, accounting for multiple IVF cycles per woman, were applied to evaluate the associations between urinary biomarkers of DBP exposures and IVF outcomes. Stratified analyses were used to explore the potential effect modifiers.

RESULTS

The included 1,048 women underwent 1,136 IVF cycles, with 960 (91.6%), 84 (8.0%), and 4 (0.4%) women contributing one cycle, two cycles, and three cycles, respectively. We found that elevated quartiles of urinary DCAA and TCAA concentrations were associated with reduced numbers of total oocytes and metaphase II oocytes and that urinary DCAA concentrations with a lower proportion of best-quality embryos (all p for trends < 0.05 ). Moreover, elevated quartiles of urinary DCAA concentrations were associated with decreased proportions of successful implantation, clinical pregnancy, and live birth (14%, 15%, and 15% decreases in adjusted means comparing the extreme quartiles, respectively; all p for trends < 0.05 ). Stratification analyses showed that the inverse associations of urinary TCAA concentrations with multiple IVF outcomes were stronger among women ≥ 30 y of age (p for interactions < 0.05 ).

DISCUSSION

Exposure to drinking water DBPs was inversely associated with some IVF outcomes among women undergoing ART treatment. Further study is necessary to confirm our findings. https://doi.org/10.1289/EHP12447.

Considerations on staffing levels for a modern assisted reproductive laboratory

The duties recently performed in the embryology laboratory have deeply increased compared to those realized a couple of decades ago. Currently, procedures include conventional in vitro fertilization (IVF) and ICSI techniques, or processing of surgically retrieved sperm, embryo culture and time-lapse monitoring, blastocyst culture, as well as trophectoderm biopsy for preimplantation genetic testing and cryopreservation. These techniques require not only time, but also high knowledge level and acutely concentration by the embryologist team. The existing data indicate that an IVF laboratory need to have adequate staffing levels to perform the required daily duties, and to work in optimal conditions that are critical to assure a high quality service, as well as avoiding incidents and to provide the best outcomes. As a result, IVF clinics have invested in human resources, but there is still a large discrepancy between IVF centres on the number of embryologists employed. Currently there is no golden standard on the human resource requirements for assisted reproductive technology procedures; therefore, in this review paper we aim to provide arguments to take into account to determine the embryology staffing requirements in an embryology laboratory to assure optimal safety and efficiency of operations.

Impact of intracytoplasmic sperm injection in women with non-male factor infertility: A systematic review and meta-analysis

OBJECTIVE

The purpose of this study is to determine whether intracytoplasmic sperm injection (ICSI) is beneficial in patients with non-male factor infertility.

METHODS

This systematic review and meta-analysis included articles from inception to May 2022. Published studies of non-male factor infertile women undergoing ICSI or in vitro fertilization (IVF) included in PubMed, Embase, web of science, Wanfang Database, and CNKI were searched by computer, without language restrictions. A random-effect model was applied to calculate the risk ratios (RRs) and their 95% confidence intervals (CIs). Letters, case reports, and review articles including meta-analyses and expert opinions were excluded. The primary endpoints were laboratory outcomes and pregnancy outcomes. The Secondary endpoints were neonatal outcomes.

RESULTS

Six randomized controlled studies and 20 retrospective cohort studies met the inclusion criteria. In meta-analytic forest plots, compared with IVF, those who received ICSI treatment were not different in fertilization rate (RR = 0.99, 95% CI [0.90-1.09], P = 0.88), total fertilization failure rate (RR = 1.30, 95% CI [1.17-1.45], P < 0.00001), and good quality embryo rate (RR = 0.94, 95% CI [ 0.86-1.02], P = 0.15), clinical pregnancy rate (RR = 0.84, 95% CI [0.70-1.01], P = 0.06), live birth rate (RR = 0.89, 95% CI [0.77-1.03], P = 0.13), miscarriage rate (RR = 1.06, 95% CI [0.78-1.43], P = 0.71), preterm neonatal delivery rate (RR = 0.92, 95% CI [0.67-1.26], P = 0.61), and low neonatal weight rate (RR = 1.13, 95% CI [0.80-1.61], P = 0.48). However, the implantation rate of IVF was better than ICSI (RR = 0.77, 95% CI [0.64-0.93], P = 0.005). In the subgroup analysis of the live birth rate of fresh embryo transfer, IVF performed in those ≥35 years had a higher live birth rate (RR = 0.82, 95% CI [0.78-0.83], P < 0.001).

CONCLUSION

The findings of this study indicate that ICSI is not superior to IVF in the treatment of infertility related to non-male factors. In order to confirm this result, more high-quality clinical studies are needed.

Opportunities and Limits of Conventional IVF versus ICSI: It Is Time to Come off the Fence

Conventional IVF (c-IVF) is one of the most practiced assisted reproductive technology (ART) approaches used worldwide. However, in the last years, the number of c-IVF procedures has dropped dramatically in favor of intracytoplasmic sperm injection (ICSI) in cases of non-male-related infertility. In this review, we have outlined advantages and disadvantages associated with c-IVF, highlighting the essential steps governing its success, its limitations, the methodology differences among laboratories and the technical progress. In addition, we have debated recent insights into fundamental questions, including indications regarding maternal age, decreased ovarian reserve, endometriosis, autoimmunity, single oocyte retrieval-cases as well as preimplantation genetic testing cycles. The “overuse” of ICSI procedures in several clinical situations of ART has been critically discussed. These insights will provide a framework for a better understanding of opportunities associated with human c-IVF and for best practice guidelines applicability in the reproductive medicine field.

Marginal differences in preimplantation morphokinetics between conventional IVF and ICSI in patients with preimplantation genetic testing for aneuploidy (PGT-A): A sibling oocyte study

Objective

This study aimed to analyze the morphokinetic behaviour between conventional IVF and ICSI, in cycles with preimplantation genetic testing for aneuploidies (PGT-A).

Materials

A randomized controlled trial (NCT03708991) was conducted in a private fertility center. Thirty couples with non-male factor infertility were recruited between November 2018 and April 2019. A total of 568 sibling cumulus oocyte complexes were randomly inseminated with conventional IVF and ICSI and cultured in an Embryoscope time-lapse system. The morphokinetic behaviour of IVF/ICSI sibling oocytes was analysed as primary endpoint. As secondary endpoints, morphokinetic parameters that predict blastocysts that will be biopsied, the day of biopsy, gender and euploid outcome was assessed.

Results

When comparing IVF to ICSI, only the time to reach the 2-cell stage (t2) was significantly delayed for IVF embryos: OR: 1.282 [1.020–1.612], p = 0.033. After standardizing for tPNf (ct parameters), only Blast(tStartBlastulation-t2) remained significant: OR: 0.803 [0.648–0.994], p = 0.044. For the analysis of zygotes that will be biopsied on day 5/6 versus zygotes without biopsy, only early morphokinetic parameters were considered. All parameters were different in the multivariate model: ct2: OR: 0.840 [0.709–0.996], p = 0.045; ct6: OR: 0.943 [0.890–0.998], p = 0.043; cc2(t3-t2): OR: 1.148 [1.044–1.263], p = 0.004; cc3(t5-t3): OR: 1.177 [1.107–1.251], p<0.0001. When comparing the development between blastocysts biopsied on day 5 versus day 6, only three morphokinetic parameters were significant: cc2(t3-t2): OR: 1.394 [1.010–1.926], p = 0.044; ctBlastocyst: OR: 0.613 [0.489–0.768], p<0.0001 and ctExpandedBlastocyst: OR: 0.913 [0.868–0.960], p = 0.0004. Multivariate analysis of gender and ploidy did not reveal differences in morphokinetic behaviour.

Conclusion

Minor morphokinetic differences are observed between IVF and ICSI. Early in the development, distinct cleavage patterns are observed between embryos that will be biopsied or not.

Prediction of Fertilization Disorders in the In Vitro Fertilization/Intracytoplasmic Sperm Injection: A Retrospective Study of 106,728 Treatment Cycles

Purpose

This study aimed to develop a risk prediction of fertilization disorders during the in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI).

Methods

A retrospective study was performed with 106,728 fresh embryo IVF/ICSI cycles from 2009 to 2019. Basic characteristics of patients, clinical treatment data, and laboratory parameters were involved. The associations between the selected variables and risks for low fertilization rate (LFR) and total fertilization failure (TFF) were investigated. Ordinal logistic regression and the receiver operating characteristic curves (ROCs) were used to construct and evaluate the prediction models.

Results

A total of 97,181 controls, 4,343 LFR and 5,204 TFF cases were involved in this study. The model based on clinical characteristics (the ages of the couples, women's BMI, types of infertility, ART failure history, the diminished ovarian reserve, sperm quality, insemination method, and the number of oocytes retrieved) had an AUC of 0.743 for TFF. The laboratory model showed that primary infertility, ART failure history, minimal-stimulation cycle/natural cycle, numbers of oocyte retrieved < 5, IVF, and Anti-Mullerian hormone (AMH) level < 1.1ng/ml are predictors of TFF, with an AUC of 0.742.

Conclusion

We established a clinical and a laboratory prediction model for LFR/TFF. Both of the models showed relatively high AUCs.

Contemporary Use of ICSI and Epigenetic Risks to Future Generations

Since the birth of Louise Brown in 1978 via IVF, reproductive specialists have acquired enormous knowledge and refined several procedures, which are nowadays applied in assisted reproductive technology (ART). One of the most critical steps in this practice is the fertilization process. In the early days of IVF, a remarkable concern was the unpleasant outcomes of failed fertilization, overtaken by introducing intracytoplasmic sperm injection (ICSI), delineating a real breakthrough in modern ART. ICSI became standard practice and was soon used as the most common method to fertilize oocytes. It has been used for severe male factor infertility and non-male factors, such as unexplained infertility or advanced maternal age, without robust scientific evidence. However, applying ICSI blindly is not free of potential detrimental consequences since novel studies report possible health consequences to offspring. DNA methylation and epigenetic alterations in sperm cells of infertile men might help explain some of the adverse effects reported in ICSI studies on reproductive health in future generations. Collected data concerning the health of ICSI children over the past thirty years seems to support the notion that there might be an increased risk of epigenetic disorders, congenital malformations, chromosomal alterations, and subfertility in babies born following ICSI compared to naturally conceived children. However, it is still to be elucidated to what level these data are associated with the cause of infertility or the ICSI technique. This review provides an overview of epigenetic mechanisms and possible imprinting alterations following the use of ART, in particular ICSI. It also highlights the sperm contribution to embryo epigenetic regulation and the risks of in vitro culture conditions on epigenetic dysregulation. Lastly, it summarizes the literature concerning the possible epigenetic disorders in children born after ART.

Analysis of Clinical Outcomes of Different Fertilization Methods in Patients with ≤3 Eggs Retrieved

Objective

To explore the intracytoplasmic sperm injection (ICSI) and in vitro fertilization (IVF) method on the clinical outcomes of infertile women with ≤3 eggs retrieved. Study Design. We retrospectively analyzed a cohort of female patients who received IVF/ICSI to assist pregnancy with retrieved eggs ≤3. The general conditions, i.e., two pronuclei (2PN) fertilization rate, abnormal fertilization rate, high-quality embryo rate, cycle cancellation rate, pregnancy rate of fresh embryo transfer, cumulative pregnancy rate, and miscarriage were compared between the two groups.

Results

When the number of retrieved eggs was one, the fertilization rate of 2PN was higher and the cycle cancellation rate was lower in the ICSI group than in the IVF group (P < 0.05). The pregnancy rates of fresh embryo transfer, frozen-thawed embryo transfer, and the cumulative pregnancy rate were all higher in the ICSI group than in the IVF group (P < 0.05). When the number of retrieved eggs was two, the pregnancy rate of frozen-thawed embryo transfer and cumulative pregnancy rate in the ICSI group were higher than those in the IVF group (P < 0.05). When the number of retrieved eggs was three, the fertilization rate of 2PN and the pregnancy rate of frozen-thawed embryo transfer were higher in the ICSI group than those in the IVF group (all (P < 0.05)).

Conclusions

For patients with one egg retrieved, ICSI fertilization can reduce abnormal fertilization rate and cycle cancellation rate and improve cumulative pregnancy rate significantly enhancing patients' benefits. However, increasing the number of eggs retrieved decreases the advantages of ICSI fertilization.

Effects of leukocytospermia on the outcomes of assisted reproductive technology

Leukocytospermia is one of the common causes of male infertility, and its effects on the clinical outcomes of assisted reproduction are controversial. There are no recommendations for the management of leukocytospermia in cases of assisted reproductive technology (ART). To investigate the impact of leukocytospermia on ART, we retrospectively compared the clinical outcomes in ART couples with or without leukocytospermia and further analysed the impact of the insemination method itself by split insemination treatment in ART couples with leukocytospermia. In this study, leukocytospermia was detected in 133 patients, namely 63 in the conventional in vitro fertilization (IVF) group, 38 in the intracytoplasmic sperm injection (ICSI) group and 32 in the split insemination group. Leukocytospermia has a negative influence on the parameters of semen samples; however, leukocytospermia did not affect the clinical outcomes of IVF or ICSI. Different insemination methods did not affect the fertilization, clinical pregnancy or live birth rates. In the split insemination study, no significant differences in clinical pregnancy and live birth rates between the IVF and ICSI groups were found; however, the numbers of two pronuclei (2PN), available embryos and good‐quality embryos in the ICSI group were higher than those in the IVF group. Leukocytospermia may be a risk factor affecting semen parameters, and more attention should be given to IVF insemination. Leukocytospermia has no significant negative effect on the outcomes of ART. ICSI may obtain better embryos than IVF, but it cannot improve the clinical pregnancy and live birth rates.

IVF or ICSI for fertility preservation?

In IVF, eggs and sperm are added together for fertilisation to occur whereas ICSI involves injecting a single sperm into each egg. ICSI is very effective where sperm count or swimming is poor (male infertility) but is slightly riskier than IVF in terms of health problems in children, although these risks are small. However, the risk of no eggs fertilising is higher for IVF compared to ICSI and couples undertaking fertility preservation, for example, before cancer treatment, usually only have time for one attempt. Using fertility preservation treatment cycle data reported to Human Fertilisation and Embryology Authority (HFEA), this study shows that ICSI results in higher number of fertilised eggs and embryos for storage or treatment compared to IVF. However, 19% of eggs are not used in ICSI treatment, so IVF appears to be better overall. Clinics should choose IVF or ICSI for fertility preservation depending on sperm characteristics rather than using ICSI for all.

Effectivity of conventional in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) when male factor is absent: a perspective point of view

An objective and individualized approach of in vitro fertilization techniques tends to decrease costs and improve the experience of infertile couples during treatment. The use of available technologies to diagnose and treat infertility based on scientific evidence seems to be the best practice, which is the guideline that motivates this review on the available techniques for laboratory oocyte insemination. Conventional IVF, the pioneering technique, was initially used in the treatment of tubal obstruction infertility, successfully expanding the treatment of infertile couples presenting with several other factors. However, it was less effective in cases of severe male factor infertility. Intracytoplasmic sperm injection, which was developed in 1992, proved to be the method of choice for treating couples with severe male factor infertility. Since then, it has been increasingly used regardless of the infertility factor. This review discusses the effectiveness of conventional in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) when the male factor is absent in all aspects, as technical and clinical outcomes, associated risks, adjustments for using with other technologies and costs. Finally we discuss the advantages and disadvantages of each one, with all aspects reviewed.

Controlled spermatozoa-oocyte interaction improves embryo quality in sheep

The current protocols of in vitro fertilization and culture in sheep rely on paradigms established more than 25 years ago, where Metaphase II oocytes are co-incubated with capacitated spermatozoa overnight. While this approach maximizes the number of fertilized oocytes, on the other side it exposes them to high concentration of reactive oxygen species (ROS) generated by active and degenerating spermatozoa, and positively correlates with polyspermy. Here we set up to precisely define the time frame during which spermatozoa effectively penetrates and fertilizes the oocyte, in order to drastically reduce spermatozoa-oocyte interaction. To do that, in vitro matured sheep oocytes co-incubated with spermatozoa in IVF medium were sampled every 30 min (start of incubation time 0) to verify the presence of a fertilizing spermatozoon. Having defined the fertilization time frame (4 h, data from 105 oocytes), we next compared the standard IVF procedures overnight (about 16 h spermatozoa/oocyte exposure, group o/nIVF) with a short one (4 h, group shIVF). A lower polyspermic fertilization (> 2PN) was detected in shIVF (6.5%) compared to o/nIVF (17.8%), P < 0.05. The o/nIVF group resulted in a significantly lower 2-cell stage embryos, than shIVF [34.6% (81/234) vs 50.6% (122/241) respectively, P < 0.001]. Likewise, the development to blastocyst stage confirmed a better quality [29% (70/241) vs 23.5% (55/234), shIVF vs o/nIVF respectively] and an increased Total Cell Number (TCN) in shIVF embryos, compared with o/n ones. The data on ROS have confirmed that its generation is IVF time-dependent, with high levels in the o/nIVF group. Overall, the data suggest that a shorter oocyte-spermatozoa incubation results in an improved embryo production and a better embryo quality, very likely as a consequence of a shorter exposure to the free oxygen radicals and the ensuing oxidative stress imposed by overnight culture.

More blastocysts are produced from fewer oocytes in ICSI compared to IVF - results from a sibling oocytes study and definition of a new key performance indicator

BACKGROUND

Which fertilization method, between ICSI and IVF in split insemination treatments, has the highest clinical efficiency in producing clinically usable blastocyst?

METHODS

211 infertile couples underwent split insemination treatments for a non-severe male factor. 1300 metaphase II (MII) oocytes were inseminated by conventional IVF and 1302 MII oocytes were micro-injected with the same partner's semen. Embryo development until blastocyst stage on day V and clinical outcomes were valuated trough conventional key performance indicators (KPI), and new KPIs such as blastocyst rate per used MII oocytes and the number of MII oocytes to produce one clinically usable blastocyst from ICSI and IVF procedures.

RESULTS

The results were  globally analyzed and according to ovarian stimulation protocol, infertility indication, and female age. The conventional KPI were online with the expected values from consensus references. From global results, 2.3 MII oocyte was needed to produce one clinically usable blastocyst after ICSI compared to 2.9 MII oocytes in IVF. On the same way, more blastocysts for clinical use were produced from fewer MII oocytes in ICSI compared to IVF in all sub-groups.

CONCLUSIONS

In split insemination treatments, the yield of clinically usable blastocysts was always superior in ICSI compared to IVF. The new KPI "number of needed oocytes to produce one clinically usable embryo" tests the clinical efficiency of the IVF laboratory.

Is controlled ovarian stimulation and insemination an effective treatment in older women with male partners with decreased total motile sperm counts?

OBJECTIVE

To assess the effect of the total motile sperm counts (TMSC) on the success of controlled ovarian stimulation (COH) and intra-uterine insemination (IUI) in women 38-42 years of age.

STUDY DESIGN

A database of all women aged 38-42 years who underwent IUI with stimulation at a University Reproductive Centre between 2009 and 2018 inclusive was developed. Including stimulation with clomiphene citrate, letrozole or gonadotropins and divided into TMSC 5.00-10.0 mil and < 5.00 mil. Statistics were compared with multivariate logistic regression, t tests or Chi-squared tests.

RESULTS

A total of 397 cycles of IUI in 397 patients were included, of which, 190 cycles with TMSC 5.00-10.0 and 207 cycles with TMSC < 5.00. There were no statistical differences in the baseline characteristics between the two groups including: age (P = 0.2), gravidity (P = 0.7), parity (P = 0.6), basal FSH (P = 0.2), basal E2 (P = 0.4), antral follicular count (P = 0.5) and the number of mature follicles stimulated (P = 0.2). As expected, TMSC was 7.6 ± 1.5 mil in the first group and 2.4 ± 1.6 mil in the second group (P < 0.0001). The clinical pregnancy rate per cycle in the 5.01-10.00 TMSC group was 9.5 vs. 3.4% when TMSC < 5.00 (P = 0.01). When evaluating only women 40-42 years of age (99 women in the 5.00-10.00 TMSC group and 95 in the group of TMSC < 5.00); the pregnancy rates were not statistically different between the two groups (7 vs. 7.3%, P = 1), nor was the clinical pregnancy rate (5 vs. 6.3%, P = 0.7).

CONCLUSIONS

Women 38-39 years of age have poorer outcomes at COH/IUI when TMSC < 5 million than if it is 5-10 million. Once a woman is 40 years of age, this effect is lost. With TMSC 5-10 million, women 38-39 years of age have respectable outcomes at COH/IUI. Clinical pregnancy rates are very low in women 40 years of age with TMSC ≤ 10 million or 38-39 years old with TMSC < 5 million and other treatments should be offered.

In vitro fertilisation (IVF) versus intracytoplasmic sperm injection (ICSI) in patients without severe male factor infertility: study protocol for the randomised, controlled, multicentre trial INVICSI

INTRODUCTION

Over the last decades, the use of intracytoplasmic sperm injection (ICSI) has increased, even among patients without male factor infertility. The increase has happened even though there is no evidence to support that ICSI results in higher live birth rates compared with conventional in vitro fertilisation (IVF) in cases with nonmale factor infertility. The lack of robust evidence on an advantage of using ICSI over conventional IVF in these patients is problematic since ICSI is more invasive, complex and requires additional resources, time and effort. Therefore, the primary objective of the IVF versus ICSI (INVICSI) study is to determine whether ICSI is superior to standard IVF in patients without severe male factor infertility. The primary outcome measure is first live birth from fresh and frozen-thawed transfers after one stimulated cycle. Secondary outcomes include fertilisation rate, ongoing pregnancy rate, birth weight and congenital anomalies.

METHODS AND ANALYSIS

This is a two-armed, multicentre, randomised, controlled trial. In total, 824 couples/women with infertility without severe male factor will be recruited and allocated randomly into two groups (IVF or ICSI) in a 1:1 ratio. Participants will be randomised in variable block sizes and stratified by trial site and age. The main inclusion criteria are (1) no prior IVF/ICSI treatment, (2) male partner sperm with an expected count of minimum 2 million progressive motile spermatozoa following density gradient purification on the day of oocyte pick up and (3) age of the woman between 18 and 42 years.

ETHICS AND DISSEMINATION

The study will be performed in accordance with the ethical principles in the Helsinki Declaration. The study is approved by the Scientific Ethical Committee of the Capital Region of Denmark. Study findings will be presented, irrespectively of results at international conferences and submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04128904. Pre-results.

The Impact of Intracytoplasmic Sperm Injection in Non-Male Factor Infertility-A Critical Review

Intracytoplasmic sperm injection (ICSI) was originally designed to overcome barriers due to male factor infertility. However, a surveillance study found that ICSI use in non-male factor infertility increased from 15.4% to 66.9% between 1996 and 2012. Numerous studies have investigated fertilization rate, total fertilization failure, and live birth rate per cycle (LBR), comparing the use of ICSI versus conventional in vitro fertilization (IVF) for non-male factor infertility. The overwhelming conclusion shows no increase in fertilization rate or LBR per cycle with the use of ICSI for non-male factor infertility. The overuse of ICSI is likely related to the desire to avoid a higher rate of total fertilization failure in IVF. However, data supporting the benefit of using ICSI for non-male factor infertility is lacking, and 33 couples would need to be treated with ICSI unnecessarily to avoid one case of total fertilization failure. Such practice increases the cost to the patient, increases the burden on embryologist’s time, and is a misapplication of resources. Additionally, there remains conflicting data regarding the safety of offspring conceived by ICSI and potential damage to the oocyte. Thus, the use of ICSI should be limited to those with male factor infertility or a history of total fertilization factor infertility due to uncertainties of potential adverse impact and lack of proven benefit in non-male factor infertility.

The outcome of intra-cytoplasmic sperm injection (ICSI): do the sperm concentration and motility matter?

OBJECTIVES

The male-factor subfertility was reported to be 30% globally; thus, the intracytoplasmic sperm injection (ICSI) procedure was implemented to improve the overall in vitro fertilization (IVF) rates. Nevertheless, at least 10% of fertilization failure still occurs. Concerning this issue, we explored the association of sperm concentration and motility with the quality of embryo development and pregnancy outcome in IVF-ICSI cycles.

METHODS

Retrospective analysis of 109 couples with male factor were done over 14 months in a tertiary university hospital in Malaysia. The data were divided into four groups; Group I: normal sperm parameters, Group II: normal sperm concentration but reduced total sperm motility, Group III: reduced sperm concentration and motility, Group IV: reduced sperm concentration but normal sperm motility. Only fresh semen samples and fresh embryo transfers were included. The fertilization, cleavage rate, embryo quality and pregnancy outcome were assessed.

RESULTS

Overall, group I had the highest oocytes yield and ICSI attempted; (10.12 + 6.50), whereas the lowest was in group IV; (7.00 + 2.82). Group II revealed the highest fertilization and cleavage rates; (54.14 + 25.36), (55.16 + 26.06), thus not surprisingly resulting in the highest number of good embryos and highest clinical pregnancy rates. The lowest cleavage and pregnancy rates were seen in group IV. However, all the outcomes were not statically significant (p>0.05).

CONCLUSIONS

Similar fertilization rate and comparable pregnancy outcome was seen among couples with normal and reduced sperm concentration and motility.

The Gender Gap in the Diagnostic-Therapeutic Journey of the Infertile Couple

Medical procreation impairs both the biological and psychological lives of couples. However, male and female attitudes to infertility are different and require a different approach during the IVF journey. Thus, the gender impact assessment (GIA) method was used to analyse original studies present in the literature. We found some gender-related differences and, subsequently, possible outcomes of intervention to improve healthy reproduction management and prevent infertility. In particular, it became apparent that there was the need for an in-depth male infertility assessment and a gender-specific follow-up.

The Morphology of Inner Cell Mass Is the Strongest Predictor of Live Birth After a Frozen-Thawed Single Embryo Transfer

Background

The scoring system for human blastocysts is traditionally based on morphology; however, there are controversies on the effect of morphology parameters on pregnancy outcomes. The aim of this study is to evaluate the predicting value of each morphology parameter on pregnancy outcomes in a setting of single embryo transfer.

Methods

This is a retrospective cohort study on patients undergoing frozen-thawed single blastocyst transfer at our center, between Jan. 2009 and Dec. 2018. A total of 10,482 cycles were analyzed. The blastocysts were scored according to the expansion and hatching status, morphology of inner cell mass (ICM), and cells of trophectoderm (TE). The primary outcome measure was live birth rate. One-way analysis of variance, chi-square test, and multiple logistic regression were used for statistical analysis.

Results

The clinical pregnancy rate was lower in the blastocysts of stage 3 (48.15%), compared with those of stage 4 (56.15%), stage 5 (54.91%), and stage 6 (53.37%). The live birth rate was lower in the blastocysts of stage 3 (37.07%), compared with those of stage 4 (44.21%) and stage 5 (41.67%). The rates of clinical pregnancy (A: 66.60%, B: 53.25%, C: 39.33%) and live birth (A: 54.62%, B: 41.29%, C: 28.45%) were both decreased with decreasing grade of ICM morphology, and these differences were pairwise significant. The miscarriage rate of blastocysts with ICM grade A was lower, compared with ICM grade C (17.53 vs. 27.66%). Blastocysts with TE morphology of C had lower rates of clinical pregnancy (43.53%) and live birth (32.57%), compared with those with TE morphology of A and B (clinical pregnancy rate: 64.26% for A, 58.11% for B; live birth rate: 52.74% for A, 45.64% for B). There were no significant differences in rates of clinical pregnancy, live birth, and miscarriage between the blastocysts with TE grade A and B.

Conclusions

The blastocyst expansion stage, ICM grade, and TE grade are all associated with pregnancy outcomes. ICM grade is the strongest predictor of live birth. A blastocyst with stage 4-5, ICM grade A, and TE grade A/B should be given priority for single embryo transfer.

ICSI Does Not Improve Live Birth Rates but Yields Higher Cancellation Rates Than Conventional IVF in Unexplained Infertility

Objectives: Unexplained infertility has been one of the indications for utilization of intracytoplasmic sperm injection (ICSI). However, whether ICSI should be preferred to IVF for patients with unexplained infertility remains an open question. This study aims to determine if ICSI improves the clinical outcomes over conventional in vitro fertilization (IVF) in couples with unexplained infertility.

Methods: This was a retrospective cohort study of 549 IVF and 241 ICSI cycles for patients with unexplained infertility at a fertility center of a university hospital from January 2016 and December 2018. The live birth rate and clinical pregnancy rate were compared between the two groups. Other outcome measures included the implantation rate, miscarriage rate, and fertilization rate.

Results: The live birth rate was 35.2% (172/488) in the IVF group and 33.3% (65/195) in ICSI group, P = 0.635. The two groups also had similar clinical pregnancy rates, implantation rates, and miscarriage rates. The fertilization rate of IVF group was significantly higher than that of ICSI group (53.8 vs. 45.7%, P = 0.000, respectively). Sixty-one and 46 patients did not transfer fresh embryos in IVF and ICSI cycles, respectively. Patients with IVF cycles had lower cancellation rates than those with ICSI (11.1 vs. 19.1%, P = 0.003, respectively).

Conclusion: ICSI does not improve live birth rates but yields higher cancellation rates than conventional IVF in the treatment of unexplained infertility.

Comparison of in vitro fertilisation/intracytoplasmic sperm injection on live birth rates in couples with non-male factor infertility and advanced maternal age

PURPOSE

To determine if the use of ICSI in women of advanced maternal age with non-male factor infertility increases chances of live birth.

METHODS

Retrospective data analysis of 10 years of cycle data from a single Australian IVF clinic (Repromed). First cycle patients only of an advanced maternal age (≥ 35 years) with non-male factor infertility utilising standard IVF or ICSI insemination and having at least three oocytes collected at egg pick up were assessed for live birth following transfer of single genetically unscreened blastocyst (N = 577). Subanalysis of clinical pregnancy, miscarriage, fertilisation, embryo utilisation rate and having a blastocyst for transfer were considered. Unadjusted, covariate adjusted and propensity score weighted analysis were performed.

RESULTS

The use of standard IVF insemination in women ≥ 35 years with non-male factor infertility increased the chance of a live birth compared with ICSI insemination (unadjusted OR = 2.72, 95% CI [1.78, 4.17]; adjusted OR = 2.64, 95% CI [1.64, 4.27] and weighted OR = 2.26, 95% CI [1.72, 2.98] 31% vs 14%). All other outcomes (fertilisation rate, embryo utilisation, blastocyst for embryo transfer and miscarriage rate) were unaffected.

CONCLUSION

In couples with advanced maternal age and non-male factor infertility, standard IVF insemination appears to increase the chance of a live birth compared with ICSI. As such, the results of this study support the use of routine IVF as the preferred insemination technique for older women in non-male factor infertility. However, future randomised controlled trials are still required to assess this policy.

The effect of ICSI in infertility couples with non-male factor: a systematic review and meta-analysis

PURPOSE

We performed a systematic review and meta-analysis of available literature to investigate the efficacy of the intracytoplasmic sperm injection (ICSI) in couples with non-male factor with respect to the clinical outcomes.

METHODS

The literature search was based on EMBASE, PubMed, and the Cochrane Library. All studies published after 1992 until February 2020 and written in English addressing patients in the presence of normal semen parameters subjected to ICSI and in vitro fertilization (IVF) were eligible. Reference lists of retrieved articles were hand-searched for additional studies. The primary outcomes were fertilization rate, clinical pregnancy rate, and implantation rate; the secondary outcomes were good-quality embryo rate, miscarriage rate, and live birth rate.

RESULTS

Four RCTs and twenty-two cohort studies fulfilling the inclusion criteria were included. Collectively, a meta-analysis of the outcomes in RCTs showed that compared to IVF, ICSI has no obvious advantage in fertilization rate (RR = 1.16, 95% CI: 0.83-1.62), clinical pregnancy rate (RR = 1.04, 95% CI: 0.66-1.64), implantation rate (RR = 1.12, 95% CI: 0.67-1.86), and live birth rate (RR = 1.17, 95% CI: 0.43-3.15). Pooled results of cohort studies demonstrated a statistically significant higher fertilization rate (RR = 1.16, 95% CI: 1.03-1.31) and miscarriage rate (RR = 1.04, 95% CI: 1.01-1.06) in the ICSI group; furthermore, higher clinical pregnancy rate (RR = 0.85, 95% CI: 0.77-0.94), implantation rate (RR = 0.78, 95% CI: 0.65-0.95), and live birth rate (RR = 0.86, 95% CI: 0.79-0.94) was founded in the IVF group; no statistically significant difference was observed in good-quality embryo rate (RR = 0.98, 95% CI: 0.93-1.04).

CONCLUSION

ICSI has no obvious advantage in patients with normal semen parameters. Enough information is still not available to prove the efficacy of ICSI in couples with non-male factor infertility comparing to IVF.

Comparison of aneuploidy rates between conventional in vitro fertilization and intracytoplasmic sperm injection in in vitro fertilization-intracytoplasmic sperm injection split insemination cycles

Objective

To evaluate the influence of insemination methods on outcomes of preimplantation genetic testing for aneuploidy (PGT-A) by assessing PGT-A results in embryos that derived from conventional in vitro fertilization (IVF) versus intracytoplasmic sperm injection (ICSI) in sibling oocytes.

Design

Retrospective cohort study.

Setting

Single academic IVF center.

Patient(s)

A total of 118 couples who underwent 131 split insemination cycles from July 2016–July 2019.

Intervention(s)

In all cycles, sibling oocytes were allocated randomly to conventional IVF or ICSI prior to stripping. Preimplantation genetic testing for aneuploidy was performed via trophectoderm biopsy and next-generation sequencing with 24-chromosome screening.

Main Outcome Measure(s)

Rates of euploid, aneuploid, and mosaic embryos per biopsy.

Result(s)

A total of 2,129 oocytes were randomized to conventional IVF (n = 1,026) and ICSI (n = 1,103). No difference was observed in the aneuploidy rates (50.3% vs. 45.2%) and percentages of mosaic embryos (1.7% vs. 2.4%) per biopsy between conventional IVF and ICSI sibling oocytes. Percentages of different aneuploidy types and aneuploidies that involved sex chromosome abnormalities (6.2% vs. 7.2%) were similar between the two groups. In the end, the overall chance to have an euploid embryo per allocated oocyte in the two groups was similar (13.2% vs. 15.5%).

Conclusion(s)

Blastocysts created with conventional IVF and ICSI using sibling oocytes had similar rates of aneuploidy and mosaicism as examined using 24-chromosome screening. It is unlikely that conventional IVF caused significant contamination during PGT-A. We recommend conventional IVF as the preferred insemination method in PGT-A cycles, and ICSI should be indicated only in cases of male-factor infertility.

The role of ICSI vs. conventional IVF for patients with advanced maternal age-a randomized controlled trial

OBJECTIVES

This study aimed to evaluate the role of intracytoplasmic sperm injection (ICSI) in the treatment of non-male factor infertile patients aged ≥ 39.

METHODS

This is a single-center, prospective, randomized controlled clinical trial, between March 2018 and December 2019. Sixty-nine patients were recruited, and sixty patients participated in the study. Their ovaries were randomized prior to the beginning of the ovarian stimulation: the oocytes from one side (n = 257) were allocated to the ICSI (ICSI arm), while those of the contralateral side (n = 258) were allocated to conventional insemination (IVF arm). The fertilization rate per oocyte retrieved, number of zygotes (2PN), and cleavage-stage embryos were assessed and compared between the two study groups.

RESULTS

The average number of zygotes (3.1 vs. 2.7 p = 0.45), the fertilization rate (72.4% vs. 65.1% p = 0.38), the average number of cleavage-stage (2.8 vs. 2.4 p = 0.29), and the average top-quality embryos (TQE) cleavage-stage embryos (1.7 vs. 1.6 p = 0.94) were comparable between the two groups. The TQE rate per randomized oocyte (41.2% vs. 41% p = 0.8) was also similar in both groups.

CONCLUSIONS

ICSI does not improve the reproductive outcomes of advanced-age patients undergoing conventional insemination for non-male factor infertility.

TRIAL REGISTRATION

NCT03370068.

ALWAYS ICSI? A SWOT analysis

PURPOSE

Intracytroplasmatic sperm injection (ICSI) is a common procedure used to improve reproductive results, even among couples without male factor infertility. However, the evidence available is still uncertain on the possible advantages and deficiencies that this procedure may have in patients with no formal indication for ICSI.

METHODS

A SWOT (strengths, weaknesses, opportunities, threats) analysis examines the possible advantages and deficiencies of performing ICSI in these patients with no formal indication.

RESULTS

The evidence suggests that ICSI is not justified for non-male factor infertile couples requiring in vitro conception. One of the major strengths associated to the procedure is the virtual elimination of cases further complicated by total fertilization failure and a combination between IVF and ICSI on sibling oocytes has been advised in the literature. Greater technical difficulties, higher costs and performing an unnecessary invasive technique in some cases represent some of the weaknesses of the procedure, and questions regarding safety issues should not be ruled out.

CONCLUSION

Despite the widespread use of ICSI in patients without a formal diagnosis of male factor infertility, evidence demonstrating its effectiveness in this population is still lacking. Additional large and well-designed randomized controlled trials are needed to clarify definitive indications for ICSI in non-male factor infertility.

Assisted Reproductive Technologies in Brazil: characterization of centers and profiles from patients treated

OBJECTIVE

The aim of this study was to analyze the application of assisted reproductive technologies (ART) in Brazil from the active clinics and the population served considering the changes in the last resolutions of the Federal Council of Medicine (CFM), which enabled the use of the techniques for anyone, regardless of their health insurance system, gender or marital status.

METHODS

This paper was based on the analysis from the "Reproductive Technologies and (in) fertility study: regulation, market and rights". We used quantitative and qualitative methodologies. In this paper, we used the empirical data produced in the quantitative study. The quantitative online survey was carried out in 2016-2018, answered by 81 fertility clinics in Brazil about their performance in 2015-2016. We opted to use the REDCap Program, a web-based application for the construction and management of online surveys and databases. The questionnaire addressed the characteristics of services, practices performed, population served and existing forms of funding.

RESULTS

The questionnaires returned corresponded to 63.1% of the clinics in the southeast region. ART is mainly offered by 90.1% private clinics. We report that 63.8% of establishments have up to 20 employees; 44.5% have been in operation between 11 and 20 years. 85.1% of the clinics reported having treated non-Brazilian residents.

CONCLUSIONS

There has been a significant increase in the provision of ART in Brazil. Access remains thoroughly dependent on its own financial resources. The new CFM resolutions have shifted from the prevailing concept of "health care" to "assisting with new family configurations".

Assisted reproductive technology in Japan: A summary report for 2017 by the Ethics Committee of the Japan Society of Obstetrics and Gynecology

PURPOSE

The Japan Society of Obstetrics and Gynecology (JSOG) has collected cycle-based assisted reproductive technology (ART) data in an online registry since 2007. Herein, we present the characteristics and treatment outcomes of ART cycles registered during 2017.

METHODS

We collected cycle-specific information for all ART cycles implemented at participating facilities and performed descriptive analysis.

RESULTS

In total, 448,210 treatment cycles and 56,617 neonates (1 in 16.7 neonates born in Japan) were reported in 2017, increased from 2016; the number of initiated fresh cycles decreased for the first time ever. The mean patient age was 38.0 years (standard deviation 4.6). A total 110,641 of 245,205 egg retrieval cycles (45.1%) were freeze-all cycles; fresh embryo transfer (ET) was performed in 55,720 cycles. A total 194,415 frozen-thawed ET cycles were reported, resulting in 66,881 pregnancies and 47,807 neonates born. Single ET (SET) was performed in 81.8% of fresh transfers and 83.4% of frozen cycles, with singleton pregnancy/live birth rates of 97.5%/97.3% and 96.7%/96.6%, respectively.

CONCLUSIONS

Total ART cycles and subsequent live births increased continuously in 2017, whereas the number of initiated fresh cycles decreased. SET was performed in over 80% of cases, and ET shifted from using fresh embryos to frozen ones.

Comparison of the assisted reproductive technology outcomes between conventional IVF and ICSI with donor oocytes in normozoospermic patients

There is no evidence for the superiority of conventional in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) using donor oocytes. This retrospective descriptive study aimed to compare the outcomes of conventional IVF (n = 506) and ICSI (n = 613) with donor oocytes in (n = 968) normozoospermic patients. Although the fertilization rate was statistically higher in the ICSI group (p < 0.001), conventional IVF provided better results than ICSI with respect to embryo quality (number of grade A embryos, p < 0.001). In addition, we observed more blastocysts in the conventional IVF group (p < 0.001) and more good quality embryos were obtained for cryopreservation compared to ICSI (p < 0.001). Regarding clinical results, there were no statistical significant differences in the positive pregnancy test, clinical pregnancy and clinical miscarriage rates between IVF and ICSI. However, the implantation rate was statistically higher when IVF was performed (50.4% vs. 43.0%, p = 0.031, OR (95% CI): 1.185 (1.050-2.530)). In conclusion, with the use of normozoospermic samples in our oocyte donation programme, IVF offers more embryo efficiency and increased implantation rates than ICSI.

ICSI Versus Conventional IVF in Women Aged 40 Years or More and Unexplained Infertility: A Retrospective Evaluation of 685 Cycles with Propensity Score Model

This study compared the cumulative live birth rates following Intracytoplasmic sperm injection (ICSI) versus conventional in vitro fertilization (cIVF) in women aged 40 years or more and unexplained infertility. A cohort of 685 women undergoing either autologous conventional IVF or ICSI was retrospectively analyzed. The effects of conventional IVF or ICSI procedure on cumulative pregnancy and live birth rates were evaluated in univariate and in multivariable analysis. In order to reduce potential differences between women undergoing either IVF or ICSI and to obtain unbiased estimation of the treatment effect, propensity score was estimated. ICSI was performed in 307 couples (ICSI group), whereas cIVF was performed in 297 couples (cIVF group), resulting in 45 and 43 live deliveries, respectively. No differences were observed in morphological embryo quality, in the number of cleavage stage embryos, in the number of transferred embryos, and in the number of vitrified embryos. As for the clinical outcome, no differences were observed in pregnancy rate, cumulative pregnancy rate, live birth rate, cumulative live birth rate, and abortion rate. The present results suggest that ICSI is not associated with increased likelihood of a live birth for unexplained, non-male factor infertility, in women aged 40 years or more.

Intracytoplasmic sperm injection (ICSI) versus conventional in vitro fertilisation (IVF) in couples with non-severe male infertility (NSMI-ICSI): protocol for a multicentre randomised controlled trial

INTRODUCTION

Intracytoplasmic sperm injection (ICSI), originally introduced as add-on to in vitro fertilisation (IVF) for couples with severe male infertility, is in current clinical practice also used in couples with mild male or even unexplained infertility. However, ICSI has involved unresolved concerns regarding the selection and damage to gametes and the health conditions of the offspring, and it is also labour intensive and therefore more expensive than conventional IVF. High-quality well-powered randomised clinical trials (RCTs) comparing ICSI and IVF are lacking.

METHODS AND ANALYSIS

We propose a multicentre, open-label RCT in 10 reproductive medical centres across China. We will study couples with non-severe male infertility (defined as a semen concentrate 5-15×106/mL or sperm with a progressive motility 10%-32%) scheduled for their first or second ICSI or IVF cycle, as low fertility rate after fertilisation are more frequent in this population, which could lead to controversy about ICSI or conventional IVF for fertilisation. On the day of oocyte retrieval, eligible participants are after informed consent be randomised to undergo either ICSI or conventional IVF in a 1:1 treatment ratio. Other standard assisted reproductive treatments are similar and parallel between two groups. Our primary outcome is ongoing pregnancy leading to live birth after the first cycle with embryo transfer. To demonstrate or refute a difference of 7% between ICSI and conventional IVF, we need to include 2346 women (1173 in each intervention arm). In addition, we will follow-up neonatal outcomes after delivery to identify the influence of ICSI on offspring.

ETHICS AND DISSEMINATION

Ethical approval was obtained from Peking University Third Hospital medical science research ethics committee. The findings will be disseminated to the public through conference presentations and peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov registry (NCT03298633).

ICSI does not offer any benefit over conventional IVF across different ovarian response categories in non-male factor infertility: a European multicenter analysis

PURPOSE

To evaluate whether ICSI offers any benefit compared with IVF in different ovarian response categories in case of non-male factor infertility.

METHODS

This is a retrospective multicenter analysis using individual patient data, conducted in 15 tertiary referral hospitals in Europe (1 center in Belgium and 14 in Spain). The study included the first cycle of all patients undergoing ovarian stimulation for IVF or ICSI in a GnRH antagonist protocol. Only patients having either IVF or ICSI for non-male factor infertility were included. Patients were divided into 4 groups based on their ovarian response as follows: group A, poor responders (1-3 oocytes); group B, suboptimal responders (4-9 oocytes); group C, normal responders (10-15 oocytes); group D, high responders (> 15 oocytes).

RESULTS

In total, 4891 patients were analyzed, of whom 4227 underwent ICSI and 664 IVF. There was no significant difference for the insemination method (ICSI vs. IVF) used among the different ovarian response categories: 87% vs. 13%, 87% vs. 13%, 86% vs. 14%, 84% vs. 16%, for groups A, B, C, and D, respectively, p value = 0.35. Mean fertilization rates and embryo utilization rates were comparable between IVF and ICSI in the whole cohort. Fresh and cumulative LBR did not differ significantly for IVF and ICSI in poor, suboptimal, normal, and high responders.

CONCLUSION

There is no advantage of ICSI over IVF as insemination method for non-male factor infertility, irrespective of the ovarian response. The number of oocytes retrieved has no value for the selection of the insemination procedure in case of non-male infertility.

Factors associated with spontaneous abortion following intracytoplasmic sperm injection (ICSI)

Objective:

The aim of this study was to describe the miscarriage rates and the factors associated with cases of spontaneous abortion observed in women offered intracytoplasmic sperm injection (ICSI).

Methods:

This cross-sectional study enrolled women who became pregnant with the aid of ICSI treated at the Babol Infertility Center (Iran) within a period of five years (2010-2015). Data were collected from patient charts and, in some cases, through phone calls. The study looked into the incidence of spontaneous abortion in women offered ICSI and the factors associated with miscarriage. The chi-square test, Fisher's exact test, and the t-test were used to analyze the data.

Results:

From a total of 145 pregnant women, 120 were included in our study. The prevalence of miscarriage was 20%. Galactorrhea was significantly more present in patients who had miscarriages (25% vs. 9.37%, p=0.04). There was a marked difference in the duration of infertility of miscarriage and non-miscarriage patients offered ICSI (6.6±8.3 vs. 4.9±7.3 years, p=0.05). No association was found between maternal age, BMI, cause of infertility, hormonal pattern, type of infertility, history of surgery, polycystic ovary syndrome, number of oocytes, or day of retrieval with miscarriage.

Is there any correlation between apoptotic genes expression in cumulus cells with embryo morphokinetics?

The aim was to assess the correlation between apoptotic genes of cumulus cells (CCs) with embryo morphokinetics as non invasive methods for embryo selection. Evaluation of cleavage activity among in vitro-fertilized embryos was dependent on determining not only expression profiles of pro- and anti-apoptotic genes in CCs surrounding ovulated oocytes but also morphokinetic parameters such as time of second PB extrusion (tPB2), pronuclei appearance (tPN), pronuclei fading (tPNf), formation of two to eight cells (t2-t8) and cleavage pattern [uneven at two cells stage, cell fusion (Fu) and trichomonas mitoses (TM)]. A total of 269 embryos from 90 intracytoplasmic sperm injection (ICSI) cycles were assessed. The data showed that t2 was associated with CCs expression of Bax, Caspase3 Bcl2 and bax/bcl2 (p = 0.000, p = 0.000, p = 0.04, p = 0.00, respectively). Uneven blastomeres embryo associated with Bax and Caspase3 (p = 0.007, p = 0.000 respectively) as well as Fu and TM embryo significantly correlated to CCs expression of Bax, Caspase3 Bcl2 and bax/bcl2 (p = 0.000, p = 0.000, p = 0.00, p = 0.00, respectively) (p = 0.006, p = 0.000, p = 0.009, p = 0.0340, respectively). Embryo morphokinetics and cleavage pattern associated with CCs apoptotic gene expression. It seems that embryo selection by morphokinetics assessment using TLM with conjunction in CCs gene expression can improve ART outcome.

The effectiveness of ICSI versus conventional IVF in couples with non-male factor infertility: study protocol for a randomised controlled trial

Study questions

Does ICSI result in a higher live birth rate as compared with conventional IVF in couples with non-male factor infertility?

What is known already

ICSI is primarily indicated for severe male factor infertility. While the use of ICSI for couples with non-male factor infertility has been increasing worldwide, this is not supported by data from randomised controlled trials. Evidence from non-randomised studies suggest no benefit from ICSI compared with conventional IVF in non-male factor infertility, if not a harm.

Study design, size, duration

This randomised, open-label, multi-centre trial aims to compare the effectiveness of one ICSI cycle and one conventional IVF cycle in infertile couples with non-male factor infertility. A total of 1064 couples will be randomly allocated to an ICSI group and a conventional IVF group. The estimated duration of the study is 30 months.

Participants/materials, setting, methods

Eligible couples are those whose husbands’ total sperm count and motility are normal, have undergone ≤2 previous IVF/ICSI attempts, use antagonist protocol for ovarian stimulation, agree to have ≤2 embryos transferred and are not participating in another IVF study at the same time. Women undergoing IVM cycles, using frozen semen or having a poor fertilisation (≤25%) in previous cycle will not be eligible. Couples will be randomised to undergo ICSI or conventional IVF (1:1) with ongoing pregnancy resulting in live birth after the first embryo transfer of the started treatment cycle as the primary endpoint. All analyses will be conducted on an intention-to-treat basis. Effect sizes will be summarised as relative risk (RR), with precision evaluated by 95% CIs.

STUDY FUNDING/COMPETING INTEREST(S)

All authors declare having no conflict of interests with regards to this trial. This work was supported by a grant from MSD [MISP #57508].

Trial registration number

NCT03428919.

Trial registration date

8 February 2018.

DATE OF FIRST PATIENT’S ENROLMENT

16 March 2018.

Should ICSI be implemented during IVF to all advanced-age patients with non-male factor subfertility?

BACKGROUD

In order to maximize In vitro fertilization (IVF) success rates in advanced- age patients, it has been suggested to favor the use of intracytoplasmic sperm injection (ICSI) over conventional insemination (CI), with the notion that ICSI would serve as a tool to overcome interference in sperm oocyte interaction and sperm oocyte penetration issues that can be related to maternal age and are not due to sperm abnormalities. We therefore aim to evaluate the role of ICSI in the treatment of non-male factor infertile patients aged ≥35 in terms of fertilization and top-quality embryo rates.

METHODS

In this retrospective cohort study, data were collected and analyzed for all patients with non-male factor infertility, aged ≥35 treated, undergoing their first IVF cycle attempt with 6 or more oocytes yield, in whom a 50% ICSI-CI division was performed.

RESULTS

Five hundreds and four oocytes were collected from 52 eligible patients. Overall, 245 oocytes underwent ICSI and 259 oocytes underwent CI. The fertilization rate was 71.0% following ICSI, compared to 50.1% in the CI treated oocytes (P < 0.001). The top quality embryo rate was 62.8% following ICSI compared to 45.5% following CI (P < 0.001). Subdividing the study population to two age groups revealed that the above differences remained significant in patients aged 35-39 yrs., whereas in those aged 40-45 yrs., the differences were non-significant but still inclined in favor of ICSI.

CONCLUSIONS

This study favors the use of ICSI in the older IVF population in order to increase both the fertilization rate and the number of top quality embryos that result per IVF cycle. Further studies are needed to establish our observations and use ICSI as the preferred approach to overcome egg sperm abnormal interactions related to advanced maternal age.

Are we Justified Doing Routine Intracytoplasmic Sperm Injection in Nonmale Factor Infertility? A Retrospective Study Comparing Reproductive Outcomes between In vitro Fertilization and Intracytoplasmic Sperm Injection in Nonmale Factor Infertility

Introduction:

Intracytoplasmic sperm insemination (ICSI) came into use in 1992 to improve fertilization in couples with male factor infertility undergoing in vitro fertilization (IVF) or in couples with fertilization failure in a prior IVF cycle. Our aim was to find out if routine ICSI has any additional benefit over conventional IVF in non male factor cases in modern Assisted Reproductive Technology (ART).

Methods:

This is a retrospective single centre study undertaken at a private IVF center. A total of 350 patients with normal male factor were included in the study of which 186 underwent conventional IVF and 134 were subjected to ICSI. They were then compared for various reproductive parameters with Live Birth Rate (LBR) being the primary outcome. P value < 0.05 was considered statistically significant.

Results:

Fertilization rates (89.99% vs 85.1%), Blastocyst formation rates (62.86% vs 50.61%) and clinical pregnancy rates (37.85% vs 32.35%) were found to be higher in the IVF group compared to the ICSI group though not statistically significant. The live birth rates in the IVF group was also higher than the ICSI group (32.71% vs 24.26%).

Conclusion:

IVF edged over ICSI in all aspects resulting in better clinical outcome with higher take home babies in non-male factor infertility. Our results show that routine ICSI should not be used as a blanket therapy for all cases in ART.

The Effect of Assisted Hatching on Live Birth Rate Following Fresh Embryo Transfer in Advanced Maternal Age

OBJECTIVE

Assisted hatching (AH) was introduced 3 decades ago as an adjunct method to in vitro fertilization (IVF) and embryo transfer (ET) to improve embryo implantation rate. Limited data are available on the effect of AH on live birth rate (LBR) in advanced maternal age. The objective of this study is to investigate the effect of AH on LBR in women aged 40 years and older.

MATERIALS AND METHODS

A retrospective study conducted at a single academic reproductive center. Women aged ≥40 years, who were undergoing their first IVF cycle were included. Laser-assisted hatching was the method used for AH and single or double embryos were transferred. Embryo transfer was performed at the cleavage or blastocyst stage. Separate analysis was performed on each ET stage. Live birth rate was the primary outcome.

RESULTS

A total of 892 patients were included. Of these, 681 women underwent cleavage ET and 211 underwent blastocyst ET. The clinical pregnancy rate in the entire group was 15.3% and the LBR was 10.2%. Baseline and cycle parameters between the AH group and the control group were comparable. Assisted hatching in the cleavage stage was associated with lower clinical pregnancy rate (odds ratio [OR], 0.52; confidence interval [CI], 0.31-0.86; P = .012) and lower LBR (OR, 0.36; CI, 0.19-0.68; P = .001). Assisted hatching did not have any effect on outcomes in blastocyst ET.

CONCLUSION

Assisted hatching does not improve the reproductive outcomes in advanced maternal age. Performing routine AH for the sole indication of advanced maternal age is not clinically justified.

Untapped Reserves: Controlling Primordial Follicle Growth Activation

Even with the benefit of assisted reproductive technologies (ART), many women are unable to conceive and deliver healthy offspring. One common cause of infertility is the inability to produce eggs capable of contributing to live birth. This can occur despite standard-of-care treatment to maximize the recovery of eggs from growing ovarian follicles. Dormant primordial follicles in the human ovary are a 'reserve ' that can be exploited clinically to overcome this problem. We discuss how controlling primordial follicle growth activation (PFGA) can produce increased numbers of high-quality eggs available for fertility treatment(s). We consider the state of the art in interventions used to control PFGA, and consider genetic and epigenetic strategies on the horizon that might improve compromised oocyte quality to increase live births.

The pioneering of intracytoplasmic sperm injection: historical perspectives

Intracytoplasmic sperm injection (ICSI) has often been heralded as a ground-breaking technique that has transformed the treatment of couples with infertility. By injecting a single spermatozoon into the cytoplasm of the oocyte, ICSI bypasses the zona pellucida and increases the chances of fertilization and subsequent embryo development, independent of semen parameters. Ever since the first live births using ICSI were reported in 1992, ICSI has become the mainstay of treating male factor infertility as well as overcoming fertilization failure associated with conventional in vitro insemination. Today, ICSI is utilized in nearly 66% of all assisted reproductive treatments worldwide and has resulted in the birth of millions of babies. The primary goal of this review is to provide historical perspectives about the pioneering of ICSI. We begin by highlighting the scientific work of early investigators who elucidated the mechanisms central to mammalian fertilization. Furthermore, we briefly discuss how these findings contributed to the development of IVF for the treatment of infertility. We then emphasize the shortcomings of IVF in treating severe forms of male factor infertility and enumerate the micromanipulation techniques that were developed to circumvent these shortcomings. Finally, we indicate how the inadequacies of these micromanipulation techniques lead to the inception, application and popularity of ICSI.

The safety of intracytoplasmic sperm injection and long-term outcomes

The pioneering of intracytoplasmic sperm injection (ICSI) approximately 25 years ago revolutionized the treatment of infertile couples. Today, ICSI remains an indispensable part of assisted reproductive treatments (ART) and has resulted in the birth of millions of babies. The 25th anniversary of ICSI marks a chronologic landmark in its evolving history. This landmark also serves as an opportunity to thoroughly appraise the safety of ICSI and analyze the long-term outcomes of ICSI-conceived children. In this review, we collate and analyze salient data accrued over the past 25 years pertaining to the long-term safety of ICSI and ICSI conceptions. We also evaluate the effects of ICSI on the perinatal outcomes, congenital malformation rates, cognitive development and reproductive health of ICSI-conceived neonates, children, adolescents and adults, respectively. In doing so, we also highlight the existence of potential confounders and biases that frequently obscure the interpretation of clinical follow-up studies.

Is there a reason to perform ICSI in the absence of male factor? Lessons from the Latin American Registry of ART

Study question

Does the use of ICSI offer any outcome advantage over IVF in patients with non-male factor infertility?

Summary answer

We did not find any outcome improvement that justifies the routine use of ICSI over IVF in non-male factor ART cycles.

What is already known

Since its introduction in Latin America, the use of ICSI has increased substantially, even among patients without male factor infertility. However, it is not clear whether ICSI provides an advantage over IVF in non-male factor infertility.

Study design size duration

A retrospective cohort study of fresh cycles performed in 155 ART clinics located in 15 Latin American countries between 2012 and 2014. Records were assessed for 49,813 ART cycles (39,564 ICSI and 10,249 IVF) performed in infertile couples who did not have male factor infertility. Student's t-test was used to analyze normally distributed data, Wilcoxon test to analyze non-normally distributed data, and Fisher's exact test for categorical data. Logistic regression was used to quantify the effect of ICSI on delivery rate, adjusting for age of female partner, number of oocytes inseminated, number of embryos transferred, and transfer at blastocyst stage as possible confounding factors. Poisson regression analysis was used to quantify the effect of ICSI on fertilization rate, adjusting for age of female partner.

Participants/materials setting method

Cycles with the diagnosis of male factor and use of cryopreserved semen and with a freeze-all strategy were excluded.

Main results and the role of chance

After correcting for age of female partner, number of oocytes inseminated, number of embryos transferred and transfer at blastocyst stage, we found that the use of ICSI was associated with a significant decrease in the odds of delivery compared to IVF (odds ratio 0.88, 95% CI 0.84 to 0.93; P < 0.0001).

Limitations reasons for caution

An important limitation of this study is the lack of randomization owing to its retrospective nature. This could result in selection bias, i.e. couples with the worst prognosis undergoing ICSI, or patients with a history of fertilization failure in IVF cycles undergoing ICSI. More than one cycle from the same couple may be included in the study.

Wider implications of the findings

The lack of an outcome benefit-and, indeed, a reduced likelihood of delivery-following ICSI in non-male factor infertile couples suggests that ICSI may not be the most appropriate clinical approach in these patients.

Study funding/competing interests

None.

The molecular characterization of porcine egg precursor cells

Female-factor infertility can be caused by poor oocyte quality and depleted ovarian reserves. Egg precursor cells (EPCs), isolated from the ovarian cortex, have the potential to be used to overcome female infertility. We aimed to define the origins of EPCs by analyzing their gene expression profiles and mtDNA content using a mini-pig model. We characterized FAC-sorted DDX4⁺-derived porcine EPCs by performing RNA-sequencing and determined that they utilize pathways important for cell cycle and proliferation, which supports the existence of adult mitotically active oogonial cells. Expression of the pluripotent markers Sox2 and Oct4, and the primitive germ cell markers Blimp1 and Stella were not detected. However, Nanog and Ddx4 were expressed, as were the primitive germ cell markers Fragilis, c-Kit and Tert. Moreover, porcine EPCs expressed self-renewal and proliferation markers including Myc, Esrrb, Id2, Klf4, Klf5, Stat3, Fgfr1, Fgfr2 and Il6st. The presence of Zp1, Zp2, Zp3 and Nobox were not detected, indicating that porcine EPCs are not indicative of mature primordial oocytes. We performed mitochondrial DNA Next Generation Sequencing and determined that one mtDNA variant harbored by EPCs was present in oocytes, preimplantation embryos and somatic tissues over three generations in our mini-pig model indicating the potential germline origin of EPCs.

Pre-implantation genetic diagnosis-should we use ICSI for all?

OBJECTIVE

Intracytoplasmic sperm injection (ICSI) is commonly used during pre-implantation genetic diagnosis (PGD) in vitro fertilization (IVF), aiming to eliminate the risk of contamination from extraneous sperm DNA. Recently, ICSI "overuse" in non-male infertility has been doubted, since it does not offer an advantage over IVF. Prompted by the aforementioned observations, we sought to assess the accuracy of IVF vs ICSI in PGD cases, as might be reflected by a difference in the prevalence of discarded embryos as a consequent of parental contamination.

METHODS

Cohort-historical study of all consecutive patients admitted to the IVF-PGD program in a large tertiary center. The percentages of complete, incomplete diagnosis, PCR failure, abnormal embryos, and the contamination rate with paternal DNA in the IVF-only and the ICSI-only groups. We reviewed the computerized files of all consecutive women admitted to our IVF for a PGD-PCR cycle. Patients were divided accordingly into three groups: an IVF group-where all the oocytes underwent IVF only, an ICSI group-where all oocytes underwent ICSI, and a mixed group-where sibling oocytes underwent both IVF and ICSI. The laboratory data and the genetic diagnostic results were collected and compared between the different insemination groups.

RESULTS

Nine-hundred and twenty-seven patients underwent IVF-PGD cycles in our program, 315 in the IVF group, 565 in the ICSI group, and 47 in the mixed group. No differences were observed in fertilization rates, the percentage of embryos available for biopsy, and the percentages of complete, incomplete diagnosis, PCR failure, or abnormal embryos, between the IVF-only and the ICSI-only groups and between the IVF and the ICSI of sibling oocytes in the mixed group. Moreover, contamination with paternal DNA, through contamination with sperm cells, was negligible. Not one single case of misdiagnosis was encountered during the study period.

CONCLUSION

It might be therefore concluded that IVF should be the preferred insemination methods in PGD cycles, and ICSI should be indicated only in cases of male-factor infertility.