Fertilizing ability of immotile spermatozoa after intracytoplasmic sperm injection

Making immotile sperm motile using high-frequency ultrasound

Sperm motility is a natural selection with a crucial role in both natural and assisted reproduction. Common methods for increasing sperm motility are by using chemicals that cause embryotoxicity, and the multistep washing requirements of these methods lead to sperm DNA damage. We propose a rapid and noninvasive mechanotherapy approach for increasing the motility of human sperm cells by using ultrasound operating at 800 mW and 40 MHz. Single-cell analysis of sperm cells, facilitated by droplet microfluidics, shows that exposure to ultrasound leads to up to 266% boost to motility parameters of relatively immotile sperm, and as a result, 72% of these immotile sperm are graded as progressive after exposure, with a swimming velocity greater than 5 micrometer per second. These promising results offer a rapid and noninvasive clinical method for improving the motility of sperm cells in the most challenging assisted reproduction cases to replace intracytoplasmic sperm injection (ICSI) with less invasive treatments and to improve assisted reproduction outcomes.

Reliability of hypo-osmotic swelling test on fresh and frozen-thawed ejaculated or testicular immotile sperm: A sibling oocyte study

The viability of sperm is a crucial factor for achieving a successful pregnancy in intracytoplasmic sperm injection (ICSI) cycles. The aim of this study was to evaluate the accuracy of the hypo-osmotic swelling test (HOST) in fresh and frozen-thawed sperm samples of different origins (ejaculated/testicular). A retrospective analysis was conducted on the outcomes of 2167 oocytes subjected to ICSI using motile and immotile-HOST-positive sperm from 2011 to 2023. We evaluated embryonic development, as well as clinical, obstetric, and neonatal outcomes in four groups based on different sperm origins (ejaculated/testicular) and processing (fresh/frozen). When comparing the results of ICSI between motile and immotile-HOST-positive sperm within each group, it was observed that there were no significant differences in the outcomes for fresh samples. However, for frozen-thawed samples, fertilization rates and blastocyst development rates were significantly lower when ICSI was performed with immotile-HOST-positive sperm compared to motile sperm. Of note, clinical, obstetric, and neonatal outcomes were statistically similar across all groups. Our findings indicate that HOST is more reliable in fresh samples than in those subjected to the freeze-thaw process. Nonetheless, HOST is considered a safe method for selecting viable sperm in all subgroups.

Sperm Morphology Assessment in the Era of Intracytoplasmic Sperm Injection: Reliable Results Require Focus on Standardization, Quality Control, and Training

Semen analysis is the first, and frequently, the only step in the evaluation of male fertility. Although the laboratory procedures are conducted according to the World Health Organization (WHO) guidelines, semen analysis and especially sperm morphology assessment is very difficult to standardize and obtain reproducible results. This is mainly due to the highly subjective nature of their evaluation. ICSI is the choice of treatment when sperm morphology is severely abnormal (teratozoospermic). Hence, the standardization of laboratory protocols for sperm morphology evaluation represents a fundamental step to ensure reliable, accurate and consistent laboratory results that avoid misdiagnoses and inadequate treatment of the infertile patient. This article aims to promote standardized laboratory procedures for an accurate evaluation of sperm morphology, including the establishment of quality control and quality assurance policies. Additionally, the clinical importance of sperm morphology results in assisted reproductive outcomes is discussed, along with the clinical management of teratozoospermic patients.

Are Clinical Outcomes of Micro-TESE in Non-obstructive Azoospermic Men Affected by the Use of Fresh or Frozen Gametes?

Background: The combination of microsurgical testicular sperm extraction (mTESE) and intracytoplasmic sperm injection (ICSI) has become a common management option, with sperm motility being positively associated with successful outcomes. However, few studies have investigated whether the use of fresh or thawed gamete combinations affect clinical outcomes.

Objectives: To determine whether the clinical outcomes of ICSI cycles using mTESE recovered testicular sperm of non-obstructive azoospermia (NOA) patients are affected by using fresh or thawed gametes.

Material and Methods: A retrospective study was conducted of NOA patients who underwent mTESE between 2017 and 2020 at Monash IVF assisted reproductive clinics in Melbourne, Australia. The impact of gamete fresh/frozen status and sperm motility was investigated on clinical outcomes such as fertilization, blastocyst formation, clinical pregnancy, and live birth rates (LBRs).

Results:A total of 103 NOA patients underwent mTESE, with a 65.1% successful surgical-sperm-retrieval. In total 56 patients contributed to 68 ICSI cycles, with a 35.1% fertilization rate and 25% LBR per embryo transfer. Compared with fresh testicular sperm, thawed testicular sperm did not affect clinical outcomes, including LBRs [16.7% vs 12.0%; odds ratio (OR) 0.68 (0.18–2.70)]. However, the use of thawed oocytes had a negative effect on fertilization rates [fresh-oocytes, 37.8%; vitrified-oocytes, 34.5%; OR 0.86 (0.02–0.48)]. Cycles using only motile sperm had a greater fertilization rate than those using a combination of motile and non-motile sperm (49.6% vs 37.2%, p ¡ 0.05). Importantly, when exclusively non-motile sperm were available (n = 26 cycles) their injection resulted in a very low fertilization rate (2.7%) and no live births were recorded.

Conclusion: Micro-TESE is an effective treatment for NOA patients, with no clear advantage of using fresh over thawed sperm, however, the use of vitrified compared with fresh oocytes requires further investigation. Importantly, patients should be informed of the poor outcomes with the use of non-motile sperm in mTESE ICSI cycles.

ICSI outcomes for infertile men with severe or complete asthenozoospermia

BACKGROUND

Severe or complete asthenozoospermia is a rare entity that can lead to male infertility. In this study, we explored whether different extents of severe or complete asthenozoospermia could affect intracytoplasmic sperm injection (ICSI) outcomes and compared the ICSI outcomes using testicular spermatozoa with those using ejaculated spermatozoa in couples with complete asthenozoospermia.

RESULTS

Ninety-seven couples with severe or complete asthenozoospermia who underwent ICSI between January 2014 and December 2018 were included. According to the sperm category used in ICSI, patients were categorized into four groups: ejaculated progressive motile sperm group (Ep-group), ejaculated non-progressive motile sperm group (En-group), ejaculated immotile sperm group (Ei-group), and testicular sperm group (TESE-group). We compared the baseline characteristics, hormone profile, semen parameters, normal fertilization, good-quality embryos on day 3, transferred embryos, and ICSI outcomes in the four groups. The clinical pregnancy rate was significantly increased in the Ep-group (65.4%, P = 0.019) and TESE-group (63.6%, P = 0.035) compared with that in the Ei-group (23.1%). The ongoing pregnancy rate in the Ei-group was significantly lower than that in the Ep-group (23.1% vs. 61.5%, P = 0.041). Moreover, the biochemical pregnancy rate, ongoing pregnancy rate, and live birth rate were much lower in the Ei-group than in the TESE-group (30.8% vs. 63.6%, 23.1% vs. 40.4% and 23.1% vs. 40.4%, respectively).

CONCLUSIONS

In couples with complete asthenozoospermia, testicular spermatozoa should be preferred to ejaculated spermatozoa for obtaining a better ICSI outcome. With the appropriate selection of testicular spermatozoa, the extent of severe or complete asthenozoospermia may not affect the ICSI outcomes. Future studies with a larger sample size are warranted to validate these findings.

An Update on Semen Physiology, Technologies, and Selection Techniques for the Advancement of In Vitro Equine Embryo Production: Section I

Simple Summary

Male fertility is often estimated by simple sperm assessment, and therefore, it is crucial to establish species-specific baselines for normal sperm parameters. In this paper, sperm physiology, function, and common abnormalities in stallions will be reviewed.

Abstract

As the use of assisted reproductive technologies (ART) and in vitro embryo production (IVP) expand in the equine industry, it has become necessary to further our understanding of semen physiology as it applies to overall fertility. This segment of our two-section review will focus on normal sperm parameters, beginning with development and extending through the basic morphology of mature spermatozoa, as well as common issues with male factor infertility in IVP. Ultimately, the relevance of sperm parameters to overall male factor fertility in equine IVP will be assessed.

Successful birth after ICSI with testicular immotile spermatozoa from a patient with total MMAF in the ejaculates: a case report

There has been no report on the outcome of vitrified blastocyst transfer from a vitrified oocyte injected with immotile testicular spermatozoa with only multiple morphological abnormalities of the sperm flagella (MMAF). A couple diagnosed with MMAF returned to the clinic to attempt pregnancy using their vitrified oocytes. Testicular spermatozoa were injected intracytoplasmically, and the following intracytoplasmic sperm injection results were observed. In the second cycle, surplus vitrified oocytes and testicular retrieved sperm were used, but no pregnancy ensued. In the third cycle, a surplus vitrified blastocyst was transferred, and a healthy female child was delivered, with a birth weight of 3050 g and a birth length of 53 cm. In this report we describe a successful pregnancy achieved in a patient presenting MMAF. The successful pregnancy was obtained from vitrified oocytes microinjected with testicular retrieved sperm in a vitrified blastocyst transfer.

Infertility due to defective sperm flagella caused by an intronic deletion in DNAH17 that perturbs splicing

Artificial insemination in pig (Sus scrofa domesticus) breeding involves the evaluation of the semen quality of breeding boars. Ejaculates that fulfill predefined quality requirements are processed, diluted and used for inseminations. Within short time, eight Swiss Large White boars producing immotile sperm that had multiple morphological abnormalities of the sperm flagella were noticed at a semen collection center. The eight boars were inbred on a common ancestor suggesting that the novel sperm flagella defect is a recessive trait. Transmission electron microscopy cross-sections revealed that the immotile sperm had disorganized flagellar axonemes. Haplotype-based association testing involving microarray-derived genotypes at 41,094 SNPs of six affected and 100 fertile boars yielded strong association (P = 4.22 × 10-15) at chromosome 12. Autozygosity mapping enabled us to pinpoint the causal mutation on a 1.11 Mb haplotype located between 3,473,632 and 4,587,759 bp. The haplotype carries an intronic 13-bp deletion (Chr12:3,556,401-3,556,414 bp) that is compatible with recessive inheritance. The 13-bp deletion excises the polypyrimidine tract upstream exon 56 of DNAH17 (XM_021066525.1: c.8510-17_8510-5del) encoding dynein axonemal heavy chain 17. Transcriptome analysis of the testis of two affected boars revealed that the loss of the polypyrimidine tract causes exon skipping which results in the in-frame loss of 89 amino acids from DNAH17. Disruption of DNAH17 impairs the assembly of the flagellar axoneme and manifests in multiple morphological abnormalities of the sperm flagella. Direct gene testing may now be implemented to monitor the defective allele in the Swiss Large White population and prevent the frequent manifestation of a sterilizing sperm tail disorder in breeding boars.

The impact of fresh and frozen testicular tissue quality on embryological and clinical outcomes

Our ability to predict the potential of testicular spermatozoa to support embryonic development is still limited. Although motility of testicular spermatozoa is associated with embryo development, the impact of morphology and the presence of spermatozoa in the testicular sample has not been previously researched. Moreover, while the majority of data indicate no effect of cryopreservation, there are studies reporting impaired clinical outcomes due to testicular cryopreservation. In a retrospective study, 118 ICSI-TESE cycles were analysed to study the impact of (a) total quality of testicular tissue, (b) testicular tissue cryopreservation and (c) presence/motility/morphology of testicular spermatozoa in fertilisation rate, embryonic development, clinical pregnancy (CPR), ongoing pregnancy (OPR) and live birth rate (LBR). Results showed that fertilisation rate was significantly affected by both total quality of testicular tissue (p < .05) and rare presence of spermatozoa (p < .01). Moreover, total tissue quality (p < .01), cryopreservation of low-quality samples (p < .01), absence of motile testicular spermatozoa (p < .01) and poor spermatozoa morphology (p < .05) had a negative impact on the number of good quality day 3 embryos. CPR, OPR or LBR was not affected by any parameters examined. Our data suggest that the quality of testicular tissue influences both fertilisation rate and embryo development. Moreover, cryopreservation of low-quality testicular samples has a negative impact on the number of available embryos for transfer.

Risk of neurodevelopmental disorders in children born from different ART treatments: a systematic review and meta-analysis

BACKGROUND

Various techniques in assisted reproductive technology (ART) have been developed as solutions for specific infertility problems. It is important to gain consensual conclusions on the actual risks of neurodevelopmental disorders among children who are born from ART. This study aimed to quantify the relative risks of cerebral palsy, intellectual disability, autism spectrum disorder (ASD), and behavioral problems in children from different ART methods by using systematic review and meta-analysis. Healthcare providers could use the results of this study to suggest the suitable ART technique and plan optimum postnatal care.

METHODS

Pubmed, Google Scholar, and Scopus databases were used to search for studies up to January 2020. Of the 181 screened full manuscripts, 17 studies (9.39%) fulfilled the selection criteria. Based on the Newcastle-Ottawa scale ratings, 7 studies were excluded, resulting in 10 studies that were eventually included in the meta-analyses. Mantel-Haenszel risk ratio model was used in the meta-analysis, and the results are described using forest plot with 95% confidence interval. Heterogeneity was assessed using the I² value.

RESULTS

Pooled evaluation of 10 studies showed that the risk of cerebral palsy in children from assisted reproductive technology (ART) is higher than children from natural conceptions (risk ratio [RR] 1.82, [1.41, 2.34]; P = 0.00001). Risk of intellectual disability (RR 1.46, [1.03, 2.08]; P = 0.03) and ASD (RR 1.49 [1.05, 2.11]; P = 0.03) are higher in intracytoplasmic sperm injection (ICSI) children compared to conventional in vitro fertilization (IVF) children. The differences in the risk of neurodevelopmental disorders in children born after frozen and fresh embryo transfers are not significant. Analysis on potential cofounder effects, including multiple birth, preterm birth, and low birth body weight highlight possibilities of significant correlation to the risks of neurodevelopmental disorders.

CONCLUSIONS

Pooled estimates suggest that children born after ART are at higher risk of acquiring cerebral palsy. ICSI treatment causes higher risk of intellectual disability and ASD. These findings suggest the importance of the availability of intensive care unit at the time of delivery and long-term developmental evaluation particularly in children from ICSI.

Thoughts on the popularity of ICSI

Purpose

Intracytoplasmic sperm injection (ICSI) is the most widely utilized assisted reproductive technique (ART) worldwide. In this feature, we review the early assisted fertilization attempts that eventually led to the development of ICSI, and discuss its current utilization in cases of male and non-male factor infertility.

Methods

We researched the literature related to the development, indications, and current use of ICSI, such as sperm structural abnormalities, male genetic indications, surgically retrieved sperm, high sperm chromatin fragmentation, oocyte dysmorphism, and preimplantation genetic testing (PGT). We also describe the potential future applications of ICSI.

Results

This review summarizes the early micromanipulation techniques that led to the inception of ICSI. We also explore its current indications, including non-male factor infertility, where its use is more controversial. Finally, we consider the benefits of future advancements in reproductive biology that may incorporate ICSI, such as in vitro spermatogenesis, neogametogenesis, and heritable genome editing.

Conclusion

The versatility, consistency, and reliability of ICSI have made it the most prevalently utilized ART procedure worldwide.

Sperm retrieval and intracytoplasmic sperm injection outcomes with testicular sperm aspiration in men with severe oligozoospermia and cryptozoospermia

INTRODUCTION

Several studies addressed the role of testicular sperm aspiration with intracytoplasmic sperm injection (ICSI) in azoospermic men, but few have included non-azoospermic men. The aim of this study was to evaluate testicular sperm aspiration (TESA) sperm retrieval rates and ICSI outcomes in men with severe oligozoospermia.

METHODS

Data were collected retrospectively from 88 consecutive, non-azoospermic, infertile men with idiopathic severe oligozoospermia who underwent TESA between January 2011 and January 2018. Patients were categorized into four groups according to sperm concentration: <5 and >1 million/ml (group 1), <1 and > 0.1 million/ml (group 2), <0.1 million/ml (group 3), and cryptozoospermia (group 4).

RESULTS

Mean male age was 37±7 years and the mean female age was 33±4 years. Sperm was recovered successfully in 90% (79/88) of the men overall and in 100% (30/30) of the men in group 1, 97% (29/30) of the men in group 2, 88% (15/17) of the men in group 3, and 45% (5/11) of the men in group 4. Most (65%, 57/88) of the couples had an embryo transfer (ET). The overall clinical pregnancy rate per ET was 46% (26/57). The clinical pregnancy rates (per ET) were 43% (9/21) in group 1, 65% (13/20) in group 2, 36% (4/11) in group 3, and 0% (0/5) in group 4.

CONCLUSIONS

Our data indicate TESA allows for high sperm retrieval rates and acceptable ICSI pregnancy rates in men with severe oligozoospermia. However, in our experience, TESA sperm retrieval rates and ICSI outcomes are poor in cryptozoospermic men.

The Role of Genetics and Oxidative Stress in the Etiology of Male Infertility-A Unifying Hypothesis?

Despite the high prevalence of male infertility, very little is known about its etiology. In recent years however, advances in gene sequencing technology have enabled us to identify a large number of rare single point mutations responsible for impeding all aspects of male reproduction from its embryonic origins, through the endocrine regulation of spermatogenesis to germ cell differentiation and sperm function. Such monogenic mutations aside, the most common genetic causes of male infertility are aneuploidies such as Klinefelter syndrome and Y-chromosome mutations which together account for around 20-25% of all cases of non-obstructive azoospermia. Oxidative stress has also emerged as a major cause of male fertility with at least 40% of patients exhibiting some evidence of redox attack, resulting in high levels of lipid peroxidation and oxidative DNA damage in the form of 8-hydroxy-2'-deoxyguanosine (8OHdG). The latter is highly mutagenic and may contribute to de novo mutations in our species, 75% of which are known to occur in the male germ line. An examination of 8OHdG lesions in the human sperm genome has revealed ~9,000 genomic regions vulnerable to oxidative attack in spermatozoa. While these oxidized bases are generally spread widely across the genome, a particular region on chromosome 15 appears to be a hot spot for oxidative attack. This locus maps to a genetic location which has linkages to male infertility, cancer, imprinting disorders and a variety of behavioral conditions (autism, bipolar disease, spontaneous schizophrenia) which have been linked to the age of the father at the moment of conception. We present a hypothesis whereby a number of environmental, lifestyle and clinical factors conspire to induce oxidative DNA damage in the male germ line which then triggers the formation de novo mutations which can have a major impact on the health of the offspring including their subsequent fertility.

The Role of Sperm Centrioles in Human Reproduction - The Known and the Unknown

Each human spermatozoon contains two remodeled centrioles that it contributes to the zygote. There, the centrioles reconstitute a centrosome that assembles the sperm aster and participate in pronuclei migration and cleavage. Thus, centriole abnormalities may be a cause of male factor infertility and failure to carry pregnancy to term. However, the precise mechanisms by which sperm centrioles contribute to embryonic development in humans are still unclear, making the search for a link between centriole abnormalities and impaired male fecundity particularly difficult. Most previous investigations into the role of mammalian centrioles during fertilization have been completed in murine models; however, because mouse sperm and zygotes appear to lack centrioles, these studies provide information that is limited in its applicability to humans. Here, we review studies that examine the role of the sperm centrioles in the early embryo, with particular emphasis on humans. Available literature includes case studies and case-control studies, with a few retrospective studies and no prospective studies reported. This literature has provided some insight into the morphological characteristics of sperm centrioles in the zygote and has allowed identification of some centriole abnormalities in rare cases. Many of these studies suggest centriole involvement in early embryogenesis based on phenotypes of the embryo with only indirect evidence for centriole abnormality. Overall, these studies suggest that centriole abnormalities are present in some cases of sperm with asthenoteratozoospermia and unexplained infertility. Yet, most previously published studies have been restricted by the laborious techniques (like electron microscopy) and the limited availability of centriolar markers, resulting in small-scale studies and the lack of solid causational evidence. With recent progress in sperm centriole biology, such as the identification of the unique composition of sperm centrioles and the discovery of the atypical centriole, it is now possible to begin to fill the gaps in sperm centriole epidemiology and to identify the etiology of sperm centriole dysfunction in humans.

Comparison of intracytoplasmic sperm injection outcome with fresh versus frozen-thawed testicular sperm in men with nonobstructive azoospermia: a systematic review and meta-analysis

PURPOSE

The purpose of the study is to explore testicular sperm cryopreservation in patients with nonobstructive azoospermia (NOA) whether affect the outcome of subsequent intracytoplasmic sperm injection (ICSI).

METHODS

A systematic review and meta-analysis was conducted by searching the MEDLINE and EMBASE databases for relevant published studies in English language (1997-2017). Studies were eligible if they included the comparison of using fresh and frozen-thawed testicular sperm followed by ICSI. Two reviewers independently performed data extraction, quality assessment and assessed the risk of bias. The overall summary risk estimated the number of events. A meta-analysis was conducted using a random effects or fixed effects model analysis according to the test of heterogeneity.

RESULTS

A total of 17 studies with 1,261 ICSI cycles were identified. Analysis of the present data showed no difference in the fertilization outcome when comparing fresh versus frozen-thawed spermatozoa (RR = 1.02, 95% CI 0.86-1.09). Similarly, no difference in CR (RR = 1.01, 95% CI 0.96-1.05), good embryo rate (RR = 1.01, 95% CI 0.95-1.09), and IR (RR = 0.93, 95% CI 0.66-1.30) was observed if the spermatozoa was fresh or frozen-thawed. Finally, no difference in CPR or LBR was noted when using fresh or frozen-thawed cycles were analyzed separately (RR = 1.03, 95% CI 0.86-1.24; RR 1.11, 95% CI 0.88-1.41, respectively).

CONCLUSIONS

In men with NOA, the ICSI outcome is not affected by whether the retrieved testicular sperm is fresh or frozen. Sperm cryopreservation ought to be considered in every surgical sperm retrieval case, which remain feasible even in patients with few testicular sperm retrieved.

Live birth after Laser Assisted Viability Assessment (LAVA) to detect pentoxifylline resistant ejaculated immotile spermatozoa during ICSI in a couple with male Kartagener's syndrome

Primary ciliary dyskinesia (PCD) is a rare, autosomal recessive disease with abnormalities in the structure of cilia, causing impairment of muco-ciliary clearance with respiratory tract infections, heterotaxia and abnormal sperm motility with male infertility. Here, with a comprehensive literature review, we report a couple with an infertility history of 9 years and three unsuccessful IVF treatments, where male partner has Kartagener's Syndrome, a subtype of PCD, displaying recurrent respiratory infections, dextrocardia and total asthenozoospermia. His diagnosis was verified with transmission electron microscopy and genetic mutation screening, revealing total absence of dynein arms in sperm tails and homozygous mutation in the ZMYND10, heterozygous mutations in the ARMC4 and DNAH5 genes. Laser assisted viability assay (LAVA) was performed by shooting the sperm tails during sperm retrieval for microinjection, following detection of pentoxifylline resistant immotile sperm. Live births of healthy triplets, one boy and two monozygotic girls, was achieved after double blastocyst transfer.

Improvement of motility after culture of testicular spermatozoa: the effects of incubation timing and temperature

Background

Sperm motility is the reliable parameter that roles in success of intracytoplasmic sperm injection (ICSI), especially in azoospermia. Selection of appropriate culture duration, temperature and media for enhancing the sperm motility is an important issue in assisted reproduction program. The aim was to evaluate the sperm motion characteristics after culturing of testicular sperm extraction (TESE) samples at different temperatures and time intervals.

Methods

In this prospective study, 27 TESE samples were collected from young azoospermic patients. The samples were cultured in Ham’s F10+20% HAS, at different temperatures (incubation at 37 vs. 25 °C) and sperm total motility was assessed at different time intervals of 0, 24, 48 and 72 h post testicular biopsy.

Results

In vitro culture at 25 °C changed sperm motility from 13% immediately after biopsy to 76% at 24 h, 43% at 48 h and 15% at 72 h. At 37 °C, the sperm motion feature was changed to 67% at 24 h, 38.40% at 48 h and 12.03% at 72 h. Sperm motility change at 24 h was incremental in both conditions of culturing, but significant at 25 °C (P≤0.05).

Conclusions

The ideal in vitro culture for testicular spermatozoa was at 25 °C after 1 day of culture, which optimized the sperm motility in azoospermic TESE samples.

Testicular sperm aspiration (TESA) for infertile couples with severe or complete asthenozoospermia

The aim of the study was to evaluate reproductive outcomes in a cohort of infertile couples with severe and complete asthenozoospermia undergoing TESA (testicular sperm aspiration) with ICSI. We conducted a retrospective study of 28 couples with complete or severe asthenozoospermia who underwent TESA between January 2010 and December 2015. We compared TESA-ICSI outcomes of these couples to ejaculate ICSI outcomes of 40 couples with severe asthenozoospermia treated during the same time period at our institution. Couples with female factor infertility and/or female aged ≥39 were excluded. Sperm retrieval rates and ICSI outcomes [(MII oocytes, fertilization rate, good embryo rate (transferred and frozen), couples with embryo transfer (per cycle started), clinical pregnancy (per embryo transfer)] were recorded. Patients were grouped based on whether they had ejaculated (Ej-group) or testicular (TESA-group) spermatozoa used. Testicular sperm patients were further classified based on whether they had complete asthenozoospermia (0% total motility) (Tc-group) or severe asthenozoospermia (≤1% progressive motility) (Ts-group). Mean (±SD) male and female ages were 36 ± 6 and 32 ± 4, respectively. Sperm recovery by testicular sperm aspiration (TESA) was successful in 100% (28/28) of the men. The overall clinical pregnancy rate (CPR) per cycle started was 34% (23/68) with a mean of 1.1 ± 0.4 embryos transferred per transfer. Fertilization rates were significantly lower in TESA-group compared to Ej-group (52% vs. 67%, respectively; p = 0.001), while male age was significantly higher in TESA-group compared to Ej-group (34 ± 6 vs. 37 ± 6, respectively; p = 0.03). Moreover, female age was significantly higher in Tc-group compared to Ts-group (30 ± 4 vs. 33 ± 3, respectively; p = 0.0285). However, there were no significant difference in clinical pregnancy rate per embryo transfer in the Tc-group, Ts-group, and Ej-group (50% vs. 45% vs. 57%, respectively; p = 0.8219). The data suggest that testicular sperm-ICSI is no better than ejaculated sperm-ICSI in couples with severe or complete asthenozoospermia. Randomized, controlled trials comparing ejaculated vs. testicular spermatozoa are needed to assess the true benefit of TESA-ICSI in these couples.

Sperm DNA damage and its role in IVF and ICSI

While the semen analysis has traditionally been relied upon to differentiate fertile and infertile men, its utility has been questioned in the current era of assisted reproductive technologies. The desire for more sophisticated diagnostic and predictive tools has led to increased use of sperm DNA damage in the management of male infertility. Despite the availability of numerous assays to measure sperm DNA damage, our understanding of the etiology, measurement, and clinical implications of sperm DNA damage remains incomplete. While the current evidence is fraught with heterogeneity that complicates attempts at comparison and meta-analysis, there does appear to be a role for sperm DNA damage in the development and maintenance of pregnancy in the era of in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). However, as noted by the American Society for Reproductive Medicine, the routine and widespread use of sperm DNA damage testing is not yet supported. Further studies are needed to standardize the measurement of sperm DNA damage and to clarify the exact role of sperm DNA damage within the myriad of other male and female factors contributing to reproductive outcomes in IVF and ICSI.

Cellular Cargo Delivery: Toward Assisted Fertilization by Sperm-Carrying Micromotors

We present artificially motorized sperm cells-a novel type of hybrid micromotor, where customized microhelices serve as motors for transporting sperm cells with motion deficiencies to help them carry out their natural function. Our results indicate that metal-coated polymer microhelices are suitable for this task due to potent, controllable, and nonharmful 3D motion behavior. We manage to capture, transport, and release single immotile live sperm cells in fluidic channels that allow mimicking physiological conditions. Important steps toward fertilization are addressed by employing proper means of sperm selection and oocyte culturing. Despite the fact that there still remain some challenges on the way to achieve successful fertilization with artificially motorized sperms, we believe that the potential of this novel approach toward assisted reproduction can be already put into perspective with the present work.

Primary ciliary dyskinesia in adults

INTRODUCTION

Primary ciliary dyskinesia is an autosomal recessive genetic disorder leading to structural and/or functional abnormalities of motor cilia. Impaired mucociliary clearance is responsible for the development of a multi-organ disease, which particularly affects the upper and lower airways.

STATE OF THE ART

In adults, primary ciliary dyskinesia is mainly characterized by bronchiectasis and chronic ear and sinus disorders. Situs inversus is found in half of patients and fertility disorders are commonly associated. Diagnosis is based on specialized tests: reduced level of nasal nitric oxide concentrations is suggestive of primary ciliary dyskinesia, but only a nasal or bronchial biopsy/brushing with analysis of beat pattern by videomicroscopy and/or analysis of cilia morphology by electronic microscopy can confirm the diagnosis. However, the diagnosis is difficult to achieve due to the limited access to these specialized tests and to difficulties in interpreting them. Genetic tests are under development and may provide new diagnostic tools. Treatment is symptomatic, based on airway clearance techniques (e.g., physiotherapy) and systemic and/or inhaled antibiotics. Prognosis is related to the severity of the respiratory impairment, which can be moderate or severe.

PERSPECTIVES AND CONCLUSIONS

Diagnosis and management of primary ciliary dyskinesia remain poorly defined and should be supported by specialized centers to standardize the diagnosis, improve the treatment and promote research.

Healthy twin live-birth after ionophore treatment in a case of theophylline-resistant Kartagener syndrome

PURPOSE

To evaluate whether it is a feasible option to target the oocyte (with Ca(2+)-ionophore) in case that sperm motility cannot be restored in Kartagener syndrome.

METHODS

A case of a male Kartagener syndrome with exclusively immotile spermatozoa that did not react to the dimethylxanthine theophylline. Thus, half of the associated oocytes were treated for 15 min with the ready-to-use- ionophore CultActive immediately after ICSI whereas the other 50 % were injected with routine ICSI without artificial oocyte activation. Rates of fertilization, blastulation, pregnancy and live birth were evaluated.

RESULTS

Fertilization check revealed that none of the conventionally injected but 4/6 (66.7 %) of the artificially activated oocytes showed two pronuclei. Three embryos were of good and one of fair quality. Corresponding blastocyst formation rate was 3 out of 4 (75 %). A double embryo transfer led to a healthy twin birth in the 34th week of gestation (two boys with a birth weight of 1724 g and 2199 g).

CONCLUSIONS

This case indicates that Ca(2+)-ionophore treatment in cycles from theophylline-resistant Kartagener syndrome patients is a feasible option. The future will show if routine application of A23187 in Kartagener or primary cilia dyskinesis patients will be of benefit.

Normal live birth after vitrified/warmed oocytes intracytoplasmic sperm injection with immotile spermatozoa in a patient with Kartagener's syndrome

The present article is a report on two cases of male Kartagener's syndrome enrolled in intraconjugal IVF programme due to akinetospermia. Viable spermatozoa were selected using a hypo-osmotic swelling test (HOST) and pentoxifylline activation and subsequently microinjected into vitrified/warmed oocytes. The treatment enabled one of these two couples to achieve a pregnancy and to give birth to a healthy baby girl.

Management of primary ciliary dyskinesia/Kartagener's syndrome in infertile male patients and current progress in defining the underlying genetic mechanism

Kartagener's syndrome (KS) is an autosomal recessive genetic disease accounting for approximately 50% of the cases of primary ciliary dyskinesia (PCD). As it is accompanied by many complications, PCD/KS severely affects the patient's quality of life. Therapeutic approaches for PCD/KS aim to enhance prevention, facilitate rapid definitive diagnosis, avoid misdiagnosis, maintain active treatment, control infection and postpone the development of lesions. In male patients, sperm flagella may show impairment in or complete absence of the ability to swing, which ultimately results in male infertility. Assisted reproductive technology will certainly benefit such patients. For PCD/KS patients with completely immotile sperm, intracytoplasmic sperm injection may be very important and even indispensable. Considering the number of PCD/KS susceptibility genes and mutations that are being identified, more extensive genetic screening is indispensable in patients with these diseases. Moreover, further studies into the potential molecular mechanisms of these diseases are required. In this review, we summarize the available information on various aspects of this disease in order to delineate the therapeutic objectives more clearly, and clarify the efficacy of assisted reproductive technology as a means of treatment for patients with PCD/KS-associated infertility.

Levels of Tektin 2 and CatSper 2 in normozoospermic and oligoasthenozoospermic men and its association with motility, fertilization rate, embryo quality and pregnancy rate

PURPOSE

To compare the expression profiles of Tektin 2 and CatSper 2 motility proteins in the spermatozoa of normozoospermic and oligoasthenozoospermic men and determine its correlation with sperm motility, fertilization rate, embryo quality and pregnancy rate.

METHODS

Tektin 2 and CatSper 2 protein expression was studied using Western Blotting and immunofluorescence. Tektin 2 and CatSper 2 protein levels were quantified by ELISA.

RESULTS

Oligoasthenozoospermic men were found to have lower fertilization rates, poor embryo quality and lower pregnancy rates as compared to normozoospermic men. The levels of Tektin 2 and CatSper 2 are significantly lower in spermatozoa of oligoasthenozoospermic men as compared to normozoospermic controls; the levels were also lower in immotile fraction as compared to motile fraction of spermatozoa obtained from normozoospermic individuals. The levels of Tektin 2 and CatSper 2 were higher in individuals demonstrating sperm motility >60 % as compared to sperm motility <30 %. Tektin 2 but not CatSper 2 levels were positively associated with fertilization rate, embryo quality and pregnancy rate.

CONCLUSION

Levels of Tektin 2 and CatSper 2 proteins are positively associated with sperm motility parameters. Measurements of Tektin 2 levels can be correlated with the clinical outcome of ICSI.

Normal live birth after testicular sperm extraction and intracytoplasmic sperm injection in variant primary ciliary dyskinesia with completely immotile sperm and structurally abnormal sperm tails

OBJECTIVE

To report on the investigation and fertility management of variant primary ciliary dyskinesia (PCD).

DESIGN

Case report.

SETTING

University-affiliated assisted reproductive technologies practice.

PATIENT(S)

A 40 year-old man presenting with 12 months' primary infertility, complete sperm immotility, severe morphologic defects, and moderate sinopulmonary disease.

INTERVENTION(S)

Electron microscopy (EM) of sperm, nasal cilial function studies, open testis biopsy, and sperm extraction for intracytoplasmic sperm injection (ICSI).

MAIN OUTCOME MEASURE(S)

Outcome of ICSI treatment using immotile testicular sperm.

RESULT(S)

EM revealed abnormal connecting pieces, shortened midpieces with attenuated mitochondrial sheaths, poorly developed annulus, abnormal outer dense fibers, and axonemes missing the two central mircotubules. Nasal ciliary beat frequency was subnormal and dyssynchronous. Immotile testicular sperm were selected for ICSI based on physical characteristics and fertilized 12 of 18 eggs. A single day-5 blastocyst achieved a normal pregnancy and delivery of a healthy 3,840-g girl at 38 weeks' gestation.

CONCLUSION(S)

Nonclassic PCD may present with structurally abnormal completely immotile sperm, with seemingly little prospect of fertility, and moderate respiratory dysfunction supporting the presence of an underlying ciliopathy. Despite testicular sperm also being immotile and showing profound structural defects that would seem to preclude fertilization, more morphologically normal sperm are capable of establishing a normal pregnancy.

Two cases of sperm immotility: a mosaic of flagellar alterations related to dysplasia of the fibrous sheath and abnormalities of head-neck attachment

OBJECTIVE

To characterize the association of two systematic sperm defects.

DESIGN

Case report.

SETTING

University, Interdepartmental Centre for Research and Therapy of Male Infertility.

PATIENT(S)

Patient 1, 42 years old, and patient 2, 38 years old, both with severe asthenozoospermia.

INTERVENTION(S)

Family history, physical examination, hormonal analysis, microbial assays, semen analysis, transmission and scanning electron microscopy, immunocytochemistry for tubulin, and fluorescence in situ hybridization (FISH) for chromosomes 18, X, and Y.

MAIN OUTCOME MEASURE(S)

Admixture of dysplasia of the fibrous sheath (DFS) and head-tail misalignment up to acephalic sperm detected by microscopic methods.

RESULT(S)

In both patients, DFS was present in incomplete form and was associated with acephalic sperm and abnormal head-tail attachment. In patient 2, spermatozoa were also affected by necrosis that may cause fragmentation leading to short flagella; submicroscopic examination allowed defining only the origin of these "stumpy" tails. Immunofluorescence confirmed the sperm alterations. FISH revealed an altered frequency of diploidy and disomy in patient 2 and a slight increase in diploidy in patient 1.

CONCLUSION(S)

The importance of ultrastructural sperm evaluation for correct identification of sperm pathologies is evident, particularly regarding assisted reproduction technology and genetic risk assessment.

Recovery, Preparation, Storage and Utilization of Spermatozoa for Fertility Preservation in Cancer Patients and Sub-Fertile Men

Sperm cryopreservation is an important part of an infertility program for patients undergoing infertility treatments, fertility assurance for vasectomy cases, and for fertility preservation due to cancer or other medical conditions. With recent developments in reproductive technology, even men with severely impaired sperm parameters can benefit from cryopreservation as procedures such as intra-cytoplasmic sperm injection (ICSI) require only a few sperm to achieve fertilization and pregnancy. The increasing success of cancer treatment and concerted efforts to ensure quality of life after successful treatment have placed great emphasis on the need to preserve the reproductive capability of young men. It is a highly effective method of protecting male fertility potential, and involves collection, freezing, and long-term storage of sperm. Based on the etiological condition of the patients, sperm can be collected by ejaculation or by surgical retrieval from epididymis or testes. The option to bank sperm should be offered systematically to all patients who may benefit. However, this is not a standard of practice yet; it may be overlooked due to lack of physician awareness regarding the need for fertility preservation and the effectiveness of this option, and/or overestimating the limitations of poor baseline sperm quality leading physician to view cryopreservation as futile. Failure to offer cryopreservation ignores the only possible reproductive option available to certain patients.

A case of severe asthenozoospermia: a novel sperm tail defect of possible genetic origin identified by electron microscopy and immunocytochemistry

OBJECTIVE

To characterize a novel flagellar defect involving 98% of sperm tails.

DESIGN

Case report.

SETTING

Interdepartmental Centre for Research and Therapy of Male Infertility, Siena, Italy.

PATIENT(S)

A 45-year-old infertile man with severe asthenozoospermia.

INTERVENTION(S)

Family history, physical examination, hormonal analysis, microbial assays, semen analysis, transmission and scanning electron microscopy, tubulin distribution investigated by immunocytochemistry, fluorescence in situ hybridization (FISH) for chromosomes 9, 16, 18, X, and Y.

MAIN OUTCOME MEASURE(S)

Flagellar abnormalities detected by microscopical methods.

RESULT(S)

An apparent heterogeneity was observed: extremely elongated tails prone to ruptures; coiled tails at different levels with a strongly rolled axoneme or with a curl in the final flagellar segment; and V-shaped, isolated, bent tails. Transmission electron microscopy revealed the presence of normal heads, disorganized flagellar structures, and dynein deficiency. The FISH analysis was normal.

CONCLUSION(S)

We report a new sperm defect, characterized by abnormal elongation of the tail, which was prone to ruptures at different levels, concomitant with coiled tails, which were impossible to measure in length. This defect remained constant in different examined ejaculates and applied to the entire sperm population of a sterile man, the son of first-degree cousins, indicating a potential genetic origin.

The biology of infertility: research advances and clinical challenges

Reproduction is required for the survival of all mammalian species, and thousands of essential 'sex' genes are conserved through evolution. Basic research helps to define these genes and the mechanisms responsible for the development, function and regulation of the male and female reproductive systems. However, many infertile couples continue to be labeled with the diagnosis of idiopathic infertility or given descriptive diagnoses that do not provide a cause for their defect. For other individuals with a known etiology, effective cures are lacking, although their infertility is often bypassed with assisted reproductive technologies (ART), some accompanied by safety or ethical concerns. Certainly, progress in the field of reproduction has been realized in the twenty-first century with advances in the understanding of the regulation of fertility, with the production of over 400 mutant mouse models with a reproductive phenotype and with the promise of regenerative gonadal stem cells. Indeed, the past six years have witnessed a virtual explosion in the identification of gene mutations or polymorphisms that cause or are linked to human infertility. Translation of these findings to the clinic remains slow, however, as do new methods to diagnose and treat infertile couples. Additionally, new approaches to contraception remain elusive. Nevertheless, the basic and clinical advances in the understanding of the molecular controls of reproduction are impressive and will ultimately improve patient care.

Successful twin birth following blastocyst culture of embryos derived from the immotile ejaculated spermatozoa from a patient with primary ciliary dyskinesia: a case report

PURPOSE

To describe the ultrastructure of spermatozoa from a patient with complete asthenozoospermia that resulted in live births following blastocyst culture.

MATERIALS AND METHODS

Analyses of spermatozoa from a 36 year old patient were performed using light and electron microscopy. The hypo-osmotic swelling test was used to select spermatozoa for intracytoplasmic sperm injection. Embryos were cultured to the blastocyst stage.

RESULTS

100% of the spermatozoa had dynein arm deficiency with secondary defects varying from 3-17%. Six oocytes were injected; five fertilized normally and one was digynic. All five zygotes formed good quality blastocysts. Three blastocysts were cryopreserved and two blastocysts were transferred. Twin females were born at 37 weeks.

CONCLUSIONS

The hypo-osmotic swelling test can be used to select viable immotile ejaculated spermatozoa from a patient with dynein arm deficiency and can produce excellent fertilization rates and blastocyst development resulting in live births.

Severe oligoasthenoteratozoospermias, secretory and obstructive azoospermias: motility as a criterion of sperm viability

PURPOSE

Comparison of pregnancy rates in cases of Secretory Azoospermias (SA), Obstructive Azoospermias (OA) and severe Oligoasthenoteratozoospermias (OATZ). Evaluation of sperm motility as a quality criterion.

METHODS

In SA cases (n = 35), 9 samples were cryopreserved. In OA cases (epididymal aspiration: n = 91; testicular biopsy: n = 206), all samples were cryopreserved. 596 OATZ ejaculates were included.

RESULTS

In SA cases, 2 pregnancies were achieved from 9 ICSI cycles. In OA, motile sperm rates were higher in testicular biopsies. After thawing sperm motility was not different between testicular and epididymal origin. 2 pregnancies were achieved with immotile testicular sperm after thawing, but none with immotile epididymal sperm. In OATZ cases, one pregnancy was obtained from the 9 cryopreserved ejaculates and 35.3% with fresh motile sperm.

CONCLUSIONS

In SA cases, the use of donor sperm is recommended due to the lower pregnancy rate achieved. Motility, before and after cryopreservation, as a criterion of sperm viability is discussed and its use should be reconsidered in some cases.

Sperm morphology and aneuploidies: defects of supposed genetic origin

As individuals with genetic sperm defects are intracytoplasmic sperm injection candidates, the study of the chromosomal constitution of their spermatozoa is of great interest. This study is a review of the current literature concerning fluorescence in situ hybridisation studies in spermatozoa with genetic sperm defect as 'round head', 'dysplasia of fibrous sheath' (DFS), 'primary ciliary dyskinesia' (PCD), the 'detached tail' and the 'absence of fibrous sheath'. Regarding sperm head defects, elevated XY disomy and diplodies were detected. Genetic defects affecting the sperm tail seemed to have a different correlation with chromosome meiotic segregation. Only chromosome 18, among the autosomes, was studied and the percentage of frequency of disomy was generally within the normal range. In the more frequently studied defect, DFS, the alterations in gonosome disomy and diploidy were recorded by different groups. Regarding PCD defects, elevated frequencies of disomy of sex chromosomes and diploidy were observed, whereas the absence of the fibrous sheath and the detached tail did not show any meiotic disturbance. The problem of genetic sperm defects should be seriously considered when these sperm are used for assisted reproduction, owing to the high risk of transmission of chromosomal imbalance and of mutations that could cause genetic sperm defects in offspring.