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Meseguer F, Giménez Rodríguez C, Rivera Egea R, Carrión Sisternas L, Remohí JA, Meseguer M. Can Microfluidics Improve Sperm Quality? A Prospective Functional Study. Biomedicines 2024; 12:1131. [PMID: 38791093 PMCID: PMC11118748 DOI: 10.3390/biomedicines12051131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 05/13/2024] [Accepted: 05/17/2024] [Indexed: 05/26/2024] Open
Abstract
The same sperm selection techniques in assisted reproduction clinics have remained largely unchanged despite their weaknesses. Recently, microfluidic devices have emerged as a novel methodology that facilitates the sperm selection process with promising results. A prospective case-control study was conducted in two phases: 100 samples were used to compare the microfluidic device with Density Gradient, and another 100 samples were used to compare the device with the Swim-up. In the initial phase, a significant enhancement in progressive motility, total progressive motile sperm count, vitality, morphology, and sperm DNA fragmentation were obtained for the microfluidic group compared to Density Gradient. Nevertheless, no statistically significant differences were observed in sperm concentration and chromatin structure stability. In the subsequent phase, the microfluidic group exhibited significant increases in sperm concentration, total progressive motile sperm count, and vitality compared to Swim-up. However, non-significant differences were seen for progressive motility, morphology, DNA structure stability, and DNA fragmentation. Similar trends were observed when results were stratified into quartiles. In conclusion, in a comparison of microfluidics with standard techniques, an improvement in sperm quality parameters was observed for the microfluidic group. However, this improvement was not significant for all parameters.
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Affiliation(s)
- Fernando Meseguer
- IVIRMA Global Research Alliance, IVIRMA Valencia, Plaza de la Policía Local 3, 46015 Valencia, Spain; (R.R.E.); (M.M.)
| | - Carla Giménez Rodríguez
- IVIRMA Global Research Alliance, IVI Foundation, Instituto de Investigación Sanitaria La Fe (IIS La Fe), 46026 Valencia, Spain; (C.G.R.); (L.C.S.)
| | - Rocío Rivera Egea
- IVIRMA Global Research Alliance, IVIRMA Valencia, Plaza de la Policía Local 3, 46015 Valencia, Spain; (R.R.E.); (M.M.)
| | - Laura Carrión Sisternas
- IVIRMA Global Research Alliance, IVI Foundation, Instituto de Investigación Sanitaria La Fe (IIS La Fe), 46026 Valencia, Spain; (C.G.R.); (L.C.S.)
| | - Jose A. Remohí
- IVIRMA Global Research Alliance, IVIRMA Valencia, Plaza de la Policía Local 3, 46015 Valencia, Spain; (R.R.E.); (M.M.)
- IVIRMA Global Research Alliance, IVI Foundation, Instituto de Investigación Sanitaria La Fe (IIS La Fe), 46026 Valencia, Spain; (C.G.R.); (L.C.S.)
| | - Marcos Meseguer
- IVIRMA Global Research Alliance, IVIRMA Valencia, Plaza de la Policía Local 3, 46015 Valencia, Spain; (R.R.E.); (M.M.)
- IVIRMA Global Research Alliance, IVI Foundation, Instituto de Investigación Sanitaria La Fe (IIS La Fe), 46026 Valencia, Spain; (C.G.R.); (L.C.S.)
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Wang J, Xiong S, Gao Y, Xia F, Wei B, Zou J, Huang G, Han W. Should ICSI be implemented on patients with poor-quality embryos in the previous IVF cycle? Heliyon 2023; 9:e17996. [PMID: 37483760 PMCID: PMC10362230 DOI: 10.1016/j.heliyon.2023.e17996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 07/01/2023] [Accepted: 07/05/2023] [Indexed: 07/25/2023] Open
Abstract
This study was to evaluate whether Intracytoplasmic sperm injection (ICSI) can improve the quality of embryo in patients with poor-quality embryos in the previous In-vitro fertilization (IVF) cycle, which was cancelled before transfer. This was a retrospective cohort study of 178 IVF and 158 ICSI cycles for patients with poor-quality embryos in the previous IVF cycle in the Center for Reproductive Medicine, Women and Children's Hospital of Chongqing Medical University from March 2016 to June 2022. The 2 PN rate, oocyte utilization rate , high-quality embryo rate and clinical pregnancy rate were compared between the two groups. Furthermore, the implantation rate, miscarriage rate and cycle cancelation rate were measured and compared. ICSI resulted in a comparable 2 PN rate, oocyte utilization rate and cycle cancelation rate with IVF. The high-quality embryo rate of ICSI group was significantly higher than that of IVF group (5.56% vs. 2.60%, P < 0.05). Eventually, a total of 239 patients performed embryo transfer. ICSI resulted in a significantly higher clinical pregnancy rate (55.56% vs. 40.98%, P < 0.05) compared with IVF, however, there were no notable differences in miscarriage rate and implantation rate. The present study suggested that ICSI significantly improved the high-quality embryo rate and clinical pregnancy of the patients with poor-quality embryos in the previous IVF cycle. Prospective randomized controlled trials are needed to further verify.
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Affiliation(s)
- Jiang Wang
- Chongqing Key Laboratory of Human Embryo Engineering, Center for Reproductive Medicine, Women and Children's Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Clinical Research Center for Reproductive Medicine, Chongqing Health Center for Women and Children, Chongqing, China
| | - Shun Xiong
- Chongqing Key Laboratory of Human Embryo Engineering, Center for Reproductive Medicine, Women and Children's Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Clinical Research Center for Reproductive Medicine, Chongqing Health Center for Women and Children, Chongqing, China
| | - Yang Gao
- Chongqing Key Laboratory of Human Embryo Engineering, Center for Reproductive Medicine, Women and Children's Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Clinical Research Center for Reproductive Medicine, Chongqing Health Center for Women and Children, Chongqing, China
| | - Fei Xia
- Chongqing Key Laboratory of Human Embryo Engineering, Center for Reproductive Medicine, Women and Children's Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Clinical Research Center for Reproductive Medicine, Chongqing Health Center for Women and Children, Chongqing, China
| | - Biao Wei
- Chongqing Key Laboratory of Human Embryo Engineering, Center for Reproductive Medicine, Women and Children's Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Clinical Research Center for Reproductive Medicine, Chongqing Health Center for Women and Children, Chongqing, China
| | - Jiayi Zou
- Chongqing Key Laboratory of Human Embryo Engineering, Center for Reproductive Medicine, Women and Children's Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Clinical Research Center for Reproductive Medicine, Chongqing Health Center for Women and Children, Chongqing, China
| | - Guoning Huang
- Chongqing Key Laboratory of Human Embryo Engineering, Center for Reproductive Medicine, Women and Children's Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Clinical Research Center for Reproductive Medicine, Chongqing Health Center for Women and Children, Chongqing, China
| | - Wei Han
- Chongqing Key Laboratory of Human Embryo Engineering, Center for Reproductive Medicine, Women and Children's Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Clinical Research Center for Reproductive Medicine, Chongqing Health Center for Women and Children, Chongqing, China
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Begon E, Lefebvre T, Arbo E, Bouée S, Darné B, Jaffré F, Languille S, Mellouhi D, Pont JC, Rousset N, Fréour T. Does paternal age affect the live birth rate in donor oocyte cycles? A systematic review and meta-analysis. J Assist Reprod Genet 2023; 40:617-626. [PMID: 36652117 PMCID: PMC10033779 DOI: 10.1007/s10815-023-02714-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 01/05/2023] [Indexed: 01/19/2023] Open
Abstract
PURPOSE While delayed parenthood is increasing worldwide, the effect of paternal age on in vitro fertilization (IVF) outcomes remains unclear. The egg donation model appears to be relevant to studying the independent impact of paternal age on clinical outcome, but the available studies are heterogeneous and contradictory. This systematic review and meta-analysis aimed to assess the relationship between paternal age and live birth rate (LBR) in egg donation cycles. METHODS A systematic search of the literature was conducted in PubMed, Embase, and the Cochrane Library from inception to June 30, 2021. All studies on egg donation cycles where LBR is reported according to male age were included. Study selection, bias assessment, and data extraction were performed by two independent reviewers according to the Cochrane methods. RESULTS Eleven studies involving 10,527 egg donation cycles were finally included. The meta-analysis showed a slight but significant and linear decrease in LBR with increasing paternal age (estimate - 0.0055; 95% CI (- 0.0093; - 0.0016), p = 0.006), with low heterogeneity (I2 = 25%). No specific threshold was identified. A similar trend toward decreased clinical pregnancy rate with advancing paternal age was found but did not reach statistical significance (p = 0.07). CONCLUSION This meta-analysis demonstrates that increasing paternal age is associated with a slight but significant and linear decrease in the live birth rate in egg donation cycles, with no apparent threshold effect. Although this requires further confirmation, this information is important for counseling men who are considering delayed childbearing.
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Affiliation(s)
- Emmanuelle Begon
- Service de chirurgie gynécologique et médecine de la reproduction, CHU Bordeaux, Hôpital Pellegrin, 33000, Bordeaux, France
| | - Tiphaine Lefebvre
- Service de biologie et médecine de la reproduction, CHU de Nantes, CHU Nantes, Nantes Université, 38 Boulevard Jean Monnet, 44093, Nantes, France
| | | | - Sarah Bouée
- Service de biologie et médecine de la reproduction, CHU Brest, Hôpital Morvan, 29200, Brest, France
| | | | - Frédérique Jaffré
- Clinique Mutualiste La Sagesse, 4 place saint Guénolé, 35 000, Rennes, France
| | | | | | | | | | - Thomas Fréour
- Service de biologie et médecine de la reproduction, CHU de Nantes, CHU Nantes, Nantes Université, 38 Boulevard Jean Monnet, 44093, Nantes, France.
- Center for Research in Transplantation and Translational Immunology, UMR 1064, Nantes Université, CHU Nantes, INSERM, F-44000, Nantes, France.
- Department of Obstetrics Gynecology and Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain.
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Nguyen HTT, Dang HNT, Nguyen TTT, Nguyen TV, Dang TC, Nguyen QHV, Le MT. Correlations between abnormalities of morphological details and DNA fragmentation in human sperm. Clin Exp Reprod Med 2022; 49:40-48. [PMID: 35255657 PMCID: PMC8923625 DOI: 10.5653/cerm.2021.04777] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 09/06/2021] [Indexed: 12/19/2022] Open
Abstract
Objective: As the associations of sperm DNA fragmentation with morphology have not been examined in detail, this study aimed to investigate the relationship between abnormalities of morphological details and DNA integrity in human sperm.Methods: In this cross-sectional study, men from infertile couples were enrolled at Hue Center for Reproductive Endocrinology and Infertility, Vietnam. Conventional semen parameters, including morphological details, were analyzed following the World Health Organization 2010 criteria. Sperm DNA fragmentation was evaluated using a sperm chromatin dispersion assay. The relationships and correlations between semen parameters, sperm morphology, and the type of halosperm and the DNA fragmentation index (DFI) were analyzed.Results: Among 130 men in infertile couples, statistically significant differences were not found in the sperm halo type between the normal and abnormal sperm morphology groups. The percentage of round-head spermatozoa was higher in the DFI >15% group (16.98%±12.50%) than in the DFI ≤15% group (13.13%±8.82%), higher values for amorphous heads were found in the DFI >15% group, and lower values for tapered heads were observed in the DFI ≤15% group; however, these differences were not statistically significant. Small-halo sperm and the DFI were positively correlated with round-head sperm (r=0.243, p=0.005 and r=0.197, p=0.025, respectively). Conclusion: The rate of general sperm morphological abnormalities in semen analysis was not related to sperm DNA integrity. However, round sperm heads were closely associated with sperm DNA fragmentation.
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Affiliation(s)
| | - Hong Nhan Thi Dang
- Center for Reproductive Endocrinology and Infertility, Hue University, Hue, Vietnam
| | | | - Trung Van Nguyen
- Center for Reproductive Endocrinology and Infertility, Hue University, Hue, Vietnam
| | - Thuan Cong Dang
- Departments of Histology, Embryology, and Pathology, Hue University of Medicine and Pharmacy, Hue University, Hue, Vietnam
| | - Quoc Huy Vu Nguyen
- Department of Obstetrics and Gynecology, Hue University of Medicine and Pharmacy, Hue University, Hue, Vietnam
| | - Minh Tam Le
- Center for Reproductive Endocrinology and Infertility, Hue University, Hue, Vietnam
- Department of Obstetrics and Gynecology, Hue University of Medicine and Pharmacy, Hue University, Hue, Vietnam
- Corresponding author: Minh Tam Le Department of Obstetrics and Gynecology, Hue University of Medicine and Pharmacy, Hue University, 6 Ngo Quyen st, Hue, Viet Nam Tel: +84-23-4626-9696 Fax: +84-23-4382-2173 E-mail:
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Villani MT, Morini D, Spaggiari G, Falbo AI, Melli B, La Sala GB, Romeo M, Simoni M, Aguzzoli L, Santi D. Are sperm parameters able to predict the success of assisted reproductive technology? A retrospective analysis of over 22,000 assisted reproductive technology cycles. Andrology 2021; 10:310-321. [PMID: 34723422 PMCID: PMC9298690 DOI: 10.1111/andr.13123] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 10/26/2021] [Accepted: 10/27/2021] [Indexed: 12/23/2022]
Abstract
Background An explosive increase in couples attending assisted reproductive technology has been recently observed, despite an overall success rate of about 20%–30%. Considering the assisted reproductive technology‐related economic and psycho‐social costs, the improvement of these percentages is extremely relevant. However, in the identification of predictive markers of assisted reproductive technology success, male parameters are largely underestimated so far. Study design Retrospective, observational study. Objectives To evaluate whether conventional semen parameters could predict assisted reproductive technology success. Materials and methods All couples attending a single third‐level fertility center from 1992 to 2020 were retrospectively enrolled, collecting all semen and assisted reproductive technology parameters of fresh cycles. Fertilization rate was the primary end‐point, representing a parameter immediately dependent on male contribution. Pregnancy and live birth rates were considered in relation to semen variables. Statistical analyses were performed using the parameters obtained according to the World Health Organization manual editions used for semen analysis. Results Note that, 22,013 in vitro fertilization and intracytoplasmic sperm injection cycles were considered. Overall, fertilization rate was significantly lower in patients with abnormal semen parameters compared to normozoospermic men, irrespective of the World Health Organization manual edition. In the in vitro fertilization setting, both progressive motility (p = 0.012) and motility after capacitation (p = 0.002) significantly predicted the fertilization rate (statistical accuracy = 71.1%). Sperm motilities also predicted pregnancy (p < 0.001) and live birth (p = 0.001) rates. In intracytoplasmic sperm injection cycles, sperm morphology predicted fertilization rate (p = 0.001, statistical accuracy = 90.3%). Sperm morphology significantly predicted both pregnancy (p < 0.001) and live birth (p < 0.001) rates and a cut‐off of 5.5% was identified as a threshold to predict clinical pregnancy (area under the curve = 0.811, p < 0.001). Discussion Interestingly, sperm motility plays a role in predicting in vitro fertilization success, while sperm morphology is the relevant parameter in intracytoplasmic sperm injection cycles. These parameters may be considered reliable tools to measure the male role on ART outcomes, potentially impacting the clinical management of infertile couples.
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Affiliation(s)
- Maria Teresa Villani
- Department of Obstetrics and Gynaecology, Fertility Centre, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Daria Morini
- Department of Obstetrics and Gynaecology, Fertility Centre, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Giorgia Spaggiari
- Department of Medical Specialties, Unit of Endocrinology, Ospedale Civile of Baggiovara, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
| | - Angela Immacolata Falbo
- Department of Obstetrics and Gynaecology, Fertility Centre, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Beatrice Melli
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Giovanni Battista La Sala
- Department of Obstetrics and Gynaecology, Fertility Centre, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Marilina Romeo
- Department of Medical Specialties, Unit of Endocrinology, Ospedale Civile of Baggiovara, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy.,Department of Biomedical, Metabolic and Neural Sciences, Unit of Endocrinology, University of Modena and Reggio Emilia, Modena, Italy
| | - Manuela Simoni
- Department of Medical Specialties, Unit of Endocrinology, Ospedale Civile of Baggiovara, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy.,Department of Biomedical, Metabolic and Neural Sciences, Unit of Endocrinology, University of Modena and Reggio Emilia, Modena, Italy
| | - Lorenzo Aguzzoli
- Department of Obstetrics and Gynaecology, Fertility Centre, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Daniele Santi
- Department of Medical Specialties, Unit of Endocrinology, Ospedale Civile of Baggiovara, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy.,Department of Biomedical, Metabolic and Neural Sciences, Unit of Endocrinology, University of Modena and Reggio Emilia, Modena, Italy
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Tarozzi N, Nadalini M, Coticchio G, Zacà C, Lagalla C, Borini A. The paternal toolbox for embryo development and health. Mol Hum Reprod 2021; 27:6311671. [PMID: 34191013 DOI: 10.1093/molehr/gaab042] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 05/30/2021] [Indexed: 11/12/2022] Open
Abstract
The sperm is essential for reconstitution of embryonic diploidy and highly specialized developmental functions. Immediately after gamete fusion, the sperm-borne PLC-zeta triggers activation, generating intracellular free Ca2+ oscillations. Mutations in the PLC-zeta encoding gene are associated with the absence of this factor in mature sperm and inability to achieve fertilization. Sperm play also a role in the greater game of the choreography of fertilization. In the human, the sperm centrioles are introduced into the oocyte environment with gamete fusion. They interact with the oocyte cytoskeletal apparatus to form a functional pair of centrosomes and ultimately regulate pronuclear juxtaposition in preparation for the first cleavage. As a consequence, the fidelity of chromosome segregation during the first cell divisions depends on the function of sperm centrioles. Sperm DNA integrity is essential for embryo development and health. Damaged DNA does not impact on the sperm fertilization ability following ICSI. However, detrimental effects emerge at pre- and post-implantation stages. Sperm-specific epigenetic factors also play an active role in the regulation of embryonic development, as shown by correlations between reduced embryo morphological quality and incorrect chromatin packaging during spermiogenesis or abnormal methylation of sperm CpG islands. This functional landscape demonstrates that the contribution of the sperm to development goes far beyond its well-established role in fertilization. Clinical studies confirm this view and indicate sperm function as a crucial aspect of research to increase the efficacy of assisted reproduction treatments.
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Turner KA, Fishman EL, Asadullah M, Ott B, Dusza P, Shah TA, Sindhwani P, Nadiminty N, Molinari E, Patrizio P, Saltzman BS, Avidor-Reiss T. Fluorescence-Based Ratiometric Analysis of Sperm Centrioles (FRAC) Finds Patient Age and Sperm Morphology Are Associated With Centriole Quality. Front Cell Dev Biol 2021; 9:658891. [PMID: 33968935 PMCID: PMC8100587 DOI: 10.3389/fcell.2021.658891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 03/19/2021] [Indexed: 12/22/2022] Open
Abstract
A large proportion of infertility and miscarriage causes are unknown. One potential cause is a defective sperm centriole, a subcellular structure essential for sperm motility and embryonic development. Yet, the extent to which centriolar maladies contribute to male infertility is unknown due to the lack of a convenient way to assess centriole quality. We developed a robust, location-based, ratiometric assay to overcome this roadblock, the Fluorescence-based Ratiometric Assessment of Centrioles (FRAC). We performed a case series study with semen samples from 33 patients, separated using differential gradient centrifugation into higher-grade (pellet) and lower-grade (interface) sperm fractions. Using a reference population of higher-grade sperm from infertile men with morphologically standard sperm, we found that 79% of higher-grade sperm of infertile men with substandard sperm morphology have suboptimal centrioles (P = 0.0005). Moreover, tubulin labeling of the sperm distal centriole correlates negatively with age (P = 0.004, R = -0.66). These findings suggest that FRAC is a sensitive method and that patient age and sperm morphology are associated with centriole quality.
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Affiliation(s)
- Katerina A. Turner
- Department of Biological Sciences, College of Natural Sciences and Mathematics, University of Toledo, Toledo, OH, United States
| | - Emily L. Fishman
- Department of Biological Sciences, College of Natural Sciences and Mathematics, University of Toledo, Toledo, OH, United States
| | - Mariam Asadullah
- Department of Biological Sciences, College of Natural Sciences and Mathematics, University of Toledo, Toledo, OH, United States
| | - Brooke Ott
- Department of Biological Sciences, College of Natural Sciences and Mathematics, University of Toledo, Toledo, OH, United States
| | - Patrick Dusza
- Department of Biological Sciences, College of Natural Sciences and Mathematics, University of Toledo, Toledo, OH, United States
| | - Tariq A. Shah
- Department of Urology, College of Medicine and Life Sciences, University of Toledo, Toledo, OH, United States
| | - Puneet Sindhwani
- Department of Urology, College of Medicine and Life Sciences, University of Toledo, Toledo, OH, United States
| | - Nagalakshmi Nadiminty
- Department of Urology, College of Medicine and Life Sciences, University of Toledo, Toledo, OH, United States
| | - Emanuela Molinari
- Yale Fertility Center, Yale School of Medicine, New Haven, CT, United States
| | - Pasquale Patrizio
- Yale Fertility Center, Yale School of Medicine, New Haven, CT, United States
| | - Barbara S. Saltzman
- School of Population Health, College of Health and Human Services, University of Toledo, Toledo, OH, United States
| | - Tomer Avidor-Reiss
- Department of Biological Sciences, College of Natural Sciences and Mathematics, University of Toledo, Toledo, OH, United States
- Department of Urology, College of Medicine and Life Sciences, University of Toledo, Toledo, OH, United States
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