Children born after intracytoplasmic sperm injection: population control study

Developmental outcomes of children born through ICSI versus conventional IVF (cIVF) in couples with non-male factor infertility

STUDY QUESTION

In non-male factor infertile couples, are there any differences in the developmental outcomes between children born through ICSI and conventional IVF (cIVF)?

SUMMARY ANSWER

In this preliminary study, ICSI and cIVF seem to have a comparable effect on developmental outcomes after 12 months in children born to non-male factor infertile couples.

WHAT IS KNOWN ALREADY

ICSI, an invasive technique, has raised concerns about potential developmental abnormalities in children. Limited data are available regarding the developmental outcomes of ICSI-conceived infants born to non-male factor infertile couples.

STUDY DESIGN, SIZE, DURATION

This prospective cohort study involved a follow-up of all children aged 12 months or older who were born from pregnancies resulting from either ICSI or cIVF as part of a previous randomized controlled trial (RCT) (NCT03428919).

PARTICIPANTS/MATERIALS, SETTING, METHODS

In the original RCT, 1064 women were randomly assigned to the ICSI or cIVF groups (532 women for each group). Follow-up was conducted with 155 couples (195 children) in the ICSI group and 141 couples (185 children) in the cIVF group. The Vietnamese version of the Ages & Stages Third Edition Questionnaires (ASQ-3) and the Development Red Flags questionnaires were completed by the participants. A total of 141 (90.1%) women (177 children) in the ICSI group and 113 (80.1%) women (145 children) in the cIVF group returned fully completed questionnaires. The primary outcomes were the developmental outcomes based on responses to the ASQ-3 and the Red Flags questionnaire.

MAIN RESULTS AND THE ROLE OF CHANCE

The mean age of children at follow-up was 19.5 ± 5.0 months in the ICSI group and 19.3 ± 5.5 months in the cIVF group. The mean height and weight of children in both groups were similar. The overall proportion of children with any abnormal ASQ-3 score did not differ significantly between the ICSI and cIVF groups (16.9% vs 13.1%, P = 0.34). The proportion of children with Red Flag signs was also comparable between the two groups (6.2% vs 9.2%, P = 0.36, ICSI vs cIVF, respectively).

LIMITATIONS, REASONS FOR CAUTION

Despite a reasonably high follow-up response rate, there is a potential risk of sampling bias, and overall, the number of children with developmental abnormalities was very small. The study relied solely on questionnaires as screening tools, rather than incorporating additional behavioral observations or physical developmental tests; this may have affected the statistical power and the significance of between-group comparisons.

WIDER IMPLICATIONS OF THE FINDINGS

The current findings contribute to the existing evidence and support the comparative safety of ICSI and cIVF regarding early childhood development. However, more extensive and prolonged follow-up data for these children are needed to draw definitive conclusions.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was received for this study, and no authors reported conflicting interests.

TRIAL REGISTRATION NUMBER

NCT04866524 (clinicaltrials.gov).

Evolution of intracytoplasmic sperm injection: From initial challenges to wider applications

Background

In vitro fertilization (IVF) has revolutionized infertility treatment. Nevertheless, male infertility requires more effective solutions. In 1992, the first-ever case of human birth via intracytoplasmic sperm injection (ICSI) was reported. ICSI involves microscopically injecting a sperm into an ovum. Successful ICSI has become a reliable therapy for couples facing infertility, a significant milestone. However, it has also introduced various challenges. This study also delves into ethical dilemmas arising from widespread ICSI use.

Methods

This review traces the history of ICSI, presenting pioneering attempts, first successful attempts, and critical reports on account of the initial skepticism toward the technology. The review also focuses on chronological progress until ICSI was recognized as effective and became widely applied.

Main findings

The review reveals that ICSI, although transformative, presents challenges. Successes include addressing male infertility and aiding fertilization. However, concerns arise regarding optimal sperm and embryo selection, genetic mutations, and long-term health implications. Ethical considerations surrounding ICSI's broad applications also surface.

Conclusions

Despite its success and effectiveness, ICSI is still evolving as a therapeutic method. By comprehensively evaluating the historical progress and the current status of ICSI and exploring its future prospects, this study highlights the importance of ICSI in infertility treatment.

Pregnancy and birth outcomes in couples with infertility with and without assisted reproductive technology: with an emphasis on US population-based studies

Infertility, defined as the inability to conceive within 1 year of unprotected intercourse, affects an estimated 80 million individuals worldwide, or 10-15% of couples of reproductive age. Assisted reproductive technology includes all infertility treatments to achieve conception; in vitro fertilization is the process by which an oocyte is fertilized by semen outside the body; non-in vitro fertilization assisted reproductive technology treatments include ovulation induction, artificial insemination, and intrauterine insemination. Use of assisted reproductive technology has risen steadily in the United States during the past 2 decades due to several reasons, including childbearing at older maternal ages and increasing insurance coverage. The number of in vitro fertilization cycles in the United States has nearly doubled from 2000 through 2013 and currently 1.7% of all live births in the United States are the result of this technology. Since the birth of the first child from in vitro fertilization >35 years ago, >5 million babies have been born from in vitro fertilization, half within the past 6 years. It is estimated that 1% of singletons, 19% of twins, and 25% of triplet or higher multiples are due to in vitro fertilization, and 4%, 21%, and 52%, respectively, are due to non-in vitro fertilization assisted reproductive technology. Higher plurality at birth results in a >10-fold increase in the risks for prematurity and low birthweight in twins vs singletons (adjusted odds ratio, 11.84; 95% confidence interval, 10.56-13.27 and adjusted odds ratio, 10.68; 95% confidence interval, 9.45-12.08, respectively). The use of donor oocytes is associated with increased risks for pregnancy-induced hypertension (adjusted odds ratio, 1.43; 95% confidence interval, 1.14-1.78) and prematurity (adjusted odds ratio, 1.43; 95% confidence interval, 1.11-1.83). The use of thawed embryos is associated with higher risks for pregnancy-induced hypertension (adjusted odds ratio, 1.30; 95% confidence interval, 1.08-1.57) and large-for-gestation birthweight (adjusted odds ratio, 1.74; 95% confidence interval, 1.45-2.08). Among singletons, in vitro fertilization is associated with increased risk of severe maternal morbidity compared with fertile deliveries (vaginal: adjusted odds ratio, 2.27; 95% confidence interval, 1.78-2.88; cesarean: adjusted odds ratio, 1.67; 95% confidence interval, 1.40-1.98, respectively) and subfertile deliveries (vaginal: adjusted odds ratio, 1.97; 95% confidence interval, 1.30-3.00; cesarean: adjusted odds ratio, 1.75; 95% confidence interval, 1.30-2.35, respectively). Among twins, cesarean in vitro fertilization deliveries have significantly greater severe maternal morbidity compared to cesarean fertile deliveries (adjusted odds ratio, 1.48; 95% confidence interval, 1.14-1.93). Subfertility, with or without in vitro fertilization or non-in vitro fertilization infertility treatments to achieve a pregnancy, is associated with increased risks of adverse maternal and perinatal outcomes. The major risk from in vitro fertilization treatments of multiple births (and the associated excess of perinatal morbidity) has been reduced over time, with fewer and better-quality embryos being transferred.

Use of ICSI in IVF cycles in women with tubal ligation does not improve pregnancy or live birth rates

STUDY QUESTION

Does ICSI improve outcomes in ART cycles without male factor, specifically in couples with a history of tubal ligation as their infertility diagnosis?

SUMMARY ANSWER

The use of ICSI showed no significant improvement in fertilization rate and resulted in lower pregnancy and live birth (LB) rates for women with the diagnosis of tubal ligation and no male factor.

WHAT IS KNOWN ALREADY

Prior studies have suggested that ICSI use does not improve fertilization, pregnancy or LB rates in couples with non-male factor infertility. However, it is unknown whether couples with tubal ligation only diagnosis and therefore iatrogenic infertility could benefit from the use of ICSI during their ART cycles.

STUDY DESIGN, SIZE, DURATION

Longitudinal cohort of nationally reported cycles in the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System (SART CORS) of ART cycles performed in the USA between 2004 and 2012.

PARTICIPANTS/MATERIALS, SETTING, METHODS

There was a total of 8102 first autologous fresh ART cycles from women with the diagnosis of tubal ligation only and no reported male factor in the SART database. Of these, 957 were canceled cycles and were excluded from the final analysis. The remaining cycles were categorized by the use of conventional IVF (IVF, n = 3956 cycles) or ICSI (n = 3189 cycles). The odds of fertilization, clinical intrauterine gestation (CIG) and LB were calculated by logistic regression modeling, and the adjusted odds ratios (AORs) with 95% confidence intervals were calculated by adjusting for the confounders of year of treatment, maternal age, race and ethnicity, gravidity, number of oocytes retrieved, day of embryo transfer and number of embryos transferred.

MAIN RESULTS AND THE ROLE OF CHANCE

The main outcome measures of the study were odds of fertilization (2PN/total oocytes), clinical intrauterine gestation (CIG/cycle) and live birth (LB/cycle). The fertilization rate was higher in the ICSI versus IVF group (57.5% vs 49.1%); however, after adjustment this trend was no longer significant (AOR 1.14, 0.97-1.35). Interestingly, both odds of CIG (AOR 0.78, 0.70-0.86), and odds of LB were lower (AOR 0.77, 0.69-0.85) in the ICSI group. Plurality at birth, mean length of gestation and birth weight did not differ between the two groups.

LIMITATIONS, REASONS FOR CAUTION

This was a retrospective study, therefore only the available parameters could be included, with parameters of interest such as smoking status not available for inclusion. Smoking status may have led practitioners to use ICSI to improve pregnancy and LB outcomes.

WIDER IMPLICATIONS OF THE FINDINGS

Studies have shown that in the USA there is an increasing usage of ICSI for non-male factor infertility despite a lack of evidence-based benefit. Our study corroborates this increasing use over the last 8 years, specifically in the tubal ligation only patient population. Even after adjusting for multiple confounders, the patients who underwent ICSI had no statistically significant improvement in fertilization rate and actually had a lower likelihood of achieving a clinical pregnancy and LB. Therefore, our data suggest that the use of ICSI in tubal ligation patients has no overall benefit. This study contributes to the body of evidence that the use of ICSI for non-male factor diagnosis does not improve ART outcomes over conventional IVF.

STUDY FUNDING/COMPETING INTERESTS

None.

An overview of studies on psychological well-being in children born following assisted reproductive technologies

Over the course of the past 35 years, assisted reproductive technologies (ARTs) have been increasingly used worldwide, while debates on their safety have been generated. Birth defects and imprinting disorders were reported in previous research. Thus, the psychological development of children born following ARTs has become a major concern nowadays. This review gives a systematic view of psychological well-being of children conceived by different types of ART, including in vitro fertilization, intracytoplasmic sperm injection (ICSI), preimplantation genetic diagnosis/screening, and in vitro maturation. The previous studies are analyzed in three sections: (1) cognitive, motor, and language developments, (2) behavior problems and socio-emotional development, and (3) parent-child relationship. We conclude that although the majority of the studies on cognitive, motor, and language developments reported comparable achievements in the ART group vs. the naturally conceived group, lower intelligence quotient (IQ) scores, worse visual-motor ability or locomotor development, and delayed receptive language competence were found in the ART group. The results on the socio-emotional development were reassuring. As for the behavior problems, a higher prevalence of behavior problems existed in ART children; moreover, ICSI children were found to be at a higher risk of autism than the general population. Meanwhile, ART parents tended to have positive parental attitudes and be more protective of their children. Some suggestions for further research are also given in this review.

Assisted reproduction and child neurodevelopmental outcomes: a systematic review

OBJECTIVE

To systematically review the existing literature on neurodevelopmental outcomes in children born after medically assisted reproduction compared with those of children born after spontaneous conception.

DESIGN

Systematic review.

SETTING

Not applicable.

PATIENT(S)

Children born after medically assisted reproduction vs. reference groups of spontaneously conceived children.

INTERVENTION(S)

Data were reviewed from worldwide published articles, without restrictions as to publication year or language. A total of 80 studies included between 31 and 2,446,044 children.

MAIN OUTCOME MEASURE(S)

Child neurodevelopmental outcomes categorized as cognitive, behavioral, emotional or psychomotor development, or diagnoses of mental disorders.

RESULT(S)

For infants, studies on psychomotor development showed no deficits, but few investigated cognitive or behavioral development. Studies on toddlers generally reported normal cognitive, behavioral, socio-emotional, and psychomotor development. For children in middle childhood, development seems comparable in children born after assisted reproduction and controls, although fewer studies have been conducted with follow-up to this age. Very few studies have assessed neurodevelopmental outcomes among teens, and the results are inconclusive. Studies investigating the risk of diagnoses of mental disorders are generally large, with long follow-up, but the results are inconsistent.

CONCLUSION(S)

It may tentatively be concluded that the neurodevelopment of children born after fertility treatment is overall comparable to that in children born after spontaneous conception.

Assisted reproductive technologies and children's neurodevelopmental outcomes

Initial reports suggested that children conceived with assisted reproductive technologies (ART) may be at increased risk for a spectrum of developmental disabilities. Evolving evidence suggests that some of the early risks may have been overstated when not taking plurality of birth or gestational age at delivery into consideration, as both are independent risk factors for neurodevelopmental disabilities arising from alterations in structure and function or limitations in activities. Continued research is needed to overcome lingering data gaps in light of the equivocal literature for many neurodevelopmental disabilities relative to ART, increasing utilization of services, and changes in the clinical management of infecund couples such as the adoption of natural cycles or in vitro maturation treatment options. Population-based cohorts with longitudinal assessment of the multifaceted nature of neurodevelopment across critical and sensitive windows is paramount for the development of empirically based guidance for clinical and population health.

Developmental outcomes among 18-month-old Malawians after a year of complementary feeding with lipid-based nutrient supplements or corn-soy flour

The major aim of this trial was to compare the development of 18-month-old infants who received complementary feeding for 1 year either with lipid-based nutrient supplements or micronutrient fortified corn-soy porridge. Our secondary aim was to determine the socio-economic factors associated with developmental outcomes in the same population. A total of 163 six-month-old rural Malawian children were enrolled in a randomized controlled trial where the control population received daily supplementation with 71 g corn-soy flour [Likuni Phala (LP)] (282 kcal) and individuals in the intervention groups received daily either 50 g of lipid-based nutrient supplement (FS50) (264 kcal) or 25 g of lipid-based nutrient supplement (FS25) (130 kcal). The main outcome measures were Griffiths' developmental scores at 0-2 years. Independent comparison of study groups was carried out using analysis of variance (ANOVA) statistics where mean raw scores, quotients, or mental ages were compared. Association of developmental outcome with predictor variables were examined using multiple regression. At 18 months of chronological age, the mean ± standard deviation (SD) mental ages in the LP, FS50, and FS25 groups were 17.9 ± 1.3, 17.9 ± 1.3, and 17.9 ± 1.2 (P > 0.99), respectively. Likewise, the mean raw developmental scores and mean developmental quotients did not differ significantly. Length-for-age z-score gain during the intervention period, and maternal education were associated with developmental outcome at 18 months (P = 0.03 and P = 0.04; respectively). In conclusion, rural Malawian infants receiving 12-month daily supplementation of their diet either with the tested lipid-based nutrient supplements or fortified corn-soy flour have comparable development outcomes by 18 months of age.

Parental infertility and developmental coordination disorder in children

BACKGROUND

It has previously been reported that children born after infertility treatment had a slight delay in early motor milestones. In this study, we examined whether children of infertile couples with or without infertility treatment had a higher risk of developmental coordination disorder (DCD).

METHODS

We used data on parental infertility and DCD among 23 167 singletons from the Danish National Birth Cohort (1996-2002). Data on time to pregnancy (TTP) and infertility treatment were collected early in pregnancy. Data on DCD in children were collected using the Developmental Coordination Disorder Questionnaire, filled in by the mothers during follow-up when the children were 7 years old. We used the recommended cut-off for the age group to classify children.

RESULTS

Compared with children born of fertile couples, children conceived after a waiting TTP of longer than 12 months had a slightly higher risk of DCD [odds ratio (OR) 1.35, 95% confidence interval (CI) 1.03-1.77], but the estimated OR was not significant in children born after infertility treatment (OR 1.19, 95% CI 0.86-1.66). None of the individual treatment procedures was significantly associated with a higher risk of DCD. Children of parents who had not planned their pregnancy showed no elevated risk.

CONCLUSIONS

Our findings are overall reassuring, although it is possible that low fecundity may be associated with a modestly increased risk of DCD.

Assessment of vision and hearing in children conceived spontaneously and by ICSI: a prospective controlled, single-blinded follow-up study

Long-term follow-up studies on the health of children born after assisted reproduction technologies are mandatory. Vision and hearing are the most important senses that continue to develop during childhood. There are few reports on vision and hearing in preschool children born after assisted conception. This prospective controlled blinded follow-up study examined 276 term-born singleton intracytoplasmic injection (ICSI) children and 273 spontaneously conceived controls at a mean age of 5.5 years and performed detailed vision and hearing test and clinically examined eyes and ears. There was no significant difference between ICSI and control children regarding the occurrence of vision or hearing impairments. Unsurprisingly, children with abnormalities in otoscopy were more likely to have an abnormal hearing test compared with children without abnormalities. Only 8.5% of ICSI parents and 25.4% of control parents whose children showed an abnormal hearing test knew about the hearing problems of their child. In conclusion, there was no difference in the development of hearing and vision in ICSI children and spontaneously conceived controls. But only few parents knew about hearing problems of their child after undergoing routine screening examinations. Parental interviews would therefore not be sufficient in order to assess vision and hearing in follow-up studies.

ICSI: Hype or hazard?

Ever since its introduction in clinical practice more than 10 years ago, intracytoplasmic sperm injection (ICSI) has been the subject of ongoing debate regarding its indications and safety. ICSI is hyped because of its potential to give couples with severe male factor infertility a chance to conceive, and because of its apparently low fertilization failure rate compared with 'classic' in vitro fertilization (IVF). Concerns about ICSI are related to technical, biological and genetic hazards. ICSI has been branded 'the ultimate rape of the oocyte', as the oocyte membrane is mechanically pierced, appearing to bypass all biological and genetic selection. ICSI has been linked in a number of reports to an increased incidence of chromosomal anomalies, congenital abnormalities and perinatal hazards in offspring conceived with this technique. The etiology of the increased risk of chromosomal anomalies in ICSI offspring, especially sex-chromosome anomalies, is thought to be partly multifactorial, partly andrological, related to paternal karyotypic abnormalities and/or abnormal sperm. The majority of studies on ICSI and IVF offspring have, setting aside inconsistencies in methodology and classification, not shown significant differences between the two techniques in terms of congenital abnormalities, however, compared to naturally conceived offspring there does show an increased risk. This risk is attributed mainly to parental factors such as maternal age, poor sperm quality and infertility as an independent risk factor. Perinatal hazards may include low birth weight and perinatal mortality. Behavioural and psychological development is carefully monitored in ICSI and IVF children with no significant differences to the development of naturally conceived children, but many factors are involved including demographics. Follow-up studies are essential to the technique of ICSI. It is our duty to inform patients of the concerns and benefits to this treatment, based on the latest data available.

Cognitive development of singletons born after intracytoplasmic sperm injection compared with in vitro fertilization and natural conception

OBJECTIVE

To investigate cognitive development of singletons conceived by intracytoplasmic sperm injection (ICSI) at 5-8 years of age.

DESIGN

Follow-up study.

SETTING

University medical center, assessments between March 2004 and May 2005.

PATIENT(S)

Singletons born between June 1996 and December 1999 after ICSI at the Leiden University Medical Center were compared with matched singletons born after IVF and natural conception (NC).

INTERVENTION(S)

Mode of conception.

MAIN OUTCOME MEASURE(S)

Intelligence quotient (IQ) was measured with the Revised Amsterdam Child Intelligence Test (short form). The investigators were blinded to conception mode.

RESULT(S)

Singletons conceived by ICSI (n = 83) achieved lower IQ scores than IVF singletons (n = 83) (adjusted mean difference IQ: 3.6 [95% confidence interval (CI) -0.8, 8.0]). After categorizing IQ outcomes (<85, 85-115, >115), no significant difference in the distribution of IQ was found. Singletons conceived by ICSI (n = 86) achieved lower IQ scores than NC singletons (n = 85); the adjusted mean difference varied between 5 and 7 points (5.6 [95% CI 0.9, 10.3]; 7.1 [95% CI 1.7, 12.5]) depending on the covariates included in the model. Adjustment for prematurity did not change the results. Percentages in IQ categories <85, 85-115, and >115 were 12%, 64%, and 24% for ICSI and 6%, 54%, and 40% for NC, respectively.

CONCLUSION(S)

In the relatively limited sample investigated, cognitive development among ICSI singletons was lower than among IVF and NC singletons. Infertility factors or unmeasured confounders may play a role.

Matched follow-up study of 5–8 year old ICSI-singletons: comparison of their neuromotor development to IVF and naturally conceived singletons

BACKGROUND

Intracytoplasmic sperm injection (ICSI) is an invasive technique of artificial reproduction. We investigated the effect of ICSI on neuromotor development in 5-8 year old singletons.

METHODS

We did a follow-up of ICSI-singletons born between 1996 and 1999 after treatment in the Leiden University Medical Center and compared them with matched controls born after in vitro fertilization (IVF) and natural conception (NC). Children underwent a thorough neurological examination that focused on minor neurological dysfunction (MND).

RESULTS

There were no differences in outcome between ICSI (n = 81) and IVF-children (n = 81), all born at term: MND prevalence 66.3% versus 61.3%, prevalence ratio (PR) 1.08 [0.83; 1.29]. MND prevalence among all ICSI-children (n = 87) was higher than among NC-controls (n = 85) (66.3% versus 50.6%, PR 1.31 [1.02; 1.55]). After adjustment for maternal age and parity, the PR remained elevated but was no longer statistically significant (adjusted PR 1.22 [0.86; 1.52]). When comparing only term ICSI and NC-children (n = 81; n = 85), the PR adjusted for maternal age and parity was 1.20 [0.83; 1.51].

CONCLUSIONS

Neuromotor outcome of 5-8 year old singletons born at term after ICSI or IVF was similar; ICSI-children (both the total group and term children only) deviated slightly from NC-controls. Part of this effect was explained by a difference in parity, but not prematurity.

Perinatal outcomes of spontaneous twins compared with twins conceived through intracytoplasmic sperm injection

OBJECTIVE

To compare perinatal outcomes in spontaneous twins compared with those conceived by intracytoplasmic sperm injection (ICSI).

DESIGN

Retrospective case-control study.

PATIENTS

Cases consisted of 274 intracytoplasmic sperm injection twins, controls were 348 naturally conceived twins delivered between 1999 and 2003 in a tertiary hospital.

MAIN OUTCOME MEASURES

Birth weight, gestational age at birth, cesarean delivery rate, perinatal mortality and morbidity, congenital anomalies, gestational diabetes and pregnancy induced hypertension.

RESULTS

Preterm deliveries (76.6% vs. 64.1% <37 weeks and 19.7% vs. 13.2% <32 weeks) and low birth weight (73% vs. 60.3% <2500 g and 19.7% vs. 12.6% <1500 g) were significantly higher in the ICSI group compared with controls. Gestational diabetes mellitus (8% vs. 2.9%) and cesarean deliveries (95.2% vs. 77.6%) were more common in cases compared with the control group. There was a significantly higher rate of perinatal morbidity (16.4% vs. 7.8%) and mortality (8% vs. 2.6%) in ICSI twins. The incidence of congenital malformations diagnosed at birth was higher in cases (4.4%) compared with controls (0.9%) but the difference was not significant when adjusted for maternal age.

CONCLUSION

Perinatal outcomes of twins after ICSI treatment are less optimal than naturally conceived twins.

Cognitive and motor development of 8-year-old children born after ICSI compared to spontaneously conceived children

BACKGROUND

As a continuation of two large-scale, multicentre studies on the development of 5-year-old ICSI children, we present results of the follow-up study undertaken on the cognitive and motor development of 8-year-old ICSI children.

METHODS

Developmental outcomes of 151 8-year-old singletons born through ICSI after 32 weeks of gestation were compared with those of 153 singletons of the same age born after spontaneous conception (SC). Part of this population was seen in a cohort at the age 5 years. Outcome measures include Wechsler Intelligence Scale for Children-Revised (WISC-R) and Movement Assessment Battery for Children (ABC).

RESULTS

Regarding intellectual functioning, ICSI children tend to obtain significantly higher total (P < 0.01), verbal (P < 0.01) and performance (P < 0.05) intelligence scores than SC children, nevertheless remaining in similar ranges. These effects are small (Cohen's d < 0.50). High maternal educational level stayed in the regression as a factor accounting for some of the variance in total IQ between the groups. In terms of motor development, no significant differences were found between ICSI and SC children regarding overall motor skills, manual, balance and ball skills.

CONCLUSION

In this follow-up study, ICSI and SC children show a comparable cognitive and motor development until the age of 8 years.

Post-neonatal health and development of children born after assisted reproduction: A systematic review of controlled studies

Long-term follow-up studies on the health and the development of children conceived by assisted reproduction (ART) are mandatory to assess the safety of ART. Meanwhile, different aspects of health of these children have been studied. To put these results together, we performed a systematic review of these publications. A Pubmed search and a hand-search of the abstract books from the annual meeting of the European Society of Human Reproduction and Embryology and the American Society of Reproductive Medicine were performed for controlled studies on the developmental outcome of children after ART, which include a matching for plurality of gestation. Regarding general health, growth, mental and psychomotor development IVF children do not differ from spontaneously conceived (SC) children. An increased need for surgical interventions may be due to an increase in the malformation rate. However, a lower birth weight and lower gestational age compared to matched controls may contribute to some health problems observed. The increased risk of neurological problems found in some large registry-based studies can partly be explained by the higher frequency of twins born, by low birth weight, and by low gestational age also found in singletons. But an effect of IVF, the parents' infertility or other factors not adjusted for in the studies cannot be excluded. In addition to this reporting bias caused by concerned parents cannot be excluded, either. To conclude, children born after assisted reproductive techniques are generally healthy and are developmentally similar to children born after SC. However, low birth weight and prematurity contributes to health care problems. An increase of neurological problems by IVF cannot be excluded. Further prospective studies on the neurological outcome are needed.

Acral and renal malformations following ICSI

This case reports a delivery of a child with limb and renal malformations following intracytoplasmic sperm injection. A 29-year-old woman and a 39-year-old man with primary infertility underwent IVF-ICSI-ET therapy cycle. The couple delivered an infant with acrorenal syndrome. When assisted reproductive techniques are used, especially ICSI, the risk of genetics abnormalities should be discussed in detail with the couple and sufficient informed consent should be obtained before starting IVF-ET procedures.

Parents’ concerns regarding their ART children

A cohort of children conceived by assisted reproductive therapy (ART) – in vitro fertilisation (IVF) and intra-cytoplasmic sperm injection (ICSI) has been followed up in a National Child Development Study (Sutcliffe et al. 1999, 2001 and Bonduelle et al. 2005). Their parents were contacted and asked questions designed to elicit any concerns on their part about their child. 329 replies were received (90% response rate), and 86 of the families posed additional questions. We found that a small number of parents (26% of respondents) raised questions about a variety of issues regarding their ART-conceived child. The most commonly expressed theme (8% of all respondents, or 27/86 (31%) of the respondents with questions) pertained to their child’s future fertility. This question was asked more frequently by ICSI than IVF parents.

Sperm chromatin structure and male fertility: biological and clinical aspects

Sperm chromatin/DNA integrity is essential for the accurate transmission of paternal genetic information, and normal sperm chromatin structure is important for sperm fertilizing ability. The routine examination of semen, which includes sperm concentration, motility and morphology, does not identify defects in sperm chromatin structure. The origin of sperm DNA damage and a variety of methods for its assessment are described. Evaluation of sperm DNA damage appears to be a useful tool for assessing male fertility potential both in vivo and in vitro. The possible impact of sperm DNA defects on the offspring is also discussed.

Laterality in five-year-olds conceived by intracytoplasmic sperm injection, standardin vitrofertilisation and natural conception: a European study

OBJECTIVE

To assess laterality in a group of European children conceived with the help of assisted reproductive therapy, or naturally conceived.

DESIGN

Prospective cohort study.

SETTING

Five European countries.

POPULATION

A total of 1525 five-year-old children divided into three groups according to conception status: naturally conceived; intracytoplasmic sperm injection (ICSI); in vitro fertilisation (IVF) group.

METHODS

All children were assessed using the McCarthy Scale of Children's Abilities (Motor Scale) with additional items using a comb, a spoon and an indirect measure was made of the parental handedness scores, using a questionnaire.

MAIN OUTCOME MEASURES

Child handedness for drawing and writing.

RESULTS

Observed handedness did not differ significantly between natural conception, IVF and ICSI in girls or boys, except for ICSI-conceived girls, fewer of whom were left-handed than the naturally conceived controls, 7.0%versus 12.4% (P < 0.05), however, this was close to the population norm of 8%. The degree of parental handedness did not significantly vary in the three groups.

CONCLUSIONS

Laterality, as assessed by handedness, may be marginally less common in girls conceived with assisted reproductive therapies than with children conceived naturally.

Obstetric outcome of patients with polycystic ovary syndrome treated by in vitro maturation and in vitro fertilization–embryo transfer

OBJECTIVE

To assess the obstetric outcome of pregnancies resulting from in vitro maturation (IVM) and IVF-ET of immature oocytes retrieved from women with polycystic ovary syndrome (PCOS).

DESIGN

Prospective observational study.

SETTING

University fertility clinic.

PATIENT(S)

One hundred thirty-nine women undergoing 203 IVM treatment cycles.

INTERVENTION(S)

Immature oocyte recovery from unstimulated ovaries. In vitro oocyte maturation and fertilization. Fresh ET and assessment of obstetric outcomes in the pregnant women.

MAIN OUTCOME MEASURE(S)

Pregnancy and obstetric outcome.

RESULT(S)

Forty-one pregnancies were obtained in 187 ETs, resulting in a pregnancy rate of 21.9%. Except for three patients lost to follow-up in these pregnancies, the abortion and live birth rates were 36.8% (14 of 38) and 63.2% (24 of 38), respectively. The mean (+/-SD) gestational age and birth weight at delivery for singletons were 38.4 +/- 2.0 weeks (range, 33-41.6 weeks) and 3,252 +/- 516 g (1,750-4,100 g), respectively. For twins these were 36.7 +/- 1.9 weeks (34.6-39 weeks) and 2,361 +/- 304 g (1,900-2,990 g), respectively. Pregnancy complications occurred in five patients (13.2%); these included preterm labor (n = 3) and placenta previa (n = 2). Two patients (5.3%) had a major congenital anomaly diagnosed by ultrasonography.

CONCLUSION(S)

The abortion rate, gestational age and birth weight at delivery, and obstetric complications of pregnancies conceived by IVM-ET in women with PCOS were comparable with those of other women with PCOS being treated by conventional IVF-ET. In vitro maturation followed by IVF-ET seems to be a useful treatment option for women with PCOS, thus avoiding the risk of ovarian hyperstimulation syndrome.

What factors affect intracytoplasmic sperm injection outcomes?

Within the last decade, intracytoplasmic sperm injection (ICSI), a new assisted reproductive technique that allows for the direct injection of spermatozoa into the oocyte, has become available to infertile couples. While most studies indicate that ICSI has success rates similar to those of traditional in vitro fertilization, there are many concerns about the safety of the procedure, including increased risks of chromosomal and developmental abnormalities in children conceived by ICSI. Factors that contribute to these increased risks have not been well elucidated. The purpose of this paper is to review the latest literature concerning 1) the adverse outcomes associated with ICSI; and 2) factors that affect the success rates of ICSI (with emphasis on paternal factors).

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to explain the procedure, intracytoplasmic sperm injection (ICSI), to outline the data surrounding chromosomal and developmental outcomes after ICSI, and to list and explain the potential factors that influence ICSI.

Should ICSI be used in non-male factor infertility?

There is general agreement that intracytoplasmic sperm injection (ICSI) should be used in male factor infertility cases, such as oligoasthenoteratozoospermia, presence of anti-sperm antibodies, or azoospermia, these cases being diagnosed through abnormal semen analysis. There are no randomized clinical trials comparing ICSI with IVF (or other interventions) where semen quality is so poor that IVF would not achieve fertilization. It is accepted that ICSI is the only treatment option in those circumstances. The role of ICSI where IVF can be expected to give a reasonable fertilization rate is the question that needs to be answered. The argument is whether or not ICSI should be used for all cases of infertility. This paper proposes and strongly supports the use of ICSI for all indications. Considerations of fertilization and embryo development, cost effectiveness and safety will be clearly discussed.

International collaborative study of intracytoplasmic sperm injection-conceived, in vitro fertilization-conceived, and naturally conceived 5-year-old child outcomes: cognitive and motor assessments

OBJECTIVE

To date, very few studies have been conducted on the neurodevelopmental well-being of children conceived through intracytoplasmic sperm injection (ICSI). The limitations of these studies often include a lack of comparison with a demographically matched, naturally conceived (NC) group and the investigation of only very young children, with relatively small samples sizes. One study showed that there were no differences in IQ scores among ICSI-conceived, in vitro fertilization (IVF)-conceived, and NC children at 5 years of age. Unfortunately, psychomotor development was not assessed in that study. Because findings regarding these children's cognitive and motor development are inconclusive, the aim of this study was to shed more light on the cognitive and motor development of 5-year-old ICSI-conceived children.

METHODS

A total of 511 ICSI-conceived children were compared with 424 IVF-conceived children and 488 NC controls. Children were recruited in 5 European countries, ie, Belgium, Denmark, Greece, Sweden, and the United Kingdom. Participation rates ranged from 45% to 96% in the ICSI and IVF groups and from 34% to 78% in the NC group. Cognitive and motor development was assessed with the Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSI-R) and McCarthy Scales of Children's Abilities (MSCA) Motor Scale, respectively. The WPPSI-R consists of 2 major scales, ie, Verbal and Performance, each including 6 subtests. The 6 Performance Scale subtests are object assembly, geometric design, block design, mazes, picture completion, and animal pegs. The 6 Verbal Scale subtests are information, comprehension, arithmetic, vocabulary, similarities, and sentences. Scores on the Performance and Verbal Scale subtests are summed to yield the performance IQ (PIQ) and verbal IQ (VIQ), respectively. Scores on both the Performance Scale and the Verbal Scale yield the full-scale IQ (FSIQ). IQ scales have a mean score of 100 and a SD of 15. Each subtest has a mean score of 10 and a SD of 3. The MSCA consists of 6 scales, ie, Verbal, Perceptual-Performance, Quantitative, General Cognitive, Memory, and Motor Scale. In this study, only the Motor Scale was administered. This scale assesses the child's coordination during performance of a variety of gross- and fine-motor tasks. Leg coordination, arm coordination, and imitative action tests provide measures of gross-motor ability. Draw-a-design and draw-a-child assess fine-motor coordination, as revealed by the levels of hand coordination and finger dexterity. The mean score for this test is 50, with a SD of .

RESULTS

No differences were identified among ICSI, IVF, and NC children with respect to VIQ, PIQ, or FSIQ scores of the WPPSI-R. Furthermore, there were no differences between groups regarding the discrepancy between VIQ and PIQ scores. These results were not influenced by gender, country, or maternal educational level. However, in the subgroup of firstborn children with mothers who gave birth at an older age (33-45 years), NC children obtained significantly better VIQ and FSIQ scores than did children conceived through assisted reproductive technologies. These differences in VIQ and FSIQ scores between ICSI/IVF and NC children were relative, because NC children scored <1 IQ point higher than ICSI/IVF children. Therefore, these scores show no clinical relevance. For Verbal Scale subtests, variables such as age of the mother at the time of the birth, educational level of the mother, and gender and nationality of the child interacted with mode of conception, resulting in clinically irrelevant differences between scores for the ICSI/IVF and NC groups on the arithmetic, vocabulary, and comprehension subtests. For Performance Scale subtests, these same demographic factors interacted with mode of conception for the block design, object assembly, and animal pegs subtests, again resulting in clinically irrelevant differences among groups. In the 3 groups (ICSI, IVF, and NC), we observed equal numbers of children scoring below 1 SD from the mean on the WPPSI-R and the MSCA.

CONCLUSIONS

This study includes a substantial number of children from several European countries. Apart from a few interaction effects between mode of conception and demographic variables, no differences were found when ICSI, IVF, and NC scores on the WPPSI-R and MSCA Motor Scale were compared. Nevertheless, the aforementioned interaction effects could indicate that demographic variables such as maternal age at the time of the birth and maternal educational level play different roles in the cognitive development of IVF and ICSI children, compared with NC children. Additional research is needed to explore and verify this finding. Previous studies revealed that ICSI children, in comparison with NC children, more frequently obtained scores below 1 SD from the mean on 3 subtests of the Performance Scale (object assembly, block design, and mazes) or showed a trend of 5.2% of ICSI children, compared with 2.5% of IVF children and 0.9% of NC children, obtaining a score below 1 SD from the mean, but those findings were not confirmed in this study. Here no differences were found among the 3 groups in the numbers of children scoring below 1 SD from the mean on the VIQ, PIQ, and FSIQ tests and the Verbal and Performance Scale subtests. Motor development results were somewhat more conclusive. There were no differences between the scores of ICSI, IVF, and NC children on the MCSA Motor Scale. No interaction effects were found between mode of conception and demographic variables, indicating that these results are not influenced by gender, nationality, maternal educational level, or maternal age at the time of the birth. Furthermore, equal proportions of children in all 3 groups scored below 1 SD from the mean. The results of this study are reassuring for parents who conceived through ICSI (or IVF). The findings indicate that the motor and cognitive development of their offspring is very similar to that of NC children. However, demographic factors such as maternal educational level and maternal age at the time of the birth might play different roles in the cognitive development of ICSI and IVF children, compared with NC children.

Assisted reproductive technologies and the risk of birth defects—a systematic review

BACKGROUND

The risk of birth defects in infants born following assisted reproductive technology (ART) treatment is a controversial question. Most publications examining the prevalence of birth defects in ICSI and IVF infants compared to spontaneously conceived infants have serious methodological limitations; despite this, most researchers have concluded that there is no increased risk.

METHODS

We carried out a systematic review to identify all papers published by March 2003 with data relating to the prevalence of birth defects in infants conceived following IVF and/or ICSI compared with spontaneously conceived infants. Independent expert reviewers used criteria defined a priori to determine whether studies were suitable for inclusion in a meta-analysis. Fixed effects meta-analysis was performed for all studies and reviewer-selected studies.

RESULTS

Twenty-five studies were identified for review. Two-thirds of these showed a 25% or greater increased risk of birth defects in ART infants. The results of meta-analyses of the seven reviewer-selected studies and of all 25 studies suggest a statistically significant 30-40% increased risk of birth defects associated with ART.

CONCLUSIONS

Pooled results from all suitable published studies suggest that children born following ART are at increased risk of birth defects compared with spontaneous conceptions. This information should be made available to couples seeking ART treatment.

Cloning and assisted reproductive techniques: Influence on early development and adult phenotype

Over the past 40 years, our increased understanding and development of cell and molecular biology has allowed even greater advances in reproductive biology. This is most evident by the development of various aspects of assisted reproductive techniques (ART), generation of transgenic animals, and most recently generation of mammals through somatic cell cloning. To date, cloning from adult somatic cells has been successful in at least 10 mammalian species. Although generating viable cloned mammals from adult cells is technically feasible and the list of successes will only continue to grow with time, prenatal and perinatal mortality is high and live cloned offspring have not been without health problems. The success of many of the proposed applications of the cloning technique obviously depends upon the health and survival of founder animals generated by nuclear transfer. This article summarizes the health consequences of cloning in mice, and discusses possible mechanisms through which these conditions may arise. In addition, we discuss the effects of ART in animal models and in humans. ART also involves some of the same procedures used in cloning, and there are reports that offspring generated by ART sometimes display aberrant phenotypes as well. It is important to point out that although these techniques do sometimes produce abnormalities, the majority of offspring are born apparently normal and survive to adulthood. Additionally, we must emphasize that the effects of ART and cloning observed in animal models do not necessarily indicate that they will occur in humans. In this article, we review studies examining the phenotype of animals generated by cloning and various ART, and discuss clinical implications of these findings.

Birth defects in children conceived by ICSI compared with children conceived by other IVF-methods; a meta-analysis

BACKGROUND

Intracytoplasmic sperm injection (ICSI) is a method of assisted reproductive technology that involves the selection of a single sperm cell and the manual injection of this cell into the egg. The lack of relevant experimental studies, the nature of the technology involving non-natural selection of the fertilizing sperm, and possible damage to the egg have caused concern that ICSI could increase the risk of birth defects. Data from available cohort studies comparing ICSI with standard in vitro fertilization (IVF) should be combined to evaluate the risks involved with ICSI.

METHODS

We reviewed more than 2500 titles and abstracts containing keywords related to ICSI and identified 22 scientific articles with data on birth defects among ICSI-births. A total of four peer-reviewed, non-overlapping prospective cohort studies provided reliable and comparable data on birth defects both for children conceived by ICSI and children conceived by standard IVF. These studies included a total of 5395 children born after ICSI.

RESULTS

The pooled estimate of the risk of a major birth defect was a 1.12-fold increase after ICSI when compared with standard IVF (risk ratio = 1.12, 95% confidence interval (CI): 0.97-1.28, P = 0.12). There was no marked heterogeneity of risk ratios between these studies (P = 0.10). We found no significantly increased risks after ICSI for any of the categories cardiovascular defects, musculoskeletal defects, hypospadias, neural tube defects, or oral clefts.

CONCLUSIONS

Our analysis does not indicate that the ICSI-procedure represents significant additional risks of major birth defects in addition to the risk involved in standard IVF. The data was limited, particularly on risks of specific categories of defects.

A prospective longitudinal study of the physical, psychomotor, and intellectual development of singleton children up to 5 years who were conceived by intracytoplasmic sperm injection compared with children conceived spontaneously and by in vitro fertilization

OBJECTIVE

To assess the somatic, psychomotor, and intellectual development of children conceived through intracytoplasmic single sperm injection (ICSI) over the whole preschool period.

DESIGN

Prospective, controlled, cohort study.

SETTING

Fertility clinic in Brussels, Belgium.

PATIENT(S)

Sixty-six ICSI-conceived children prospectively compared with 52 IVF-conceived and 59 spontaneously conceived children. All children were full-term singletons.

INTERVENTION(S)

Home visits by a trained psychologist. Standardized interviews. Assessments using the revised Brunet-Lézine scale and the revised Wechsler preschool and primary scale of intelligence.

MAIN OUTCOME MEASURE(S)

Physical growth and general health. Formal developmental and intellectual assessments.

RESULT(S)

Children conceived by ICSI were healthy: no significant differences appeared in the incidence of combined congenital malformations (11.3%), health problems (44.1%), surgical interventions (18.6%), and hospitalizations (6.8%), nor for the developmental assessments (mean developmental quotient at 9 months: 93.9; at 18 months: 102.0). For the intellectual assessments, the between-group differences disappeared when adjusted for levels of parental education (mean intelligence quotient at 3 years: 97.0; at 5 years: 103.3).

CONCLUSION(S)

This pilot study shows that throughout the preschool period, ICSI-conceived children have psychomotor and intellectual development similar to that of IVF-conceived and spontaneously conceived children. These conclusions need to be confirmed by multicenter studies.

Concerns regarding the follow-up of children conceived after assisted reproduction in Latin America

Children born through assisted reproduction are not usually followed up in Latin America. However, in spite of all the social-economic and cultural complexity of this part of the world, professionals involved in assisted reproduction should not relinquish the responsibility of following up these children. In May 2002, the Centre for Human Reproduction Sinhá Junqueira, started a specific project for evaluation and follow-up of its children. It is the first centre in Brazil, and probably in Latin America, with this aim, and this paper reports initial results concerning the intellectual development of these children.

Is intracytoplasmic sperm injection safe?

OBJECTIVE

To review the pregnancy and birth outcomes of patients undergoing intracytoplasmic sperm injection (ICSI).

DESIGN

Selective review of the literature.

SETTING

Couples undergoing either conventional IVF or ICSI and their resulting offspring.

PATIENT(S)

None.

MAIN OUTCOME MEASURE(S)

None.

INTERVENTION(S)

None.

RESULTS

These observational studies are unfortunately inherently biased. Regardless, the information and experiences from these large centers cannot be ignored. These experiences reveal that birth weight may be decreased by an amount that is generally not clinically relevant. Chromosomal and genetic abnormalities are increased probably only as a direct corollary to the underlying parental risk. Congenital malformations reveal no clustering of any single specific abnormality. Developmental assessment is available for up to 2 years, and no major delays have been identified in either motor or mental function.

CONCLUSION(S)

Intracytoplasmic sperm injection appears to be a safe alternative for couples who otherwise would be unable to achieve pregnancy. The inherent risks associated with these genetically "at risk" couples mandate thorough evaluation and counseling before undertaking ICSI.

Practitioner review: outcomes for parents and children following non-traditional conception: what do clinicians need to know?

BACKGROUND

The birth of the first 'test-tube' baby in 1978 has led to the creation of family types that would not otherwise have existed.

METHODS

This paper examines research on the psychological outcomes for parents and children in assisted reproduction families with particular attention to the issues and concerns that have been raised by creating families in this way.

RESULTS

Parents of children conceived by assisted reproduction appear to have good relationships with their children, even in families where one parent lacks a genetic link with the child. With respect to the children themselves, there is no evidence of cognitive impairment in singleton children born at full term as a result of assisted reproduction procedures, although the findings regarding the cognitive development of intracytoplasmic sperm injection (ICSI) children are currently unclear. In relation to socioemotional development, assisted reproduction children appear to be functioning well.

CONCLUSIONS

Few studies have included children at adolescence or beyond, and little is known about the consequences of conception by assisted reproduction from the perspective of the individuals concerned. In addition, there are some types of assisted reproduction family, such as families created through a surrogacy arrangement or through embryo donation, about whom little is known at all. Although existing knowledge about the impact of assisted reproduction for parenting and child development does not give undue cause for concern, there remain a number of unanswered questions in relation to children born in this way.

A retrospective case-control study of developmental and other outcomes in a cohort of Australian children conceived by intracytoplasmic sperm injection compared with a similar group in the United Kingdom

OBJECTIVE

To investigate the possibility that children born after ICSI were at increased risk for neurodevelopmental delay.

DESIGN

Retrospective case-control study.

SETTING

IVF clinic.

PATIENT(S)

Fifty-eight singleton children born after ICSI and 38 normally conceived singleton children (controls), matched for relevant sociodemographic characteristics, from Australia and 208 case-patients and 221 controls from the United Kingdom.

MAIN OUTCOME MEASURE(S)

Antenatal and perinatal, and sociodemographic characteristics; physical health, including congenital abnormalities; and neurodevelopment by using the Griffiths scales of mental development.

RESULT(S)

Eighty-five percent of case-patients and 96% controls were assessed at a mean age of 13 months. Neurodevelopmental scores were similar in all children. Perinatal outcome was similar, apart from more caesarean sections in the case-patients. Rates of congenital anomalies were similar (5.6% among case-patients vs. 5.7% among controls). Children from fathers with oligozoospermia showed no extra problems. Children born after ICSI in the United Kingdom and Australia were similar.

CONCLUSION(S)

Children conceived after ICSI did not differ from their naturally conceived peers in physical health or development at ages up to 15 months.

The role of food supplements in the treatment of the infertile man

Recently, concerns have been raised about the presumptive increased risk of serious undesirable side effects in children born after IVF and intracytoplasmic sperm injection (ICSI). These treatments must, therefore, be reserved as the ultimate option after evidence-based and cause-directed treatment of the male patient with deficient semen has been exhausted. The present authors found that sperm quality and function improved with the intake of complementary food supplementation using a combination of zinc and folic acid, or the antioxidant astaxanthin (Astacarox), or an energy-providing combination containing (actyl)-carnitine (Proxeed). Also, double blind trials showed that the latter two substances increase spontaneous or intrauterine insemination- (IUI-) assisted conception rates. Extracts of Pinus maritima bark (Pycnogenol), which inhibits the cyclo-oxygenase enzyme, reducing prostaglandin production and inflammatory reaction, and extracts of the Peruvian plant Lepidium meyenii were shown to improve sperm morphology and concentration, respectively, in uncontrolled trials. Linseed (flaxseed) oil contains alfa-linolenic acid and lignans. The former corrects the deficient intake of omega-3 essential fatty acids, which is correlated with impaired sperm motility among subfertile men. Lignans are precursors of enterolacton, which inhibits aromatase and reduces the ratio of 16-OH over 2-OH oestrogen metabolites. The resulting reduction in oestrogen load may favourably influence Sertoli cell function.

Current and future genetic screening for male infertility

Although much of male infertility is currently unexplained, it is likely that underlying defects in critical genes or entire gene pathways are responsible. Because powerful technologies exist to bypass severe male-factor infertility, improving the diagnosis of genetic infertility is important for the infertile couple, not only to explain the problem but also to inform them of conditions potentially transmissible to offspring.

Outcome in the second year of life after in-vitro fertilisation by intracytoplasmic sperm injection: a UK case-control study

BACKGROUND

There have been reports suggesting that children born after in-vitro fertilisation by intracytoplasmic sperm injection (ICSI) are at increased risk of neurodevelopmental delay. We have undertaken a case-control study of this issue.

METHODS

We studied 208 singleton children conceived by ICSI and a control group of 221 normally conceived singleton children. Children were recruited from 22 fertility centres and local nurseries throughout the UK. Controls were selected to match cases as closely as possible for social class, maternal educational attainment, region, sex, and race. The primary outcome measure was neurodevelopmental scoring; secondary measures were perinatal outcomes, postnatal health, and congenital abnormalities. A single examiner assessed all the children.

FINDINGS

A follow-up rate of 90% for the ICSI group was achieved at a mean age of 17 months. No difference between the study children and controls was found in mean neurodevelopmental scores (98.08 [SD 10.93] vs 98.69 [9.99]) or any subscales on the Griffiths' scales of mental development. Perinatal outcome was similar apart from a higher rate of caesarean section (73 [35.1%] vs 53 [24.0%], p=0.015) and a lower mean birthweight (3163 [SD 642] vs 3341 [606] g, p=0.013) in the study group. Rates of major congenital abnormality were also similar overall (ten [4.8%] study vs ten [4.5%] control), although there were significantly more congenital anomalies among children born to fathers with oligozoospermia than in other children.

INTERPRETATION

This population study did not show any significant difference between children conceived after ICSI and their naturally conceived peers in terms of physical health and development.

Non-reproductive heritable disorders in infertile couples and their first degree relatives

The genetic safety of intracytoplasmic sperm injection (ICSI) remains a matter of continuing debate. One source of concern is the limited knowledge about the general genetic constitution and background of patients who need sophisticated reproductive technology to procreate. It has been postulated that such individuals could be carriers of genetic lesions that might result in an increased prevalence of heritable disorders among their offspring. To investigate this issue, we determined the frequency of potentially heritable non-reproductive diseases in 621 infertile couples and their first degree relatives. A total of 1302 fertile couples who underwent genetic counselling prior to prenatal diagnosis served as controls. The infertile patients had a slightly higher prevalence of potentially heritable non-reproductive disorders ('significant genetic risk factors') than the controls (1. 9 versus 0.9%; P = 0.015). In contrast, such diseases were less prevalent in their families than in the fertile couples' families. Our data do not support the hypothesis that their familial genetic background predisposes children born after ICSI to malformations or other non-reproductive genetic diseases.

Clustering of male infertility in the families of couples treated with intracytoplasmic sperm injection

Intracytoplasmic sperm injection (ICSI) is an effective treatment modality for male factor infertility, but it could promote the transgenerational transmission of genetic defects causing gametogenic failure. Cytogenetic and molecular techniques permit the diagnosis of some infertility-causing genetic aberrations, but many more probably evade detection with currently available technology. The analysis of the recurrence pattern of infertility in infertile couples' families could define the importance of heritable factors in the pathogenesis of human infertility. We have subjected 621 consecutive infertile couples treated with ICSI in a single institution to a comprehensive genetic workup including documentation of the family history, karyotyping and various DNA tests. In all, 1302 fertile couples served as controls. Of the infertile couples 6.4% were shown to have a fertility problem with a definite genetic basis. Male, but not female fertility problems displayed a distinct pattern of familial aggregation. In addition, the infertile couples had fewer siblings than the fertile controls, a finding compatible with suboptimal fertility already among the infertile couples' parents. In summary, our data indicate that male factor infertility should be considered a potentially heritable condition. The recurrence risk for infertility in the offspring of couples treated with ICSI might be substantial.

Analysis of spermatozoa from seven ICSI males with constitutional sex chromosomal abnormalities by fluorescent in situ hybridization

PURPOSE

The objective was to estimate the risk for subfertile males with a constitutional sex chromosomal abnormality of transmitting such a chromosome abnormality to their children, conceived by intracytoplasmic sperm injection (ICSI).

METHODS

Semen samples were obtained from seven severely oligospermic ICSI candidates. Six of them had a numerical sex chromosomal abnormality, including mosaic 45,X/46,XY, mosaic 46,XY/47, XXY, 47,XXY (Klinefelter's syndrome), and 47,XYY. One male had a structural abnormality, namely, an inversion of the Y chromosome. The semen was studied by three-color fluorescent in situ hybridization (FISH) with probes specific for chromosomes 18,X, and Y.

RESULTS

Chromosomal aneuploidy rates of any of the three chromosomes were significantly higher than the aneuploidy rates observed in three control samples but comparable to the rates observed in 10 ICSI candidates with oligoasthenoteratozoospermia (OAT) and a normal constitutional karyotype.

CONCLUSIONS

Our data indicate that males with (mosaic) sex chromosomal abnormalities have no higher risk of producing offspring with a sex chromosomal abnormality by ICSI than OAT males with a normal karyotype.