Deborah Strassburger

Intracytoplasmic injection of fresh and cryopreserved testicular spermatozoa in patients with nonobstructive azoospermia—a comparative study

OBJECTIVE To compare the outcome of intracytoplasmic sperm injection (ICSI) with fresh and frozen-thawed testicular spermatozoa in patients with nonobstructive azoospermia. DESIGN Retrospective analysis of consecutive ICSI cycles. SETTING In Vitro Fertilization Unit, Assaf Harofeh Medical Center. PATIENT(S) Eighteen with nonobstructive azoospermia in whom testicular sperm was found after testicular sperm extraction. INTERVENTION(S) Testicular sperm retrieval, cryopreservation, and ICSI with fresh or frozen-thawed testicular spermatozoa. MAIN OUTCOME MEASURE(S) Two-pronuclear fertilization; embryo cleavage rates, mean number of embryos transferred per cycle, and their relative quality, embryo implantation, clinical pregnancy, and ongoing pregnancy rates (PRs) per ET. RESULT(S) No statistically significant differences were noted in all parameters examined between ICSI cycles with fresh or cryopreserved testicular spermatozoa from the same nine patients and comparing all ICSI cycles performed; with fresh (25 cycles) and thawed (14 cycles) testicular spermatozoa, respectively: two-pronuclear fertilization, 47% versus 44%; embryo cleavage rates, 94% versus 89%; implantation rates, 9% versus 11%; and clinical PR, 26% versus 27%. The delivery or ongoing PR using fresh sperm was better (21% versus 9%), but the difference did not reach statistical significance. The cumulative clinical PRs and ongoing PRs per testicular sperm extraction procedure were 36% and 24%, respectively. CONCLUSION(S) Testicular sperm cryopreservation using a simple freezing protocol is promising in patients with nonobstructive azoospermia augmenting the overall success achieved after surgical sperm retrieval.

Intracytoplasmic sperm injection outcome of ejaculated versus extracted testicular spermatozoa in cryptozoospermic men

OBJECTIVE To compare intracytoplasmic sperm injection (ICSI) outcome of patients with cryptozoospermia after use of ejaculated versus testicular sperm in different cycles of the same patients. DESIGN Retrospective cohort study. SETTING University-affiliated infertility center. PATIENT(S) A total of 17 patients with cryptozoospermia who underwent a total of 116 ICSI cycles. INTERVENTION(S) The patients initially underwent several ICSI cycles using ejaculated sperm (n = 68, 58.6%) that were followed by ICSI cycles using testicular sperm (n = 48, 41.4%). MAIN OUTCOME MEASURE(S) Fertilization rate, pregnancy rate (PR). RESULT(S) There were no significant differences in fertilization rates between the two subgroups. A comparison between testicular sperm extraction (TESE) versus ejaculated sperm cycles revealed significantly higher implantation rate (20.7% vs. 5.7%), higher PR (42.5% vs. 15.1%), and higher take home baby rate (27.5% vs. 9.4%). A multivariable logistic regression analysis showed three significant predictors for pregnancy, namely the use of testicular sperm (odds ratio [OR] 5.1, 95% confidence interval [95% CI] 1.8-14.8), use of motile sperm (OR 12.9, 95% CI 2.1-79.1), and female age (OR 0.83, 95% CI 0.7-0.9). CONCLUSION(S) Testicular sperm extraction is justified in patients with cryptozoospermia who fail to conceive by ICSI using ejaculated spermatozoa, as it offers higher PR.

Increased frequency of female partner chromosomal abnormalities in patients with high-order implantation failure after in vitro fertilization

OBJECTIVE To find the type and frequency of chromosomal abnormalities in a selected group of high-order implantation failure (> or =6 IVF trials and > or =15 transferred embryos) and to evaluate its impact on pregnancy outcome. DESIGN A retrospective study. SETTING In vitro fertilization (IVF) unit in a university affiliated hospital. PATIENT(S) Sixty-five couples with high-order implantation failure in IVF and embryo transfer. INTERVENTION(S) In vitro fertilization/embryo transfer (ET), work-up for implantation failure, cytogenetic analysis of the couple. MAIN OUTCOME MEASURE(S) We studied the type and frequency of chromosomal changes, quality of embryos, cumulative pregnancy rates, and pregnancy outcome. RESULT(S) The mean number of treatment cycles per patient, before karyotyping was 7.8 +/- 2.4 (range: 6 to 16 cycles). The mean cumulative number of all transferred embryos per patient was 25.7 +/- 10.3 (range: 9 to 65 embryos). Chromosomal abnormalities were found in 10 of 65 (15.4%) cases: translocations in six, mosaicism in two, and inversion or deletion in another two. The morphologic characteristics of the transferred embryos and the cumulative pregnancy rates were similar in patients with implantation failure with and without chromosomal changes. Three of the 16 patients with abnormal karyotype delivered and three miscarried within a follow-up period of 1 year. CONCLUSION(S) A high frequency of chromosomal aberrations was found in a selected group of high-order implantation failures, a similar frequency to recurrent miscarriages. Karyotyping is recommended as part of the work-up for repeated implantation failure in assisted reproduction. Treatment options include further IVF trials, preimplantation genetic diagnosis, or oocyte donation, tailored according to the type of chromosomal change. An international registry should be considered to assist in counseling these patients.

The cytogenetic constitution of embryos derived from immature (metaphase I) oocytes obtained after ovarian hyperstimulation

OBJECTIVE To examine the chromosomal content of embryos resulting from metaphase I (MI) oocytes obtained after ovarian hyperstimulation for IVF. DESIGN Prospective cohort study. SETTING University-based IVF Center, Assaf Harofeh Medical Center, Tel Aviv University, Israel. PATIENT(S) One hundred fifty women undergoing assisted reproduction technique (ART). INTERVENTION(S) Intracytoplasmic sperm injection (ICSI) was performed in MI oocytes that were retrieved after ovarian stimulation. A portion of these oocytes extruded their polar body (rescued in vitro-matured metaphase II [IVM-MII]) after different incubation periods and the remainder did not (arrested MI oocytes). Fluorescence in situ hybridization was performed using probes for chromosomes X, Y, 18. MAIN OUTCOME MEASURE(S) Fertilization rate, number of blastomeres, and embryo euploidy. RESULT(S) Embryos from rescued IVM-MII oocytes showed significantly higher fertilization rates and more blastomeres per embryo compared with those from arrested MI oocytes (58.5% vs. 43.9% and 5.7 vs. 5.0, respectively). The chromosomal analysis of these embryos revealed a high rate of aberrations (80.6%), mainly complex mosaics. This rate was elevated in embryos from arrested IVM oocytes (97.2%), and after longer incubation periods. No chromosomally normal embryos were found after 24 hours of incubation of their corresponding oocytes. CONCLUSION(S) Embryos originating from MI oocytes have a high rate of chromosomal aneuploidy, and their replacement should be reconsidered.

Successful pregnancy after 24 consecutive fetal losses: lessons learned from surrogacy

OBJECTIVE To offer surrogacy as a treatment option to patients in whom maternal rather than fetal factors are responsible for high-order unexplained habitual abortions. DESIGN Case report. SETTING University hospital. PATIENT(S) A 36-year-old woman with 24 consecutive abortions over 11 years. INTERVENTION(S) A regular IVF procedure in the aborting woman and transfer of two good-quality embryos to the surrogate mother, who had previously received hormones. MAIN OUTCOME MEASURE(S) Ovarian response, oocytes, fertilization, and embryo quality in the aborting patient. Endometrial thickness, implantation, pregnancy, and delivery in the surrogate mother. RESULT(S) Transfer of two embryos to the surrogate mother led to a clinical pregnancy, which was uneventful until term. Cesarean section was performed for breech presentation, with delivery of a healthy male. CONCLUSION(S) Surrogacy can be offered as a treatment option to patients in whom maternal rather than fetal factors are responsible for high-order unexplained habitual abortions.

Birth of Healthy Twins Resulting from Donated Oocytes and Posthumous Use of Frozen–Thawed Spermatozoa Obtained Prior to Chemotherapy

The improvement in life expectancy, following better cancer therapy combined with new options in treating male infertility have increased the use of sperm freezing. We describe a rare case of twin pregnancy of a childless widow, using donated oocytes after ICSI with her deceased husbands banked frozen spermatozoa. Sperm was frozen before chemotherapy treatment and a written consent for future thawing and injection to donor oocytes was given. Use of thawed spermatozoa after death was not mentioned in the consent form. During the husbands illness years, ICSI of donated oocytes fertilized with thawed spermatozoa yielded three embryos, but no pregnancy was achieved after ET. While waiting for a subsequent oocyte donation, the male partner died of his malignancy. The woman expressed her wish to be treated with the frozen spermatozoa of her deceased husband. Since the original informed consent did not cover postmortem use of the husbands sperm, a special application for its use was made and subsequently approved by the Israeli Ministry of Health legal advisor. Another six donated oocytes were fertilized with the deceaseds thawed spermatozoa, and the transfer of four embryos to the uterine cavity resulted in a twin pregnancy and later delivery of two healthy babies. This case emphasizes the importance of written informed consent signed by patients with a life-threatening disease at the time of banking spermatozoa, and discussing the possibility of its posthumous use. Several legal and ethical concerns are discussed.

In vitro fertilization surrogacy in rare coexisting Mayer-Rokitansky-Kuster-Hauser syndrome and triple X karyotype

OBJECTIVE To report the responses to IVF surrogacy attempts in a female with a heretofore never described combination of Mayer-Rokitansky-Kuster-Hauser (MRHK) syndrome and triple X karyotype. DESIGN Case report. SETTING Reproductive unit of a university-affiliated medical center. PATIENT(S) A 29-year-old female diagnosed as having both MRHK syndrome and a triple X (47XXX) karyotype. INTERVENTION(S) Five cycles of IVF surrogacy. MAIN OUTCOME MEASURE(S) Recovery of oocytes after controlled ovarian stimulation. RESULT(S) A maximum of five oocytes were retrieved by percutaneous abdominal aspiration of a single subcostal left ovary. After five unsuccessful IVF trials due to low ovarian response attributed to her coexisting MRHK syndrome and triple X karyotype, the patients choice was oocyte donation. CONCLUSION(S) An abnormal karyotype can coexist with MRKH syndrome, albeit very rarely, and probably accounts for a low ovarian response to attempts to achieve IVF surrogacy.

Nationwide use of postmortem retrieved sperm in Israel: a follow-up report

A follow-up study of the subsequent use of all postmortem frozen sperm samples during 2003-2010 is reported. Only the sister of one of the 10 unmarried deceased men was in contact with the bank. Four widows elected to discard the frozen sperm and all of the remaining spouses were uninterested in its fate. Because none of the samples were requested for use, the need for sperm procurement should be reconsidered.

Using sperm posthumously: national guidelines versus practice

Under pressure from involved families and time limitations, Israeli judges tend to authorize postmortem sperm retrieval and freezing, even in unmarried men and in contradiction to current, albeit non-legally binding, guidelines of the Attorney General. Postmortem sperm retrieval in our institution (2003 to June 2009) was successful in 17 cases, motile sperm was found in 16/17, and cryopreservation was performed in 15/16: no application for use of any of the postmortem frozen samples has been performed thus far.

Computerized cell-scanning system for evaluating human spermatogenesis in non-obstructive azoospermic patients

There may be incompatibility between testicular histopathological evaluation and testicular sperm extraction (TESE) outcome. Assessment for sperm presence and different pathological disturbances of non-obstructive azoospermia (NOA) remains challenging. An assay for maximal sampling and accurate identification of testicular cells from NOA patients undergoing TESE and autopsied fertile controls was developed. Testicular cells stained and scanned automatically for morphology underwent fluorescence in-situ hybridization using centromeric probes for chromosomes X, Y and 18 after destaining. Cells were automatically classified according to ploidy, and ratios of haploid cells and autosomal (18) and sex-chromosome bivalent rates were calculated. Identification of testicular cells in suspension enabled prediction of spermatogenesis in seven of eight Sertoli-cell-only syndrome patients. Haploid/diploid cell ratios were 67.6:32.2 for controls and 9.6:90.4 for patients. Both autosomal (18) and sex-chromosome bivalents were present in patients (4.1 ± 5.82%) and controls (19.7 ± 8.95%). Few tetraploid pachytene spermatocytes were observed. More secondary spermatocytes with NOA showed two distinct signals for chromosome 18 (27.9 ± 32.69%) compared with controls (0.4 ± 0.35%). The computerized cell-scanning system enables simultaneous application of morphology and chromosome analysis of testicular cells, which enhance assessing different pathological disturbances and estimating the likelihood of a successful second TESE procedure.