Zsolt Nagy

Microsurgical epididymal sperm aspiration and intracytoplasmic sperm injection : a new effective approach to infertility as a result of congenital bilateral absence of the vas deferens

OBJECTIVEnTo present and assess the efficacy of a new approach for the treatment of infertility due to congenital bilateral absence of the vas deferens.nnnDESIGNnA retrospective study of consecutive trials.nnnSETTINGnCentre for Reproductive Medicine, which is a tertiary referral institution.nnnPATIENTSnTwelve couples suffering from infertility because of congenital bilateral absence of the vas deferens.nnnINTERVENTIONSnA microsurgical epididymal sperm aspiration procedure was performed in the husbands, followed by intracytoplasmic sperm injection of oocytes recovered from the wives. Cleaving embryos were transferred to the uterine cavity 48 hours after the intracytoplasmic sperm injection procedure.nnnMAIN OUTCOME MEASURESnSperm parameters after microsurgical epididymal sperm aspiration, fertilization, cleavage, and pregnancy rates.nnnRESULTSnIn all 14 microsurgical epididymal sperm aspiration procedures, sperm was retrieved. Notwithstanding the poor quality of this epididymal sperm, a fertilization rate of 58% was achieved after intracytoplasmic sperm injection. On 10 occasions, embryos were transferred and five patients became pregnant, i.e., an overall pregnancy rate of 35.7% per started trial and 50.0% per transfer. Another two patients became pregnant after replacement of frozen-thawed embryos, which increases the pregnancy rate to 50.0% per microsurgical epididymal sperm aspiration procedure. Early pregnancy wastage was 57%, limiting the ongoing pregnancy rate to 21.4% per microsurgical epididymal sperm aspiration procedure.nnnCONCLUSIONnThis study shows the combined microsurgical epididymal sperm aspiration-intracytoplasmic sperm injection procedure to be highly efficient in achieving fertilization in vitro, even after recovery of grossly impaired epididymal sperm.

Using ejaculated, fresh, and frozen-thawed epididymal and testicular spermatozoa gives rise to comparable results after intracytoplasmic sperm injection*

OBJECTIVEnTo describe the preparation of fresh or frozen-thawed epididymal and testicular sperm for intracytoplasmic single sperm injection and to compare the fertilization, embryo quality, and pregnancy rates (PRs) obtained after using these spermatozoa to the results when freshly ejaculated sperm was used for microinjection.nnnDESIGNnRetrospective analysis of 1,034 consecutive microinjection cycles. Ejaculated (965 cycles), fresh epididymal (43 cycles), frozen-thawed epididymal (9 cycles), and testicular sperm (17 cycles) was used for intracytoplasmic sperm injection.nnnSETTINGnProcedures were performed in a tertiary IVF center coupled with an institutional research environment.nnnMAIN OUTCOME MEASURESnSemen density and motility were judged by the World Health Organization criteria and sperm morphology was evaluated by the Tygerbergs strict criteria. After microinjection, oocyte intactness, fertilization, embryo cleavage, transfer, and PRs were evaluated and compared.nnnRESULTSnThe median values of total sperm count, total motility and normal morphology were 17.85 x 10(6), 37%, 8% for freshly ejaculated sperm; 46.20 x 10(6), 12%, 9% for fresh epididymal sperm; 0.15 x 10(6), 0%, 0% for frozen-thawed epididymal sperm; and 0.54 x 10(6), 0% for testicular sperm (morphology was not determined). The percentage of intact oocytes after microinjection ranged from 84% to 90%. Normal fertilization rates were high when fresh or frozen-thawed epididymal and testicular spermatozoa were used for the injection (56%, 56%, 48%, respectively) but were significantly lower than for ejaculated sperm (70%). There was a higher proportion of transferable embryos obtained after ejaculated sperm injection than after testicular sperm injection. Forty percent, 58%, 33%, and 46% of cycles had positive serum hCG using ejaculated, fresh, or frozen-thawed epididymal and testicular sperm. Initial pregnancy loss occurred in 26.3% of the conception cycles.nnnCONCLUSIONnIntracytoplasmic sperm injection can provide high normal fertilization, cleavage, and PRs when fresh or frozen-thawed epididymal and testicular spermatozoa are used, but normal fertilization rates are significantly lower than after microinjection with ejaculated sperm.

Normal pregnancies resulting from testicular sperm extraction and intracytoplasmic sperm injection for azoospermia due to maturation arrest

OBJECTIVEnTo see whether testicular sperm extraction could be used to perform intracytoplasmic sperm injection (ICSI) for men with nonobstructive azoospermia caused by maturation arrest.nnnDESIGNnUncontrolled prospective trial of an attempt to find occasional elongated spermatids or spermatozoa in testes of azoospermic patients with maturation arrest and to use these haploid cells for ICSI.nnnSETTINGnEuropean university-based center for reproductive medicine and private American community hospital.nnnPATIENTSnThirty-eight azoospermic males without obstruction and with biopsy-documented maturation arrest, seven of whom elected, with their wives, to undergo scrotal exploration and testicular sperm extraction with ICSI in an attempt to become pregnant.nnnINTERVENTIONSnHistologic evaluation of spermatid development in 38 patients with azoospermic maturation arrest. Testicular sperm extraction with ICSI in seven random volunteers from this group.nnnMAIN OUTCOME MEASURESnPresence or absence of mature spermatids in the testis biopsy specimen of patients with azoospermic maturation arrest. Fertilization, cleavage, and pregnancy after testicular sperm extraction and ICSI in patients with azoospermic maturation arrest.nnnRESULTSnAll seven patients with azoospermic maturation arrest had occasional sperm found with testicular sperm extraction. Five had sufficient numbers (between 6 and 30) for ICSI, and those five had ETs. In four, the partners became pregnant. In all 38 patients examined, the maturation defect was in meiosis rather than in spermiogenesis.nnnCONCLUSIONnNonobstructive azoospermia caused by maturation arrest may be treated with testicular sperm extraction with ICSI apparently as successfully as Sertoli cell only.

Intracytoplasmic sperm injection

Intracytoplasmic sperm injection (ICSI) with ejaculated, epididymal or testicular spermatozoa was first successful in 1992 and has since become the widely accepted treatment for couples with severe male-factor infertility. The outcome of several thousands of ICSI cycles in terms of fertilization, embryo cleavage and implantation is similar to that for conventional in-vitro fertilization in couples with tubal or idiopathic infertility. To evaluate the important issue of safety of the new technique of ICSI, a prospective follow-up study of children born after ICSI was carried out. The aim was to compile data on karyotypes, congenital malformations, growth parameters and developmental milestones. Parents agreement to genetic counseling was obtained, as well as prenatal diagnosis, followed by a physical examination of the children at 2 months, 1 and 2 years. Important outcome data to be examined comprise information on major and minor congenital malformations obtained prenatally or after birth, as well as on the further development of the children.

High Fertilization and Implantation Rates After Intracytoplasmic Sperm Injection

Previously reported better fertilization rate after intracytoplasmic single sperm injection (ICSI) than after subzonal insemination of several spermatozoa was confirmed in a controlled comparison of the two procedures in 11 patients. Intracytoplasmic sperm injection was carried out in 150 consecutive treatment cycles of 150 infertile couples, who had failed to have fertilized oocytes after standard in-vitro fertilization (IVF) procedures or who were not accepted for IVF because not enough motile spermatozoa were present in the ejaculate. A single spermatozoon was injected into the ooplasm of 1409 metaphase II oocytes. Only 117 oocytes (8.3%) were damaged by the procedure and 830 oocytes (64.2% of the successfully injected oocytes) had two distinct pronuclei the morning after the injection procedure. The fertilization rate was not influenced by semen characteristics. After 24 h of further in-vitro culture, 71.2% of these oocytes developed into embryos, which were transferred or cryopreserved. Only 15 patients did not have embryos replaced. Three-quarters of the transfers were triple-embryo transfers. High pregnancy rates were noticed since 67 pregnancies were achieved, of which 53 were clinical, i.e. a total and clinical pregnancy rate of 44.7% and 35.3% per started cycle and 49.6% and 39.2% per embryo transfer. A total of 237 supernumerary embryos were cryopreserved in 71 treatment cycles.