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Table of Contents
ORIGINAL ARTICLE
Year : 2016  |  Volume : 3  |  Issue : 1  |  Page : 30-38

The difference in the outcomes between surgically retrieved and ejaculated spermatozoa for intracytoplasmic sperm injection cycles in sulaimanyah province


Head of General Surgery Department at Sulaimania University, Sulaimania KRG, , Human Embryology, Lecturer in Sulaimania University, Sulaimnia KRG, Iraq

Date of Web Publication5-Jul-2017

Correspondence Address:
Ismaeel H.A Aghaways
Head of General Surgery Department at Sulaimania University, Sulaimania KRG
Iraq
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Source of Support: None, Conflict of Interest: None


DOI: 10.5530/ami.2016.1.9

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  Abstract 


Background: Intracytoplasmic sperm injection (ICSI) is introduced as a treatment modality for severe male factors infertility. It is an effective form of infertility treatment. Progress in the micromanipulation, now is bringing a new way in the treatment of severe male factor infertility to achieve acceptable rates of fertilization and pregnancy success.
Objective: To evaluate the difference between ejaculated and surgically retrieved sperm on intra cytoplasmic sperm injection (ICSI) outcomes.
Design: A Correlative study. Setting: Dwarozh- IVF center.
Patients and Methods: One hundred twenty patients have been taken in Dwarozh and International infertility centers in Sulaimani, for male infertility indications with normoovulatory female partners of ages less than 38 years, from 1st of September 2010 to 1st of September 2013. We divided patients into two groups: patients with normal ejaculation;group one (G1), and patients with surgically retrieved spermatozoa (normal sperms); group two (G2), all underwent Intracytoplasmic Sperm Injection (ICSI) cycles.
Main Outcome Measures: Fertilization, cleavage, biochemical and clinical pregnancy rates.
Results: The fertilization rate has been found 72.6% in G1, while in G2 it is 60.4% and a significant statistical difference was observed in fertilization rates between the two groups with a P value of less than 0.01. Also it has been found that in G1, 90.2% of oocytes were cleaved, while in G2, 89% of oocytes were cleaved, no significant statistical difference was observed in cleavage rates between the two groups, with a P value of more than 0.05. It has been found that in G1, pregnancy was positive (+ve) biochemically in 65% of the cases, while pregnancy was positive (+ve) clinically in 45% of the cases. In G2 pregnancy were (+ve) biochemically in 28.3%, while pregnancy was (+ve) clinically in 15% of the cases, with significant statistical differences in both biochemical and clinical pregnancies between the two groups with a P value of less than 0.01.
Conclusions: It has been found, with the use of ICSI cycles in the treatment of male factor infertility, there are significant differences in reproductive outcomes between cycles using ejaculated and surgically retrieved sperm. The data show that ICSI is aacceptable treatment option in oligospermic and azoospermic males. Acceptable rates of fertilization, cleavage and pregnancy success can be attainwith ICSI from patients with Azoospemia, reaching levels comparable with those of patients using ejaculated spermatozoa for ICSI.

Keywords: Ejaculate sperm, Surgical retrieved sperm, Fertilization, Pregnancy rate


How to cite this article:
Aghaways IH, Falah KM, Ali AA. The difference in the outcomes between surgically retrieved and ejaculated spermatozoa for intracytoplasmic sperm injection cycles in sulaimanyah province. Acta Med Int 2016;3:30-8

How to cite this URL:
Aghaways IH, Falah KM, Ali AA. The difference in the outcomes between surgically retrieved and ejaculated spermatozoa for intracytoplasmic sperm injection cycles in sulaimanyah province. Acta Med Int [serial online] 2016 [cited 2019 Nov 17];3:30-8. Available from: http://www.actamedicainternational.com/text.asp?2016/3/1/30/209716




  Introduction Top


The definition of infertility; is the absence of conception after 12 months of regular, unprotected intercourse.[1] Because a small number of normal couples conceive between 1 and 2 years, the World Health Organization (WHO) recommends 24 months of unprotected intercourse as the preferred definition of infertility.[1] Up to 50% of infertility is due to male factors.[2]

Failure of fertilization of the normal ovum is due to defective sperm development, function, or inadequate numbers.[2] There may be abnormalities of morphology (teratospermia) or motility (asthenospermia), low sperm numbers (oligospermia), combined disorders (oligoasthenospermia), or absent sperm (azoospermia).[2]

Oligospermia is defined as a sperm count of less than 20 million/mL.[1] Oligospermia is rarely seen as an isolated seminal abnormality, but it is usually associated with disturbed in motility and morphology.[1] Azoospermia; when zero sperm was found in the ejaculate and is found in about 1% of all men and in 10% to 15% of infertile males.[3]

Azoospermiais two type; obstructive azoospermia (OA) or non-obstructive azoospermia (NOA).[4] (OA) is characterized by an occlusion or partial absence of the reproductive tract with the presence of normal spermatogenesis. On the other hand, NOA is characterized by impaired spermatogenesis.[5]

Progress in the micromanipulation within the field of assisted reproductio,open a new way in the management of severe male factor infertility. The advent of Intra Cytoplasmic Sperm Injection (ICSI) in 1992, which entail the injection of a single sperm into the oocyte is an important breakthrough that has open a new era in the treatment of male infertility.[6]

ICSI is sometimes the only effective way to treat infertility.[7] ICSI can also be successfully performed using epididymal or testicular spermatozoa. Testicular spermatozoa may be recovered from testicular tissue in every patient with OA, but also in about half of patients with NOA.[8]

Sperm retrieval techniques (SRTs) are surgical methods for retrieving spermatozoa from the epididymis and the testicles of a patient diagnosed with azoospermia. From the clinical standpoint, the goals are two-folds:

  1. to obtain an adequate number of the highest quality sperm possible, which can be immediately used for ICSI or alternatively cryopreserved for future ICSI attempts, and
  2. to minimize damage to the reproductive tract.[9]


Evaluation and assessment of semen is neccessary for both diagnosis of male infertility and selection of patients for treatment with in vitro fertilization (IVF) or ICSI. In conventional IVF, sperm function is essential for normal fertilization: sperm must be able to bind to zona pellucida (ZP), start the acrosome reaction and penetrate the ZP and fuse with the oolemma before fertilization takes place. In contrast, in ICSI since sperm directly injected into cytoplasm of oocyte; most sperm functions are not required Therefore, the decision to use IVF or ICSIas a treatment is mostly dependent on results of sperm tests.[10]

Normal fertilization was confirmed by the presence of 2 pronuclei and 2 polar bodies 16–20 hour after IVF or ICSI.[11]

After fertilization and completion of second maturation division of the oocyte, the sperm head and the nucleus of the oocyte then form the male and female pronuclei, respectively. When they unite, forming the zygote.[12]

Once the zygote has reached the two-cell stage, it undergoes a cleavage divisions, increasing the numbers of cells. These cells, which become smaller with each cleavage division, are known as blastomere.[13]

Selection of embryos for transfer is based on cleavage to the 2-cell stage at 25 hour and 27 hour after ICSI, increases implantation and pregnancy rates.[14] The success of embryo implantation depends primarily on the embryoquality.[15]

High quality (grade A) embryos were defined as those having all of the following characteristics: either 4-6 cells on day 2 or 8-10 cells on day 3 of development, less than 15% fragmentation, symmetric blastomeres, absence of multinucleation, colorless cytoplasm with moderate granulation with no inclusions, absence of perivitelline space granularity and absence of zonapellucidadysmorphism. Embryos lacking any of the above characteristics are considered as low quality.[16]

Pregnancy will be considered Clinical, when 4th-7th gestational week fetus with fetal heart activity is confirmed by ultrasonography. If there is no fetus, the pregnancy will be considered biochemical pregnancy.[17]


  Objectives Top


As the male infertility became an obvious problem in our locality and we don't have a previous study or reference database in that concern so we conducted this study to have a more clear background on this aspect.

According to the references we have, up to 50% of infertility cases are due to male factor infertility.

The use of ejaculated and surgically retrieved sperm, coupled with ICSI, has become a globally established procedure for couples with azoospermic male partners who wish to have biological offspring.

The aim of this study is to compare success rates between surgically retrieved (normal sperms) and ejaculated spermatozoa for ICSI cycles in terms of fertilization, cleavage, biochemical and clinical pregnancy rates.


  Patients and Methods Top


One hundred twenty patients have been taken in Dwarozh and International infertility centers in Sulaimani, for male infertility indications with normoovulatory female partners of ages less than 37 years, from the 1st of September 2010 to the 1st of September 2013. Patients are divided into two groups; group one (G1) patients with normal ejaculation (oligospermia) and group two (G2) patients with surgically retrieved normal spermatozoa (azoospermia), all underwent (ICSI) cycles. Outcomes included fertilization, cleavage, biochemical and clinical pregnancy rates between the two groups.

Inclusion Criteria

  1. Normoovulatory females ≤37 years.[18],[19]


  2. (females with normal hormonal profile, normal ovaries, uterus and bilateral patent uterine tubes tested by ultrasonography and hysterosalpingography)

  3. Males with mild, moderate and sever oligospermia (G1)
  4. Azoospermic males (obstructive and non obstructive) in (G2) with normal sperms after surgically retrieved procedure
  5. Normal oocytes (normal M II oocytes should have a homogenous granule, round or oval polar body and clear zonapellucida)


Patients that cannot meet the above criteria are excluded.

Ovarian Stimulation

Hormonal stimulation of the ovary had been done by gynaecologist with an optimum stimulation protocol, started with transvaginal ultrasonography (Siemens, Sonoline G20, Siemens Medical Solutions USA, Inc.) to determine the number of antral follicle >5-7 is accepted. In the second day of the ovarian cycles females were sent for hormonal investigation in blood for FSH (3.9-12 mIU/ml), LH (1.5-8 mIU/ml), Estradiol (E2) (18-147 pg/ml), and Progesterone (P4) (≤ 0.25-0.54 ng/ml).

Stimulation protocols are short agonist and antagonist. In agonist protocol, induction of the ovary was started with gonadotropin releasing hormone (GnRH) agonist (Decapeptyl, Ferring GmbH, Germany) on second day and gonadotropins (Gonal-f, LaboroteriesSereno S.A, Switeerland; Fostimon, IBSA, Lugano 3, Suisse; Puregon, Schering-plough, NV.Organon, Oss, Netherland; Menegon, Ferring GmbH, Germany; and Merional, IBSA, Lugano 3, Suisse). Antagonist protocol was started with gonadotropins but on the seventh or eighth day of the cycle and especially when the dominant follicle reached >14mm in mean diameter, 0.25 mg Cetrorelix Acetate (Cerotide, Sereno, Germany), which is (GnRH) antagonist, was administered subcutaneously daily until the day of human chorionic gonadotropin (hCG) admininisteration.

Follow up of induction had been started by using transvaginal ultrasound (G20, Siemens, United States) and E2, when ultrasound show ≥ 4-5 follicles with diameters of ≥15-17 mm and E2 >500pg/ml,induction of final oocyte maturation is performed, generally by an injection of hCG (Choriomon, IBSA, Lugano 3, Suisse; and ovitrelle, IndustriaFarmacuticaSereno S.P.A, Bari, Italy). HCG acts as an analogue of luteinising hormone, and ovulation would occur between 38 and 40 hrs. After a single hCG injection, the egg retrieval is performed at a time usually between 34 and 36 hrs after hCG injection, that is, just prior to when the follicles would rupture.

Oocyte Retrieval

The oocytes were retrieved from the patients by gynecologist 34-36 hrs following hCG administration, using a transvaginal technique involving an ultrasound-guided needle using 16 gage 35 cm double lumen aspiration needle (William A.cook, Australia pty Ltd.).

The retrieval procedure usually takes between 20 to 40 minutes, depending on the number of mature follicles and is usually done under general anaesthesia. Through this, needle follicles can be aspirated, and the follicular fluid aspirated into tube containing aspiration media and heparin (FerticultAspiration,Fertipro N.V, Belgium), then the oocyte-cumulus complex was collected under stereo microscope (Nikon, SMZ 1500, Tokyo, Japan) and washed with flushing media (Ferticult flushing, Fertipro N.V, Belgium) then placed inside IVF media (Ferticult IVF, Fertipro N.V, Belgium) in incubator at 37°Centigrade and 5% Carbon dioxide (CO2) for 1-2 hours, see the image 2.3. The oocytes denudated by Hyaluronidase enzyme in HEPES-buffered medium containing 80 IU/ml (Hayse, Fertipro N.V, Belgium) to clean all the granulosa cells surrounding the zona under stereo microscope (Nikon, SMZ 1500, Tokyo, Japan), then incubated until the time of ICSI.

Sperm Preparation

In the meantime, sperm is prepared for fertilization by removing inactive cells and seminal fluid in a process called sperm washing.

In case of oligospermia, fresh ejaculated semen was collected by masturbation. On the day of oocyte retrieval, we waited for 20 minutes until thez obtained seminal fluid liquefied. After that, analysis was done with Makler chamber (Polymedoo Inc., Yorktown, NY) using phase contrast microscope (Olympus, BX 41, Tokyo, Japan) see image 2.5. The semen was prepared using colloidal silica density gradient centrifugation (Sil-select Stock, Fertipro N.V Belgium) with these steps:

  1. A dual gradient system was prepared (45%-90%) by mixing 1 ml. Sil-select with 9 ml. flushing media (Flushing media, Fertipro N.V Belgium) for high density gradient 90%, and mixing of 5.5 ml. of flushing media with 4.5 ml. of Sil-select for low density gradient 45% is used.
  2. Then 2.5 ml. of the high density gradient 90% was transferred into a sterile disposable centrifuge tube.
  3. Then 2.5 ml. of low density gradient 45 % was slowly transferred over the previous layer.
  4. Then gently 2.5 ml. of liquefied semen was added onto the upper layer using a sterile pipette.
  5. After the preparation of layers centrifuged with (Rotofix 32 A, Hettich, Germany) for 15-18 min. at 1500 round per minute (RPM),
  6. After centrifugation the supernatant was removed down the pellet.
  7. The pellet then mixed with 2-3 ml. of flushing media.
  8. Centrifuged for 8-10 minutes.
  9. Supernatant was removed down to the pellet, then the last 2 steps were repeated again.
  10. The pellet was mixed with 0.5 ml of flushing media, the final solution incubated at 37oC, 5% CO2 until the of ICSI procedure.


While in case of azoospermia, sperms are retrieved by the urologist, under local anesthesia, either by Percutaneous Epididymal Sperm Aspiration (PESA) or testicular sperm aspiration (TESA).

The technical procedure for PESA involved the insertion of a needle attached to a syringe through the scrotal skin into the epididymis. Originally, the use of a larger butterfly needle was described. Currently, most experts use a fine needle (26 gauge) attached to a tuberculin syringe containing sperm washing medium. The epididymis is stabilized between the index finger, thumb and forefinger. After creating negative pressure by pulling the syringe plunger, the tip of the needle is gently and slowly moved in and out inside the epididymis until fluid is aspirated. If motile sperm are not obtained, PESA may be repeated at a different site (from the cauda to caput epididymis) until an adequate number of motile sperm is retrieved.

Testicular Sperm Aspiration (TESA)

In TESA, the testis is divided into three poles, upper, middle and lower poles. A needle was inserted through the scrotal skin into the anteromedial or anterolateral portion of the upper pole at an oblique angle toward the medium and lower poles. These aspirations are usually carried out using either fine (testicular fine-needle aspiration; TEFNA) or a scalp butterfly canula gauge 23 attached to a syringe. The testicular parenchyma is aspirated by creating negative pressure and the tip of the needle is moved within the testis to disrupt the seminiferous tubules, the specimen was sent to the laboratory for microscopic examination. TESA can be carried out in the contralateral testis if no sperms are obtained during the first attempt.

The obtained tissues from the epididymis or the testis were placed in a special media for handling gametes. By using a scalpel or surgical blade, the tissue was sliced or dissected mechanically, and wet slides prepared was examined under phase contrast microscope (Olympus BX41 Tokyo, Japan) at 200x magnification, as shown in image 4.5. It was then placed in a flushing media for washing. After that, if sperm was found then dissected to remove tissues and blood cells, and then the content was placed into Appendorf tube and kept in an incubator for 30 minutes under 37°C then centrifuged for 5-10 minutes. The supernatant was removed. After adding 1 ml of flushing media, it was then kept in incubator for another 30 minutes and centrifuged for 5-10 minutes. The supernatant was discarded and the remaining was used.

Intracytoplasmic Sperm Injection Technique

The ICSI procedure carried out 38-42 hours after hCG injection and is performed only for metaphase II (MII) oocytes that had extruded their first polar bodies. The microinjection procedure was performed on a heated stage at 37°C under an inverted microscope (Integra Ti, R.I, Olympus, IX51/IX70, Tokyo, Japan) at 400×magnification, as shown in image 2.7. A drop of prepared sperm was placed in an ICSI dish (Nunc A/S, Denmark), and the sperm was aspirated with an injection pipette and transferred to a 4 ml. droplet of polyvinylpyrrolidone solution (PVP, Fertipro N.V Belgium), used for immobilization of spermatozoa. Active spermatozoa must first be immobilized; this is accomplished by gently tapering the tail, then it is drawn into the injection pipette from its tail. Meanwhile, the oocytes were placed in 5 μl. droplets of flushing media which was covered by light weight mineral oil (Ferticult Mineral oil, Fertipro N.V, Belgium). The oocyte was held by a holding pipette (Holding Pipette, Research Instruments Ltd, United Kingdom) with the polar body at twelve or six o'clock position. The injecting pipette (Injection Pipette, Research Instruments Ltd, United Kingdom) containing immobilized spermatozoon is introduced at three o'clock position through the zonapellucida and oolemma, deep into the ooplasm. After injection, the oocytes were rinsed or washed and stored in 25 μl. of culture medium (G1-INF media, Fertipro N.V Belgium) under oil in aculture dish. They were incubated at 37oC in an atmosphere of 5% of CO2 for 16-18 hours.

Fertilization

At 16–18 hours after ICSI, the oocytes were checked by embryologist on inverted ICSI microscope (Integra Ti, R.I., Olympus, IX51/IX70, Tokyo, Japan) for survival and fertilization. The numbers of polar bodies and pronucleiwere recorded. The normal fertilization is confirmed by the presence of two clearly visible pronuclei in ooplasm and two polar bodies in perivitelline space. Embryo cleavage are evaluated 2 days after ICSI procedure.



Embryo Culture

Typically, embryos were cultured in G1- IVF medium (G1-IVF media Fertipro N.V Belgium) until having reached the 6 to 8 cell stage three days after retrieval. Embryos were placed into an extended culture system, and the transfer would be done if high quality embryos were available on day 2 or 3 of retrieval.

Embryo Transfer and Implantation

The number of embryo to be transferred depends on the number available. For each couples, one to four embryos were transferred. Embryo transfere was performed on day 2 or 3 of retrieval, with the use of a thin plastic catheter (Gynetics Medical Products N.N, Lomell, Belgium). Support of the leuteal phase was achieved by progesterone (UTEROGESTAN® Laboratories Besins International) and (Primolute® Depot 250 mg. Bayer Schering Pharma) and also by (Cyclogest 400, Activas, Barnstaple, UK), duphaston tablet 10 mg (Abbott Biological B.V., Netherlands). Biochemical pregnancy was assessed by serum βHCG concentration 15 days post-embryo transfer (βHCG higher than 20-25 mIU/ml) and confirmed by the presence of a gestational sac on ultrasonography at least four weeks after the procedure (clinical pregnancy).






  Results Top


In this study, one hundred twenty cycles were analyzed. Group one (G1), 60 cycles with mild to moderate oligospermia, using ejaculated spermatozoa. Group two (G2), 60 cycles with azoospermia using testicular or epididymal spermatozoa.

There were no differences between the two groups in terms of female age, male age and the number of oocyte retrieved with a P value of 0.3864, 0.5033, 0.5399, respectively, which are more than 0.05 [Table 1].
Table 1: Comparison between oligospermia and azoospermia in terms of female age, male age and retrieved oocyte

Click here to view


Independent two samples t test for the difference between two samples' mean was used to test the significant differences. P value >0.05 is statistically considered not significant while P value < 0.05 was considered significant.

In G1, 561 oocytes were retrieved, out of which 424 oocytes (75.5%) reached maturation M II. All of them were injected, and the oocyte fertilization rates were (72.6%) 308 out of 424 injected oocytes, as shown [Table 2].
Table 2: Comparison between G1 and G2 in terms of oocyte maturation, fertilization, cleavage, and embryo transfer

Click here to view


In G2, 594 oocytes were retrieved, out of which 437 oocytes (73.5%) reached maturation M II. The oocyte fertilization rate was (60.4%) 264 out of 437 injected oocytes, as shown in [Table 2].

With a P value of (0.002) less than 0.01, there were a highly significant difference statistically in fertilization rates between the two groups, as shown [Table 2].

In G1, 278 (90.2%) oocytes were cleaved out of 308 fertilized oocytes, and 188 (67.6%) embryos out of 278 cleaved zygotes were transferred into mothers' uterine cavity, as shown in [Table 2].

In G2, 235 (89%) oocytes were cleaved out of 264 fertilized oocytes, and 179 (76.1%) embryos out of 235 cleaved zygotes were transferred into mothers' uterine cavity, as shown in [Table 2].

P value for cleavage was 0.6457, which was more than 0.05, so there was no significant difference statistically in cleavage rates between the two groups, as shown in [Table 2].

While P value for transferred embryo was 0.0497, which was less than 0.05, there was a significant difference statistically in transferred embryos between the two groups.

For the difference between two proportions Z test was used to test the significant differences. P value of < 0.05 is statistically considered significant. P value of < 0.01 is statistically considered highly significant. P value of > 0.05 is statistically considered not significant.

In G1, pregnancy was positive (+ve) biochemically in 39 cases from 60 cycles (65%) of cases, and 21 (35%) were negative (-ve).While in G2 pregnancy was (+ve) biochemically in 17 cases from 60 cycles (28.3%) and 43 (71.7%) were (-ve). P value for biochemical pregnancy in both groups is <0.01 which is considered highly significant statistically.



In G1, pregnancy was (+ve) clinically in 27 cycles (14.36%) of the cases were (+ve). In G2 pregnancy were (+ve) clinically in 9 cycles (5.02%) of the cases. P value for clinical pregnancy in both groups is <0.01 which considered highly significant statistically.



The data was entered into a Microsoft Excel Spreadsheet, after data cleaning; the data was transported into SPSS (Statistical Package for the Social Sciences-version 20.0) package software program for statistical analysis.


  Discussion Top


As the male infertility became an obvious problem in our locality and there is no reference database in that concern so this study is conducted to have a more clear background on this aspect.

The question of whether male factor infertility would affect the outcome of ICSI has gained great attention since the introduction of ICSI for the treatment of patients with extremely poor-quality sperm. Currently, ICSI can be successfully used for even the most severe cases of azoospermia.[20] The use of ejaculated and surgically retrieved sperm coupled with intracytoplasmic sperm injection has become a globally established procedure for couples with azoospermic male partners who wish to have biological offspring. Surgical methods have been developed to retrieve spermatozoa from the epididymides and the testes of such patients.[9]

The outcomes of ICSI were compared based on the sperm sources; a tendency towards reduced fertilization rates was observed in Group 2.

It has been found that in (G1) (75.5%) of oocytes reached maturation MII with a fertilization rate of (72.6%), while in (G2) (73.5%) of oocytes reached maturation MII with a fertilization rate of (60.4%), there were highly significant different in fertilization rates between the two groups with a P value of less than 0.01. and this agrees with[19],[20],[21] which they have found that fertilization rates were reduced, as the sperm quality decreased, indicating that sperm quality can affect the fertilization process. Analysis of unfertilized oocytes after ICSI have revealed that the main causes of unfertilization are failure to complete oocyte activation and sperm head decompensation, nevertheless, sperm retrieved from the testis, epididymis or ejaculation may have a different concentration, motility or morphology and differ in their degree of maturity and chromosomal or DNA composition. For instance, rates of DNA fragmentation, chromosomal aneuploidy, and mitochondrial dysfunctionare significantly higher in the sperm of oligozoospermia and/or asthenozoospermia and/or teratozoospermia (OAT) males compared with unaffected controls. Furthermore, aberrant DNA methylation of imprinted loci in sperm from oligospermic patients has been reported. Generally, testicular and epididymal sperm are considered to have a low degree of maturity and a high malformation rate.

It has been found that in G1, 90.2% of oocytes were cleaved while in G2, 89% of oocytes were cleaved, so there was no significant difference in cleavage rates between the two groups, with a P value of more than 0.05. This agrees with[18],[20],[22] which they have found that there were no statistical differences in the cleavage rates and high cleavage rates can be achieved with intracytoplasmic testicular sperm injection from patients with azospermia, reaching levels comparable with those of ICSI using ejaculated spermatozoa.

It has been found that in G1, pregnancy was +ve biochemically in 65% of the cases, and 35% were -ve. While pregnancy was +ve clinically in 45% of the cases +ve, 55% were -ve.

While in G2, pregnancy was +ve biochemically in 28.3%, and 71.7% was -ve. While pregnancy was +ve clinically in 15% of the cases and 85% was -ve.

So, there were highly significant differences in both biochemical and clinical pregnancies between the two groups with a P value of less than 0.01. And this agrees with[21],[23] which they have found that the pregnancy rate is significantly lower than that achieved with ejaculated sperms from patients with severe male factor infertility.

While Contrary to our study in terms of fertilization are.[18],[23],[24],[25]

Explanation: the number of cases was higher in their study, and the spermatozoa were successfully retrieved in all 43 patients with obstructive azoospermia and in 72.6% of 73 non-obstructive cases, they have found that Testicular spermatozoa recovered from patients with obstructive and all types of NOA were as much as effective as ejaculated spermatozoa in ICSI, and the sperm from azospermic patients had the same fertilization rates after ICSI as normal ejaculated sperm.

In[18] they observed that there were no significant differences in fertilization rate between the two groups.

Explanation: the mnIVF represents a unique IVF scenario in that a single oocyte is obtained and a single spermatozoon is used. They claim that there were no data to show even a modest impact of sperm source on ICSI outcome. Therefore their study assumed that the use of a single, surgically retrieved spermatozoa, would adversely impact reproductive outcome when compared with a use of single ejaculated spermatozoa.

In terms of cleavage our resultsdo not agree with[19] which they have found that fertilization and cleavage rates, quality of embryos as well as blastocyst development rates were significantly lower, as semen quality decreased.

Explanation: they observed a negative relationship between sperm quality and embryo development suggesting that sperm can affect embryogenesis from a very early stage, a possible explanation for this may be that testicular spermatozoa are less mature and subsequently less competent to fertilize than ejaculated spermatozoa.

In terms of biochemical and clinical pregnancy

Contrary to our study are.[18],[19],[24],[26] In[18] eighty-one modified natural IVF-ICSI (mnIVF-ICSI) cycles utilizing ejaculated sperm were compared to forty-four mnIVF-ICSI cycles using surgically retrieved sperm. There were no significant differences between the two groups neither in the biochemical nor the clinical pregnancy rates.

Explanation

They used a retrospective cohort study to evaluate the outcome of mnIVF-ICSI cycles to compare 81 mnIVF-ICSI first cycles using ejaculated spermatozoa with 44 mnIVF-ICSI first cycles using surgically retrieved spermatozoa. Follicular development was monitored and GnRH antagonist was commenced when the dominant follicle reached 14 mm. At the same time Indomethacin was given three times a day until the day before oocyte retrieval to delay follicular rupture and reduce premature ovulation. And in all cycles single-embryo transfer was perfomed.

The benefits of mnIVF treatment are the use of minimal amount of medication with almost no risk of ovarian hyper stimulation syndrome, the relatively easier oocyte retrieval. Furthermore, since mnIVF almost always results in only one oocyte being aspirated, single-embryo transfer will almost always be done. They concluded that in most studies to date, the source of spermatozoa (ejaculated or surgically retrieved) used in ICSI cycles has had no significant impact on clinical outcomes and this is also true within the context of single-embryo transfer.


  Conclusions Top


It has been found that with the use of ICSI cycles for the treatment of male factor infertility there are significant differences in reproductive outcomes between cycles using ejaculated and surgically retrieved sperm. The data suggest that ICSI is a viable treatment option in oligospermic and azoospermic males. High fertilization, cleavage, and pregnancy rates can be achieved with ICSI from patients with Azoospemia, reaching levels comparable with those of ICSI using ejaculated spermatozoa.


  Acknowledgments Top


Iwould like to show my gratitude to Dwarozh-IVF center in Sulaimania, KRG, Iraq for their assistance so I am grateful for all….



 
  References Top

1.
Edmund Sabanegh Jr, Ashok Agarwal, Marc Goldstein, Male Infertility, Alan J. Wein, Campbell-walsh urology. Tenth edition, Saunders Elsevier Philadelphia, USA, 2012; pages: 616-648, 60.  Back to cited text no. 1
    
2.
David M. Albala, Allen F. Morey, Leonard G. Gomella, John P. Stein. Infertility, Oxford american handbook of urology. Oxford University Press, New York, USA, 2011, chapter 11, page 470, 476.  Back to cited text no. 2
    
3.
Marmar, J. L. (2001): The Diagnosis and Treatment of Male in the New Millennium. Int. J. Fertil.; 46 (3): 116–129.  Back to cited text no. 3
    
4.
Hui D. L, HyoSerk Lee, Se Hwan Park, DaeGi Jo, Jin Ho Choe, JoongShik Lee, et al. Causes and classification of male infertility in Korea. Clin Exp Reprod Med. 2012 December; 39(4): 172–175.  Back to cited text no. 4
    
5.
Semião-Francisco L, Braga DP, FigueiraRde C, Madaschi C, Pasqualotto FF, Iaconelli A Jr, et al. Assisted reproductive technology outcomes in azoospermic men: 10 years of experience with surgical sperm retrieval. Aging Male. 2010 Mar; 13(1):44–50.  Back to cited text no. 5
    
6.
Rubina M, Goral Gandhi, Gautam N. Allahbadia. In vitro fertilization/intracytoplasmic sperm injection for male infertility. Indian J Urology, 2011 Jan-Mar; 27(1): 121–132.  Back to cited text no. 6
    
7.
David Mortimer Genesis Fertility Centre. The future of male infertility management and assisted reproduction technology. Hum Reprod. 2000 Vol. 15, (Suppl. 5) page 98–110.  Back to cited text no. 7
    
8.
Tournaye H, Camus M, Vandervorst M, Nagy Z, Joris H, Van Steirteghem A, et al. Surgical Sperm retrieval for intracytoplasmic sperm injection. Int. J Androlology, 1997: 20 Suppl 3:69–73.  Back to cited text no. 8
    
9.
Sandro C Esteves, Ricardo Miyaoka, José Eduardo Orosz, Ashok Agarwal. An update on sperm retrieval techniques for azoospermic males. Clinics (Sao Paulo), February 2013; 68(S1): 99–110.  Back to cited text no. 9
    
10.
Liu DY and Baker HW. Evaluation and assessment of semen for IVF/ICSI. Asian J Androl. Dec 2002; 4(4):281–5.  Back to cited text no. 10
    
11.
Lee MJ, Lee RK, Lin MH, Hwu YM. Cleavage speed and implantation potential of early-cleavage embryos in IVF or ICSI cycles. J Assist Reprod Genet. Aug 2012; 29(8):745–50.  Back to cited text no. 11
    
12.
Shigehito Yamada, and Tetsuya Takakuwa, Developmental Overview of the Human Embryo. The human embryo. InTech, Rijeka, Croatia, 2012, page: 8.  Back to cited text no. 12
    
13.
T. W. Sadler, First week of development: Ovulation to implantation, T. W. Sadler. Langman's Medical Embryology. 12th edition, Lippincot Williams and Wilkins, Philadelphia, USA, 2012, pages 25–26, 37, 243.  Back to cited text no. 13
    
14.
Bos-Mikich A, Mattos AL, Ferrari AN. Early cleavage of human embryos: an effective method for predicting successful IVF/ICSI outcome. Hum Reprod. Dec 2001; 16(12):2658–61.  Back to cited text no. 14
    
15.
Noriko Yoshii, Toshio Hamatani, Noboru Inagaki, Takeshi Hosaka, Osamu Inoue, Mitsutoshi Yamada, et al. Successful implantation after reducing matrix metalloproteinase activity in the uterine cavity. ReprodBiolEndocrinol. 2013; 11: 37.  Back to cited text no. 15
    
16.
Braga DP1, FigueiraRde C, Ferreira RC, Pasqualotto FF, Iaconelli A Jr, Borges E Jr. Contribution of in-vitro maturation in ovarian stimulation cycles of poor-responder patients. Reprod Biomed Online. 2010 Mar; 20(3):335–40.  Back to cited text no. 16
    
17.
Abbas Aflatoonian, FatemehMansooriMoghaddam, MehriMashayekhy, FarnazMohamadian, Comparison of early pregnancy and neonatal outcomes after frozen and fresh embryo transfer in ART cycles. J Assist Reprod Genet. December 2010; 27(12): 695–700.  Back to cited text no. 17
    
18.
Jamal W, Vélez MP, Zini A, Phillips S, Hemmings R, Kadoch IJ. Surgically retrieved spermatozoa versus ejaculated spermatozoa in modified natural IVF-ICSI cycles. Reprod Biomed Online. 2012 Sep; 25(3):242–7.  Back to cited text no. 18
    
19.
Kalliopi E. Loutradi, Basil C. Tarlatzis, Dimitrios G. Goulis, Leonidas Zepiridis, ThoulaPagou, Elisabeth Chatziioannou, et al. The effects of sperm quality on embryo development after intracytoplasmic sperm injection, J Assist Reprod Genet. Feb 2006; 23(2): 69–74.  Back to cited text no. 19
    
20.
Yue-hong Lu, Hui-juanGao, Bai-jia Li, Ying-mingZheng, Ying-hui Ye, Yu-li Qian, et al. Different sperm sources and parameters can influence intracytoplasmic sperm injection outcomes before embryo implantation. J Zhejiang UnivSci B. January 2012; 13(1): 1–10.  Back to cited text no. 20
    
21.
Göker EN, Sendag F, Levi R, Sendag H, Tavmergen E. Comparison of the ICSI outcome of ejaculated sperm with normal, abnormal parameters and testicular sperm. Eur J ObstetGynecolReprod Biol. 2002; 104(2):129–136.  Back to cited text no. 21
    
22.
Ariel Hourvitz, Adrian Shulman, IgaelMadjar, Jacob Levron, David Levran, ShlomoMashiach, et al. In Vitro Fertilization Treatment for Severe Male Factor: A Comparative Study of Intracytoplasmic Sperm Injection with Testicular Sperm Extraction and with Spermatozoa from Ejaculate, J Assist Reprod Genet. July 1998; 15(6): 386–389.  Back to cited text no. 22
    
23.
Schatte EC; Orejuela FJ; Lipshultz LI; Kim ED; Lamb DJ, Treatment of infertility due to anejaculation in the male with electroejaculation and intracytoplasmic sperm injection, J Urol. 2000; 163(6):1717–20.  Back to cited text no. 23
    
24.
Bukulmez O, Yucel A, Yarali H, Bildirici I, Gurgan T. The origin of spermatozoa does not affect intracytoplasmic sperm injection outcome. Eur J ObstetGynecolReprod Biol. 2001; 94(2):250–255.  Back to cited text no. 24
    
25.
Verza S Jr, Esteves SC. Sperm defect severity rather than sperm source is associated with lower fertilization rates after intracytoplasmic sperm injection. IntBraz J Urol. 2008; 34(1):49–56.  Back to cited text no. 25
    
26.
R C Pinheiro, J Lambert, F Bénard, F Mauffette, P Miron. Effectiveness of in vitro fertilization with intracytoplasmic sperm injection for severe male infertility, CMAJ. Nov 30, 1999; 161(11): 1397–1401.  Back to cited text no. 26
    



 
 
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