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The purpose of this review is to address the critical need for standardization and clarity in the use of key performance indicators (KPIs) within the realm of in vitro fertilization (IVF), particularly emphasizing the integration of preimplantation genetic testing (PGT) processes. This review is timely and relevant given the persistently modest success rates of IVF treatments, which stand at approximately 30%, and the growing complexity of IVF procedures, including PGT practices. The review synthesizes recent findings across studies focusing on technical and clinical KPIs in embryology and genetic laboratories, identifying gaps in current research and practice, particularly the lack of standardized KPIs and terminology. Recent findings highlighted include the critical evaluation of technical KPIs such as Intracytoplasmic Sperm Injection (ICSI) fertilization rates, embryo development rates, and laboratory performance metrics, alongside clinical KPIs like the proportion of mature oocytes and clinical pregnancy rates. Notably, the review uncovers a significant gap in integrating and standardizing KPIs for PGT applications, which is essential for improving IVF outcomes and genetic diagnostic accuracy. The implications of these findings are profound for both clinical practice and research. For clinical practice, establishing a standardized set of KPIs, especially for PGT, could significantly enhance the success rates of IVF treatments by providing clearer benchmarks for quality and performance. For research, this review underscores the necessity for further studies to close the identified gaps, promoting a more integrated and standardized approach to KPIs in IVF and PGT processes. This comprehensive approach will not only aid in improving clinical outcomes but also in advancing the field of reproductive medicine., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Studies have explored the assisted reproductive technology (ART) outcomes of Y-chromosome azoospermia factor c (AZFc) microdeletions, but the effect of sperm source on intracytoplasmic sperm injection (ICSI) remains unknown. To determine the ART results of ICSI using testicular sperm and ejaculated sperm from males with AZFc microdeletions, we searched Embase, Web of Science, and PubMed to conduct a systematic review and meta-analysis. The first meta-analysis results for 106 cycles in five studies showed no significant differences in the live birth rate between the testicular sperm group and the ejaculated sperm group (risk ratio: 0.97, 95% confidence interval [CI]: 0.73-1.28, P = 0.82). The second meta-analysis of 106 cycles in five studies showed no difference in the abortion rate between the testicular sperm group and ejaculated sperm group (risk ratio: 1.06, 95% CI: 0.54-2.06, P = 0.87). The third meta-analysis of 386 cycles in seven studies showed no significant difference in clinical pregnancy rates between the testicular sperm group and the ejaculated sperm group (risk ratio: 1.24, 95% CI: 0.66-2.34, P = 0.50). Inevitable heterogeneity weakened our results. However, our results indicated that testicular sperm and ejaculated sperm yield similar ART outcomes, representing a meaningful result for clinical treatment. More properly designed studies are needed to further confirm our conclusions., Competing Interests: None

Purpose: To explore the pregnancy outcomes, and neonatal status, arising from embryo transfer in unicornual uterine infertility patients., Methods: We analyzed 2499 cycles of clinical data from in vitro fertilization/intracytoplasmic sperm injection-embryo transfer (IVF/ICSI-ET) from 1st May 2016 to 1st May 2018 in the Reproductive Center of the Third Affiliated Hospital of Zhengzhou University, including 109 women with unicornuate uterus (the observation group) and 2390 women with normally shaped uterus (the control group)., Results: There were no significant differences in embryo implantation rate, clinical pregnancy rate or miscarriage rate (41.88 % VS 42.36 %, P = 0.904; 48.62 % VS 55.94 %, P = 0.133; 11.01 % VS 8.99 %, P = 0.474) between the two groups. The live birth rate in the observation group was lower than that in the control group (35.78 % VS 45.82 %, P = 0.040). The fetal birth weight of the observation group was lower than that of the control group among single-born live births (3009.12 ± 430.59 g VS 3413.40 ± 492.25 g, P = 0.017), but the differences were not observed in the sex ratio at birth, premature birth rate, low birth weight infant (LBW) rate and macrosomia rate (P > 0.05). The fetal birth weight of the observation group was lower than that of the control group among twins live births (2480.00 ± 190.32 g VS 2606.02 ± 471.59 g), but the difference between the groups did not reach statistical significance (P > 0.05)．Logistic regression analysis showed that age, number of embryos transplanted and uterine morphology were independent influencing factors of live birth., Conclusion: Compared with women with normal uterus, the live birth rate of women with unicornuate uterus is low, and the birth weight of newborns with single birth is reduced., Competing Interests: Declaration of Competing Interest The authors report no declarations of interest., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Research Question: Is PIEZO-intracytoplasmic sperm injection (ICSI) coupled with a new novel operational fluid (perfluoro-n-octane) superior to standard ICSI?, Design: A cohort of patients (n = 69) undertaking microinjection were recruited between January and November 2019 and were then prospectively case-matched. Patients required six or more mature oocytes for inclusion in the study. PIEZO-ICSI uses high-speed microinjection drilling to penetrate the zona and oolemma and deposit the spermatozoa into the cytoplasm, compared with the traditional 'cutting' action of ICSI. The primary outcome was fertilization, with secondary outcomes including oocyte degeneration, abnormal fertilization, embryo cryopreservation and embryo utilization., Results: PIEZO-ICSI resulted in significantly higher fertilization rates (80.5 ± 2.4% vs 65.8 ± 2.3%, P < 0.0001) and lower oocyte degeneration rates (4.4 ± 1.3% vs 8.6 ± 1.2%, P = 0.019) and abnormal fertilization rates (2.9 ± 1.1% vs 7.4 ± 1.1%; P = 0.003) compared with standard ICSI. This improvement in fertilization was of most benefit in patients aged ≥38 years. This increase in fertilization increased the number of good quality embryos that were available for cryopreservation/transfer (3.8 ± 0.2 vs 3.1 ± 0.2; P = 0.038), such that patients on average had one extra usable embryo per cycle compared with standard ICSI. There were no differences to Day 5 embryo development or clinical pregnancy from fresh embryo transfer (57.1% PIEZO-ICSI vs 60.0% ICSI) between microinjection methods, although pregnancy outcomes were underpowered., Conclusions: PIEZO-ICSI significantly increased fertilization rates, thereby increasing the number of embryos available for cryopreservation compared with standard ICSI. Further prospective studies assessing cumulative pregnancy rates are warranted., (Copyright © 2021 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.)

Study Question: Is ICSI better than conventional IVF for non-male factor infertility?, Summary Answer: IVF should be the choice of assisted reproductive technique in non-male factor infertility cases., What Is Already Known: Although total fertilization failure is a major concern for patients and professionals, the overall risk/benefit analysis favors conventional IVF in non-male factor infertility cases. However, according to the ESHRE EIM database pertaining to 1997-2012, the use of IVF has been continuously decreasing in favor of ICSI., Study Design, Size, Duration: Randomized controlled double-blind study involving 138 women undergoing ART in a private Center., Participants/materials, Setting, Methods: All couples with a female partner ≤42 years of age and without severe male factor (total progressive motile sperm with normal morphology >10.000) were included in the study. Exclusion criteria were: history of total fertilization failure, less than 6 cumulus oocyte complexes (COC) available for fertilization, prenatal genetic testing (PGT) cycles, unwillingness to participate and couples undergoing total cryopreservation for any indication. On the day of oocyte pick up, sibling COCs were randomly allocated to fertilization with IVF or denudation followed by ICSI to MII oocytes. The decision to transfer IVF or ICSI embryo(s) depended on embryo quality. Women receiving two embryos were given only IVF or ICSI embryos. Neither the clinician performing the transfer nor the patients were aware of the fertilization method used to generate the embryos transferred. Main outcome parameters were fertilization, clinical pregnancy, implantation and miscarriage rates., Main Results and the Role of Chance: Demographic variables, ovarian reserve and infertility etiology, duration of stimulation, total gonadotropin consumption, peak estradiol levels were similar for IVF-ET and ICSI-ET groups. Mean number of COCs (18.95 vs 19.24), number of embryos transferred (1,81 vs 1,81), the ratio of good quality embryos/total embryos (56.89 % and 55.97 %), clinical pregnancy rates (63 % vs 49 %), implantation rates (31 % vs 28 %), and abortion rates (12,5 % vs 8,1 %) were also similar. A total of 1306 COCs were allocated for IVF while 1331 COCs were denuded for ICSI. Fertilization rate per inseminated oocyte was significantly higher in ICSI group (56,20 % vs 63,78 %). There were ten cases of total fertilization failure, all in the IVF group. Although overall fertilization rate was higher for ICSI, it was similar in both groups when cases with total fertilization failure were excluded., Limitations, Reasons for Caution: The non-availability of live birth rates is a limitation. Randomization of sibling oocytes, not patients requires careful interpretation of pregnancy and implantation rates., Wider Implications of the Findings: Lower cost, ease of application and similar clinical outcome makes IVF the choice of fertilization method in non-male factor infertility cases., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Purpose: To determine if oocyte denudation and ICSI at 36.5 versus 39 h post HCG and/or Lupron trigger (2.5 h versus 5 h post-oocyte retrieval) influences fertilization and blastulation rates in good prognosis couples METHODS: We performed a prospective, randomized controlled trial of 12 patients undergoing IVF with ICSI at an academic fertility center, resulting in 206 MII oocytes analyzed. At time of retrieval, patients with more than 10 oocytes retrieved had their oocytes randomized into two groups-one group for oocyte denudation and ICSI at 36.5 h post HCG and/or Lupron trigger and the other group for these procedures at 39 h post HCG and/or Lupron trigger (2.5 and 5 h after oocyte retrieval). Primary outcomes were fertilization and blastulation rates., Results: No difference was observed in fertilization rate, total blastulation rate, or day of blastulation based on timing of denudation and ICSI (all p > 0.05). Multiple regression analyses for fertilization and blastulation controlling for age and BMI revealed no difference in fertilization based on time of ICSI (p = 0.38, 0.71, respectively). A conditional logistic regression to account for multiple oocytes derived from each patient also found no difference in fertilization or blastulation based on timing of ICSI, even when controlling for age and BMI (p = 0.47, 0.59, respectively)., Conclusion(s): In good prognosis couples, we observed no difference in fertilization or blastulation rates based on timing of ICSI within the currently accepted 2- to 6-h window post-retrieval based on a 34-h trigger. The oocyte appears to have a physiological tolerance for fertilization during this window of time, and variability in the timing of ICSI during this window is unlikely to have an impact on cycle outcome., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Sperm morphology was once believed as one of the most predictive indicators of pregnancy outcome in assisted reproductive technology (ART). However, the impact of teratozoospermia on in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) outcomes and its offspring remains inconclusive. In order to evaluate the influence of teratozoospermia on pregnancy outcome and newborn status after IVF and ICSI, a retrospective study was conducted. This was a matched case-control study that included 2202 IVF cycles and 2574 ICSI cycles and was conducted at the Reproductive and Genetic Hospital of CITIC-Xiangya in Changsha, China, from June 2013 to June 2018. Patients were divided into two groups based on sperm morphology: teratozoospermia and normal sperm group. The pregnancy outcome and newborn outcome were analyzed. The results indicated that couples with teratozoospermia had a significantly lower optimal embryo rate compared to those with normal sperm morphology in IVF (P = 0.007), while there were no statistically significant differences between the two groups in terms of the fertilization rate, cleavage rate, implantation rate, and pregnancy rate (all P > 0.05). Additionally, teratozoospermia was associated with lower infant birth weight in multiple births after IVF. With regard to ICSI, there was no significant difference in both pregnancy outcome and newborn outcome between the teratozoospermia and normal groups (both P > 0.05). Furthermore, no increase in the risk of birth defects occurred in the teratozoospermia group after IVF/ICSI. Consequently, we believe that teratozoospermia has limited predictive value for pregnancy outcomes in IVF/ICSI, and has little impact on the resulting offspring if multiple pregnancy is avoided., Competing Interests: None

Intracytoplasmic sperm injection (ICSI) efficiently addresses male factor infertility. However, the occurrence of abnormal fertilization, mainly characterized by abnormal pronuclei (PN) patterns, merits investigation. To investigate abnormal fertilization patterns following ICSI and identify their respective associations with abnormal parameters in semen analysis (SA), a retrospective observational study including 1855 cycles was performed. Male infertility diagnosis relied on the 2010 WHO criteria. The population was divided into groups based on their SA results. The presence of 2PNs and extrusion of the second polar body (PB) indicated normal fertilization. A Kruskal-Wallis test along with a Wilcoxon post hoc evaluation and Bonferroni correction was employed for comparison among the groups. For the pregnancy rate, logistic regression was employed. No correlation was established between the SA abnormalities and the 1PN or 3PN formation rates. The highest and lowest 0PN rates were reported for the oligoasthenoteratozoospermic and normal groups, respectively. The lowest cleavage formation rates were identified in the oligoasthenozoospermic and oligoasthenoteratozoospermic groups. The aforementioned groups along with the oligoteratozoospermic group similarly presented the lowest blastocyst formation rates. For the clinical pregnancy rate, no statistically significant difference was observed. In conclusion, the incidence of two or more abnormal SA parameters - with the common denominator being oligozoospermia - may jeopardize normal fertilization, cleavage, and blastocyst rates. Once the developmental milestone of achieving blastocyst stage status was achieved, only oligoasthenozoospermia and oligoasthenoteratozoospermia were associated with lower rates. Interestingly, following adjustment for the number of blastocysts, no statistically significant differences were observed., Competing Interests: None

Objectives: The male-factor subfertility was reported to be 30% globally; thus, the intracytoplasmic sperm injection (ICSI) procedure was implemented to improve the overall in vitro fertilization (IVF) rates. Nevertheless, at least 10% of fertilization failure still occurs. Concerning this issue, we explored the association of sperm concentration and motility with the quality of embryo development and pregnancy outcome in IVF-ICSI cycles., Methods: Retrospective analysis of 109 couples with male factor were done over 14 months in a tertiary university hospital in Malaysia. The data were divided into four groups; Group I: normal sperm parameters, Group II: normal sperm concentration but reduced total sperm motility, Group III: reduced sperm concentration and motility, Group IV: reduced sperm concentration but normal sperm motility. Only fresh semen samples and fresh embryo transfers were included. The fertilization, cleavage rate, embryo quality and pregnancy outcome were assessed., Results: Overall, group I had the highest oocytes yield and ICSI attempted; (10.12 + 6.50), whereas the lowest was in group IV; (7.00 + 2.82). Group II revealed the highest fertilization and cleavage rates; (54.14 + 25.36), (55.16 + 26.06), thus not surprisingly resulting in the highest number of good embryos and highest clinical pregnancy rates. The lowest cleavage and pregnancy rates were seen in group IV. However, all the outcomes were not statically significant (p>0.05)., Conclusions: Similar fertilization rate and comparable pregnancy outcome was seen among couples with normal and reduced sperm concentration and motility., (© 2021 Walter de Gruyter GmbH, Berlin/Boston.)

Objective: To report a live birth from a patient with complete zona-free oocytes due to abnormal zona production and to reveal full time-lapse blastocyst development footage of its originating embryo., Methods: A 34-year-old woman presented with a history of failed fertilization via standard in vitro fertilization insemination and a potential absence of zona pellucida. A total of 3 intracytoplasmic sperm injection cycles were undertaken with all oocytes collected being zona-free. Embryos created in the initial 2 cycles were cultured in the G1+/G2+ sequential media in a benchtop incubator. During the final successful cycle, the culture strategy was shifted to single step media (G-TL) in an Embryoscope+ incubator., Results: The first 2 attempts led to a biochemical pregnancy or no blastocyst available for transfer. In the third cycle, 13 out of 24 collected oocytes were subjected to injection, with 4 being normally fertilized. Two blastocysts were subsequently formed, in which one was cryopreserved and the other transferred. A live baby girl (1570g) was subsequently delivered at 34 weeks of gestation by cesarean section., Conclusion: Live birth can be achieved for patients with zona production deficiency. Adjustment in ovarian stimulation and subsequent embryo culture strategies may have potentially contributed to the success of the 3rd cycle.

Purpose: The summary presented herein represents Part II of the two-part series dedicated to the Diagnosis and Treatment of Infertility in Men: AUA/ASRM Guideline. Part II outlines the appropriate management of the male in an infertile couple. Medical therapies, surgical techniques, as well as use of intrauterine insemination (IUI)/in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) are covered to allow for optimal patient management. Please refer to Part I for discussion on evaluation of the infertile male and discussion of relevant health conditions that are associated with male infertility., Materials/methods: The Emergency Care Research Institute Evidence-based Practice Center team searched PubMed®, Embase®, and Medline from January 2000 through May 2019. When sufficient evidence existed, the body of evidence was assigned a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinions. (Table 1) This summary is being simultaneously published in Fertility and Sterility and The Journal of Urology., Results: This Guideline provides updated, evidence-based recommendations regarding management of male infertility. Such recommendations are summarized in the associated algorithm. (Figure 1) CONCLUSION: Male contributions to infertility are prevalent, and specific treatment as well as assisted reproductive techniques are effective at managing male infertility. This document will undergo additional literature reviews and updating as the knowledge regarding current treatments and future treatment options continues to expand., (Copyright © 2020 Author. Published by Elsevier Inc. All rights reserved.)

Intracytoplasmic sperm injection, while typically effective for overcoming low or absent fertilization in couples with a clear abnormality of semen parameters, is frequently used in combination with assisted reproductive technologies for other etiologies of infertility in the presence of semen parameters that meet the World Health Organization 2010 normative reference values. This committee opinion provides a critical review of the literature, where available, to identify situations where this may or may not be of benefit. This document replaces the previously published document of the same name, last published in 2012 (Fertil Steril 2012;98:1395-9)., (Copyright © 2020 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: Cystic fibrosis transmembrane conductance regulator (CFTR) and adhesion G protein-coupled receptor G2 (ADGRG2) have been identified as the main pathogenic genes in congenital bilateral absence of the vas deferens (CBAVD), which is an important cause of obstructive azoospermia. This study aimed to identify the disease-causing gene in two brothers with CBAVD from a Chinese consanguineous family and reveal the intracytoplasmic sperm injection (ICSI) outcomes in these patients., Methods: Whole-exome sequencing and Sanger sequencing were used to identify the candidate pathogenic genes. Real-time polymerase chain reaction, immunohistochemistry, and immunofluorescence were used to assess the expression of the mutant gene. Moreover, the ICSI results from both patients were retrospectively reviewed., Results: A novel hemizygous loss-of-function mutation (c.G118T: p.Glu40*) in ADGRG2 was identified in both patients with CBAVD. This mutation is absent from the human genome databases and causes an early translational termination in the third exon of ADGRG2. Expression analyses showed that both the ADGRG2 mRNA and the corresponding protein were undetectable in the proximal epididymal tissue of ADGRG2-mutated patients. ADGRG2 expression was restricted to the apical membranes of non-ciliated epithelia in human efferent ducts, which was consistent with a previous report in mice. Both ADGRG2-mutated patients had normal spermatogenesis and had successful clinical outcomes following ICSI., Conclusions: Our study verifies the pathogenic role of ADGRG2 in X-linked CBAVD and broadens the spectrum of ADGRG2 mutations. In addition, we found positive ICSI outcomes in the two ADGRG2-mutated CBAVD patients.

Background: Only a few microbial studies have conducted in IVF (in vitro fertilization), showing the high-variety bacterial contamination of IVF culture media to cause damage to or even loss of cultured oocytes and embryos. We aimed to determine the prevalence and counts of bacteria in IVF samples, and to associate them with clinical outcome., Methods: The studied samples from 50 infertile couples included: raw (n = 48), processed (n = 49) and incubated (n = 50) sperm samples, and IVF culture media (n = 50). The full microbiome was analyzed by 454 pyrosequencing and quantitative analysis by real-time quantitative PCR. Descriptive statistics, t-, Mann-Whitney tests and Spearman's correlation were used for comparison of studied groups., Results: The study involved normozoospermic men. Normal vaginal microbiota was present in 72.0% of female partners, while intermediate microbiota and bacterial vaginosis were diagnosed in 12.0 and 16.0%, respectively. The decreasing bacterial loads were found in raw (35.5%), processed (12.0%) and sperm samples used for oocyte insemination (4.0%), and in 8.0% of IVF culture media. The most abundant genera of bacteria in native semen and IVF culture media were Lactobacillus, while in other samples Alphaproteobacteria prevailed. Staphylococcus sp. was found only in semen from patients with inflammation. Phylum Bacteroidetes was in negative correlation with sperm motility and Alphaproteobacteria with high-quality IVF embryos., Conclusion: Our study demonstrates that IVF does not occur in a sterile environment. The prevalent bacteria include classes Bacilli in raw semen and IVF culture media, Clostridia in processed and Bacteroidia in sperm samples used for insemination. The presence of Staphylococcus sp. and Alphaproteobacteria associated with clinical outcomes, like sperm and embryo quality.

The increased commercialisation of intracytoplasmic sperm injection (ICSI) in horses creates more opportunities to incorporate advanced reproductive technologies, such as sex-sorted, refrozen and lyophilised spermatozoa, into a breeding program. This paper reviews the status of these semen-handling technologies in light of their use in equine ICSI programs. Pregnancies have been achieved from each of these advanced technologies when combined with ICSI in horses, but refinements in the semen-handling processes underpinning these technologies are currently being explored to produce more reliable and practical improvements in the results from equine ICSI.

Study Question: How many non-conformances occur in an ART laboratory and how often do they occur?, Summary Answer: The limited data to date demonstrate that IVF laboratories have a very low non-conformance rate compared with reported non-conformances in other medical laboratories, especially when one considers the high-complexity of procedures performed., What Is Known Already: ART involves a series of very complex patient and laboratory procedures. Although it is assumed that strict measures control ART laboratories, there is very little published data on non-conformances., Study Design, Size, Duration: In accordance with the ISO 9001:2008 standard, Boston IVF has created an electronic database to record non-conformances in the IVF laboratory. We reviewed the non-conformances reported between March 2003 and December 2015. The non-conformances were categorized into four grades largely based upon their impact on the outcome or continuation of an IVF treatment cycle: None/Minimal (not measurably decreasing the likelihood of success), Moderate (a negative impact but not loss of a cycle), Significant (loss of a cycle or majority of gametes or embryos) and Major (infrequent errors that have an extreme impact on a patient or patients such as a confirmed pregnancy or birth involving misidentification of sperm, egg or embryo, or an extreme equipment or documentation failure that affects numerous patients). The category of problem or error associated with the Non-conformance Report was also noted., Participants/materials, Setting, Method: Retrospective analysis of an electronic database registering non-conformances at a large IVF laboratory., Main Results and the Role of Chance: During the study period, a total of 36 654 IVF treatment cycles (fresh and frozen embryo transfer cycles) were conducted which involved a total of 181 899 individual laboratory procedures encompassing egg retrievals, sperm preparations, inseminations, embryo transfers, etc. When combining both moderate and significant non-conformances, 99.96% of procedures and 99.77% of cycles proceeded with no non-conformances. No Major grade non-conformances were reported., Limitations, Reasons for Caution: A comparison of non-conformances between IVF clinics is difficult because of different classifications., Wider Implications of the Findings: Errors are inevitable and it is incumbent on all IVF centers to be honest and transparent, both within the organization and with patients when errors occur. Robust systems for identifying, documenting, analyzing and implementing improvements should be established and maintained., Study Funding/competing Interest(s): No external funding was used for this study. The authors have no conflicts of interest.

Objective: To evaluate the multivariate embryo selection model by van Loendersloot et al. (2014) (VL) in a different geographical context., Design: This is a retrospective external validation study of a 5-year cohort of women undergoing in vitro fertilization or intracytoplasmatic sperm injection., Setting: Two outpatient fertility clinics., Patient(s): A total of 1,197 women who underwent 1,610 fresh in vitro fertilization or intracytoplasmatic sperm injection cycles with single embryo transfer were included., Intervention(s): None., Main Outcome Measure(s): The area under the receiver operating characteristics curve for diagnostic efficacy was used to assess the discriminative value of the model. Calibration for testing the validity of the VL model was performed using the Hosmer-Lemeshow goodness-of-fit test and a calibration plot., Result(s): Three hundred thirty-three patients (21%) achieved a viable pregnancy of at least 11 weeks. The area under the receiver operating characteristics curve using the VL model was 0.68. No significant difference between the predicted implantation rate and the observed implantation rates was showed using the Hosmer-Lemeshow (X 2 = 6.70). The calibration plot showed an intercept of the regression line of 0.34 and the estimated slope was 0.72., Conclusion: The investigated VL model was able to distinguish between higher and lower implantation potential of embryos in our clinical setting., (Copyright © 2018 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

We conducted this meta-analysis to explore the prognostic value of outpatient (or office) hysteroscopy (OH) preceding in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) cycles in women who had experienced repeated implantation failure (RIF), particularly in regard to the conflicting evidence reported by previous studies. Two reviewers independently searched Pubmed, MEDLINE, Web of Science, Cochrane Library and Embase to identify all publications of clinical trials of hysteroscopy with or without endometrial biopsy in RIF patients. The primary outcome measures were clinical pregnancy rate (CPR) and live birth rate (LBR). Pooled relative ratios (RRs) with 95% confidence intervals (CIs) were calculated. Publication bias was detected using funnel plots and Egger's regression tests. Six eligible studies comprising 4143 patients were included. The CPR and LBR were both significantly higher in RIF patients with OH than RIF patients without OH (CPR: RR 1.34, 95% CI 1.14-1.57, P < 0.05; LBR: RR 1.29, 95% CI 1.03-1.62, P < 0.05). Subgroup analysis revealed a significant association between OH and CPR in Asia (CPR: RR 1.49, 95% CI 1.31-1.69; P < 0.05) rather than in Europe (CPR: RR 1.08, 95% CI 0.93-1.26; P = 0.291). However, there was no evidence of a significant difference in either CPR or LBR between the normal and abnormal OH groups (CPR: RR 0.92, 95% CI 0.83-1.02, P = 0.12; LBR: RR 0.76, 95% CI 0.37-1.56, P = 0.450). Hysteroscopy may potentially improve pregnancy outcomes in patients with RIP., (© 2018 Japan Society of Obstetrics and Gynecology.)

Background: Several markers were studied previously in order to predict the pregnancy outcome of assisted reproductive techniques; however, serum beta human chorionic gonadotropin was found to be the most predictive marker., Aims: To evaluate the value of serum beta human chorionic gonadotropin levels in discriminating biochemical and clinical pregnancies 12 days after embryo transfer, while determining the factors predicting ongoing pregnancy was established as the secondary aim., Study Design: Retrospective cross-sectional study., Methods: A total of 445 pregnant cycles were retrospectively analysed in 2359 embryo transfer cycles. Patients were divided into two groups according to the outcome of pregnancy: biochemical and clinical., Results: The cut-off value of beta human chorionic gonadotropin levels on day 12 in predicting clinical pregnancies was 86.8 IU/mL with 65.1% sensitivity and 74.7% specificity [CI: 0.76 (0.71-0.81). Receiver operating characteristic curve analysis revealed different cut-off values for embryo transfer days (57 mIU/mL for day 3 embryo transfer CI: 0.59-0.79 and 87 mIU/mL for day 5 embryo transfer, CI: 0.74-0.86). Subgroup analysis of clinical pregnancies revealed a significant difference between ongoing pregnancies and early fetal losses regarding duration of infertility (81.3±54.4 vs. 100.2±62.2 months), serum oestradiol on hCG day (2667.4±1276.4 vs. 2094.6±1260.5 pg/mL), number of transferred embryos (1.9±0.8 vs. 1.5±0.7) and the prevalence of diminished ovarian reserve as an indication (2.3% vs 12.2%)., Conclusion: Beta human chorionic gonadotropin levels on day 12 following embryo transfer provide an important parameter for the prediction of clinical pregnancy; however, other stimulation parameters are indicated in the prediction of ongoing pregnancies.

Cycles with progesterone elevation during controlled ovarian stimulation (COS) for IVF/ICSI are commonly managed with a "freeze-all" strategy, due to a well-recognized detrimental effect of high progesterone levels on endometrial receptivity. However, also a detrimental effect of elevated progesterone on day-3 embryo quality has recently been found with regards to top quality embryo formation rate. Because blastocyst culture and cryopreservation are largely adopted, we deemed relevant to determine whether this detrimental effect is also seen on blastocyst quality on day 5-6. This issue was investigated through a large two-center retrospective study including 986 GnRH antagonist IVF/ICSI cycles and using top quality blastocyst formation rate as the main outcome. Results showed that on multivariate analysis sperm motility (p<0.01) and progesterone levels at ovulation triggering (p = 0.01) were the only two variables that significantly predicted top quality blastocyst formation rate after adjusting for relevant factors including female age, BMI, basal AMH and total dose of FSH used for COS. More specifically, progesterone levels at induction showed an inverse relation with top quality blastocyst formation (correlation coefficient B = -1.08, 95% CI -1.9 to -0.02) and ROC curve analysis identified P level >1.49 ng/ml as the best cut-off for identification of patients at risk for the absence of top quality blastocysts (AUC 0.55, p<0.01). Our study is the first to investigate the top quality blastocyst formation rate in relation to progesterone levels in IVF/ICSI cycles, showing that increasing progesterone is associated with lower rates of top quality blastocyst. Hence, the advantages of prolonging COS to maximize the number of collected oocytes might eventually be hindered by a decrease in top quality blastocysts available for transfer, if increasing progesterone levels are observed. This observation extends the results of two recent studies focused on day-3 embryos and deserves further research.

Intracytoplasmic sperm injection (ICSI) is the most frequently applied method for fertilization making the process of identifying the perfect spermatozoon fundamental. Herein we offer a critical and thorough presentation on the techniques reported regarding (i) handling and preparing semen samples, (ii) identifying and 'fishing' spermatozoa, and (iii) improving key factors, such as motility for a successful ICSI practice. These approaches are suggested to make the process easier and more effective especially in atypical and challenging circumstances. Furthermore, we present an epigrammatic opinion-where appropriate-based upon our collective experience. Techniques such as intracytoplasmic morphologically selected sperm injection, hyaluronic binding, polarized light microscopy, and annexin V agent identification for comparing sperm cells and their chromatin integrity are analyzed. Moreover, for the demanding cases of total sperm immotility the use of the hypoosmotic swelling test, methylxanthines, as well as the option of laser assisted immotile sperm selection are discussed. Finally, we refer to the employment of myoinositol as a way to bioreactively improve ICSI outcome for oligoasthenoteratozoospermic men. The diversity and the constant development of novel promising techniques to improve ICSI from the spermatozoon perspective, is certainly worth pursuing. The majority of the techniques discussed are still a long way from being established in routine practices of the standard IVF laboratory. In most cases an experienced embryologist could yield the same results. Although some of the techniques show great benefits, there is a need for large scale multicenter randomized control studies to be conducted in order to specify their importance before suggesting horizontal application. Taking into consideration the a priori invasive nature of ICSI, when clinical application becomes a possibility we need to proceed with caution and ensure that in the pursuit for innovation we are not sacrificing safety and the balance of the physiological and biological pathways of the spermatozoon's dynamic., Abbreviations: ICSI: intracytoplasmic sperm injection; IVF: in vitro fertilization; PGD: reimplantation genetic diagnosis; IVM: in vitro maturation; HCV/HIV: hepatitis C virus/human immunodeficiency virus; IMSI: intracytoplasmic morphologically selected sperm injection; DGC: density gradient centrifugations; S-U: swim-up; ART: assisted reproduction technology; IUI: intrauterine insemination; PVP: polyvinylpyrrolidone; HA: hyaluronic acid; MSOME: motile sperm organelle morphology examination; ZP: zona pellucida; MACS: magnetic activation cell sorting; HOST: hypo-osmotic swelling test; TESE: testicular sperm extraction; MMP: mitochondrial membrane potential; OAT: oligoasthenoteratozoospermic.

Objective: This study aimed to assess the levels of microbial contamination in semen samples before and after the micro swim-up (MSU) procedure in intra-cytoplasmic sperm injection (ICSI). The new method is an upgrade to the classic wash swim-up procedure., Methods: Semen analysis and microbiological tests were carried out before and after the MSU procedure. A total of twenty semen samples were analyzed., Results: Pathogens were observed in semen samples only before MSU and never after ICSI. Microbiological tests revealed a large prevalence of gram-positive cocci [Staphylococcus spp. (n=16, 80%) and viridans streptococci (n=10, 50%)]. The results of this study indicate that direct MSU in ICSI improved the ICSI workflow., Conclusion: The new workflow is faster and more affordable, and is likely to prevent infection problems that could arise from the normal microbial flora of the semen., Competing Interests: CONFLICT OF INTERESTS No conflict of interests have been declared.

Up to 15% of all couples of reproductive age are diagnosed with subfertility and about one-third of those will have male factor infertility as a contributing factor. Intracytoplasmic sperm injection (ICSI) has proven to be invaluable for couples with severely compromised semen parameters. Since its introduction into the clinical practice in 1992, the indications for ICSI were dramatically expanded to include various patient populations with normal or mildly abnormal semen parameters. Moreover, some fertility programs choose to perform ICSI for all of their patients needing assisted reproductive technologies. By all means, the male factor indications for ICSI are not well defined, apart from its absolute utility with surgically obtained spermatozoa in the presence of low motility, or in cases of severe defects with sperm concentration and motility. Based on current evidence, ICSI is not indicated for routine use. Its adoption for previous history of total fertilization failure, in vitro oocyte maturation, cryopreserved oocytes, polyploidy prevention, poor-quality oocytes, diminished ovarian reserve, and advanced reproductive age are not supported by current evidence, albeit further research with well-designed studies is warranted. Finally, from a biological standpoint ICSI is considered to be more invasive, more energy consuming for the oocyte itself and its adverse genetic and epigenetic effects cannot be ruled out. Although more studies are needed to clarify definitive indications for ICSI, many of its current applications can be deemed empiric at this time., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Successful and consistent outcomes in human in vitro fertilization (IVF) can be readily achieved by all IVF clinics through consideration and optimization of each procedure associated with the collection and processing of gametes, culminating in the resultant culture and transfer of healthy embryos. Furthermore, understanding the interactions between the individual components of the IVF cycle will assist when trouble-shooting possible problems in a laboratory which could have an adverse effect on cycle outcome. This article will review handling of oocytes and embryo culture, preparation of gametes for insemination and microinjection, selection of the most viable gametes and embryos, cryopreservation, and successful embryo transfer from the laboratory perspective., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Objective: To determine if comprehensive embryology training for clinical Reproductive Endocrinology fellows could be completed to a level of proficiency equivalent to that of experienced embryologists., Method: Clinical fellows were integrated into the clinical embryology team and were trained to perform all the various procedures utilized in clinical embryology. The fellows were trained to the same standards as the clinical embryology staff and underwent the same certification and sign off procedures. To determine if inclusion of clinical fellows on the embryology team impacted outcomes, outcomes for individual oocytes/embryos and the clinical cases where the fellows perform embryology procedures were compared to the outcomes of those oocytes/embryos and cases performed by the full time embryology staff., Results: Clinical procedures performed by the fellows included isolation and processing of oocytes following retrieval, loading catheters for embryo transfer, and vitrification (N = 823 cases). Micromanipulation procedures compared included ICSI and assisted hatching (N = 650 cases). For each procedure, the outcomes in those cases performed by the RE fellows were equivalent to those done by the fully trained clinical embryology staff., Conclusions: When fellows are trained to perform embryology procedures as an integral part of their fellowship curricula, laboratory efficiencies and clinical outcomes are fully maintained. This experience provides valuable insight into the ART process critical to this subspecialty. It also empowers fellows to fully participate in research relating to the viability of gamete and embryos and optimization of the clinical ART laboratory.

Study Question: Is it possible to develop a trustworthy instrument to evaluate the patient's perspective on fertility care and to document fully all methodological steps, including validation?, Summary Answer: A validated instrument has been developed for both women and men undergoing assisted reproduction to monitor the quality of care on a regular basis, similar to live birth rates and other effectiveness data. WHAT IS KNOWN ALREADY?: Within fertility care, several instruments have been developed, but many have significant methodological problems and few have been validated. Most instruments focus exclusively on women and no questionnaires have been directed at women and men separately., Study Design, Size and Duration: The questionnaire specific to IVF treatments (QPP-IVF) is based on the theoretical foundation of the validated general instrument, quality of care from patients perspective (QPP), for both women and men. The QPP-IVF was developed and validated by quantitative methods. A two-centre study ran between September 2011 and May 2012., Participants/materials, Setting, Methods: In all, 655 women and men participated. The measurements consisted of two kinds of evaluations: the rating of perceived reality of care and the rating of the subjective importance of various aspects of treatment. The questionnaire consisted of 43 items for women and 42 items for men. An exploratory factor analysis was performed for women for all items of subjective importance. Eigenvalue, explained variance and factor loading are given for each factor. Internal consistency of subscales was assessed by Cronbach's alpha, item discriminant validity and percentage scaling success. For external validity, a correlation with fertility quality of life (FertiQoL) was performed and for reliability, a test-retest analysis was carried out. Sensitivity analyses were performed by known-group analyses. All significance tests were two sided and conducted at the 5% significance level., Main Results and the Role of Chance: The QPP-IVF instrument, divided into four dimensions, seemed a valid and reliable way of measuring the quality of care from a patient's perspective, for both women and men. The item-scaling test confirmed 10 underlying factors, with scaling success in all subscales and Cronbach's alpha >0.70 for women in almost all subscales. It was somewhat lower for men but still acceptable. The external validity was acceptable, with significant correlation between QPP-IVF and FertiQoL. The test-retest analysis confirmed that QPP-IVF was a stable instrument, with intra-class correlation coefficients from 0.74 to 0.89 for women. Sensitivity analyses indicated a sensitive instrument., Limitations, Reason for Caution: The response rate to the questionnaire was 67.5%. Although considered acceptable in questionnaire studies, this response level might introduce a certain risk of selection bias. The questionnaire was developed and validated only in Sweden., Wider Implications of the Findings: The QPP-IVF may be of use for purposes of quality improvement and national comparisons. Future studies should focus on establishing the QPP-IVF as a valuable instrument for measuring the quality of care outside Sweden., Study Funding/competing Interest: The study was supported by the LUA/ALF agreement at Sahlgrenska University Hospital, Gothenburg, Sweden and by Hjalmar Svensson's Research Foundation. None of the authors declared any conflict of interests.

Long-term pituitary down-regulation with a gonadotrophin-releasing hormone (GnRH) agonist for 3–6 months prior to IVF/intracytoplasmic sperm injection (ICSI) improves clinical pregnancy rates in endometriosis patients. However, some discussion about this treatment strategy still exists. This retrospective study from a tertiary-care university hospital examined the efficacy and safety of IVF/ICSI with and without long-term pituitary down-regulation in severe endometriosis patients (surgically confirmed American Society for Reproductive Medicine stages III and IV). All first IVF/ICSI treatment cycles between January 2009 and January 2012 were analysed. In patients treated with (n = 68) and without (n = 45) long-term pituitary down-regulation, 13 (19.1%) versus nine (20.0%) ongoing pregnancies after fresh embryo transfer (adjusted OR 0.58, 95% CI 0.18–1.86,) and 24 (35.3%) versus 10 (22.2%) ongoing pregnancies after fresh and cryopreserved embryo transfers (adjusted OR 1.62, 95% CI 0.60–4.38) were accomplished, respectively. Three complications (2.7%) and three recurrences (2.7%) were reported, only in patients treated with long-term pituitary down-regulation. The 1-year cumulative endometriosis recurrence rate was 7.3%. IVF/ICSI in patients with severe endometriosis is safe with low complication and recurrence rates. A favourable effect, albeit non-significant, of long-term pituitary down-regulation in achieving an ongoing pregnancy was observed only after including cryopreserved embryo transfers., (Copyright © 2013 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.)

Aims: To study the effect of adenomyosis on in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) outcomes in infertile patients., Methods: We performed a retrospective, database-searched cohort study based on 10,268 patients undergoing controlled ovarian hyperstimulation and IVF/ICSI between 2009 and 2011 in our unit. Adenomyosis was diagnosed by transvaginal ultrasound. A high-quality matched cohort study with strict inclusion criteria was conducted. We compared the basic characteristics and main IVF/ICSI outcomes between the two groups., Results: We identified 83 patients with adenomyosis, of whom we included 77, and strictly matched them to 77 patients without adenomyosis. Higher day 3 estrogen levels and a longer duration of gonadotropin stimulation days were found in women with adenomyosis compared to control subjects. Patients with adenomyosis had a nonsignificant trend toward a lower clinical pregnancy rate and a higher miscarriage rate (p = 0.103 and 0.09, respectively). The delivery rate was significantly lower in the adenomyosis group in comparison to the matched controls (p = 0.022)., Conclusions: Within the limitations of a retrospective study (albeit with a remarkably large number of observations), our results suggest that transvaginal ultrasound-diagnosed adenomyosis could have a negative impact on the main IVF/ICSI outcomes. Improving the diagnostic validity and scoring of disease severity in patients with adenomyosis is suggested.

Objective: To identify the association between oocyte dysmorphisms and blastocyst developmental competence., Design: Case-control study., Setting: Private assisted reproduction center., Patient(s): This study included 5,516 embryos, which were obtained from 605 patients undergoing intracytoplasmic sperm injection cycles in which ET was performed on day 5 of embryo development., Intervention(s): Intracytoplasmic sperm injection and ET., Main Outcome Measure(s): The morphologic characteristics of the blastocysts, namely the degree of blastocoel expansion and hatching status, the size and compactness of the inner cell mass (ICM), and the cohesiveness and number of trophectoderm cells, were correlated with oocyte dysmorphisms., Result(s): Of the 5,516 embryos evaluated, 2,920 (52.9%) reached the blastocyst stage. The blastocysts' degree of expansion and hatching status were decreased by the presence of aggregates of smooth endoplasmic reticulum clusters, large perivitelline space, and shape abnormalities. The presence of a large perivitelline space also decreased the ICM and trophectoderm cell quality. Aggregates of smooth endoplasmic reticulum clusters also decreased the ICM quality, pregnancy rate, and the miscarriage rate., Conclusion(s): The results presented here suggest that the individual identification of oocyte dymorphisms may be a prognostic tool for blastocyst development and quality. However, the results do not diminish the importance of cleavage-stage embryo morphology assessment to predict blastocyst development competence., (Copyright © 2013 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the use of a diagnostic testis biopsy and a repetition of testicular sperm extraction (TESE) surgeries in azoospermic patients and its impact on the outcome of TESE., Design: Retrospective, case-control study., Setting: University IVF center and hospital., Patient(s): A total of 552 azoospermic patients undergoing TESE for intracytoplasmic injection., Intervention(s): At the time of the TESE, a piece of testicular tissue was prepared for histopathologic evaluation., Main Outcome Measure(s): Sperm retrieval rate., Result(s): Testicular sperm retrieval was successful in 100% of patients with obstructive azoospermia, 95.6% of patients with hypospermatogenesis, 47.9% of patients with maturation arrest, and 28.6% of patients with Sertoli cell-only syndrome in cases with no previous testicular surgery; in 100%, 91.4%, 32%, and 13.3%, respectively, in cases with a history of one testicular surgery; and in 100%, 10%, 0, and 0, respectively, in cases with a history of two testicular surgeries., Conclusion(s): Testicular sperm retrieval may be successful for some patients in each histopathologic category of azoospermia, with variable degrees of success for different histopathologic categories. The repetition of testicular surgeries decreases the chance of finding sperm in subsequent testicular sperm retrieval procedures., (Copyright © 2013 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

The increasing focus on developing new tools to more accurately diagnose and select individual sperm before intracytoplasmic sperm injection will allow us to counsel and treat couples with greater confidence and efficiency. Current sperm selection techniques are based on the premise that if an ejaculated spermatozoon has cleared spermatogenesis with the correct morphology and/or membrane properties then it is most likely normal. Techniques that are designed to prepare a clean "normal" sperm population or that assist in selecting an individual "normal" spermatozoon are currently being investigated. The use of techniques, including density-gradient preparation, electrophoretic separation, microfluidics, high-magnification sperm morphology selection, and hyaluronic acid binding, is discussed. The research evidence that supports the interrelated developmental and genetic integrity of the selected sperm, particularly sperm DNA damage and clinical outcome evidence are presented., (Copyright © 2013 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To study the chromosome constitution and in vitro development of embryos derived from monopronucleated (1PN) zygotes after intracytoplasmic sperm injection (ICSI)., Design: Prospective study., Setting: Private assisted reproduction center., Patient(s): Fifty-four 1PN 2PB zygotes obtained from 48 ICSI cycles., Intervention(s): Pronuclear diameter measured 18 ± 2 hours after ICSI and embryonic in vitro development assessed until the blastocyst stage or arrest; embryos disaggregated and all cells analyzed for chromosomes 13, 18, 21, X, and Y by fluorescent in situ hybridization (FISH)., Main Outcome Measure(s): Pronuclear size, in vitro embryo development, and cytogenetic characteristics., Result(s): All the embryos were chromosomally abnormal (7.4% diploid mosaic, 16.7% haploid mosaics, 5.5% aneuploid mosaic, and 70.4% chaotic mosaic), and 35.2% showed a Y chromosome. No difference in the pronuclear size was observed according to the type of abnormality. Only 7.4% of the embryos resulted in blastocysts with good morphologic features., Conclusion(s): Despite showing only one pronucleus, most of the zygotes resulted from fertilization. Embryos derived from 1PN ICSI zygotes are chromosomally abnormal. Neither the pronuclear size nor the in vitro developmental ability of these embryos can be predictive of their chromosomal constitution. According to our results, embryos that develop from 1PN ICSI zygotes should be discarded for any reproductive purpose., (Copyright © 2013 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Approximately 40% of sterility in couples can be attributed to male subfertility and intracytoplasmic sperm injection (ICSI) has become a powerful tool in assisted reproduction to overcome male infertility. Intracytoplasmic morphologically selected sperm injection (IMSI) is an advanced and sophisticated method of ICSI, where prior to sperm injection the morphology of the sperm is evaluated under high magnification. In addition, the IMSI procedure involves a few minor modifications in sperm preparation which are not carried out during the conventional ICSI procedure, such as the use of MSOME criteria, the requirement for a glass-bottomed dish for selection, prolonged sperm manipulation following separation from the seminal fluid, and sperm storage prior to microinjection. These variations are discussed in this chapter.

Objective: To evaluate the relationship between sperm nuclear vacuoles and sperm morphology and to investigate the influence of the rate of spermatozoa with head vacuolization (SVR) in a seminal sample on the clinical outcomes in couples undergoing intracytoplasmic sperm injection., Materials: 26 patients undergoing infertility investigations were included and were divided in two groups according to an SVR ≤ 20,28 % (Group A) or > 20,28 % (Group B), and were investigated to verify the influence of SVR on the fertilization rate, embryo quality, pregnancy and implantation rates., Results: Abnormal spermatozoa with nuclear vacuoles were significantly higher (p < 0.001) than the percentage of normal spermatozoa with nuclear vacuoles. Patients in group A had a percentage of abnormal sperm with nuclear vacuole significantly lower compared to group B (p < 0,001), but there was no difference in the percentage of normal sperm with nuclear vacuoles. Fertilization rates and the number of top quality embryos did not differ between the two groups. The pregnancy and implantation rates were significantly higher in Group A compared to Group B (respectively p < 0,05 and p < 0.001)., Conclusions: For the first time, we propose a cut off value in the proportion of sperms with nuclear vacuolization on the total of sperm in seminal samples, and demonstrate a relationship between SNV and clinical outcomes after ICSI. The SNV rate could be introduced as an easy diagnostic evaluation prior to perform an ICSI cycle.

Objective: To conduct a meta-analysis of studies assessing the effect of IVF and intracytoplasmic sperm injection (ICSI) on birth defects., Design: Meta-analysis., Setting: Centers for reproductive care., Patient(s): Patients treated by IVF and/or ICSI., Intervention(s): We identified all studies published by September 2011 with data related to birth defects in children conceived by IVF and/or ICSI compared with spontaneously conceived children, or birth defects in the children conceived by IVF compared with those by ICSI. Risk ratios from individual studies were pooled with the fixed and random effect models., Main Outcome Measure(s): Risk of birth defects in children conceived by IVF and/or ICSI., Result(s): Of 925 studies reviewed for eligibility, 802 were excluded after screening titles and abstracts, 67 were excluded for duplicated data, data unavailable, or inappropriate control group, 56 were included in the final analysis. Among the 56 studies, 46 studies had data on birth defects in children conceived by IVF and/or ICSI (124,468) compared with spontaneously conceived children. These studies provided a pooled risk estimation of 1.37 (95% confidence interval [CI]: 1.26-1.48), which is also evident in subgroup analysis. In addition, 24 studies had data on birth defects in children conceived by IVF (46,890) compared with those by ICSI (27,754), which provided an overall no risk difference., Conclusion(s): Children conceived by IVF and/or ICSI are at significantly increased risk for birth defects, and there is no risk difference between children conceived by IVF and/or ICSI., (Copyright © 2012 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the influence of the male partner's lifestyle, including eating and social habits, on semen quality and intracytoplasmic sperm injection (ICSI) success., Design: Observational study., Setting: Private fertility clinic., Patient(s): Two hundred fifty male patients undergoing ICSI cycles., Intervention(s): We recorded dietary and social habits using a food frequency questionnaire adapted to meet specific study objectives. Evaluation of semen parameters and ICSI outcomes were performed., Main Outcome Measure(s): Frequency of intake of food items and social habits were registered on a scale with five categories ranging from no consumption to repeated daily consumption., Result(s): The sperm concentration was negatively influenced by body mass index (BMI) and alcohol consumption and was positively influenced by cereal consumption and the number of meals per day. The sperm motility was also negatively influenced by BMI, alcohol consumption, and smoking habit, whereas it was positively influenced by the consumption of fruits and cereals. The consumption of alcohol had a negative influence on the fertilization rate. The consumption of red meat as well as being on a weight loss diet had a negative impact on the implantation rate. In addition, the consumption of red meat and being on a weight loss diet had an effect on the pregnancy chance., Conclusion(s): Couples seeking assisted reproduction treatments must be advised about the drastic effect of both the male and female lifestyle on treatment success., (Copyright © 2012 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

To evaluate the effects of sperm with different parameters and sources on the outcomes of intracytoplasmic sperm injection (ICSI), 1972 ICSI cycles were analyzed retrospectively. Groups 1 to 5 were composed of cycles using ejaculated sperm and were grouped according to sperm quantity, quality, and morphology into normal (288 cycles), or mild (329 cycles), moderate (522 cycles), severe (332 cycles), and extremely severe (171 cycles) oligozoospermia and/or asthenozoospermia and/or teratozoospermia (OAT) groups. Group 6 was composed of 250 cycles using testicular or epididymal sperm, and Group 7 consisted of 80 cycles using frozen-thawed sperm. We found that fertilization rates were gradually reduced from Groups 1 to 6, and reached statistical difference in Groups 5 and 6 (P<0.05). The high-quality embryo rate was higher in Group 1 than in Groups 2, 3, 5, 6, and 7 (P<0.05). No statistical differences were observed in the rates of embryo cleavage, clinical pregnancy, miscarriage, live-birth, premature birth, low birth weight, weeks of premature birth, average birth weight, or sex ratio for all seven groups (P>0.05). A total of nine cases of malformation were observed, with a malformation rate of 1.25% (9/719). In conclusion, different sperm sources and parameters can affect ICSI outcomes before embryo implantation. A full assessment of offspring malformation will require further study using a larger sample size.

Objective: To develop and test a simple, feasible approach to improve spindle assembly and developmental competence of human in vitro matured oocytes by parthenogenetic activation in maturation medium., Design: Prospective, randomized study., Setting: University research laboratory-based assisted reproductive technology laboratory., Patient(s): Four hundred thirty-two patients with male factor infertility undergoing intracytoplasmic sperm injection (ICSI) cycles., Intervention(s): In vivo failed-to-mature oocytes from the ICSI cycles were divided into four groups according to differing duration after the extrusion of first polar body (0-1, 2-3, 4-5, and 8-9 hours). Oocytes spindles in each group were immunostained for α-tubulin and chromosomes, and observed by confocal microscopy., Main Outcome Measure(s): Rate from pronuclear stage to blastocyst, embryo grading at the eight-cell and blastocyst stages, and spindle assembly., Result(s): There was a statistically significantly higher rate of development at the eight-cell and blastocyst stages in the 2- to 3-hour and 4- to 5-hour groups. The grading results at the eight-cell and blastocyst stages also showed that the proportion of embryos of high quality was similar among the 2- to 3-hour and 4- to 5-hour groups, and in these groups it was statistically significantly higher than the 0- to 1-hour and 8- to 9-hour groups. The results of immunofluorescence demonstrated that there was a statistically significantly higher rate of normal spindle assembly in the 2- to 3-hour and 4- to 5-hour groups., Conclusion(s): Optimal timing of maturation benefits the development of competence of in vitro matured oocytes by promoting normal spindle assembly., (Copyright © 2011. Published by Elsevier Inc.)

The comparison between the outcomes of intracytoplasmic morphologically selected sperm injection performed in couples with male factor infertility according to the World Health Organization guidelines from 1999 and 2010 was the objective of this study. Our results suggest that the sperm selection under high magnification results in improved treatment outcomes in patients with oligoasthenoteratozoospermia, according to the new World Health Organization guidelines., (Copyright © 2011 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the relevance of sperm DNA oxidation caused by free radicals in samples obtained via testicular biopsies by means of flow cytometry by correlating the measurements of 8-hydroxy-2'-deoxyguanosine (8-OHdG) with embryo features and pregnancy achievement., Design: Prospective cross-sectional study., Setting: Private University-affiliated setting., Patient(s): Fifty-seven azoospermic patients undergoing testicular sperm extraction (TESE) were analyzed in their corresponding assisted reporductive technology cycles using ovum donation to standardize female's characteristics., Intervention(s): None., Main Outcome Measure(s): Quantification of the adduct 8-OHdG in testicular tissue samples, and its effect on markers of embryo quality and reproductive success, and its relevance as marker of TESE sperm quality., Result(s): We found the status of sperm DNA oxidation to have very little clinical relevance for several parameters of embryo quality, fertilization rates, early (days 2-3) and late (days 5-6) development, and achievement of pregnancy., Conclusion(s): The TESE obtained cells from azoospermic males do not possess a DNA oxidation status of significant importance in the success of assisted reproduction treatments, as determined by 8-OHdG measurement of each category of cell ploidy., (Copyright (c) 2010 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate DNA fragmentation in morphologically normal sperm recovered from the same sample used for intracytoplasmic sperm injection (ICSI) and to correlate DNA damage with embryo quality and pregnancy outcome., Design: Prospective study., Setting: Academic center., Patient(s): 36 infertile men participating in the ICSI program., Intervention(s): Terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate-fluorescein nick end labeling (TUNEL) assay and morphologic assessment by phase contrast., Main Outcome Measure(s): Simultaneous assessment of sperm morphology and DNA fragmentation by TUNEL assay was performed in the same cell, then the percentage of normal sperm with fragmented DNA (normal SFD) was correlated with embryo quality and pregnancy outcomes., Result(s): A highly statistically significant negative correlation was found between the percentage of normal SFD and embryo quality. This association was confirmed for the transferred embryos and for the total embryo cohort. The receiver operating characteristics curve analysis demonstrated that the percentage of normal SFD and embryo quality were statistically significant predictors of pregnancy. When the percentage of normal SFD was

Purpose: To evaluate intracytoplasmic sperm injection (ICSI) outcome of women over age 39 and to determine when to discourage such couples to undergo IVF using their own oocytes., Methods: Four hundred ninety-five consecutive women (n=668 cycles) over age 39 were evaluated by year-by-year age increments to discriminate the independent prognostic factors for the achievement of pregnancy., Results: Although the ovarian hyperstimulation performance (COH) and embryological data were not too diverse, the clinical pregnancy rates per embryo transfer decreased from 26 to 13% from age 40 to 44. According to logistic regression, the female age seems to be the only variable in order to predict an ongoing pregnancy. The miscarriage rate increased with advancing female age. It was 33% at age 40 but increased to 100% by age 45., Conclusions: The performance of COH and embryological data is not discouraging among women over 39 years in ICSI cycles. However, increased miscarriages as well as decreased implantation rate are mainly responsible for the poor performance of patients with advanced female age. Irrespective of the ovarian reserve testing, ICSI may be refused at age 45 and thereafter.

Purpose: To determine the relationship between sperm morphological abnormalities, DNA fragmentation and fertilization rate in intracytoplasmic sperm injection (ICSI)., Methods: Sperm samples from 20 ICSI cycles were analysed. Morphology was assessed according to strict criteria, and DNA fragmentation was measured by terminal deoxynucleotidyl transferase (TdT)-mediated fluorescein-dUTP nick end labelling (TUNEL) using flow cytometry., Results: A negative correlation was found between the percentage of spermatozoa with elongated heads and fertilization rate. There was a significant difference in the amount of morphological abnormalities between sperm samples with low and high degree of DNA fragmentation. The percentages of amorphous heads and overall head abnormalities were significantly higher in sperm samples with elevated degree of DNA fragmentation. No correlation was found between sperm DNA fragmentation and fertilization rate., Conclusions: Head abnormalities, especially amorphous heads, are related to elevated degree of DNA fragmentation. Elongated heads, when detected as predominant abnormal form in sperm samples, may affect fertilization in ICSI.

Objective: To evaluate the impact on the rates of clinical pregnancy and live birth of polyploidy after intracytoplasmic sperm injection (ICSI)., Design: Retrospective cohort study., Setting: University-based IVF center., Patient(s): One hundred forty-three patients undergoing their first IVF-embryo transfer cycle requiring ICSI., Intervention(s): None., Main Outcome Measure(s): Patients were divided into two groups on the basis of the proportion of post-ICSI triploid fertilization that was observed at the time of fertilization assessment: group 1 included patients with 20% 3PN zygotes. The primary outcomes compared between groups were pregnancy and implantation rates; secondary outcome measures included clinical-pregnancy rate and live-birth rate per embryo transfer., Result(s): Pregnancy, implantation, clinical-pregnancy, and live-birth rates were significantly higher in the cohort of patients who had 20% of zygotes appearing triploid (relative risk [RR] for pregnancy, 2.4 [95% confidence interval {CI}, 1.22-4.77]; RR for implantation, 2.6 [95% CI, 1.17-5.56]; RR for clinical pregnancy, 2.8 [95% CI, 1.16-6.85]; and RR for live birth, 2.6 [95% CI, 1.06-6.38]). The proportion of 3PN zygotes after ICSI had a statistically significant inverse relationship to clinical-pregnancy rate., Conclusion(s): The proportion of triploid zygotes after ICSI serves as a negative prognostic indicator for IVF cycle outcome. This finding suggests that triploidy proportion is a surrogate marker of oocyte competence that represents the integrity of the oocytes in the entire recruited cohort. Such findings therefore may influence recommendations for embryo transfer number and freezing of supernumerary embryos.

Purpose: to determine the relationship between the morphology of the first spindle pole of human oocytes and rates of fertilization, fragmentation and embryo quality in procedures of Intracytoplasmic Sperm Injection (ICSI)., Methods: retrospective study of 582 consecutive ICSI cycles, from July 2003 to July 2005. The morphology of the first spindle pole (SP) was assessed through the analysis of 3,177 oocytes in metaphase II, immediately before the ICSI procedure, always by the same observer. SP has been classified in the following categories: normal size intact, fragmented or augmented SP. Fertilization rate and fragmentation, and the number and rate of good quality embryos in each one of the three groups studied have been evaluated, 48 hours after ICSI (D2). Embryos with four cells, without fragmentation and with symmetric blastomeres in D2 were considered as of good quality., Results: rates of fertilization, fragmentation and of good quality embryo formation, resulting from oocyte insemination, with augmented SP (20.7, 16.7 and 5% respectively) were significantly lower than the ones from intact and normal size SP (70.8, 62.5 and 19%, respectively) or from fragmented SP oocytes (69.7, 60.5 and 17.1%, respectively)., Conclusions: it has been observed that the presence of augmented first spindle pole is related to worse rates of fertilization, fragmentation and bad quality embryo formation. Nevertheless, fragmentation in the first spindle pole of the oocyte does not seem to affect ICSI results.

The aim of this prospective randomized study was to assess the advantages of a new modified intracytoplasmic sperm injection (ICSI) technique called intracytoplasmic morphologically selected sperm injection (IMSI) over the conventional ICSI procedure in the treatment of patients with severe oligoasthenoteratozoospermia. The new procedure consisted of IMSI based on a preliminary motile sperm organellar morphology examination under x6600 high magnification. A total of 446 couples with at least two previous diagnoses of severe oligoasthenoteratozoospermia, 3 years of primary infertility, the woman aged 35 years or younger, and an undetected female factor were randomized to IVF micro-insemination treatments: ICSI (n = 219; group 1) and IMSI (n = 227; group 2). A comparison between the two different techniques was made in terms of pregnancy, miscarriage and implantation rates. The data showed that IMSI resulted in a higher clinical pregnancy rate (39.2% versus 26.5%; P = 0.004) than ICSI when applied to severe male infertility cases. Despite their initial poor reproductive prognosis, patients with two or more previous failed attempts benefited the most from IMSI in terms of pregnancy (29.8% versus 12.9%; P = 0.017) and miscarriage rates (17.4% versus 37.5%). At present, 35 healthy babies have been born following the introduction of this promising technique in daily IVF practice.

Background: To date, assisted reproductive technology (ART) with sperm washing is offered to serodiscordant couples with an human immunodeficiency virus-1 (HIV-1) infected male partner in order to have a child while reducing the risk of transmission to the woman. However, ART programmes are not possible if the man is azoospermic. We report here the first birth following intracytoplasmic sperm injection (ICSI) using frozen epididymal spermatozoa obtained after surgical sperm retrieval in a HIV-1 infected man with obstructive azoospermia. METHODS; Sperm obtained by micro-epididymal sperm aspiration was frozen after density gradient preparation and tested for HIV-RNA and DNA. ICSI with frozen sperm was performed., Results: A twin pregnancy was obtained following ICSI. Two healthy girls were born. Maternal HIV-1 RNA and HIV-1 serology were negative during pregnancy and at delivery., Conclusions: This case report demonstrates that ART is possible in azoospermic HIV-1 infected men. On the basis of current knowledge, we propose a strategy to reduce HIV-1 transmission risk during sperm retrieval and ICSI in couples where the man is HIV-1 infected and azoospermic.