ICSI outcomes using testicular spermatozoa in non‐azoospermic couples with recurrent ICSI failure and no previous live births

Abstract

BackgroundThe use of testicular over ejaculated spermatozoa for ICSI has been presented as an alternative to overcome infertility in men with poor semen parameters or high levels of sperm DNA fragmentation.ObjectiveTo evaluate the efficacy of testicular ICSI outcomes in couples with no previous live birth and recurrent ICSI failure using ejaculated spermatozoa by comparison to the outcomes of couples with similar history of recurrent ICSI using ejaculated spermatozoa only.Materials and MethodsA total of 145 couples undergoing ejaculated or testicular ICSI cycles with no previous live births and with at least two previous failed ICSI cycles with ejaculated spermatozoa were evaluated retrospectively. ICSI was performed either with ejaculated (E‐ICSI) or with testicular (T‐ICSI) spermatozoa. Semen parameters and sperm DNA quality were assessed prior to the oocyte collection day. Primary outcomes included cumulative live birth and pregnancy rates. Secondary analysis included percentage of DNA fragmentation in ejaculated spermatozoa (SCSA® and TUNEL).ResultsPatients undergoing T‐ICSI (n = 77) had a significantly higher clinical pregnancy rate/fresh embryo transfer (ET) (27.9%; 17/61) and cumulative live birth rate (23.4%; 15/64) compared to patients using E‐ICSI (n = 68) (clinical pregnancy rate/fresh ET: 10%; 6/60 and cumulative live birth rate: 11.4%; 7/61). Further, T‐ICSI yield significantly better cumulative live birth rates than E‐ICSI for men with high TUNEL (≥36%) (T‐ICSI: 20%; 3/15 vs. E‐ICSI: 0%; 0/7, p < 0.025), high SCSA® (≥25%) scores (T‐ICSI: 21.7%; 5/23 vs. E‐ICSI: 9.1%; 1/11, p < 0.01), or abnormal semen parameters (T‐ICSI: 28%; 7/25 vs. E‐ICSI: 6.7%; 1/15, p < 0.01).ConclusionsThe use of testicular spermatozoa for ICSI in non‐azoospermic couples with no previous live births, recurrent ICSI failure, and high sperm DNA fragmentation yields significantly better live birth outcomes than a separate cohort of couples with similar history of ICSI failure entering a new ICSI cycle with ejaculated spermatozoa.

Sperm DNA Fragmentation: A New Guideline for Clinicians

“…A metaanalysis of five studies favored the use of testicular sperm by demonstrating better clinical pregnancy and live birth rates [12]. The utilization of testicular sperm is further supported by recent reports and better reproductive outcomes that have been reported in both oligozoospermic and normozoospermic men with prior ICSI failure [269,270]. Nonetheless, the invasive nature of sperm retrieval procedures and the higher rates of sperm aneuploidy with testicular sperm can be considered as potential disadvantages for this treatment approach which certainly warrants further investigation [271,272].…”

Extended indications for sperm retrieval: summary of current literature

“…Recent studies providing live birth data corroborate the effectiveness of testicular sperm for ICSI in men with high SDF 29– 31 . Thus, despite the limited evidence and lack of randomized controlled trials, data from seven retrospective studies and three prospective studies, including a total of 830 patients and 902 ICSI cycles, suggest that Testi-ICSI is superior to ICSI with ejaculated sperm to overcome infertility among non-azoospermic men with elevated SDF in semen.…”

“… a Herrero et al . 31 reported cumulative live birth rates. b 2PN fertilization rate with use of testicular sperm; data from previous cycles with use of ejaculated sperm not provided. c The authors reported only one pregnancy with ejaculated sperm which miscarried. d Number of intracytoplasmic sperm injection (ICSI) cycles. e Inferred from the study’s reported data. f Cumulative live birth rates. g Alharbi et al . 32 reported pregnancy rates per embryo transfer; live birth data were incomplete as a number of patients achieving clinical pregnancy were lost in follow-up.…”

Effects of the sperm DNA fragmentation index on the clinical and neonatal outcomes of intracytoplasmic sperm injection cycles

“…Since TESE/TESA is an invasive method, it is generally recommended that testicular spermatozoa are an alternative for patients with high sperm DFI who have failed recurrent ICSI cycles or other less invasive interventions [45]. It has been reported that testicular spermatozoa significantly increase clinical pregnancy and live-birth rates and decrease miscarriages in patients with high sperm DFI who suffer from recurrent ICSI failure [46][47][48]. Healthy live birth is the most important for patients with high sperm DFI, regardless of testicular spermatozoa or other less invasive interventions.…”