Does Severe Teratozoospermia Affect Blastocyst Formation, Live Birth Rate, and Other Clinical Outcome Parameters in ICSI Cycles?

ARTICLE IN PRESS Does severe teratozoospermia affect blastocyst formation, live birth rate, and other clinical outcome parameters in ICSI cycles?

Dan B. French, M.D.,a Edmund S. Sabanegh, Jr., M.D.,a James Goldfarb, M.D.,b and Nina Desai, Ph.D., H.C.L.D.b a Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland; and b Department of Obstetrics and Gynecology, Cleveland Clinic Fertility Center, Beachwood, Ohio

Objective: To determine if strict morphology correlates with outcome parameters in couples undergoing intracytoplasmic sperm injection (ICSI). Design: Retrospective review. Setting: Academic nonprofit IVF center. Patient(s): Couples undergoing IVF/ICSI. Intervention(s): In vitro fertilization and ICSI. Main Outcome Measure(s): Samples were evaluated for total sperm count, motlity, progression, and morphology using Kruger’s strict criteria. The ICSI cycle outcome parameters included fertilization, clinical pregnancy, implantation, live birth, and blastulation rates and blastocyst quality. Result(s): Fertilization rates were high (74%–77%), and clinical pregnancy rates ranged from 60% (subgroup with 0% normal sperm) to 56% (subgroup with R7% normal forms). The highest pregnancy and live birth rates were observed in eggs fertilized with sperm from specimens with the most severe teratozoospermia. The blastulation rate was similar among subgroups. The percentage of high-quality blastocysts was significantly greater in the severely teratozoospermic patients compared with patients with R5% normal sperm (37% vs. 28%). This is likely because in the lower morphology subgroups, female factors are less prevalent and the primary infertility problem is male factor. Conclusion(s): These data suggest that we reconsider the diagnostic value of strict morphology in assisted reproductive technology cycles involving ICSI. Sperm morphology assessed by Kruger’s strict criteria had little prognostic value in ICSI cycle outcomes. Sperm morphology did not appear to influence blastocyst development or blastocyst morphology. Microscopic selection of sperm with ‘‘normal’’ morphology during the ICSI procedure allowed excellent outcomes even in samples with severe teratozoospermia. (Fertil Steril 2009;-:-–-. 2009 by American Society for Reproductive Medicine.) Key Words: Sperm morphology, in vitro fertilization, ICSI, blastocyst development

Morphologic evaluation of spermatozoa is an integral part of considerable debate. Numerous other reports suggest that the semen analysis work-up for infertility. Kruger et al. pro- abnormal morphology is not an accurate predictor of preg- posed that sperm classiﬁcation on the basis of stricter mor- nancy or cycle outcome parameters (6–11). phologic criteria could be useful in predicting successful The relevance of the assessment of sperm morphology of fertilization (1). In a meta-analysis of outcomes in intrauter- the overall semen sample as it pertains to IVF with intracyto- ine insemination cycles, a trend toward better pregnancy rates plasmic sperm injection (ICSI) is even less clear. Oocyte fer- was indicated when sperm morphology was >4% (2). Severe tilization through ICSI circumvents many problems, such as teratozoospermia with <4% normal forms in the semen sam- poor motility, poor zona binding, and poor acrosome reaction, ple was also associated with poorer fertilization outcomes which are frequently found in association with specimens hav- during IVF (3, 4). A meta-analysis of sperm morphology ing abnormal sperm morphology. Multiple studies have shown and IVF outcome parameters in 49 different studies using that with IVF/ICSI, semen samples with poor Kruger mor- conventional IVF similarly concluded that sperm morphol- phology have similar fertilization and pregnancy rates to those ogy assessment may be valuable as a diagnostic tool in eval- with normal morphology (8, 9, 11–13). McKenzie et al. (14) uating male infertility (5). This, however, is still an area of analyzed ICSI outcomes in a subset of severe teratozoospermic patients with 0% normal sperm. They concluded that Received June 5, 2008; revised October 27, 2008; accepted October 29, sperm morphology had little predictive value regarding fertil- 2008. ization and pregnancy outcome in men undergoing ICSI for D.F. has nothing to disclose. E.S. has nothing to disclose. J.G. has nothing severe teratozoospermia. Some of the studies analyzing mor- to disclose. N.D. has nothing to disclose. phology and ICSI outcomes were small and not all of them Reprint requests: Nina Desai, Ph.D., H.C.L.D., Cleveland Clinic Fertility Center, Suite 220 South Building, 26900 Cedar Rd., Beachwood, OH included live birth rates or examined detailed subsets of 44122 (FAX: 216-839-3181; E-mail: [email protected]). patients across the spectrum of morphologic impairment.

0015-0282/09/$36.00 Fertility and Sterility Vol. -, No. -, - 2009 1 doi:10.1016/j.fertnstert.2008.10.051 Copyright ª2009 American Society for Reproductive Medicine, Published by Elsevier Inc. ARTICLE IN PRESS

The role of paternal factors in embryonic development, as protocol used. Oocytes were recovered by transvaginal aspi- well as the effect of the ICSI procedure itself remains contro- ration of follicles under ultrasound guidance. Oocytes were versial. Several studies have suggested that ICSI-derived cultured in microdrops of human tubal fluid (HTF) medium embryos have reduced developmental capacity (15–18).In (LifeGlobal, Guilford, CT) supplemented with 10 mg/mL contrast, others using severely teratozoospermic sperm human serum albumin (Cooper Surgical, Trumball, CT) have seen no difference in blastulation rates with ICSI under an oil overlay. Culture dishes were incubated at 37C (19, 20). with 5.5% CO2. Mature oocytes were fertilized by ICSI 3–4 h after the retrieval. Fertilization check was performed The objective of the present study was to determine if crit- 18–20 h after the ICSI procedure. Normally fertilized zygotes ical assessment of sperm morphology during the pre-IVF were subsequently moved to microdrops containing HTF me- semen analysis correlated with ICSI cycle outcome parame- dium with 10% synthetic serum substitute (SSS, Irvine, CA) ters. We analyzed the impact of severe teratozoospermia on and cultured for an additional 2 days. fertilization, embryonic development to the blastocyst stage, and pregnancy. To our knowledge, this is the first large ICSI Embryo transfer was performed on day 3 under ultrasound series that examines live birth outcomes in sperm morphol- guidance using a Wallace catheter. Embryo selection for day ogy subgroups ranging from severely teratozoospermic to 3 transfer was based on morphologic parameters. Embryos normal. This information should help us to gain a better un- were graded on the basis of cell number, regularity of blasto- derstanding of paternal effect on embryonic development and meres, good blastomere expansion, fragmentation level, and the influence of the ICSI technique itself on embryonic devel- signs of embryonic compaction. Spare embryos not trans- opment. fered or frozen on day 3 were kept in culture and frozen at the blastocyst stage. Pregnancy testing was performed 15 days after the embryo transfer. Clinical pregnancy was con- MATERIALS AND METHODS firmed by the presence of a fetal heart on ultrasonic examina- Patients tion at 6–8 weeks of pregnancy. The IVF cycles with ICSI were performed at the Cleveland Clinic Fertility Center from January 2004 to December Data Collection and Statistical Analysis 2006 and retrospectively analyzed. Day 5 transfers accounted for 65 cycles, and these were not included in the present anal- Cycle outcome data was collected under Institutional Review ysis. During the time interval encompassed by this study, Board approval from the IVF lab data registry. The primary ICSI was the laboratory’s preferred method of fertilization outcome measures tabulated were fertilization rate, blasto- unless the patient specifically requested standard insemina- cyst formation, embryos transfered, pregnancy rate, and tion. Cases involving some or all conventional IVF were implantation rate. The implantation rate was calculated by di- eliminated (5%). Cycles in which semen specimens had viding the number of fetal heart tones by the total number of insufficient sperm (usually <1 106/mL) to allow morpho- embryos transfered. Multiple pregnancy and live birth rates logic assessment were also excluded. Only women <37 years were also monitored. Patients were stratified into groups of age were included in the analysis, to minimize the contri- based on their sperm morphology assessment. Using Kruger’s bution of maternal age as a confounding variable. As a result, strict criteria, eight subgroups were analyzed: 0%, 1%, 2%, 1,074 ICSI cycles were available for analysis. Patients were 3%, 4%, 5%–7%, and >7% normal sperm morphology. Dif- divided into subgroups based on sperm morphology. ferences in outcome measures between groups were compared using the Chi-squared test and the Student t test. P values of <.05 were considered to be statistically signifi- Sperm Morphology Assessment cant. Semen samples were evaluated for total count, percentage motile sperm, forward progression, and sperm morphology. RESULTS Sperm were stained using Diff-Quik (Dade Behring, Newark, A total of 1,074 ICSI cycles were included in this analysis. Delaware). Sperm morphology was assessed using Kruger’s The semen characteristics in each morphology subgroup strict criteria (21). A total of 100 sperm were graded at are portrayed in Figure 1. The percentage of patients in each evaluation and percentage normal forms determined. each morphology group with either a compromised sperm Sperm morphology grading was performed by one of two count or overall motility of <40% is shown. As might be andrology technicians, and uniformity of grading between expected, patients in the more teratozoospermic morphology the two andrology technicians was routinely monitored using subgroups (<4% normal sperm) also exhibited deficits in control slides. other sperm parameters. Table 1 depicts the relationship between sperm morphol- IVF Procedure ogy based on Kruger’s strict assessment and cycle outcome Down-regulation with leuprolide acetate (Lupron; TAP Phar- parameters. Fertilization rates were high regardless of sperm maceuticals, Lake Forest, IL) followed by ovulation induc- morphologic parameters. Intracytoplasmic sperm injection tion with gonadotropins was the primary stimulation resulted in 74%–77% of oocytes being fertilized. The average

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FIGURE 1

Percentage of patients with concentration and motility impairment among morphology subgroups.

Sperm Parameters in Morphology Sub Groups 35 Percent of patients 30

20 Count <=10 mill/ml 15 Motility <40%

0 0% 1% 2% 3% 4% 5-7% >7% Sperm morphology

French. Severe teratospermia and ICSI clinical outcomes. Fertil Steril 2009.

number of oocytes retrieved, mature oocytes for injection, To better understand these data, we looked at patient diag- number of embryos transfered, and patient age were similar nosis across the different morphology subgroups. Figure 2 across morphology subgroups. depicts the percentage of patients with each diagnosis for each sperm morphology subgroup. From these data it would Clinical pregnancy outcomes were excellent, ranging from appear that in the lower morphology subgroups, female fac- 60% in the subgroup with the most severe teratospermia (0% tors are less prevalent and the primary infertility problem is normal sperm) to 56% in the patient set with the highest per- male factor. In the 0%–1% normal sperm subgroup, approx- centage normal spermatozoa. The implantation rate per em- imately 38% of couples had male factor as their primary di- bryo transferred ranged from 31% to 41% (Table 1). The agnosis. At the other extreme, in the subgroup with >7% variations in the main outcome parameters of fertilization, normal sperm, female factors such as ovulatory dysfunction, pregnancy, and embryo implantation did not correlate with tubal factor, polycystic ovary, and endometriosis were the sperm morphology. Our data suggest that in cycles in which primary diagnosis in 45% of couples. Another 41% of oocyte fertilization is mediated through ICSI, poor sperm patients had unexplained infertility. Only 14% of couples in morphology at the time of semen analysis has no significant this subgroup had male factor as the primary diagnosis based impact on clinical outcome parameters. This is further shown on low sperm count, motility, or progression. by the fact that the highest pregnancy and live birth rates were observed in the group of patient eggs fertilized with sperm Severe teratozoospermia did not negatively affect ICSI from specimens with the most severe teratozoospermia, i.e., success. The live birth rate per transfer ranged from 44% to the subgroup with 0% normal sperm morphology. 56%. The observed variation in live birth rate among the different morphology subgroups was not found to be significant. Culturing the ‘‘spare’’ embryos not transferred on day 3 for The miscarriage rate was 4%–5% for all but one of the sub- an additional 3 days gave us the opportunity to further groups (Table 1). Among the 774 live births, only four birth observe development to the blastocyst stage and to assess defects were reported to the clinic—three were cardiac prob- the quality of the blastocysts. Table 1 summarizes both the lems and one was classified as genetic. Follow-up beyond the percentage of blastocysts formed and the percentage of immediate neonatal period was not conducted. high-quality blastocysts deemed to be suitable for freezing based on morphology. Blastocyst quality assessment was based on the degree of expansion, presence of an adequate DISCUSSION cell number, and differentiation of the inner cell mass and This study represents the first large ICSI series to analyze em- the trophectoderm. The blastulation rate was not different bryonic development, pregnancy outcomes, and live birth among the different sperm morphology subgroups (P¼.07). rates in different sperm morphology subgroups based on We did, however, find that the percentage of high-quality Kruger’s classification system. Stratification of data in this blastocysts was significantly greater in the severely terato- manner allowed for evaluation and comparison of outcomes zoospermic patients with 0% normal sperm compared with based on degree of teratozoospermia. In this study, fertiliza- patients with R5% normal sperm (37% vs. 28%; P<.005). tion, implantation, pregnancy, and live birth rates were not

Fertility and Sterility 3 ARTICLE IN PRESS

TABLE 1 Kruger strict morphology and ICSI cycle outcome. % normal sperm morphology 0% 1% 2% 3% 4% 5%–7% >7% Transfers 138 167 137 129 113 236 154 Maternal age 32.3 3.2 32.7 2.7 32.4 2.9 32.5 2.5 32.0 3.9 32.3 3.5 32.8 3.8 (mean SD) No. of oocytes 13.3 6.1 14.4 6.8 14.2 6.8 13.5 6.5 13.1 6.7 13.8 6.8 12.9 6.1 (mean SD) No. of oocytes 10.2 5.0 11.0 5.7 11.0 5.7 10.6 5.3 10.1 4.9 10.3 4.8 9.3 4.8 injected (mean SD) Fertilization rate 75% 75% 77% 77% 74% 76% 77% No. of embryos 2.3 0.48 2.4 0.65 2.4 0.57 2.5 0.57 2.3 0.58 2.3 0.51 2.4 0.60 transfered (mean SD) Blastulation rate 50% 43% 44% 47% 41% 42% 45% with spare embryos Blastocysts of high 37%a 29% 26% 31% 27% 28% 29% quality suitable for freezing Clinical pregnancy 60% 59% 56% 49% 57% 54% 56% rate Implantation rate 36% 39% 32% 31% 41% 34% 33% Live birth 56% 54% 47% 44% 52% 49% 52% rate per transfer Miscarriage rate 4% 5% 9% 5% 5% 5% 4% Total deliveries 77 90 64 57 59 115 80 Singleton 55 49 37 35 30 72 53 Twins 19 38 24 20 23 39 27 Triplets 3 332640 a Signiﬁcantly different from other morphology subgroups (P<.05).

French. Severe teratospermia and ICSI clinical outcomes. Fertil Steril 2009.

statistically different among various morphology subgroups, the entire sample, making the initial semen morphology even including those with severe teratozoospermia. More- assessment irrelevant. This concept has been taken to the over, a negative paternal effect on blastocyst development subcellular level in new techniques such as intracytoplasmic as a result of ICSI and/or use of sperm from patients with morphologically selected sperm injection and motile sperm severe teratozoospermia was not observed. organellar morphology examination (MSOME). In these techniques, investigators select sperm for ICSI using a high- Although strict sperm morphology may affect fertilization power 1,000 objective to magnify and allow more critical rates in intrauterine insemination (2) and cycles with conven- assessment of sperm morphology. Sperm nucleus morphol- tional IVF insemination (3), this association is not seen when ogy by the MSOME method has positively correlated with ICSI is used. Numerous studies, including the present work, fertilization and pregnancy rates (22, 23). Experience with support the conclusion that poor sperm morphology on pre- these methods, however, is too limited to draw deﬁnitive con- IVF semen analysis using Kruger’s strict criteria does not clusions regarding efﬁcacy and potential for augmenting the correlate to either poor fertilization and/or pregnancy rates birth rate of healthy infants after ICSI. in ICSI cycles (8, 9, 11–14). The most likely explanation for this is that during ICSI the Looking at how sperm morphology correlates with sperm embryologist can microscopically select individual sperm function, DNA damage, and chromosomal status may help in that appear morphologically ‘‘normal,’’ from even the most understanding the prognostic value of strict morphology impaired specimens. Thus, fertilization occurs with sperm assessment. Data from several studies suggest that abnormal that may not be representative of the sperm population within sperm morphology does not necessarily translate into

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FIGURE 2

Etiology of infertility by sperm morphology subgroups.

Patient Diagnosis in Sperm Morphology Subgroups

100%

80% % of patients 60% Other Endometriosis Ovulatory 40% Tubal Unexplained 20% Male Factor

0% 0% 1% 2% 3% 4% 5-7% >7% % Normal Forms

French. Severe teratospermia and ICSI clinical outcomes. Fertil Steril 2009.

abnormal chromosomal content (24–26). Celik-Ozenci et al. genes are particularly susceptible to damage and are labeled (27), using fluorescent in situ hybridization, found that 10% such that only the maternal or paternal copy is expressed. of sperm with disomic nuclei were categorized as normal It has been suggested that the ICSI process itself disrupts by strict morphology. Sperm morphology defects may serve these fragile genes, leading to their loss of function and in more as a barrier to reaching and penetrating the oocyte turn manifestation of imprinting disorders, such as Angelman zona. Sperm DNA fragmentation may affect cycle outcome, syndrome and Beckwith-Wiedemann syndrome. Among embryonic development, and blastocyst formation (28–31). children with Beckwith-Weidemann syndrome, 4.6% were However, no clear relationship has been shown between mor- identified as having been conceived by ART (mostly ICSI), phologic attributes of sperm and degree of DNA damage which was an increase from the baseline rate of 0.76% of (32–34). live births resulting from ART in the general population (40). Although no such cases were noted in the present series, Despite its efficacy as a tool for oocyte fertilization, there developmental disturbances are clearly more difficult to track is continued concern that the use of the ICSI technique elim- than congenital anomalies. inates any opportunity for ‘‘natural selection’’ of the sperm that will ultimately fertilize the oocyte. Although the risk Paternal effect on blastocyst quality has been a question of of birth defects in children conceived through ART is in- great interest. Janny and Menezo (41) suggested a correlation creased over that of natural conception, the fear that ICSI between impaired semen parameters and reduced blastocyst will result in higher rates of major birth defects compared development in conventional IVF cycles. Others have re- with conventional IVF has not been substantiated by current ported poorer blastocyst development in embryos derived data. A recent meta-analysis showed a 30%–40% increased from ICSI versus conventional IVF (15). Miller and Smith risk of major birth defects with assisted reproduction (either (16) observed that a greater number of ICSI-derived embryos IVF or ICSI) compared with natural conception (35). A study arrested at the 5–8-cell stage, corresponding to the time of pa- comparing 1,462 children conceived through IVF or intra- ternal genome activation. Moreover, fewer ICSI-derived em- uterine insemination with 8,422 naturally conceived children bryos (14%) developed to blastocyst compared with IVF found the incidence of birth defects to be 6.2% with IVF or embryos (28%). Kihaile et al. (18) compared sibling oocytes IUI versus 4.4% with natural conception. However, no differ- inseminated or injected with sperm from patients with severe ence was seen in the risk of birth defects when comparing tra- teratozoospermia. Despite a higher fertilization rate, devel- ditional IVF and ICSI (36). A meta-analysis of four studies opment was compromised in the ICSI group, with fewer with a total of 5,395 children born after ICSI confirms embryos progressing to the blastocyst stage. Both groups a lack of statistically significant increase in birth defects had severe teratospermia, suggesting that something inherent with ICSI compared with conventional IVF (37). in the ICSI process itself affects blastocyst development. Another concern has been that the ICSI process itself Contradictory results were obtained by Van Landuyt et al. causes damage to imprinted genes (38, 39). These methylated (20), who found that sibling oocytes from ICSI versus

Fertility and Sterility 5 ARTICLE IN PRESS conventional IVF showed similar rates of embryonic devel- 3. Kruger TF, Acosta AA, Simmons KF, Swanson RJ, Matta JF, opment and blastocyst formation. Oehninger S. Predictive value of abnormal sperm morphology in in vitro fertilization. Fertil Steril 1988;49:112–7. The present findings did not indicate a negative effect of 4. Grow DR, Oehninger S, Seltman HJ, Toner JP, Swanson RJ, the ICSI technique on blastocyst formation. We achieved Kruger TF, et al. Sperm morphology as diagnosed by strict criteria: a blastulation rate of between 41% and 50% among the differ- probing the impact of teratozoospermia on fertilization rate and pregnancy outcome in a large in vitro fertilization population. Fertil Steril ent sperm morphology subgroups using ICSI. We did not 1994;62:559–67. observe a correlation between severe teratozoopsermia and 5. Coetzee K, Kruge TF, Lombard CJ. Predictive value of normal sperm poorer blastocyst quality. A significantly greater percentage morphology: a structured literature review. Hum Reprod Update of high-quality blastocysts was obtained in the most severely 1998;4:73–82. teratospermic subgroup, with 0% normal forms, probably 6. Check JH, Adelson HG, Schubert BR, Bollendorf A. Evaluation of sperm morphology using Kruger’s strict criteria. Arch Androl 1992;28:15–7. owing to a lower contribution of female factor infertility in 7. Check ML, Bollendorf A, Check JH, Katsoff D. Reevaluation of the clin- this group. These data suggest that Kruger’s strict morphol- ical importance of evaluating sperm morphology using strict criteria. ogy was not useful in predicting either the rate of blastocyst Arch Androl 2002;48:1–3. development or the morphologic characteristics of the result- 8. Svalander P, Jakobsson AH, Forsberg AS, Bengtsson AC, Wikland M. ing blastocysts in ICSI cycles. The outcome of intracytoplasmic sperm injection is unrelated to ‘‘strict criteria’’ sperm morphology. Hum Reprod 1996;11:1019–22. We acknowledge several limitations of this report. The 9. Lundin K, Soderlund B, Hamberger L. The relationship between sperm contribution of female diagnosis to cycle outcome could not morphology and rates of fertilization, pregnancy and spontaneous abor- tion in an in-vitro fertilization/intracytoplasmic sperm injection pro- be completely assessed. Even though the most important vari- gramme. Hum Reprod 1997;12:2676–81. able affecting oocyte quality, maternal age, was controlled for 10. Robinson JN, Lockwood GM, Dokras A, Egan DM, Nicholson SC, in our data set, we recognize that genetic factors and ovarian Ross C, et al. Does isolated teratozoospermia affect performance in in- response to stimulation also play significant roles. The rela- vitro fertilization and embryo transfer? Hum Reprod 1994;9:870–4. tionship between sperm morphology, ICSI, and birth defects 11. Keegan BR, Barton S, Sanchez X, Berkeley AS, Krey LC, Grifo J. Iso- lated teratozoospermia does not affect in vitro fertilization outcome and could not be adequately addressed in this investigation. A is not an indication for intracytoplasmic sperm injection. Fertil Steril more controlled study with ICSI and IVF of sibling oocytes 2007;88:1583–8. is needed to confirm our observation that the intracytoplasmic 12. Nagy ZP, Liu J, Joris H, Verheyen G, Tournaye H, Camus M, et al. The sperm injection technique itself was not disruptive to subse- result of intracytoplasmic sperm injection is not related to any of the quent normal embryonic development and live birth rate. three basic sperm parameters. Hum Reprod 1995;10:1123–9. 13. Kupker W, al-Hasani S, Schulze W, Kuhnel W, Schill T, Felberbaum R, Also, long-term follow-up at multiple IVF centers and a larger et al. Morphology in intracytoplasmic sperm injection: preliminary re- live birth data set will be necessary to truly assess the impact sults. J Assist Reprod Genet 1995;12:620–6. of ICSI on birth defects and imprinting disorders. Finally, this 14. McKenzie LJ, Kovanci E, Amato P, Cisneros P, Lamb D, Carson SA. study excluded the subgroup of men with semen densities of Pregnancy outcome of in vitro fertilization/intracytoplasmic sperm injec- under 1 million, owing to logistical problems performing tion with profound teratospermia. Fertil Steril 2004;82:847–9. 15. Dumoulin JC, Coonen E, Bras M, van Wissen LC, Ignoul-Vanvuchelen R, morphology assessments on small numbers of spermatozoa. Bergers-Jansen JM, et al. Comparison of in-vitro development of em- Further study of this subgroup is certainly warranted. Terato- bryos originating from either conventional in-vitro fertilization or intra- zoospermia combined with severe oligozoospermia could po- cytoplasmic sperm injection. Hum Reprod 2000;15:402–9. tentially affect ICSI outcomes, by reducing the likehood of 16. Miller JE, Smith TT. The effect of intracytoplasmic sperm injection and locating a ‘‘normal’’ sperm for injection. semen parameters on blastocyst development in vitro. Hum Reprod 2001;16:918–24. In conclusion, the present data suggest that, in ICSI cycles, 17. Shoukir Y, Chardonnens D, Campana A, Sakkas D. Blastocyst develop- Kruger strict morphology is not predictive of fertilization ment from supernumerary embryos after intracytoplasmic sperm injection: a paternal influence? Hum Reprod 1998;13:1632–7. rates, clinical pregnancy rates, blastulation, or blastocyst 18. Kihaile PE, Misumi J, Hirotsuru K, Kumasako Y, Kisanga RE, quality. Microscopic selection of sperm with ‘‘normal’’ mor- Utsunomiya T. Comparison of sibling oocyte outcomes after intracyto- phology during the ICSI procedure allowed excellent out- plasmic sperm injection and in vitro fertilization in severe teratozoosper- comes even in samples with severe teratozoospermia. The mic patients in the first cycle. Int J Androl 2003;26:57–62. live birth rate was similarly unaffected by sperm morphology 19. Oehninger S, Kruger TF, Simon T, Jones D, Mayer J, Lanzendorf S, et al. A comparative analysis of embryo implantation potential in patients with parameters. Kruger strict criteria, as paternal factor, and/or severe teratozoospermia undergoing in-vitro fertilization with a high the ICSI procedure itself did not appear to negatively impact insemination concentration or intracytoplasmic sperm injection. Hum blastocyst development or pregnancy outcome. Reprod 1996;11:1086–9. 20. Van Landuyt L, De Vos A, Joris H, Verheyen G, Devroey P, Van Steirteghem A. Blastocyst formation in in vitro fertilization versus intracytoplasmic sperm injection cycles: influence of the fertilization proce- REFERENCES dure. Fertil Steril 2005;83:1397–403. 1. Kruger TF, Menkveld R, Stander FS, Lombard CJ, Van der Merwe JP, 21. Kruger TF, Acosta AA, Simmons KF, Swanson RJ, Matta JF, Veeck LL, van Zyl JA, et al. Sperm morphologic features as a prognostic factor in et al. New method of evaluating sperm morphology with predictive value in vitro fertilization. Fertil Steril 1986;46:1118–23. for human in vitro fertilization. Urology 1987;30:248–51. 2. Van Waart J, Kruger TF, Lombard CJ, Ombelet W. Predictive value of 22. Bartoov B, Berkovitz A, Eltes F, Kogosowski A, Menezo Y, Barak Y. normal sperm morphology in intrauterine insemination (IUI): a struc- Real-time fine morphology of motile human sperm cells is associated tured literature review. Hum Reprod Update 2001;7:495–500. with IVF-ICSI outcome. J Androl 2002;23:1–8.

6 French et al. Severe teratospermia and ICSI clinical outcomes Vol. -, No. -, - 2009 ARTICLE IN PRESS

23. Berkovitz A, Eltes F, Yaari S, Katz N, Barr I, Fishman A, et al. The mor- 32. Evenson DP, Jost LK, Marshall D, Zinaman MJ, Clegg E, Purvis K, et al. phological normalcy of the sperm nucleus and pregnancy rate of intracy- Utility of the sperm chromatin structure assay as a diagnostic and prog- toplasmic injection with morphologically selected sperm. Hum Reprod nostic tool in the human fertility clinic. Hum Reprod 1999;14:1039–49. 2005;20:185–90. 33. Trisini AT, Singh NP, Duty SM, Hauser R. Relationship between human 24. Martin RH, Rademaker A. The relationship between sperm chromo- semen parameters and deoxyribonucleic acid damage assessed by the somal abnormalities and sperm morphology in humans. Mutat Res neutral comet assay. Fertil Steril 2004;82:1623–32. 1988;207:159–64. 34. Donnelly ET, Steele EK, McClure N, Lewis SE. Assessment of DNA in- 25. Rosenbusch B, Strehler E, Sterzik K. Cytogenetics of human spermato- tegrity and morphology of ejaculated spermatozoa from fertile and infer- zoa: correlations with sperm morphology and age of fertile men. Fertil tile men before and after cryopreservation. Hum Reprod 2001;16:1191–9. Steril 1992;58:1071–2. 35. Hansen M, Bower C, Milne E, de Klerk N, Kurinczuk JJ. Assisted repro- 26. Viville S, Mollard R, Bach ML, Falquet C, Gerlinger P, Warter S. Do ductive technologies and the risk of birth defects—a systematic review. morphological anomalies reﬂect chromosomal aneuploidies? Case re- Hum Reprod 2005;20:328–38. port. Hum Reprod 2000;15:2563–6. 36. Olson CK, Keppler-Noreuil KM, Romitti PA, Budelier WT, Ryan G, 27. Celik-Ozenci C, Jakab A, Kovacs T, Catalanotti J, Demir R, Bray- Sparks AE, et al. In vitro fertilization is associated with an increase in Ward P, et al. Sperm selection for ICSI: shape properties do not predict major birth defects. Fertil Steril 2005;84:1308–15. the absence or presence of numerical chromosomal aberrations. Hum 37. Lie RT, Lyngstadaas A, Orstavik KH, Bakketeig LS, Jacobsen G, Reprod 2004;19:2052–9. Tanbo T. Birth defects in children conceived by ICSI compared with chil- 28. Muriel L, Garrido N, Fernandez JL, Remohi J, Pellicer A, de los dren conceived by other IVF-methods; a meta-analysis. Int J Epidemiol Santos MJ, et al. Value of the sperm deoxyribonucleic acid fragmentation 2005;34:696–701. level, as measured by the sperm chromatin dispersion test, in the outcome 38. Kurinczuk JJ. Safety issues in assisted reproduction technology. From of in vitro fertilization and intracytoplasmic sperm injection. Fertil Steril theory to reality—just what are the data telling us about ICSI offspring 2006;85:371–83. health and future fertility and should we be concerned? Hum Reprod 29. Seli E, Gardner DK, Schoolcraft WB, Moffatt O, Sakkas D. Extent of 2003;18:925–31. nuclear DNA damage in ejaculated spermatozoa impacts on blastocyst 39. Young LE, Fernandes K, McEvoy TG, Butterwith SC, Gutierrez CG, development after in vitro fertilization. Fertil Steril 2004;82:378–83. Carolan C, et al. Epigenetic change in IGF2R is associated with fetal 30. Virro MR, Larson-Cook KL, Evenson DP. Sperm chromatin structure overgrowth after sheep embryo culture. Nat Genet 2001;27:153–4. assay (SCSA) parameters are related to fertilization, blastocyst develop- 40. DeBaun MR, Niemitz EL, Feinberg AP. Association of in vitro fertiliza- ment, and ongoing pregnancy in in vitro fertilization and intracytoplas- tion with Beckwith-Wiedemann syndrome and epigenetic alterations of mic sperm injection cycles. Fertil Steril 2004;81:1289–95. LIT1 and H19. Am J Hum Genet 2003;72:156–60. 31. Tarozzi N, Bizzaro D, Flamigni C, Borini A. Clinical relevance of sperm 41. Janny L, Menezo YJ. Evidence for a strong paternal effect on human DNA damage in assisted reproduction. Reprod Biomed Online 2007;14: preimplantation embryo development and blastocyst formation. Mol 746–57. Reprod Dev 1994;38:36–42.

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