1. Selecting sperm for ICSI - IMSI Allan Pacey University of Sheffield Sheffield Teaching Hospitals

2. A.Pacey@Sheffield.ac.uk http://www.twitter.com/allanpacey

3. Intra Cytoplasmic Sperm Injection Palermo et al., (1992) Lancet 340: 17-18

4. What does ICSI bypass? Suarez and Pacey (2006) Human Reprod Update 12: 23-37

5. Sperm Transport Suarez and Pacey (2006) Human Reprod Update 12: 23-37 Cervix Utero-tubal junction Sperm-epithelial interactions Sperm-oocyte interaction

6. Summary of sperm functions in relation to mode of conception Mode of fertilisation / conception coitusICIUIGIFTIVFICSI Passage through cervical mucusYNNNNN Transport through the uterusYYNNNN Passage through the UTJYYYNNN Sperm-epithelial interactionYYY?NN CapacitationYYYYYN Sperm Egg BindingYYYYYN Passage through zona pellucidaYYYYYN Decondensation of sperm DNAYYYYYY Pacey (2005) What Makes ‘Good Sperm’? In Implantation and Early Development. RCOG Press. pp. 119 - 128.

7. Pacey (2005) What Makes ‘Good Sperm’? In Implantation and Early Development. RCOG Press. pp. 119 - 128. Summary of sperm functions in relation to mode of conception Mode of fertilisation / conception coitusICIUIGIFTIVFICSI Passage through cervical mucusYNNNNN Transport through the uterusYYNNNN Passage through the UTJYYYNNN Sperm-epithelial interactionYYY?NN CapacitationYYYYYN Sperm Egg BindingYYYYYN Passage through zona pellucidaYYYYYN Decondensation of sperm DNAYYYYYY

8. DNA Quality % FAS positive cells Lewis & Simon (2010) Human Fertility 13: 201-217

9. Nagy et al., (1995) Human Reproduction 10: 1123-1129 ICSI and semen parameters

10. Motile Sperm Organelle Morphology Examination (MSOME) Bartoov et al., (2002) Journal of Andrology 23: 1-8

11. Motile Sperm Organelle Morphology Examination (MSOME) Bartoov et al., (2002) Journal of Andrology 23: 1-8

12. Motile Sperm Organelle Morphology Examination (MSOME) Bartoov et al., (2003) Fertility and Sterility 80: 1413-1419

13. Antinori et al., (2008) RBM Online 16: 835-841 Prospective RCT (IMSI)

14. Antinori et al., (2008) RBM Online 16: 835-841 ICSI (n=219) IMSI (n=227) Mean age (years)31.91 ±3.3031.65 ± 3.23 No of previous ICSI failures1.45 ±1.571.46 ± 1.69 No of MII oocytes recovered6.29 ± 3.046.58 ± 3.34 No of injected oocytes2.92 ± 0.262.90 ± 0.29 No of 2PN zygotes2.76 ± 0.422.75 ± 0.45 No of transferred embryos/patient2.37 ± 0.672.47 ± 0.68 Clinical pregnancy rate (%)58/219 (26.5%)89/227 (39.2%) Implantation rate (%)59/521 (11.3%)97/560 (17.3%) Miscarriage rate (%)14/58 (24.1%)15/89 (16.9%) Prospective RCT (IMSI)

15. Antinori et al., (2008) RBM Online 16: 835-841 Prospective RCT (IMSI) ICSI (n=219) IMSI (n=227) Mean age (years)31.91 ±3.3031.65 ± 3.23 No of previous ICSI failures1.45 ±1.571.46 ± 1.69 No of MII oocytes recovered6.29 ± 3.046.58 ± 3.34 No of injected oocytes2.92 ± 0.262.90 ± 0.29 No of 2PN zygotes2.76 ± 0.422.75 ± 0.45 No of transferred embryos/patient2.37 ± 0.672.47 ± 0.68 Clinical pregnancy rate (%)58/219 (26.5%)89/227 (39.2%) Implantation rate (%)59/521 (11.3%)97/560 (17.3%) Miscarriage rate (%)14/58 (24.1%)15/89 (16.9%)

16. How is IMSI done? Sperm obtained and prepared Observed using Nomarski differential interference contrast optics Images captures on a video camera and projected on a monitor Total magnification = x6,600 Each cell observed individually by a second embryologist Antinori et al., (2008) RBM Online 16: 835-841

17. What do sperm vacuoles represent ? Sperm from infertile men have a higher incidence of: DNA Fragmentation Errors of chromatin packaging Aneuploidy Therefore, does the appearance of sperm vacuoles represent a non-invasive way of detecting one or more of these.

18. Sperm DNA fragmentation (TUNEL) #1 Oliveria et al., (2010) Fertility and Sterility 94: 1937-1940

19. Watanabe et al., (2011) Human Reproduction (in press) Sperm DNA fragmentation (TUNEL) #2

20. Franco et al., (2011) Int Journal of Andrology (in press) Sperm chromatin packaging Normal SpermSperm with vacuoles Positive staining337719 Negative Staining498632

21. Cássia et al., (2011) Fertility and Sterility 95: 990-993 Sperm and embryo aneuploidy CharacteristicICSI (n=60) IMSI (n=60) P value Female age (years)38.1 ± 5.437.3 ± 3.20.5866 Male age (years)42.6 ± 8.043.6 ± 8.90.7330 Total gonadotrophin dose (IU)2,601 ± 6762,697 ± 659 0.6592 Total aspirated follicles13.2 ± 8.217.3 ± 10.70.0976 Total retrieved oocytes8.6 ± 5.212.9 ± 9.70.1705 Sperm concentration (x10 6 /ml)22.2 ± 5.321.8 ± 6.70.7954 Sperm progressive motility (%)35.634.80.6823 Fertilisation rate (%)84.376.70.0638 Embryos1.1 ± 1.01.7 ± 1.00.1705

22. IMSI was associated with lower risk of: −Sex chromosome abnormality (OR 0.57; CI 0.37-0.90) −Chaotic embryo development (OR 0.64; CI 0.43-0.96) Sex chromosome aneuploidy was higher in ICSI embryos compared to IMSI embryos (23.5% vs 15.0%; P=0.920) Unexpected higher incidence of euploid XX embryos derived from IMSI cycles compared to ICSI (30.0% vs 21.6%; P=0.0326) Sperm and embryo aneuploidy Cássia et al., (2011) Fertility and Sterility 95: 990-993

23. So what do more recent trials say? Oliveria et al., (2011) Reprod Biol and Endocrinol 9:99 CharacteristicICSI (n=100) IMSI (n=100) P value Female age (years)36.7 ± 4.0 P=0.80 Male age (years)40.3 ± 6.039.8 ± 6.2P=0.50 Total gonadotrophin dose (IU)--- Total aspirated follicles--- Total retrieved oocytes--- Sperm concentration (x10 6 /ml)70.7 ± 60.470.4 ± 83.40.97 Sperm progressive motility (%)49.6 ± 23.751.8 ± 19.70.55 Fertilisation rate (%)62.0 ±26.565.4 ±23.50.34 Embryos2.7 ± 1.0 0.44

24. So what do more recent trials say? Oliveria et al., (2011) Reprod Biol and Endocrinol 9:99 CharacteristicICSI (n=100) IMSI (n=100) P value Implantation rate (%)9.8%13.6%0.21 Pregnancy / cycle (%)19.0%26.0%0.73 Miscarriage rate (%)31.6%15.4%0.28 Ongoing pregnancies/cycle (%)13.0%22.0%0.13 Live birth/cycle (%)12.0%21.0%0.12 Our results suggest that IMSI does not provide a significant improvement in clinical outcome compared to ICSI, at least in couples with repeated implantation failures after conventional ICSI. However, it should be noted that there were clear trends for lower miscarriage rates (approx 50% reduced) and higher rates of ongoing pregnancy and live births (both nearly doubled) within the IMSI group.

25. Meta Analysis Souza et al., (2010) RBM Online 21: 450-455 The meta-analysis results demonstrated no significant difference in fertilization rate between ICSI and IMSI groups. However, a significantly improved implantation (OR: 2.72; 95% CI: 1.50-4.95) and pregnancy rate (OR 3.12; 95% CI 1.55-6.26) was observed in IMSI cycles. The results showed a significantly decreased miscarriage rate (OR 0.42; 95% CI 0.23-0.78) in IMSI cycles as compared with ICSI cycles. However, more randomized controlled trials are needed to confirm these results.

26. Globozoospermia Sermondade et al., (2011) Human Reproduction (in press)

27. In theory IMSI offers some advantage to sperm selection because of the high magnifications involved (x6,000). A single meta-analysis shows that IMSI improves pregnancy rates and decreases miscarriage rates – we need more studies! The science is unclear with many unsubstantiated claims made about what ‘qualities of sperm’ are being selected for. A Health Economic Analysis is needed given the additional staff time involved in performing IMSI (e.g. two embryologists). Should only be offered to patients in the context of an appropriately controlled clinical trial. Conclusions

28. A.Pacey@Sheffield.ac.uk http://www.twitter.com/allanpacey Thank You!