Transcript The role of IMSI in sperm selection

The role of IMSI in sperm
selection
Monica Antinori
R.A.P. R.U.I
International Associated Research Institute for Human Reproduction
Rome, Italy.
INTRODUCTION
A different prognosis can be assigned on the basis of different normal morphology
thresholds (poor prognosis: ≤4%; good prognosis: 5-14%; normal: >14%) in order to choose
an adequate infertility management .
Kruger et al., 1988; Grow et al., 1994
Predictive value of sperm morphology for fertilization and pregnancy outcomes in IVF
treatments.
Kruger et al., 1986; 1987; Parinaud et al., 1993; Ombelet et al., 1997; Eilish T. et al., 1998
Correct selection of spermatozoa improves ICSI outcome
Kahraman et al., 1999; Miller and Smith, 2001; De Vos et al., 2003
INTRODUCTION II
According to some authors, ICSI outcome is not related to strict morphology of the
sperm used for microinjection
Oehninger et al., 1995; Kupker et al., 1998; Host et al., 2001; Celik-Ozenci et al.,2004
No differences in terms of fertilization and clinical pregnancy rates have been shown
when samples with poor morphology (<5% normal cells) were used
Gomez 2000
Fertilization, embryo development and pregnancy seem to be achievable even if normal
spermatozoa are not available (100% of terato-zoospermia)
Nagy et al., 1995; Tasdemir et al.,1997; Mckenzie et al., 2004
In the routine ICSI procedure,
sperm cells Recently new devices to achieve high
are selected from the sperm pool under a magnification levels (6600x) have been
regular microscope that magnifies 200-400x
proposed in order to detect subtle ultrastructural
alterations
that
would
be
impossible to identify with conventional
methods.
.
Sperm sub-cellular
organelles
Bartoov , et al.,1999
Specific Morphological Malformations of the Sperm Cell
Subcellular Organelles (other than nucleus) Observed by
MSOME
SPERM CELL
SUBCELLULAR
ORGANELLES
SPECIFIC MALFORMATIONS
Acrosome
Partial; Vesiculated; Lack
PostAcrosomal Lamina
Vesiculated; Lack
Neck
Abaxial; Disorder;
Cytoplasmic droplet
Tail
Coiled; Broken; Multi; Short;
Lack
Mitochondria
Partial; Disorganization; Lack
VACUOLES
ACROSOMAL LACK
Bartoov , et al,1999
Criteria for morphologically normal
nucleus
-Oval shape
-Longitudinal symmetry
-Smooth content
Oval Shape
Normal shape
LARGE
OVAL
WIDE
NORMAL
SHORT
SMALL
OVAL
3.28μm
(±0.20)
NARROW
4.75μm
(±0.28)
LONG
Smooth Content
1. No vacuoles/only one vacuole
with a diameter greater than
0.78±0.18µm
Vacuolated spermatozoa
I
E
2. No extrusion or invagination of
the nuclear chromatin mass
Regional disorder
vacuoles
estrusion
Sperm Functional Morphology is
based on:
-High power light microscopy
-Single cell examination
-Real time observation
-Examination of only motile sperm cells
-Fine organellar morphology
Motile Sperm Organellar Morphology
Examination
97 men from an unselected group of couples undergoing infertility
investigation
Oliveira 2010
HA bound
HA unbound
spermatozoa
spermatozoa
P value
normal spermatozoa
2.7
2.6
ns
large/small spermatozoa
1.5
1.7
ns
wide/narrow
3.1
2.8
ns
regional disorder
4.7
4.3
ns
Vacuoles 4-50%
72.5
72
ns
Vacuoles > 50%
15.6
16.5
ns
Petersen 2010
DNA
status
• Fragmentation
• Aneuploidies
Clinical
outcomes
• Pregnancy
• Abortion
• Embryo quality
• Bartoov
Classifications
System
• Equipment
Set Up
•Chablon design
•Cassuto & Barak
•Vanderzwalmen
•Our proposal
Hazout et al. 2006
30 patients in an unselected group of couples undergoing infertility
investigation and treatment
Franco et al. 2008
Mitosensor
Acridine orange
Tunel
Aneuploidies
Garolla et al. 2008
Oliveira 2010
5- 50% vacuolized
> 50% vacuolized
RBM Online2010
Msome and acrosomal status assessment were
simultaneously performed on 3237 spermatozoa of 30
man with the following sperm parameter:
• concentration 65.6±0.2 x 106/ml
•Progressive motility: 43± 18%
•Vitality:79 ± 7.8%
•Normal morphology (David’s criteria):29 ± 4.6%
Kacem et al. 2010
Kacem et al. 2010
MSOME on acrosome reacting spermatozoa
A:Some protruding blebs are visible in the anterior part of the head
D:In the following picture the corresponding area shows a “vacuolelike” image
Kacem et al. 2010
“Thoughts on IMSI”
Giampiero Palermo et al.
In : "Biennial
Review of Infertility, Volume 2" New York Inc. Springer-Verlag;
June 2011
“Crater” characterization for IMSI
N°of (%)
Large
Small
None
ICSI
23
63
20
256
Fertilization
14(60.9)
54(85.7)
16(80.0) 167 (70.8)
Blastocyst
Development
7(50.0)
28 (54.9)
4(25.0)
Oocytes injected
85 (51.0)
•January 2006 - June 2007
•Study design: prospective randomized
•Original Group: 446 couples
•Inclusion criteria : 1) at least 2 previous diagnoses of severe
oligo-astheno-terato-zoospermia
2) at least 3 years of primary infertility
3) the woman being 35 or younger
4) an undetected female factor
•COH: GnRH Antagonist regimen (ganirelix acetate) + rFSH
•OPU 35-36h after HCG
•Transfer D3
Antinori et al. 2008
Antinori et al. 2008
IMSI resulted in a significantly higher pregnancy rate
than ICSI in all treated cases (P = 0.004) and notably
in patients with ≥ 2 failures for whom the success
rate increased by over 100% (P = 0.017), which
confirms the data already published in the literature
Number of
fertiized eggs
Number of top quality
embryos
Setti et al. 2010
Number of gestational sacs
Number of Pregnancies
Setti et al. 2010
2011
Unselected infertile population
BARTOOV’S CLASSIFICATION
Bartoov’s retrieval hierarchy of morphologically evaluated
"second best" sperm cells with minimally impaired nuclei.
Choice
Specific nuclear malformations
1
Large Oval
1
Small Oval
2
Wide forms (> 3.7 μm width)
2
Narrow forms (< 2.9 μm width)
3
Regional disorder
4
Large vacuoles +Normal Shape/Size
5
Abnormal forms + Large vacuoles
Cassuto & Barak
SCORE SYSTEM
Score of spermatozoa: 2 Head + 3 Vacuole + Base
CLASS I (4-6) = 6 POINTS
CLASS II (1-3) = 2 POINTS
CLASS III (0) = 0 POINTS
Cassuto & Barak
SCORE SYSTEM
VANDERLZWALMEN CLASSIFICATION
Grade
Specific nuclear malformations
I
Normal form and no vacuoles
II
Normal form and ≤ 2 small vacuoles
III
Normal form >2 small vacuoles or at least one large
vacuole
IV
Large vacuole and abnormal head shapes or other
abnormalities
VANDERLZWALMEN CLASSIFICATION
VANDERLZWALMEN 2008
RAPRUI CLASSIFICATION
Choice
1 st
Specific nuclear malformations
Oval-Symmetric-Smooth nucleus
(even with a small vacuole in the middle : 0.78 m)
2nd
Vacuolization < 15% (only small anterior vacuoles)
3rd
Vacuolization 15-30% (only small anterior vacuoles)
3rd
Size and shape anomalies, no vacuoles
(Large/Small; Wide/Narrow )
3rd
Normal nucleus with neck cytoplasmic droplet
100%
90%
80%
70%
60%
50%
D3
40%
D2
30%
D1
20%
10%
0%
2C
3C
G1
4C
2C
3C
G3
4C
IMSI at RAPRUI
January 2005 and Dec 2010: 2082 IMSI cycles
Mean age: 36.6 yrs
Couples with >previous ICSI 2 failures
46.4%
Mean n° failures/couple in this group
3.87
IMSI OBSTETRIC OUTCOMES
N° Deliveries
335
( 291 singletons+ 38twins+6 triplets)
N° Live Birth
380
Cesarean section
326 (85.7%)
Gestational age (weeks,mean±SD)
37.4 ± 2.6
Birth weight (gr, mean±SD)
2980 ± 652
Obstetric complication
(211 females;169 males)
13 ( 3.8%)
7 PROM; 1gestational diabetes;
5 hypertensive desease
5 (1.4%)
Congenital anomalies
(genetic deseases,malformations)
1big vessels trasposition
1ipot. left ventricle*
1body stalk sindrome*
1Down sindrome*
1trysomy 18*
*terapeutical abortion
MSOME evaluation
in daily IVF routine
•Expensive equipment to reach the necessary
magnification (microscope, camcorder, composite
system of lenses)
•Experienced embriologists (hard training)
• Work in pairs cold be usefull to increase accuracy of
the evaluation
•Time consuming
“IMSI as a Valuable Tool for Sperm Selection
During ART ”
Monica Antinori, Pierre Vanderzwalmen and Yona Barak
In : "Biennial
Review of Infertility, Volume 2" New York Inc. Springer-Verlag;
June 2011
The introduction of IMSI has fostered a deeper understanding of those
mechanisms that interfere with male fertility potential in both natural
and assisted reproduction.
The lack of standardization in terms of basic techniques and
morphological evaluation criteria, its routine application available in
only a few ART units due to man-hours and high costs involved ,all
these factors create skepticism regarding IMSI’s cost-effectiveness.
All things considered, the most important question is : is it
ethically acceptable, according to the current literature, to not
provide the infertile couple with spermatozoa of the best quality
available when the technology gives you the opportunity to do
so, even with the knowledge that this could compromise the
ART success rate?
In order to fully answer this question, it’s important to first
change the pervasive mind-set which is limiting the full
potential that could be gained by employing the most
technologically advanced procedures like IMSI.
ART treatments can no longer be considered mere “shots in
the dark” they must become a decisive therapy, with much
more weight being given to the first attempt.
Thank you