Selection of sperm for ICSI: hyaluronan binding

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1 Selection of sperm for ICSI: hyaluronan binding Dave Morroll Director of Embryology

Reference Values Volume: 2.0 2.0 1.5 (1.4-1.

2 Concn (x10 6 ml): 20 20 15 (12-16) Total

(%): 50 50 32 (31-34) % normal morph: 30-4 (3.

2 Reference Values Volume: ( ) ph: >7.2 Concn (x10 6 ml): (12-16) Total count(x10 6 ): (33-46) Prog Motility (%): (31-34) % normal morph: 30-4 ( ) Vitality (% alive): (55-63) WBCs (x10 6 ml): <1.0 % MAR: <50

Male infertility male factor Male factor in ~40-50% of all infertile couples The selection of sperm for ICSI is critical and directly influences the male contribution to the embryo.

3 Male infertility male factor Male factor in ~40-50% of all infertile couples The selection of sperm for ICSI is critical and directly influences the male contribution to the embryo. In vivo the process of sperm selection is absent from sperm selection for ICSI. Here a sperm sample is most commonly visually assessed under the microscope and the sperm for injection is chosen based on motility and morphology. But unfit sperm with compromised development and DNA fragmentation can still look normal and healthy and if picked for fertilization this can lead to poor embryo quality and possible pregnancy loss.

4 Compaction of chromatin Moser, Salzburg, 2011

5 DNA Packing, IR & CPR Group Implantation Rate CPR/ET Chromomycin Per ET Per Cycle CMA 3 <44% <CMA 3 <60% CMA 3 >60% Esterhuizen et al, 2000

Immature sperm have not developed receptors for hyaluronic acid and will not bind to HA A sperms ability to bind to HA correlates to:

7 Sperm Delivery Sperm Analysis Sperm Purification Sperm Injection (IUI+ IVF) Sperm Selection (ICSI) Sperm Cryo Hyaluronan binding theory: Mature sperm have completed the plasma membrane remodeling and have receptors for and can bind to hyaluronic acid. Immature sperm have not developed receptors for hyaluronic acid and will not bind to HA A sperms ability to bind to HA correlates to: Cellular maturity, Less chromosomal aneuploidy, Less DNA fragmentation, Increased chromatin integrity Normal head morphology = better fertilizing potential Mature sperm = Best Sperm

8 Huszar et al, RBM Online 2007

9 Embryologist challenge: - How to pick the best sperm for ICSI? Classic: selection of good morphology and motility sperm based on visual evaluation of prepared sperm in PVP (viscous media) BUT - Visual selection alone can allow selection of sperm with compromised development, nuclear, and cytoplasmic competence. New: diagnostics and selection based on physiology, behavior & morphology with HBA PICSI SpermSlow

Hyaluronan Binding Assay (HBA ) Sperm that bind HA: have completed the spermiogenetic process of sperm plasma membrane remodelling, cytoplasmic extrusion and nuclear maturity (Huszar

10 Hyaluronan Binding Assay (HBA ) Sperm that bind HA: have completed the spermiogenetic process of sperm plasma membrane remodelling, cytoplasmic extrusion and nuclear maturity (Huszar et al, 2003) are mature with a high density of HA receptors and bind permanently to HA sperm unable to bind HA are more likely to have deficient membrane remodelling (Cayli et al, 2003)

11 HBA

12 HBA

13 Sperm Quality & ICSI No correlation between head shape and aneuploidy (Celik-Ozenci et al, 2004) Higher aneuploidy rates in morphologically normal spermatozoa from OAT men (Burrello et al, 2004) Abnormal histone modification & DNA demethylation in sperm from severe oligospermic men (Carrell et al, 2007, 2008, 2009; Olivia et al, 2009)

14 HBA Score (%) HBA & Kruger Strict Criteria 100 R2 = 0, Morphology (%) Worrilow

15 HBA & total motile sperm R2 = 0, Total Motile Sperm HBA score % Log. (HBA score %) Worrilow

ICSI & HBA The selection of sperm for injection that have no DNA fragmentation is essential to optimise treatment outcomes and health of children born HA-bound sperm show a

16 ICSI & HBA The selection of sperm for injection that have no DNA fragmentation is essential to optimise treatment outcomes and health of children born HA-bound sperm show a significant (5-fold) reduction in chromosomal aneuploidies (Jakab et al, 2005) Selection based on sperm-ha binding seems to be useful in maximising safety and efficacy of ICSI

17 ICSI & HBA HA-selection permits a more physiological ICSI uses a natural substance and avoids any potential damaging effect of PVP (Jean et al, 2001) Currently, two ready-to-use systems specially designed for sperm-ha binding selection are available: PICSI (Sperm Selection Device, MidAtlantic Diagnostic-ORIGIO) SPERM SLOW TM (MediCult - ORIGIO)

18 HA-ICSI: PICSI

19 HA-ICSI : SpermSlow Clean medium Sperm Slow Sperm suspension Spermatozoa bound to HA in the junction zone of the droplets can be selected and easily detached by injecting pipette.

20 Studies: ICSI with HA-bound sperm Authors HA-System N of treatments or patients HA-bound spermatozoa determine : Menezo et Nicollet Abstract IFFS meeting 2004 Sperm Slow 92 HA-ICSI vs 110 PVP-ICSI Positive trend on ICSI outcome Sanchez et al Abstract ESHRE meeting 2006 not described 18 HA-ICSI versus control group No differences on FR, PR, IR. Lower aneuploidies in HA-bound spermatozoa Worrilow et al Abstract ASRM meeting 2007 PICSI 240 couples (PICSI vs PVP-ICSI) Significant improvement in FR, embryo quality. Reduction in the MR Nasr-Esfahani et al JARG 2008 home made 50 couples (sibling oocytes injected with HA-ICSI or PVP-ICSI) Significant improvement FR Van Den Berg et al RBM Online 2009 Sperm Slow 44 couples (sibling oocytes injected with HA-bound or HA-not bound spermatozoa) No differences in fertilization (zygote score) Worrilow et al Abstract ESHRE meeting 2010 PICSI 215 couples (PICSI vs PVP-ICSI) Significant improvement in embryo quality (DAY 3-5)

SpermSlow Significantly higher Embryo Developmental Rate.

component of the cumulus oophorus cell complex surrounding the oocyte.

(HA) favors selection of spermatozoa without DNA fragmentation and with normal nucleus, resulting in improvement of embryo quality.

Live Birth 19 29 * Significantly higher EDR in HA-ICSI group compared to PVP-ICSI group. 40.0% 20.

21 SpermSlow Significantly higher Embryo Developmental Rate. Better Embryo Quality Lower DNA fragmentation Rate Safe biological and biodegradable Hyaluronic acid (HA) is a naturally occurring substance and is the main component of the cumulus oophorus cell complex surrounding the oocyte. Lodovico Parmegiani, leading KOL in HA sperm selection, show a clear benefit in using SpermSlow HA selected sperm for ICSI Physiological ICSI : Hyaluronic acid (HA) favors selection of spermatozoa without DNA fragmentation and with normal nucleus, resulting in improvement of embryo quality. Fertil Steril 2010; vol 93, no 2. PVP-ICSI (N=107) HA-ICSI (N=125) EDR 84.0 ± 1, ± 0,8 * No. Live Birth * Significantly higher EDR in HA-ICSI group compared to PVP-ICSI group. 40.0% 20.0% Embryo Developmental Rate (EDR) Best Quality Embryo Rate (Grade 1 Embryos) N= % * 35.8% SpermSlow contains HA in solution and only slows down the movement of mature sperm using HA-binding, to allow for the selection of the most mature, viable spermatozoa for ICSI. 0.0% PVP-ICSI N= 228 * Significantly Higher BQER (p=.046) HA-ICSI * N= 282 The fact that only mature and DNA intact sperms are selected results in significant improvement of embryo quality. * Significantly lower (P.001) N=20 N=20

22 Study 1 - Results Spematozoa bound to HA show a significant reduction in DNA fragmentation compared with spermatozoa immersed in PVP (Parmegiani et al, Fertil Steril 2009)

23 Spematozoa bound to HA show a significant improvement in nucleus normalcy compared with spermatozoa immersed in PVP (Parmegiani et al, Fertil Steril 2009)

24 Study 3: Results Injection of HA-bound spermatozoa (HA-ICSI) significantly improves embryo quality and development (Parmegiani et al, Fertil Steril 2009)

25 Blastocyst Coversion Rate (%) Blast Conversion Rate (%) PICSI % 67.0% 68.0% 66.0% 69.0% 66.0% 67.0% 71.0% 72.0% 77.0% Control p Value % % 41.0% 41.0% 38.0% 47.0% >90 >80 >70 <65 <50 <40 <30 <20

26 Clinical Pregnancy Rate (%) p-value CPR by initial HBA score % % % 69.2% 72.7% % 36.4% 46.2% 41.9% 50.0% 44.0% 46.2% 41.7% 33.3% 42.9% 33.3% 0.5 PICSI 20 Control 10 0 >90 >80 >70 <65 <50 <40 <30 < Initial HBA Score

27 ICSI + HBA: multi-centre study

28 HBA & PICSI Significantly reduced pregnancy loss rate 15% of all ICSI patients has 65% HBA score and will benefit from PICSI The combination of the diagnostic abilities of the Hyaluronan Binding Assay (HBA) and the HA-sperm selection in the PICSI dish (pick your sperm for ICSI), gives a significant reduction in pregnancy loss rate. Large U.S. study by Katy Worrilow et al,. shows a significant decrease in pregnancy loss rate when selecting sperm based on hyaluronan binding Worrilow et al. (2012) Use of hyaluronan in the selection of sperm for intracytoplasmic sperm injection (ICSI); significant improvement in clinical outcomes-multicenter, double blinded and randomized trial. Humrep, Nov ICSI patients participating-multi-center ntrial (10 center) - Randomized, double blinded, controlled. 20% 15% Pregnancy Loss Rate (PLR) Cntr (ICSI) HA bound (PICSI) 15.1% * Unexplained pregnancy loss can be due to the fact that the sperm selected in the ICSI process was immature and had compromised DNA integrity. The fact that only mature and DNA intact sperms are selected results in a significant 28 reduction in Pregnancy Loss Rate. 10% 5% 5.3% 3.5% 3.3% 0% >65% HBA score 65% HBA score n=114 n=133 Statistical significance (*) is indicated at P>0,05 28

29 Reduce the effects of the paternal genome on embryo development Selection of most competent sperm Reduced fragmentation Higher rate of blastocyst formation Improved blastocyst quality Higher CPR for low binders Lower miscarriage rate

TECNICHE E SIGNIFICATO DELLA SELEZIONE SPERMATICA PER ICSI

TECNICHE E SIGNIFICATO DELLA SELEZIONE SPERMATICA PER ICSI Enzo Troilo Lodovico Parmegiani GynePro Medical Centers Bologna - Italy www.gynepro.it Intracytoplasmic Sperm Injection (ICSI) The selection of