Dr. Marcos Meseguer (marcos.meseguer@ivi.es) Dr. Nicolás Garrido (nicolas.garrido@ivi.es) Help Wanted; Sperm donation in the era of ICSI Sperm Donation Is defined as the altruistic gift of the male gametes from an anonymous man to help single women and couples to procreate. Sperm donor selection; ; a safe option? 1
Sperm donor selection; different pattern Graduated Other 5% 2% University students 93% Cultural Background Other 75% Graduated 2% University Students 23% Sperm Donors Oocyte donors Sperm donor selection Sperm Donor serology (Spanish assisted reproduction law obliged) Blood type and Rh Human immunodeficency virus Syphilis Hepatitis B virus Hepatitis C virus Herpes simplex virus Cytomegalovirus Microbiological semen cultures (Chlamydia trachomatis and Neisseria gonorrhoeae) Sperm donor selection Results of blood analysis; total positive 2.6 % Cytomegalovirus No positives of HIV, Chlamydia and Syphilis 4 Herpes 5 Hepatitis C 1 Hepatitis 5 B Student population based on assumptions that people with better knowledge of the risks of unprotected sex would be less prone to acquiring STD. Donor population carries no higher risk for the general population in terms of transmitting sexually acquired infections 2
Sperm donor selection Semen cultures 8 72,5 6 % 4 27,5 2 Negatives Positives Semen cultures also presented a very high prevalence previously corroborated (Cottell et al., 2). Sperm donor selection Results of 62.1 % 36.7 % Ureaplasma Mycoplasma Gonorrhoea Chlamydia Other 4.9 % 3.1 %.6 % Other microorganisms included those not considered as sexual transmitted disease (not relevant): f.i. Enterobacterium, Klebsiella, Proteus, Haemiphilus, Staphilococcus, Citrobacter, Acinetobacter, Morganella, etc... Sperm donor selection Many micro-organisms found in the semen samples are nonpathogenic, probably due to an inadequate manner of sample recovery (Klebsiella spp., Proteus spp., Haemophilus spp., Citrobacter spp., etc.) (Cottell et al., 2). Since we do not perform the microbiological tests in all the samples, undoubtedly some positive samples for microbiological cultures must have been inadvertently used without causing any clinical consequences. It is impossible to analyze every sample; the preparatory techniques together with the presence of a wide spectrum antibiotics in the media used for IVF should eliminate these micro-organisms even reducing their presence by 95% (Steyaert et al., 2) this frequency of analysis (bimonthly) in the donors should, we believe, be safe enough. 3
Sperm donor selection 2 Sperm donors and donations 15 Number 1 Donations New Donors 5 26 25 24 23 22 21 2 1999 1998 1997 1996 1995 1994 Year A considerable increase of sperm donations because of the International Sperm Bank http://www.bancodesemeninternacional.net/ Clinical indications of Sperm donation 4
Historical indications to employ donated sperm Basically, they can be divided into: No sperm available Women without male partners. Ejaculatory dysfunction. Azoospermia, necrozoospermia in the male partner. Alive, motile sperm available for assisted reproduction treatments Repeated IVF/ICSI failure. Paternal transmission of genetic defects. Sexually transmitted infections (HIV). Indications; classical distribution IUI Women without male partner TREATMENTS IN SINGLE WOMEN 18 16 14 12 NUMBER 1 8 6 114 126 134 173 4 78 56 42 2 31 33 35 2 1 3 5 11 18 3 C1 199 1991 1992 1993 1994 1995 1996 1997 1998 1999 2 21 22 23 24 25 26 YEAR Apparent increase in the number of treatments 5
Women without male partner; Intrauterine Insemination IUI with donor sperm in single women 4 35 3 Nº cycles Without partner patients % of total 25 Number 2 15 1 5 2,4 23,4 26,2 38,5 35,2 3,4 2,7 18,9 26 25 24 23 22 21 2 1999 Year There is no tendency in the proportion of procedures Women without male partner; Intrauterine Insemination Donor IUI pregnancy 7 66,7 Pregnancies Pregnancy rat e/ pat ient Pregnancy rat e/ cycle 6 56,3 5 4 38,9 41,3 41,7 37, 38,1 41,7 3 26 29,4 24,3 2 14 19,4 15 2,8 17,5 2, 19, 18,5 1 1 1 8 9 5 26 25 24 23 22 21 2 1999 Y ear Women without male partner; IVF 35 3 IVF in single women IVF donor IVF wit hout part ner % total 25 Cases 2 15 1 5 36,1 21,5 15,8 33, 22, 11,6 8,3 11,6 26 25 24 23 Year 22 21 2 1999 Increased proportion of IVF treatments 6
Women without male partner; IVF Donor IVF pregnancies 7 6 63,6 59, 55,2 62,9 61,1 Pregnancies Pregnancy/patient Pregnancy/cycle 55,6 6, 5, 5, 5 45,8 45,5 Cases/Rates 4 3 35 32,1 23 27,8 29,7 22 33,3 25, 2 16 11 1 5 1 3 26 25 24 23 22 21 2 1999 Year s Women without male partner TREATMENTS IN SINGLE WOMEN 39,5 39 38,5 AGE (YEARS) 38 37,5 37 36,5 37,25 37,12 37,12 37,42 37,58 38,41 39,31 39,7 36 35,5 C1 35 1999 2 21 22 23 24 25 26 YEAR We have older patients and this would explain the increased proportion ortion of IVF cycles in single women Ejaculatory dysfunction Retrograde Ejaculation This problem is easily solvable, just by alkalinizing the urine and obtaining motile spermatozoa to be frozen or employed in assisted reproduction techniques. Briefly, 2-32 3 doses of bicarbonate the night before and the same morning when the sperm are going to be obtained, masturbate and ejaculate, recover the next urine Impotence and/or anejaculation Actually, it can be treated either by the administration of specific pharmacological treatments, such as Viagra. If no sperm is recovered opened testicular biopsy or epydidimal aspiration could be performed to obtain sperm. 7
Azoospermia TREATMENTS IN AZOOSPERMIA DIAGNOSE 2 18 16 14 NUMBER 12 1 8 6 9 4 111 114 92 122 143 136 188 2 C1 1999 2 21 22 23 24 25 26 YEAR Apparent increase in the number of treatments Azoospermia; IUI IUI in azoospermic patients 4 35 3 25 Nº cycles Azoospermia patients % of total Number 2 15 1 5 37,1 3,5 34,5 45,5 45,1 57,2 53,1 42,7 26 25 24 23 22 21 2 1999 Year Decreased proportion of IUI treatments; higher sperm recovery for f ICSI Azoospermia; IUI Donor IUI pregnancy Azoospermia 8 Pregnancies 7 64, 65, 66,7 66,7 Pregnancy rate/patient Pregnancy rate/cycle 6 54,5 52,9 Rates/Number 5 4 3 2 1 16 26,7 41,7 39,1 31,6 31, 32,3 32,3 24,3 2,9 21,3 12 13 1 1 9 9 1 26 25 24 23 22 21 2 1999 Year Higher pregnancy rates compare to single women; high proportion of fertile women 8
Azoospermia; IVF IVF in azoospermia 35 3 25 IVF donor IVF azoospermia % total Cases 2 15 1 5 2,4 16,6 15,8 16,5 22, 28,9 26,7 42, 26 25 24 23 Year 22 21 2 1999 Decreased proportion of IVF treatments; higher sperm recovery for f ICSI Azoospermia; IVF Donor IVF in azoospermia 1 8 Pregnancies Pregnancy rate/w oman Pregnancy rate Cases/Rates 6 4 2 26 25 24 23 22 21 2 1999 Years Higher pregnancy rates compare to single women Repeated IVF/ICSI failure TREATMENTS IN ICSI FAILURE 14 12 1 NUMBER 8 6 14 95 18 121 4 2 53 68 66 58 C1 1999 2 21 22 23 24 25 26 YEAR Stabilization in the number of treatments 9
Repeated IVF/ICSI failure;iui IUI in ICSI failure 4 35 3 25 Nº cycles ICSI failure % of total Number 2 15 1 5 27,8 29,4 25,5 33, 25,4 18,8 24,6 31,5 26 25 24 23 22 21 2 1999 Year There is no tendency in the proportion of procedures Repeated IVF/ICSI failure;iui Donor IUI pregnancy Azoospermia 8 Pregnancies 7 6 56,3 55,9 54,5 66,7 53,8 Pregnancy 68,2 rate/patient Pregnancy rate/cycle 6, Rates/Number 5 4 3 2 1 27 27,6 46,2 27,1 27,3 22,8 18 19 18 12 33,3 7 26,9 34,1 33,3 15 15 26 25 24 23 22 21 2 1999 Year Similar pregnancy rates than azoospermic patients Repeated IVF/ICSI failure; IVF Donor IVF in ICSI faillure 35 3 25 IVF donor IVF ICSI failure % total Cases 2 15 1 5 32,9 35,1 33,6 51,1 48,8 59,5 86,7 52,2 26 25 24 23 Year 22 21 2 1999 Decreased proportion of IVF treatments; higher ICSI efficacy, improvement in the embriology laboratory conditions. 1
Repeated IVF/ICSI failure; IVF Donor IVF in ICSI failure 1 8 Pregnancies Pregnancy rate Cases/Rates 6 4 48,9 5,9 55,9 47,9 46,8 43,1 51,9 44,4 2 26 25 24 23 22 21 2 1999 Years Pregnancy rates comparable to azoospermic patients Repeated IVF/ICSI failure; indication for donor sperm change; DNA FRAGMENTATION The degree of DNA fragmentation was inversely correlated with fertilization rate, embryo ability to achieve blastocyst stage, and embryo morphological quality. There were no correlation between sperm DNA fragmentation and pregnancy outcome in IVF We have pregnancies with more than 8% of DNA fragmentation Repeated IVF/ICSI failure; indication for donor sperm change; DNA OXIDATION The determination of sperm DNA oxidation influencing embryo morphology has indicated the relevance of sperm contribution to embryo development. We observed a minor decrease of DNA oxidation in patients who did not achieve pregnancy, this could be due to embryo selection before transfer No association with pregnancy could be explained by the ability of the oocyte to fight against DNA oxidative damage or by the poor contribution of the sperm DNA to this issue. 11
Repeated IVF/ICSI failure; indication for donor sperm change; Antioxidant defence The determination of a sperm mrna (GPX), influencing early embryo morphology, has been pointed the relevance of paternal mrna contribution to the embryo development. The observation of poorer blastocyst quality related with sperm GPx1 activity subscribes the importance of this enzyme defining sperm quality, considered in consequence like a biochemical marker. Finally, no effect in reproductive outcome is observed Repeated IVF/ICSI failure; indication for donor sperm change; sperm morphology We found a significant association between fertilization rate and the sperm morphology (74.7 % (normal) vs. 66.4% (abnormal)). Pronuclear score and symmetry morphology. was not associated with sperm There was not a significant correlation between percentage and type of embryo fragmentation on day 2 and 3 and sperm morphology. Embryo cleavage was also not associated with sperm morphology. Asymmetry on day 2 and 3 was not correlated with the injected normal or abnormal sperm. A reduced percentage of embryos that reached the blastocyst stage in those becoming from abnormal forms (58,3 % vs. 51.6%). Implantation rate was clearly decreased in those embryos becoming from an abnormal microinjected sperm (26.6% vs. 22.3%). Albert C, De los Santos MJ, Meseguer M. IFFS Durban, 27 Sexually transmitted infections; HIV Sperm wash with nested PCR is the appropriate method to use in the assisted reproduction techniques that are offered to serodiscordant couples. The detection limits exhibited by one-round PCR do not offer a sufficient guarantee that transmission of all viral particles. 12
Sexually transmitted infections; HIV To date, sperm wash, nested PCR and ICSI is a safe and effective procedure that avoids HIV and HCV transmission with reasonable pregnancy rates, and is cost-effective. Sexually transmitted infections; HIV Semen analysis, according to the WHO criteria, of HIV- and HCV-affected patients showed no differences from that of non-infected males. Low CD4 blood levels, and a long evolution of the disease do not negatively affect sperm quality. Sexually transmitted infections; HIV In a small percentage of HIV patients, it is impossible to recover spermatozoa after said procedures because of their highly impaired spermatogenesis. We have established that less rigorous methods, such as repeated centrifugation, yield nested polymerase chain- reaction HIV- and hepatitis C virus negative specimens, even in sperm samples from men with severe oligoasthenozoospermia. 13
Sexually transmitted infections; HIV HIV-1 1 infection in serodiscordant couples with infected males does not appear to have a significantly negative impact on embryo development or ICSI outcome. Sexually transmitted infections; HIV AID in serodiscordant couples Few cycles performed before 2 in which we get authorization by our local government. Only a total of 17 cycles were performed with a pregnancy rate of 2 % per cycle Paternal Transmission of genetic defects; sperm donation TREATMENTS IN MALE GENETIC DISORDERS 25 PGD-PCR program 2 NUMBER 15 1 AID IVF 5 3 3 1 1 1 2 1999 2 21 22 23 24 25 26 YEAR 14
Paternal Transmission of genetic defects TREATMENTS IN MALE GENETIC DISORDERS 35, 33,33 3, 26, 25, 2, 15, 1, 5,, AID IVF Global pregnancy rates Paternal Transmission of genetic defects Chromosomal abnormalities; numerical and structural PGD Y Y linked diseases Microdeletions; specially on Yq11; AZF (azoospermia( factors). Around 15% of the men with azoospermia are carriers of AZF microdelections (specially on AZFc region) PCR Paternal Transmission of genetic defects Genetic diseases Monogenic HEMOPHIILIA A Control DNA ALPORT s SYNDROME X FRAGIL SYNDROME CISTIC FIBROSIS NEUROPHIBROMATOSIS Type I PGD-PCR BTM 1 BTM 2 Afected embryo Afected embryo HUNTINGTON DESEASE POLIQUISTOSIS Healthy embryo MIOTONIC DISTROPHY etc Sporadic Single Gene diseases without molecular study; Neurofibromatosis I Osteogenesis imperfecta Marfan Syndrome Tuberous Sclerosis Oligogenic or Polygenic; Sperm Donation Cardiomiopathy Diabetes Retinosis pigmented 15
Indications; actual distribution 1999-26 Global ICSI failure 28% HIV 1% Genetic 3% Without couple 26% ICSI failure 37% HIV 1% Genetic 2% Without couple 26% Azoospermia 42% IUI Genetic 1% Without couple 26% Azoospermia 34% ICSI failure 5% IVF Azoospermia 23% Indications; distribution 26 Global 26 ICSI failure 37% HIV 1% Genetic 2% Without couple 26% ICSI failure 25% Without couple 35% Azoospermia 34% Azoospermia 4% Thank you! 16