ICSI

Do We Treat Male Infertility in the Era of ICSI ?

Dr. Anand K. Shinde M. D. (Gyn )

IVF Consultant

& Director of Andrology At“IVF Pune”, 7th floor Deenanath Mangeshkar Hospital Pune-4

Tel : 40151777

Do We Treat Male Infertility in the Era of ICSI ?

The Main Points of this presentation would be--

What is “Era of ICSI”

What is “ Treating the male factor ” ?

Is there any controversy ?

Male Factor Infertility

Barring coital difficulties or severe hypospadias or ejaculatory

dysfunctions, the “Male factor” in Infertility means poor

numbers or poor quality of Sperms. The Topic of Male factor Infertility is vast. We can give only a

glimpse of it here. Quality & number of Sperms produced by the testes is

determined mainly by the interaction of 3 factors-

1. Genetic make up of the Spermatogonia

2. Normal Sertoli and Leydig Cell function

3. The interaction of Sertoli, Leydig & Germ cells

with endogenous factors and the environment.

Male Factor Treatment

For “Male Factor” Treatment there can be two

strategies to optimize or “nurture” sperm production

and quality

1. Preproduction nurturing before ejaculation

2. Post production nurturing for preserving and

optimizing sperm quality and function after

ejaculation.

Male Factor Treatment Means

1 Interventions for better production (numbers/qualities) of Sperm in fertile/ infertile male

2 Interventions called Assisted reproductive techniques used to bypassdefects in Sperm function.

Treating the Male Factor

ICSI is one such 'Post Production' nurturingtechnique, which is effective in certain male factor.

First ICSI pregnancy was reported by Palermo ( Lancet 1992)

So what does this ICSI era mean ?

Era of ICSI ICSI – Impressive, Complete Solution to Infertility?

'For decades, various therapies have been proposed to improve semen parameters in cases of male factor infertility.

Administration of antiestrogens & androgen have been found to be ineffective. No peer review data are available to demonstrate the benefit of the use of IUI or correction of varicocoele.

The conventional treatement for the male factor infertility has little value and has been revised & abandoned.

ICSI has to be considered as the method of choice and should replace ineffective conventional therapies (Devroey P, 1998)

Era of ICSI “There no longer seems to be any category of male factor infertility

that cannot be treated with ICSI. Even for azoospermia caused by either obstruction or by germinal failure, ICSI may be performed successfully. Of all the factors studied, the only factor that seems to matter is the age of wife and her ovarian reserve”.(Silber 1998)

Age of wife

Under 20 --- 40% Live Deliveries / Cycle

Under 35 --- 34%

Under 40 --- 13%

Above 40 --- 04% Live Deliveries / Cycle

ICSI is actually the assisted fertilization technique with highest incidence of pregnancies & “take home baby rate” ( Garcea 1998)

If ICSI is the ultimate “Cure All” or “Panacea" then will there be “Disuse Atrophy” of the branch called Andrology?

For the answer let us look at the 'text book' list of ICSI indications.

Immotile Cilia Syndrome Testicular/ Epididymal sperm retrieval(Azoospermia

cases) Globozoospermia Frozen- thawed sperm with poor survival Poor fertilization with previous IVF attempt Severe O.A.T., Necrospermia.

Era of ICSINow let us examine the first indication for ICSI

viz.” Immolite Cilia Syndrome”.What are the 'Andrology' inputs here?

Do We just do ICSI & forget about the man and related health issues?

No !Look at these brain teasers.

How do we know which sperm is alive, when all Sperms are non motile? Answer : HOST

Is sperm from ejaculate better or TESA is better for fertilization?

Are you sure that it is a case of Kartagener's Sydrome while talking to the couple? Answer : Difficult without Electron Microscopy.

Are you sure it is not an E.coli seminal infection & not Kartagener's? Answer: You should have ruled it out first.

Kartagener's is considerd autosomal recessive but can it be autosomal dominant or X-linked? (Ans: May be)

Are there inherited enzyme defects in Sperm Glycolysis Metabolism, in case of 100% Immobility ? ( Glyceraldehyde-3-phospate Dehydrogenase GAPDS) ( Ans: May be)

Have you ruled out chronic sinusitis, situs inversus & autosomal dominant Polycystic Kidney Disease? ( Ans: No, sorry I forgot.)

If you have not given regard to any of above what is

doing “just ICSI” ?. It amounts to negligence! A Friend of mine said “Anand about 25% of my patients

of hysterectomy for menorrhagia have constipation, weight gain lethergy”. He had not done TSH in any of the menorrhagia cases!

Look at these brain teasers.

Regarding these issues the comment by Hector Chemes & Craig Niederberger (J of Androl 2005 vol 26 ) is an eye opener-

‘Should infertologists go ahead with assisted reproduction (particularly ICSI) without a proper diagnosis of patient's pathology? Is the role of the andrologist just to provide a technological solution' for the couple? To physicians treating infertility, ICSI provides a tool by which dsyfunctional, even dead sperms may be used to fertilize the ovum. Providers of this powerful technology may ask the question, why does one need a complete diagnosis if the therapy is highly effective regardless of of the aetiology, especially if the diagnosis involves sophisticated tools & test? The answer is :- ..... these forms of treatment involve reproduction & involve germ line transmission to the offspring. What use is counsellings if one does not know which disease you are dealing with?!

( Craig Niederberger 2005)

SIGA -Andromeda

Welcome to S I G A

ICSI

Too few Sperms? Use ICSI. Too few motile Sperms? Use ICSI … Only non motile Sperms? Use ICSI …. Only dead Sperms ? Use ICSI ….. No Sperms ? Try Spermatids …..

No spermatids ? Try Stem cells or invitro maturation.

Remember we are using ICSI to bypass Sperm dysfunction. What about the causes of dysfunction? Obviously we are neglecting other issues pertaining to the man.

Issues which should not be neglected Issues of General Health of

the man – A- Sepsis, M .A.G.I incidence-

15 to 40 % of infertile male. Has implications as chronic

reservoir of infection/ U.T.I. Transmission to wife Obstructive Azoospermia,

Necrospermia. Affects Sperm quality ,

aptoptosis & DNA damage. Remember ‘Swim Up’ method

does not select non- apoptotic sperms!

Issues which should not be neglected B) Hypogonadism & Andropause Hypogonatrophic Hypogonadism ( 1-2% of Male in fertility) Low FSH / LH Low Testosterone (less than 300 ng / dL) Severe Oligo /Azoospermia

Whitten et al (Fertil Steril 2006)

reported response to Clomiphene in a select group. Adult onset idiopathic form may benefit.

C.C increases LH levels and intra-testicular testosterone.

Hussein (J Androl 2005) reported 63% rate of

sperms in ejaculate in Nonobstructive Azoospermia cases, accompanied by change in pattern on biopsy

Hypoandrogenism in infertile men

Hypoandrogenism – S. Testo < 300 ng / dL

Non obstructive Azoo 45 % Oligospermia 43% Normal Semen Analysis 35 % Obstructive Azoo 17% General Population 17%

( University of Illinois , Chicago- Aleksander Chudnovsky and Craig Niederberger)

Oral Testosterone in oil : Pharmacokinetic

Effects of 5 Alpha Reduction by Finasteride

JOHN K. AMORY

(J of Androl. Vol. 22, 2006)

The issue of prostate stimulation was addressed.

Natural Selection Versus Selection by man

Nature selects one sperm for fertilizing depending on normality of the sperm.

OR Man selects one sperm for

ICISI. Human sperm bound to the

zona pellucida have normal nuclear chromatin as assessed by acridine orange fluorescence – D.Y. Liu ( Human Reproduction Vol.22, 2007) - Sperm binding to human ZP is highly selective for double stranded DNA.

Issues which should not be neglected

A) Genetics & Male Factor1. Why does Varicocoele surgery fail

in some and succeed in some?

2. Which Oligo –asthenospermias will respond to Antioxidants?

3. Why do we have fertilization failure, Arrested Embryos & 30 to 35% only pregnancy rate even with good ICSI?

4. The answer could be in the ‘head’ i.e. nucleus of the Sperm !

Normal Spermatogenesisdepends on mitosis and meiosis in

orderly fashion …..

Histopathology – Biopsy – FNAC – TESE – TESA are all interlinked with genetics

and environment …..

Open biopsyOpen biopsy

Needle biopsy

Histopathology – Biopsy – FNAC – TESE – TESA are all interlinked with genetics and

environment

Sertoli cells with sperms

Sertoli cell only syndrome

Histopath reporting should be as follows

Testicular Biopsy ( Spermatogenesis Reporting)

1. Normal Testicular Biopsy : Full Spermatogenesis in entire Biopsy and normal inter tubular tissues.

2. Hypospermatogenesis : All stages of spermatogenesis are present , but reduced to varying degrees.

3. Germ cell arrest : Total arrest at particular stage most often spermatogonial or primary spermatocyte stage. Arrest in Spermiogenesis is uncommon . If spermatids are seen don’t call it arrest but call it hypospermatogenesis.

Histopath reporting should be as follows

4. Sertoli cell only – No tubules contain any germ cells.

5. Seminiferous tubule Hyalinization – No germ cells. No Sertoli cell. Fibrosis present.

6. Carcinoma in Situ – Pre invasive malignant cells seen in place of Spermatogonia. Some tubules show ongoing Spermatogenesis.

7. Immature testis ( Prepubertal)- Rare , seen in hypogoado trophic Hypogonadism. Tubules lack lumen, cells are immature Sertoli cells- Gonocytes. Few Leydig cells.

Y chromosome :- Long Arm Microdeletions

Multiplex PCR is used to diagnose

micro delections on the long arm of Y chromosomes.

These deletions are an important cause of male infertility. It

should be performed in all

Azoospermic and Oligoseprmic men.

Does ICSI cause any chromosomal defects ?

• ICSI as a procedure does not cause any chromosal defects. But ICSI using defective Sperms form infertile male may transmit Sex Chromosome abnormalities, Autosomal abnormalities including translocations (13, 14),inversions and numerical abnormalities. This is solved naturally by nature in form of failure of implantation……

Embryos ICSI-Ejaculate

ICSI-TESE

Normal 43% 25%

Aneuploid 26% 16%

Mosaics 26% 56%

Polyploidy 04% 06%

Haploid 03% 02%

Varicocoele and Genetics

Monozygous and Dizygous twins show different pattern of scrotal temperature.

Infertile men with varicocoele show high % of sperms with Intense Nuclear Damage – Maria Enciso – J of Androl. Vol. 27, 2006.

Studies on Varicocoele III : Ultrastuctural Sperm Evaluation and 18, X & Y Aneuploidies, Baccio M Baccetti, J of Androl. Vol. 27, 2006.

DNA Damage in Sperms from Men with Varicocele

(SCD Test- Sperm chromatin dispersion)

Sequential FISH on SCD Processed Spermatozoa

X= Green , Y = Red, 18 = Blue, Halo is Blue Grey (SCD)

Issues which should not be neglected

Candidates for ICSI also happen to be candidates for testicular Tumours…. High prevalence of testicular cancer in azoopermic men

without spermatogenesis- M Mancini. Human

Reproduction Vol. 22, 2007.

The prevalence of testicular nodules and cancer in

azoospermic men with complete SCOS is very high. In

these subjects, the role of clinical evaluation, ultrasound

and biopsy should be emphasized.

Towards a non invasive method for early detection of testicular neoplasia in semen

analysis by identification of fetal germ cell – specific markers

C.E. Hoei – Hansen Human Reprod vol 22, 2007

Immunocytological semen analysis based on

expression of fetal gem cell markers in exfoliated

cells has auxiliary diagnostic value , as it detects

some patients with CIS / incipient tumour but a

negative result does not exclude Testicular germ

cell tumours.

Positive Negative

Positive Semen PositiveCIS Tubule

Immunocytological semen analysis for CIS

Sonographic Testicular Micro Lithiasis as an indicator of pre-malignant conditions in

normal & infertile men

Sigrid V Eckardstein ( J of Androl Vol 22, 2001)

Testicular Microlithiasis (USG) can indicate germ cell tumours.

Infertility , Testicular Mal-descent, presence of atrophic testis are risk factors.

2.3% showed Microlithiasis & were advised Biopsy &/or USG follow up.

Microlithiasis in presence of atrophic testes is highly significant.

Breakthroughs in Andrology ?

1. Reduced Seminal Parameters associated with environmental DDT Exposure and p,p’- DDE Concentrations in Men in Chiapas, Mexico – A Cross Sectional study.

Christiaan De Jager, J of Androl. Vol-27, 2006.

2. Report from Andhra Pradesh - quarry town (Kadappa) has 5% Azoospermia rate in young married men !

(Stone Quarry Pollutants + Cotton Pesticides ) – Embryo Talk 2006.

New frontiers..........

Promise & Limitations of Germ cell transplantation in the Testis

M.D. Grisworld ( J. Anrolg. Vol 22, 2001)

In vitro culture systems hold promise of culturing germ cells- to mature spermatozoa ( Sousa, 2002)

Conclusion !

• If there is azoospermia or severe oligospermia…

• If sperms cannot undergo Capacitation, bind to zona, undergo acrosome reaction or fuse with the Oocyte’s plasma membrane … ICSI would help.

• But , why these sperm defects arose & what can be done to ‘Nurturing’ the sperm, remains the Andrology domain …..!

Do We Treat Male Infertility in the Era of ICSI ?

We Do Treat Male Infertility in the Era of ICSI !

Thank You ......

Dr. Anand K. Shinde

M. D. (Gyn )

IVF Consultant

& Director of Andrology

At “ IVF Pune”, 7th floor Deenanath Mangeshkar Hospital Pune-4.,

Tel : 40151777

Dr. Anand K. ShindeM.D

• Consultant at IVF Pune, DMH Pune - 4 • Director Andrology IVF Pune, DMH Pune - 4