Regular (ICSI) versus ultra-high magnification (IMSI) sperm selection for assisted reproduction

Regular (ICSI) versus ultra-high magnification (IMSI) sperm

selection for assisted reproduction (Review)

Teixeira DM, Barbosa MAP, Ferriani RA, Navarro PA, Raine-Fenning N, Nastri CO, Martins

WP

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library2013, Issue 7

http://www.thecochranelibrary.com

Regular (ICSI) versus ultra-high magnification (IMSI) sperm selection for assisted reproduction (Review)

Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

http://www.thecochranelibrary.com

T A B L E O F C O N T E N T S

1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . . . . . . . . . . . . . . . . . . .

5BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Figure 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Figure 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Figure 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Figure 6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

14DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

17CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

32DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Analysis 1.1. Comparison 1 Ultra high (IMSI) versus regular magnification (ICSI), Outcome 1 Live birth per allocated

couple. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Analysis 1.2. Comparison 1 Ultra high (IMSI) versus regular magnification (ICSI), Outcome 2 Clinical pregnancy per

allocated couple. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Analysis 1.3. Comparison 1 Ultra high (IMSI) versus regular magnification (ICSI), Outcome 3 Miscarriage per clinical

pregnancy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Analysis 2.1. Comparison 2 IMSI versus ICSI: subgroup analysis by sperm quality, Outcome 1 Clinical pregnancy. . 35

35APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

39CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

39DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . .

iRegular (ICSI) versus ultra-high magnification (IMSI) sperm selection for assisted reproduction (Review)


[Intervention Review]

Regular (ICSI) versus ultra-high magnification (IMSI) spermselection for assisted reproduction

Danielle M Teixeira1, Mariana AP Barbosa1 , Rui A Ferriani1, Paula A Navarro1, Nick Raine-Fenning2 , Carolina O Nastri1, Wellington

P Martins1

1Department of Obstetrics and Gynecology, Medical School of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, Brazil. 2Division

of Obstetrics and Gynaecology, School of Clinical Sciences, University of Nottingham, Nottingham, UK

Contact address: Wellington P Martins, Department of Obstetrics and Gynecology, Medical School of Ribeirao Preto, University of

Sao Paulo, Hospital das Clínicas da FMRP-USP, 8 andar, Campus Universitário, Campus Universitario da USP, Ribeirao Preto, Sao

Paulo, 14048-900, Brazil. [email protected].

Editorial group: Cochrane Menstrual Disorders and Subfertility Group.

Publication status and date: New, published in Issue 7, 2013.

Review content assessed as up-to-date: 8 May 2013.

Citation: Teixeira DM, Barbosa MAP, Ferriani RA, Navarro PA, Raine-Fenning N, Nastri CO, Martins WP. Regular (ICSI) versus

ultra-high magnification (IMSI) sperm selection for assisted reproduction. Cochrane Database of Systematic Reviews 2013, Issue 7. Art.

No.: CD010167. DOI: 10.1002/14651858.CD010167.pub2.


A B S T R A C T

Background

Subfertility is a condition found in up to 15% of couples of reproductive age. Gamete micromanipulation, such as intracytoplasmic

sperm injection (ICSI), is very useful for treating couples with compromised sperm parameters. Recently a new method of sperm

selection named ’motile sperm organelle morphology examination’ (MSOME) has been described and the spermatozoa selected under

high magnification (over 6000x) used for ICSI. This new technique, named intracytoplasmic morphologically selected sperm injection

(IMSI), has a theoretical potential to improve reproductive outcomes among couples undergoing assisted reproduction techniques

(ART).

Objectives

To compare the effectiveness and safety of IMSI and ICSI in couples undergoing ART.

Search methods

We searched for randomised controlled trials (RCT) in electronic databases (Cochrane Menstrual Disorders and Subfertility Group

Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL,

LILACS), trials registers (ClinicalTrials.gov, Current Controlled Trials, World Health Organization International Clinical Trials Registry

Platform), conference abstracts (ISI Web of knowledge), and grey literature (OpenGrey); in addition, we handsearched the reference

lists of included studies and similar reviews. We performed the last electronic search on 8 May 2013.

Selection criteria

We considered only truly randomised controlled trials comparing ICSI and IMSI to be eligible; we did not include quasi or pseudo-

randomised trials. We included studies that permitted the inclusion of the same participant more than once (cross-over or ’per cycle’

trials) only if data regarding the first treatment of each participant were available.

1Regular (ICSI) versus ultra-high magnification (IMSI) sperm selection for assisted reproduction (Review)


mailto:[email protected]

Data collection and analysis

Two review authors independently performed study selection, data extraction, and assessment of the risk of bias and we solved

disagreements by consulting a third review author. We corresponded with study investigators in order to resolve any queries, as required.

Main results

The search retrieved 294 records; from those, nine parallel design studies were included, comprising 2014 couples (IMSI = 1002; ICSI

= 1012). Live birth was evaluated by only one trial and there was no significant evidence of a difference between IMSI and ICSI (risk

ratio (RR) 1.14, 95% confidence interval (CI) 0.79 to 1.64, 1 RCT, 168 women, I2 = not applicable, low-quality evidence). IMSI was

associated with a significant improvement in clinical pregnancy rate (RR 1.29, 95% CI 1.07 to 1.56, 9 RCTs, 2014 women, I2 = 57%,

very-low-quality evidence). We downgraded the quality of this evidence because of imprecision, inconsistency, and strong indication

of publication bias. We found no significant difference in miscarriage rate between IMSI and ICSI (RR 0.82, 95% CI 0.59 to 1.14, 6

RCTs, 552 clinical pregnancies, I2 = 17%, very-low-quality evidence). None of the included studies reported congenital abnormalities.

Authors’ conclusions

Results from RCTs do not support the clinical use of IMSI. There is no evidence of effect on live birth or miscarriage and the evidence

that IMSI improves clinical pregnancy is of very low quality. There is no indication that IMSI increases congenital abnormalities.

Further trials are necessary to improve the evidence quality before recommending IMSI in clinical practice.

P L A I N L A N G U A G E S U M M A R Y

Regular (ICSI) versus ultra-high magnification (IMSI) sperm selection for assisted reproduction

Background: sperm micromanipulation, such as intracytoplasmic sperm injection (ICSI), is very useful for treating couples in which

the male partner has a reduced sperm concentration or motility, or both. Recently, a new method of sperm selection named ’motile

sperm organelle morphology examination’ (MSOME) has been described, which analyses sperm under ultra-high powered (6000x)

magnification. Initial studies have shown that intracytoplasmic morphologically selected sperm injection (IMSI), using spermatozoa

selected under high magnification, is associated with higher pregnancy rates in couples with repeated implantation failures.

Search date: we searched the medical literature in May 2013 for studies that evaluated the effectiveness and safety of using ultra-high

magnification (over 6000x) for sperm selection prior to ICSI, compared with the use of a conventional ICSI procedure, with a 200-

400x magnification.

Study characteristics: we found nine randomised controlled trials, evaluating 2014 couples, that had compared regular ICSI with IMSI

for assisted reproduction. These studies were funded by fertility centres and universities.

Key results and quality of the evidence: for live birth, there was low-quality evidence compatible with either benefit or harm: for women

with a 38% chance of achieving live birth using regular ICSI, the chance of achieving live birth using ultra-high magnification (IMSI)

would be between 30% and 63%. For clinical pregnancy, there was very-low-quality evidence compatible with benefit: for women

with a 33% chance of achieving pregnancy using regular ICSI, the chance of achieving pregnancy using IMSI would be between 36%

and 52%; the quality of this evidence was downgraded because of imprecision, inconsistency of the observed effect across studies,

and high risk of publication bias. For miscarriage, there was very-low-quality evidence compatible with either benefit or harm: for

pregnant women with an 22% risk of miscarriage using regular ICSI, the risk using IMSI would be between 13% and 25%. There was

no evidence concerning congenital abnormalities. We concluded that the current evidence does not support using IMSI: there is no

evidence of benefit for live birth and miscarriage, we are very uncertain of the beneficial effect of IMSI in clinical pregnancy, and there

is no evidence of the effect of this intervention on congenital abnormalities. More studies to improve the evidence quality are necessary

before recommending IMSI in clinical practice.



S U M M A R Y O F F I N D I N G S F O R T H E M A I N C O M P A R I S O N [Explanation]

Regular (ICSI) compared with ultra-high magnification (IMSI) for assisted reproduction

Patient or population: couples undergoing assisted reproduction techniques

Intervention: sperm selection under ultra-high magnification (IMSI)

Comparison: sperm selection under regular magnification (ICSI)

Outcomes Illustrative comparative risks* (95% CI) Relative effect

(95% CI)

No of Participants

(studies)

Quality of the evidence

(GRADE)

Assumed risk Corresponding risk

ICSI IMSI NNTB

Live birth per allocated

couple

38 per 100 44 per 100

(30 to 63)

- RR 1.14 (0.79 to 1.64) 168

(1 study)

⊕⊕©©

low1

Clinical pregnancy per

allocated couple

33 per 100 43 per 100

(36 to 52)

10

(5 to 33)

RR 1.29 (1.06 to 1.55) 2014

(9 studies)

⊕©©©

very low2

Miscarriage per clinical

pregnancy

22 per 100 18 per 100

(13 to 25)

- RR 0.82 (0.59 to 1.14) 552

(6 studies)

⊕©©©

very low3

Congenital abnormali-

ties per clinical preg-

nancy

No evidence.

The median control group risk across studies was used as the basis for the assumed risk. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the

comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; ICSI: intracytoplasmic sperm injection; IMSI: intracytoplasmic morphologically selected sperm injection; NNTB: number needed to treat for an additional beneficial

outcome; RR: risk ratio.

GRADE Working Group grades of evidence

High quality: Further research is very unlikely to change our confidence in the estimate of effect.

Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.

Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

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1. The quality of the evidence was downgraded two levels due to very serious imprecision.

2. The quality of the evidence was downgraded one level due to the high risk of bias in the included studies; another level due to

inconsistency across studies; and one further level because publication bias was strongly suspected.

3. The quality of the evidence was downgraded two levels due to very serious imprecision; and another level due to the high risk of bias

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B A C K G R O U N D

Description of the condition

Subfertility is a condition found in up to 15% of couples of re-

productive age and until the late 1970s, there were few options

for treating these couples. Since the first successful in vitro fer-

tilisation (IVF) was described, the efficacy of subfertility treat-

ment has greatly improved. However, it was soon realised that the

technique had great limitations in achieving pregnancy in couples

with compromised semen parameters. During the 1980s, some

other assisted reproductive technology techniques (ART) were de-

veloped focusing on gamete micromanipulation. However, for all

these techniques, spermatozoa had to be progressively motile and

needed to have the potential for an acrosome reaction, leaving in-

fertility due to severe male factors inadequately treated. Then, in

1992, the first successful intracytoplasmic sperm injection (ICSI)

was reported (Palermo 1992). For ICSI, after sperm preparation

an optical magnification of 200x to 400x is used to examine the

sample. The best ’normal looking’ motile spermatozoa are selected

based on their major morphology and then injected into oocytes

retrieved after ovarian stimulation. With ICSI, even men with se-

vere male factor infertility could possibly achieve pregnancy. How-

ever, despite 20 years of technological improvements, both clini-

cal pregnancy and live birth rates remain relatively low at approx-

imately 35% and 25% per started cycle, respectively (Jungheim

2010).

Description of the intervention

In the early 2000s, a new method of sperm selection named ’motile

sperm organelle morphology examination’ (MSOME) was de-

scribed (Bartoov 2002). This technique requires the analysis of

minor morphological criteria using ultra-high magnification (≥

6000x) microscopy. The ART using MSOME to select the sperm

was named intracytoplasmic morphologically selected sperm in-

jection (IMSI) (Bartoov 2003). When using this technique, the

motile sperm fraction is examined based on six subcellular or-

ganelles: acrosome, postacrosomal lamina, neck, mitochondria,

tail, and nucleus.

How the intervention might work

By using MSOME, some organelle malformations that are not

detectable using magnifications of 200x to 400x can be detected.

Sperm selection based on these small details is thought to improve

reproductive outcomes (Berkovitz 2006).

Why it is important to do this review

Initial reports have shown that IMSI is associated with higher

pregnancy rates in couples with repeated implantation failures (

Bartoov 2002; Bartoov 2003). However, both the effectiveness

and safety of IMSI in clinical practice remain unclear. Since there

are no large published studies, a systematic review of the best

available evidence is needed to facilitate a more robust conclusion.

Although a systematic review and meta-analysis on this issue has

been published (Setti 2010), the authors of that review evaluated a

single database (MEDLINE) and supplemented the evidence from

a single randomised controlled trial (RCT) with non-randomised

studies to improve precision, which is poorly justifiable, as this

decision increases the risk of obtaining a biased estimate (Higgins

2011). The present review aims to perform a wider and updated

search, considering only the evidence from RCTs .

O B J E C T I V E S

To compare the effectiveness and safety of IMSI and ICSI in cou-

ples undergoing ART.

M E T H O D S

Criteria for considering studies for this review

Types of studies

We considered only RCTs for inclusion; we excluded quasi- or

pseudo-randomised trials. We included studies that allowed the

inclusion of the same participant more than once (cross-over or

’per cycle’ trials) only if we could obtain the data regarding the

first inclusion of each participant.

Types of participants

Couples undergoing ART.

Types of interventions

Intracytoplasmic injection of sperm selected under high magnifi-

cation (≥ 6000x = IMSI) compared to intracytoplasmic injection

of sperm selected under regular magnification (200x to 400x =

ICSI).

Types of outcome measures

Primary outcomes

Effectiveness: live birth per allocated couple.



Secondary outcomes

Effectiveness: clinical pregnancy per allocated couple.

Adverse events: miscarriage per clinical pregnancy; congenital ab-

normalities per live birth.

Although fertilisation and implantation rates were important out-

comes for this review, we did not include them in the quantita-

tive meta-analysis due to use of differing denominators (injected

oocytes for fertilisation rate and transferred embryos for implan-

tation rate). However, we included implantation and fertilisation

rates in the review for completeness, and describe them in the

Characteristics of included studies table.

Search methods for identification of studies

We developed the search strategy in consultation with the Men-

strual Disorders and Subfertility Group (MDSG) Trials Search

Co-ordinator. We did not limit searches by language or publica-

tion status.

Electronic searches

We performed the electronic searches on 31 August 2012 and

updated them on 8 May 2013.

We searched for RCTs in the following electronic databases:

• MDSG Specialised Register (Appendix 1; inception to 8

May 2013);

• Cochrane Central Register of Controlled Trials

(CENTRAL) (Appendix 2; 2013, Issue 2);

• MEDLINE (Appendix 3; 1946 to 8 May 2013), this search

was combined with the Cochrane highly sensitive search strategy

for identifying randomised trials (Higgins 2011);

• EMBASE (Appendix 4; 1980 to 8 May 2013), this search

was combined with trial filters developed by the Scottish

Intercollegiate Guidelines Network (SIGN) (www.sign.ac.uk);

• CINAHL (www.ebscohost.com/cinahl/) (Appendix 5;

inception to 7 May 2013);

• LILACS (regional.bvsalud.org) (Appendix 6; inception to 7

May 2013);

• PsycINFO (Appendix 7; inception to 8 May 2013).

We searched for study protocols and ongoing trials in the following

trials registers (Appendix 8):

• ClinicalTrials.gov (clinicaltrials.gov);

• Current Controlled Trials (www.controlled-trials.com);

• World Health Organization (WHO) International Clinical

Trials Registry Platform search portal (apps.who.int/trialsearch/

Default.aspx).

We searched for conference abstracts in the Web of Knowledge

(http://wokinfo.com; Appendix 9).

We searched for grey literature in Open Grey (www.opengrey.eu/)

(Appendix 10).

We searched for similar reviews in the Database of Abstracts of

Reviews of Effects (DARE) (Appendix 11).

Searching other resources

We handsearched the reference lists of included articles and related

reviews.

Data collection and analysis

We conducted data collection and analyses in accordance with the

Cochrane Handbook for Systematic Reviews of Interventions (Higgins

2011).

Selection of studies

Two review authors (DMT and MAPB) independently reviewed

titles and abstracts, and checked for duplicates using the pre-es-

tablished criteria for inclusion. We resolved disagreements by con-

sulting a third review author (WPM). We retrieved the full-text

manuscripts of trials considered potentially eligible for inclusion

and two review authors (DMT and MAPB) independently evalu-

ated eligibility of these trials. We resolved disagreements by con-

sulting a third review author (WPM). We corresponded with study

investigators as required to clarify study eligibility. We placed no

limitations regarding language, publication date or publication

status.

Data extraction and management

We extracted data from eligible studies using a data extraction form

designed and pilot-tested by the review authors. Where studies

had multiple publications, we used the main trial report as the

reference and obtained additional details from secondary papers.

We contacted study authors in order to resolve any data queries, as

required. Two review authors (DMT and WPM) independently

extracted the data and any disagreements between these review

authors were resolved by consulting a third review author (CON).

Assessment of risk of bias in included studies

Two review authors (DMT and WPM) independently assessed

the risk of selection bias (random sequence generation and allo-

cation concealment); performance bias (blinding of participants

and personnel); detection bias (blinding of outcome assessors); at-

trition bias (incomplete outcome data); reporting bias (selective

outcome reporting); and other potential sources of bias (e.g. a dif-

ference in the number of embryos transferred, age of participants,

co-interventions). We resolved any disagreements by consulting a

third review author (CON). To judge the risk of bias, we used The

Cochrane Collaboration’s criteria for judging risk of bias (Higgins

2011): we classified the trials as being at ’low’, ’high’, or ’unclear’

risk of bias.



http://www.sign.ac.uk/methodology/filters.html

http://www.ebscohost.com/cinahl/

http://www.ebscohost.com/cinahl/

http://regional.bvsalud.org/php/index.php?lang=en

http://clinicaltrials.gov/ct2/search

http://www.controlled-trials.com

http://www.controlled-trials.com

http://apps.who.int/trialsearch/Default.aspx



http://www.opengrey.eu/

Measures of treatment effect

For dichotomous data (e.g. live birth rates), we used the numbers

of events in the control and intervention groups of each study to

calculate the Mantel-Haenszel risk ratio (RR). We prefer to use

RR because odds ratio (OR) is harder to understand and apply

in practice. Misinterpretation of the OR as if it equated to the

RR will tend to overestimate the intervention effect, especially

when events are common, and there is concern that this occurs

quite frequently in published reports of individual studies and

systematic reviews (Higgins 2011). However, if we had observed a

zero cell count or prevalence less than 1%, the Peto fixed-effect OR

would have been used because this method is found to be the least

biased and most powerful, providing the best confidence interval

(CI) coverage in these situations (Higgins 2011); in additional

the OR value in such situations is very similar to RR, avoiding

misinterpretations. We calculated the 95% CI to determine the

precision of the estimates. We considered the clinical relevance of

any statistically significant findings; in these situations, we also

determined the number needed to treat for an additional beneficial

outcome (NNTB) or an additional harmful outcome (NNTH).

Unit of analysis issues

The primary analysis was per couple randomised. Exceptions were

miscarriage, where we considered the number of clinical pregnan-

cies in each group as the denominator, because miscarriage is a

harm that can only occur in pregnant women; and congenital ab-

normalities, which would be analysed per live birth (but this out-

come was not reported by any study). We did not find any studies

that permitted the participant to be included more than once, as

cross-over or ’per cycle’ trials. We counted the delivery of a mul-

tiple pregnancy (e.g. twins or triplets) as one live birth event.

Dealing with missing data

We analysed the results on an intention-to-treat (ITT) basis, as far

as possible, and we contacted most of the original investigators to

obtain missing data. We planned that where these data were unob-

tainable, clinical pregnancy (and subsequent live birth or miscar-

riage) would be assumed not to have occurred in participants with

unreported outcomes. This was not necessary, because all studies

reported the occurrence of clinical pregnancy after embryo trans-

fer for all participants.

Assessment of heterogeneity

We assessed heterogeneity using the I2 statistic and addressed sub-

stantial heterogeneity (I2 > 50%) by: checking again that the data

were correct; performing the planned subgroup analysis; excluding

studies with high risk of bias; and, if it could not be explained, we

incorporated the heterogeneity by using a random-effects model.

Assessment of reporting biases

In view of the difficulty of detecting and correcting for publica-

tion bias and other reporting biases, we aimed to minimise their

potential impact by ensuring a comprehensive search for eligible

studies and by being alert for duplication of data. Even though

only nine studies were included, a funnel plot was used to explore

the possibility of small studies effect (a tendency for estimates of

the intervention effect to be more beneficial in smaller studies) for

clinical pregnancy.

Data synthesis

We combined the data from primary studies to compare IMSI

versus ICSI. An increased risk of a particular outcome associated

with IMSI, which may be beneficial (e.g. live birth) or detrimental

(e.g. miscarriage), was displayed graphically in the meta-analysis

to the right of the centre line and a decreased risk to the left of the

centre line.

Subgroup analysis and investigation of heterogeneity

We planned to perform the following subgroup analyses if sub-

stantial heterogeneity (I2 > 50%) was observed.

• Sperm quality: studies including only couples where the

male partner had poor sperm quality, or partners with good or

unselected sperm quality.

• Sperm source: ejaculate or surgical.

• Previous unsuccessful embryo transfers: studies including

only women with repeated previous unsuccessful embryo

transfers, or any women.

However, we could only perform the first subgroup analysis as no

studies evaluated only sperm obtained from surgical procedures or

only women with repeated previous unsuccessful embryo transfers.

Sensitivity analysis

We performed sensitivity analyses to verify whether the conclu-

sions about live birth and clinical pregnancy would differ if eligi-

bility was restricted to studies without high risk of bias.

Overall quality of the body of evidence: ’Summary of

findings’ table

We generated a ’Summary of findings’ table using GRADEpro

software. This table evaluated the overall quality of the body of evi-

dence for the main review outcomes, using the following GRADE

criteria: study limitations (i.e. risk of bias), consistency of effect,

imprecision, indirectness, and publication bias. Judgements about

evidence quality (high, moderate, low, or very low) were justified,

documented and incorporated into the reporting of results for

each outcome.



R E S U L T S

Description of studies

See: Characteristics of included studies; Characteristics of excluded

studies.

Results of the search

The search retrieved 270 records after removing duplicates. We

considered 28 to be potentially eligible and examined them for

eligibility. Nine trials (from 12 records) met our inclusion criteria,

and we excluded 11 studies (from 12 records). Three studies are

awaiting classification. The study flow diagram is shown in Figure

1.



Figure 1. Study flow diagram.



Included studies

Study design and setting

We included nine RCTs in the review. All were single-centre studies

conducted in academic centres from Italy (Antinori 2008), Turkey

(Balaban 2011), Brazil (Figueira 2011; Setti 2011; Setti 2012a;

Setti 2012b), Slovenia (Knez 2011; Knez 2012), and Tunisia (

Mahmoud 2011).

Participants

The studies included 1002 women in the intervention groups

(IMSI) and 1012 women in the control groups (ICSI). Five studies

included only couples in which the male partner had poor sperm

quality (Antinori 2008; Knez 2011; Knez 2012; Mahmoud 2011;

Setti 2011); three included women with advanced maternal age

(Figueira 2011; Setti 2012a; Setti 2012b); and one study included

couples who underwent ART without specifying further details

(Balaban 2011). One of the nine trials excluded couples with fe-

male factor infertility (Antinori 2008), and three excluded women

with polycystic ovaries syndrome (PCOS) or endometriosis (Knez

2011; Knez 2012; Setti 2012b).

Interventions

All studies compared regular (ICSI) versus ultra-high magnifica-

tion (IMSI).

Outcomes

• One study reported live birth.

• Nine studies reported clinical pregnancy.

• Six studies reported miscarriage.

• No studies reported congenital abnormalities.

Excluded studies

We excluded 11 studies from the review, for the following reasons:

• eight were not RCTs (observational studies);

• three randomly allocated the oocytes, not the couples.

Risk of bias in included studies

See table Characteristics of included studies; Figure 2; and Figure

3 for detailed information.

Figure 2. Risk of bias graph: review authors’ judgements about each risk of bias item presented as

percentages across all included studies.



Figure 3. Risk of bias summary: review authors’ judgements about each risk of bias item for each included

study.



Allocation

Five of the nine studies were at low risk of selection bias related

to sequence generation, as they used computer randomisation or

a random numbers table. The other four studies did not describe

the method used and were at unclear risk of this bias. Two studies

were at low risk of selection bias related to allocation concealment,

as they used sealed opaque envelopes prepared by research nurses

(Antinori 2008; Knez 2011). The other seven studies did not

describe the method for allocation concealment and we classified

them to be at unclear risk of bias.

Blinding

We did not consider that blinding of participants, personnel, and

outcome assessors was likely to influence findings for any of the

outcomes evaluated by this review (live birth, pregnancy rates,

miscarriage and congenital malformations). We judged all studies

to be at low risk of bias in this domain.

Incomplete outcome data

We considered all nine studies to be at low risk of bias in this

domain, as they stated that all allocated women were analysed.

Selective reporting

We considered all nine studies to be at low risk of selective report-

ing bias, because clinical pregnancy was reported by all included

studies. Although eight studies did not report live birth and nine

studies did not report congenital malformations, we believe these

studies might not be designed to evaluate these outcomes, as they

take longer to be assessed.

Other potential sources of bias

We deemed four studies to be at high risk of other bias, because

there were substantial differences regarding the mean number of

oocytes retrieved or embryos transferred between groups, or both

(Figueira 2011; Setti 2011; Setti 2012a; Setti 2012b). We con-

sidered three studies to be at unclear risk of bias, because there

was insufficient information to compare the number of oocytes

retrieved or embryos transferred, or both, per participant (Knez

2011; Knez 2012; Mahmoud 2011). We judged two studies to

be at low risk of other potential sources of bias (Antinori 2008;

Balaban 2011).

Effects of interventions

See: Summary of findings for the main comparison

1. Ultra-high magnification (IMSI) versus regular

(ICSI) sperm selection for assisted reproduction

Primary outcomes

1. 1 Live birth (effectiveness)

No significant difference was observed between the IMSI and ICSI

groups (RR 1.14, 95% CI 0.79 to 1.64, 1 RCT, 168 women, I2 =

not applicable, low-quality evidence; Analysis 1.1, Figure 4 ).

Figure 4. Forest plot of comparison: 1 Ultra high (IMSI) versus regular magnification (ICSI), outcome: 1.1

Live birth per allocated couple.

Secondary outcomes1.2 Clinical pregnancy (effectiveness)

IMSI was associated with a significantly higher rate of clinical



pregnancy than ICSI (RR 1.29, 95% CI 1.07 to 1.56, 9 RCTs,

2014 women, I2 = 57%, very-low-quality evidence, Figure 5). The

resulting NNTB was 10 (95% CI 5 to 33).

Figure 5. Forest plot of comparison: 1 Ultra high (IMSI) versus regular magnification (ICSI), outcome: 1.2

Clinical pregnancy per allocated couple.

Subgroup analysis (separating the studies by those that included

only couples with poor sperm quality and those that included cou-

ples with good or unselected sperm quality) did not reduce the ob-

served heterogeneity (Analysis 2.1). Sensitivity analysis restricting

the eligibility to studies without high risk of bias did not change

this estimate. We used a random-effects model to incorporate the

observed heterogeneity. The funnel plot suggested a small studies

effect (Figure 6), and therefore we strongly suspected publication

bias.



Figure 6. Funnel plot of comparison: 1 Ultra high (IMSI) versus regular magnification (ICSI), outcome: 1.2

Clinical pregnancy per allocated couple.

1.3 Miscarriage (adverse events)

No significant difference between the groups was observed in mis-

carriage rates (RR 0.82, 95% CI 0.59 to 1.14, 6 RCTs, 552 women,

I2 = 17%, very-low-quality evidence; Analysis 1.3).

1.4 Congenital abnormalities (adverse events)

None of the included studies reported congenital abnormalities.

D I S C U S S I O N

Summary of main results

There was no evidence of an effect on live birth (low-quality evi-

dence) or miscarriage (very-low-quality evidence). The use of IMSI

for sperm selection was associated with an improvement in the

clinical pregnancy rate. However, we deemed this evidence to be

of very low quality, and therefore we are very uncertain about this

estimate. No included studies reported congenital abnormalities.

See Summary of findings for the main comparison for further de-

tails.

Overall completeness and applicability ofevidence

The objectives of this review were addressed by the included stud-

ies. Five studies included only couples with poor sperm quality

and four included couples with good or unselected sperm quality;

however, such subgroup analysis (Analysis 2.1) did not add to the

global analysis. No study sorted the participants accordingly the

sperm source - ejaculate or surgical - or by previous unsuccess-

ful embryo transfers. However, the quality of the pooled evidence

does not allow robust conclusions and we are uncertain about the

true effect of IMSI on the studied reproductive outcomes. In this

way, the review findings do not support the use of IMSI in clinical

practice.

Quality of the evidence

We considered the pooled evidence to be very-low to low-quality

(see Summary of findings for the main comparison). Issues such

as risk of bias in the included studies, imprecision and strong

suspicion of publication bias contributed to the downgrading of

the evidence quality.



The evidence of effect on live birth was deemed low-quality be-

cause only one study reported this outcome, with very serious

imprecision in the estimate (Balaban 2011). There were only 69

events, and the 95% CI included appreciable harm, no effect, and

appreciable benefit.

We considered the evidence of effect on clinical pregnancy to be

of very-low-quality. We considered four out of the nine included

studies to be at high risk of potential bias, regarding differences

in the mean number of oocytes retrieved or embryos transferred

between groups, or both (see Assessment of risk of bias in included

studies; Figure 3). In addition, there was inconsistency across the

included studies; and publication bias was strongly suspected, as

funnel plot analysis (Figure 6) suggested a small studies effect.

Regarding miscarriage, we considered the evidence to be of very-

low-quality. This occurred because the four out of six studies that

reported this outcome were considered to be at high risk of bias

related to differences in the mean number of oocytes retrieved or

embryos transferred between groups, and there was also very seri-

ous imprecision in the estimate. There were only 107 miscarriages

across both groups, and the 95% CI was compatible with both

appreciable harm and no effect.

There was no evidence from RCTs on the effect of IMSI on con-

genital abnormalities.

Potential biases in the review process

We did not identify potential biases in the review process.

Agreements and disagreements with otherstudies or reviews

Another review evaluated the effect of IMSI (Setti 2010). It in-

cluded studies recovered from a single database (MEDLINE) and

supplemented evidence from a single RCT with non-RCT stud-

ies. In accordance to our review, they reported a significant im-

provement in clinical pregnancy rates. However, they observed a

beneficial effect of IMSI decreasing the risk of miscarriage while

we observed no evidence of such effect.

A U T H O R S ’ C O N C L U S I O N S

Implications for practice

The current evidence from randomised controlled trials does not

support the clinical use of intracytoplasmic sperm injection (in-

tracytoplasmic morphologically selected sperm injection (IMSI)):

there is no evidence of effect on live birth or miscarriage and the

evidence that IMSI improves clinical pregnancy is of very low qual-

ity. There is no evidence regarding the effect of this intervention

on the risk of congenital abnormalities. Further trials are neces-

sary to improve the quality of the evidence before recommending

IMSI in clinical practice.

Implications for research

More studies are needed to evaluate the effect of IMSI on live birth,

clinical pregnancy, miscarriage, and congenital abnormalities.

A C K N O W L E D G E M E N T S

We acknowledge the important help provided by Helen Nagels,

Managing Editor from the Cochrane Menstrual Disorders and

Subfertility Group, and by Marian Showell, Trials Search Co-or-

dinator for the Cochrane Menstrual Disorders and Subfertility

Group.

R E F E R E N C E S

References to studies included in this review

Antinori 2008 {published data only}

Antinori M, Licata E, Dani G, Cerusico F, Versaci C,

d’Angelo D, et al.Intracytoplasmic morphologically

selected sperm injection: a prospective randomized trial.

Reproductive BioMedicine Online 2008;16(6):835–41.

[PUBMED: 18549694]∗ Antinori S, Licata E, Dani G, Cerusico F, Versaci C,

Antinori M. A prospective randomized trial to verify the

efficacy of IMSI procedure in daily IVF routine. Human

Reproduction 2008;23 Suppl 1:i165.

Balaban 2011 {published data only}

Balaban B, Yakin K, Alatas C, Oktem O, Isiklar

A, Urman B. Clinical outcome of intracytoplasmic

injection of spermatozoa morphologically selected under

high magnification: a prospective randomized study.

Reproductive Biomedicine Online 2011;22(5):472–6.

[PUBMED: 21324747]

Figueira 2011 {published data only}

Figueira RCS, Braga DPAF, Pasqualotto EB, Pasqualotto

FF, Iaconelli A, Borges E. The role of morphological

nuclear integrity of the sperm cells in preimplantation

genetic aneuploidy screening cycles outcome. Journal fur

Reproduktionsmedizin und Endokrinologie 2010;7:250–1.∗ Figueira RDC, Braga DP, Setti AS, Iaconelli A Jr,

Borges E Jr. Morphological nuclear integrity of sperm

cells is associated with preimplantation genetic aneuploidy

screening cycle outcomes. Fertility and Sterility 2011;95(3):



990–3. [PUBMED: 21130987]

Knez 2011 {published data only}

Knez K, Zorn B, Tomazevic T, Vrtacnik-Bokal E, Virant-

Klun I. The IMSI procedure improves poor embryo

development in the same infertile couples with poor

semen quality: a comparative prospective randomized

study. Reproductive Biology and Endocrinology 2011;9:123.

[PUBMED: 21875440]

Knez 2012 {published data only}

Knez K, Tomazevic T, Zorn B, Vrtacnik-Bokal E,

Virant-Klun I. Intracytoplasmic morphologically selected

sperm injection improves development and quality of

preimplantation embryos in teratozoospermia patients.

Reproductive Biomedicine Online 2012;25(2):168–79.

[PUBMED: 22717245]

Mahmoud 2011 {published data only}

Mahmoud K, Triki-Hmam C, Terras K, Zhioua F, Hfaiedh

T, Ben Aribia MH. How and in which indication the IMSI

could improve outcomes?. Human Reproduction 2011;26

Suppl 1:i181.

Setti 2011 {published data only}

Setti AS, Figueira Rde C, Braga DP, Iaconelli A Jr, Borges

E Jr. Intracytoplasmic morphologically selected sperm

injection benefits for patients with oligoasthenozoospermia

according to the 2010 World Health Organization

reference values. Fertility and Sterility 2011;95(8):2711–4.

[PUBMED: 21458802]

Setti 2012a {published data only}

Iaconelli JA, Figueira RCS, Setti AS, Braga DPAF,

Pasqualotto EE, Borges E Jr. Gender incidence on

intracytoplasmic morphologically selected sperm injection

approach: a prospective randomized study. Human

Reproduction 2011;26 Suppl 1:i71.∗ Setti AS, Figueira RC, Braga DP, Iaconelli A Jr, Borges E

Jr. Gender incidence of intracytoplasmic morphologically

selected sperm injection-derived embryos: a prospective

randomized study. Reproductive BioMedicine Online 2012;

24(4):420–3. [PUBMED: 22377154]

Setti 2012b {published data only}

Setti AS, Figueira, RDC, de Almeida Ferreira Braga DP,

Iaconelli A, Borges E. IMSI is beneficial in cases of advanced

maternal age: a prospective randomized study. Reproductive

BioMedicine Online 2012;Withdrawn. [DOI: 10.1016/

j.rbmo.2012.10.020]

References to studies excluded from this review

Apryshko 2010 {published data only}

Apryshko VP, Yakovenko SA, Sivozhelezov VS, Yutkin EV,

Rutman BK, Troshina MN, et al.IMSI based on Hoffman

modulation contrast: 5 years experience. Reproductive

BioMedicine Online 2010;20:S25.

Bartoov 2003 {published data only}

Bartoov B, Berkovitz A, Eltes F, Kogosovsky A, Yagoda

A, Lederman H, et al.Pregnancy rates are higher with


than with conventional intracytoplasmic injection. Fertility

and Sterility 2003;80(6):1413–9. [PUBMED: 14667877]

Berkovitz 2005 {published data only}

Berkovitz A, Eltes F, Yaari S, Katz N, Barr I, Fishman A,

et al.The morphological normalcy of the sperm nucleus

and pregnancy rate of intracytoplasmic injection with

morphologically selected sperm. Human Reproduction

2005;20(1):185–90. [PUBMED: 15471930]

Berkovitz 2006 {published data only}

Berkovitz A, Eltes F, Lederman H, Peer S, Ellenbogen A,

Feldberg B, et al.How to improve IVF-ICSI outcome by

sperm selection. Reproductive Biomedicine Online 2006;12

(5):634–8. [PUBMED: 16790113]

Braga 2011 {published data only}

Braga DPAF, Setti AS, Figueira RC, Nichi M, Martinhago

CD, Iaconelli A Jr, et al.Sperm organelle morphologic

abnormalities: contributing factors and effects on

intracytoplasmic sperm injection cycles outcomes. Urology

2011;78(4):786–91. [PUBMED: 21820702]

Cassuto 2011 {published data only}

Cassuto NG, Hazout A, Benifla JL, Balet R, Larue L,

Viot G. Decreasing birth defect in children by using high

magnification selected spermatozoon injection. Fertility and

Sterility 2011;1:S85.

De Vos 2013 {published data only}

De Vos A, Van de Velde H, Bocken G, Eylenbosch G,

Franceus N, Meersdom G, et al.Does intracytoplasmic

morphologically selected sperm injection improve embryo

development? A randomized sibling-oocyte study. Human

Reproduction 2013;28:617–26.

Hazout 2005 {published data only}

Hazout A, Dumont-Hassan M, Junca AM, Cohen

Bacrie P, Tesarik J. High-magnification ICSI overcomes

paternal effect resistant to conventional ICSI. Reproductive

Biomedicine Online 2005;12(1):19–24. [PUBMED:

16454928]

Mauri 2011 {published data only}

Mauri AL, Petersen CG, Oliveira JB, Massaro FC, Baruffi

RL, Franco JG Jr. Comparison of day 2 embryo quality after

conventional ICSI versus intracytoplasmic morphologically

selected sperm injection (IMSI) using sibling oocytes.

European Journal of Obstetrics, Gynecology, and Reproductive

Biology 2011;150(1):42–6. [PUBMED: 20171776]

Oliveira 2011 {published data only}∗ Oliveira JBA, Cavagna M, Petersen CG, Mauri

AL, Massaro FC, Silva LFI, et al.Pregnancy outcomes

in women with repeated implantation failures after


(IMSI). Reproductive Biology and Endocrinology 2011;9:99.

[PUBMED: 21781299]

Oliveira JBA, Petersen CG, Mauri AL, Massaro FC, Baruffi

RLR, Franco JG Jr. Clinical outcomes of IMSI in previous

ICSI failures. Fertility and Sterility 2010;1:S55.



Wilding 2011 {published data only}

Wilding M, Coppola G, di Matteo L, Palagiano A, Fusco

E, Dale B. Intracytoplasmic injection of morphologically

selected spermatozoa (IMSI) improves outcome after

assisted reproduction by deselecting physiologically poor

quality spermatozoa. Journal of Assisted Reproduction and

Genetics 2011;28(3):253–62. [PUBMED: 21072684]

References to studies awaiting assessment

Check 2013 {published data only}

Check JH, Bollendorf A, Summers-Chase D, Yuan W,

Horwath D. Isolating sperm by selecting those with normal

nuclear morphology prior to intracytoplasmic sperm

injection (ICSI) does not provide better pregnancy rates

compared to conventional ICSI in women with repeated

conception failure with in vitro fertilization. Clinical and

Experimental Obstetrics & Gynecology 2013;40:15–7.

Parinaud 2013 {unpublished data only}

Setti 2012c {published data only}

Setti AS, Braga DPAF, Figueira RCS, Colturato SS,

Iaconelli A, Borges E. Intracytoplasmic morphologically

selected sperm injection (IMSI) benefits in the presence of

unexplained infertility: a prospective randomized study.

Fertility and Sterility 2012; Vol. 98 Suppl 1, issue 3:S80.

Additional references

Bartoov 2002

Bartoov B, Berkovitz A, Eltes F, Kogosowski A, Menezo

Y, Barak Y. Real-time fine morphology of motile human

sperm cells is associated with IVF-ICSI outcome. Journal of

Andrology 2002;23(1):1–8. [PUBMED: 11780915]

Higgins 2011

Higgins JPT, Green S (editors). Cochrane Handbook

for Systematic Reviews of Interventions Version 5.1.0

[updated March 2011]. The Cochrane Collaboration,

2011. Available from www.cochrane-handbook.org.

Jungheim 2010

Jungheim ES, Ryan GL, Levens ED, Cunningham AF,

Macones GA, Carson KR, et al.Embryo transfer practices

in the United States: a survey of clinics registered with the

Society for Assisted Reproductive Technology. Fertility and

Sterility 2010;94(4):1432–6. [PUBMED: 19748089]

Palermo 1992

Palermo G, Joris H, Devroey P, Van Steirteghem AC.

Pregnancies after intracytoplasmic injection of single

spermatozoon into an oocyte. Lancet 1992;340(8810):

17–8. [PUBMED: 1351601]

Setti 2010

Setti AS, Ferreira RC, Braga DPAF, Figueira RCS, Iaconelli

A Jr, Borges E Jr. Intracytoplasmic sperm injection

outcome versus intracytoplasmic morphologically selected

sperm injection outcome: a meta-analysis. Reproductive

Biomedicine Online 2010;21(4):450–5. [PUBMED:

20800549]∗ Indicates the major publication for the study



C H A R A C T E R I S T I C S O F S T U D I E S

Characteristics of included studies [ordered by study ID]

Antinori 2008

Methods Randomised controlled trial conducted in a private assisted reproduction centre (Italy).

Period of enrolment not reported

Participants Inclusion criteria: at least 2 previous diagnoses of severe oligoasthenospermia; 3 years

of primary infertility; absence of female factor

Interventions Couples were randomised into 2 groups:

Intervention: oocytes injected with spermatozoon selected under ultra-high magnifica-

tion (IMSI): on the basis of MSOME criteria, the examination and spermatozoa selec-

tion for IMSI procedure was performed in real time using an inverted light microscope

equipped with high-power Nomarski optics, enhanced by digital imaging to achieve

a magnification up to 6300x, and the Eppendorf Micromanipulation System (Trans-

fer-Man NK2, Eppendorf, Germany). Only spermatozoa with normal head dimension

(length 4.75 ± 0.28 µm; width 3.28 ± 0.20 µm) and shape, with no or maximum 1 vac-

uole (0.78 ± 0.18 µm) were microinjected; spermatozoa with abnormal head size were

excluded (such spermatozoa were identified by superimposing a transparent celluloid

form representing the correct spermatozoon size on the examined gametes). 2 sperma-

tozoa for each oocyte were selected to be inseminated using the classical ICSI technique

Control: oocytes injected with spermatozoon selected under regular magnification

(ICSI): no further details

Outcomes Clinical pregnancy, miscarriage, and implantation rates.

Notes We considered 2 publications to be related to the same study although the numbers of

participants were not the same, because the only difference we observed was that the

newer publication had evaluated more participants; the authors did not answer our e-

mails to resolve these data queries

Live birth and congenital abnormalities not reported.

Implantation rate: 23.0% (IMSI) vs. 16.6% (ICSI); P value not reported.

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Unclear risk Not reported.

Allocation concealment (selection bias) Low risk Sealed, opaque envelopes prepared by a re-

search nurse.

Blinding of participants and personnel

(performance bias)

All outcomes

Low risk Blinding of participants and personnel was

not considered as a potential source of bias



Antinori 2008 (Continued)

Blinding of outcome assessment (detection

bias)

All outcomes

Low risk Blinding of outcome assessment was not

considered as a potential source of bias

Incomplete outcome data (attrition bias)

All outcomes

Low risk No loss to follow-up.

Selective reporting (reporting bias) Low risk Not suspected.

Other bias Low risk None.

Balaban 2011

Methods Randomised controlled trial conducted in a private assisted reproduction centre (Turkey)

between February and July 2009

Participants Eligibility criteria: unselected women undergoing assisted reproduction treatment



tion (IMSI). The procedure was performed in real time using an inverted microscope

(Olympus IX-71; Japan) with actual digitally enhanced magnification, as determined by

a 0.01 mm Olympus objective micrometer, at 6300x. Normal-shaped nuclei were de-

fined as smooth, symmetric, having an oval configuration, with mean length and width

limits of 4.75 ± 0.28 and 3.28 ± 0.20 µm, respectively, with a homogeneous nuclear

chromatin mass with no regional nuclear disorders and containing no more than one

small vacuole with a borderline diameter of 0.78 ± 0.18 µm. Mean time needed for

IMSI = 21 minutes


(ICSI): not specified; the mean time needed for regular ICSI = 14 minutes

Outcomes Duration of ICSI procedure; 2-pronuclei fertilisation rate; embryos with 4 blastomeres

on day 2 post fertilisation; embryos with 8 blastomeres on day 3 post fertilisation; grade 1

and 2 embryos on transfer day; clinical pregnancy; live birth; implantation; and multiple

pregnancy rate

Notes Miscarriage and congenital abnormalities not reported.

Implantation rate: 66/228 = 28.9% (IMSI) vs. 42/215 = 19.5% (ICSI); P value = 0.02

(however, study authors reported that P = NS [not significant])

Risk of bias



bias)

Low risk Computer-generated randomisation list.

Allocation concealment (selection bias) Unclear risk Not reported.



Balaban 2011 (Continued)


(performance bias)

All outcomes




bias)

All outcomes




All outcomes



Other bias Low risk None.

Figueira 2011

Methods Randomised controlled trial conducted in a private assisted reproduction centre (Brazil)

between May and December 2009

Participants Eligibility criteria: women undergoing assisted reproduction treatment in conjunction

with pre-implantation genetic screening for aneuploidy, as a result of advanced maternal

age; sperm concentration > 1,000,000/mL and sperm motility > 20%; at least 6 oocytes

available on oocyte retrieval


Intervention: oocytes injected with spermatozoon selected under ultra-high magnifi-

cation (IMSI): sperm morphology selection was assessed using an inverted Nikon Di-

aphot microscope (Eclipse TE 300; Nikon, Tokyo) equipped with high-power DIC

(Nomarski). The total calculated magnification was 6600x. The sperm cells exhibiting

normally shaped nuclei (smooth, symmetric, and oval configuration) and normal nuclear

chromatin content (if it contained no more than 1 vacuole, which occupies < 4% of the

nuclear area) were selected for injection


(ICSI): sperm morphology selection was assessed using an inverted Nikon Diaphot mi-

croscope (Eclipse TE 300; Nikon, Tokyo) with a Hoffmann modulation contrast system

under 400x magnification

Outcomes Sperm nuclear morphology at high-magnification ICSI; incidence of aneuploidy in de-

rived embryos; clinical pregnancy rate

Notes All embryos were submitted to pre-implantation genetic diagnosis and aneuploidy screen-

ing. On the morning of day 3 of embryo development, 1 cell per embryo was biopsied

by laser zona drilling using a 1.48 mm infrared diode laser (Octax Laser Shot System,

MTG, Bruckberg, Germany). After the biopsies, the embryos were returned to the cul-

ture medium. The removed blastomere nuclei were spread using 0.1 N HCl and 0.01%

Tween 20 (Sigma, Dorset, UK). Briefly, the individual nuclei were placed on a slide in 1

drop of HCl-Tween spreading solution and observed until the cell had lysed. The slides



Figueira 2011 (Continued)

were then air dried and dehydrated before FISH analysis was performed. All embryos

were analysed for chromosomes X, Y, 13, 16, 18, 21, and 22. For the purpose of this

study, the blastomeres were classified as normal when 2 sexual and 2 of each tested auto-

somal chromosomes were present. Blastomeres with 2 or more chromosomal numerical

abnormalities were classified as chaotic. Embryos with abnormal findings in biopsied

nuclei were not submitted for re-analysis. Embryo transfer was performed on day 4 using

a soft catheter with transabdominal ultrasound guidance. Only the embryos found to

be chromosomally normal were considered for embryo transfer, and a maximum of 3

embryos were transferred. The cycle was cancelled if normal embryos were absent after

FISH


Implantation rate: 55.6% (IMSI) vs. 40.9% (ICSI); P value = 0.59.

Study authors were contacted to clarify information about the 4 different included

studies, from the same groups of authors (Figueira 2011; Setti 2011; Setti 2012a; Setti

2012b). All questions on methods of randomisation, patient overlapping, and data “per

woman” were clarified

Risk of bias



bias)

Low risk Computer-generated balanced table in sets

of 10.



(performance bias)

All outcomes




bias)

All outcomes




All outcomes



Other bias High risk The number of oocytes retrieved and em-

bryos transferred were significantly differ-

ent between groups (P value < 0.01). In the

article, study authors reported that differ-

ences were not significant (P value = 0.20

and P value = 0.17, oocytes retrieved and

embryos transferred, respectively)



Knez 2011

Methods Randomised controlled trial conducted in an academic setting (Slovenia) between Oc-

tober 2009 and June 2010

Participants Eligibility criteria: all embryos arrested after prolonged 5-day embryo culture to the

blastocyst stage in their previous conventional ICSI attempts; poor semen quality charac-

terised by the incidence of teratozoospermia by less than 14% of morphologically normal

sperm according to the Strict Kruger Criteria, oligozoospermia by a sperm concentration

of < 20 million/mL and asthenozoospermia by < 50% of motile sperm according the

WHO criteria; women without PCOS or endometriosis and age < 42 years



tion (IMSI): sperm were selected in dishes with a glass bottom (GWSt 1000; Will Co.,

Wells BV, Amsterdam, The Netherlands) and monitored under an inverted microscope

with a heated stage equipped with DIC (Nikon ECLIPSE TE2000-S, Japan). Approxi-

mately 5 elongated droplets of SpermSlow medium (Origio, Denmark) were placed on

the bottom of a glass dish to immobilise the sperm. A smaller droplet of prepared sperm

was placed near each SpermSlow droplet. Then the connections were made between

the sperm and the SpermSlow droplets for sperm to swim into the SpermSlow droplets

and to bind to the HA. All droplets were covered with paraffin oil (Origio, Denmark)

. For observation under 6000x magnification, a droplet of immersion oil was inserted

underneath the glass dish (under the SpermSlow droplet). One droplet of SpermSlow

with bound sperm was monitored by the immersion objective, DIC, and Nikon Digital

Sight DS-Ri1 camera. The single (mature) sperm that was bound to the HA and had

the best morphology was chosen, aspirated in the microinjection pipette, scored in 3-

dimensions, and evaluated according to the morphology and head vacuoles at 6000x

magnification


(ICSI): the sperm selection for microinjection was performed at a magnification of 200x

to 400x. Sperm with severe head-shape defects clearly seen under the magnification (pin,

amorphous, tapered, round, and multinucleated head) were excluded from microinjec-

tion into the oocyte

Outcomes Fertilisation, blastocyst, implantation, and pregnancy rates

Notes Live birth and congenital abnormalities not reported.

Implantation rate: 6/35 = 17.1% (IMSI) vs. 3/44 = 6.8% (ICSI); P = 0.17.

Study author was contacted to clarify information about the 2 different included studies

(Knez 2011 and Knez 2012). All questions on methods of randomisation, patient over-

lapping, and data “per woman” were clarified

Risk of bias



bias)

Low risk Computer-generated random numbers

(unrestricted randomisation list)



Knez 2011 (Continued)

Allocation concealment (selection bias) Low risk Sealed, opaque envelopes prepared by a re-

search nurse.


(performance bias)

All outcomes




bias)

All outcomes




All outcomes



Other bias Unclear risk Study authors did not report the num-

ber of oocytes retrieved in the groups. The

number of transferred embryos per partici-

pant was not significantly different between

groups

Knez 2012

Methods Randomised controlled trial conducted in an academic setting (Slovenia) between Jan-

uary and October 2011

Participants Eligibility criteria: at least 6 mature oocytes available upon oocyte retrieval; isolated

teratozoospermia, which was determined as having < 14% of morphologically normal

spermatozoa according to the Kruger strict criteria, > 15 million spermatozoa per millilitre

and at least 40% motile spermatozoa; women without PCOS or endometriosis



tion (IMSI): a single spermatozoon bound to the HA and with the best morphology was

chosen, aspirated in the microinjection pipette, scored in 3-dimensions and evaluated

according to the morphology and head vacuoles at 6000x magnification


(ICSI): spermatozoa without severe head shape defects clearly seen under the microscope

(pin, amorphous, tapered, round, and multinucleated head) were selected at magnifica-

tion 200x to 400x

Outcomes Fertilisation, blastocyst, implantation, and pregnancy rates

Notes Live birth, miscarriage, and congenital abnormalities not reported

Implantation rate not reported.

Study author was contacted to clarify information about the 2 different included studies

(Knez 2011; Knez 2012). All questions on methods of randomisation, patient overlap-



Knez 2012 (Continued)

ping, and data “per woman” were clarified

Risk of bias



bias)




(performance bias)

All outcomes




bias)

All outcomes




All outcomes



Other bias Unclear risk Study authors did not provide the number

of transferred embryos per participant nei-

ther the SD for the number of oocytes re-

trieved (mean 11.0 with IMSI vs. 9.8 with

ICSI)

Mahmoud 2011

Methods Randomised controlled trial conducted in a private assisted reproduction centre (Tunisia)

between April 2009 and November 2010

Participants Eligibility criteria: oligoasthenozoospermia based on WHO references values. Terato-

zoospermia evaluated by the strict criteria of Kruger sperm morphology; healthy woman

aged < 37 years



tion (IMSI): 6600x magnification, using Leica 6800 station


(ICSI)

Outcomes Fertilisation rate, percentage of good-quality embryos, and the rates of clinical pregnancy

and implantation



Mahmoud 2011 (Continued)

Notes Live birth, miscarriage, and congenital abnormalities not reported

Implantation rate: 19.2% (IMSI) vs. 17.2% (ICSI); P value = not significant.

Study authors were not contacted because we were unable to obtain their contact details

Risk of bias



bias)




(performance bias)

All outcomes




bias)

All outcomes




All outcomes



Other bias Unclear risk Study authors did not report the number of

oocytes retrieved and embryos transferred

Setti 2011


. Period of enrolment not reported

Participants Eligibility criteria: first IVF treatment; abnormal semen parameters according to WHO,

except for azoospermia; use of fresh semen sample; absence of a known female factor

infertility; and at least 6 oocytes available on retrieval



tion (IMSI): sperm selection was examined at high magnification with an inverted mi-

croscope (Eclipse TE 300; Nikon, Tokyo, Japan) equipped with high-power DIC optics

(Nomarski). The total calculated magnification was 6600x



croscope (Eclipse TE 300; Nikon, Tokyo) with a Hoffmann modulation contrast system

under 400x magnification



Setti 2011 (Continued)

Outcomes Clinical pregnancy, implantation rate, and miscarriage.


Implantation rate: 158/664 = 23.8% (IMSI) vs. 28/156 = 25.4% (ICSI); P value = 0.

60





Risk of bias



bias)

Low risk Computer-generated randomisation list.



(performance bias)

All outcomes




bias)

All outcomes




All outcomes





ent between groups (P value < 0.01 for

both). In the article, study authors re-

ported that differences were non-signifi-

cant (P value = 0.29 for oocytes retrieved

and P = 0.27 for embryos transferred)

Setti 2012a


between May 2009 and December 2010

Participants Eligibility criteria: women undergoing assisted reproduction treatment in conjunction

with pre-implantation genetic screening for aneuploidy, as a result of advanced maternal

age; no severe spermatogenic alteration; at least 6 oocytes available on oocyte retrieval



Setti 2012a (Continued)


Intervention: oocytes injected with spermatozoon selected under ultra-high magnifi-

cation (IMSI): sperm selection was examined at high magnification using a similar in-

verted microscope equipped with high-power DIC optics (Nomarski). The total cal-

culated magnification was 6600x. The sperm cells exhibiting normally shaped nuclei

(smooth, symmetric, and oval configuration) and normal nuclear chromatin content (if

it contained no more than 1 vacuole, which occupied < 4% of the nuclear area) were

selected for injection



croscope (Eclipse TE 300; Nikon, Tokyo, Japan) with a Hoffmann modulation contrast

system under 400x magnification

Outcomes Clinical pregnancy, implantation rate, miscarriage, and gender incidence

Notes All embryos were submitted to pre-implantation genetic diagnosis and aneuploidy screen-

ing. On the morning of day 3 of embryo development, 1 cell per embryo was biopsied

by laser zona drilling using a 1.48 mm infrared diode laser (Octax Laser Shot System,

MTG, Bruckberg, Germany). Following the biopsies, the embryos were returned to the

culture medium. The removed blastomere nuclei were spread using 0.1 mol/L HCl and

0.01% Tween 20 (Sigma, Dorset, UK). Briefly, the blastomeres were placed on a slide

in a drop of HCl-Tween spreading solution and observed until the cell had lysed. The

slides were then air-dried and dehydrated before FISH analysis was performed. All em-

bryos were analysed for chromosomes X, Y, 13, 16, 18, 21, and 22. For the purpose of

this study, the blastomeres were classified as normal when 2 sexual and 2 of each tested

autosomal chromosomes were present. Embryo transfer was performed on day 5 using a

soft catheter with transabdominal ultrasound guidance. Only the embryos found to be

chromosomally normal were considered for embryo transfer, and up to a maximum of

3 embryos were transferred


Implantation rate: 46.1% (IMSI) vs. 41.6% (ICSI); P value = 0.59.





Risk of bias



bias)




(performance bias)

All outcomes





Setti 2012a (Continued)


bias)

All outcomes




All outcomes





ent between groups (P value = 0.01). In the

article, study authors reported these differ-

ences as not significant

Setti 2012b

Methods Prospective randomised clinical trial performed in a private fertility centre (Brazil). Period

of enrolment not reported

Participants Eligibility criteria: women of good physical and mental health; undergoing ICSI as a

result of advanced maternal age (≥ 37 years old); with regular menstrual cycles of 25-35

days; normal basal FSH and LH concentrations; body mass index < 30 kg/m2; presence

of both ovaries and intact uterus; absence of PCOS, endometriosis and gynaecological/

medical disorders; and a negative result in a screening for sexually transmitted diseases. All

male partners were normozoospermic, according to the WHO reference values (2010).

No woman had received any hormone therapy for at least 60 days preceding the study


Intervention: sperm selection in the IMSI group was analysed under high magnification

using an inverted Nikon Diaphot microscope equipped with high-power DIC optics.

The total calculated magnification was 6600x. An aliquot of the sperm cell suspension

was transferred to a microdroplet of modified human tubal fluid medium containing

8% polyvinyl pyrrolidone (Irvine Scientific, Santa Ana, CA, USA) in a sterile glass dish

(FluoroDish; World Precision Instrument, Sarasota, FL, USA). The dish was placed on

a microscope stage above an Uplan Apo 100 oil/1.35 objective lens previously covered

by a droplet of immersion oil. The sperm cells that were selected for injection exhibited

normally shaped nuclei (smooth, symmetric and oval configuration) and normal nuclear

chromatin content (if it contained no more than 1 vacuole that occupied < 4% of the

nuclear area)

Control: sperm selection in the ICSI group was analysed under 400x magnification

using an inverted Nikon Eclipse TE 300 microscope

Outcomes Fertilisation rate, high-quality embryo rate on day 3, blastocyst formation rate, number

of transferred embryos, implantation rate, miscarriage rate and pregnancy rate



Setti 2012b (Continued)


Implantation rate: 38.3% (IMSI) vs. 12.1% (ICSI). P value = 0.03.

This article has been withdrawn. Authors were contacted for more information regarding

the reasons why this happened. Authors had also been contacted to clarify information

about the 4 different included studies, from the same groups of authors (Figueira 2011;

Setti 2011; Setti 2012a; Setti 2012b). All questions on methods of randomisation, patient

overlapping and data “per woman” were clarified

Risk of bias



bias)

Low risk Computer-generated randomisation table.



(performance bias)

All outcomes




bias)

All outcomes




All outcomes

Low risk No loss of follow-up.


Other bias High risk Although there was no significant differ-

ence in the number of oocytes retrieved,

and despite the total number of embryos

being higher in the ICSI group, more em-

bryos per woman were transferred in the

IMSI group

This article has been withdrawn.

DIC: differential interference contrast; FISH: fluorescent in situ hybridisation; FSH: follicle-stimulating hormone; HA: hyaluronate;

HCl: hydrochloric acid; ICSI: intracytoplasmic sperm injection; IMSI: intracytoplasmic morphologically selected sperm injection;

IVF: in vitro fertilisation; LH: luteinising hormone; MSOME: motile sperm organella morphology examination; PCOS: polycystic

ovaries syndrome; SD: standard deviation; WHO: World Health Organization.



Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion

Apryshko 2010 Not an RCT (observational study).

Bartoov 2003 Not an RCT (observational study).

Berkovitz 2005 Not an RCT (observational study).

Berkovitz 2006 Not an RCT (observational study).

Braga 2011 Oocytes (not participants) were allocated.

Cassuto 2011 Not an RCT (observational study).

De Vos 2013 Oocytes (not participants) were randomly allocated.

Hazout 2005 Not an RCT (observational study).

Mauri 2011 Oocytes (not participants) were randomly allocated.

Oliveira 2011 Not an RCT (observational study).

Wilding 2011 Not an RCT (observational study).

RCT: randomised controlled trial.

Characteristics of studies awaiting assessment [ordered by study ID]

Check 2013

Methods Prospective randomised clinical trial performed in a fertility centre (USA). Period of enrolment not reported

Participants Eligibility criteria: women aged ≤ 39, undergoing ART, with failure to have a successful conception after 3 consec-

utive embryo transfers and whose male partner had a DNA fragmentation index > 30%


Intervention: sperm selection in the ICSI group was analysed under high magnification

Control: sperm selection in the ICSI group was analysed under normal magnification

Outcomes Live birth and pregnancy rate.

Notes Authors were contacted for further information regarding period of enrolment, eligibility criteria and results



Parinaud 2013

Methods Randomised controlled trial conducted in 9 different assisted reproduction centres (France). Period of enrolment not

reported

Participants Eligibility criteria: couples undergoing ICSI due to male infertility, with < 1 million motile spermatozoa recovered

after gradient preparation and at least 3 million sperm cells in the ejaculate. Couples in which the female age was >

38 years or FSH level was > 9.0 mL/mlU were excluded from the study


Intervention: sperm selection in the ICSI group was analysed under 6000x magnification


Outcomes Number of deliveries and implantation rate.

Notes The study was registered at ClinicalTrials.gov and has already been completed. Authors were contacted for further

information, since study has not been published yet

Setti 2012c

Methods Prospective randomised clinical trial performed in a private fertility centre (Brazil). Period of enrolment not reported

Participants Eligibility criteria: women undergoing ICSI as a result of unexplained fertility.


Intervention: sperm selection in the ICSI group was analysed under 6000x magnification


Outcomes Fertilisation rate, high-quality embryo rate, number of transferred embryos, implantation rate and pregnancy rate

Notes Miscarriage, live birth and congenital abnormalities not reported

Implantation rate: 39.6% (IMSI) vs. 19.4% (ICSI). P value = 0.019.

Authors were contacted for further information regarding period of enrolment and eligibility criteria

ART: assisted reproduction technique; DNA: deoxyribonucleic acid; FSH: follicle-stimulating hormone; ICSI: intracytoplasmic sperm

injection; IMSI: intracytoplasmic morphologically selected sperm injection; IU: international units.



D A T A A N D A N A L Y S E S

Comparison 1. Ultra high (IMSI) versus regular magnification (ICSI)

Outcome or subgroup titleNo. of

studies

No. of

participants Statistical method Effect size

1 Live birth per allocated couple 1 168 Risk Ratio (M-H, Fixed, 95% CI) 1.14 [0.79, 1.64]

2 Clinical pregnancy per allocated

couple

9 2014 Risk Ratio (M-H, Random, 95% CI) 1.29 [1.07, 1.56]

3 Miscarriage per clinical

pregnancy

6 552 Risk Ratio (M-H, Fixed, 95% CI) 0.82 [0.59, 1.14]

Comparison 2. IMSI versus ICSI: subgroup analysis by sperm quality

Outcome or subgroup titleNo. of

studies

No. of

participants Statistical method Effect size

1 Clinical pregnancy 9 2014 Risk Ratio (M-H, Random, 95% CI) 1.29 [1.07, 1.56]

1.1 Only poor sperm quality 5 1500 Risk Ratio (M-H, Random, 95% CI) 1.29 [0.98, 1.70]

1.2 Good or unselected sperm

quality

4 514 Risk Ratio (M-H, Random, 95% CI) 1.33 [0.97, 1.82]

Analysis 1.1. Comparison 1 Ultra high (IMSI) versus regular magnification (ICSI), Outcome 1 Live birth per

allocated couple.

Review: Regular (ICSI) versus ultra-high magnification (IMSI) sperm selection for assisted reproduction

Comparison: 1 Ultra high (IMSI) versus regular magnification (ICSI)

Outcome: 1 Live birth per allocated couple

Study or subgroup IMSI ICSI Risk Ratio Weight Risk Ratio

n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

Balaban 2011 38/87 31/81 100.0 % 1.14 [ 0.79, 1.64 ]

Total (95% CI) 87 81 100.0 % 1.14 [ 0.79, 1.64 ]

Total events: 38 (IMSI), 31 (ICSI)

Heterogeneity: not applicable

Test for overall effect: Z = 0.71 (P = 0.48)

Test for subgroup differences: Not applicable

0.05 0.2 1 5 20

Favours ICSI Favours IMSI



Analysis 1.2. Comparison 1 Ultra high (IMSI) versus regular magnification (ICSI), Outcome 2 Clinical

pregnancy per allocated couple.



Outcome: 2 Clinical pregnancy per allocated couple


n/N n/N

M-H,Random,95%

CI

M-H,Random,95%

CI

Antinori 2008 120/327 78/306 16.3 % 1.44 [ 1.13, 1.83 ]

Balaban 2011 47/87 36/81 13.8 % 1.22 [ 0.89, 1.66 ]

Figueira 2011 32/60 28/60 12.3 % 1.14 [ 0.80, 1.64 ]

Knez 2011 5/20 3/37 1.9 % 3.08 [ 0.82, 11.59 ]

Knez 2012 25/52 17/70 8.6 % 1.98 [ 1.20, 3.27 ]

Mahmoud 2011 41/93 42/95 13.5 % 1.00 [ 0.72, 1.38 ]

Setti 2011 93/250 92/250 16.7 % 1.01 [ 0.80, 1.27 ]

Setti 2012a 43/80 36/80 13.6 % 1.19 [ 0.87, 1.64 ]

Setti 2012b 18/33 4/33 3.2 % 4.50 [ 1.71, 11.87 ]

Total (95% CI) 1002 1012 100.0 % 1.29 [ 1.07, 1.56 ]


Heterogeneity: Tau2 = 0.04; Chi2 = 18.76, df = 8 (P = 0.02); I2 =57%



0.05 0.2 1 5 20




Analysis 1.3. Comparison 1 Ultra high (IMSI) versus regular magnification (ICSI), Outcome 3 Miscarriage

per clinical pregnancy.



Outcome: 3 Miscarriage per clinical pregnancy


n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

Antinori 2008 20/120 18/78 36.9 % 0.72 [ 0.41, 1.28 ]

Figueira 2011 0/32 1/28 2.7 % 0.29 [ 0.01, 6.91 ]

Knez 2011 0/5 2/3 5.1 % 0.13 [ 0.01, 2.11 ]

Setti 2011 29/93 28/92 47.6 % 1.02 [ 0.67, 1.58 ]

Setti 2012a 0/43 3/36 6.4 % 0.12 [ 0.01, 2.25 ]

Setti 2012b 6/18 0/4 1.3 % 3.42 [ 0.23, 51.03 ]

Total (95% CI) 311 241 100.0 % 0.82 [ 0.59, 1.14 ]


Heterogeneity: Chi2 = 6.00, df = 5 (P = 0.31); I2 =17%



0.05 0.2 1 5 20

Favours IMSI Favours ICSI



Analysis 2.1. Comparison 2 IMSI versus ICSI: subgroup analysis by sperm quality, Outcome 1 Clinical

pregnancy.


Comparison: 2 IMSI versus ICSI: subgroup analysis by sperm quality

Outcome: 1 Clinical pregnancy


n/N n/N

M-H,Random,95%

CI

M-H,Random,95%

CI

1 Only poor sperm quality

Antinori 2008 120/327 78/306 16.3 % 1.44 [ 1.13, 1.83 ]

Knez 2011 5/20 3/37 1.9 % 3.08 [ 0.82, 11.59 ]

Knez 2012 25/52 17/70 8.6 % 1.98 [ 1.20, 3.27 ]

Mahmoud 2011 41/93 42/95 13.5 % 1.00 [ 0.72, 1.38 ]

Setti 2011 93/250 92/250 16.7 % 1.01 [ 0.80, 1.27 ]

Subtotal (95% CI) 742 758 57.0 % 1.29 [ 0.98, 1.70 ]




2 Good or unselected sperm quality

Balaban 2011 47/87 36/81 13.8 % 1.22 [ 0.89, 1.66 ]

Figueira 2011 32/60 28/60 12.3 % 1.14 [ 0.80, 1.64 ]

Setti 2012a 43/80 36/80 13.6 % 1.19 [ 0.87, 1.64 ]

Setti 2012b 18/33 4/33 3.2 % 4.50 [ 1.71, 11.87 ]

Subtotal (95% CI) 260 254 43.0 % 1.33 [ 0.97, 1.82 ]




Total (95% CI) 1002 1012 100.0 % 1.29 [ 1.07, 1.56 ]




Test for subgroup differences: Chi2 = 0.02, df = 1 (P = 0.90), I2 =0.0%

0.05 0.2 1 5 20




A P P E N D I C E S

Appendix 1. Menstrual Disorders and Subfertility Group search strategy

Search results for Menstrual Disorders and Subfertility Group (MDSG) database, 8 May 2013:

Keywords CONTAINS “icsi”or “ICSI failure”or “ICSI injection site”or“intracytoplasmic sperm injection”or“intracytoplasmic sperm

injection cycle”or “intracytoplasmic sperm injection techniques”or Title CONTAINS “icsi”or “ICSI failure”or “ICSI injection

site”or“intracytoplasmic sperm injection”or“intracytoplasmic sperm injection cycle”or “intracytoplasmic sperm injection techniques”

AND

Keywords CONTAINS “IMSI” or “intracytoplasmic morphologically selected sperm injection” or Title CONTAINS “IMSI” or

“intracytoplasmic morphologically selected sperm injection”

22 records

Appendix 2. CENTRAL search strategy

Database: EBM Reviews - Cochrane Central Register of Controlled Trials, 2013, Issue 2

Search strategy:

--------------------------------------------------------------------------------

1 icsi.tw. (684)

2 intracytoplasmic sperm injection$.tw. (417)

3 exp Sperm Injections, Intracytoplasmic/ (334)

4 conventional intracytoplasmic injection$.tw. (1)

5 regular magnification.tw. (0)

6 or/1-5 (886)

7 intracytoplasmic morphologically selected sperm injection$.tw. (11)

8 IMSI.tw. (11)

9 MSOME.tw. (0)

10 motile sperm organelle morphology examination$.tw. (0)

11 high magnification.tw. (18)

12 or/7-11 (27)

13 6 and 12 (10)

Appendix 3. MEDLINE search strategy

Search results for Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R)

<1946 to Present>, 8 May 2013:

1 icsi.tw. (5253)


3 exp Sperm Injections, Intracytoplasmic/ (4426)



6 or/1-5 (7703)


8 IMSI.tw. (40)

9 MSOME.tw. (29)



12 or/7-11 (1101)

13 6 and 12 (62)

14 randomized controlled trial.pt. (348,486)

15 controlled clinical trial.pt. (85,883)

16 randomized.ab. (266,743)



17 placebo.tw. (147,938)

18 clinical trials as topic.sh. (164,266)

19 randomly.ab. (194,103)

20 trial.ti. (113,955)

21 (crossover or cross-over or cross over).tw. (56,715)

22 or/14-21 (857,284)

23 exp animals/ not humans.sh. (3,809,801)

24 22 not 23 (790,248)

25 13 and 24 (14)

Appendix 4. EMBASE search strategy

Database: EMBASE <1980 to 8 May 2013>

Search strategy:

--------------------------------------------------------------------------------

1 exp intracytoplasmic sperm injection/ (11,216)

2 icsi.tw. (8334)




6 or/1-5 (13,225)


8 IMSI.tw. (111)

9 MSOME.tw. (59)



12 or/7-11 (1374)

13 6 and 12 (142)

14 Clinical Trial/ (877227)

15 Randomized Controlled Trial/ (341,619)

16 exp randomization/ (61290)

17 Single Blind Procedure/ (17,333)

18 Double Blind Procedure/ (114,409)

19 Crossover Procedure/ (36,788)

20 Placebo/ (217,264)

21 Randomi?ed controlled trial$.tw. (86,231)

22 Rct.tw. (11,331)

23 random allocation.tw. (1232)

24 randomly allocated.tw. (18,653)

25 allocated randomly.tw. (1878)

26 (allocated adj2 random).tw. (718)

27 Single blind$.tw. (13,248)

28 Double blind$.tw. (135,874)

29 ((treble or triple) adj blind$).tw. (312)

30 placebo$.tw. (187828)

31 prospective study/ (231,998)

32 or/14-31 (1,324,701)

33 case study/ (19,500)

34 case report.tw. (242,862)

35 abstract report/ or letter/ (866,817)

36 or/33-35 (1,124,107)

37 32 not 36 (1,288,419)



38 13 and 37 (34)

Appendix 5. CINAHL search strategy

Search results for Cumulative Index to Nursing and Allied Health Literature (CINAHL), 7 May 2013:

((intracytoplasmic sperm injection*) OR (icsi) OR (conventional intracytoplasmic injection*) OR (regular magnification)) AND

((intracytoplasmic morphologically selected sperm injection*) OR (IMSI) OR (MSOME) OR (motile sperm organelle morphology

examination*) OR (high magnification))

0 records

Appendix 6. LILACS search strategy

Search results for Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), 7 May 2013:

((intracytoplasmic sperm injection$) OR (icsi) OR (conventional intracytoplasmic injection$) OR (regular magnification)) AND

((intracytoplasmic morphologically selected sperm injection$) OR (IMSI) OR (MSOME) OR (motile sperm organelle morphology

examination$) OR (high magnification))

1 record

Appendix 7. PsycINFO search strategy

Search results for PsycINFO, 8 May 2013:


2 icsi.tw. (38)



5 or/1-4 (50)


7 IMSI.tw. (1)

8 MSOME.tw. (0)



11 or/6-10 (21)

12 5 and 11 (0)

Appendix 8. Trials registers search strategy

Search results for ClinicalTrial.gov, 7 May 2013:

(imsi) OR (msome) OR (motile sperm organelle morphology examination) OR ((high magnification) AND (sperm))

6 records

Search results for Current Controlled Trials, 7 May 2013:

(imsi) OR (msome) OR (motile sperm organelle morphology examination) OR ((high magnification) AND (sperm))

0 records

Search results for World Health Organization International Clinical Trials Registry Platform, 7 May 2013:

IMSI OR MSOME

6 records



Appendix 9. Web of Knowledge search strategy

Search results for Web of Knowledge, 7 May 2013:

(((intracytoplasmic sperm injection*) OR (icsi) OR (conventional intracytoplasmic injection*) OR (regular magnification)) AND


examination*) OR (high magnification)))

240 records

Appendix 10. OpenGrey search strategy

Search results for OpenGrey, 7 May 2013:

((intracytoplasmic sperm injection*) OR (icsi) OR (conventional intracytoplasmic injection*) OR (regular magnification)) AND


examination*) OR (high magnification))

0 records

Appendix 11. DARE search strategy

Search results for Database of Abstracts of Reviews of Effects (DARE), 7 May 2013:

((intracytoplasmic sperm injection$) OR (icsi) OR (conventional intracytoplasmic injection$) OR (regular magnification)) AND

((intracytoplasmic morphologically selected sperm injection$) OR (IMSI) OR (MSOME) OR (motile sperm organelle morphology

examination$) OR (high magnification))

5 records

C O N T R I B U T I O N S O F A U T H O R S

Drafting the protocol: Danielle M Teixeira, Mariana AP Barbosa, Rui A Ferriani, Paula A Navarro, Nick Raine-Fenning, Carolina O

Nastri, Wellington P Martins.

Development of search strategy: Danielle M Teixeira, Wellington P Martins.

Search for trials: Danielle M Teixeira, Mariana AP Barbosa, Wellington P Martins.

Obtaining copies of trials: Danielle M Teixeira, Wellington P Martins.

Selection of which trials to include: Danielle M Teixeira, Mariana AP Barbosa, Wellington P Martins.

Extraction of data from trials: Danielle M Teixeira, Mariana AP Barbosa, Wellington P Martins.

Assessment of risk of bias in included studies: Danielle M Teixeira, Mariana AP Barbosa, Carolina O Nastri.

Entry of data into RevMan: Danielle M Teixeira, Carolina O Nastri, Wellington P Martins.

Drafting the review: Danielle M Teixeira, Mariana AP Barbosa, Rui A Ferriani, Paula A Navarro, Nick Raine-Fenning, Carolina O

Nastri, Wellington P Martins.



D E C L A R A T I O N S O F I N T E R E S T

The authors declare no conflicts of interest.

S O U R C E S O F S U P P O R T

Internal sources

• Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), Brazil.

Scholarship

• Hospital das Clínicas FMRP-USP, Brazil.

Salary

• Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Brazil.

Scholarship

• Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP), Brazil.

Scholarship

External sources

• No sources of support supplied

D I F F E R E N C E S B E T W E E N P R O T O C O L A N D R E V I E W

None.



Regular (ICSI) versus ultra-high magnification (IMSI) sperm selection for assisted reproduction

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