Topic: Male Factor Infertility

Topic: Male Factor Infertility Topic Overview: Male Factor Infertility Comparisons of pregnancy rates at insemination based on total motile sperm counts from the 1999 and 21 World Health Organization (WHO) semen analysis norms (Dahan) Revisiting DNA integrity in function of sperm motility (Zanko) Age of the sperm donor: does it really matter - an analysis of 1,48,576 assisted reproduction treatment cycles (Ghuman) The quest for the less than ideal spermatozoon does it generate good quality embryos? (Neri) Does body mass index (BMI) influence sperm parameters in infertile men? (Mirallié-Nussbaumer)

O-2 Comparisons of pregnancy rates at insemination based on total motile sperm counts from the 1999 and 21 World Health Organization(WHO) semen analysis norms MH Dahan Session 4, Male infertility Study Background and Aim Background For the last 5-years semen analysis norms in the fertile population have been calculated by the WHO and have decreased at each reassessment The 21 WHO manual uses for the first time fertile men as a reference. The 5 th centile was used to calculate the lower limits of normal It could be assumed that this reassessment of limits should have clinical implications, translating into lower pregnancy rates Particularly, if they are to be used for treatment planning in an infertile population Aim To determine whether the 21 semen analysis parameters are better predictors of pregnancy than the 1999 limits when intra uterine inseminations (IUI) are performed. WHO, World Health Organization Dahan MH. Session 4. O-2

Study Materials and Methods Retrospective study All semen analysis performed on the day of IUI were enrolled for evaluation (N=2,229) for a period of 2.5 years Fresh semen for IUI was evaluated using a count slide at 37 o C and processed by density gradient, in couples with 1-year of infertility and 1 patent fallopian tube Specimens were categorised by the TMSC and the following groups: 1999 normal: 2 M TMSC 1999 abnormal, but normal by 21: 19.9-7.2 M TMSC 21 abnormal: <7.2 M TMSC TMSC, total motile sperm count Dahan MH. Session 4. O-2 Baseline characteristics of subjects in the three TMSC groups TMSC Normal 1999 N=697 Abnormal 1999 but Normal 21 N=164 Abnormal 21 N=12 Maternal Age (years) Duration of infertility (months) Previous pregnancies 37 ± 6 38 ± 6 37 ±6 23 ± 12 24 ± 14 24 ± 15 1.3 ± 1.3 1.2 ± 1.1 1.1 ±.9 Number of mature follicles 2.4 ± 1.3 2.4 ± 1.3 2.2 ± 1.1 Max Day 3 FSH (mlu/ml) 7.6 ± 2.4 8.1 ± 2.5 7.9 ± 2.5 FSH, follicle-stimulating hormone Dahan MH. Session 4. O-2

Comparison of semen analysis parameters in the three TMSC groups TMSC Normal 1999 N=697 Abnormal 1999 but Normal 21 N=164 Abnormal 21 N=12 Volume (ml) 3.2 ± 1.6 2.6 ± 1.5 2.2 ± 1.9 Concentration (M/mL) 65 ± 43 23 ± 14 15 ± 11 Percent motile (%) 57 ± 17 31 ± 13 17 ± 12 Total motile sperm count (M) 114 ±17 13 ±4 3.5 ± 2 TMSC, total motile sperm counts Dahan MH. Session 4. O-2 No difference in pregnancy rates between abnormal 1999/normal 21 and the abnormal 21 groups 25 2 21 P=.5 18 17 15 1 Pregnancy Rates 5 1999 Normal 1999 abnormal, 21 normal 21 abnormal A post-hoc analysis found no difference in pregnancy rates between abnormal 1999/normal 21 and the abnormal 21 groups (P=.77), even when correcting for confounding effects Dahan MH. Session 4. O-2

Conclusions and Clinical Implications Conclusions Abnormal patients by the 21 guidelines are no less likely to conceive than those who were abnormal by the 1999 limits Therefore, changing these limits has little clinical implications, since only values above the 1999 limits correlate with a higher pregnancy rate Clinical implications Pregnancy rates remain excellent below the 1999 and 21 parameters of normal for TMSC. Therefore controlled ovarian stimulation combined with IUI remains feasible for patients affected with male factor infertility. Dahan MH. Session 4. O-2 O-156 Revisiting DNA integrity in function of sperm motility A Zanko Session 42, Sperm DNA integrity

Study Background and Aim Background During the later stages of spermiogenesis, DNA breakages are physiologically induced to allow tight chromatin compaction Only spermatozoa with repaired chromatin reach the ejaculate In the male genital tract, oxygen-free radicals mostly from decaying spermatozoa and other cells are the main cause of DNA damage and responsible for the compromised ART outcome Therefore, tests for sperm DNA integrity are gaining popularity However, sperm chromatin fragmentation does not always correlate with ICSI outcome Aim To revisit the role of DNA fragmentation index (DFI) by measuring the DFI of exclusively motile spermatozoa in relation to clinical outcome. ART, assisted reproductive technology; ICSI, intra-cytoplasmic sperm injection; DFI, DNA Fragmentation index Zanko A. Session 42. O-156 Study Materials and Methods Couples with previous ART failure were screened for sperm DNA fragmentation and inseminated by ICSI DFI was plotted against abstinence period and semen parameters A total of 253 couples with 568 ICSI cycles were analysed and compared DFI was assessed by TUNEL and SCSA tests A normalised DFI (mdfi) was calculated by taking the initial DFI x a constant x motility, and was correlated with clinical outcome Zanko A. Session 42. O-156

DFI was positively correlated with abstinence period 7 6 P<.1 Patients with abnormal DFI (%) 5 4 3 2 1 47.4 41.7 36.6 28.2 74/262 15/41 1/24 9/19 3 >3 4 >4 5 >5 Abstinence (days) The abstinence period ranged from 1 to 18 days Zanko A. Session 42. O-156 Higher sperm motility had the lowest incidence of DNA fragmentation 7 6 56.9* *P<.1 DNA fragmentation (%) 5 4 3 2 1 16.5* 6.3* Initial Immotile Motile Zanko A. Session 42. O-156

Clinical pregnancy (%) In women 35 years, mdfi was correlated with ICSI clinical outcome 5 4 3 2 1 31.* 26.7 28 *P<.5 17.6* DFI mdfi mdfi, but not DFI, was associated with implantation rates and clinical outcomes in women 35 years undergoing ICSI Implantation (%) 19.3 12.4 11.2 7.1 25 3 >25 >3 25 3 >25 >3 Normal Abnormal Normal Abnormal 5 4 3 2 1 mdfi = DFI x.322 x motility P<.5 DFI mdfi Zanko A. Session 42. O-156 Conclusions and Clinical Implications Conclusions DNA fragmentation positively correlates with abstinence DNA fragmentation inversely correlates with motility When normalised DFI was found to be correlated with ICSI clinical outcome Clinical implications This study indicates that damage to the chromatin is a postspermatogenic phenomenon and it occurs while the sperm is progressing through the male genital tract. Further research in additional studies is required to understand the implications of these findings for clinical practice. Zanko A. Session 42. O-156

O-157 Age of the sperm donor: does it really matter - an analysis of 1,48,576 assisted reproduction treatment cycles NK Ghuman Session 42, Sperm DNA integrity Study Background and Aim Background Although it is well known that advanced maternal age has a negative effect on fertility and pregnancy outcome, the influence of paternal age or sperm donor age on these outcomes is less well researched Substantial evidence of reproductive outcome based on male donor age is lacking Aim To determine whether the age of the sperm donor affects the chances of success in women undergoing assisted reproduction for the first time. Ghuman NK. Session 42. O-157

Study Materials and Methods UK Human Fertilisation and Embryology Authority (HFEA) data registry from year 1991 to 212 1,48,576 treatment cycles analysed 237,853 sperm donation cycles 39,282 first sperm donation treatment cycles in selected groups, i.e. women aged 18-34 years and women >37 years Ghuman NK. Session 42. O-157 Study Materials and Methods (con t.) 3,97 cycles in 18 34 year women 9,185 cycles in >37 years women 25,925 DI cycles 4172 IVF/ICSI cycles 649 DI cycles 2695 IVF/ICSI cycles Above groups were sub-divided in 6 sub-groups based on sperm donor age (<2, 21 25, 26 3, 31 35, 36 4 and 41 45 years) Regression Logistics was applied to compare Live births in sub-groups in all four groups separately IVF, in-vitro fertilisation; DI, donor insemination Ghuman NK. Session 42. O-157

Age of the sperm donor does not alter the live birth rate in females undergoing ART Live birth rate (%) 35 3 25 2 15 1 5 3.4% 28.3% 17% 16.6% 11% 12% 9.7% * 3.1% 4.6% <2 21 25 26 3 31 35 36 4 41 45 Sperm donor age group (years) 18 34 years women IVF/ICSI treatment cycles >37 years women IVF/ICSI treatment cycles 18 34 years women DI cycles >37 years women DI cycles Impact of sperm donor age on live birth failed to reach statistical significance in any of the age groups Ghuman NK. Session 42. O-157 Conclusions and Clinical Implications Conclusions Age of the sperm donor does not significantly alter the live birth rate in females undergoing ART As the study is based on available data registry, potential confounders such as smoking, body mass index were not accounted There was no follow-up of the children Clinical implications This is probably the first study to conduct an analysis of impact of sperm donor age on live birth using a large national database. Although female age is a key predictor of outcome in ART, sperm donor age appears to have less of an impact on outcome. Ghuman NK. Session 42. O-157

O-16 The quest for the less than ideal spermatozoon does it generate good quality embryos? QV Neri Session 42, Sperm DNA integrity Study Background and Aim Background Cryptozoospermic and azoospermic men often provide scarce and dysmorphic spermatozoa plagued by poor motility The genomic integrity and competence of these spermatozoa are of concern In pseudo-/azoo-spermic men, an extensive search is required to find suitable spermatozoa to be injected The increasing search time is inversely related to sperm availability, morphology, kinetic characteristics and genomic integrity Aim To assess the clinical outcome of less than ideal spermatozoa identified in ejaculated and testicular specimens. Neri QV. Session 42. O-16

Study Materials and Methods In a retrospective cohort analysis, ICSI outcomes were reviewed as a function of the length of microscopic sperm search carried out in ejaculated (n=2197) and testicular specimens (n=118) Fertilisation, pregnancies, deliveries, and child health in relation to increasing search time were compared to controls with a large selection of spermatozoa An extended sperm quest of ejaculated and TESE samples was performed The genomes of the sperm were screened TESE, testicular sperm extraction Neri QV. Session 42. O-16 Trend towards decreasing fertilisation rates with increased search time Fertilisation (%) 1 9 8 7 6 5 4 3 2 1 Ejaculated TESE 75.5 58.5 53.8 48.3 61.1 46.7 43.9 33.9 27 25.2 Control 3 6 min 61 12 min 121 18 min >18 min Search time Neri QV. Session 42. O-16

A strenuous search for the male gamete is rewarded by the achievement of pregnancy 8 Ejaculated 8 TESE 7 7 Clinical pregnancy (%) 6 5 4 3 2 1 38.4 32.7 Control 3 6 min 48.1 61 12 min 121 18 min 5 >18 min Clinical pregnancy (%) 6 5 4 3 2 1 41.2 43.6 Control 3 6 min 35.5 61 12 min 31 121 18 min 22.7 >18 min Search time Search time Neri QV. Session 42. O-16 Morphologically and kinetically impaired spermatozoa affect fertilisation but not embryo developmental competence Percentage 1 9 8 7 6 5 4 3 2 Ejaculated 1 9 75.6* Motile 8 7 *P=.1 Immotile 59.1* 6 43.3 4.9 33.6* 23.5 23.5 Percentage 5 4 3 26.4* 2 TESE * P=.1 Motile Immotile 42.3 4.5 28.4 23.9 1 1 Fertilization Clinical Pregnancy Delivery/Ongoing Fertilization Clinical Pregnancy Delivery/Ongoing Neri QV. Session 42. O-16

Conclusions and Clinical Implications Conclusions An exhaustive sperm quest in specimens from men with severely compromised spermatogenesis yielded morphologically and genomically impaired spermatozoa that retained the ability to activate oocytes This can only be explained by the ability of the oocyte to overcome eventual male genomic errors Clinical implications With ICSI, the ability to achieve a pregnancy appears to be relatively unaffected by the abating quality and scarcity of spermatozoa retrieved. Neri QV. Session 42. O-16 O-17 Does body mass index influence sperm parameters in infertile men S Mirallié-Nussbaumer Session 4, Male infertility

Study Background and Aim Background Extreme BMI categories, i.e. underweight and obese categories, are known to negatively impact female fertility and ART success rates In men, the evidence is not as clear Some researchers have shown that male obesity leads to altered semen parameters and lower success rates in ART cycles Aim To investigate the correlation between BMI and semen parameters in a population of unselected subfertile men. Mirallié-Nussbaumer S. Session 4. O-17 Study Materials and Methods Prospective monocentric study All men who came for a first routine fertility evaluation at the andrology laboratory received a questionnaire dealing with various demographic characteristics Participants were classified into four groups according to their BMI: <18.5 kg/m 2 18.5-25 kg/m 2 25-3 kg/m 2 >3 kg/m 2 Sperm analysis was performed with strict adherence to WHO 5th edition recommendations Kinetic parameters were assessed with a CASA system CASA, computer-aided semen analyser Mirallié-Nussbaumer S. Session 4. O-17

CASA kinetic parameters were comparable in all BMI groups Abstinence delay was comparable in all groups CASA kinetic parameters (VCL, VSL, ALH) were not significantly different among the 4 BMI groups Mean volume of the ejaculate, sperm concentration, total sperm numeration, and morphology were not significantly different among the 4 BMI groups VCL, curvilinear velocity; VSL, straight-line velocity; ALH, amplitude of lateral head displacement Mirallié-Nussbaumer S. Session 4. O-17 Mean progressive motility was significantly lower in underweight men Progressive motility 1 9 8 7 Percentage 6 5 4 3 *P<.5 29.3* 39.5 41.4 39.1 2 1 Underweight (n=18) Normoweight (n=769) Overweight (n=385) Obese (n=94) However, the population of underweight men was limited Mirallié-Nussbaumer S. Session 4. O-17

Conclusions and Clinical Implications Conclusions Contrary to what has already been described in other studies, this study did not find any significant difference in terms of conventional sperm parameters and CASA parameters between obese, overweight and normoweight infertile men However, progressive sperm motility was significantly lower in underweight men compared with other categories Clinical implications The issue of the correlation between BMI and sperm parameters in infertile men remains to be fully addressed. A specific focus in future studies should be put on underweight infertile men, as they might constitute a particular patient subgroup. Mirallié-Nussbaumer S. Session 4. O-17 Summary

Summary: Male Factor Infertility Dahan et al: Pregnancy rates remain excellent below the 1999 and 21 WHO parameters of normal for TMSC Therefore controlled ovarian stimulation combined with IUI remains feasible for patients affected with male factor infertility Zanko et al: Damage to the chromatin is a post-spermatogenic phenomenon and it occurs while the sperm is progressing through the male genital tract Further research in additional studies is required to understand the implications of these findings for clinical practice Ghuman et al: Age of the sperm donor does not significantly alter the live birth rate in females undergoing ART Summary: Male Factor Infertility (con t.) Neri et al: An exhaustive sperm quest in specimens from men with severely compromised spermatogenesis yielded morphologically and genomically impaired spermatozoa that retained the ability to activate oocytes This can only be explained by the ability of the oocyte to overcome eventual male genomic errors Mirallié-Nussbaumer et al: The issue of the correlation between BMI and sperm parameters in infertile men remains to be fully addressed A specific focus in future studies should be put on underweight infertile men, as they might constitute a particular patient subgroup