Abstract
Purpose
To evaluate reproductive outcomes of artificial insemination and IVF with donor sperm (AID or IVF-D) for male-factor couples with a history of unsuccessful ICSI attempt.
Methods
This retrospective cohort includes couples with severe male-factor infertility who failed ICSI treatment, and subsequently underwent semen donation treatment. We report the following outcomes: (1) live birth rates in AID and IVF-D treatment for couples with severe male infertility factors and prior ICSI failures; (2) paternal impact on embryo development of the same oocyte cohort; (3) prognostic factors in obtaining a live birth with donor semen.
Results
Of 92 women with failed ICSI cycles (26 with multiple attempts), 45 couples underwent AID treatment. Live birth rate per cycle of AID was 18.9%. Fifty-three patients underwent IVF-D including 6 couples who previously did not conceive with AID. Embryological outcomes including fertilization, viable cleavage embryos, and blastocyst formation rates were significantly lower in ICSI cycles with partner sperm compared with IVF-D (P < 0.01). Logistic regression analysis showed that female age and the severity of spermatogenetic disorder are prognostic factors in obtaining a live birth with donated sperm.
Conclusion
Couples with severe male infertility factor (azoospermia or extreme oligoasthenospermia) and a history of unsuccessful ICSI cycles benefit from treating with donor sperm. ICSI fertilization, embryo viability, and progression of the embryo to the blastocyst stage are significantly deteriorated by semen parameters. The prognostic factors identified may help couples plan their treatment and prepare for their parenthood journey.
Electronic supplementary material
The online version of this article (10.1007/s10815-020-01828-0) contains supplementary material, which is available to authorized users.
Keywords: Azoospermia, Oligoasthenospermia, Blastulation rate, Failed ICSI, Donor sperm
Introduction
Infertility is defined as the failure to conceive after 1 year of unprotected intercourse and affects approximately 10–15% of couples of reproductive age [1], with a male factor accounting for 25–50% [2].
The introduction of ICSI by the work of Van Steirteghem and colleagues has revolutionized the management of couples with male-factor infertility and these requiring surgical sperm retrieval, offering a chance of conception for these patients [3, 4]. However, patients with extreme low sperm quality can undergo repeated attempts of ICSI before achieving a live birth. Although an early small study from Mansour et al. [5] argued that abnormal sperm parameters did not influence fertilization rate, association of the paternal original factors to embryonic development has been reported by recent researches [6–8]. Strassburger et al. [7] have described that ICSI success rates are reduced in couples with very low sperm concentration either azoospermia or cryptozoospermia. A large observational cohort study of 1219 consecutive ART cycles showed that male-factor infertility negatively influenced ICSI fertilization and blastulation rates but had no effect on blastocyst quality [8].
Sperm donation is proposed as the last straw for a couple faced with ICSI failures. They may choose to undergo an artificial insemination or conventional IVF with donor sperm (AID/IVF-D) based on individual indication [9]. For couples performing AID without first having attempted of ICSI, the pregnancy rate per cycle goes from 14 to 29.1% per cycle and the cumulative pregnancy rate after six cycles is 60% [10–12]. However, very little information is available regarding the fate of couples after failure of ICSI with husband semen. After transition to donor sperm, a notable chance of achieving a live birth should be expected in such infertile patients. If so, can we get certain prognostic information through evaluating the failed ICSI?
To embark on the parent journey through ART is often costly, accompanied by medical, financial, and emotional stress. Patients need a good understanding of their challenges and chances before they finalize any treatment decision.
Our aim is to identify relevant parameters that might act as prognostic factors for future treatment with donor semen after unsuccessful ICSI attempts and to assess specific aspects of paternal impact on preimplantation embryo of the same oocyte population.
Materials and methods
Institutional approval
This study was approved by the Ethics Review Board of the Northwest Women’s and Children’s Hospital, Xi’an, China.
Patients
This study was designed as a cohort retrospective study at the Northwest Women’s and Children’s Hospital. The data presented in this study were based on clinical and laboratory results obtained from our assisted reproductive center. Given the retrospective nature of the work, no specific consent was required from the patients.
A cohort of couples with severe male-factor infertility with a history of failed ICSI attempt, and subsequently treated with sperm donation was collected from May 2015 through Oct 2018. Inclusion criteria are as follows: (1) diagnosed with severe male-factor infertility, including azoospermia and oligoasthenospermia; (2) at least one previous ICSI or ICSI-TESE attempt for male infertility, with or without embryo transfer(s) fresh and/ or frozen, and without delivery; (3) followed by at least one cycle with donor sperm, either via intrauterine insemination or IVF. Cycles were excluded: (1) cycles canceled prior to oocyte retrieval; (2) cycles with oocyte donation; (3) cycles for pre-implantation genetic diagnosis/screening (PGD/PGS) and (4) incomplete follow-up.
Azoospermia is defined as absence of sperm cells in the ejaculate in at least three consecutive spermiograms for which testicular sperm extraction (TESE) can be performed; men with cryptozoospermia also fell into this group, defined as spermatozoa absent from fresh preparations but observed in a centrifuged pellet none [13]; severe oligoasthenospermia is defined as a sperm concentration of less than 5 × 106/ml and motility < 20% [14].
When previous ICSI attempts using semen from the partner failed, a subsequent artificial insemination or IVF attempt was performed using donor sperm in order to compare fertilization and embryo formation of the same oocyte population.
The IVF-D indication for donor sperm included tubal obstruction (hysterosalpingography or laparoscopy), polycystic ovary syndrome (PCOS), endometriosis, and reduction of ovarian reserve. Patients failed with multiple cycles of AID were treated by IVF-D.
Baseline characteristics including maternal and paternal age, duration of prior infertility, gravidity, parity and severity of spermatogenetic disorder were analyzed. All women were evaluated for tubal permeability for AID, and for ovarian function by means of day 3 hormone determination. The AID is an initial treatment; IVF was recommended after failed attempts at achieving pregnancy (at least 3 cycles in our case), or if other pathologies (i.e., tubal obstruction, endometriosis, PCOS, and reduction of ovarian reserve).
Sperm preparation
The sperm samples required for ICSI procedure are obtained either from freshly ejaculated semen or via TESE. Presence of motile sperm was assessed under the inverted microscope. In all cases, surgical sperm retrieval was performed by the same group of three surgeons.
The donor sperm samples were supplied by Shaanxi Province Human Sperm Bank. The general procedures for donor recruitment, sperm freezing, and selection of recipients were the same, in accordance with the standards of National Health and Family Planning Commission (NHFPC) of the People’s Republic of China. All donor samples were studied by means of periodical analysis to eliminate the presence of sexually transmitted diseases and genetic disorders. Briefly, the requirements for donor semen are as follows: semen volume ≥ 2 ml, concentration ≥ 60 × 106/ml, progressive motility ≥60%, and normal morphology of ≥30%, and patients were healthy and had no chromosome abnormality [15]. Samples were thawed and prepared by density gradients when required, after selection to match the receiving couple’s phenotypical characteristics and blood type.
Ovarian stimulation protocol of IVF/ICSI
The ovarian stimulation protocol has been described previously [16]. In brief, stimulation protocols were used with a combination of GnRH agonist/GnRH antagonist and recombinant FSH. Ovarian response was monitored by serial ultrasound examination and hormone measurement. Ten thousand units of human chorionic gonadotrophin (hCG) was administered in patients when three follicles were > 18 mm. Oocyte retrieval was performed 36 h later by transvaginal ultrasonography-guided aspiration.
ICSI procedure and embryo assessment
The ICSI procedures have been described elsewhere [17]. The oocyte was considered fertilized if a second polar body was extruded or if two pro-nuclei were observed 16 h after insemination. Normally fertilized oocytes were transferred into fresh drops of cleavage medium.
A morphologic score was given for day 3 embryo according to the number of blastomeres, homogeneous degree of blastomeres, and degree of cytoplasmic fragmentation: grade I (8–10 blastomeres, even homogeneous blastomeres < 10% cytoplasmic fragmentation), grade II (6–7 or > 10 blastomeres with even homogeneous blastomeres of no cytoplasmic fragmentation; 8–10 blastomeres, even homogeneous blastomeres with 10–20% cytoplasmic fragmentation), grade III (uneven and non-homogeneous blastomeres with 20–50% cytoplasmic fragmentation), and grade IV (uneven and non-homogeneous blastomeres with > 50% cytoplasmic fragmentation). Grades I, II, and III were identified as embryos available. Grade I and grade II were identified as high-quality embryo [18].
Cleavage-stage embryos were cultured to blastocyst-stage, if a couple has four or more good embryos on day 3. On day 5/6, the quality of the blastocysts was evaluated using Gardner and Lane’s classification [19]. After 5 or 6 days of co-culture, the total number of blastocysts was assessed. Only embryos with true compact inner cell mass were considered blastocysts. Equally skilled embryologists took turns at performing embryo grading and freezing to reduce the cases of discordance among them. In some cases, blastocyst transfer was programmed but no blastocyst was available or the blastocyst quality was not qualified; in that case, no embryo was transferred.
The vitrification, warming procedure, endometrial preparation, and embryo transfer procedures were done according to standard protocols [20]. All embryo transfers were performed using a Wallace catheter and guided with an abdominal ultrasound scan. One or two of the best quality embryos were transferred into the uterus on day 3 or 5. After embryo transfer, the remaining viable embryos were cryopreserved. Patients failing to achieve a clinical pregnancy after fresh embryo transfer would go through cryopreserved cycles until all vitrified embryos were transferred or a live child was obtained.
ART with donor sperm
Aid
A baseline transvaginal ultrasound scan was performed on day 5 of the menstrual cycle to rule out preexisting ovarian cyst(s). AID was performed in natural or stimulated cycles. Women were inseminated in a natural cycle when cycles were regular and ovulatory. After a failed attempt in the natural cycle or in case of anovulation, ovarian stimulation was used. Ovarian stimulation was conducted by either administering letrozole or HMG. An injection of 10,000 IU hCG was then given to trigger ovulation. Intrauterine insemination was performed 36 to 40 h after hCG injection.
IVF-D procedure
Conventional IVF fertilization is performed 2–2.5 h after oocyte retrieval. Each oocyte is incubated with approximately 40,000 sperm and fertilization is allowed to occur naturally. Fertilization was assessed 16–18 h following routine IVF and presence of two pro-nuclei indicated normal fertilization. Each egg is incubated with approximately 40,000 sperms and the culture volume is 0.7 ml. Generally, two eggs are co-cultured with sperms in each well.
Serum β-hCG was measured 14 days after cleavage-stage embryo transfer and 9 days after blastocyst transfer. Clinical pregnancy was defined by the ultrasound confirmation of an intrauterine gestational sac after 6 weeks of gestation. Live birth was defined as the delivery of a live-born infant (> 24 weeks of gestation).
Outcomes
Outcome was the likelihood of achieving a live birth for a couple via AID or complete cycle of IVF-D. One complete IVF cycle included all fresh and frozen embryo transfers resulting from one episode of ovarian stimulation.
Statistical analysis
Comparison of the results between groups in the case of continuous variables was made by using Student’s t test for data with normal distribution and non-parametric Mann–Whitney U-test for data with skewed distribution. Comparison of the results between groups in the case of categorical variables was made with the use of contingency table analysis. For data that did not meet the requirement for a Chi-square test, Fisher’s exact test was used. Binary logistic regression analysis (stepwise forward entry) was used to determine independent factors that affect the prognostic of future pregnancy rate with sperm donation. SPSS version 21 (IBM Corp., USA) was used for statistical analysis. P < 0.05 was considered to be significant.
Results
Characteristics of the patients and ICSI cycles
During the study period, 92 couples who had severe male infertility factors and with failed ICSI cycles (26 with multiple attempts), subsequently used donor sperm (Fig. 1). Patient characteristics and the number of previous ICSI cycles performed are shown in Table 1. The mean age of the female patients was 29.2 ± 4.4 years at first ICSI cycle and the male population was 31.1 ± 4.5 years. The mean duration of infertility was 2.8 ± 2.2 years. The proportions of men diagnosed with azoospermia/cryptozoospermia and oligoasthenospermia were 43.5% and 56.5%, respectively.
Fig. 1.
Flow chart and schematic overview of the couples changed into donor sperm treatment after ICSI failures
Table 1.
Main characteristics of the study population
| Total | |
|---|---|
| No. of couples | 92 |
| Infertility type | |
| Primary infertility (n, %) | 69 (75) |
| Secondary infertility (n, %) | 23 (25) |
| Male infertility indication | |
| Oligo, n (%) | 52 (56.5) |
| Azoo/Crypto, n (%) | 40 (43.5) |
| Female age at ICSI (years) | 29.2 ± 4.4 |
| Male age at ICSI (years) | 31.1 ± 4.5 |
| Duration of infertility (years) | 2.8 ± 2.2 |
| BMI (kg/m2) | 21.4 ± 2.8 |
| Basal serum FSH, IU/L | 7.5 ± 3.0 |
| AFC, n | 11.5 ± 5.3 |
| Previous failed ICSI cycles | 121 |
| 1, n (%) | 66 (71.7) |
| 2, n (%) | 23 (25.0) |
| 3, n (%) | 3 (3.3) |
| No. of cycle cancelations, n | 41 |
| Fertilization failure, n (%) | 9 (22.0) |
| No viable embryo, n (%) | 16 (39.0) |
| Failed to form blastocysts, n (%) | 16 (39.0) |
Oligo, oligoasthenospermia; Azoo, azoospermia; Crypto, cryptozoospermia; ICSI, intracytoplasmic sperm injection; BMI, body mass index; AFC, antral follicular count
Reproductive outcomes
Outcomes of AID cycles
Of the selected population, 45 couples underwent AID treatment. Ninety AID cycles were completed during the study period. The clinical pregnancy rate per cycle of donor insemination was 22.2% (20/90), and the overall AID clinical pregnancy rate per couple was 44.4% (20/45) (Fig. 2). All women conceived within 4 cycles and 50% of pregnancies were obtained during the first AID cycle. Three women suffered from spontaneous miscarriages, resulting in 17 live births including 12 females and 5 males. We observed a live birth rate (LBR) of 18.9% (17/90) per cycle of AID, with a mean of 1.5 ± 0.8 donor insemination cycles (ranges from 1 to 4 cycles). (Supplemental Table 1). Six out of the 28 women who did not achieve a live birth successfully after three to four cycles of donor insemination subsequently changed into IVF-D treatment.
Fig. 2.
Cumulative rates of pregnancy and live birth of artificial insemination with donor sperm
Outcomes of IVF-D
Overall, 53 patients of the study population used IVF-D, from which 572 oocytes were recovered (mean 10.0 ± 5.2), resulting in 306 viable embryos on day 3 (mean 5.4 ± 3.7), with a two-pronuclear fertilization rate of 66.8%. A total of 105 embryos were transferred (51 in cleavage stage and 54 in blastocyst stage), with a mean of 1.72 embryos transfer. All surplus embryos were cryopreserved. Among the 43 cycles that progressed to clinical pregnancy as defined by the observation of a fetal heartbeat, 9 resulted in additional losses from miscarriage. These overall cases resulted in a delivery rate of 59.6% per retrieval (34/57) and 55.7% per embryo replacement (34/61), resulting in the birth of 43 neonates including 9 twins (24.3%), consisting of 16 females and 27 males (Supplemental Table 2).
Paternal influence on embryo viability
We compared the embryological outcomes of the ICSI cycles with husband sperm and subsequent IVF-D cycles. Although the mean numbers of oocytes retrieved were similar between the two groups, rates of fertilization and post-fertilization development were significantly different between them. In the group with husband sperm, a total of 27 (22.3%) cycles were canceled either secondary to total fertilization failure (8 cycles) or poor embryo quality (19 cycles with no viable embryos). Total fertilization rate and the two-pronuclear fertilization rate were significantly decreased when compared with the group with donor sperm (P < 0.01). Cleavage rate was similar in the two groups (P = 0.827). Of the cultured cleaved embryos, significantly fewer reached the blastocyst stage in the ICSI group (Table 2). Progression to blastocyst from 8-cell embryos was 27.3% in the ICSI group and 62.8% in the IVF-D group (P < 0.01). When the timing of blastocyst formation was studied (day 5 versus day 6), more embryos in the group with sperm donation reached the blastocyst stage on day 5 compared with the group with husband sperm (P < 0.01) (Table 2).
Table 2.
Analysis of cycle characteristics and embryo data in different sperm sources
| Variable | ICSI with partner sperm | IVF-D | P |
|---|---|---|---|
| No. of couples | 53 | 53 | |
| Cycles of oocytes retrieved | 69 | 57 | |
| No. oocytes retrieved, n (mean ± SD) | 754 (10.9 ± 5.3) | 572 (10.0 ± 5.2) | 0.35 |
| Cycles of CFF, n (%) | 3 (4.3) | 1 (1.8) | 0.40 |
| Fertilization rate, n (%) | 352 (56.2) | 477 (83.4) | < 0.01 |
| 2PN fertilization rate, n (%) | 328 (52.4) | 382 (66.8) | < 0.01 |
| Cleavage rate, n (%) | 349 (99.1) | 471 (98.7) | 0.83 |
| Viable embryos on day 3, n (mean ± SD) | 207 (3.0 ± 2.5) | 306 (5.4 ± 3.7) | < 0.01 |
| High-quality embryos, n (%) | 70 (33.8) | 178 (58.2) | < 0.01 |
| Cycles cultured to blastocyst stage, n | 22 | 35 | |
| Cycles reaching to blastocysts, n (%) | 12 (54.5) | 29 (82.9) | 0.02 |
| Cycles with no blastocysts available, n (%) | 10 (45.5) | 6 (17.1) | 0.02 |
| Embryos cultured to blastocysts, n | 99 | 231 | |
| Blastocyst formation rate, n (%) | 27 (27.3) | 145 (62.8) | < 0.01 |
| Timing of blastocyst formation | |||
| Blastocysts on day 5, n (%) | 15 (55.6) | 130 (89.7) | < 0.01 |
| Blastocysts on day 6, n (%) | 12 (44.4) | 15 (10.3) | < 0.01 |
ICSI, intracytoplasmic sperm injection; IVF-D, in vitro fertilization with donor sperm; CFF, complete fertilization failure; 2PN, two pronuclei
Results of the previous ICSI outcomes were further evaluated according to the sperm parameters. ICSI fertilization rate and numbers of viable embryos did not differ between male with azoospermia and those diagnosed with oligoasthenospermia. A trend toward a higher rate of blastulation was seen with oligoasthenospermia samples compared with those with azoospermia (33.3% vs 27.5%), although differences were not significant (Table 3).
Table 3.
Characteristics of previous ICSI cycles according to the severity of sperm disorders
| Azoo/Crypto | Oligo | P | |
|---|---|---|---|
| No. of couples, n | 40 | 52 | - |
| No. of failed ICSI cycles, n | 48 | 73 | - |
| Male age at 1st ICSI, year | 30.4 ± 4.6 | 31.6 ± 4.3 | 0.13 |
| No. of oocytes retrieved, n | 10.2 ± 5.4 | 11.0 ± 5.6 | 0.53 |
| No. of MII oocytes, n | 8.8 ± 5.2 | 8.9 ± 4.7 | 0.93 |
| No. of 2PN, n | 4.2 ± 3.6 | 4.4 ± 3.4 | 0.73 |
| Fertilization rate, n (%) | 214 (50.5) | 348 (53.5) | 0.34 |
| 2PN fertilization rate, n (%) | 201 (47.4) | 322 (49.5) | 0.51 |
| No. of viable embryos, n | 3.2 ± 3.0 | 2.7 ± 2.6 | 0.26 |
| No. of high-quality embryos, n | 1.4 ± 1.9 | 1.0 ± 1.8 | 0.18 |
| Rate of high-quality embryo, n (%) | 67 (43.2) | 68 (35.1) | 0.12 |
| No. of cryopreserved D3 embryos, n | 0.7 ± 1.2 | 0.8 ± 1.2 | 0.56 |
| Rate of blastulation, n (%) | 27 (27.5) | 31 (33.3) | 0.36 |
| Cycles with at least one blastocyst, n (%) | 10 (52.6) | 12 (60.0) | 0.64 |
| No. of cryopreserved blastocysts, n | 0.4 ± 0.9 | 0.4 ± 1.0 | 0.94 |
| No. of total cryopreserved embryos, n | 1.1 ± 1.5 | 1.2 ± 1.3 | 0.66 |
ICSI, intracytoplasmic sperm injection; Azoo, azoospermia; Crypto, cryptozoospermia; Oligo, oligoasthenospermia; MII, metaphase II; 2PN, two pronuclei
Prognostic factors on live birth chances with sperm donation
The characteristics of the study population treated with sperm donation between the pregnant and not pregnant groups are analyzed retrospectively (Supplemental Table 3). The reproductive outcomes were not affected by parity, infertility duration, and number of previous ICSI performed as well as numbers of oocytes retrieved and matured (metaphase II). Cumulative LBR was not different according to the methods of sperm retrieval (ejaculated sperm or testicular sperm). With regard to male-infertility indication, live birth rates per cycle with semen donation were higher when men presented azoospermia than in patients with oligoasthenospermia, though there was no difference in male age between the two subgroups (30.4 ± 4.6 vs 31.6 ± 4.3, P = 0.13). In the case of azoospermia, 27 couples (67.5%) obtained live birth after donation semen, while in men with oligoasthenospermia, only 24 (46.2%) of live births were achieved (P = 0.04). A significantly higher rate of live birth in AID/IVF-D treatment was noted in couples with lower rate of fertilization and blastocyst formation, as well as fewer numbers of embryos cryopreserved in prior intraconjugal ICSI procedure compared with those without the respective condition (P < 0.01; P = 0.01, and P < 0.01, respectively). The proportion of cycles with the formation of at least one blastocyst was greatly lower in patients who have achieved delivery (45.5%) in comparison with those who have not (76.5%), though this was of borderline statistical significance (P = 0.05).
These factors were used as independent variables in multivariate logistic regression analysis. The results are shown in Table 4. In the final model, the variables that significantly predicted the live birth with sperm donation were severity of spermatogenetic disorder (P = 0.012, OR = 3.088, 95% CI 1.281–7.446) and female age at the first ICSI treatment (P = 0.014, OR = 0.793, 95% CI 0.658–0.955) (Table 4).
Table 4.
Prognostic parameters and odds ratios (OR) obtained from logistic regressions for live birth with sperm donation
| Independent variablesa | P value | Odds ratio | 95% CI |
|---|---|---|---|
| Female age, years | 0.014 | 0.793 | 0.658–0.955 |
| Male indication | 0.012 | 3.088 | 1.281–7.446 |
aDependent variable: chance of live birth with sperm donation
Discussion
Male-factor infertility refers to the inability of the male to cause pregnancy in a clinically sound female [21]. Since 1992, the emergence of ICSI has opened a new avenue to achieve pregnancy for couples with severe male-factor infertility [3]. However, not all couples obtain parenthood with ICSI and failures continue to persist. Understanding the role of paternal factors is of critical importance to counsel couples of the existing therapeutic schemes and improve successful chances.
Embryo quality depends on both the quality of the oocyte and sperm that have created the embryo. Different from previous studies, embryological outcomes in the present study were analyzed in the same cohort of women, indicating the embryological outcomes were mainly due to the paternal effect. In this study, we found spermatozoa from severe male-factor patients resulted in low blastulation rate, which appears to be an indicator of developmental capacity of the embryo. The rate of progression to the blastocyst stage was significantly decreased in the intraconjugal ICSI cycles. After changing male gametes, significantly improved rate of progression to the blastocyst stage was seen in the same cohort of women (P < 0.01), reinforcing that abnormal semen parameters would compromise preimplantation embryonic development. More significantly, we found a reduced proportion of rapid developing blastocysts (day 5) in ICSI cycles with husband sperm compared with cycles with sperm donation, suggesting that semen parameters may play a role in the timing of preimplantation development. The delayed blastocyst formation supported that sperm-related factors hinder the potential of the cleavage stage embryo to develop into a blastocyst. Association of the paternal factor to embryonic development has been reported by several groups [6, 22, 23]. In a retrospective study of 1266 ICSI cycles, a significant decreased blastulation rate was seen when men with severe oligozoospermia were utilized for ICSI [6]. Decreased progressive motility and sperm morphology were reported to be correlated with diminished blastocyst development and quality [22]. Desai et al. [23] described that embryos from azoospermic patients exhibited delayed in cell cycle events, from ability to undergo compaction thru morulation, blastocyst formation, and expansion. It should be noted that we failed to find a significant difference in the rate of cleavage between the two treatment cycles. The possible reasons for the non-significance of the difference may be associated with the fact that paternal influence is hidden in the first 3 days and seen only after genomic activation at the 4–8-cell stage [24]. A paternal effect on embryo viability and quality is most likely to manifest itself after embryonic genome activation, i.e., during the phase of extended embryo growth up to the blastocyst phase. In line with multiple published reports, we have observed that the ICSI fertilization rate and the embryo quality were significantly lower in couples with extremely low semen quality. Borges et al. [25] have shown that spermatozoa from semen with severely impaired parameters decrease fertilization rate and proposed sperm motility as a prognostic marker of fertilization rate in ICSI cycles. Couples with extreme severe oligoasthenospermia have a reduced ICSI fertilization rate when compared with those undergoing ICSI for other indications [26]. The limited availability of spermatozoa utilized for ICSI, which subsequently lead to the selection of a suboptimal sperm for injection, could be the potential mechanisms [8, 26]. With all the findings above, in addition to decreased fertilization rate, severely impaired parameters were appeared to be associated with lower and slower rate of blastulation.
Faced with ICSI failures, the commonly proposed alternative solution is changing male gametes. Before starting the new ART program, patients frequently request information about the probability of success. From our observation, reproductive outcomes in AID cycles for couples switched from ICSI are encouraging. In this series, including 45 couples undertaking 90 AID cycles, the live birth rate per cycle of was 18.9% and the overall cumulative live birth rate per couple was 37.8%. These findings are consistent with previous studies reporting a LBR per cycle (16.6%) in AID for couples with poor results in ICSI cycles [27]. When donor sperm is used in ART for IVF, 34 couples (59.6%) succeeded in being parents with a cumulative 55.7% per embryo transfer which was also notably higher than the average LBR of 27.9% reported in US Centers for Disease Control and Prevention’s National ART Surveillance System (NASS) in 2018 [28]. We postulated that the disparities may lie in the higher percentage of older women (73.4% female age was > 35 years) in the population studies by Gerkowicz et al. [28]. Additionally, indications for donor sperm treatment may also influence the IVF-D issue since not all couples were diagnosed with male-related factor in the latter study. Taken together, these results supported that the sperm donation was a reasonable and effective option for male infertility after failed attempts of ICSl.
Evaluating the previous failed IVF cycle provides us useful prognostic information. When comparing the parameters of previous ICSI cycles in couples who did or did not obtain a live birth in later donation cycle, we found that the severity of the spermatogenic disorder seemed to be the crucial factor. More azoospermic patients achieved a live birth by the use of third-party donor sperm (Supplementary Table 3). In multivariate logistic regression, the extreme severity of spermatogenetic disorder was significantly associated with a greater chance of obtaining a live birth (OR = 3.088, 95% CI [1.281–7.446], P = 0.012). This difference may be related to the fact that in cases with azoospermic or cryptozoospermia, most female partners are fertile and have never been in contact with a male gamete for reproductive purposes. The use of donor sperm overcomes the ICSI failure specifically caused by the sperm-related defect. While in the case with oligoasthenospermia, indications are more complicated and female-related factors may not be excluded completely. We therefore hypothesized that azoospermia could be taken as a good prognosis for AID clinical pregnancy, which has been confirmed by another study [29]. Female age was also a key factor found to be significantly influencing live birth with semen donation. Among purely assisted reproductive-related parameters, women’s ages are well known to influence reproductive success [30, 31]. As the number of attempts increased, the female age increased and the age-related decline in female fertility would be more obvious. It was not surprising that we found advanced maternal age in ICSI was associated with lower chance of live birth in subsequent cycles using donor sperm. Report by Benchaib [32] confirmed the same finding. Transition to semen donation therefore should be proposed according to the woman’s age after each ICSI failure. Regarding embryo quality, based on our data, no relationship was found between embryo quality obtained at previous ICSI procedure and probability of pregnancy in donor cycles, which was in accordance with that reported by Hennebicq et al. [29] and it has also been shown a high rate of pregnancy in AID whatever the previous embryo quality [33]. The current literature on embryo quality and its effect on future ART with donor-sperm treatment outcomes is still controversial. Positive relationship between embryo quality and live birth rate in AID has been suggested previously. Couples who had obtained top-quality embryos tended to achieve higher cumulative LBR in AID than couples with poor-quality embryos (68.0% versus 54.5%, respectively), suggesting a positive relationship between embryo quality and live birth rate [27]. Conversely, another France study by Saias-Magnan and Mandelbaum indicated that women with good-quality embryos during intraconjugal ICSI had better pregnancy rates in AID (above 19% per cycle) than those with poor-quality embryos (5.8% per cycle) [34]. The differences may be attributed to the low numbers of patients with poor embryos (under 6% per cycle) after ICSI cycles in that multicenter study. In the present report, although, in the univariate comparison, patients with a history of unsuccessful ICSI cycles because of poor-embryo quality seem to be more likely to have a baby after semen donation treatment, these associations disappeared when sperm characteristics were taken into account. Among examined parameters on embryo quality, none was significant prognostic for the likelihood of live birth in final multivariate analysis. The interference of male effect on preimplantation embryo development could be the possible explanation. The advanced paternal age was found in couples who have had a baby, but its effects reduced in the multivariate regression analysis. Bias caused by female age may interpret the effect given the fact that male age is always correlated with female age.
Strengths and limitations
This study provides some important strengths compared with previous studies on this topic. As one of the key determinants of achieving a live child in ART, developmental competence of embryo depends on both the quality of the oocyte and sperm. The most valuable aspect of the current data is that we limited the comparison within the same cohort of women minimizing the potential maternal factor interference. Additionally, we estimated the overall chance of having a baby over complete IVF cycles including fresh and frozen transfer, which is particularly critical considering the flushing of embryo cryopreservation and increasing single embryo transfers.
Albeit the results are compelling, a limitation of this study is its small sample size. To our knowledge it accounts for the highest number of couples reported in literature faced with ICSI failures and underwent another ART cycle with sperm donation. The sperm parameters correlated to embryonic development to the blastocyst stage, but its involvement in clinical pregnancy and delivery could not be confirmed, since we restricted our analysis with a unique group of male-factor couples who failed ICSI attempts. In this study, morphology of the spermatozoa used for injection into the oocytes was not taken into account. In some cases, the very low sperm count made it difficult to identify morphologically normal sperm for injection [7]. However, this bias is limited because there is currently no reliable evidence on the effect of sperm morphology on ICSI results [35]. Moreover, the potential impact of IVF/ICSI technique aspects on clinical outcomes should not be ignored, which could be a significant limitation of our study. Only ICSI cycles that failed were compared with all donor IVF cycles, which might have led to selection bias and limited external validity of the findings.
Implications of our study
The present data may be useful in advising male-factor infertile couples for their assisted reproductive treatment. Couples may become disappointed and stop treatment with attempted ICSI failures. Data in the present study indicated that negative impact of paternal infertility ranges from decreasing the fertilization rate, lowering the cleavage/blastocyst rate of the developing embryo, even with no inference of maternal-related factors. The results could help severe male-factor patients to have a better awareness of their reproductive problems, and prepare emotionally and financially for their journey to parenthood.
When analysis was performed on cycles where a transfer at blastocyst stage was programmed, the proportion of cycles without blastocyst to transfer was higher in cycles with partner sperm. Combined with the reduced blastulation rate, blastocyst transfer policy may not be considered for couples with severe male factor in order to reduce the rate of cycles with no to embryo transfer.
In this study, we are not trying to debunk the critical importance of ICSI in ART. The implementation of surgical sperm retrievals in conjunction with ICSI cycles has allowed azoospermic men to establish a successful pregnancy. ICSI remains of paramount importance in cases of for severe male-factor patients.
Conclusions
The current study confirmed the unfavorable effect of paternal infertility on ICSI fertilization and competence of embryo including lowering and slowing blastocyst formation rate. Embryo-transfer strategy in such cases could be tailored to an early stage to reduce the possibility of cycles without embryo transfer. Results can help couples with severe male factor, particularly those with a history of unsuccessful ICSI attempt, plan their time, estimate success prognosis, and improve success rates. It seems that younger patients with a history of unsuccessful ICSI cycles because of azoospermia seem to be more likely to have a baby after semen donation treatment. Nonetheless, as these cohorts assessed are relatively small, further multicenter studies would be welcome in order to confirm these preliminary findings.
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Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Footnotes
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