pared to performing ICSI with normal sperm. Furthermore, the study would determine if the use of ICSI with sperm aspirated from the testes for mostly non-obstructive azoospermia led to higher miscarriage rates relative to the other two groups. Design: Retrospective review. Materials and Methods: All IVF cycles using ICSI during a specific time period in women age ⬍39 were evaluated and compared for various parameters but most importantly for clinical and live delivered pregnancy rates (PRs), implantation, and miscarriage rates. The majority of the women had a previous fresh transfer but some had all embryos cryopreserved (possibly for risk of ovarian hyperstimulation syndrome or inadequate endometrial thickness). All women were treated with a graduated oral and/or vaginal estradiol (E2) regimen followed by progesterone support. Though ICSI was usually performed because of male factor problems sometimes the procedure was used with normal sperm especially for unexplained infertility for fear that a sperm binding defect could be present. Only embryo transfers (ETs) with 3 day old embryos were included. Results: The couples were divided into 3 groups: grp. 1-ICSI with sperm aspirated from testes (n⫽40); grp. 2-ICSI performed with ejaculated sperm with normal semen parameters (n⫽140); and grp. 3-oligo and/or asthenozoo, and/or teratozoospermia, or low hypo-osmotic swelling test scores, or antisperm antibody (n⫽346). There was no difference in female age, peak serum E2, or average number of embryos transferred for groups 1-3. The percent having at least one 8-cell embryo transfer was 15.5%, 22.5%, and 17.9% (p⫽NS). Similarly there was no difference in the percentage of top embryos transferred with no fragmentation of blastomeres-18.1% vs. 14.5% vs. 17.8%. There were no differences in clinical PR (27.8% vs. 37.4% vs. 31.9%), live delivery rate (15.0% vs. 26.4% vs. 26.0%), or implantation rate per embryo (13.5% vs. 14.3% vs. 14.9%). However grp. 1 using immature sperm aspirated from testes had a significantly higher miscarriage rate (40% vs. 22.4% vs. 12.6%). Conclusions: The decision to evaluate the effect of immature testicular sperm vs. normal ejaculated sperm vs. abnormal ejaculated sperm using a frozen embryo model rather than a fresh embryo model was based on 2 factors: 1) a greater chance of transferring some de-selected embryos, 2) all female partners would be on the same hormonal regimen and not on the potpourri of ovarian hyperstimulation regimens that could be a confounding variable in interpretation of PR, implantation and miscarriage rate. The previous publication demonstrating higher miscarriage rates with abnormal sperm with conventional insemination of sperm also showed that in a smaller series the use of ICSI seemed to eliminate the higher miscarriage risk. These data confirm with larger numbers that there is no increased risk of miscarriage from abnormal sperm when ICSI is performed. However, the data demonstrated that even with ICSI, immature sperm obtained from testicular aspiration resulted in higher miscarriage rates.
P-247 IVF embryo quality and pregnancy rates are improved with sperm from fresh testicular biopsy samples versus frozen biopsy samples. Vincent W. Aoki, Aaron L. Wilcox, Cindy Thorpe, Douglas T. Carrell. Univ of Utah, Salt Lake City, UT; Abbott Northwest Hosp, Minneapolis, MN. Objective: The purpose of this study was to investigate any statistical differences in IVF outcome when using a fresh testicular biopsy sample versus a frozen testicular biopsy sample with intra-cytoplasmic sperm injection (ICSI). Design: A retrospective chart review was conducted in 92 consecutive first-attempt IVF cycles involving ICSI with either fresh or frozen testicular biopsy samples. In particular, we compared fertilization rates, embryo quality, pregnancy, delivery, and spontaneous abortion rates between these two groups. Materials and Methods: Forty consecutive first-attempt IVF-ICSI cycles using sperm from fresh testicular biopsy samples and fifty-two consecutive first-attempt IVF-ICSI cycles utilizing frozen testicular biopsy samples were included in the study. Ovarian stimulation was performed using standard techniques of GNRH-agonist down-regulation and controlled stimulation with recombinant follicle stimulating hormone (FSH) combined with urinary-derived gonadotropin. Oocyte retrieval was conducted 36 hours after hCG injection. Testicular biopsy involved removal of a small piece of testicular tissue that was subsequently minced in HEPES-buffered HTF medium. In those cases where fresh testicular biopsy samples were utilized,
the resulting suspension was prepared for ICSI via density gradient centrifugation on the day of oocyte retrieval. Otherwise, the suspension was cryopreserved by the addition of a Test-Yolk Buffer cryoprotectant (1: 1), which was cooled in liquid nitrogen vapors for twenty minutes and stored in liquid nitrogen until use. Frozen samples were thawed and prepared for ICSI via density gradient centrifugation on the day of oocyte retrieval. Embryos were cultured in HTF medium and transferred on day-three. Fertilization rates and embryo quality in the two groups were evaluated for statistical difference using a two-sample T-test. Pregnancy, delivery, and spontaneous abortion rates in the two groups were evaluated statistically using a Chi-square analysis. Results: Results indicate a significantly increased ICSI fertilization percentage with frozen versus fresh testicular biopsy samples (76.5% 3.1 vs. 68.3% 2.6; p ⬍ 0.05). However, embryo quality was significantly improved in fresh testicular biopsy cases versus frozen testicular biopsy cases with mean embryo scores of 4.54 0.31 and 3.62 0.2, respectively (p ⬍ 0.05). Chemical pregnancy rates (60% vs. 49.1%), clinical pregnancy rates (56.4% vs. 41.2%), and delivery rates (48.7% vs. 31.2%) were each higher in the fresh group versus the frozen group, although these differences were not significant. Accordingly, the spontaneous abortion rate was lower in the fresh biopsy group (21.7%) versus the frozen biopsy group (33.3%), although this difference was not significant. Confounder analysis indicated there were no differences in any of the measures with respect to male diagnosis. Furthermore, there were no differences in either male diagnosis or female age composition between the fresh and frozen testicular biopsy groups. Conclusions: Although the use of frozen biopsy samples has logistical advantages, we conclude it may be advantageous to utilize fresh testicular biopsy samples in IVF-ICSI cases whenever possible, since fresh specimens yielded significantly improved embryo quality, generally higher pregnancy rates, and lower spontaneous abortion rates.
P-248 A significantly higher early pregnancy loss rate is seen with Intracytoplasmic Sperm Injection (ICSI) versus Standard In Vitro Fertilization (IVF). Laurie J. McKenzie, Paula Amato, Ertug Kovanci, Dolores Lamb, Larry Lipshultz, Sandra A. Carson. Baylor Coll of Medicine, Houston, TX. Objective: To determine whether male factor and/or ICSI impact embryonic implantation in comparison to non-male factor standard IVF. Design: A retrospective study was conducted in a university-affiliated IVF program from the years 1994-2001. Methods: Pregnancy outcomes following ICSI (n⫽464) for male factor only, were compared to pregnancy outcomes for women undergoing IVF for tubal factor infertility (n⫽242). The primary outcomes measured were rates of biochemical pregnancy, miscarriage rate, ectopic pregnancy rate and live birth rate. All patients underwent a standard stimulation protocol with Lupron(r) downregulation following by (human menopausal gonadotropins) for controlled ovarian hyperstimulation. Embryo transfer was performed on day 2 in all patients. Exclusion criteria were any infertility diagnosis other than male factor for the ICSI group, and any diagnosis other than tubal factor in the IVF group. Results: The ICSI and IVF groups were similar with respect to both mean age (34.2 and 34.6, respectively, p⫽ .25) and number of embryos transferred (4.56 and 4.70, respectively, p ⫽.14). The pregnancy rate (defined as a ␤HCG ⬎5 two weeks after embryo transfer) was statistically different between the two groups, with the ICSI group having a slightly higher pregnancy rate than the IVF group (52.5% versus 42.9%, p⫽of 0.019). Live birth rates differed between the two groups with a higher delivery rate in the IVF group (62.5% of positive pregnancy tests) versus the male factor/ICSI group (47.5%, p⫽.015). The rate of pregnancy loss (spontaneous abortion and biochemical pregnancies) however, differed between the two groups with an overall loss rate of 51.5% for patients undergoing ICSI, as compared to a 32.7% loss rate for IVF patients (p⬍.001). The greater loss rate is secondary to a higher spontaneous abortion rate (defined as documented gestational sac on ultrasound) in the ICSI group compared to the IVF group (36.4% versus 19.2%, pⱕ.01). Additionally, there was a higher ectopic pregnancy rate among the tubal/IVF group as compared to the male factor/ ICSI group 4.8% versus 0.8%, respectively, p valueⱕ.001). Conclusions: The significantly higher loss rate in the IVF-ICSI group suggests that either male factor infertility and/or ICSI per se may be associated with abnormal embryos that fail to successfully implant.
Vol. 80, Suppl. 3, September 2003