report from the ESHRE ICSI Task Force

Survey on intracytoplasmic sperm injection: report fromthe ESHRE ICSI Task Force

Basil C.Tarlatzis1 and Helen Bili

1st Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki and IVF Center,'Geniki Kliniki', Thessaloniki, Greece

'To whom correspondence should be addressed at: Infertility and IVF Center, 'Geniki Kliniki', 2 GraviasStreet, Thessaloniki 546 45, Greece

Intracytoplasmic sperm injection (ICSI) hasrevolutionized the treatment of male infertility,since normal fertilization and ongoing preg-nancies can be achieved with severely affectedspermatozoa. Hence, the application of ICSI israpidly expanding around the world, necessitat-ing an accurate assessment of the efficacy andsafety of this novel technique. The EuropeanSociety of Human Reproduction and Embry-ology (ESHRE) Task Force is gathering dataannually on the clinical results, the pregnancyoutcome and the follow-up of children bornafter ICSI using ejaculated, epididymal andtesticular spermatozoa, in order to be able toprovide reliable information on these importantissues. During the 3 years 1993-1995, thenumber of centres performing ICSI increasedfrom 35 to 101, and the total number of ICSIcycles performed per year rose from 3157 to23 932. The incidence of oocytes damaged bythe procedure remained low (<10%) and thefertilization rates obtained with ejaculated, epi-didymal and testicular spermatozoa in 1995were 64,62.5 and 52% respectively. Thus, -90%of the couples had an embryo transfer and theviable pregnancy rate was 21% for ejaculated,22% for epididymal and 19% for testicularspermatozoa (with 25-30% multiple pregnan-cies). Furthermore, 3149 transfers of frozen-thawed embryos were performed and 7-11% ofthem resulted in a viable pregnancy. The ICSIresults were similar during this 3 year period,irrespective of the origin of the spermatozoa.The perinatal outcome of children born afterICSI was not different from those born afterin-vitro fertilization (IVF) or natural concep-

tion, and was only affected by multiplicity.Moreover, the incidence of major or minormalformations was not increased, but the chro-mosomal, especially the sex-chromosomal, aber-ration rate was slightly elevated. To summarize,a very high success rate is obtained by ICSIindependently of the source of the spermatozoa,verifying the superiority of ICSI over conven-tional IVF. The procedure seems to be safe, butfurther follow-up of the children is necessaryin order to be able to assess its safety moreaccurately.Key words: ICSI/malformations/pregnancy rate

Introduction

Assisted reproduction technologies (ART) havecome a long way since Edwards and Steptoe (1978)pioneered in-vitro fertilization (IVF) and embryotransfer in the human. IVF was also useful as amode of treatment of male infertility, although theresults with this indication were less satisfactory(Tournaye et ah, 1992). Partial zona dissectionand subzonal insemination have not been able toimprove these results substantially, although highersuccess rates have been reported in selected cases(Fishel et ah, 1992).

Nevertheless, the major breakthrough in thetreatment of male infertility was the introductionof intracytoplasmic sperm injection (ICSI), becauseit enabled patients with extremely impaired spermquality (Palermo et ah, 1992), who had not previ-ously been accepted in classical IVF programmes,to achieve high fertilization and pregnancy rates.This has led to the rapid spreading of the application

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B.C.Tarlatzis and H.Bili

of ICSI in ART centres, radically changing thetreatment of severe male factor infertility andaltering the prospects of couples with repeatedfailed fertilizations in conventional IVF.

Soon after the birth of the first ICSI child,questions were raised about the potential long-term effects of the technique per se on the childrenborn, since, using ICSI, the never-proven selectionof spermatozoa by the zona pellucida and theoolemma is bypassed (Butler, 1995). Moreover, ithas been argued that the genetic defects responsiblefor sperm impairment could be passed to the maleoffspring. All these speculations and concernsabout ICSI are obviously of crucial importancesince they may be associated with significantgeneral and public health problems.

In addition, ICSI involves a high financial costfor both the couple and the health care system,necessitating an accurate assessment of its efficacy.

The ICSI Task Force of the European Societyof Human Reproduction and Embryology (ESHRE)was originally established in 1994, with the aimof gathering information about the experience ofcentres practising ICSI in order to be able toaccumulate sufficient data to address the issues ofsafety and efficacy. The first report on the activitiesof the ESHRE ICSI Task Force was published in1996 (Tarlatzis, 1996). In this paper, the ICSIresults of 1995 are reviewed and are presented onbehalf of all the members of the ICSI Task Force.

Advantages and limitations of the ICSI TaskForce

The analysis of cumulative data on ICSI frommany different centres has important advantagescompared with the results coming from individualcentres. Data from a large number of cases can becollected in a short time period, and thus it is easierto assess the average likelihood of fertilization,achievement of pregnancy and incidence of mal-formations using this procedure. Moreover, thestudied population is more representative becauseof the contribution of centres from different partsof the world, giving the opportunity to have moreglobal estimations.

On the other hand, there are some disadvantagesinherent to the method of data collection, includingthe different degree of experience using ICSI and

heterogeneity in the indications, techniques andnumber of cycles and follow-up procedures inthe participating centres. Furthermore, adequateinformation on pregnancy and neonatal outcomemay be lacking since they are not always recordedin some IVF centres. Nevertheless, the advantagesoutweigh the disadvantages and, hence, this effortis pursued with the aim of stimulating the centresto participate in this endeavour in order to be ableto provide reliable information on the efficacy andsafety of ICSI.

Methodology

Data collection

In order to gather information from the participat-ing centres (listed in Table I), the ICSI Task Forcedistributed paper data forms on which each cliniccould summarize its practice and outcome results.These forms comprised four categories: (i) thosereferring to the clinical experience with ICSI, (ii)those concerning the follow-up of children bornafter ICSI, (iii) those aiming to evaluate childrenborn with congenital malformations, and (iv) twoforms for recording the results of cryopreservationafter ICSI using ejaculated, epididymal and testicu-lar spermatozoa and also the follow-up of childrenborn after the transfer of frozen-thawed ICSIembryos. The forms were completed by eachcentre's clinicians or biologists and were sub-sequently sent to the ICSI Task Force Secretariatfor data coding and analysis.

The requested entries on the clinical experienceform included the indications for using ICSI, theICSI results obtained using ejaculated, epididymaland testicular spermatozoa, the number of meta-phase II oocytes injected, damaged and normallyfertilized, the number of embryos transferred orfrozen and data on the achievement and outcomeof pregnancies after these procedures.

As biochemical pregnancies (or preclinical abor-tions) were considered to be those showing amoderate and temporary rise in |3-human chorionicgonadotrophin (J3-HCG) concentrations, clinicalpregnancies were identified by the rising of P-HCG concentrations and the presence of gestationalsac(s) within the uterine cavity on ultrasonographyor by the detection of trophoblastic tissues in

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Report from the ESHRE ICSI task force

Table I. List of participating centres

No. Centre City Country

1 University Hospital Leiden2 St Elisabeth Hospital3 Univ of Ottawa4 Werlin-Zarutskie Fertility Centers5 North Carolina Center for Reproductive Medicine6 A.C.H. Ninewells Hospital7 Florence Center of Ambulatory Surgery and Infertility8 Concept Fertility Centre9 Hiroshima Hart Clinic10 University of Virginia11 Endokrinologische Praxisgemeinschaft12 Fertility Centre Virga Jesse Hospital13 Ideon-Kliniken14 Assisted Conception Unit15 Academic Medical Centre16 Institute of Reproductive Medicine17 Baylor Center for Reproductive Health18 City West IVF19 University Center for Reproductive Endocrinology and Fertility20 BIRTH21 Reproductive Technology22 Dept. Human Reproduction, Univ Clinic23 Clinic Dr Fred Maleika24 Centre For Reproductive Medicine25 Advanced Fertility Service26 Egyptian IVF-ET27 Univ Central Hospital of Oulu28 Clinic of Endocrinology29 Gemeinschaftspraxis Prof Dr Bregula, Dr Hamori, Dr Behrens30 Reproductive Resource Center of Greater Kansas City31 Center for Reproductive Health32 Cooper Center for IVF33 Noth Shor ART34 Center for Reproductive Medicine35 Fertility Clinic36 Sydney IVF Pty Ltd37 Universitats Frauenklinik38 Centro Procreazione Assistita39 Instituto Bernebeu40 NYU-Program for In Vitro Fertilization41 Regional IVF Unit42 Hopital Erasme43 Institute for Assisted Reproduction44 Reproductive Biology Associates45 Center for Reproductive Medicine46 Maribor Teaching Hospital47 Medical College of Virginia48 Medicina della Riproduzione49 Reproductive Endocrinology and Infertility50 Vaestoliitto Fertility Clinic51 Fertilitetskliniken Cionia52 Genetics and IVF Institute53 In Vitro Fertilization Center of South Jersey54 Schoysman Infertility Management55 Moscow Centre for Infertility Treatment 'EKO'56 Arzte fur Frauenheilkunde und Geburtshilfe57 S.l.S.M.E.R.58 Sevgi Hospital, Assisted Reproductive Techniques and

Reproductive Endocrinology Unit

LeidenTilburgOttawaIrvineCaryDundeeFirenzeSubiacoHiroshimaCharlottesvilleHamburgHasseltMalmoLeedsAmsterdamGiessenDallasWestmeadNew BrunswickBruggeSeattleZagrebStuttgartMunich

New YorkCairoOuluZurichErlangenOverland ParkCincinnatiMarltonSt LeonardsFlintOdenseSydneyTubingenBariAlicanteNew YorkManchesterBrusselsCharlotteAtlantaSan RamonLjubljanskaRichmondMilanoSeoulHelsinkiHojBjergFairfaxMarltonBrusselsMoscowDiisseldorfBolognaAnkara

The NetherlandsThe NetherlandsCanadaUSAUSAUKItalyAustraliaJapanUSAGermanyBelgiumSwedenUKThe NetherlandsGermanyUSAAustraliaUSABelgiumUSACroatiaGermanyGermanyUSAEgyptFinlandSwitzerlandGermanyUSAUSAUSAAustraliaUSADenmarkAustraliaGermanyItalySpainUSAUKBelgiumUSAUSAUSASlovakiaUSAItalyKoreaFinlandDenmarkUSAUSABegiumRussiaGermanyItalyTurkey

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Table I. Continued

No. Centre City Country

59 PIVET Medical Centre60 Fertility Center Scandinavia61 UAMS ART Program62 University Hospital Nijmegen63 University Hospital Utrecht64 Oregon Health Sciences University Embryology Lab65 Helsinki University Central Hospital66 International Hospital IVF Center67 Genker Institute for Fertility Technology68 Assisted Reproduction Unit69 IVF Centre70 Reproductive Medicine Unit71 Felicitas Infertility Centre72 Centre for Reproductive Medicine73 Centre for Reproductive Medicine74 The Churchill Clinic75 Carl Von ...kliniken76 Center for Advanced Reproductive Care77 Foothills Hospital, Regional Fertility Program78 Al Salama Hospital79 AVA-clinic80 Centre for Reproductive Medicine,

Dutch-speaking Brussels Free University81 Clinic In-Tiimi82 Assisted Procreation Centre83 The Midwest Center for Reproductive Health, P.A.84 Flinders Reproductive Medicine85 St Mother Obstetrics and Gynaecology Clinic86 Centre For Fertility and Reproductive Medicine87 Kaali Institute88 The Infertility Center of St Louis89 Academic Hospital90 California Fertility Associates91 University of Berne, Division of Endocrinology92 The Center for Reproductive Medicine and Infertility

Cornell Medical Center93 Fertility Institute94 Embryogenesis95 Centre for Human Reproduction96 Euromedica IVF Infertility and IVF Center97 Geniki Kliniki98 IVF Unit Assaf Harofeh99 Medisch Centrum voor Vruchtbaarheidsdiagnostiek en ET100 IVF-Unit University of Goteborg101 Instituto Universitario Dexeus

PerthGoteborgLittle RockNijmegenUtrechtPortlandHelsinkiIstanbulGenkAberdeenLiibeckWoodvilleHelsinkiEdegemNewcastle/TyneLondonUppsalaRedondo BeachCalgaryJeddahTampereBrussels

KuopioPisaSt Louis ParkBedford ParkKitakyushu CityNewarkBudapestSt LouisMaastrichtSanta MonicaBerneNew York

AthensAthensAthensAthensThessalonikiZerifinLeuvenGoteborgBarcelona

AustraliaSwedenUSAThe NetherlandsThe NetherlandsUSAFinlandTurkeyBelgiumUKGermanyAustraliaFinlandBelgiumUKUKSwedenUSACanadaSaudi ArabiaFinlandBelgium

FinlandItalyUSAAustraliaJapanUSAHungaryUSAThe NetherlandsUSASwitzerlandUSA

GreeceGreeceGreeceGreeceGreeceIsraelBelgiumSwedenSpain

the uterine curettage material (de Mouzon andLancaster, 1995). Clinical pregnancies that werespontaneously terminated before the 20th week ofgestation were considered to be clinical abortions,whereas those remaining comprised the ongoingclinical pregnancies and the deliveries, which as awhole constitute the viable pregnancies (Tar-latzis, 1996).

The children follow-up form was filled-in for

the total number of children born after ICSI, theirmean gestational age and birthweight, as wellas the minor and major neonatal malformationsobserved. Major malformations were consideredthose causing functional impairment and requiringsurgical correction; all the others were classified asminor (Holmes, 1976). Moreover, the informationobtained from prenatal ultrasound and prenatal orpostnatal karyotyping was recorded. A special part

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Table II. Indications for intracytoplasmic sperm injection(ICSI) reported for 1995 by the European Society of HumanReproduction and Embryology (ESHRE) Task Force

Indication for performing ICSI

Abnormal semenFailed in-vitro fertilizationObstructive azoospermiaNon-obstructive azoospermiaPreimplantation diagnosisOther (globozoospermia, antispermantibodies,idiopathic infertility etc.)

No. of centres

99967363

823

of this form was devoted to the methodology andthe length of time of the follow-up of the children.

Another form was completed individually forevery child born with congenital malformations,including information on the pregnancy, the deliv-ery and the physical examination of the childsystem-by-system, as well as the treatment and theprognosis.

Participating centres

Data forms were sent to all centres that had alreadytaken part in the previous ICSI Task Force survey,as well as to new ICSI centres known from theliterature or from national registries. Up to 31December 1995, 101 centres had submitted theirclinical results based on 2 to 2507 cycles (seeTable I). Their participation in this endeavour wasof paramount importance and is greatly appreciatedby the ESHRE ICSI Task Force.

Analysis of data

All data were entered into two different programsof a personal computer. Centre identification andaddress were stored in filemaker pro 2.1 Bvl andthe data in Excel spreadsheets (Microsoft Excelversion 5.0a). Analyses and graphs were also doneusing the same program, as previously described(Tarlatzis, 1996).

Indications and number of cycles

Although ICSI was originally developed to treatmale infertility, it is now also used for otherdisorders (Table II). Abnormal semen quality wasthe main indication for ICSI in 1995 (99 centres),


ICSI CYCLES 1993-1995

21876

1993 1994

— O — EJACULATED SPERM

£ EPIMDYMAL SPERM

— - O — TESTICULAR SPERM

Figure 1. Numbers of intracytoplasmic sperm injection(ICSI) cycles for 1993, 1994 and 1995 as reported to theEuropean Society of Human Reproduction and Embryology(ESHRE) Task Force.

Table III. Distribution of centres according to the number ofintracytoplasmic sperm injection (ICSI) cycles performed peryear between 1993 and 1995 inclusive

No. of cycles/year No. of centres performing ICSI

<100100-200200-300300-400400-500500-1000>1000Total

1993

259

135

1994

331095512

65

1995

43221075104

101

followed by failed IVF (96 centres), obstructiveazoospermia (73 centres), non-obstructive azoos-permia (63 centres), preimplantation diagnosis(eight centres) and globozoospermia, antispermantibodies, idiopathic infertility, etc (23 centres).A similar distribution of ICSI indications was alsoobserved in 1994 (Tarlatzis, 1996).

In 1995, 101 clinics performing ICSI reporteda total of 23 932 cycles (21 876 with ejaculated,1127 with epididymal and 929 with testicularspermatozoa), which represents an almost two-foldincrease over 1994. Thus, the impressive rise inthe application of this technique between 1993 and1995 seems to be continuing (Figure 1). Similarly,

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Table IV. Intracytoplasmic sperm injection (ICSI) results using ejaculated, epididymal and testicular spermatozoa

No. of oocytes (Mil) injectedNo. (%) of oocytes damagedNo. (%) of oocytes fertilizedNo. (%) of good embryos(transferred/frozen)No. (%) of embryo transfersNo. (%) of cycles with freezing

Ejaculated

143 59813 374 (9.3)91 898 (64)62 444 (43.5)

15 407 (86)4 154(23.2)

Epididymal

9197762 (8.3)

5745 (62.5)4202 (45.7)

952 (88.1)235 (21.8)

Testicular

7834668 (8.5)

4051 (51.7)3046 (38.9)

731 (90)216 (26.6)

the number of centres performing a larger numberof cycles per year also increased in 1995, althoughvariations between centres still existed (Table III).

Fertilization and embryo transfer

Using ejaculated spermatozoa from the 143 598metaphase II (Mil) oocytes injected, 13 374 (9.3%)were damaged during the ICSI procedure and 91898 (64%) were normally fertilized, creating 62444 good quality embryos that could be transferredor frozen (43.5% of injected oocytes and 67.9%of fertilized oocytes). These led to 15 407 (86.0%)embryo transfers and 4154 cycles (23.2%) withembryo freezing (Table IV).

In the cycles with epididymal spermatozoa, ofthe 9197 Mil oocytes injected, 762 (8.3%) weredamaged and 5745 (62.5%) fertilized, leading to4202 embryos that were available for transfer orfreezing (45.7% of injected oocytes and 73.1% offertilized oocytes). Thus, 952 embryo transfers(88.1%) and 235 cycles with freezing (21.8%)were accomplished (Table IV). Moreover, the ICSIresults were similar when classified according tothe aetiology of obstruction, i.e. congenital oracquired (Table V).

When testicular spermatozoa were used, of the7834 Mil oocytes injected, 668 (8.5%) were dam-aged and 4051 (51.7%) fertilized, giving rise to3046 good quality embryos that could be trans-ferred or frozen (38.9% of injected oocytes and75.2% of fertilized oocytes). As a result, 731(90.0%) embryo transfers were performed andthere were 216 (26.6%) cycles with transfer offrozen-thawed embryos (Table IV). On the otherhand, when the ICSI data were analysed accordingto the aetiology of azoospermia, patients with non-obstructive azoospermia tended to have lower

fertilization and embryo transfer rates than theobstructive cases (Table VI). This is probably dueto the lower chances of finding spermatozoa, at allor in sufficient numbers, in patients with non-obstructive lesions. According to Tournaye et al.(1997), this is possible in ~50% of these patients.

Therefore, it is evident that the fertilization ratesafter ICSI, even with severely impaired spermato-zoa, are significantly higher that those with classicalIVF in cases of male infertility (Tournaye et al,1992). Moreover, most of the fertilized oocytes(67.9-75.2%) developed into high quality embryosthat could be either transferred or frozen. Thus,even in cases of non-obstructive or obstructiveazoospermia, 84.7 and 91.1% of the patientsrespectively will have an embryo transfer, animpossible rate for these patients with classicalIVF or any other assisted reproduction technique,and 22.6 and 26.2% respectively are expected tohave a frozen/thawed embryo transfer.

It is noteworthy that the incidence of oocytesdamaged during the procedure in 1995 rangedbetween 8.3 and 9.3% and did not differ fromthat observed in previous years (Tarlatzis, 1996).Hence, oocyte damage seems to be an inherentdrawback of the ICSI procedure per se. Moreover,the incidence of fertilization and the rate of devel-opment of good quality embryos were similar in1994 and 1995, except for the cases with epididy-mal spermatozoa, where more oocytes fertilized(52.5 and 62.5% respectively) and more goodquality embryos were available in 1995 (61.7 and73.1% of fertilized oocytes respectively).

Achievement of pregnancy

The main factor determining the effectiveness ofan assisted reproduction technique, such as ICSI,

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Table V. Intracytoplasmic sperm injection (ICSI) results for 1995 with epididymal spermatozoa according to the aetiology ofobstruction

Aetiology of obstruction

No. of centresNo. of cyclesNo. of patientsNo. of oocytes (Mil) injectedNo. (%) of oocytes damagedNo. of oocytes fertilizedNo. of embryos transferred/frozen

% per injected oocyte% per fertilized oocyte

No. (%) of embryo transfersNo. (%) of cycles with freezing

Unspecified

8161131

1677177 (10.6)986 (58.8)601

35.860.9

150 (93.2)52 (32.3)

Congenital

30341245

2826229 (8.1)

1729 (61.2)1292

45.774.7

283 (83)63 (18.5)

Acquired

37578461

4694356 (7.6)

3030 (64.5)2309

49.276.2

519 (89.8)120 (20.8)

Table VI. Intracytoplasmic sperm injection (ICSI) results for 1995 with testicular spermatozoa according to the aetiology ofazoospermia

Aetiology of azoospermia

No. of centresNo. of cyclesNo. of patientsNo. of oocytes (Mil) injectedNo. (%) of oocytes damagedNo. (%) of oocytes fertilizedNo. of embryos transferred/frozen

% per injected oocyte% per fertilized oocyte

No. of embryo transfersNo. (%) of cycles with freezing

Unspecified

7186153

1686131 (7.8%)907 (53.8%)72042.779.4

179 (96.2%)62 (33.3)

Obstructive

32339298

3401302 (8.9%)

1860 (54.7%)1336

39.371.8

309 (91.1%)89 (26.2)

Non-obstructive

30287247

2747235 (8.5%)

1284 (46.7%)990

36.077.1

243 (84.7%)65 (22.6)

is the achievement of a pregnancy and especiallyof a viable pregnancy.

In 1995, a fresh embryo transfer was performedin 15 407 (86.0%) ICSI cycles with ejaculatedspermatozoa, resulting in 5012 positive P-HCGtests (28.0% per cycle) and 3808 viable pregnancies(1908 ongoing and 1900 delivered; 21.3% percycle; Table VII). In the ICSI cases with epididymalspermatozoa, a fresh embryo transfer was done in952 (88.1%) cycles, leading to 322 positive 0-HCG tests (29.8% per cycle) and 236 viablepregnancies (83 ongoing and 153 delivered; 21.8%per cycle; Table VII).

On the other hand, in cases of ICSI with testicularspermatozoa, 731 (90.0%) fresh embryo transferswere accomplished, resulting in 218 positive 0-

HCG tests (26.8% per cycle) and 152 viablepregnancies (18.7% per cycle; Table VII).

The overall results for ejaculated, epididymaland testicular spermatozoa in 1995 were similar tothose recorded in 1993-1994. Nevertheless, theresults using testicular spermatozoa showed a slightdecline in the number of positive P-HCG tests andin the viable pregnancy rate (Figure 2), possiblydue to the larger number of cycles performed andto the wider application of this procedure to lessfavourable cases.

Regarding frozen-thawed embryo transfers afterICSI, a total of 3363 cycles were accomplishedduring 1995 in 57 centres (Table VIII). Of those,2990 embryo transfers were done in 3146 cyclesafter ICSI using ejaculated spermatozoa, giving

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Table VII. Pregnancy outcome after intracytoplasmic sperm injection (ICSI) using ejaculated, epididymal and testicularspermatozoa in 1995

Source of spermatozoa

Ejaculated Epididymal Testicular

No. of positive p-HCG testsNo. (%) of viable pregnanciesNo. of ongoing pregnanciesNo. of delivered pregnanciesNo. (%) of biochemical pregnanciesNo. (%) of clinical abortionsNo. (%) of ectopic pregnancies

5012 (28%)3808 (21.3)19081900464 (9.3)723 (14.4)70(1.4)

322 (29.8%)236 (21.8)8315341 (12.7)34 (10.6)0(0)

218 (26.8%)152 (18.7)827022 (10.1)34 (15.6)1 (0.5)

Table VIII. Results for 1995 of frozen-thawed embryo transfers after intracytoplasmic sperm injection (ICSI) using ejaculated,epididymal and testicular spermatozoa



No. of cyclesNo. of zygotes/embryos thawedNo. (%) of zygotes that survivedNo. (%) of zygotes transferredNo. (%) of embryo transfersNo. (%) of positive p-HCG testsNo. (%) of viable pregnancies

3146120417669 (63.7)6574 (54.6)2990 (95)525 (16.7)341 (10.8)

144466292 (62.7)241 (51.7)91 (63.2)22 (15.3)13(9)

73336213 (63.4)191 (56.8)68 (93.1)8(11)5 (6.8)

8 0 * 5 -

4096-

2 0 5 6 -

095

g9.4% 90% TESTICULAR SPERM M 1 99 3

D 1 99 4

^ 1 995

Embryotransfers

Positive(5-HCG/cyde

Viablepregn ./cycle

Figure 2. Achievement of pregnancy using testicular spermatozoa for 1993, 1994 and 1995 as reported to the EuropeanSociety of Human Reproduction and Embryology (ESHRE) Task Force. P-HCG = p-human chorionic gonadotrophin.

rise to 525 (16.7%) positive P-HCG tests and341 (10.8%) viable pregnancies. With epididymalspermatozoa, 91 transfers of frozen/thawedembryos were performed in 144 cycles, leading to

22 (15.3%) positive p-HCG tests of which 13(9.0%) were viable pregnancies. On the otherhand, 68 frozen-thawed embryo transfers wereperformed in 73 cycles with testicular spermatozoa,

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resulting in 8 (11.0%) positive (3-HCG tests and 5(6.8%) viable pregnancies.

Early pregnancy losses and ectopicpregnancies

The implantation rates after IVF and ICSI, evenin cases of good quality embryos, remain relativelylow despite the progress in ovarian stimulation andculture conditions. Moreover, the implantation aswell as the miscarriage rates are significantlyaffected by the woman's age, primarily due tooocyte and embryo quality (Lancaster et al, 1995).

In the cases where ejaculated spermatozoa wereused in 1995, of the 5012 positive (3-HCG tests,464 (9.3%) were biochemical pregnancies, 723(14.4%) were clinical abortions and 70 (1.4%)were ectopic pregnancies (Table VII). On the otherhand, in cases using epididymal spermatozoa, ofthe 322 positive (3-HCG tests, 41 (12.7%) werebiochemical pregnancies and 34 (10.6%) clinicalabortions, and no ectopics were observed (TableVII). With testicular spermatozoa, of 218 positivep-HCG results, 22 (10.09%) were biochemicalpregnancies, 34 (15.59%) were clinical abortions,and 1 (0.45%) was an ectopic (Table VII). It isnoticeable that the incidence of early pregnancyloss after ICSI is similar to that after IVF (Lancasteret al, 1995), whereas the incidence of ectopicpregnancies (0-1.4%) is lower than that observedin standard IVF (4.3%). This difference is probablydue to the fact that most women undergoing ICSIhave normal tubes, in contrast with the patientsundergoing classical IVF (Marcus and Brinsden,1995).

The pregnancy outcome after frozen-thawedembryo transfers was similar to that of freshtransfers. Thus, using frozen-thawed embryos fromejaculated spermatozoa, 72 (13.7%) biochemicalpregnancies, 83 (15.8%) clinical abortions and 10(1.9%) ectopic pregnancies were observed, whereaswith epididymal spermatozoa, 3 (13.6%) biochem-ical pregnancies, 2 (9.1%) clinical abortions andno ectopics were obtained (Figure 3). In addition,using embryos from testicular spermatozoa, 22(10.1%) biochemical pregnancies, 34 (15.6%) clin-ical abortions and 1 (0.5%) ectopic pregnancy wererecorded.


Multiple gestations

The incidence of multiple pregnancies after ICSIin 1995 was approximately the same as in 1993and 1994, ranging from 27.9 to 30.4%, and similarresults have also been reported after the transferof frozen-thawed ICSI embryos. These findingsconfirm the good quality of ICSI embryos andfurther support the need to reduce the number ofembryos replaced (Staessen et al, 1995).

The avoidance of multiple pregnancies, especi-ally those of high order, is currently one of themost pressing problems not only for ICSI but alsofor classical IVF, since multiple gestations areassociated with poor fetal outcome, which impairsthe ultimate purpose of having a healthy baby.Obtaining a pregnancy is not enough, since thegestation must be maintained until a healthy livebaby is born at term. However, many programmes,especially new ones, are unwilling to reduce thenumber of transferred embryos, in order to ensurehigh pregnancy rates. On the other hand, recentstudies have shown that the elective transfer oftwo good quality embryos does not compromise thesuccess rate of IVF or ICSI (Staessen et al, 1995).

Perinatal outcome

Despite the important advances in prenatal andneonatal care, preterm delivery remains a majorproblem in everyday obstetric practice, rangingbetween 5 and 10% of all births in developedcountries (Creasy, 1989). Assisted reproductiontechniques are associated with a 25% pretermdelivery rate as well as a 33% low birth weightrate (Doyle et al, 1992). This high incidenceof preterm birth and low birth weight in IVFpregnancies has been noted not only in multiplepregnancies but also in the singletons (Doyle et al,1992; Lancaster, 1996).

This pattern does not seem to be the same forthe ICSI babies, since the mean gestational ageand the mean birth weight for singleton pregnancieswere similar to those observed in the generalpopulation, whereas they were significantly lowerin high order multiple pregnancies (Table IX).These findings for the ICSI babies are in agreementwith those observed by Wisanto et al. (1995,1996),and, also, in certain countries concerning the IVFbabies (Lancaster, 1996).

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Figure 3. Pregnancy outcome for 1995 of frozen-thawed embryo transfers after intracytoplasmic sperm injection (ICSI) usingejaculated, epididymal and testicular spermatozoa, as reported to the European Society of Human Reproduction andEmbryology (ESHRE) Task Force.

Table IX. Perinatal outcome of children born after intracytoplasmic sperm injection (ICSI), up to 31 December 1995


No. of centresNo. of children born

SingletonTwinsTripletsQuadruplets

Mean gestational age (weeks)SingletonTwinsTripletsQuadruplets

Mean birth weight (g)SingletonTwinsTripletsQuadruplets

Ejaculated

6024861384534

391

137.638.736.031.432.0

29183201242317321763

Epididymal

1411959255

38.238.436.933.0

3172322927311636

Testicular

76327152

36.538.336.232.3

2809339624201859

It is noteworthy that no significant differences inperinatal outcome were observed between childrenborn after ICSI using ejaculated, epididymal ortesticular spermatozoa (Table IX).

Genetic and malformation risks

ICSI, as a new treatment modality in reproductivemedicine, has raised concerns on the possible

genetic and malformation risks associated with thisprocedure.

It has been generally claimed that fertilizingspermatozoa are somehow selected and that onlynormal spermatozoa achieve fertilization (Yanagi-machi, 1995). Yet, with the possible exception ofsperm morphology and motility, there is no evid-ence in humans or in animals supporting this'selection' procedure (Yanagimachi, 1995). Never-

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Table X. Congenital malformations in children born after intracytoplasmic sperm injection (ICSI)and testicular spermatozoa

No. of children bornNo. (%) of malformations

MajorMinor

No. of abnormalities detected by ultrasoundNo. of therapeutic abortions


Ejaculated

2486

47 (1.9)185 (7.4)1717

Epididymal

119

03 (2.5)00

using ejaculated, epididymal

Testicular

63

3 (4.8)2 (3.2)00

theless, if such a selection mechanism exists, it isimportant to examine what the implications mightbe when these selective barriers are bypassed usingICSI. Thus, the follow-up of children born afterICSI is of great significance, although it is a verydifficult project since it requires special arrange-ments at the centres and substantial funding inorder to be done properly. Hence, only 17 of the101 centres that have submitted ICSI results for1995 are performing a prospective follow-up ofthe children and only nine as a part of a specialproject, while another 46 centres are trying tocollect information by contacting the infertilityspecialist, the paediatrician, or the nurses.

Concerning the incidence of congenital mal-formations, among 2486 children born after ICSIusing ejaculated spermatozoa, 47 (1.9%) major and185 (7.4%) minor malformations were reported,whereas no major and 3 (2.5%) minor ones wereobserved in 119 babies born after the use ofepididymal spermatozoa and there were 3 (4.8%)major and 2 (3.2%) minor malformations in 63babies resulting from testicular spermatozoa(Table X). Similar results have been also recordedin the children born with frozen-thawed ICSIembryos, although the numbers for epididymaland testicular spermatozoa were too small forcomparison (Table XI). These incidences of majorand minor congenital malformations using sperma-tozoa of all categories are consistent with thosereported previously for ICSI (Wisanto et al. 1995;Bonduelle et al, 1994, 1995), and for IVF (MRCWorking Party, 1990; Rizk et al, 1991), but arealso within the range observed in the generalpopulation (Office of Population Censuses and

Surveys, 1988; New York State Department ofHealth, 1990).

Furthermore, the prenatal genetic screening of539 fetuses after ICSI with ejaculated, epididymaland testicular spermatozoa revealed 11 (2%) abnor-mal karyotypes, while the postnatal screening of99 babies showed 2 (2%) abnormal karyotypes(Table XII). On the other hand, in 27 prenatalkaryotypes of fetuses from frozen-thawed embryosin five centres, one (3.7%) was abnormal, whereasone postnatal screening revealed one normal karyo-type. Obviously, these numbers are too small todraw any conclusions.

Recently, Bonduelle et al. (1996) studied a totalof 486 karyotypes in 877 children born after ICSIand found that 6 (1.2%) were de-novo chromo-somal abnormalities (mainly of the sex chromo-somes) and 6 (1.2%) were familial structuralaberrations, values that are higher than expectedin the general population (Jacobs et al, 1992).This distinction of chromosomal abnormalities can-not be applied to the data collected by the ICSITask Force, since they were not recorded separately.However, the total incidence of 2% observed bythe ICSI Task Force, which probably includes bothtypes of abnormalities, is similar to the 2.4%reported by Bonduelle et al. (1996). It seems,therefore, that the rate of chromosomal aberrationsin children born after ICSI is slightly elevated andthis is probably related to the problem of maleinfertility per se. For this reason, it is recommendedthat karyotypes of the male partners are performedin order to detect the pre-existing aberrations andto counsel the couples for prenatal screening untilthis issue is resolved with larger amounts of data.

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Table XL Congenital malformations in children produced from frozen-thawed intracytoplasmic sperm injection (ICSI)embryos according to the type of spermatozoa used for ICSI



No. of children bornNo. (%) of malformations

MajorMinor

No. of abnormalities detected by ultrasoundNo. of therapeutic abortions

139 1

3 (2.2)13 (9.3)01

0000

0000

Table XII. Karyotypes of children born after intracytoplasmicsperm injection (ICSI) using ejaculated, epididymal andtesticular spermatozoa

Prenatal diagnosisNo. of centresNo. of karyotypesNo. of 46,XXNo. of 46,XYNo. of others

Postnatal diagnosisNo. of centresNo. of karyotypesNo. of 46.XXNo. of 46,XYNo. of others

19539259266

11 (2%)

6994948

2 (2%)

Conclusions

All gathered data concerning ICSI in 1995 showeda high success rate of fertilization and achievementof pregnancy irrespective of sperm origin. More-over, there did not appear to be an increasedrisk of major or minor congenital malformations,although a slight increase of chromosomal aberra-tions, especially of the sex chromosomes, wasobserved. Undoubtedly, this database is not largeenough to allow definite conclusion, and this furthersupports the need to continue the follow-up ofchildren born after ICSI. Centres should be encour-aged to join collective forces, such as the ESHRETask Force on ICSI.

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report from the ESHRE ICSI Task Force

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Transcript of report from the ESHRE ICSI Task Force