The role of IMSI in sperm selection

1
The role of IMSI in sperm selection

• Monica Antinori

R.A.P. R.U.I International Associated Research
Institute for Human Reproduction Rome, Italy.
2
INTRODUCTION
A different prognosis can be assigned on the
basis of different normal morphology thresholds
(poor prognosis 4 good prognosis 5-14
normal gt14) in order to choose an adequate
infertility management .

Kruger et al., 1988 Grow et al., 1994
Predictive value of sperm morphology for
fertilization and pregnancy outcomes in IVF
treatments. Kruger et al., 1986 1987 Parinaud
et al., 1993 Ombelet et al., 1997 Eilish T. et
al., 1998
Correct selection of spermatozoa improves ICSI
outcome
Kahraman et al., 1999 Miller and Smith, 2001 De
Vos et al., 2003
3
INTRODUCTION II
According to some authors, ICSI outcome is not
related to strict morphology of the sperm used
for microinjection Oehninger et al., 1995
Kupker et al., 1998 Host et al., 2001
Celik-Ozenci et al.,2004
No differences in terms of fertilization and
clinical pregnancy rates have been shown when
samples with poor morphology (lt5 normal cells)
were used

Gomez 2000
Fertilization, embryo development and pregnancy
seem to be achievable even if normal spermatozoa
are not available (100 of terato-zoospermia)
Nagy et
al., 1995 Tasdemir et al.,1997 Mckenzie et al.,
2004
4
Recently new devices to achieve high
magnification levels (6600x) have been proposed
in order to detect subtle ultra-structural
alterations that would be impossible to identify
with conventional methods.
In the routine ICSI procedure, sperm cells are
selected from the sperm pool under a regular
microscope that magnifies 200-400x
5
.
Sperm sub-cellular organelles
Bartoov , et al.,1999
6
Specific Morphological Malformations of the Sperm
Cell Subcellular Organelles (other than nucleus)
Observed by MSOME
SPERM CELL SUBCELLULAR ORGANELLES SPECIFIC MALFORMATIONS
Acrosome Partial Vesiculated Lack
Post-Acrosomal Lamina Vesiculated Lack
Neck Abaxial Disorder Cytoplasmic droplet
Tail Coiled Broken Multi Short Lack
Mitochondria Partial Disorganization Lack
7
ACROSOMAL LACK
VACUOLES
Bartoov , et al,1999
8
Criteria for morphologically normal nucleus

• -Oval shape
• -Longitudinal symmetry
• -Smooth content

9
Oval Shape
LARGE OVAL
Normal shape
WIDE
4.75µm (0.28)
NORMAL
LONG
SHORT
3.28µm (0.20)
SMALL OVAL
NARROW
10
Smooth Content

• No vacuoles/only one vacuole with a diameter
  greater than 0.780.18µm
• Vacuolated spermatozoa
• No extrusion or invagination of the nuclear
  chromatin mass
• Regional disorder

I
E
11
vacuoles
estrusion
12
Sperm Functional Morphology is based on
-High power light microscopy -Single cell
examination -Real time observation -Examination
of only motile sperm cells -Fine organellar
morphology Motile Sperm Organellar Morphology
Examination
MSOME
13
97 men from an unselected group of couples
undergoing infertility investigation
14
(No Transcript)
15
Oliveira 2010
16
HA bound spermatozoa HA unbound spermatozoa P value
normal spermatozoa 2.7 2.6 ns
large/small spermatozoa 1.5 1.7 ns
wide/narrow 3.1 2.8 ns
regional disorder 4.7 4.3 ns
Vacuoles 4-50 72.5 72 ns
Vacuoles gt 50 15.6 16.5 ns
Petersen 2010
17

• Bartoov
• Cassuto Barak
• Vanderzwalmen
• Our proposal

• Equipment
• Chablon design

18
Hazout et al. 2006
19
30 patients in an unselected group of couples
undergoing infertility investigation and treatment
20
(No Transcript)
21
Garolla et al. 2008
22
Oliveira 2010
gt 50 vacuolized
5- 50 vacuolized
23
RBM Online2010

• Msome and acrosomal status assessment were
  simultaneously performed on 3237 spermatozoa of
  30 man with the following sperm parameter
• concentration 65.60.2 x 106/ml
• Progressive motility 43 18
• Vitality79 7.8
• Normal morphology (Davids criteria)29 4.6

24
Kacem et al. 2010
25
Kacem et al. 2010
26
MSOME on acrosome reacting spermatozoa ASome
protruding blebs are visible in the anterior part
of the head DIn the following picture the
corresponding area shows a vacuole-like image
Kacem et al. 2010
27
Thoughts on IMSI Giampiero Palermo et
al. In "Biennial Review of Infertility, Volume
2" New York Inc. Springer-Verlag June 2011
Crater characterization for IMSI Crater characterization for IMSI Crater characterization for IMSI Crater characterization for IMSI Crater characterization for IMSI
Nof () Large Small None ICSI
Oocytes injected 23 63 20 256
Fertilization 14(60.9) 54(85.7) 16(80.0) 167 (70.8)
Blastocyst Development 7(50.0) 28 (54.9) 4(25.0) 85 (51.0)
28

• January 2006 - June 2007
• Study design prospective randomized
• Original Group 446 couples
• Inclusion criteria 1) at least 2 previous
  diagnoses of severe
• 
  oligo-astheno-terato-zoospermia
• 
  2) at least 3 years of primary infertility
• 
  3) the woman being 35 or younger
• 
  4) an undetected female factor
• COH GnRH Antagonist regimen (ganirelix acetate)
  rFSH
• OPU 35-36h after HCG
• Transfer D3

29
Antinori et al. 2008
30
Antinori et al. 2008
31
CONCLUSION
IMSI resulted in a significantly higher pregnancy
rate than ICSI in all treated cases (P 0.004)
and notably in patients with 2 failures for
whom the success rate increased by over 100 (P
0.017), which confirms the data already published
in the literature
32
(No Transcript)
33
Number of fertiized eggs
Number of top quality embryos
Setti et al. 2010
34
Number of Pregnancies
Number of gestational sacs
Setti et al. 2010
35
2011
Unselected infertile population
36
(No Transcript)
37
BARTOOVS CLASSIFICATION
38
(No Transcript)
39
Bartoovs retrieval hierarchy of morphologically
evaluated "second best" sperm cells with
minimally impaired nuclei.
Choice Specific nuclear malformations
1 Large Oval
1 Small Oval
2 Wide forms (gt 3.7 µm width)
2 Narrow forms (lt 2.9 µm width)
3 Regional disorder
4 Large vacuoles Normal Shape/Size
5 Abnormal forms Large vacuoles
40
(No Transcript)
41
Cassuto Barak SCORE SYSTEM
Score of spermatozoa 2 Head 3 Vacuole
Base
CLASS I (4-6) 6 POINTS
CLASS III (0) 0 POINTS
CLASS II (1-3) 2 POINTS
42
Cassuto Barak SCORE SYSTEM
43
VANDERLZWALMEN CLASSIFICATION
Grade Specific nuclear malformations
I Normal form and no vacuoles
II Normal form and 2 small vacuoles
III Normal form gt2 small vacuoles or at least one large vacuole
IV Large vacuole and abnormal head shapes or other abnormalities
44
VANDERLZWALMEN CLASSIFICATION
VANDERLZWALMEN 2008

45
RAPRUI CLASSIFICATION
Choice Specific nuclear malformations
1 st Oval-Symmetric-Smooth nucleus (even with a small vacuole in the middle 0.78 ?m)
2nd Vacuolization lt 15 (only small anterior vacuoles)
3rd Vacuolization 15-30 (only small anterior vacuoles)
3rd Size and shape anomalies, no vacuoles (Large/Small Wide/Narrow )
3rd Normal nucleus with neck cytoplasmic droplet
46
(No Transcript)
47
(No Transcript)
48
IMSI at RAPRUI
January 2005 and Dec 2010 2082 IMSI
cycles Mean age 36.6 yrs Couples with
gtprevious ICSI 2 failures 46.4 Mean n
failures/couple in this group 3.87
49
IMSI OBSTETRIC OUTCOMES
N Deliveries 335 ( 291 singletons 38twins6 triplets)
N Live Birth 380 (211 females169 males)
Cesarean section 326 (85.7)
Gestational age (weeks,meanSD) 37.4 2.6
Birth weight (gr, meanSD) 2980 652
Obstetric complication 13 ( 3.8) 7 PROM 1gestational diabetes 5 hypertensive desease
Congenital anomalies (genetic deseases,malformations) 5 (1.4) 1big vessels trasposition 1ipot. left ventricle 1body stalk sindrome 1Down sindrome 1trysomy 18 terapeutical abortion
50
MSOME evaluation in daily IVF routine
ADDITIONAL CRITICAL POINTS

• Expensive equipment to reach the necessary
  magnification (microscope, camcorder, composite
  system of lenses)
• Experienced embriologists (hard training)
• Work in pairs cold be usefull to increase
  accuracy of the evaluation
• Time consuming

51
IMSI as a Valuable Tool for Sperm Selection
During ART Monica Antinori, Pierre
Vanderzwalmen and Yona Barak In "Biennial
Review of Infertility, Volume 2" New York Inc.
Springer-Verlag June 2011
The introduction of IMSI has fostered a deeper
understanding of those mechanisms that interfere
with male fertility potential in both natural and
assisted reproduction.
The lack of standardization in terms of basic
techniques and morphological evaluation criteria,
its routine application available in only a few
ART units due to man-hours and high costs
involved ,all these factors create skepticism
regarding IMSIs cost-effectiveness.
52
All things considered, the most important
question is is it ethically acceptable,
according to the current literature, to not
provide the infertile couple with spermatozoa of
the best quality available when the technology
gives you the opportunity to do so, even with
the knowledge that this could compromise the
ART success rate?
53
In order to fully answer this question, its
important to first change the pervasive mind-set
which is limiting the full potential that could
be gained by employing the most technologically
advanced procedures like IMSI.
ART treatments can no longer be considered mere
shots in the dark they must become a decisive
therapy, with much more weight being given to the
first attempt.
54
(No Transcript)
55
(No Transcript)
56
(No Transcript)
57
Thank you