unexplained intracytoplasmic sperm injection failure: a review article

1

TABLE OF CONTENTS

TABLE OF CONTENTS ......................................................................................................................... 1

LIST OF FIGURES AND TABLES ............................................................................................................ 2

LIST OF ABBREVIATIONS .................................................................................................................... 3

INTRODUCTION ................................................................................................................................. 4

INTENDED LEARNING OUTCOMES (ILOS) ............................................................................................ 5

INTRACYTOPLASMIC SPERM INJECTION SYNOPSIS ............................................................................. 6

The steps involved in ICSI ................................................................................................................. 6

Indications of ICSI ............................................................................................................................. 9

Factors affecting success rates of ICSI ........................................................................................... 10

FAILED INTRACYTOPLASMIC SPERM INJECTION ................................................................................ 12

A). Intracytoplasmic sperm injection failure due to fertilization failure.......................................... 13

1). Oocyte related factors ................................................................................................................. 13

2). Sperm related factors .................................................................................................................. 15

3). Procedural effects of the ICSI technique .................................................................................. 16

B). Intracytoplasmic Sperm Injection Failure Due To Implantation Failure ..................................... 18

1). Uterine anomalies ........................................................................................................................ 19

2). Thin Endometrium ..................................................................................................................... 19

3). PELVIC FACTORS ................................................................................................................... 19

UNEXPLAINED ICSI FAILURE ............................................................................................................. 20

(POSSIBLE CAUSES AND MANAGEMENTS) ........................................................................................ 20

A). Unexplained ICSI failure due to fertilizationfailure................................................................... 20

1). Oocyte related factors ................................................................................................................. 20

2). Sperm related factors .................................................................................................................. 23

B). Unexplained ICSI failure due to implantation failure ................................................................ 24

1). Maternal factors .......................................................................................................................... 24

2). Embryonic Factors ...................................................................................................................... 30

Recent advances in managements of unexplained ICSI failure ....................................................... 32

Clinical Approach to a Case of Unexplained ICSI Failure ................................................................ 35

Options for patients after repeated unexplained ICSI cycle failure ................................................ 38

Assisted reproductive technology in Islamic perspectives ............................................................. 38

SUMMARY AND CONCLUSION ......................................................................................................... 40

REFERENCES .................................................................................................................................... 42

الملخص قه ل فش ) العشب الح جه ش س غيش الم ب ش (الم ........................................................................................... 49

2

LIST OF FIGURES AND TABLES

Figures:

FIGURE 1: STEPS OF INTRACYTOPLASMIC SPERM INJECTION ............................. 7

FIGURE 2: STAGES OF EMBRYO DIVISION .................................................................. 8

FIGURE 3: ASSESSMENT OF EMBRYO QUALITY ........................................................ 8

FIGURE 4: EMBRYO CRYOPRESERVATION ................................................................ 8

FIGURE 5 : MAIN CAUSES OF ICSI FAILURE ............................................................. 12

FIGURE 6: ICSI FAILURE DUE TO FERTILIZATION FAILURE ................................ 13

FIGURE 7: NORMAL AND ABNORMAL MORPHOLOGY OOCYTES ........................ 17

FIGURE 8: OOCYTES WITH VACULOLES AND CENTRAL GRANULARITY .......... 17

FIGURE 9: POOR ICSI TECHNIQUE WITH FAILURE OF FERTILIZATION ............ 17

FIGURE 10: CAUSES OF IMPLANTATION FAILURE .................................................. 18

FIGURE 11: UNEXPLAINED ICSI FAILURE DUE TO FERTILIZATION FAILURE .. 20

FIGURE 12: UNEXPLAINED ICSI FAILURE DUE TO IMPLANTATION FAILURE .. 24

FIGURE 13: PICSI DISH FOR SPERM SELECTION ..................................................... 34

FIGURE 14: POLSCOPE (LEFT) AND MEIOTIC SPINDLE (RIGHT ........................... 34

Tables

TABLE (1): EDESSY OVARIAN RESERVE SCORE FOR PREDICTION OF

OVARIAN RESPONSE IN ASSISTED REPRODUCTIVE

THERAPY…………………. …

14

3

LIST OF ABBREVIATIONS

Abbreviations List

Antral Follicle Count AFC

Assisted Hatching AH

Anti Müllerian Hormone AMH

Anti Phospholipids Antibodies APLA

Assisted Reproductive

Technologies ART

American Society For

Reproductive Medicine ASRM

Adenosine Triphosphate ATP

Adenosine Triphosphatase ATPase

Congenital Absence Of Vas

Deferentia CAVD

Clomiphene Citrate CC

Cyclic Guanosin

Monophosphate CGMP

Controlled Ovarian Hyper

stimulation COH

Estradiol E2

Endometrial Bleeding

Associated Factor EBAF

Embryo Transfer ET

Follicle Stimulating Hormone FSH

Gamete Intraphlopian Transfer GIFT

Gonadotrophin Releasing

Hormone GNRH

Germinal Vesicle GV

Heparin Binding Epidermal

Growth Factor HBEGF

Human Chorionic Gonadotropin HCG

Human Leucocytic Antigen HLA

Hypo Osmotic Swelling HOS

Intracytoplasmic Sperm

injection ICSI

Insulin Like Growth Factor

Binding Protein1 IGFBP1

Interleukin IL

Intended Learning Outcomes ILOs

Intracytoplasmic

Morphologically Selected Sperm

Injection IMSI

Inositol Trisphosphate IP3

In Vitro Fertilization IVF

Intravenous Immunoglobulin IVIG

Leutinizing Horme LH

Abbreviations List

Leukaemia Inhibitory Factor LIF

Low Molecular Weight Heparin LMWH

Microsurgical Epididymal

Sperm Aspiration MESA

Metaphase I MI

Metaphase II MII

Mean Ovarian Volume MOV

Magnetic Resonance Imaging MRI

Motile Sperm Organelle

Morphology Examination MSOME

Mitochondrial DNA mtDNA

Mucin 1 MUC1

National Health Service NHS

Natural Killer NK

Ovarian Hyperstimulation

Syndrome OHSS

Ovarian Reserve Score ORS

Premature Chromosomal

Condensation PCC

Polycystic Ovary Syndrome PCOS

Percutaneous Epididymal Sperm

Aspiration PESA

Preimplantation Genetic

Diagnosis PGD

Preimplantation Genetic

Screening PGS

Phospholipase C PLC

Randomized Controlled Trials RCTs

Repeated Implantation Failure RIF

Round Spermatid Injection ROSI

Round Spermatid Nucleus

Injection ROSNI

Testicular Fine Needle

Aspiration TEFNA

Testicular Sperm Aspiration TESA

Testicular Sperm Extraction TESE

Total Failed Fertilization TFF

T Helper TH

United Kingdom UK

United States Of America USA

Uterine Sensitization Associated

Gene 1 USAG 1

Zygote Intra Fallopian Transfer ZIFT

Zona Pellucid ZP

Unexplained ICSI Failure Review article

4

INTRODUCTION

When all other forms of assisted fertilization fail, intracytoplasmic sperm

injection (ICSI) is the method of choice to overcome male factor infertility. The ICSI

procedure allows direct injection of a single spermatozoon into the cytoplasm of an

oocyte. Thus, fertilization is possible in cases in which sperm motility is impaired and

inability to penetrate the zonapellucid (ZP) is the major cause of infertility. ICSI is

possible with spermatozoa obtained from ejaculation, microsurgical epididymal sperm

aspiration (MESA), percutaneous epididymal sperm aspiration (PESA) or testicular

sperm extraction. In addition, indications for ICSI include idiopathic infertility and

repeated conventional IVF failures(Kim et al. 2014).

Despite the improvements in ICSI technology and methods, many couples

experience multiple failures. After each failed attempt, pregnancy rates in subsequent

attempts decrease by as much as 57% with the most remarkable decrease after the third

attempt (Javed & Michael 2012).

Failure of ICSI may be due to either fertilization or implantation failure. The

causes of ICSI failure may be due to known causes or they may be unexplained.Total

failed fertilization (TFF) refers to failure of fertilization in all the mature oocyte and

the term „failed fertilization‟ refers to failure of fertilization in any mature oocyte. For

all ages and with all the different sperm types, fertilization after ICSI is at about 70–

80%. This suggests that, despite injecting spermatozoainto mature oocytes, failed

fertilization still occurs(Cohen & Alikani 2013). TFF is a distressing event for the

infertile couple as well as the fertility professionals. TFF occurs in 1–3% of ICSI

cycles. Some patients may face repeated TFF in spite of normal sperm parameters and

good ovarian response(Javed et al. 2010).

The process of implantation depends on the communication between the

embryo and the endometrium, which produces numerous factors and signals required

for successful implantation and pregnancy outcome after ICSI. Despite great

investigative effort, this process largely remained an enigmatous „black box‟. Our

understanding of the implantation process did not enhance at the same rate as the

preceding steps of COH, Ovum retrieval and micro insemination. And the tools to

intervene within it are extremely limited. The implantation of the transferred embryos

still remains the major success limiting factor. Although the investigation for

implantation failure causes is sometimes fruitful, the vast majority of the cases remain

obscure or „idiopathic’ (von Grothusen et al. 2014).

Unexplained ICSI failure is a difficult unresolved challenge in reproductive

medicine and a source of endless patient frustration and despair. Though far from

resolution, several investigative measures and therapeutic interventions were found to

be useful in this complex condition(Javed & Michael 2012)


5

INTENDED LEARNING OUTCOMES (ILOS)

To discuss the causes and remedies for failed fertilization after clinical

ICSI.

To describe the maternal and embryonic factors associated with

implantation failure and describe the various therapeutic approaches to

cope with them.

To extract the possible causes for unexplained ICSI failure and suggesting

a systemic approach for diagnosis and treatment.

To high light the recent advances in technologies used for improving

success rate of ICSI and help managing unexplained failure in near future.


6

INTRACYTOPLASMIC SPERM INJECTION SYNOPSIS

The efficacy of assisted reproductive technologies (ART) has improved

significantly since the first reports of successful pregnancies and live births after

in vitro fertilization (IVF) by Steptoe and Edwards(Steptoe & Edwards 1978).

The most common ART procedure is IVF. An important innovation in

ART is assisted fertilization by intracytoplasmic sperm injection (ICSI).The

ICSI procedure is used in conjunction with IVF, gamete intra fallopian transfer

(GIFT) and zygote intra fallopian transfer (ZIFT). Pregnancy rates with ICSI are

comparable to rates achieved through standard IVF treatment. Fertilization rates

of 70–80% per injected oocyte have been reported,clinical pregnancy rates range

from 26–57% with delivery rate ranges reported to be 18–54%when surgically

retrieved epididymal or testicular spermatozoa are used(Javed et al. 2010).

The steps involved in ICSI

1. Controlled ovarian hyperstimulation (COH) and monitoring:Key

components involve selection of the appropriate COH protocol and

gonadotropin dosage, close monitoring of follicular growth and serum E2

levels, adjustment of gonadotropin dosage to avoid hyper response, and

individualized timing of human chorionic gonadotropin (hCG) injection.

2. Sperm extraction: The sperm sample is evaluated and processed to select

healthy, viable sperm for fertilization. If there is an absence of sperm,

surgical extraction procedures are performed. Microsurgical epididymal

sperm aspiration (MESA) is used when sperm are unable to move through

the genital tract. In this procedure, sperm are extracted directly from the

epididymides. Sperm may also be extracted from the testes in a procedure

called testicular sperm aspiration (TESA) or testicular fine needle

aspiration (TEFNA). Other techniques include testicular sperm extraction

(TESE), percutaneous epididymal sperm aspiration (PESA), vasal sperm

aspiration, and seminal vesicle sperm aspiration aided by

transrectalUltrasonography. Indications for MESA and PESA include

bilateral congenital absence of vas deferentia(CAVD), cystic fibrosis, and

failed vasectomy reversal. Indications for TESA, TEFNA and TESE

include nonobstructiveazoospermia, obstructive azoospermia,

anejaculation, complete terato/necrozoospermia, and complete sperm

immobility(Nasr-Esfahani et al. 2010)

3. Ovum retrieval:Transvaginal ultrasoundguided egg retrieval/follicle

aspiration through a long thin needle passed through the vagina into the


7

ovary, and eggs are aspirated from the follicles using the ultrasound image

as a guide.

4. Micromanipulation and fertilization with ICSI: Cumulus cells are

removed from the oocyte. A single sperm is injected directly into the

cytoplasm of a mature egg using a microinjection pipette.

5. Embryo transfer: The selected fertilized embryos are placed in a catheter,

combined with atransfer growth medium, and inserted through the cervix

into the uterus. When fertilization occurs, the developing embryos may be

incubated for 2–3 days in culture and then placed into the uterus. In other

cycles, embryos are cultured for 5–6 days (i.e., extended culture) and then

transferred into the uterus at the blastocyst stage. During the natural

process of embryo development, when the embryo reaches the blastocyst

stage (i.e., 6–7 days after fertilization) it is ready for implantation.

6. Embryo cryopreservation: If there are embryos that are not needed for

transfer in the current cycle, cryopreservation may be used. This is a

process in which the embryos are frozen in liquid nitrogen and may be

thawed for future use. (Liu et al. 2007). Figure (1) shows steps of ICSI,

figure (2) shows stages of embryo division, figure (3) shows assessment

of embryo quality and figure (4) shows embryo cryopreservation.

(Palermo et al. 2009)

FIGURE 1: STEPS OF INTRACYTOPLASMIC SPERM INJECTION

1. Hyperstimulatedovary by U/S 2. Ovum retrieval

3. Micro insemination 4,5&6.embryo transfer


8

FIGURE 2:STAGES OF EMBRYO DIVISION

FIGURE 3: ASSESSMENT OF EMBRYO QUALITY

FIGURE 4: EMBRYO CRYOPRESERVATION


9

Indications of ICSI

Male factor: Abnormal semen parameters may be a contributing factor in up

to 40% of infertile couples. Fertilization is possible in cases in which the sperm

motility and ability to penetrate the zonapellucida are impaired. Injection is possible

with sperm obtained from ejaculation, MESA, PESA, or TESE (Javed & Michael

2012).

Tubal factor: Tubalfactor infertility accounts for 30% of cases of female

infertility. Tubal damage has classically been associated with pelvic inflammatory

disease. Other causes of tubal obstruction may be either intrinsic (e.g. ascending

salpingitis) or extrinsic (e.g. surgical sterilization) in origin (Berkkanoglu et al.

2014).

Endometriosis: The incidence of endometriosis is reported to be in the range

of 9–50% among women whounderwent laparoscopy for infertility evaluation. The

exact pathophysiology of endometriosis and its effects on fertility remain enigmatic.

Proposed mechanisms of damage include distortion of adnexal anatomy and adverse

peritoneal environment characterized by increased inflammatory cytokines

andoxidative stress. This may interfere with follicular development, ovum pick up,

fertilization, and embryo development(de Mouzon et al. 2009).

Ovulatory dysfunction: Ovulatory dysfunction is a very common cause of

female infertility, accounting for 25% of diagnoses. In this category, polycystic ovary

syndrome (PCOS) is most common(Huang & Rosenwaks 2012).

Unexplained infertility: The incidence of unexplained infertility ranges from

10–30%. Unexplained infertility is the absence of an identifiable cause of infertility

despitea thorough investigation demonstrating tubal patency, normal semen

parameters, ovulation, normal ovarian reserve, and a normal endometrial cavity(Li et

al. 2013b).

Fertility preservation: In recent years, individuals with cancer and

oncologists have been increasingly aware of the effect ofcancer treatment on fertility.

The only strategy of female fertility preservation recognized by the American Society

of ClinicalOncology and the American Society of Reproductive Medicine is

cryopreservation of embryos. Other fertilitypreservation procedures, such as

cryopreservation of oocytes and ovarian tissues and in vitro maturation, have enjoyed

increasing success (Salama et al. 2013)

Preimplantation genetic diagnosis and screening (PGD &

PGS):Preimplantation stage embryos can be screened for aneuploidy, genetic diseases,

and inheritedchromosome abnormalities, enabling transfer of genetically normal,

euploid embryo(s)(Simpson 2010).


10

Factors affecting success rates of ICSI

Although many attribute ICSI success to innovations in the ART laboratory,

we believe that the success of IVF treatment can be optimized by taking an

individualized, patient directed approach in the management of women undergoing

ovarian hyperstimulation. Key components involve selection of the appropriate COH

protocol and gonadotropin dosage, close monitoring of follicular growth and serum

estradiole (E2) levels, adjustment of gonadotropin dosage to avoid hyper response, and

individualized timing of human chorionic gonadotropin (hCG) injection.We believe

this approach to COH monitoring improves oocyte and embryo quality, pregnancy and

implantation rates, and, minimizes the risk of ovarian hyperstimulation syndrome

(OHSS)(Javed & Michael 2012).

A. Selection of an appropriate controlled ovarian hyperstimulation protocol:A

significant clinical challenge in determining the optimal COH protocol is

predicting and managingvariability between women. The central question when

designing an IVF protocol is whether the woman will likely have a good or poor

response to exogenous gonadotropin stimulation. We believe the appropriate IVF

protocol should be determined on the basis of an aggregate of patient

characteristics and ovarian reserve assessment. Predictive factors of ovarian

response include patient characteristics, such as age, parity, reproductive history,

body mass index, and prior response to ART treatment. Endocrine markers of

ovarian reserve, including basal follicle stimulating hormone (FSH), oestradiol

(E2), inhibin B, and, more recently, anti Müllerian hormone (AMH) levels, are

also useful in distinguishing good and poor responders(Lee et al. 2012).

Ultrasonographic assessments of the ovary, including antral follicle count (AFC),

ovarian volume, and ovarian blood flow, have also been extensively evaluated as

potential markers of ovarian reserve(Huang & Rosenwaks 2012).

Dynamic evaluation of ovarian reserve, including Clomiphen citrate (C C)

challenge testing, GnRH agonist stimulation testing and exogenous FSH ovarian

test. A recent meta-analysis concluded that all the dynamic ovarian reserve tests

have limited predictive values.AMH and AFC seem to be the two most accurate

predictors of ovarian responseto COH(Kaur & Arora 2013).

Advantages of AMH over AFC and other endocrine and sonographic markers of

ovarian reserve include consistent serum levels throughout the menstrual cycle and

minimal cycletocycle variability(Huang & Rosenwaks 2012).

According to ovarian response to COH, responders may be classified into:

1. Normal responders:Normal responders are characterized by young maternal

age (less than 35 years), normal body mass index, adequate ovarian reserve

(AFC between 6 and 10), normal basal FSH and E2 levels (FSH < 10 mIU/ml,

E2 <75 IUpg/ml), short duration of subfertility, a history of previous live birth,


11

and previous successful IVF treatment. Commonly used COH protocols include

the midluteal, GnRH agonist down regulation or „long‟protocol and, more

recently, the GnRH antagonist COH protocol, which is also known as the

„short‟ protocol(Kaur & Arora 2013)..

2. High responders:Womenwith polycystic ovaries (PCO) on ultrasound are at

greater risk of developing OHSS.The incidence of OHSS has been reported to

be as high as 30%. Other known risk factors for OHSS include young age, lean

body weight, and a history of OHSS , high gonadotropin doses, high absolute

levels (greater than 3000 pg/ml), and rapidly rising E2 levels also represent risk

factors for OHSS(Huang & Rosenwaks 2012).

3. Poor responders:The reportedprevalence ranging from 10–25%. The variations

in the prevalence rate can be attributed to a lack of a universally accepted

definition of a poor response. European Society of Human Reproduction and

Embryology consensus working groupdefined poor ovarian response as having

at least two of the following three features(Ferraretti et al. 2011):

a) Advancedmaternal age (40 years) or any other risk factor for diminished

ovarian reserve;

b) Previous history of poor ovarian response (fewer than three oocytes

retrieved with a conventional COH protocol); and

c) An abnormal ovarian reserve test (AFC less than five to seven follicles

or AMH more than 0.5–1.1 ng/ml)

It is notsurprising that age is the most important determining factor of

success in women undergoing IVF/ICSI. Advanced maternal age is associated

with a decline in the number of oocytes retrieved, embryos available for

transfer, and embryo quality, ultimately resulting in lower implantation,

pregnancy, and live birth rates(Huang & Rosenwaks 2012).

B. Timing and dose of human chorionic gonadotropin:

In normal responders who are undergoing an IVF/ICSI cycle for the first

time, hCG is usuallyadministered when two or more follicles reach a size of

17 mm or larger in diameter. Ideally, the E2 level should be greater than 400

pg/ml for 3 days.

In women with a history of retrieval of mostly immature oocytes,

consideration should be given tocontinue COH until the follicles attain 19–

20mmin diameter before triggering with hCG.

In women who are treated with Clomiphen citrate or letrozole COH

protocols, hCG injection is usually given when follicles reach 19–20

mm(Chen et al. 2014).


12

FAILED INTRACYTOPLASMIC SPERM INJECTION

ICSIhas become method of choice to achieve fertilization. Fertilization is

possible in cases in which the sperm motility and ability to penetrate the zonapellucida

are impaired. Fertilization rate after ICSI is at about 70 to 80% in all ages combined.

This suggests that, despite injecting sperm into mature oocytes, failed fertilization still

occurs.Despite the improvements in ICSI technology many couples experience

multiple failures.After each failed attempt, pregnancy rates in subsequent attempts

decrease by as much as 57% with the most remarkable decrease after the third

attempt(Javed & Michael 2012).

On the other hand failure of ICSI may be due to implantation failure. The

process of implantation depends on the communication between the embryo and the

endometrium. Despite great investigative effort, this process largely remained an

enigmatous „black box‟ and understanding of the implantation process did not enhance

at the same rate as that of follicular recruitment, oocyte quality and aspiration, embryo

quality culture, and the tools to intervene within it are extremely limited. Despite a

significant increase in ICSI success rates up to more than double the spontaneous

fecundity of young fertile couples, the implantation of the transferred embryos still

remains the major success limiting factor. The vast majority of the causes remain

obscure or „idiopathic‟(von Grothusen et al. 2014).In the current part of our review

we will discuss the main causes of ICSI failures (figure 5) that are commonly

investigated and dealt with.

FIGURE 5 : MAIN CAUSES OF ICSI FAILURE

CAUSES OF ICSI FAILURES

A). FERTILIZATION FAILURE B). IMPLANTATION FAILURE


13

A). Intracytoplasmic sperm injection failure due to fertilization failure

Total failed fertilization (TFF) refers to failure of fertilization in all mature

oocytes and “failed fertilization” refers to failure of fertilization in any mature

oocyte. TFF is a distressful event for the infertile couple as well as the fertility

professionals.TFF occurs in 1-3% of ICSI cycles. (Mansour et al. 2009).Figure (6)

shows causes of ICSI failure due to fertilization failure.

FIGURE 6: ICSI FAILURE DUE TO FERTILIZATION FAILURE

1). Oocyte related factors

a) Poor ovarian response to (COH):

Nowadays, with the delayed age of conception among females, there is

consequently a reduction of ovarian reserve. The ovarian response to COH depends

mainly on the ovarian reserve(Pastor et al. 2005).

The incidence of poor response is estimated by 5–24% of all IVF/ICSI cycles.

Most researchers agree that poor responders are those who produce less than three to

four oocytes or have a low E2 peak level [the average upper limit equals 500 pg/ml or

even 1000 pg/ml on the day of administration of the HCG hormone] in a previous

stimulation cycle. The available logical solution for the poor ovarian response in the

ICSI cycles is the cycle cancellation with the subsequent failure of the ICSI trial.

However, this solution represents a major disappointment and harbors a negative

psychological impact on the patients (Shohieb et al. 2012).

Edessy ovarian reserve score (Edessy ORS) correlates multiple parameters for

prediction of ovarian response in assisted reproductive therapy (ART)(Edessy et al.

2013a)table (1).

A). Fertilization failure

1. Oocyte related factors

a). Response to COH

b). Poor Morphology

c). Poor Maturity 2. Sperm related

factors

a). Motility

b). Origin

c).Maturity

3. Technique of ICSI Procedure


14

Table (1): Edessy ovarian reserve score for prediction of ovarian

response in assisted reproductive therapy

Score

Variable 0 1 2

AMH(ng/ml) <1 1-5 ≥ 5

FSH (mIu/ml) ≥ 10 5-10 ≤ 5

E2 (pg/ml) ≥ 50 20-50 ≤ 20

AFC (no) < 3 3-8 ≥ 9

MOV (Cm3) ≤ 6 6-10 ≥ 10

FSH : Follicle stimulating hormone

AFC : Antralfollicle count

E2: Estradiol

MOV: Mean ovarian volume

Interpretation of EdessyORS:

Patients with score < 3 are poor responders.

Patient with score 3 are borderline responders

Patients with score > 3 are good responders.

Patient with score 9 are high responders and at high risk for ovarian

hyperstimulation syndrome (Edessy et al. 2013a)

a) Poor Oocyte morphology:

Normal features of a healthy mature oocyte at metaphase II

(MII)includepresence ofa polar body, a round even shape, light color cytoplasm with

homogenous granularity, a small perivitelline space without debris and

acolourlesszonapellucida (figure 7 A).In oocytes denuded for ICSI, the morphological

structure and the nuclear maturity but not cytoplasmic maturity can be assessed in

detail. The MII oocytes with apparently normal cytoplasmic organization may exhibit

extracytoplasmic characteristics, such as increased perivitelline space, perivitelline

debris and/or fragmentation of the first polar body, which have been suggested to

reduce developmental competence of the oocyte involved (figure 7&8)(Machtinger et

al. 2013).

(Meriano et al. 2001) reportedlower pregnancy and implantation rates when

the transferred embryos originated from cycles with more than 50% dysmorphic

oocytes and the same dysmorphism repeated from one cycle to the other. The

abnormal changes in thecytoplasm of MII oocytes may be a reflection of delayed

cytoplasmic maturation that is unsynchronized with nuclear maturity.


15

a) Oocyte maturity

One of the major causes of TFF after ICSI is a low number of retrieved MII

oocytes. About 20% of retrieved oocytes from ovarian stimulation cycles are

immature, either at metaphase I (MI) or germinal vesicle (GV) stage. The fertilization

rate of retrieved MI oocytes that remained MI at the time of ICSI is lower than the

fertilization rate of retrieved sibling MI progressing to MII in vitro (25% compared

with 62.2%, respectively). It is less than half when compared with the fertilization rate

of retrieved sibling MII oocytes (69.5%). Despite the use of varying culture techniques

and different stimulation protocols, such in vitro matured oocytes consistently have

lower fertilization rates, frequent cleavage blocks and overall retarded cleavage rate

compared with sibling MII oocytes (Combelles et al. 2010).

2). Sperm related factors

a) Sperm motility and progression:

Whether sperm movement is slow or rapid generally has no influence on ICSI

results. However, injection of immotile spermatozoa usually results in impaired

fertilization, where a non viable immotile spermatozoon is injected into an oocyte. In

the case of an immotile spermatozoon, it is possible that the spermatozoon may be

dead. The most common practice to select viable non motile spermatozoa for ICSI

involves the hypo osmotic swelling (HOS) test. Upon exposure of the spermatozoa to

hypo osmotic conditions, the intact semi permeable sperm membrane allows an influx

of water and results in swelling of the cytoplasmic space and curling of the sperm tail

fibers. Only viable spermatozoa react to the HOS solution since dead spermatozoa are

unable to maintain the osmotic gradient (Konc et al. 2006).

b) Sperm origin:

Azoospermia is the most severe form of male factor infertility. The condition

is currently classified as „obstructive‟ or „non obstructive‟. Obstructive azoospermia is

the result of obstruction in either the upper or lower male reproductive tract. Non

obstructive azoospermia is the result of testicular failure where sperm production is

severely impaired or nonexistent, although in many cases spermatozoa may be found

and surgically extracted directly from the testicles. After ICSI, ejaculated or surgically

extracted spermatozoa, when motile and morphologically normal, result in similar

fertilization, implantation and clinical pregnancy rates(Van Peperstraten et al. 2008).

b) Sperm maturity:

Round spermatid nucleus injection (ROSNI) or round spermatid injection (ROSI)

are methods in which precursors of mature spermatozoa obtained from ejaculated

specimens or testicular sperm extraction are injected directly into oocytes. ROSNI has

been proposed as a treatment for men in whom other more mature sperm forms


16

(elongating spermatids or spermatozoa) cannot be identified for ICSI. It is not widely

performed and not as successful as ICSI and it is still an experimental procedure.

Patients who may be candidates for ROSNI should be clearly informed about the

limitations and potential risks of the procedure (Practice et al. 2012)

3). Procedural effects of the ICSI technique

The risk of oocyte damage by the ICSI procedure is low in humans and may

be related to both the skill of the person performing the injection procedure itself and

to the quality and quantity of the gametes used during the procedure (Shen et al.

2003).

Common technical failures include:

Failure to deposit the spermatozoon within the oocyte cytoplasm. Thus, the

spermatozoon is deposited next to the membrane so that when the oolemma

returns to its original position, the spermatozoon is pushed out into the

perivitelline space ( Figure 9 A), or is trapped inside a sac formed by the

membrane ( Figure 9 B)

The spermatozoon mayalso adhere to the tip of the injection needle or remain

within the injection needle and be pulled out upon withdrawal of the needle from

the cytoplasm.

The degeneration of oocytes after ICSI is often a result of use of injection pipette

that is too large or not sharp enough.

Aspiration of the ooplasm is used to make sure that the oocyte membrane is

broken during injection. However, if the ooplasm is aspirated too much,

degeneration of the oocyte frequently results (Figure 9 C).

Improper positioning and orientation of the polar body and needle position can

damage or disrupt the metaphase plate during needle entry.

Injection of motile spermatozoa without immobilization leads to poor fertilization

rates. A spermatozoon with a moving tailcan be seen in the oocyte and

spermatozoon–oocyte interaction is obstructed by the normal sperm plasma

membrane. Damage to the sperm membrane is generally considered necessary for

successful oocyte activation as it induces gradual disruption of other parts of the

sperm membrane allowing entry of sperm nucleus decondensing factor of the

oocyte to induce initial swelling of the head resulting in sperm plasma membrane

ruptures and release of sperm associated oocyte activating factors thus oocyte

activation finally induced (Javed et al. 2010).

(Esfandiari et al. 2005)


17

FIGURE 7: NORMAL AND ABNORMAL MORPHOLOGY OOCYTES

(A) NORMAL OOCYTE, (B & C) CYTOPLASMIC VACUOLES

(D AND E) FRAGMENTATION, (F) PERIVITELLINE DEBRIS

(G, H, & I) ABNORMAL ZONA PELLUCIDA AND CYTOPLASM

FIGURE 8: OOCYTES WITH VACULOLES AND CENTRAL GRANULARITY

1st ROW: VACUOLES IN OOCYTES CYTOPLASM.

2nd RAW: INCREASED OOCYTES CENTRAL GRANULARITY.

FIGURE 9: POOR ICSI TECHNIQUE WITH FAILURE OF FERTILIZATION

(A) A SPERMA TRAPPED IN PERIVITELLINE SPACE (ARROW)

(B) A SPERM TRAPPED IN A MEMBRANE FOLD (ARROW)

(C) AN ATRETIC OOCYTE


18

B). Intracytoplasmic Sperm Injection Failure Due To Implantation

Failure

Implantation failure is defined as the failure to achieve a pregnancy following

ICSI cycles in which 1 to 2 reasonably good embryos were transferred.Repeated

implantation failure (RIF) is defined as the failure to achieve a pregnancy following

repeated ICSI cycles. However in most currently operating IVF programs, three

unsuccessful cycles in which 1 to 2 reasonably good embryos were transferred will

attract a special investigative attention(Gat et al. 2014).The process of implantation

depends on the communication between the embryo and the endometrium; this process

largely remained an enigmatous „black box. The implantation of the transferred

embryos still remains the major success limiting factor. Although the investigationfor

implantation failure is sometimes fruitful, the vast majority of the cases remain

obscure or „idiopathic‟ (Polanski et al. 2014).

Here, we will describe the commonly investigated maternal factors that are

associated with implantation failure and describe the various therapeutic approaches to

cope with them (figure 10) Uterine Anatomical Anomalies.

B). Implantation failure

1). Uterine anomalies

2). Thin endometrium

3). Pelvic pathology

FIGURE 10: CAUSES OF IMPLANTATION FAILURE


19

1). Uterine anomalies

Hysteroscopically visible uterine anomalies can be diagnosed in up to a

quarter of the patients with a normally appearing cavity in their initial

hysterosalpingogram or hysteroscopy.The impact of lesions minimally, or not

distorting the uterine cavity on implantation, remains controversial. However, the

surgical correction of gross intracavitary anomalies, such as protruding submucous

fibroids, adhesion or long septa was found to be beneficial(Lorusso et al. 2008).

2). Thin Endometrium

The evidence regarding the importance of endometrial thickness, as measured

by Ultrasonographic examination, to implantation is equivocal. While some authors

have shown a strong association between this parameter to implantation, others have

failed to show such a relationship. Different minimal endometrial thickness thresholds

were suggested as essential for successful implantation. In most published studies, no

pregnancy was achieved when the thickness of the preovulatory endometrium was < 6

mm (Shufaro & Schenker 2011).

Several therapeutic approaches have been suggested to overcome the problem

of thin endometrium as lowdose aspirin, vaginal sildenafil in addition to stimulation

with highdose oral and vaginal estrogens. The purpose of these strategies is to increase

the global and implantation site endometrial blood flow(Demir et al. 2013).

3). PELVIC FACTORS

Patients with hydrosalpinges have lower implantation rates because of the

detrimental effectof the fluid on the endometrium and the embryo as well.

Laparoscopic salpingectomy before ICSI significantly increased live birth rate and

pregnancy rates when compared with no treatment (Berkkanoglu et al. 2014). It is

therefore the recommendation of both the ASRM(USA) and NHS(UK) to surgically

remove fluid filled distally occluded tubes prior to any ICSI treatment(Johnson et al.

2010).


20

UNEXPLAINED ICSI FAILURE

(POSSIBLE CAUSES AND MANAGEMENTS)

This part of review aims to determine the possibility of subtle factors for ICSI

failure, which may not be indicated by standard fertility tests, contributing to the

reduced fertilization rates or implantation rates.The suggested causes of unexplained

ICSI failure and its possible managementwill be discussed under two main topics,

fertilization failure and implantation failure.

A). Unexplained ICSI failure due to fertilizationfailure

Some patients may face repeated TFF in spite of experienced practitioners, normal

sperm parameters and good ovarian response. In such cases, the actual reason for

failed fertilization after ICSI is unknown; it may be attributed to oocyte activation

failure or inability of sperm to be condensed and processed by oocyte (figure11).


a) Oocyte activation failure:

Oocyte activation is a complex series of events that results in the release of the

cortical granules, activation of membrane bound ATPase, resumption of meiosis with

the extrusion of the second polar body and finally the formation of male and female

pronuclei. The retrieved oocyte activates when the sperm enters by ICSI. In cases of

oocyte activation failure, artificial means of oocyte activation are helpful(Machtinger

et al. 2013).The oocytes remain arrested at MII if maturation has been completed.

A). Fertilization failure


a).ACTIVATION FAILURE

b). DYSFUNCTION


a).STRUCTURAL DEFECT

b). CHROMOSOMAL

CONDENSATION

c). DNA DAMAGE

FIGURE 11:UNEXPLAINED ICSI FAILURE DUE TO FERTILIZATION

FAILURE


21

When one sperm contacts the oolemma and penetrates into the ooplasm, intracellular

calcium oscillation occurs. This increase in the concentration of calcium underlies

oocyte activation and initiation of development. A factor from sperm is responsible for

inducing calcium oscillations and stimulating inositol trisphosphate (IP3)

production(Miyazaki & Ito 2006).

Injection of cytosolic sperm extracts (without nucleus) into oocytes produce the

calcium responses associated with fertilization. The active component of this extract

contained a protein that possessed phospholipase C (PLC) like activity capable of

inducing production of IP3 and that the PLC activity was highly sensitive to calcium.

It has to be established that PLC is the sole calcium oscillation–inducing factor and

how its absence has an impact on male fertility(Yoon et al. 2008).Two steps are

important for successful fertilization following ICSI, namely immobilization of the

sperm and rupture of the oolemma in order to facilitate the liberation of the cytosolic

sperm factor responsible for the oscillator function(Javed & Michael 2012).

Possible management:

Assisted oocyte activation:it is very efficient in patients with a suspected

oocyterelated activation deficiency and previous TFF after conventional ICSI.

However, when there was a prior history of low fertilization, one should be careful and

test the efficiency of assisted oocyte activation on half of the sibling oocytes, because

assisted oocyte activation is not always beneficial for patients with previous low

fertilization and a suspected oocyterelated activation deficiency. For these patients, a

split assisted oocyte activationICSI cycle using sibling oocytes can help to distinguish

between a molecular oocyterelated activation deficiency and a previous technical or

other biological failure.It aims to mimic the action of sperm penetration (Vanden

Meerschaut et al. 2012).

Assisted oocyte activation treatments include:

Calcium ionophore: it increases the fertilization rate, the number of embryos,

and the ongoing pregnancy rate for couples with low fertilizationrates,

particularly in cases of 100% globozoospermia(Eldar-Geva et al. 2003).

Treatment with 10 mm/l strontium chloride for 60 min, 30 min after ICSl:

it results in activation and fertilization of all injected oocytes, development of

the embryos to the blastocyst stage and delivery in patients with RFF. (Vanden

Meerschaut et al. 2012).

Piezoelectric stimulation of oocyte:this can generate micropores in the cell

membrane of gametes and to induce sufficient calcium influx through the pores

to activate cytoplasm through calcium dependent mechanisms. Like any other

new assisted reproductive procedure, the impact on oocyte and embryo health

must be evaluated to assess the incidences of aneuploidy and mosaicism in the


22

resultant embryos(Nasr-Esfahani et al. 2010).

b) Oocyte dysfunction:

Oocyte maturation includes nuclear maturation and cytoplasmic maturation,

and both of them are essential for the fertilization and embryo development. The

nuclear maturation was discussed in the previous chapter of this review, while the

cytoplasmic maturation is difficult to evaluate and may be a cause for repeated

fertilization failure(Javed & Michael 2012).

Itis reported that mitochondria may be used to estimate cytoplasmic

maturation because oocyte maturation in vitro is accompanied by the distribution

changes of active mitochondria in addition to distinct cumulus morphological changes.

The mitochondrion plays a vital role in the oocyte cytoplasm; it can provide adenosine

triphosphate (ATP) for fertilization and preimplantation embryo development and also

act as stores of intracellular calcium and proapoptotic factors. During the oocyte

maturation, mitochondria are characterized by distinct changes of their distribution

pattern from being homogeneous to heterogeneous, which is correlated with the

cumulus apoptosis(Wang et al. 2009).

Mitochondria are energy supplying organelles, whose functional integrality is

essential for cellular survival and development. Recent studies have shown that low

quality oocytes have some agerelated dysfunctions, which include the decrease in

mitochondrial membrane potential, increase of mitochondrial DNA (mtDNA)

damages, chromosomal aneuploidies, the incidence of apoptosis, and changes in

mitochondrial gene expression. Therefore, mitochondria can be seen as signs for

oocyte quality evaluation(Steffann & Fallet 2010).

Possible management:

Allomitochondrial transfer:Microinjection of mitochondria into oocytes may

compensate for the insufficiency of active mitochondria and raise the morula

formation rate. (Yi et al. 2007).

Self-mitochondrial transfer: the transfer of self granulosa cell mitochondria

was also proved to enhance fertilization and pregnancy rates by improving

oocyte/embryo quality during pre-implantation development (Kong et al.

2004).

Drugs:anti-oxidants antagonize the possible mitochondrial impairments

during cellular metabolism results from oxidative damage, apoptotic

inducement, which can help to overcome or reduce disadvantageous factors to

mitochondria(Armstrong 2007)


23


a) Sperm structural defects:

Single structural defects involving the totality of ejaculated spermatozoa are

among rare cases of untreatable human male infertility. This form of infertility is of

genetic origin and is generally transmitted as an autosomal recessive trait. An in depth

evaluation of sperm morphology by transmission electron microscopy (TEM) can

improve the diagnosis of male infertility and can give substantial information about

the fertilizing competence of spermatozoa(Francavilla et al. 2007).Low fertilization

rates after ICSI in patients with round headed sperm, globozoospermia, is a result of

reduced ability of round headed sperm to activate the oocyte. Apart from low

fertilization rates associated with the use of round headed sperm, cleavage rates are

also compromised. Assisted oocyte activation and ICSI restore fertilization, embryo

cleavage and development for patients with globozoospermia(Heindryckx et al.

2005)

Premature chromosomal condensation

When a cell with chromosomes in MII fuses with an interphase cell the nuclear

membrane of the cell in interphase dissolves and its chromatin condenses. This

phenomenon is called premature chromosomal condensation (PCC). Following

penetration of the spermatozooninto an oocyte, oocyte activation is triggered, resulting

in completion of meiosis and formation of both male and female pronuclei. Under

some circumstances, although the spermatozoon is within the oocyte, fertilization fails

to occur, the oocyte remains in the MII stage and the sperm head undergoes PCC

separate from the oocyte chromosomes.The failure of fertilization after ICSI may

result from either the lack or deficiency of activating factors in the spermatozoon or

from the lack of ooplasmic factors triggering sperm chromatin decondensation(Javed

et al. 2010).

a) Sperm DNA damage:

DNA damage in the male germ line is associated with poor fertilization rates,

defective preimplantation embryonic development and high rates of miscarriage and

morbidity in the offspring. NuclearDNA damage in mature spermatozoa can arise

because of errors in chromatin rearrangement during spermiogenesis, abortive

apoptosis and oxidative stress(Aitken & De Iuliis 2010).

Possible management:(Aitken et al. 2009)found that,there are two major

strategies that may be considered for the treatment of men exhibiting high levels of

DNA damage in their spermatozoa:

(i) Selective isolation of relatively undamaged spermatozoa; and

(ii) Antioxidant treatment.


24

B). Unexplained ICSI failure due to implantation failure

Failure of conception despite the repeated transfer of apparently good quality

embryos is a significant clinical problem in ICSI practice.There is a range of different

embryo or endometrial related abnormalities that underlie implantation failure. Logical

approaches to investigation and treatment can only begin if causal associations are

proved (Shufaro & Schenker 2011).Figure (12) shows possible causes of ICSI failure

due to implantation failure

FIGURE 12: UNEXPLAINED ICSI FAILURE DUE TO IMPLANTATION FAILURE

1). Maternal factors

a) Endometrial receptivity:

It is estimated that up to two thirds of implantation failures are due to defects in

endometrial receptivity. In USA, the overall implantation rate for IVF-ET remains

around 29% and has not improved significantly over the past 5 years of reporting

(Miller et al. 2012). A functioning and receptive endometrium is crucial for embryo

implantation. During the menstrual cycle the endometrium undergoes both

morphologic and biologic changes that prepare it for interaction with the embryo, and

ultimately for successful implantation. Once all biological changes occur, the embryo

can attach, invade and finally implant. This crucial stage referred to as the “window of

implantation”(Shufaro & Schenker 2011).

Implantation window is a period during which the endometrium is optimally

receptive to implanting blastocyst. The endometrium is normally a nonreceptive

environment for an embryo. Implantation of the human embryo may occur only during

a 6-10 days postovulation (a window lasting approximately 4 days, from days 20-24 of

the cycle), and surrounded by refractory endometrial status. It is critical to recognize

the time for ET that would best corresponds with the implantation window for optimal

results in assisted reproductive technology (Polanski et al. 2014)

B). IMPLANTATION FAILURE

1). MATERNAL FACTORS

a).Endometrial receptivity

b). Hyper coagulability

c). Immunologicfactors

2). EMBRYONIC FACTORS

a). Genitic abnormality

b). Embryo culture

c). Zone hardening


25

Factors Affecting Endometrial Receptivity:

1. Hormonal factors:the following hormones was found to affect endometrial

receptivity

a) Estrogen and progesterone: Serum levels of estradiol (E2) appear to be of

relatively little value in predicting endometrial maturation, this is because

maturity depends upon estrogen receptor development, which is

genetically coded for each individual and, therefore, similar levels of

estrogen can initiate different levels of endometrial maturity in different

individuals.

b) Gonadotropin hormones: the uterine concentration of LH receptors and

their occupancy by LH increased in the peri implantation period. This is

considered as evidence for the role of LH in implantation and subsequent

decidualization.

c) GnRh agonist and GnRh antagonist:both were found to be associated with

low LH luteal levels. These low LH levels may lead to an insufficient

corpus luteum function and consequently, to a shortened luteal phase or to

the low luteal progesterone concentration frequently described after

ovulation induction. These changes lead to shift forwards of implantation

window. It can be prevented by progesterone supplementation which

improves endometrial histology.

2. Genetic factor: The following gene must be expressed at the time of ovulation

and has been shown to be essential for human implantation Hoxa 10 gene,

uterine sensitization associated gene1 (USAG1), Endometrial bleeding

associated factor (EBAF).The mechanisms by which these genes affect

endometrial receptivity are unknown.

3. Effect of age:There is significant decline in human fecundity with advancing

age, which may be due to decreased levels of progesterone receptors promoted

by the low levels of E2 receptors.

(Von Grothusen et al. 2014)


26

Markers of Endometrial Receptivity:

I) Biochemical Markers

a) Endometrial adhesion molecules: They include 4 main families: integrins,

cadherins, selectins and immunoglobulin superfamily.The role of cadherins or

selectins in implantation is unknown.Three integrins are expressed on glandular

endometrium only during cycle days 20 to 24. These molecules areα1β1, α4β1,

and αvβ3.These three integrins have been proposed as the best of the

biochemical markers of endometrial receptivity.

b) Endometrial antiadhesion molecules:Mucins are a family of antiadhesion

molecules the most important of which is (MUC1) presents on the surface of

human epithelial cells. The high peri implantation levels of MUC1 could play a

role in "shielding" the implanting blastocyst from other inhibitory factors on the

epithelial surface and hence maintenance of early pregnancy.

c) Endometrial cytokines:Although many cytokines play a role in implantation, a

vital role has been clarified in four of them, namely: Leukaemia inhibitory

factor (LIF), interleukin1&11(IL1& IL11) and colonystimulating factorbut their

exact role are currently unclear.

d) Endometrial growth factors: Heparin bindingepidermal growth factor

(HBEGF) and Insulin like growth factor binding protein1 (IGFBP1)are major

products of secretory endometrium and decediua. Their role awaits further

investigation.

e) Endometrial immune markers:The endometrium has a large population of

lymphomyeloid cells that play a role in the implantation process;the

significance of these findings in relation to endometrial receptivity is unclear at

present.

(Ganesh et al. 2014)

II. Morphological Markers:

a) Pinopodes:It is the characteristic presence of histological protrusions in the

surface membrane of epithelial cells of the endometrium under the influence of

estrogen and progesterone during the menstrual cycle.Pinopodes appear around

the 20th day of the menstrual cycle, and itsformation is considered asa

functional marker of uterine receptivity.

b) Epithelial tight junction changes: they undergo a significant decrease between

days 13 and 23 of the menstrual cycle to reduce the integrity of the epithelial

barrier to allow implantation to occur.



27

Assessment of endometrial receptivity:

Invasive assessment: All the above parameters can be accurately predicted by

biochemical assessments of markers, histological study of pinopodes. But these

tests are invasive and expensive, cannot be repeated many times and need highly

advanced laboratory and trained personal(Malhotra et al. 2010).

Non invasive assessment (Edgell et al. 2013)

1) TransvaginalUltrasonography:

Endometrial thickness: a thin endometrium (<7mm) or athick

endometrium (>14mm) seems to be a sign of suboptimal implantation.

Endometrial pattern:a triple line appearance is considered as a predictive

of pregnancy(Simon & Laufer 2012).

2) Threedimensional volumetry of the endometrium: a minimumvolume of 2ml

was found to be a prerequisite for a receptive endometrium and that no

pregnancy could be achieved when endometrial volume measured <1ml.

3) Doppler ultrasound studies of uterine arteries: the role of uterine artery blood

flow assessment in the prediction of endometrial receptivity is controversial;

some workers have reported significant correlation between pregnancy rates

and uterine artery Doppler flow values while others have failed to show such a

relationship(Achache & Revel 2006)

4) Magnetic resonance imaging (MRI): as a result of its high cost, MRI is

unlikely to be incorporated into routine infertility practice.

Strategies for improving endometrial receptivity:

I) Development of COH protocols with minimum effect on endometrium

through:

a) Use of ovarian stimulation protocols other than Clomiphen citrate (CC)

because of its anti receptivity effect.

b) Correction the endometrial alterations induced by CC by vaginal hormonal

supplementation with estradiol and progesterone gel.

c) Exogenic 17 estradiol during ICSI cycles: A sufficient concentration of

estrogen is necessary for endometrial proliferation during the follicular

phase, for implantation and progress of pregnancy.

d) Decreasing estradiol levels during the pre implantation period in high

responders, through the use of FSH stepdown regimen.

e) Low doses of antiprogesterone to prevent the precocious luteinization

premature appearance of implantation window.

II) Avoidance of the endometrium during stimulated cycles: by freezing the

embryos and transferring them in subsequent natural cycles.



28

III) Improveuterine vascularization by:

a) Low dose aspirin: this treatment significantly improves uterine and ovarian

blood flow velocity.

b) L-arginine (Nitric oxide donor): L-arginine supplementation improves the

uterine blood flow and endometrial receptivity.

c) Sildenafil (Viagra): it is 5phosphodiasterase inhibitor that prevents the

breakdown of cGMP and potentiates the effect of nitric oxide on vascular

smooth muscle. Vaginal sildenafil may be effective for improving uterine

blood flow and endometrial receptivity, implantation rate and pregnancy

rate(Malinova et al. 2013).

IV) Treatment of the pathological conditions:

d) Luteal phase defect: A vaginal suppository containing progesterone is

inserted twice daily starting 2-3 days after ovulation until menstruation

occurs or through the 10th week of pregnancy.

e) Autoimmune conditions: An increase in both implantation and pregnancy

rates with predinosolone and low dose aspirin therapy in autoantibody

positive women was demonstrated.

f) Performing two endometrial samplings (in the follicular luteal phase of the

cycle, antecedent to the embryo transfer cycle):Significant improvement in

the clinical pregnancy rate (32.7 % vs13.7 %), the live birth rate (22.4 % vs

9.8 %) and the implantation rate (13.07%vs 7.1 %) was found in patients

who underwent the procedure compared to controls. The exact mechanism

for such appreciative effect is not fully understood. However, it is

postulated that a biopsy induces an inflammatory response that prepare the

endometrium for implantation. Elevated pro inflammatory cytokines in the

regenerative endometrium could play a role in implantation competence

(Gnainsky et al. 2010). Interestingly, this beneficial inflammatory effect

lasts at least one additional month, thus improving implantation in the

subsequent cycle(Granot et al. 2012).

b). States of Hypercoagulability:

The role of inherited and acquired hypercoagulable states (thrombophilia) in

implantation failure is presumed to be similar to recurrent miscarriages. Recent studies

had associated both inherited and acquired thrombophilias with repeated implantation

failure (RIF) and poor ICSI outcome, especially in those defined as having

“unexplained infertility” when compared to control populations.Screening for

thrombophilia in RIF is still controversialhowever it is the authors' opinion that

thrombophilia screening to be a part of the evaluation of implantation failure(Polanski

et al. 2014).


29

Management:

Low molecular weight heparin:the effectiveness in increasing the

implantation, pregnancy, and live birth rates was proven in some prospective

randomized controlled trials(Qublan et al. 2008). On the other hand an equal amount

of studies ruling out such a connection or the therapeutic effectiveness of heparin also

exists (Bellver et al. 2008).Thus, It is the authors' personal impression that once

thrombophilia is diagnosed and prophylactic low dose LMW heparin is administered,

the ART success rates increase. In addition, heparin prophylaxis is also important for

patient safety during the hyperestrogenic state created by controlled ovarian

stimulation (COH) and pregnancy(Shufaro & Schenker 2011).

c) Immunological Factors:

A number of studies indicate a major role for the immunologic system in the

process of implantation, and in the subsequent maintenance of pregnancy(Singh et al.

2011). A conception must be recognized as nonself in order totrigger an immunologic

process that prevents the maternal immune system from rejecting it. Couples who

share common HLA alleles may experience recurrent pregnancy loss, or as suggested

by Elram et al.,may suffer from RIF. The exact molecular mechanism is still obscure.

However, inadequate response of the maternal immune system to stimulation by

paternal antigens, due to HLA sharing, has been implicated(Elram et al. 2005). Such

inadequate response may involve the imbalance of T helper 1: T helper 2 (TH1:TH2)

response, causing the maternal system to be more cytotoxic(Dahl & Hviid 2012).

Management:

a) paternal leukocytes immunization:it is no longer recommended because of

the possible side effects to the mother and the fetus due to an unpredicted

immune response to either autologic or allogenic blood components (Simon &

Laufer 2012).

b) High dose intravenous immunoglobulin (IVIg)administration: this treatment

carries less risk and was found to benefit patients with RIF who share HLA

alleles with their partner. Treatment consists of 30 g of IVIg before embryo

transfer (ET) and a second similar dose when a fetal heart rate is noticed. Due to

the high costs of both HLA testing and IVIg treatmentit is suggested that the

assessment of the immune system contribution to RIF be carried out last, and

only after all other causes are ruled out(Li et al. 2013a).

c) Infusion of 20 % intralipid solution: it is recentlyreported to improve

outcomes in women with RIF(Simon & Laufer 2012).Infusion of 2– 4 ml of 20

% intralipid solution dilutes in 250 ml of saline can effectively suppress natural

killer (NK) cell activity in patients with abnormal NK cytolytic activity. This

modulation of the immune system lasting for several weeks is the basis for


30

intralipid treatment in RIF in which increased cytotoxic NK activity was

found.The TH1:TH2 activity ratio was decreased following treatment with

intralipid. This cytokine activity alteration was considered responsible for the

successful outcome that resulted. (Roussev et al. 2008).

2). Embryonic Factors

Despite the significant advancement in human extracorporeal embryo culture,

the existing knowledge and tools to investigate and treat implantation failure due to

embryonic causes is limited. The recognizedembryonic factors include genetic

abnormalities, suboptimal growth in culture and zona hardening.

a) Genetic Abnormalities:

Chromosomal abnormalities are not infrequent in human embryos cultured in

vitro and such embryos have a reduced implantation potential. The percentage of

embryonic aneuploidy was found to be higher in RIF cases than in

controls(Hardarson et al. 2012). The disruption of chromosome replication and

segregation in a greater than anticipated fraction of the cultured early human embryos

might be a common cause for RIF. In most cases the parental karyotypes are normal

and the embryonic chromosomal aberrations found are incidental or secondary to

disturbed gametogenesis(Shufaro & Schenker 2011).

Management:Preimplantation genetic screening (PGS) allows selecting only

the chromosomally normal embryos for transfer.Parental karyotype determination

should be a part of the RIF investigation, especially if a history of miscarriages exists.

If a parental translocation or other anomaly is discovered, than preimplantation genetic

diagnosis (PGD) is warranted like any other inherited condition.Ifthe parental

karyotype is normal, the performance of genetic screening is of no benefit(Simpson

2010).

b) Embryo Culture and Transfer:

Embryo quality assessed by morphologic criteria on either day 2 or 3 after

fertilization would continue to develop in utero, reach the blastocyst stage and then

implant. However, even embryos that are morphologically defined as good quality

may cease to develop and fail to progress into a blastocyst stage. This may be due to

either suboptimal local conditions or intrinsic factors within the embryos(Shufaro &

Schenker 2011).

Management:

Selection of a suitable Culture media:In some cases, patient specific culture

conditions are required for optimal embryonic development. In some cases of

implantation failure it might be beneficial to empirically alter the culture

media when in vitro embryo culture is suboptimal(Simon & Laufer 2012).


31

Coculture of embryos with homologous endometrial cells:it was suggested

to improve culture conditions due to the secretion of embryotrophic factors,

such as nutrients, growth factors and cytokines, and neutralization of harmful

substances(Levitas et al. 2004). Using this method, an impressive pregnancy

rate was reported in a large patient group with RIF(Spandorfer et al.

2004)However, most IVF units are not equipped and do not have facilities and

personnel required for routine performance of co-culture(Spandorfer et al.

2004).

Embryo culture to the blastocyst stage before transfer: this methodharbors

several benefits. The blastocyst is placed in the endometrial cavity 5 to 6 days

after fertilization, as in natural conception. Culturing the embryos to the

blastocyst stage examines the activation of the entire embryonic genome and

biologically selects in vitro the embryos with the highest implantation

potential. However, in vitro embryo loss is inherent to blastocyst culture and

might jeopardize the entire treatment cycle(Glujovsky et al. 2012).

Zygote intra fallopian transfer (ZIFT):it seems more physiological than

placing embryos of day 2–3 cleavage stage into the uterine cavity. When the

ZIFT procedure is applied, the fertilized egg benefits from endosalpingeal

secretions and reaches the endometrium as a blastocyst at a time that coincides

more closely with the window of implantation. ZIFT has been reported to be

superior to transcervical embryo transfer and it can be considered an effective

mode of treatment for patients with repeated failure of implantation in IVF-

ET. (Simon & Laufer 2012).

Embryo transfer technique:Use of the best transfer technique is mandatory

in each cycle and obvious in RIF. ET with soft a traumatic catheters under

ultrasound guidance to assure midcavity placement is the superior and almost

universally accepted standard in ART.(Simon & Laufer 2012)

C). Zona Hardening (ZH):

Increased ZP thickness and hardness was associated with lower implantation

rates. Thus, failure of the ZP to rupture has been suggested as a possible cause of

RIF (Shufaro & Schenker 2011).

Management: different mechanical, chemical and optical techniques were

used in order to regionally weaken the ZP or even create an opening in it in

order to assist hatching (AH) and implantation.It seems that AH is beneficial in

selected cases of poor prognosis, and bares no actual risk(Cohen & Alikani

2013).


32

Recent advances in managements of unexplained ICSI failure

Several new techniques are now under trial toassess managing of unexplained

ICSI failure due to oocyte, sperm or embryo related factors. These techniques include:

1) PICSI dishes for sperm selection:The PICSI device, a dish similar to ICSI dish,

contains 3 microdots of hyaluronan hydrogel which need to be hydrated by media

before ICSI (figure 13). The prepared sperm sample is placed at the edge of the

micro drop of PICSI dish. Its idea depends on the fact that mature, biochemically

competent sperm bind to the hyaluronan where they can be isolated by the

embryologist and used for ICSI. PICSI is a method of selecting the best possible

sperm for fertilization in the IVF protocols. The formation of hyaluronicacid

(HA)binding sites on the sperm plasma membrane is one of the signs of sperm

maturity(Worrilow et al. 2013).

2) Intracytoplasmic Morphologically Selected Sperm Injection (IMSI):

examination ofunstained spermatozoa at 6000 or higher magnification to select

sperm with best morphology. It is based on a high magnification motile sperm

organelle morphology examination (MSOME). Such examination helps to identify

spermatozoa with a normal nucleus and nuclear content. This proceduretakes a

time of 60- 210 min(Klement et al. 2013).It requires two embryologists working

together on the same sample at the same time to minimize the subjective nature of

sperm evaluation.The IMSI procedure improved clinical outcomes in the infertile

couples with male infertility and poor embryo development over the previous ICSI

attempts (Kim et al. 2014).

3) Polscope: It is a digital, orientationindependent polarized light

microscopedesigned to image the oocyte spindle noninvasively based on the

inherent optical property of highly ordered molecules as they are illuminated with

polarized light. The Polscope (figure 15) is used to protect the meiotic spindle from

damage during ICSI. The oocytes having Polscopevisualized spindle have higher

fertilization rate. When the spindle is located at 0°-30° in relation to the first polar

body, ICSI achieves highest fertilization rat. (Omidi et al. 2014).


33

4) Time-lapse imaging: Continuous image monitoring of the cultured embryo may

provide a complete picture of the developmental kinetics that the embryo

undergoes. The method analyzes the fertilized egg and the embryo at a few

predefined time points, thus, missing all the events that occurred between these

points. Processing the data retrieved on the day of embryo transfer might help

improve selection of embryos with the highest potential for implantation.

Currently, in most IVF units, selection of embryos for transfer is based mainly on

morphologic criteria of embryos on the day of transfer, and the timing of cell

divisions of early cleaved embryos. Edessy et al found in their study that that early

cleavage could be an additional factor for selecting embryos with a higher potential

of implantation and successful pregnancy (Edessy et al. 2013b). However, embryo

morphology and timing of cell division are not sufficient criteria, since they cannot

truly determine the molecular signature of a human embryo, or accurately predict

its implantation potential. The efficacy of time-lapse analysis has still to be

evaluated in prospective randomized studies, to determine whether it can improve

implantation rates. Patients with RIF might benefit from such an assessment, since

routine embryo selection as currently applied may be deceiving, especially for this

group of patients (Hashimoto et al. 2014).

5) ‘Omics’ technologies: In culture, the developing embryo is metabolically active,

utilizing both the substances it produces and those supplemented in the culture

media, and secreting its metabolites to the adjacent vicinity. In recent years,

transcriptomic and proteomic, as well as metabolomic, approaches were developed

to promote investigation of the expression of thousands of genes, proteins and

other metabolites. Study of the „omics‟ group has contributed to understand the

gene regulatory structure involved in the embryo implantation process. It is

currently possible to assess nutrient uptake as well as the metabolic production of

the embryo. Exploring appropriate gene activation and expression, either in the

embryo or in the endometrium, may help improve selection of embryos for transfer

at the appropriate phase of the secretory endometrium. Nevertheless, the „omics‟

approach requires sophisticated, complex and expensive systems, making it

difficult to apply routinely in every IVF program setup (Javed & Michael 2012).


34

FIGURE 13: PICSI DISH FOR SPERM SELECTION

FIGURE 14: POLSCOPE (LEFT) AND MEIOTIC SPINDLE (RIGHT


35

Clinical Approach to a Case of Unexplained ICSI Failure

Unexplained ICSI failure is a difficult unresolved challenge in

reproductive medicine and a source of endless patient frustration and despair.

Though far from resolution, several investigative measures and therapeutic

interventions were found to be useful in this complex condition according to the

current review

If the condition is due to fertilization failure:

Repeated ICSI treatment can be useful or necessary because there is a

high possibility of achieving normal fertilization if a reasonable number of

oocytes with normal morphology are available and motile sperm can be found.

If there are no motile sperm present in the first ejaculate, a second sample

should be required followed by PESA or TESE to obtain motile sperm. In this

way, a sufficient number of motile sperm for ICSI are usually found in most

men with severe asthenozoospermia(Palermo et al. 2009).A history of failed

fertilization may be related to some gamete abnormality that may be modified or

corrected at the next cycle. It has been documented that for a particular patient,

fertilization results can be quite varied when followed through several ICSI

cycles at the same centre. The differences between fertilization rates are

unexplained. Onethird of the patients with TFF achieved pregnancy with their

own oocytes in a subsequent ICSI cycle. Since followup ICSI treatment has

been shown to result in fertilization in 85% of cases, repeated ICSI attempts are

suggested in TFF(Javed & Michael 2012)

If the condition is due to implantation failure:

Patients should undergo hysteroscopy to assess the uterine cavity. Three

dimensional Ultrasonography, as well as hysterosalpingographyare

complimentary tools to be performed as needed. Once an abnormality

associated with implantation failure is recognized, treatment options should

be considered to include uterine septectomy, removal of intrauterine


36

adhesions, endometrial polypectomy or myomectomy (particularly the

submucous type), and excision of hydrosalpinx.

Thin unresponsive endometrium is hart to manage. Available treatments

include high dose estrogen, the application of vaginal estrogen pills, aspirin

and other medications that may increase blood flow to the endometrium, and

mechanical endometrial stimulation by biopsy sampling.

In repeated implantation failure, patients are advised to undergo blood tests

for thrombophilia as well as for connective tissue diseases that involve

antiphospholipide antibodies. Once detected, a consultation with a

hematologist and connective tissue disease specialist is advocated and

treatment with low molecular weight heparin (LMWH) is recommended.

However, when anti phospholipids antibodies (APLA) syndrome is

diagnosed, a concomitant treatment with mini dose aspirin and/or

corticosteroids should be considered. Initiation of LMWH should be

considered from the early stimulation period or from the day of embryo

transfer. A patient‟s family and personal medical history, particularly her

previous IVF experience, are important for reaching a decision. Patients with

no history of thrombotic events, personally or among close relatives, and

who already experienced several uneventful IVF treatments, may be

considered suitable to start LMWH on the day of ET. Patient with APLA

syndrome, or with a history of a disease that can be attributed to a

hypercoagulability trait, should start anticoagulation concomitant with

gonadotropin administration. Treatment with LMWH should be stopped 24 h

before egg retrieval and reinitiated the day following ovum pickup.

Investigation of causes of implantation failure may include morphologic

analysis of the sperm. Testing the sperm cells for DNA fragmentation and

abnormal chromatin packaging is reasonable if RIF seem to be associated

with male factor. This test, however, should also be carried out in patients

with apparently normal sperm parameters. If advanced morphologic


37

evaluation of the sperm or other methods of assessing DNA integrity reveal a

high percentage of abnormal sperm cells, IMSI should be considered as a

means of improving implantation.

If the results of all tests mentioned above are normal, consideration of a

possible contribution of the couple‟s immunologic system to implantation

failure is recommended. This can first be performed by checking for the

presence of an immunologic reaction following a mutual cross match

between the serum and lymphocytes of the couple. If no reaction results, then

the maternal immune system is apparently nonresponsive to paternal antigen

components. This may be due to the couple‟s similarity in human leukocyte

antigen (HLA) components. In such case, a similarity of alleles in Class I and

Class II HLA compatibility should be tested. If such a similarity is found,

high dose IV immunoglobulin (IVIg) should be offered as suggested by

(Elram et al. 2005)before embryo transfer followed by an additional dose as

soon as a heart beat is visualized, at about 6 weeks of gestation

Preliminary results using intralipid infusion to support implantation are rather

encouraging. However, the real benefit of such treatment in patients with

increased NK cytotoxic activity experiencing RIF has not been proved yet in

largescale randomized controlled studies.

Better selection of the embryo for transfer is expected oncethe new methods

of time-lapse imaging and „omics‟ technology are applied. Thesemethods can

accurately assess embryo morphology and its metabolic activity.

(Simon & Laufer 2012)


38

Options for patients after repeated unexplained ICSI cycle failure

Physicians should counsel patients based on the best possible evidence available

and allow the couple to make an informed choice. The adverse result of a failed

ICSI cycle does not imply a hopeless prognosis for future ICSI treatment. Very

subtle improvements in semen parameters and/or oocyte yield/quality may result in

fertilization in a subsequent ICSI attempt. Otherwise, the options of adoption and

remaining childless should be discussed with the couple with psychological support

(Palermo et al. 2009)

Assisted reproductive technology in Islamic perspectives

New "Assisted Reproductive Technologies" (ARTs) are only allowed if they

are performed in the context of an intact marriage, i.e., during the life span of

marriage, while both partners are alive, using the husband/wife gametes, and the

resulting embryo is implanted and carried in the wife's womb.

Donor sperm insemination, donated oocytes or embryos are available solutions

in non-Islamic countries, however these solution are forbidden in Islamic countries as

it is considered as a type of prostitution. There is no religious objection to an infertile

married couple pursuing any form of infertility treatment including in vitro

fertilization, surgical sperm retrieval and microassisted conception methods. However,

there must be strict control to ensure that the gametes belong to the husband and wife.

This relationship is described as 'halal' (permitted), whereas any union of gametes

outside a marital bond, whether by adultery or in the laboratory, is 'haraam'

(forbidden). Therefore, donor sperm, oocyte or embryo pregnancies are strictly

forbidden in all schools of Islamic law. Similarly, treating any other situation outside a

marriage relationship, for example fertilization of an ovum from cryopreserved sperm

after divorce of the couple or death of the husband would be 'haraam' and strictly

forbidden. The Qur'anic guidance is quite clear that the couple can pursue all permitted

treatments but may need to accept that they may not achieve a pregnancy and be

infertile. Adoption is encouraged in Islam with the specific rule that the child must be

able to identify its biological father by keeping his name (Husain 2000).

Surrogacy is prohibited because confusion of lineage is inherent in all types of


39

surrogacy. In addition, there are inherent legal concerns, especially when a dispute

arises among the prospective parents(Serour 2008).

Allah Saied in Glorious Qur'an,In the name of Allah

To Allah belongs the dominion of the heavens and the earth; He creates what he wills.

He gives to whom He wills female [children], and He gives to whom He wills males. Or He

makes them [both] males and females, and He renders whom He wills barren. Indeed, He is

Knowing and Competent (Glorious Qur'an, Chapter 25: no42.Ayah 49 & 50).

ن الرحيم بسم الله الرحم

ي ه ب لم ن ي ش اء إن اث ا و ي ه ب لم ن ي ش اء الذكور ي خلق م ا ي ش اء ل له ملك السم او ات و ال رض

(50) إنه ع ليم ق دير و ي جع ل م ن ي ش اء ع قيما أ و يز وجهم ذكر ان ا و إن اث ا (94)

ص د ق اهلل الع ظيم

(05و 49سورة الشورى آية ) -القرآن الكريم

http://quran.ksu.edu.sa/tafseer/qortobi/sura42-aya50.html

http://quran.ksu.edu.sa/tafseer/qortobi/sura42-aya50.html


40

SUMMARY

Some patients may face repeated total fertilization failure in spite of

experienced practitioners, normal sperm parameters and good ovarian response.

In such cases, the actual reason for failed fertilization after ICSI is unknown; it

may be attributed to oocyte activation failure, as more than 80% of these oocytes

contain a sperm, or oocyte dysfunction or inability of sperm to be decondensed

and processed by the oocyte.

Failure of implantation despite the transfer of apparently good quality

embryos is a significant clinical problem in ICSI practice.

Successful implantation is a complex process involving two main players,

the mother as a host and the embryo.

Problems originated from the host environment, such as abnormal uterine

anatomy, non-receptive endometrium and the medical condition of the mother

(such as thrombophilia and abnormal immunologic response) can adversely

affect the crosstalk between the embryo and the endometrium that is crucial for

successful implantation.

Similarly, this endometrium-embryo interaction may be hampered if the

embryo is disordered. Embryo abnormality can originated from either paternal

sperm factors or from the oocyte and its capability of being fertilized normally

and cleave.

Accordingly, the investigation and treatment of patient with implantation

failure should focus on both male and female risk factors that once identified

should be managed and treated appropriately.


41

Conclusions

Unexplained ICSI failure is a difficult unresolved challenge in

reproductive medicine and a source of endless patient frustration and despair.

Though far from resolution, several investigative measures and therapeutic

interventions were found to be useful in this complex condition.

Managements of unexplained ICSI failure include:

If the condition is due to fertilization failure:

o Repeated ICSI treatment should be tried because there is a high possibility

of achieving normal fertilization if a reasonable number of oocytes with

normal morphology are available and motile sperm can be found.

o If there are no motile sperm present in the first ejaculate, a second sample

should be required followed by PESA or TESE to obtain motile sperm. In

this way, a sufficient number of motile sperm for ICSI are usually found

in most men with severe asthenozoospermia

If the condition is due to implantation failure:

o Patients should undergo hysteroscopy to assess the uterine cavity. Three

dimensional Ultrasonography, as well as hysterosalpingographyare

complimentary tools to be performed as needed.

o Thin unresponsive endometrium is hart to manage. Available treatments

include high dose estrogen, the application of vaginal estrogen pills,

aspirin and other medications that may increase blood flow to the

endometrium, and mechanical endometrial stimulation by biopsy

sampling.

o Patients are advised to undergo blood tests for thrombophilia as well as

for connective tissue diseases that involve antiphospholipide antibodies.

o Morphologic analysis of the sperm.

o Checking for the presence of an immunologic reaction following a mutual

cross match between the serum and lymphocytes of the couple.

o Using intralipid infusion to support implantation is encouraging.

o Better selection of the embryo for transfer is expected once the new

methods of time-lapse imaging and „omics‟ technology are applied.


42

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49

س )ف الملخص العشب ب ش غيش الم جه ش قه الم ل الح (ش

تشنو طشقة اىحق اىجش األو األخرش ىيققر ىينررشم رش يرل نر ث لرذ اى شرو

ذ.بقذ تيل اىطشقة ؤد إى اىشقس بشإللبشط اىأط اىشذ

قذه اإلخصشب بقذ اىحق اىجش قذ صو إى % ن األعشس جتقة زا ق 07 -07إ

ث عي اىشغ لق اىحا اى داخو اىبضة إ ث شك غربة ىقرذ اإلخصرشب. قرش بقر

يرية خصارش األصاج نشو اإلخصشب اىتنشس ش ؤد إى تقيرو غربة اىحرو بقرذ مرو حشىرة نش

بقذ اىحشىة اىرشىرة.

اىجذش بشىزمش ث ثير لش ت نشو صساعة اىج داخو اىشل شجر إىر خيرو نر اىقشبيرة

% ىر رضد رزا اىقرذه بغربة 92اىشلة. إ قذه اىضساعة اىشجح ىيج ن اى شت اىتحرذ لراى

يحظة خاله اىخظ عات األخش .

إىرر غررل عشىررة ىيجررشد قتررذ عيرر عشررو الررذ بررو رر ررة تنشيررة رر إ اىارره

اىقاررو اىختي ررة تبررذث بررشىتق اىررذق، ىنررو لشىررةم اإلتررش بنررو ت شاررو خصررش مررو لشىررة عيرر لررذ م

ا تش بأ ن قو اإلخصشب اىخشسج اىرز جرش نر عيرة إخصرشب اىبضرشت ر األجرة

طبقش ألعي غتشت اىجد داخرو اىقو.رشك اىنررش ر األعربشب عي ثعي غت اىتقة

ى شو اىحق اىجش بقضش قير بقضرش اخرش غرش قير. رزا اىبحر تقرشأل ىربق األعربشب

اىؤدة ىي شو غش اىبشس ىيحق اىجش حشىة دساعتش اقتشاد عالجش إ ثن.

يمكه مىاقشتاألسباب المحتملت لفشل الحقه المجهش غيش المبشس تحت هزيه المحىسيه:و

أوال: فشل اإلخصاب:

قذ تقش بق اىغذات عذ جشد عية اإلخصشب غش اىبشس سغر مر اىقرش برش ر

ر اىخبش اىتشع عي ز اىتقة.عيشء األجة

لألاسباب اآلتيت:ويمكه أن يعضي رلك

رر ررز اىبضررشت 07نشررو تشررظ اىبضررة بررشىحا اىرر لرر جررذ ث ثمرررش رر ٪

تحت عي لاشت ة رىل نشىبضة غش شطة.

.خيو ن ظ ة اىبضة

قشىجترش باعرطة نشرو ث عذ قذس اىحاشت اىة عي نل تنشثف جشتشش رؤد إىر

اىبضة


50

ثاويا: فشل صساعت األجىت داخل الشحم

قذ تقش بق اىغذات اى شو غرش اىبرشس ىضساعرة األجرة داخرو اىرشل سغر مر األجرة

جررشد صساعرة األجررة ر عيررة ققرذ تطرر عير عررشي .اىقىرة ىيررشل رات عرة جررذ ظششرش

.س غ ش األ مضف اىج

شة وعذيذة تمىع التصاق األجىت بجذاس الشحم. ومه هزي األسباب:و تىجذ أسباب كثي

جرررد عرررب خيقرررة برررشىشل ث ثسا ى رررة ىررر تشرررخ عررري ش ث جرررد لرررشجض سلررر ث

اىتصشقشت بتجف اىشلم مزىل جد صا ذ ىحة.

.جد تذد بئلذ قشت نشىب

.ضقف عل اىغششء اىبط ىيشل

ثيش األعبشب. اىقشبيةاىشلةضقف

.اىقاو اىنتغبة ث اىساثة ىضشد تجيظ اىذ ث ق عشاش اىغىة بشىذ

ضرش إىر رىررل األجغرش اىضررشد تأثشاترش اىختي رةم مررزىل اىخالرش اىضررشد ر ثلررذ

األجة األعبشب اىت طي، عيش اع اىقق ر األعبشب اىشعة ث ثعبشب تجقو اىجغ قتبش

غشبة عي األ نطشد تيل األجة.

.اىخيو اىصبغ ىألجة

صشد عل اىغال اىخشسج ىيبضشت ث األجة ش غتيض عو نتحشت غشعذ ى قرظ

اىج ىيخشج زا اىغال .

ر اىجذش بشىزمش ث عالج اى شو غش اىبشس ىيحق اىجش قتذ عي تقر را اى شرو ث

ل م نشو إخصرشب ث نشرو صساعرة ثر حشىرة اىبحر نر األعربشب اىغرشبقة ىنرال اىرع حشىرة

غررشعذ اىحقرر اىجررش ىيحررا عالجرر بررشىقالج اىشعررل رر اعررتخذا اىتقررشت اىحذرررة رررو اى قررظ اى

رش رىرل ىتحغر ترش اى اىختشس بشىشنو اى شش اعتخذا شس اىبىغنب ثطبشق بنغر غ

اىحق اىجش.

unexplained intracytoplasmic sperm injection failure: a review article

Healthcare

unexplained icsi failure

sperm related factors

implantation failure

fertilization failure

icsi technique

indications of icsi

oocyte related factors

pelvic factors