Different fertilization rates between immotile testicular spermatozoa and immotile ejaculated spermatozoa for ICSI in men with Kartagener’s syndrome: case reports

Human Reproduction Different fertilization rates between immotile testicular spermatozoa and immotile ejaculated spermatozoa for ICSI in men with Kartagener's syndrome: case reports G.Westlander 0 1 M.Barry 0 1 O.Petrucco 0 1 R.Norman 0 1 0 Reproductive Medicine Unit, University of Adelaide , 180 Fullarton Road, Dulwich SA 5065 , Australia 1 World Health Organization (1999) WHO Laboratory Manual for the examination of Human Semen and SpermCervical Mucus Interaction, 4th Edition, Cambridge University Press , Cambridge We report two cases of infertility treatment in couples where males suffered from Kartagener's syndrome (KS) and a total absence of motile sperm in the ejaculate. A total of three ICSI cycles was carried out. In all cycles, viable ejaculated or testicular spermatozoa were selected using the hypo-osmotic swelling (HOS) test. Case 1: In the rst ICSI cycle total fertilization failure occurred after using ejaculated spermatozoa. In the following cycle testicular spermatozoa were used for ICSI, resulting in 75% fertilized oocytes and a pregnancy. Case 2: In the same ICSI cycle 50% of the oocytes were injected with ejaculated and 50% with testicular spermatozoa. The fertilization rates were 44 and 56% respectively and high quality embryos were achieved in both groups. One single embryo derived from testicular sperm was transferred with a resulting singleton pregnancy. In conclusion, testicular sperm for ICSI seem to have reliable fertilization capacity in men with KS, while ejaculated sperm, even if tested viable, seem more unpredictable. HOS test for selection of viable sperm for ICSI is recommended when ejaculated as well as testicular sperm are used for ICSI. hypo-osmotic swelling test/ICSI/immotile cilia syndrome/Kartagener's syndrome/testicular sperm aspiration Introduction The immotile cilia syndrome (ICS) is an autosomal recessive disease characterized by defective cilial ultrastructure in ciliated cells and affects ~1 in 20 000 newborns. The dynein arms connecting the microtubules are shortened or absent with the consequence of sperm immobility and ciliary epithelial dysfunction (Palmblad et al., 1984). Men with ICS and simultaneous presence of situs inversus and bronchiectasis are referred to as having Kartagener's syndrome (KS) (Afzelius, 1985). Total asthenozoospermia (absence of any motile sperm in the ejaculate) is a severe problem. Even when the most advanced assisted reproductive technique such as ICSI are used, fertililization rates have been low using immotile ejaculated sperm (Nijs et al., 1996; Nagy et al., 1998). Even if fertilization is achieved, embryos of lower quality tend to be produced (Nijs et al., 1996) and very low numbers of ongoing pregnancies have so far been achieved using immotile spermatozoa from the ejaculate (Kahraman et al., 1996; Nijs et al., 1996). Several studies have recently reported improved fertilization and ongoing pregnancy rates when using testicular sperm for ICSI compared with ejaculated sperm in cases of total asthenozoospermia (Kahraman et al., 1996; Nijs et al., 1996; Shulman et al., 1999). To date, only a few reports have been published where fertilization and pregnancies have been successful in couples with male ICS/KS and totally immotile spermatozoa. Total fertilization failure (Nijs et al., 1996; Abu-Musa et al., 1999; Cayan et al., 2001), reduced fertilization rates (Papadimas et al., 1997) but also normal fertilization rates, pregnancies and births (von Zumbusch et al., 1998) have been reported after ICSI with ejaculated immotile spermatozoa. Cayan et al. (2001) reported normal fertilization rates and also a pregnancy in two cases where testicular immotile spermatozoa were used for ICSI. We report here two cases, where immotile spermatozoa from the ejaculate as well as from testes, have been used for ICSI in couples with male KS. This is the rst report where male gametes from both ejaculated and testicular origins have been used for ICSI in the same cycle. Materials and methods Case 1 The patient was a 41-year-old male diagnosed with KS on the basis of medical issues including recurrent middle ear infections, sinusitis, bronchiectasis and situs inversus. His semen analysis had repeatedly shown totally immotile spermatozoa but also severe oligozoospermia where only occasional immotile spermatozoa had been present in the ejaculate. Transmission electron microscopy reveals the severity of defects in sperm tail ultrastructure and therefore is of benet. However, this was not carried out in this case due to the low number of ejaculated sperm. Serum FSH, LH and testosterone were normal and the patient also had a normal 46,XY karyotype. Screening of the Y-chromosome did European Society of Human Reproduction and Embryology not show any microdeletions. He had two brothers, one with ICS including recurrent airway infections and immotile sperm but no situs inversus. The female partner was 35 years old and healthy. After two previous children from a donor insemination programme, the couple were interested in the IVF/ICSI programme to conceive a child with the patient's sperm. Before treatment the couple underwent genetic counselling for ICS/ KS and genetic issues concerning testicular failure. Institutional review board approval was not required to proceed with therapy. Therapeutic approach and results First cycle (November 2001) After an ovarian stimulation by a long protocol using GnRH agonist (Synarel; Rydalmere, NSW, Australia) in association with recombinant FSH (Gonal-F; Serono Australia Pty Ltd, Frenchs Forest, NSW, Australia) 11 oocytes were recovered. Semen analysis conrmed total asthenozoospermia and the hypo-osmotic swelling (HOS) test (World Health Organization, 1999) was used to identify viable sperm for ICSI. In-house sperm washing media was diluted with an equal volume of `milli Q' water (18 ohm) to use in identifying HOS positive spermatozoa. In the ICSI dish a long drop of HOS media was made alongside the polyvinyl pyrrolidone (PVP) and oocyte drops. A small aliquot of washed spermatozoa was placed in the hyper-osmotic long drop and the ICSI procedure started immediately. Those spermatozoa that exhibited head swelling and discernable tail coiling were deemed viable. They were then aspirated with the injection pipette and placed into the 10% PVP solution where they were left for several minutes until the sperm head reduced in size to a normal appearance. The spermatozoa were then stroked across the mid-piece with the injection pipette as if they were motile and injected into mature oocytes. Injected oocytes were then placed into group culture and checked for fertilization 18 h post-injection. The ICSI procedure was performed according to the method described by Payne et al. (1995). Seven of the oocytes were injected with HOS positive sperm. No fertilization occurred. Second cycle (April 2002) After using a similar ovarian stimulation protocol as in the rst cycle, eight oocytes wer (...truncated)