ICSI after Pesa/tesa and cleaving
4 Replies
wrenster - November 11

Hi there

My DH has obstructive azospermia, we don't know why but think he has always had it as always produced virtually no semen on ejaculation. A Pesa/Tesa revealed live sperm although many are abnormal (not surprising as squashed up inside DH!). His sample has been frozen and we had 6 vials in 'stock'.

I have no known fertiliy issues and I am 35. We have had ICSI twice. First time resulted in only 3 average quality embies from frozen sperm & 12 eggs. Got the impression that my eggs were not all optimal. We had a 3 cell and a 4 cell transferred at day 2 (clinic standard is day 2). Second time I made a big effort with ultra healthy lifestyle thinking I could improve my egg quality.
We had 10 eggs and I think they were better quality, and 6 fertilised, one wiped out after day 1, the others, all 'average' quality went on to be 7 or 8 cells at day 3. The clinic would not let me go to blast as their policy is that you need six embies to do so, so I had a day 3 transfer of the two embies that they said were the ones that 'cleaved early'. Q 1 - Is early cleaving a good sign?

I've read in your posts that up to day 3 the egg quality defines success and then sperm DNA kicks in after this. So I guess for this cycle I just have to wait and see... no way of knowing what the sperm DNA is like until the end of my 2ww. But for future cycles (Q2) - I am wondering what will increase our chances?

- I've heard that skill of embyoligist in selecting the right sperm is critical and this can be very difficult. Is this true? How would I know how good my embrylogist is? I am in the UK and have only seen IVF success rates published nothing more specific.

- I am also wondering if we would be better off having surgical sperm retrieval on day of EC to get live sperm, would that increase chances? Doesn't freezing make the sperm even worse quality than it was to start with?

Hope you enjoyed your holiday - I have just joined this website and think this is a fantastic resource!




Dr Smith - November 16

Within a certain range, early cleavage is a good sign. If it is very rapid (i.e. way ahead of the natural division cycle), it is a sign of abnormality, as is slow division.

All things being equal, success (term pregnancy) with testicular/epididymal sperm is significantly lower than with ejaculated sperm. It is related to the packaging of the DNA inside the sperm head. Testicular, and to some extent epididymal, sperm have not completed the "packaging" process so when it comes time to unwind inside the egg things go wrong. As you pointed out, the detrimental effect of this abnormality does not manifest until after Day 3. In TESA/PESA cases, significantly fewer embryos make it to the blastocyst stage, or, if the do, the developmental potential of the blastocyst is lower. Hence the hurry to put them back in on Day 3 rather than risk nothing to transfer in Day 5.

A healthy life style may improve your chances of implantation IF an embryo reaches the blastocyst stage, but a healthy lifestyle will not affect the quality of your eggs in a genetic sense. Unfortunately, you can't repair a genetically abnormal egg (or sperm for that matter) by excercising frequenty and eating right. There is nothing you or your husband can do to improve the developmental potential of the embryos. Tweaking stimulation protocols can sometimes help a little by getting more mature eggs at retrieval, but in the end its simply a numbers game. The more eggs that fertilize, the better the chance of getting a good egg with a good sperm.

Choosing the "best" sperm will contribute to the success of ICSI. However, when working with testicular sperm, they all look bad and picking a "good" one is virtualy impossible. It is a little easier with epididymal sperm, but not much. There is some variation in the skill level of embryologists working in an IVF lab. However, due to the difficulting of TESA cases, they are almost invariably performed by the most experienced and senior embryologist(s). I don't think you have to worry there.

There have been some reports lately that cryopreservation of sperm can induce genetic damage. I don't know how much stock I put in these reports. Frozen-thawed sperm has been used safely in ART procedures for more than 20 years and this is the first time anyone has suggested there may be a genetic problem with the sperm. It also doesn't make a whole lot of biological sense becase, in mature sperm, the DNA is very tightly packed inside the sperm head and, because of this, most chemical substances cannot penetrate the nucleus to alter the DNA. If you believe their report, then testicular sperm may be suseptable to cryodamage becasue the packaging process may be incomlete. I always prefer working with fresh testicular sperm on the day of egg retieval because there's more to choose from to get the "good" sperm. Frozen-thawed is more convient for the lab, but I think fresh is better (my opinion only - not based on scientific evidence).


wrenster - November 21

Thanks very much for your answers to my questions. Unfortunately my cycle was negative so we need to think about what to do next.

There is a clinic in London that has the highest success rates in the country for IVF (about 50% success for transfer of 2 embryos vs national average of about 25-30%) however it is very, very much more expensive. One of the reasons they seem to achieve success is due to thorough investigation (of the woman) and very close monitoring during stimulation. We had been considering using this clinic; however I am starting to think that the success rates are unlikely to apply in our case as all the monitoring in the world will not change the sperm quality and thus the embryo quality.

Would you agree with this?

What would you say are the chances of success in a case like ours?



Dr Smith - November 22

As with most things in life - you get what you pay for. A more detailed diagnostic workup and close attention to the ovarian stimulation do result in improved success rates. Personally, I put a lot of weight on this.

In your case, I'd say its worth a trip to London to see if they have an idea about any possible problems from your side of the equation. When there is a severe problem with the sperm, there is tendency for docs to skip over a thorough diagnostic workup on the female partner. They assume that the problem is all on the sperm side. Assumptions, especially in medicine, are dangerous. I'd talk to them about how they might do things differently in your case (i.e. fresh sperm on the day of retrieval). I don't think the 50% success rate is applicable in your case, but there is a "trickle down" effect. Programs with very good success rates in the best prognosis patients also have higher than average rates in "difficult" cases. Worth a look-see I think. You have very little to loose and a lot to gain by talking to them. Make a bit of a holiday out of it. Take in a show while you're there. Stay in a romantic hotel...


wrenster - November 22

Thanks - I'll look into it. You are right about assumptions - I have not really had much investigation, just a few blood tests and some ultrasound monitoring during my stimms. Its possible that they could have missed something. And a romantic weekend away would be nice ....




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