Iranian Society of Gynecology Oncology

Document Type : Original Research Article

Authors

1 Fertility and Infertility Research Center, Health Technology Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran

2 Student Research Committee, Medical School, Kermanshah University of Medical Sciences, Kermanshah, Iran

3 Medical Biology Research Center, Health Technology institute, Kermanshah University of Medical Sciences, Kermanshah, Iran

Abstract

Background & objective: Various parameters can affect the success of intra cytoplasmic sperm injection (ICSI). This study aims to compare the results of fertility in formerly infertile couples who underwent ICSI considering different parameters.
Materials & Methods: In this retrospective study, 261 cases of infertile couples who referred to Motazedi Infertility Center in Kermanshah, and had successful ICSI from 2011 to 2017, were examined. Statistical analysis was performed after collecting the data.
Results: The highest ICSI success rates were in the age range of 31-40 years (58.2%), and 21-30 years (55.8%), in men and women, respectively. Regarding the duration of infertility, the highest success rate was observed in couples who were infertile for less than five years (51.8%). In this study, all the patients’ endometrial thicknesses were normally higher than 4 mm. In terms of the number of embryos formed, the success percentage was 68% with three formed embryos. The hormonal variations and distribution percentages were as following: AMH ranging from 1.01 to 5 ng/mL (55.6%), TES ranging from 0 to 50 nmol/L (53%), TSH ranging from 1.01 to 5 μU/mL (81.6%), FSH ranging from 5.01 to 10 IU/L (58.9%), PRO ranging from 5.01 to 10 ng/mL (24%), LH ranging from 1.01 to 5 IU/L (46.7%), and DHEA-S ranging from 1.01 to 5 ng/mL (18.9%).
Conclusion: According to the results, it seems that the success of ICSI technique in infertile couples depends on some parameters including variations in reproductive hormones, number of embryos, couples’ ages, and duration of infertility.

Keywords

Main Subjects

Introduction
 


Infertility is one of the couples’ issues all around the world which can be caused by either one of the partners. Their lack of childbearing naturally leads them to ask for the help of modern fertility techniques in this field (1). Intra cytoplasmic sperm injection (ICSI) is one of these methods used when the sperm quality is not good or the conditions for the sperm reaching the egg in the uterus are not provided (2). Although ICSI was initially utilized in 1992 to treat infertile men (3), its application is not only limited to them. For about two decades, the percentage of using this technique has increased in many infertility treatments centers in Europe, America, and other countries (4, 5). The percentage of utilizing ICSI technique for factors other than male infertility was high in infertility centers. On the other hand, the concerns regarding its usage have increased since this technique is expensive and time consuming and can create damage to gametes (6-8). Many studies have shown that using ICSI in non-male infertility did not improve the desired clinical results (9-11). In non-severe male infertility, like mild oligospermia, the outcome of fertilization and pregnancy after ICSI is unclear compared to conventional in vitro fertilization (IVF) methods. Randomized studies conducted on sibling oocytes have demonstrated contradictory results (12, 13).Furthermore, other studies have proven that there is no difference between ICSI and conventional IVF methods in embryo quality, implantation, pregnancy, or live birth rate (14, 15).
However, a variety of indicators, including maternal age, unexplained infertility, number of oocytes and their quality, and previously failed fertilization, affect the ICSI success rate and greatly influence the chances of successful fertilization and embryo formation (16). These indications have been extensively studied and formed international guidelines so that treatment centers can implement standard treatment methods (17). Despite the increase in the application of this technique in infertility treatment centers, there are still controversies about the using this technique, and little is known about the benefits of applying ICSI in the treatment of non-male factor infertility. Given the status quo, evaluating the factors affecting ICSI success among infertile people in medical centers is needed to obtain definitive results. The current study aims to investigate a randomized controlled clinical trial, compare the results of ICSI in infertile couples, and test possible differences between the results. In other words, this study aims to compare several parameters, including age, hormonal variations, changes in endometrial thickness, and the number of embryos formed as a result of ICSI in couples who referred to Motazedi Treatment Center in Kermanshah, Iran, for treatment.


 

 
Materials and Methods

In this retrospective study, 261 cases who had a successful ICSI at Motazedi Hospital in Kermanshah, Iran, from 2011 to 2017, were examined in terms of age, hormonal variations, duration of marriage and infertility, type of infertility, endometrial thickness, and the number of embryos formed. This study was ethically approved by the Ethics Committee of the Kermanshah University of Medical Sciences, Iran. The records of patients referred to this infertility center were collected via the electronic systems available. The patients’ data, such as age, gender, body mass index (BMI), and the number of antral follicles, laboratory test results including levels of anti-müllerian hormone (AMH), testosterone (TES), thyroid-stimulating hormone (TSH), follicle-stimulating hormone (FSH), prolactin (PRO), luteinizing hormone (LH), and dehydroepiandrosterone sulfate (DHEA-S), and details of their husbands’ semen analyses, including sperm count, motility, and morphology, were collected from their records.

Eligibility Criteria

Eligible couples referred to the infertility center from 2011 to 2017 were selected for screening.

Inclusion Criteria

Inclusion criteria included

  • Infertile couples who dealt with infertility for at least a year and referred to the infertility center to be treated with ICSI.

  • Infertile couples who planned for the first or second IVF/ICSI cycle.

  • Men who did not have severe infertility.

  • Women treated with gonadotrophin-releasing hormone agonist (GnRH-a) or gonadotrophin-releasing hormone antagonist (GnRH-ant).

  • Patients who did not have a history of obstetric surgery.

Exclusion Criteria

Exclusion criteria were

  • Infertile couples whose data were incomplete and did not have a successful ICSI.

  • Infertile couples with underlying diseases, like diabetes, hypertension, anemia, liver and kidney diseases, and various cancers.

  • Infertile couples who took a variety of medications other than fertility drugs.

  • Women without oocytes.

  • Men without sperm.

Stimulation Protocol and Embryological Methods

Ovarian stimulation with GnRH-a was performed on the 21stday of the menstrual cycle before super-ovulation and the third day of the next menstrual cycle after injecting human menopausal gonadotropin (HMG) (150-225 IU). The patients were given 1000 units of Human chorionic gonadotropin (HCG) when at least two follicles reached 18 mm in diameter. The oocyte retrieval was done 36-39 hours later under light anesthesia using vaginal ultrasound. For the ICSI cycle, the surrounding cumulus was removed to assess oocyte maturation two hours after the recovery. Oocytes in metaphase stage II were injected with the husband’s sperm at least an hour after the removal of cumulus cells. Oocytes that were not fully mature were discarded. The fertilization was evaluated 16-18 hours after the inoculation.

Embryo Quality

Cleaved embryos were considered high quality embryos (Grade I or II) when they were observed with four cells on the second day and seven to eight cells on the third day, with less than 20% fragmentations and without any morphological abnormalities. In this clinic, the number of embryos transferred to mothers depended on the maternal age such that two embryos were transferred to mothers under 35 years of age, and three embryos were transferred to mothers over 35 years old. However, if a patient had low or poor-quality embryos, the embryos were transferred on the second day of the luteal phase. The ratio of good embryos was calculated by dividing the number of good embryos by the number of cleaved embryos. In order to reduce the effect of the minimum number of embryos, only four cleaved embryos were used in the data analysis.

Hormonal Markers

Serum concentrations of AMH, TES, TSH, FSH, PRO, LH, and DHEA-S were measured by the relevant kits in the laboratory of the same infertility center. According to the measurements made for different hormones, various groupings were considered for them. Thus, AMH, TES, TSH, FSH, PRO, LH, and DHEA-S were divided into groups of six, five, five, four, nine, five, and three, respectively.

 

Statistical Analysis

Data analyses were carried out by SPSS 22 (SPSS Inc., Chicago, IL., USA). Data values were reported as M±SEM. The chi-square test was used to analyze the associations between nominal qualitative variables, and the Spearman correlation coefficient was used to rank quantitative or qualitative variables. P-values less than 0.5 were considered significant.


 

Results

The Couples’ Age
The patients underwent ICSI between the ages of 21 to 60 years. To better investigate the association between the couples’ age and ICSI success, the female population was divided into five groups, and the male population was classified into four groups (Figure 1) (Tables 1, 2). The highest success rate was observed in men aged 31-40 years and a mean age of 34.64±5.77 (58.2%), and women aged 21-30 years and a mean age of 25.47±5.78 (55.8%). The results indicated a statistically significant difference between the couples’ age and pregnancy rates.

 

Table 1. The men’s age range and the ICSI success rate

Men’s age Frequency Percentage distribution P-value
Range 21.00 - 30.00 64 25.5  
31.00 - 40.00 146 58.2
41.00 - 50.00 39 15.5
51.00 - 60.00 2 0.8
Total 251 100.0 0.01
 
 

Table 2. The women’s age range and the ICSI success rate

Women’s age Frequency Percentage distribution P-value
Range
 
<= 20.00 3 1.2  
21.00 - 30.00 140 55.8
31.00 - 40.00 92 36.7
41.00 - 50.00 15 6.0
51.00 - 60.00 1 0.4
Total 251 100.0 0.01

 

Figure 1. The age range of these men and women and its association with the ICSI success rate. The highest success rate was observed in men aged 31-40 years and a mean age of 34.64±5.77 (58.2%), and women aged 21-30 years and a mean age of 25.47±5.78 (55.8%). 

Figure 1. The age range of these men and women and its association with the ICSI success rate. The highest success rate was observed in men aged 31-40 years and a mean age of 34.64±5.77 (58.2%), and women aged 21-30 years and a mean age of 25.47±5.78 (55.8%).

 
Duration of Infertility
The data collected from the infertile couples referred to this infertility center during the mentioned period demonstrated that their maximum infertility duration was 25 years. As shown in Table 3 and Figure 2, the couples were divided into five groups considering the duration of infertility. Among these groups, the highest success rate was reported in infertility of fewer than five years (51.8%). However, a statistically significant difference was observed between the duration of infertility and ICSI success.
 

Table 3. Examining the duration of infertility and the ICSI success rate

Duration of infertility (y) Frequency Percentage distribution P-value
Range
 
<= 5.00 130 51.8  
5.01 - 10.00 89 35.5
10.01 - 15.00 21 8.4
15.01 - 20.00 8 3.2
20.01 - 25.00 3 1.2
Total 251 100.0 0.001
 
Figure 2. Examining the duration of infertility and its association with ICSI success rate. Among these groups, the highest success rate was reported in infertility of fewer than five years (51.8%).

Figure 2. Examining the duration of infertility and its association with ICSI success rate. Among these groups, the highest success rate was reported in infertility of fewer than five years (51.8%).

 

Endometrial Thickness

In the present study, all the patients’ endometrial thicknesses were normal and higher than 4 mm.

The Number of Formed Embryos

To evaluate the number of embryos formed and ICSI success, the Smirnov-Kolmogorov test was used to examine the data. As can be seen in Table 4 and Figure 3, the number of embryos formed for each patient was placed in its related group, and the number of groups associated with this parameter was five. In this study, the success rate in the number of embryos formed was three, with a 68% success. The ICSI result showed a statistically significant relationship.

 
Figure 3. Evaluating the number of embryos formed

Figure 3. Evaluating the number of embryos formed

 

Hormonal Variations

In the current study, hormonal variations of AMH, TES, TSH, FSH, PRO, LH, and DHEA-S were examined.

AMH Variations

AMH was tested in the patients and recorded as M±SEM. The results of which are shown in Table 5. As can be seen in this Table, the maximum and minimum serum AMH levels in the patients were reported to be 11<amh<20 best="" categorize="" levels="" ml.="" ng="" these="" to=""></amh<20>

 

Table 4. The number of embryos formed

Number of embryos formed Frequency Percentage distribution P-value
Range
 
1 5 0.38  
2 70 29.88
3 178 68.19
4 5 1.14
5 3 0.38
Total 261 100 0.0001
 

Table 5. The AMH variations

AMH Frequency Percentage distribution P-value
Level 0.11 - 1.00 6 2.8  
1.01 - 5.00 119 55.6
5.01 - 10.00 18 8.4
10.01 - 15.00 53 24.7
15.01 - 20.00 18 8.4
Total 214 100 0.32

 

TES Variations

The maximum and minimum serum TES levels in the patients were reported to be 0<tes<250 as="" divided="" five="" groups.="" in="" into="" l.="" levels="" nmol="" serum="" shown="" tes="" these="" were="">Table 6, most of the patients had serum TES levels in the range of 0-50 nmol/L, with a 53% distribution. The data showed a statistical difference between the serum TES levels and the ICSI success rate.</tes<250>

 

Table 6. The TES variations

TES Frequency Percentage distribution P-value
Level 0 -50.00 127 53  
50.01 -100.00 72 30
100.01 -150.00 14 5.8
150.01 - 200.00 18 7.5
200.01 - 250.00 8 3.3
Total 240 100 0.01
 

TSH Variations

The maximum serum TSH level in the patients was 15 μU/mL. These serum TSH levels were classified in five groups. As noted in Table 7, most of the patients had serum TSH levels ranging from 1.01 to 5 μU/mL, with a distribution of 81.6%. The data indicated a statistical difference between these serum TSH levels and the ICSI success rate.
 

FSH Variations

The serum FSH levels in the patients were reported to be 0<fsh<20 a="" accurate="" as="" assessment.="" categorized="" demonstrated="" for="" four="" fsh="" groups="" in="" into="" iu="" l.="" levels="" more="" these="" were="">Table 8, most of the patients had serum FSH levels in the range of 5.01-10 IU/L, with a distribution of 58.9%. The data showed a statistical difference between the serum FSH levels and the ICSI success rate.</fsh<20>
 

PRO Variations

The serum PRO levels in the patients were reported as 0<pro<45 a="" accurate="" as="" categorized="" evaluation.="" for="" groups="" in="" into="" levels="" ml.="" more="" ng="" nine="" pro="" shown="" these="" were="">Table 9, most of the patients had serum PRO levels ranging from 5 to 10 ng/mL, with a 24% distribution. The data demonstrated a statistical difference between the serum PRO levels and the ICSI success rate.</pro<45>

 

Table 7. The TSH variations

TSH Frequency Percentage distribution P-value
Level
 
<= 0.10 12 4.7  
0.11 - 1.00 14 5.5
1.01 - 5.00 205 81.6
5.01 - 10.00 14 5.5
10.01 - 15.00 6 2.3
Total 251 100 0.02
 

Table 8. The FSH variations

FSH Frequency Percentage distribution P-value
Level 0 - 5.00 61 23.6  
5.01 - 10.00 152 58.9
10.01 - 15.00 35 13.5
15.01 - 20.00 10 3.8
Total 258 100 0.01
 

Table 9. The PRO variations

 
PRO Frequency Percentage distribution P-value
Level 0 – 5 20 8.16  
5.01-10 59 24
10.01 - 15.00 44 17.9
15.01 - 20.00 54 22
20.01 - 25.00 34 13.8
25.01 - 30.00 14 5.7
30.01 - 35.00 10 4
35.01 - 40.00 4 1.63
40.01 -45.00 6 2.44
Total 245 100 0.01

 

LH Variations
The serum LH levels in the patients were reported to be 11<lh<20 a="" accurate="" as="" categorized="" demonstrated="" evaluation.="" five="" for="" groups="" in="" into="" iu="" l.="" levels="" lh="" more="" these="" were="">Table 10, most of the patients had serum LH levels in the range of 1.01-5 IU/L, with a distribution of 45.8%. The data showed a statistical difference between the serum LH levels and the ICSI success rate.

DHEA-S Variations
The serum DHEA-S levels in these patients were reported as 11<dhea-s<20 a="" accurate="" as="" categorized="" dhea-s="" evaluation.="" for="" groups="" in="" into="" levels="" ml.="" more="" ng="" shown="" the="" three="" were="">Table 11, most of the patients had serum DHEA-S levels in the range of 1.01-4 ng/mL, with a 68% distribution. The data indicated a statistical difference between the serum levels of DHEA-S and the ICSI success rate.</dhea-s<20></lh<20>

 

Table 10. The LH variations

LH Frequency Percentage distribution P-value
Level 0.11 - 1.00 15 5.8  
1.01 - 5.00 117 45.8
5.01 - 10.00 82 32
10.01 - 15.00 31 12
15.01 - 20.00 10 4
Total 100 100 0.02

 
Table 11. The DHEA-S variations

DHEA-S Frequency Percentage distribution P-value
Level .11 - 1.00 54 24.5  
1.01 - 4.00 150 68
4.01 - 20.00 16 7
Total 220 100 0.01

 
Table 12. The results of hormonal tests of women referred to the infertility center

  Total Abnormal Normal
AMH 214 38 (82%) 176 (18%)
TES 240 46 (19.2%) 194 (80.8%)
FSH 258 51 (19.7%) 251 (80.3%)
TSH 251 28 (11%) 223 (88.84%)
Prolactin 245 57 (23%) 188 (78%)
LH 255 45 (18%) 210 (82%)
DHEA-S 220 16 (7%) 204 (93%)

 

 

 

Discussion

 

The results showed that ICSI-related indicators, including the variations in AMH, TES, TSH, FSH, PRO, LH, and DHEA-S, couples’ age, duration of infertility, and the number of embryos formed, were effective in the ICSI success rate. In the present study, the data associated with these indicators were evaluated using the records of 261 patients referred to the infertility center over 6 years. These cases were selected based on the inclusion criteria with the utmost care and sensitivity so that the obtained data is reliable and usable for women of childbearing age. These data showed that 214 patients had serum AMH levels in the range of 11<amh<20 among="" ml.="" ng="" people="" these=""> Some studies have shown that AMH levels may be affected by race, ethnicity, and geographical location (18-20). However, in 2016, Du et al. stated that the maximum and minimum AMH levels in different age groups were 6.23 ng/mL and 1.09 ng/mL, respectively (21). Moreover, other studies reported AMH levels in various age groups as 0.95±0.14 - 4.94±0.17, 3.24±123 - 3.91±1.37, and 0.46±0.59- 2.5±2.0 ng/mL (22-24). This is while the difference in AMH levels may be mainly due to the sample size in the studies, women’s health status, economic and nutritional status, and the like. Additionally, menopausal age has been reported differently in various parts of the world (25, 26), which may indicate differences in AMH levels at various ages. This is while many efforts have been made to identify patients based on a good prognosis of AMH levels (27, 28). Our study has concluded that AMH can be a reliable indicator for predicting success in ICSI in the Iranian society, with the range of 1.01-5 ng/mL. Another parameter evaluated in this study was the determination of FSH and LH levels in the patients. As shown in Tables 7 and 9, the maximum and minimum serum levels of FSH and LH were reported to be 0<fsh<20 11="" and="" iu="" l="">et al., (30) the levels of FSH and LH in women with successful ICSI were 3.5±1.6 IU/L and 1.9±1.2 (IU/L), respectively. This is consistent with our results on the levels of FSH and LH. Furthermore, in a 2015 study conducted by Kolibianakis on women treated successfully with Corifollitropin alfa and beta using ICSI, the authors reported FSH and LH levels of approximately 10 and 5 IU/L, respectively (31), which are consistent with the results of this study. Additionally, in 2017, Tannuset al. reported that FSH and LH levels were almost 7 and 4.5 IU/L in women aged 35-40 years old treated with GnRH-a and HCG, respectively (32).
Regarding the results of TES evaluation, 214 patients had testosterone levels of 0<tes<250 among="" l.="" nmol="" patients="" these=""> In the current study, serum PRO levels of 245 patients were in the range of 0<pro<45 59="" about="" ml="" ng="" of="" patients="" whom=""></pro<45></tes<250></fsh<20></amh<20>


 

Conclusion

Based on the results of the present study, parameters, such as variations in reproductive hormones, number of embryos, couples’ age, and duration of infertility, can affect the success rate of the ICSI technique in infertile couples. The results of this study can be considered as a reliable reference for the correct interpretation of the data in the successful implementation of the ICSI technique.

 


 

Acknowledgments

We would like to thank Miss Farzaneh Esmaeili for her excellent help in collecting data.
 

 

 

Conflicts of Interest

Authors declared no conflict of interests.

 

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