JBRA Assisted Reproduction 2018;22(2):89-94

doi: 10.5935/1518-0557.20180022 Original article

How general semen quality influences the blastocyst formation rate:

Analysis of 4205 IVF cycles
Mariana M Piccolomini1, Tatiana CS Bonetti1,2, Eduardo La Motta1,2, Paulo C Serafini1,3, Jose R Alegretti1

1
Huntington - Medicina Reprodutiva. São Paulo, Brazil
2
Disciplina de Ginecologia Endocrinológica, Departamento de Ginecologia, Escola Paulista de Medicina da
Universidade Federal de São Paulo (UNIFESP-EPM), São Paulo, Brazil
3
Disciplina de Ginecologia, Departamento de Obstetrícia e Ginecologia, Faculdade de Medicina, Universidade de
São Paulo (FMUSP). São Paulo, Brazil

ABSTRACT It is clear that blastocyst transfer leads to higher live

Objective: To select embryos with higher implanta- birth rates per transfer. However, there is a risk of losing
tion potential, the extended culture has been the most embryos that do not survive until day 5 (D5), which ulti-
frequently applied strategy worldwide, and consequently mately results in lower cumulative live birth rates per cou-
leads to higher live birth rates per transfer. Sperm quali- ple (Maheshwari et al., 2016). The following factors may
ty is a determining feature, and it may influence the out- affect the potential for an embryo to develop to the blas-
comes of IVF from fertilization to embryo development. tocyst stage: advanced maternal age (Yan et al., 2012),
Therefore, we hypothesize that blastocyst formation may paternal age (Dain et al., 2011), endometriosis (Borges et
also be impaired by general semen quality. al., 2015), diminished ovarian reserve (Katz-Jaffe et al.,
Methods: We analyzed 4205 IVF cycles. Four study 2013) and abnormal sperm quality (Chapuis et al., 2017).
groups were designed according to semen quality: normal, Despite the multifactorial characteristics of infertility,
mild alteration, severe alteration and epididymis. All cycles sperm quality is a determining feature. The male factor is
were intended to extend embryo culture until the blasto- present in approximately 50% of the cases, regardless of
cyst stage, and embryo development was evaluated. female factors. Previous studies have shown that sperm
Results: Regarding cleavage rate, the normal and mild motility reduction is a critical parameter that affects fer-
alteration semen groups were equivalent, and the severe tilization rates, number of embryos developed (Chapuis
alteration and epididymis semen groups were equivalent to et al., 2017) and rate of good quality embryos on day 3
each other. The blastocyst formation rate decreased with (Zheng et al., 2016). Additionally, sperm morphology has
semen quality. At least one blastocyst formed in 79.9% of been associated with top quality embryo rates at the cleav-
cycles for the normal semen group, whereas the percent- age stage (day 3) (Meng et al., 2016).
age of cycles with the formation of at least one blastocyst Sperm quality is a determining feature which may
was slightly lower for the mild alteration (75.6%), severe influence IVF outcomes, from fertilization to embryo de-
alteration (76.4%) and epididymis (76.8%) semen groups. velopment; therefore, we hypothesize that the blastocyst
A multivariate logistic regression showed that for each ad- formation rate may also be impaired. This perception is an
ditional cleaved embryo on day 3, the chance of having important aspect of forecasting blastocyst formation rates.
at least one blastocyst doubles. Additionally, the chance Therefore, the aim of this study was to retrospectively
of having at least one blastocyst decreased when semen evaluate the blastocyst formation rate of different sperm
presented mild or severe alterations. quality groups in a large cohort of IVF cycles.
Conclusion: The general quality of sperm is a good
predictor of blastocyst formation, significantly affecting the MATERIALS AND METHODS
likelihood of having at least one blastocyst at the end of This was a retrospective cohort study involving 4,205
the cycle. Based on our findings, it is necessary to consider IVF cycles performed between January 2015 and Decem-
general semen quality and the number of cleaved embry- ber 2016 at a private reproductive medicine center in Bra-
os when forecasting the possibility of blastocyst formation zil. The study included all consecutive couples with an in-
and transfer in an extended culture system. dication for IVF, submitted to ovarian stimulation with their
own oocytes and ejaculate or epididymis sperm. The cy-
Keywords: blastocyst formation rate, semen quality, em- cles using testicular sperm were excluded from the study.
bryo transfer, in vitro fertilization According to ethical guidelines, institutional review board
approval was not required for this study due to its retro-
INTRODUCTION spective nature and anonymized data.
Extended embryo culture and transfer at the blastocyst
stage is an alternative process that enables embryo selec- Study design
tion at more advanced stages of development, increasing Ejaculated semen samples were collected by masturba-
pregnancy rates and minimizing the risk of multiple preg- tion after 3 to 5 days of ejaculation abstinence. Epididymis
nancies (Kupka et al., 2014). Extended culture has been sperm samples were collected by epididymis puncture. The
the most frequently applied strategy worldwide, especially samples were analyzed according to World Health Organi-
since recent guidelines have emphasized the single em- zation (WHO) recommendations, and sperm quality was
bryo transfer approach (Maheshwari et al., 2016). Other considered normal for samples with more than 15 mil-
advantages of extended embryo culture to the blastocyst lion motile spermatozoa, without motility or morpholog-
stage are the possibility of trophectoderm biopsy for ge- ical alterations. Sperm quality was considered abnormal
netic analysis, and the time-lapse approach for evaluating for samples with less than 15 million motile spermatozoa
embryo development (Zheng et al., 2016). and/or some kind of motility or morphological alteration

Received June 18, 2017

89
Accepted December 29, 2017
Original article 90

according to WHO parameters (World Health Organization, remaining cycles, 744 were cancelled, because the embry-
2010). The following four groups were classified according os did not develop until the blastocyst stage (18.7%). The
to semen quality, as per WHO (World Health Organization, cycles with blastocyst formation underwent fresh transfer
2010) criteria: or blastocyst cryopreservation.

• Normal: cycles in which the ejaculated semen Data analysis

analysis resulted in normal parameters for concen- The primary goal of this study was to determine the
tration, motility and morphology (n=977). blastocyst formation rate, which was calculated by the
• Mild alteration: cycles in which the ejaculated se- number of blastocysts per number of fertilized oocytes.
men analysis resulted in one or two abnormal pa- The fertilization rate (number of normal fertilized oocytes
rameters for concentration (5-14 million/ml), mo- per number of oocytes injected) and the cleavage embryo
tility (<6 million/ml) and/or morphology (<4%) rate (number of cleaved embryos per number of normal
(n=2358). fertilized oocytes) was also calculated. The results were
• Severe alteration: cycles in which the ejaculated analyzed based on the four pre-established groups.
semen analysis resulted in <5 million sperm/mL or The patients' demographic data was evaluated using
alterations in the three parameters for concentra- descriptive statistics and presented as means and frequen-
tion, motility and morphology (n=724). cies. Continuous variables were compared using mean and
• Epididymis: cycles in which epididymis sperm was frequency comparison tests (ANOVA or Student's t-test
used (n=146). and Pearson' X2, respectively). Regression analyses were
used to evaluate the association between variables. Data
Sperm Preparation analyses were performed using the SPSS 22 (IBM SPSS
Fresh or cryopreserved semen samples were used for Software, USA), and we considered p-values ≤0.05 to be
IVF. Epididymis sperm samples were placed in the culture statistically significant.
medium (HTF modified, Irvine, USA), supplemented with
a 15% synthetic serum substitute (SSS, Irvine Scientif- RESULTS
ic) right after puncture, and washed by centrifugation at
From 4,205 cycles, 32,031 MII oocytes were recovered
1,600 rpm for 10 min. Both ejaculated and epididymis
and 10,925 blastocysts developed. The demographic data
sample preparations were performed using a medium cul-
of the women included in this study and semen character-
ture gradient (Isolate, sperm separation medium, Irvine
istics according to groups are described in Table 1. Despite
Scientific, USA) according to manufacturer instructions,
significant differences found regarding the women's ages,
and were suspended in 0.5 mL of sperm rinse (Vitrolife),
the number of oocytes, MII collected and the numerical
and then used for ICSI.
values were very close and not clinically relevant. On the
other hand, the differences found in the semen analysis
Ovarian stimulation, oocyte fertilization and em-
were expected due to group classifications.
bryo culture
The fertilization rates on study groups were 80.1% for
All women received controlled ovarian stimulation, ac-
the normal ones, 79.4% for those with mild alteration,
cording to our clinic's routine protocols. Briefly, pituitary
75.4% for those with severe alterations and 70.7% for the
blockade was achieved with a GnRH antagonist (Orgal-
epididymis ones (p<0.001). Despite the statistical signif-
utran® 0.25 mg, MSD) or agonist (Lupron®, Abbott) ac-
icance concerning fertilization rates, the numerical differ-
cording to a standard protocol. Ovarian stimulation was
ences were not clinically important, since all groups had at
performed with recombinant FSH (Gonal F®, Merck Sero-
least 70% of oocytes fertilized after ICSI. The same was
no or Puregon®, MSD) with and without hMG (Menopur®,
found for the number of cleaved embryos and blastocysts
Ferring) and initiated on day 2 or 3 of the menstrual cy-
formed (Figures 1A and 1B).
cle. The initial gonadotrophin dose was determined by the
Regarding embryo cleavage rates, the statistical dif-
clinical profile of the patient and adjusted according to the
ferences on the severe alteration and epididymis groups
ovarian response. Follicle development was monitored by
to the mild alteration and normal groups are probably
ultrasonographic assessment; when women had at least
due to the huge number of cycles included in this study,
two follicles that were ≥18 mm in diameter, final oocyte
as the numbers are very similar, and differences are not
maturation was triggered with 250µg of recombinant hCG
clinically important (Figure 2A). The same was found
(rhCG, Ovidrel®, Merck Serono). Oocyte aspiration was
for blastocyst formation rates, in which statistical differ-
performed 35-36 hours after triggering.
ences do not represent clinical significance (Figure 2B).
The oocytes were denuded and then assessed for ma-
Additionally, at least one blastocyst formed in 79.9% of
turity stage. All mature metaphase II (MII) oocytes were
the cycles, when the normal semen was used for ICSI
fertilized by intracytoplasmic sperm injection (ICSI) (Pal-
- which was significantly lower for the mild alteration
ermo et al., 1992). On day 1 (D1), the normally fertilized
group (75.6%, p=0.006). But it was not significant when
oocytes - defined as having two pronuclei (2PN) and two
compared to the severe alteration (76.4%, p=0.079)
polar bodies - were identified and cultured in groups until
and epididymis (76.8% p=0.374) semen groups. How-
day 3 (D3) in 1 mL of cell culture medium (G-1 Plus, Vi-
ever, as it happened before, there was no clinical signif-
trolife) under a layer of paraffin oil (OVOIL, Vitrolife), in
icance concerning the differences.
incubators with 5% O2 and 5% CO2.
Aiming to rule-out confounding factors, we built a lo-
From D3 until the blastocyst stage (D5 or D6), the em-
gistic regression model, to evaluate the influence of semen
bryos were cultured in 1 mL of medium containing 10%
quality on the likelihood of having at least one blastocyst
human albumin (CSCM, Irvine Scientific) under a layer of
at D5, adjusted for maternal age, number of MII oocytes
paraffin oil. The embryos were then incubated in triple gas
collected and embryos cleavage on D3. The adjusted mul-
incubators (90% N2, 5% O2 and 5% CO2). The blastocysts
tivariate logistic regression showed that the likelihood
were morphologically classified according to Gardner et
of having at least one blastocyst decreased by approxi-
al. (2000). All cycles were intended for extended embryo
mately 50% (p<0.001, OR=0.667) and 35% (p=0.027,
culture until the blastocyst stage. The cycles in which the
OR=0.738) when semen presented mild alterations and
embryo did not develop until the blastocyst stage were
severe alterations, respectively. There was no significant
cancelled. Of the 4,205 cycles, 233 were cancelled due
influence of the epididymis sperm group on the likelihood
to non-cleaved embryos on D3 (5.5%); from the 3,972

JBRA Assist. Reprod. | v.22 | nº2 | Apr-May-Jun/ 2018

 Semen quality and blastocyst formation - Piccolomini, MM. 91

Table 1. Demographic characteristics of women included in the study, and ovarian stimulation outcomes according to
study groups

Groups Normal Mild alterations Severe alteration Epididymis p

Women age (years) (mean±SD) 37.1±4.1 37.3±3.9 36.0±4.0 36.6±4.3 <0.001

Number of oocytes collected (mean±SD) 10.0±7.0 9.8±6.7 11.2±7.0 12.0±8.4 <0.001
Number of MII (mean±SD) 7.60±5.7 7.4±5.4 8.2±5.5 8.9±6.7 <0.001
Semen analysis
-Concentration 80.0±48.1 52.8±40.3 4.6±3.9 ---- <0.001
-Motility 51.1±33.7 31.2±27.2 1.7±1.7 ---- <0.001
-Morphology 4.8±1.2 1.9±0.8 1.3±0.6 ---- <0.001

Figure 1. Comparison of number of cleaved embryos on D3 (A) and number of blastocyst formed on D5 (B) in
the study groups.

Figure 2. Comparison of (A) cleavage rate (number of cleaved embryos on D3 / number of fertilized) and (B)
blastocyst formation rate (number of blastocysts formed on D5 / number of fertilized) in the study groups

of having at least one blastocyst, despite OR indicating ap- influence (Chen et al., 2009). Moreover, the first proposal of
proximately 35% less possibility, which was similar to the sperm morphology as a predictor of IVF outcomes was by
semen group with severe alteration (Table 2). Kruger et al. (1986) in the 80s, who reported a relationship
between men with an increased proportion of sperm with
DISCUSSION abnormal morphology and decreased likelihood of preg-
nancy. Many studies were subsequently carried out, and
Many studies show contradictory results, and there is
the Kruger morphology criteria has been considered the
no consensus as to which seminal parameter (i.e., con-
main parameter of IVF indication; Kruger's classification
centration, motility or morphology) is best for evaluating
is still used as strict criteria in the manual for semen ex-
sperm potential in IVF. Several authors suggest that severe
amination of the WHO (World Health Organization, 2010).
oligospermia is an important factor, it reduces fertilization
Morphology defects can hide a genetic abnormal condition
potential and embryo quality (Meng et al., 2016); however,
of the sperm cells (Magli et al., 2012). However, the effect
other authors have shown that severe oligospermia has no

JBRA Assist. Reprod. | v.22 | no2| Apr-May-Jun/ 2018

Original article 92

Table 2. Multivariate logistic regression model to determine possibility of having at least one blastocyst formed, adjusted
for confounders
Coefficient Standard error of Coefficient p value OR
Women age (years) -0.084 0.012 <0.001 0.919
Number of MII oocytes recovered -0.122 0.024 <0.001 0.885
Number of embryos at cleavage stage (D3) 0.846 0.042 <0.001 2.330
Semen with mild alteration -0.405 0.108 <0.001 0.667
Semen with severe alteration -0.303 0.137 0.027 0.738
Epididymis sperm -0.302 0.230 0.188 0.739

of morphology on the likelihoods of embryo implantation Zheng et al. (2016) demonstrated that a reduced num-
and pregnancy is still contradictory in the literature (De ber of motile spermatozoa diminished fertility and embryo
Vos et al., 2003; Loutradi et al., 2006). Additionally, sever- quality on day 3; however, if there was a good embryo
al authors have recently demonstrated that men present- for transfer, the likelihoods of implantation and pregnancy
ing 0% of normal sperm are still able to obtain natural were similar. Then, it was suggested that the implantation
pregnancy (Kovac et al., 2017). There is a high correlation rate was the important parameter to evaluate the ability
of sperm motility with the capacity of sperm to reach the of an individual embryo to be implanted and it was not
oocyte in a natural conception; thus, sperm selection tech- associated with sperm quality (Zheng et al., 2016). We did
niques are currently used, pushing the sperm to a motility not evaluate the clinical outcomes, which is a limitation of
challenge (swim-up) or forcing them through a differential this study. However, our primary goal was to evaluate the
gradient, aiming to mimic the natural selection character- blastocyst formation rate, which is a parameter of embryo
istics seen in vivo (Sakkas et al., 2015). quality and implantation potential. There was a greater
However, men commonly present not just one alter- likelihood of implantation when the embryo was trans-
ation, but a combination of sperm defects, and it is neces- ferred in the blastocyst stage (Alves da Motta et al., 1998;
sary to consider the three factors together. In our study, Glujovsky et al., 2012; Harton et al., 2013; Kolibianakis et
we classified semen samples into four groups, considering al., 2002; Maheshwari et al., 2016).
all parameters; the presence of three normal parameters The blastocyst formation is also dependent on many
was considered the normal group, and three abnormal pa- other factors, and to analyze whether the association of
rameters or a concentration lower than 5 million sperm/ semen quality and the blastocyst formation was indepen-
ml was considered a severe alteration. Other levels of al- dent of oocyte/female factors, we built a multiple logistic
teration in one or two semen parameters were considered regression model adjusted for maternal age, number of
mild alterations. Epididymis sperm was considered in an MII oocytes recovered and number of cleaved embryos.
individual group. This approach allowed for a broad view of Considering that normal semen does not influence the
the semen quality and male reproductive potential. presence or absence of one formed blastocyst (dependent
We considered the hypothesis that in ICSI cycles where variable), patients classified as mild alteration or severe
one spermatozoa with better quality parameters is chosen alteration had a significantly lower likelihood of having a
and injected in the oocyte, the intrinsic quality is still af- blastocyst (50% and 35% less chance, respectively), inde-
fected by the general semen quality, and it is impossible to pendent of oocyte/female factors.
tell the best spermatozoa based on the genetic information We did not find a significant association of epididymis
alone. Therefore, the potential of embryo development is sperm with blastocyst formation, which may be due to a
also affected (Zheng et al., 2016). Based on the group smaller number of cycles included in this group compared
classifications, we evaluated the effects of semen quality to the other groups. However, the effects of epididymal
on blastocyst development in a large cohort of patients/ sperm on IVF outcomes is still controversial in the litera-
oocytes. ture (Aboulghar et al., 1997; Meniru et al., 1998; Nicop-
Our findings showed that the lower the semen quality, oullos et al., 2004).
the lower the blastocyst formation rate. However, despite Notably, the logistic regression model also showed that
the statistically significant decrease in blastocyst forma- the number of cleaved embryos is a significant predictor
tion, the clinical relevance is small as the difference be- of having a blastocyst at the end of the cycle. Our results
tween the higher (normal semen group=44.2%) and low- suggest that poor semen quality decreases the chance
er (epididymis group=35.5%) blastocyst formation rates of having a blastocyst, despite of univariate analysis had
is less than 10%. Also, the difference between the mean shown a numerically similar blastocyst formation rates. Ac-
number of blastocysts formed is only 0.4 (normal semen cordingly, the worse the semen quality, the more cleaved
group=2.8 and epididymis group=2.4). embryos are required for blastocyst formation. Future
Studies published more than 2 decades ago report that studies should be performed to establish the better meth-
both diminished sperm morphology quality and concen- od for embryo transfer, considering both semen quality and
tration lower the likelihood of good morphology embryo number of cleaved embryos.
formation. However, those semen parameters were evalu- In summary, we suggest that the general sperm quali-
ated separately, and the embryos were classified based on ty, considering the three main parameters of concentration,
cleavage stage (Parinaud et al., 1993). We also noticed the motility and morphology, can predict the blastocyst forma-
cleavage rate, and the differences follow the same pattern tion rate. Hence, it is essential to consider the general semen
that blastocysts have; as there is a statistical difference quality and number of cleaved embryos in counselling couples
but it is not clinically relevant. undergoing IVF with extended culture to blastocyst transfer.

JBRA Assist. Reprod. | v.22 | nº2 | Apr-May-Jun/ 2018

 Semen quality and blastocyst formation - Piccolomini, MM. 93

ACKNOWLEDGEMENTS Harton GL, Munné S, Surrey M, Grifo J, Kaplan B, Mc-

We are very thankful to the Huntington Medicina Re- Culloh DH, Griffin DK, Wells D; PGD Practitioners Group.
produtiva team for conducting the IVF cycles. Diminished effect of maternal age on implantation after
preimplantation genetic diagnosis with array comparative
genomic hybridization. Fertil Steril. 2013;100:1695-703.
Conflicts of interest
PMID: 24034939 DOI: 10.1016/j.fertnstert.2013.07.2002
None to declare.
Katz-Jaffe MG, Surrey ES, Minjarez DA, Gustofson RL, Ste-
Corresponding Author: vens JM, Schoolcraft WB. Association of abnormal ovar-
Mariana Moraes Piccolomini ian reserve parameters with a higher incidence of aneu-
Huntington - Medicina Reprodutiva ploid blastocysts. Obstet Gynecol. 2013;121:71-7. PMID:
São Paulo, Brazil 23262930 DOI: 10.1097/AOG.0b013e318278eeda
Email: [email protected]
Kolibianakis E, Bourgain C, Albano C, Osmanagaoglu K,
REFERENCES Smitz J, Van Steirteghem A, Devroey P. Effect of ovarian
stimulation with recombinant follicle-stimulating hormone,
Aboulghar MA, Mansour RT, Serour GI, Fahmy I, Kamal A,
gonadotropin releasing hormone antagonists, and human
Tawab NA, Amin YM. Fertilization and pregnancy rates after
chorionic gonadotropin on endometrial maturation on the
intracytoplasmic sperm injection using ejaculate semen and
day of oocyte pick-up. Fertil Steril. 2002;78:1025-9. PMID:
surgically retrieved sperm. Fertil Steril. 1997;68:108-11.
12413988 DOI: 10.1016/S0015-0282(02)03323-X
PMID: 9207593 DOI: 10.1016/S0015-0282(97)81484-7

Kovac JR, Smith RP, Cajipe M, Lamb DJ, Lipshultz LI. Men
Alves da Motta EL, Alegretti JR, Baracat EC, Olive D, Seraf-
with a complete absence of normal sperm morphology ex-
ini PC. High implantation and pregnancy rates with transfer
hibit high rates of success without assisted reproduction.
of human blastocysts developed in preimplantation stage
Asian J Androl. 2017;19:39-42. PMID: 27751992 DOI:
one and blastocyst media. Fertil Steril. 1998;70:659-63.
10.4103/1008-682X.189211
PMID: 9797094 DOI: 10.1016/S0015-0282(98)00263-5

Kruger TF, Menkveld R, Stander FS, Lombard CJ, Van

Borges E Jr., Braga DP, Setti AS, Vingris LS, Figueira RC,
der Merwe JP, van Zyl JA, Smith K. Sperm morpholog-
Iaconelli A Jr. Endometriosis Affects Oocyte Morphology
ic features as a prognostic factor in in vitro fertilization.
in Intracytoplasmic Sperm Injection Cycles? JBRA As-
Fertil Steril. 1986;46:1118-23. PMID: 2946611 DOI:
sist Reprod. 2015;19:235-40. PMID: 27203199 DOI:
10.1016/S0015-0282(16)49891-2
10.5935/1518-0557.20150046

Kupka MS, Ferraretti AP, de Mouzon J, Erb K, D’Hooghe

Chapuis A, Gala A, Ferrières-Hoa A, Mullet T, Bring-
T, Castilla JA, Calhaz-Jorge C, De Geyter C, Goossens
er-Deutsch S, Vintejoux E, Torre A, Hamamah S. Sperm
V; European IVF-Monitoring Consortium, for the Euro-
quality and paternal age: effect on blastocyst formation
pean Society of Human Reproduction and Embryolo-
and pregnancy rates. Basic Clin Androl. 2017;27:2. PMID:
gy. Assisted reproductive technology in Europe, 2010:
28127436 DOI: 10.1186/s12610-016-0045-4
results generated from European registers by ESHRE.
Hum Reprod. 2014;29:2099-113. PMID: 25069504 DOI:
Chen X, Zhang W, Luo Y, Long X, Sun X. Predictive value of 10.1093/humrep/deu175
semen parameters in in vitro fertilisation pregnancy out-
come. Andrologia. 2009;41:111-7. PMID: 19260848 DOI:
Loutradi KE, Tarlatzis BC, Goulis DG, Zepiridis L, Pa-
10.1111/j.1439-0272.2008.00898.x
gou T, Chatziioannou E, Grimbizis GF, Papadimas I, Bon-
tis I. The effects of sperm quality on embryo develop-
Dain L, Auslander R, Dirnfeld M. The effect of paternal age ment after intracytoplasmic sperm injection. J Assist
on assisted reproduction outcome. Fertil Steril. 2011;95:1- Reprod Genet. 2006;23:69-74. PMID: 16575547 DOI:
8. PMID: 20932518 DOI: 10.1016/j.fertnstert.2010.08.029 10.1007/s10815-006-9022-8

De Vos A, Van De Velde H, Joris H, Verheyen G, Devro- Magli MC, Crippa A, Muzii L, Boudjema E, Capoti A, Scara-
ey P, Van Steirteghem A. Influence of individual sperm velli G, Ferraretti AP, Gianaroli L. Head birefringence proper-
morphology on fertilization, embryo morphology, and ties are associated with acrosome reaction, sperm motility
pregnancy outcome of intracytoplasmic sperm injec- and morphology. Reprod Biomed Online. 2012;24:352-9.
tion. Fertil Steril. 2003;79:42-8. PMID: 12524062 DOI: PMID: 22285248 DOI: 10.1016/j.rbmo.2011.12.013
10.1016/S0015-0282(02)04571-5
Maheshwari A, Hamilton M, Bhattacharya S. Should we be
Gardner DK, Lane M, Stevens J, Schlenker T, School- promoting embryo transfer at blastocyst stage? Reprod
craft WB. Blastocyst score affects implantation and preg- Biomed Online. 2016;32:142-6. PMID: 26673100 DOI:
nancy outcome: towards a single blastocyst transfer. 10.1016/j.rbmo.2015.09.016
Fertil Steril. 2000;73:1155-8. PMID: 10856474 DOI:
10.1016/S0015-0282(00)00518-5
Meng XQ, Gong Y, Huang J, Zeng YM, Quan S, Zhong Y.
[Impact of sperm midpiece morphology on embryo de-
Glujovsky D, Blake D, Farquhar C, Bardach A. Cleav- velopment following intracytoplasmic morphologically se-
age stage versus blastocyst stage embryo transfer in lected sperm injection]. Nan Fang Yi Ke Da Xue Xue Bao.
assisted reproductive technology. Cochrane Database 2016;36:255-9. Chinese. PMID:26922026
Syst Rev. 2012;(7):CD002118. PMID: 22786480 DOI:
10.1002/14651858.CD002118.pub4

JBRA Assist. Reprod. | v.22 | no2| Apr-May-Jun/ 2018

Original article 94

Meniru GI, Gorgy A, Batha S, Clarke RJ, Podsiadly BT, Sakkas D, Ramalingam M, Garrido N, Barratt CL. Sperm
Craft IL. Studies of percutaneous epididymal sperm aspi- selection in natural conception: what can we learn from
ration (PESA) and intracytoplasmic sperm injection. Hum Mother Nature to improve assisted reproduction outcomes?
Reprod Update. 1998;4:57-71. PMID: 9622413 DOI: Hum Reprod Update. 2015;21:711-26. PMID: 26386468
10.1093/humupd/4.1.57 DOI: 10.1093/humupd/dmv042

Nicopoullos JD, Gilling-Smith C, Almeida PA, Nor- World Health Organization. WHO laboratory manual for the
man-Taylor J, Grace I, Ramsay JW. Use of surgical examination and processing of human semen. 5th ed. Ge-
sperm retrieval in azoospermic men: a meta-analysis. neva: World Health Organization; 2010.
Fertil Steril. 2004;82:691-701. PMID: 15374716 DOI:
10.1016/j.fertnstert.2004.02.116 Yan J, Wu K, Tang R, Ding L, Chen ZJ. Effect of mater-
nal age on the outcomes of in vitro fertilization and em-
Palermo G, Joris H, Devroey P, Van Steirteghem AC. Preg- bryo transfer (IVF-ET). Sci China Life Sci. 2012;55:694-8.
nancies after intracytoplasmic injection of single sper- PMID: 22932885 DOI: 10.1007/s11427-012-4357-0
matozoon into an oocyte. Lancet. 1992;340:17-8. PMID:
1351601 DOI: 10.1016/0140-6736(92)92425-F Zheng J, Lu Y, Qu X, Wang P, Zhao L, Gao M, Shi H, Jin
X. Decreased Sperm Motility Retarded ICSI Fertilization
Parinaud J, Mieusset R, Vieitez G, Labal B, Richoil- Rate in Severe Oligozoospermia but Good-Quality Embryo
ley G. Influence of sperm parameters on embryo quali- Transfer Had Achieved the Prospective Clinical Outcomes.
ty. Fertil Steril. 1993;60:888-92. PMID: 8224276 DOI: PLoS One. 2016;11:e0163524. PMID: 27661081 DOI:
10.1016/S0015-0282(16)56292-X 10.1371/journal.pone.0163524

JBRA Assist. Reprod. | v.22 | nº2 | Apr-May-Jun/ 2018