Impact of Oral An/oxidant Treatment in Men with High Sperm DNA Fragmenta/on
and Repeated ART Failures
Preliminary Results
Emre Göksan Pabuçcu1, Aslı Yarcı Gürsoy
1, Mine Kiseli1, Özgür Doğuş Demirkıran2, Arzu Bostancı Durmuş1, Gamze Sinem Çağlar1, Recai Pabuçcu2
1Ufuk Üniversitesi Tıp Fakültesi, Kadın Hastalıkları ve Doğum Ana Bilim Dalı, Ankara
2Centrum Klinik Tüp Bebek Merkezi, Ankara
Sperm DNA Damage
• is now considered an important factor in the aeVology of male inferVlity
• may be present in men with both abnormal and normal semen parameters
• rouVne semen parameters are not robustly predicVve of pregnancy outcomes
Zhang et al 2008
Oleszscuk et al 2013
Zhang et al 2008
LocalizaVon of Damages
ROS
Reac/ve Oxygen Species (ROS): O2, H2O2
• Successful capacitaVon
• Acrosome reacVon
• ChromaVn
compacVon during transport of the
spermatozoa
An/-‐oxidants (AO):
Seminal plasma
enzymaVc and non enzymaVc Aos are
scavengers of ROS
Reac/ve Oxygen Species (ROS): O2, H2O2
• Successful capacitaVon
• Acrosome reacVon
• ChromaVn compacVon during transport of
spermatozoa
An/-‐oxidants (AO):
Seminal plasma enzymaVc and non enzymaVc AOs
Lipid peroxida/on
DNA damage
High Sperm DNA FragmentaVon
• DFI > 20-‐30% should be considered as
high SDF
High SDF Outcomes..
• Decreased pregnancy odds in natural pregnancy
• Reduced no of good quality embryos and decreased pregnancy rates in IVF cycles
• significantly increased risk of miscarriage,
implantaVon failure or failure to progress to delivery even in ICSI cycles
• Repeated pregnancy loss
Olesczuk et al 2013 Evenson and Wixon 2008
Zhang et al 2008, Jiang et al 2011
Bungum et l 2007, Kennedy et al 2011
What Should We Do?
• Modifying lifestyle
• Environmental modificaVons
• Dietary anV-‐oxidants (veggies)
• An/-‐oxidant supplementa/on
• ICSI rather than IVF
• Sperm selecVon techniques
• Using tesVcular sperm in ART
Aim of the Study
• To evaluate the impact of oral an/oxidant (OA) treatment on ART outcomes
In normo-‐zoospermic males with high SDF and with repeated ART failures
Methods and Design
• Electronic database of an assisted reproducVon center between 2014 and 2015
Inclusion criteria
(i) at least 2 unsuccessful ART ajempts;
(ii) Women between 18 and 40 years of age
(iii) sperm count with at least 15 million/ml
(iv) high DFI levels (>30%) (v) CompleVon of 6-‐months OAO treatment
Exclusion criteria
(i) Oligozoospermia and azoospermia;
(ii) male subjects
with obvious abnormaliVes (varicocele) (iii) Poor responders
(iv) PGS-‐Thaw ET cycles
(v) uterine or tubal pathology;
(vi) subjects with geneVc disorders;
(vii) heavy smokers
(viii) couples with ferVlizaVon failure history
Methods
• All male subjects were documented to complete their 6-‐months course of OAO treatment
• Accordingly, a new OS cycle was iniVated
Methods
• SDF was measured using TUNEL assay during first admission
• OAO: was commercially available formula comprised of selenium, zinc, Coenzyme-‐
Q10, vitamin-‐C, folic acid and vitamin-‐B12 twice daily
• All women underwent OS with antagonist protocol (150-‐300 IU)
total of
24
couples were undergone a new ICSI cycleResults
Age (years)
mean(SD) 33.25 ± 5.18
No of previous attempts (n)
mean(SD) 3.17±1.55
AMH (ng/ml)
mean(SD) 2.20 ± 1.39
TPMSC (million)
mean(SD) 50 (10 - 68)
DFI (%)
mean(SD) 43.33 ± 5.87
BMI of women (kg/m2)
mean(SD) 24.33 ± 3.17
Duration of ovarian stimulation (days)
mean(SD) 11.26 ± 1.25
Mature oocytes (MII)
mean(SD) 6.39 ± 4.18
Fertilization (%)
mean(SD) 74.30 ± 18.94
Implantation (%)
mean(SD) 26.50 ± 36.61
Available No of good quality embryos!
mean(SD)
1.5±0.9!
Clinical pregnancy rate per started
cycle %, (n) 40.9 (9/24)
Ongoing pregnancy rate per started
cycle %, (n) 36.4 (8/24)
Miscarriage %, (n) 4.2 (1/24)
Cycle cancelations %, (n) 8.3 (2/27)
Discussion
• In the presence of high SDF:
• Increasing scavenger
capacity with OAOs
• Choosing
spermatozoa with bejer genomic integrity
• TesVcular sperm
• Morphologically bejer sperm
• High SDF compromises overall pregnancy odds..
• Be^er pregnancy outcomes were detected with ICSI rather than IVF
• ICSI: bejer morphology: bejer genomic integrity??
IVF
ICSI
Zhao et al 2014
Miscarriages..
but miscarriage risk is sVll evident despite ICSI (late paternal effect..)
Zhao et al 2014
It seems that ICSI-‐only does not prevent
miscarriages despite good ferVlizaVon rates..
SDF and Morphology
• High SDF could even be
present in apparently normal spermatozoa
• During ICSI, selecVon of
damaged but apparently normal spermatozoaècould be
possible
Pabuccu et al 2016
Avendano et al 2009
Morphology
correlates well with SDF
High miscariages with high SDF despite ICSI
Our Data
• Our populaVon are consisted of those with at least 2 prior unsuccessful ICSI ajempts
• 74 % ferVlizaVon rate
• 8/24 ongoing pregnancies…
• Only 1 miscarriage was detected
• An/-‐oxidant effect?????
AnVoxidants
• Vit-‐C
• Vit-‐E
• Selenium
• Coenzyme Q-‐10
• Zinc
• Astaxsanthine
Par/cularly mo/lity was shown to enhanced following 1-‐6 months dura/on of OAOs
OAO and SDF
AnV Oxidants
• To date, over 100 clinical and experimental studies have examined the efficacy of OAO
• RCTs: beneficial effect in terms of semen parameters
• has generally been associated with improvement in sperm DNA integrity
• differences in vitamin dosages, duraVon of treatment and paVent populaVon
Zini et al 2011
Formula…
• Mechanism of acVon
• Best formula
• OpVmal duraVon
Yet to be
elucidated…
Final Remarks..
• We did not have post treatment SDF data (cost)
• We did not have control group
(yet)
• Included only those with repeated ART (ICSI) failures with at least one good
quality ET history and without apparent
cause of previous failures
• If there is no Vme limitaVon (DOR, woman’s age..)
• No other confounding factors (embryo quality, endometrium etc..)
• 6-‐months course of OAO treatment seems
beneficial in terms of ferVlizaVon, implantaVon and miscarriages in paVents with high SDF and previous ART ajempts even sperm parameters are normal
