How can the quality of embryos and sperm be improved before Intracytoplasmic Sperm Injection (ICSI)?

Improving Embryo and Sperm Quality Before ICSI

Antioxidant supplementation and lifestyle modifications are the most effective interventions for improving embryo and sperm quality before ICSI, with antioxidant treatment showing significant improvements in fertilization rates and clinical pregnancy outcomes. 1, 2

Understanding Oxidative Stress and Fertility

• Oxidative stress is a major factor in male infertility, affecting sperm quality and function, as well as sperm DNA integrity 1
• Oxidative stress can lead to sperm DNA damage, reduced DNA integrity, and is associated with poor fertilization, embryo development, miscarriage, and implantation failure 1
• Environmental exposures and poor lifestyle choices (e.g., smoking) are significant contributors to oxidative stress 1

Interventions to Improve Sperm Quality

Antioxidant Supplementation

• Combination antioxidant therapy has shown significant benefits in improving sperm parameters and ICSI outcomes 2
• Effective antioxidant combinations include:
  • Myo-inositol, alpha-lipoic acid, folic acid, coenzyme Q10, zinc, selenium, and vitamins B2, B6, and B12 2
  • Zinc and folic acid combination 3
  • Omega-3 fatty acids, particularly alpha-linolenic acid and docosahexaenoic acid 4, 5

Lifestyle Modifications

• Smoking cessation is strongly recommended as non-smokers have higher chances of pregnancy (OR = 2.23) 6, 7
• Weight loss for obese patients and regular physical exercise can enhance sperm parameters 6
• Avoiding diets high in lipophilic foods, soy isoflavones, and sweets which have been shown to lower semen quality 5

Timing Considerations

• Spermatogenesis takes approximately 74 days (about 2.5 months), so interventions should be started at least this far in advance of ICSI 6
• Hormonal treatments may begin to show improvements in parameters within weeks, but full spermatogenic effects require at least 2.5 months 6

Special Considerations for Severe Male Factor Infertility

For Oligozoospermia or Azoospermia

• Genetic testing (karyotype and Y-chromosome microdeletion analysis) should be performed for men with severe oligozoospermia (<5 × 10^6/ml) or non-obstructive azoospermia before any therapeutic procedure 1
• Testicular sperm extraction (TESE) may be considered for men with high sperm DNA fragmentation (SDF) levels, as testicular sperm has lower SDF levels than ejaculated sperm 1
• Avoid testosterone monotherapy as it can suppress sperm production 8, 9

For High Sperm DNA Fragmentation

• Testicular sperm may have better outcomes in ICSI compared to ejaculated sperm for men with high SDF 1
• Consider testicular sperm extraction only after common risk factors for elevated SDF have been excluded and other treatments to reduce SDF have failed 1

Improving Embryo Quality

• Omega-3 fatty acid supplementation before conception has been shown to improve embryo morphology 4
• High intakes of eicosapentaenoic acid and docosahexaenoic acid may reduce estradiol response and the number of follicles after ovarian stimulation 4
• Total omega-3 intake, particularly alpha-linolenic acid and docosahexaenoic acid, improves embryo morphology 4

Important Caveats and Pitfalls

• Routine measurement of reactive oxygen species (ROS) is not currently recommended due to lack of standardized testing methods 1
• The European Association of Urology does not recommend routine testing of ROS 1
• Medical treatments for idiopathic oligoasthenoteratozoospermia have limited efficacy and may delay more effective assisted reproductive technology options 6
• Age-related decrease in oocyte quality cannot be bypassed by ICSI alone, as patient age correlates inversely with fertilization rate 7
• Sperm cryopreservation should be considered before any treatments that might further impair fertility 6