AOA in Recurrent Fertilization Failure
Condition: Infertility Primary
MeSH terms: Infertility
Study type: Interventional
Phase: Phase 4

Summary: 
      Background: Despite the high success rate of ICSI, total fertilization failure still occurs
      in 1-3% of all ICSI cycles and can recur in subsequent cycles, even when a sufficient number
      of oocytes and motile spermatozoa are available. Several reports show that the majority of
      couples suffering from ICSI failure benefit from the application of ICSI combined with
      assisted oocyte activation. A variety of artificial activating methods is used in human
      assisted reproduction treatment, including physical, mechanical or chemical stimuli, which
      provoke one or more calcium rises in the oocyte cytoplasm. Study Design: Randomized
      controlled trial. Setting: A university fertility center. Methods: 150 infertile patients who
      underwent ICSI and all had history of recurrent fertilization failure. The patients were
      randomly allocated into 2 equal groups. Group1=75 patients who underwent ICSI without oocyte
      activation. Group2 patients =75 and underwent ICSI Patient underwent ICSI with oocyte
      activation. Reproductive outcomes were compared between both groups. Results: there were
      significant differences between groups regarding number of oocytes retrieved, number of
      mature oocyte, fertilization rate and pregnancy rate. Conclusion: Assisted oocyte activation
      with calcium ionophore results in significant improvement in the fertilization, cleavage and
      pregnancy rates after ICSI.
    

Detailed description: 
      This study is a randomized controlled trial included 150 ICSI patients with history of
      recurrent fertilization failure. Patients had undergone ICSI trials in ART unit, Al-Azhar
      University, Cairo, Egypt, from July 2017 to November 2018. The study was approved by the
      university medical ethical committee (under registry number 202010454) and all couples had
      signed a written consent before initiation of the study and the treatment cycles. AOA
      candidate couples were counseled regarding the procedure. The patients were selected
      according to the following criteria:

      Inclusion Criteria: -

        1. Age between 20 and 40 years old.

        2. Cases with history of total fertilization failure in previous ICSI cycles

        3. Oocytes with normal morphology.

        4. Male factor infertility. Exclusion Criteria: - Abnormal oocyte morphology degenerated or
           immature oocytes.

      Two groups were randomly designated:

      The first Group: The oocytes were treated by calcium ionophore. This group involved 75 ICSI
      cycles.

      The Second Group: Oocytes were not treated by calcium ionophore. This group involved 75 ICSI
      cycles.

      Methods:

        1. Ovarian stimulation:

           All women received ovarian stimulating drugs according to the ART protocols (long
           agonist, flare up or antagonist protocols). Deca 0.1 was given s.c. daily, for
           down-regulation in short and long protocol while cetrotide 0.25 was given s.c. daily for
           down-regulation in antagonist protocol. Follicular development was monitored by
           ultrasound scanning and serum estradiol. Patients received 10,000 IU of Human Chronic
           Gonadotrophin (HCG) when most of the follicles measured more than 17-20 mm in diameter.

        2. Semen preparation:

           • The husband was asked to submit a semen sample in a sterile plastic container after a
           2 to 3-day period of abstinence and about 2 hours before the ICSI procedure. The
           specimen container must be clean, sterile and wide mouthed to minimize collection error.

        3. Oocyte retrieval:

             -  Under general anesthesia, the oocytes were aspirated by a specialized,
                ultrasound-guided needle (Labotect aspiration catheter, Germany) at 34-36 h after
                HCG injection. Warmed HEPES buffered medium (Irvine Scientific, Irvine, CA, USA)
                was used for handling and washing of oocytes.

             -  After ICSI, the whole injected oocytes were washed with Global total Fertilization
                Medium (Global pharm, Life Global, Brussels, Belgium, Europe) and the patients were
                randomly allocated into two equal groups (75 patients each) by using computer-based
                randomization program. Group one in which, the injected oocytes were transferred to
                a medium that contain 10 µmol of calcium ionophore (GM508 Cult-Active, Gynemed,
                Germany) and were incubated for 10 minutes, then again oocytes were washed with
                Global total Fertilization Medium (Global pharm, Life Global, Brussels, Belgium,
                Europe) and were incubated at 37°C in 6% CO2. In group two, the injected oocytes
                were not submitted to calcium ionophore activation.

             -  18 hours after injection, the whole injected oocytes in both groups were evaluated
                for fertilization, cleavage and quality at the day of embryo transfer (ET).

      Embryo Transfer

      • After ET, luteal phase support was conducted (intramuscularly progesterone injection 100 mg
      daily) for 14 days until pregnancy test.

      After data collection, both groups were compared regarding oocyte number, oocyte
      fertilization rate, number and quality of embryos, implantation rate and clinical pregnancy
      rate.
    

Intervention name(s): Calcium Ionophore A23187
Intervention type(s): Drug
Intervention description(s): Calcium Ionophore A23187 is used in laboratories to increase intracellular Ca2+ levels in intact cells. It also uncouples oxidative phosphorylation, the process cells use to synthesize Adenosine triphosphate which they use for energy. In addition, A23187 inhibits mitochondrial ATPase activity. A23187 also induces apoptosis in some cells (e.g. mouse lymphoma cell line, or S49, and Jurkat cells) and prevents it in others (e.g. cells dependent on interleukin 3 that have had the factor withdrawn).
In IVF field, Ca Ionophore can be used in case of low fertilization rate after ICSI procedure, particularly with Globozoospermia (Round Head sperm syndrome), Ca Ionophore will replace absence of sperm acrosom, and plays role in oocyte activation after ICSI. Recommended use is 0.5 microgram/ml twice for 10 min interrupted with fresh media with 30 min incubation, followed with regular injected eggs culture for IVF.
Other intervention name(s): non
Intervention MeSH terms: Calcimycin; Calcium; Ionophores; Calcium Ionophores
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment