This document discusses the impact of male factors on recurrent pregnancy loss (RPL). It notes that while the female is typically evaluated extensively for causes of RPL, the male contribution is often overlooked except for karyotyping. However, the male genome contributes half of the genetic material to embryos and animal studies suggest the male is important for placental development. Possible male causes of RPL discussed include chromosomal abnormalities in sperm (structural or numerical), gene mutations, and sperm quality issues. The document advocates for more extensive evaluation of genetic factors in both males and females to better understand RPL.

1. Impact
of
male
factor
on
recurrent
pregnancy
loss
Osama
M
Warda
MD
Prof.
of
obstetrics
and
gynecology
Mansoura
university

2. Background
• Recurrent
pregnancy
loss
(RPL)
is
tradi=onally
defined
as
3
or
more
consecu=ve
pregnancy
losses(RCOG),
OR
as
2
or
more
consecu=ve
pregnancy
losses
(ACOG).
• Greater
than
50%
of
cases
remain
unexplained,
even
aLer
an
extensive
workup
(Puschecka
&
Jeyendranb
2007).
• The
en=re
evalua=on
focuses
on
the
female,
with
the
excep=on
of
gene=cs
of
the
products
of
concep=on
and
gene=cs
of
the
individuals
of
the
couple.
osama
warda
2

3. Background
• The
female
evalua=on
may
reveal
one
of
the
following
major
causes:
1-­‐
Endocrine
causes,
2-­‐
Anatomical
causes;
uterine
defects,
3-­‐
Infec;ous
causes,
4-­‐
Immunological
causes,
5-­‐
Gene;c
causes,
6-­‐Thrombophilia.
• Gene;c
abnormali=es
are
the
commonest
cause
of
spontaneous
miscarriage
cons=tu=ng
about
50%
of
cases.
osama
warda
3

4. Background
• Gene=c
abnormali=es
within
the
individuals
of
the
couple
occur
in:
-­‐
1–4%
of
couples
with
RPL
-­‐
0.7%
of
the
general
popula=on
(
Li
TC
et
al
2002)
osama
warda
4

5. Background
• The
gene=c
evalua=on
of
the
products
of
concep=on
and
of
the
couple
typically
consists
only
of
the
karyotypes.
• A
karyotype
includes
an
evalua=on
of
the
number
of
chromosomes
and
any
large
dele;ons,
duplica;ons
or
transloca;ons.
(Puschecka
E
&
Jeyendranb
R
2007)
osama
warda
5

6. Background
• The
most
common
karyotype
abnormali=es
that
are
iden=fied
within
the
products
of
concep=on
are
missing
or
addi;onal
chromosomes.
• These
assays
will
not
detect
small
dele;ons,
subs;tu;ons,
duplica;ons,
transloca;ons
or
point
muta;ons.
(These
smaller
gene;c
disorders
may
account
for
many
more
of
these
miscarriages).
osama
warda
6

7. Male
as
a
poten9al
cause
of
RPL
• It
would
make
sense
that
recurrent
pregnancy
loss
may
have
a
male
factor
since
the
male
gamete
contributes
one-­‐half
of
the
genomic
content
to
the
embryo.
osama
warda
7

8. Male
as
a
poten9al
cause
of
RPL
• karyotype
of
the
male
was
the
only
evalua=on
done
.
• The
gene=cs
of
recurrent
abor=on
may
result
from
two
chromosomal
abnormali=es:
1-­‐
a
structural
abnormality
derived
from
one
parent
(transloca;on,
inversions,
etc.);
or
2-­‐
the
occurrence
of
a
numerical
abnormality
(extra
or
missing
chromosome),
which
is
usually
not
inherited.
osama
warda
8

9. Male
as
a
poten9al
cause
of
RPL
• Animal
studies;
The
male
genome
contributes
more
to
the
placenta
than
the
female
genome.
-­‐
In
androgenodes
(pregnancy
conceived
with
two
male
gametes)
the
pregnancy
consists
of
en=rely
placenta,
whereas;
-­‐
in
gynegenodes
(pregnancy
conceived
from
two
female
gametes)
the
pregnancy
results
in
an
embryo
with
no
or
very
li]le
placenta.
(Spindle
et
al
1996)
osama
warda
9

10. Male
as
a
poten9al
cause
of
RPL
• Animal
studies:
The
findings
from
mouse
studies
suggest
that
the
male
may
be
important
for
decidual
vascular
remodeling
and
this
mechanism
may
not
occur
or
may
be
abnormal
in
some
cases
of
recurrent
pregnancy
loss
(Dixon
et
al.
2006)
osama
warda
10

11. Possible
Male
causes
of
RPL
(2)
Sperm
factors
(a)
Sperm
chromosome
(i)
Structural
abnormality
(ii)
Numerical
abnormality
(b)
Gene
muta9ons
(i)
HLA-­‐G
polymorphisms
(ii)
Thrombophilia
muta=ons
(iii)
Microdele=ons
of
the
Y
chromosome
(c)
Sperm
quality
(1) Chromosomal
abnormali9es;
karyotyping
(a)
Structural
abnormali9es
(
transloca9ons)
(b)
Numerical
abnormali9es
osama
warda
11
(4)
Miscellaneous
factors
(a)
Mannan
binding
protein
(MBP)
(b)
Therapeu=c
agents
(c)
Others
(3)
Paternal
age

12. Possible
Male
causes
of
RPL
(1) Chromosomal
abnormali9es;
(a)
Structural
abnormali9es
(b)
Numerical
abnormali9es
osama
warda
12

13. osama
warda
13
This
study
demonstrated
a
strong
associa9on
between
RPL
and
the
prevalence
of
chromosomal
abnormali9es
and
inherited
thrombophilia.
Given
the
high
rate
of
consnguineous
marriages
in
the
Saudi
popula9on,
these
results
underline
the
importance
of
systemic
cytogene9c
inves9ga9on
and
gene9c
counselling
preferably
at
the
premarital
stage
or
at
least
during
early
pregnancy
phase
through
PGD

14. CONCLUSION:
Couples
with
pregnancy
loss
produce
chromosomally
abnormal
embryos
in
a
significantly
higher
percentage
than
those
not
having
this
reproduc;ve
problem
which
are
mainly
due
to
non-­‐dysjunc;on.
Once
an
unbalanced
transloca;on
in
the
(fetus
/
child
)has
been
iden;fied,
parental
karyotype
is
essen;al.
osama
warda
14

15. A
total
of
495
couples
were
included
in
the
study.
Mean
age
of
the
female
pa=ents
was
30.6
years
(range:
19–44).
Parental
chromosome
analysis
was
performed
in
all
of
the
495
couples.
Among
these
990
subjects,
a
major
chromosomal
abnormality
was
detected
in
28
cases
(2.8%
of
all
cases,
5.7%
of
the
couples)
.
16
(57.1%)
of
the
abnormali;es
were
in
females,
and,
12
(42.9)
of
the
abnormali=es
were
in
males.
osama
warda
15

16. Structural
Chromosomal
Abnormali=es
Transloca=ons
-­‐
Reciprocal
transloca;ons
are
usually
an
exchange
of
material
between
non-­‐homologous
chromosomes.
-­‐
Robertsonian
transloca;on
is
a
type
of
transloca=on
caused
by
breaks
at
or
near
the
centromeres
of
two
acrocentric
chromosomes.
The
reciprocal
exchange
of
parts
gives
rise
to
one
large
metacentric
chromosome
and
one
extremely
small
chromosome
that
may
be
lost
from
the
organism
with
li]le
effect
because
it
contains
so
few
genes.
The
resul=ng
karyotype
in
humans
leaves
only
45
chromosomes,
since
two
chromosomes
have
fused
together.
osama
warda
16

17. osama
warda
17

18. Structural
Chromosomal
Abnormali9es
• If
the
re-­‐arrangement
of
the
chromosomes
results
in
crea=ng
gametes
with
unbalanced
transloca;ons,
then
the
resul=ng
offspring
typically
do
not
result
in
live
births
but
abort.
• Couples,
where
one
or
both
carry
a
balanced
transloca=on,
are
at
higher
risk
for
miscarriage
due
to
the
fact
that
they
may
produce
balanced
or
unbalanced
gametes.
osama
warda
18

19. Structural
Chromosomal
Abnormali=es
• Balanced
transloca=ons
are
associated
with
reduced
pregnancy
rates
and
increased
miscarriages.
• The
es=mated
incidence
of
Robertsonian
transloca=on
is
about
0.1%
in
the
general
popula=on
[Morel
&
Bresson
2001].
• In
couples
with
recurrent
abor=on,
the
prevalence
is
reported
as
high
as
approximately
8%
[Sugiura
et
al
2004]
osama
warda
19

20. Structural
Chromosomal
Abnormali=es
•
Men
with
a
transloca=on
can
have
gametes
with
a
normal,
a
balanced
or
an
unbalanced
complement
of
chromosomes
that
can
lead
to
normal,
balanced
or
unbalanced
offspring.
• If
one
parental
carrier
has
a
21q21q
transloca=on
or
iso-­‐chromosome,
then
there
is
a
100%
recurrence
risk
of
trisomy
21
–
and
about
50
–
80%
risk
of
trisomy
21
fetuses
result
in
miscarriage
[Leporrier
et
al
2003]
osama
warda
20

21. Structural
Chromosomal
Abnormali=es
• A
Japanese
study
[Sugiura
et
al
2004]
of
1,284
recurrent-­‐loss
couples
revealed
higher
miscarriage
rates
associated
with
the
male
as
the
carrier
of
the
abnormal
karyotype
In
these
cases,
men
with
reciprocal
transloca=ons
had
a
61.1%
miscarriage
rate,
men
with
Robertsonian
transloca=ons
had
a
36.4%
miscarriage
rate,
and
men
with
inversions
had
a
miscarriage
rate
of
28
–
42.9%.
• They
concluded
that
“The
pregnancy
prognosis
with
either
maternal
or
paternal
reciprocal
transloca;ons
is
poorer
than
without
them.
The
presence
of
a
reciprocal
transloca;on
is
thus
a
risk
factor
in
couples
who
have
recurrent
miscarriages.”
osama
warda
21

22. Numerical
chromosomal
abnormali=es
• Chromosomal
abnormali=es
involving
an
abnormal
number
of
chromosomes
typically
result
in
miscarriage
when
this
occurs
in
the
fetus;
living
men
may
have
an
extra
chromosome.
• The
more
common
of
these
disorders
include
Down’s
syndrome
(trisomy
21;
incidence
1
in
600)
and
Kleinfelter’s
syndrome
(47,
XXY;
incidence
1
in
2000).
Most
of
these
men
are
thought
to
have
significantly
reduced
fer=lity
or
sterility
and
high
miscarriage
rates
of
50%
or
more
[Leporrier
et
al
2003]
.
osama
warda
22

23. osama
warda
23
Fer=lity
associa=on
of
Memphis
–USA
(2017)

24. Chromosomal
rearrangements
were
found
in
170
individuals
(3.5%).
Transloca;ons
were
seen
in
72
(42.35%)
cases.
Of
these,
reciprocal
transloca=ons
cons=tuted
42
(24.70%)
cases
while
Robertsonian
transloca=ons
were
detected
in
30
(17.64%)
cases.
7
(4.11%)
cases
were
mosaic,
8
(4.70%)
had
small
supernumerary
marker
chromosomes
and
1
(0.6%)
had
an
inters==al
microdele=on.
Nearly,
78
(1.61%)
cases
with
heteromorphic
variants
were
seen
of
which
inversion
of
Y
chromosome
(57.70%)
and
chromosome
9
pericentromeric
variants
(32.05%)
were
predominantly
involved.
osama
warda
24

25. Conclusion
:
Gene=c
variables
appear
to
play
a
complex
role
in
the
efficiency
of
human
reproduc=on.
Classically,
high
rates
of
chromosomal
errors
have
been
among
the
leading
e9ologies
for
fetal
loss
and
more
recent
studies
have
begun
to
highlight
the
important
role
that
specific
single
gene
defects
may
play
in
pregnancy
maintenance.
PGD
may
be
indicated
in
a
small
propor;on
of
couples
with
defined
transloca;ons
or
select
single
gene
disorders.
osama
warda
25

26. (2)
Sperm
factors
(a)
Sperm
chromosome
(i)
Structural
abnormality
(ii)
Numerical
abnormality
(b)
Gene
muta9ons
(i)
HLA-­‐G
polymorphisms
(ii)
Thrombophilia
muta=ons
(iii)
Microdele=ons
of
the
Y
chromosome
(c)
Sperm
quality
osama
warda
26

27. CONCLUSION:
Semen
profile
and
sperm
func=on
tests
scores
were
significantly
lower
in
the
RPL
group
when
compared
to
the
control
group.
Through
this
pilot
study
it
is
significant
that
male
factor
might
be
a
possible
contribu;ng
factor
towards
RPL.
Apart
from
rou;ne
semen
analysis,
sperm
func;on
tests
may
be
an
informa;ve
tool
in
cases
of
idiopathic
RPL.
Therefore
both
the
partners
should
be
evaluated
and
treated
simultaneously
in
order
to
achieve
successful
pregnancy.
osama
warda
27

28. osama
warda
28
Conclusion
:
this
study
concluded
that
there
is
a
posi9ve
associa9on
of
sperm
dysfunc9on
with
RPL,
hence
male
can
be
considered
for
rou9ne
evalua9on
along
with
the
female
in
order
to
achieve
desirable
outcome

29. Sperm
chromosome:
numerical
abnormality
• In
current
prac=ce
it
is
possible
to
study
the
karyotypes
of
peripheral
white
blood
cells
from
men
whose
wives
have
recurrent
pregnancy
as
well
as
to
analyze
the
germline
in
the
gamete:
individual
sperm
chromosomes.
• Rubio
et
al.
[1999]
studied
12
sperm
samples
from
couples
with
two
or
more
first-­‐trimester
losses
who
were
under-­‐
going
IVF
.
They
found
that
sex
chromosome
diosmy
and
diploidy
significantly
higher
than
control.
This
implicates
the
impact
of
paternal
effects
despite
the
age
of
the
female.
osama
warda
29

30. osama
warda
30
This
study
suggests
that
polymorphic
variants
have
an
impact
on
fer=lity.
Moreover,
the
results
show
a
rela=onship
between
polymorphisms
and
aneuploidy
in
spermatozoa
and
embryos.

31. Sperm
chromosome:
numerical
abnormality
• Carrell
et
al.
[2003]
reported
a
sta;s;cally
higher
mean
sperm
aneuploidy
rate
in
men
of
unexplained
recurrent
miscarriage
couples
than
in
the
general
popula;on
or
fer;le
controls.
Addi=onally,
they
found
that
the
percentage
of
aneuploid
sperm
was
correlated
to
the
percentage
of
apopto=c
sperm
using
a
TUNEL
assay
.
• DNA
fragmenta;on
is
a
hallmark
of
apoptosis
in
human
sperm.
Many
Studies
showed
increased
apoptosis
in
the
semen
of
infer=le
men
and
increased
abnormal
sperm
morphology
inversely
correlated
with
IVF
outcome.
osama
warda
31

32. Sperm
chromosome:
structural
abnormality
• The
sperm
chroma;n
structure
assay
measures
increased
sperm
chroma=n
suscep=bility
to
acid
denatura=on
(Evenson
et
al
1999,
Spano
et
al
2000)
• Higher
sperm
chroma=n
structure
assay
values
predict
39%
of
miscarriages
[Evenson
et
al
1999].
• In
studies
correla=ng
sperm
DNA
integrity
and
outcomes
of
IVF
cycles
;
The
spontaneous
miscarriage
rate
is
increased
in
ICSI
cycles
when
pa=ents
with
known
meio;c
disorders
associated
with
increased
frequencies
of
diploidy
are
compared
with
controls
[Aran
et
al
1999].
osama
warda
32

33. osama
warda
33

34. osama
warda
34
In
men
with
aneuploidy
in
sperm
or
who
carry
a
chromosomal
transloca=on,
pre-­‐implanta=on
gene=c
screening
(PGS)
combined
with
in
vitro
fer=liza=on
(IVF)
and
intra-­‐cytoplasmic
sperm
injec=on
(ICSI)
can
increase
chances
of
live
birth.

35. osama
warda
35
Men
with
RPL
have
increased
sperm
aneuploidy
compared
with
controls.
A
total
of
40%
of
men
with
RPL
and
normal
sperm
density/mo=lity
had
abnormal
sperm
aneuploidy.
Men
with
oligo-­‐asthenozoospermia
and
abnormal
strict
morphology
had
a
greater
percentage
of
sperm
aneuploidy
compared
with
men
with
normal
semen
parameters.

36. osama
warda
36
Conclusion
:
Protamine-­‐1
and
protamine-­‐2
mRNA
levels
as
well
as
the
protamine
mRNA
ra=o
and
all
rou=ne
semen
parameters
revealed
significant
differences
between
recurrent
miscarriage
couples
and
healthy
volunteers
(P
<
0.01)

37. osama
warda
37
The
increase
in
abnormal
sperm
parameters,
sperm
DNA
fragmenta=on,
nuclear
chroma=n
decondensa=on,
and
sperm
aneuploidy
suggest
possible
causes
of
unexplained
RPL.

38. Gene
muta=ons
• Gene
muta=ons
may
occur
in
any
gene.
The
muta=ons
may
be
a
single
point
muta;on
resul=ng
in
an
amino
acid
change
or
they
may
be
dele;ons
or
subs;tu;ons
or
inser;ons
• common
gene
muta=ons
associated
with
miscarriage
include:
1-­‐HLA-­‐G
polymorphisms
(Aldrich
et
al
2001)
2-­‐
Thrombophilia
muta=ons
(Jivraj
et
al
2006)
3-­‐
Microdele=on
of
the
Y
chromosome
(Dewan
et
al
2006)
osama
warda
38

39. Sperm
Quality
• Evidence
is
accumula=ng
for
paternal
genome
effects
in
early
embryonic
development.
Sperm
integrity
is
vital
for
sperm
–
egg
interac=ons,
fer=liza=on
and
early
embryonic
development
(Tesarik
et
al
2004).
• The
paternal
genome
provides
the
centrosome
in
the
first
mito=c
division
aLer
fer=liza=on
(Sathananthan
AH
1997).
• Sperm
quality
has
been
associated
with
the
embryo’s
ability
to
reach
the
blastocyst
stage
and
progress
to
implanta=on.
Paternally
expressed
genes
modulate
the
prolifera=on
and
invasiveness
of
trophoblast
cells
and
later
placental
prolifera=on
(Tesarik
et
al
2004).
osama
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39

40. Sperm
Quality
-­‐ One
study
found
a
rela=on
between
tapered
sperm
morphology
and
unexplained
recurrent
miscarriage
(
Sbracia
et
al
1996).
-­‐ Another
study
found
correla=on
with
hypoosmo;c
swelling
test
scores
in
the
recurrent
miscarriage
(Bucke[
et
al
1997)
-­‐ A
3rd
study
found
an
associa=on
with
poor
sperm
quality
and
repeated
early
pregnancy
loss
as
measured
by
an
increase
in
sperm
nuclear
vacuoles
or
abnormal
chroma;n
condensa;on
(Gopalkkrishnan
et
al.
2000)
.
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40

41. Possible
Male
causes
of
RPL
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41
(4)
Miscellaneous
factors
(a)
Mannan
binding
protein
(MBP)
(b)
Therapeu=c
agents
(c)
Others
(3)
Paternal
age

42. Paternal
age
• Cytogene=c
analysis
of
semen
specimens
from
donors
demonstrates
increased
frequency
of
numerical
and
structural
chromosome
aberra;ons
in
the
sperm
from
men
59
–
74
years
old
compared
with
sperm
from
men
who
are
23–29years
old
(Kleinhaus
et
al
2006︎).
• The
risk
of
miscarriage
increased
steadily
with
paternal
age
of
40
years
and
older,
especially
if
the
mother
is
35
years
or
older
(De
La
Rochebrochard
et
al
2003)
.
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42

43. Paternal
age
• A
Danish
study
showed
a
two-­‐fold
increase
in
early
fetal
death
when
the
father
was
over
50
years.
• There
is
an
associa=on
between
paternal
age
and
the
frequency
of
the
sperm
DNA
fragmenta;on
index
.
In
general,
a
high
DNA
fragmenta=on
index
(>
30%)
is
associated
with
reduced
fer=lity
and
a
low
live
birth
rate,
and
with
a
high
miscarriage
rate.
(
Wyrobek
et
al.
2006︎)
.
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43

44. Paternal
age
• Paternal
age
is
also
associated
with
gain-­‐of-­‐
func;on
muta;ons
within
sperm
that
have
detrimental
effects
on
embryos.
These
muta=ons
occur
in
3
iden=fied
hot
spots:
FGFR2,
FGFR3,
and
RET.
These
genes
encode
for
tyrosine
kinase
receptors
.
Each
of
these
muta=ons
is
associated
with
an
autosomal
dominant
effect
on
the
progeny
(achondroplasia,
Apert’s
syndrome,
etc.)
–
if
they
survive
to
delivery.
(
Crow
JF,
2003)
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45. Miscellaneous
factors
• Addi=onal
factors
that
may
affect
sperm
and
recurrent
pregnancy
loss
include
the
following:
(1)
Mannan
binding
protein
(2)
Therapeu=c
agents
(3)
others
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46. Mannan
Binding
Protein
(MBP)
• There
is
associa=on
between
a
deficiency
in
MBP
protein
in
either
male
or
female
partner
and
recurrent
miscarriages.
(Kilpatrick
et
al
1995).
This
associa=on
was
stronger
when
the
individuals
were
homozygous
for
the
mutant
allele
responsible
for
MBP
deficiency.
At
a
cut-­‐
off
level
value
of
MBP
=
0.6
the
recurrent
pregnancy
loss
was
35%
(Kilpatrick
et
al
1999).
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46

47. Therapeu=c
agents
• Ionizing
radia=on,
air
pollu=on,
and
other
environmental
exposures
have
been
implicated
in
inducing
muta;ons
or
sperm
aneuploidy
(
Puschecka
E
&
Jeyendranb
2007).
•
Medical
treatment
(i.e.
chemotherapy
and
radia=on)
for
cancer
treatment
can
increase
the
mutagenic
rate
of
sperm
DNA
(Puschecka
et
al
2004).
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47

48. Therapeu=c
agents
• Some
studies
reported
that
the
nucleoside
analog
reverse
transcriptase
inhibitor
exposure,
typically
used
to
treat
HIV
and
other
retroviral
disorders
,
could
induce
an
altera=on
on
the
mitochondrial
energy-­‐
genera=ng
ability
of
spermatozoa
leading
to
increased
sperm
DNA
fragmenta=on
and
eventually
recurrent
pregnancy
loss
(Sergerie
et
al.204)
.
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49. CONCLUSION
• The
appropriate
management
for
male
partners
of
couples
with
recurrent
pregnancy
loss
(RPL)
or
recurrent
implanta=on
failure
during
in
vitro
fer=liza=on
(IVF)
remains
unclear.
•
Despite
normal
semen
parameters,
male
partners
in
couples
with
RPL
or
recurrent
implanta=on
failure
could
have
underlying
gene=c
abnormali=es
in
sperm
DNA
that
can
be
iden=fied.
(
Dickey
&
Ramasamy2015)
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49

50. CONCLUSION
• There
are
a
couple
of
diagnos=c
tests
that
we
recommend
in
the
evalua=on
of
these
men,
the
first
being
DNA
Fragmenta=on
Index
(DFI)
and
the
second,
fluorescence
in
situ
hybridiza=on
(FISH)
for
evalua=ng
sperm
aneuploidy.
• Taken
together,
both
DFI
and
FISH
tes=ng
are
recommended
in
the
work-­‐up
of
male
factor
in
couples
with
recurrent
pregnancy
loss
or
recurrent
IVF
failure.
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51. CONCLUSION
• Men
with
increased
DFI
in
ejaculated
sperm
may
be
counseled
for
a
tes=cular
biopsy
in
combina=on
with
ICSI,
•
Those
with
increased
sperm
aneuploidy
can
be
advised
to
undergo
IVF
combined
with
PGS.
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51

52. CONCLUSION
• High
magnifica=on
ICSI
(
=
IMSI):
in
a
Cochrane
review
authors
concluded
that
results
from
RCTs
do
not
support
the
clinical
use
of
IMSI.
There
is
no
evidence
of
effect
on
live
birth
or
miscarriage
and
the
evidence
that
IMSI
improves
clinical
pregnancy
is
of
very
low
quality
(Teixeira
et
al
2013)
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52

53. CONCLUSIONS
• An=oxidants
may
help
to
reduce
sperm
DNA
fragmenta=on
rates
,
hence
lower
pregnancy
loss
rates
(Greco
et
al
2005).
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53

54. osama
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54
THANK
YOU
FOR
YOUR
ATTENTION

55. osama
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55

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60.
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72. osama
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