使用卵子細胞質內精子注射治療重度男性不孕症患者

Treatment of Severe Male-Factor Infertility Using Intracytoplasmic Sperm Injection (ICSI)

卵子細胞質內精子注射(ICSI)是近年來發展出治療男性不孕症的一種重要方法。由於需要精細的儀器及技術，如果能瞭解其技巧，將可提高成功的機會。本研究的目的在報告本院如何提高ICSI成功率的經驗，分析不同的適應症及精子來源做ICSI的結果，並探討婦女年齡和懷孕率的關係。自1994年1月至1996年9月，我們針對嚴重精液不正常的病人用射出的精子，及阻塞性無精子病人由顯微手術副睪吸精術或睪九切片取精術取精做ICSI，共有118個治療週期，其中前面12個週期並沒有使精子不動，也沒有吸細胞質，屬於第一時期，以後的106個週期有使精子不動，也有吸細胞質，屬於第二時期。結果發現兩個時期的卵子傷害率並無差別，但第二時期的正常受精率(67.8% vs 17.6%)及懷孕率(44.3% vs 8.3%)比第一時期明顯的高。在注射前用注射針壓切精子尾巴，可破壞精子細胞膜，使精子變成不動，可能促進ICSI受精過程中精子與卵子的活化；吸入細胞質，可將卵子細胞膜吸破，並幫助確定將精子注入細胞質內。在第二時期使用新鮮射出精子、冷凍射出精子、新鮮副睪精子、冷凍副睪精子、新鮮睪九精子之正常受精率與懷孕率並無明顯差別，ICSI需要極少數的精子，只要有活的精子，均可接受冷凍。有一例使用精細胞注射13顆卵子，其中4顆正常受精，兩顆分裂為胚胎。婦女年齡20～29歲的卵子數與30～39歲接近，但比≧40歲明顯的多，ICSI卵子傷害率與正常受精率三組無明顯差別，但懷孕率≧40歲(9.1%)比20～29歲(42.3%)與30～39歲(50.7%)低，其可能原因包括獲得的胚胎較少且品質較差。

Intracytoplasmic sperm injection (ICSI) has recently become an important tool to treat severe male-factor infertility. It requires skill to achieve high success rates. The purpose of this study is to report techniques to improve fertilization and pregnancy rates with ICSI. The results of treatments from various sources of sperm were analyzed and compared. We also ascertained the relationship between the success of ICSI and maternal age. From January 1994 through September 1996, patients with severe semen abnormalities, those with obstructive azoospermia receiving microsurgical epididymal sperm aspiration (MESA) or testicular sperm extraction (TESE), and patients with previous fertilization failure in in-vitro fertilization program were recruited for ICSI treatments. A total of 118 cycles were performed. The first stage consisted of 12 cycles with no immobilization of sperm and no aspiration of cytoplasm during the ICSI procedures. In the subsequent 106 cycles, the second stage, we performed immobilization of sperm prior to injection and aspiration of ooplasm during ICSI. Fertilization (67.8% vs 17.6%) and pregnancy (44.3% vs 8.3%) rates of the second stage were greater than those of the first stage, Breaking the tail, thereby immobilizing the sperm and damaging the cell membrane, might promote decondensation of the sperm head and activation of the oocyte. Aspiration of cytoplasm can rupture the oolemma and helps to assure the injection of sperm into the cytoplasm. There were no differences in the fertilization and pregnancy rates using sperm from fresh ejaculate, frozen ejaculate, fresh epididymal aspirate, frozen epididymal aspirate and testicular extraction. All viable sperm was suitable for cryopreservation, regardless of its quality. The pregnancy rates in women aged of 20 to 29 years (42.3%) and 30 to 39 years (50.7%) were greater than those of women ≧40 years of age (9.1%), although the egg damage rate and fertilization rate were not different. The causes may be attributed to the reduced number of eggs recovered and poor quality of embryos.