Reproductive Medical Center，TongjiHospital，Tongji University，Shanghai 200065
Abstract：Objective：To explore the efficacy and the clinical value of late- intracytoplasmic sperm injection in case of standard in vitro fertilization failure.Methods：Articles about rescue intracytoplasmic sperm injection（rescue-ICSI）performed after standard in vitro fertilization failure（IVF）from January 2009 through February 2016 were retrieved from Ovid MEDLINE，EM-BASE and CNKI by randomized controlled trials（RCT）and reference documents of selected literature were also retrieved by hand. The quality evaluation of selected literature was performed byMeta analysis. Results：A total of 10 articles were included out of which 7 were RCT between ICSI and rescue-ICSI. The other 3 were RCT between early-ICSI and late-ICSI. There were 5 articles of quality B and 5 articles of quality C. Fertilization rate，cleavage rate and pregnancy rate in rescue-ICSI group were significantly lower than those in normal ICSI group while the abnormal fertilization rate were significantly higher than that in ICSI group（P<0.05）. Fertilization rate，embryo quality and pregnancy rate were higher in early-ICSI group than those in late-ICSI group. The difference is statistical significance（P<0.05）；The abnormal fertilization rate and cleavage rate were higher in early rescue ICSI but the differences had no statistical significance（P>0.05）.Conclusion：Clinical outcome is comparatively low in late-ICSI than ICSI group. However late-ICSI provides pregnancy in some cases with total fertilization failure（TFF）in same cycle. Late-ICSI should be practiced and can be considered an option in case of TFF.
Key words：in vitro fertilization，total fertilization failure，rescue-ICSI，late-ICSI
Introduction：
Unexpected failure to achieve fertilization during an IVF cycle where the sperm seems to be normal not only gives patient emotional and financial burden，but also challenges the clinician. Reinsemination of unfertilized oocytes can be done to achieve some late fertilization i.e[15]. to “rescue” what otherwise would be a total fertilization failure（TFF）[16]. Incidence of TFF after IVF using normal sperm was reported to be 3.52%. In some of the IVF failed cycles rescue ICSI have been beneficial[17]. There is 2-3% failure rate in rescue ICS. After introducing ICSI technology reports on oocytes quality，embryo quality and pregnancy rate have been reported [1，2].
According to the study on the principle of medicine research，which use Cochrane system evaluation method of RCT on IVF failed cycle using rescue ICSI，has now published systematic evaluation research literature. We explore its application value in clinical treatment.
1. DATA ANALYSIS
1.1The Inclusion and exclusion criteria
Inclusion criteria：IVF treatment cycle having low fertility rate，rescue-ICSI after fertilization failure in IVF treatment and routine ICSI treatment for infertility. Exclusion criteria：A retrospective study and a literature review of incomplete or important incomplete information.
1.2IVF fertilization and intervention evaluation index measures after checking the prokaryotic and second polar bodie is to confirm fertilization in early-ICSI group that is fertilized after 4-8h of fertilization failure and late-ICSI group that is fertilized after 18-22h of fertilization failure. After fertilization failure sperm is injected in MII oocyte. Fertilization，embryo development，embryo quality，follow-up and outcome of pregnancy were observed and documented. The evaluation indexes include the fertilization rate，blastocyst formation，cleavage rate，embryo quality，implantation rate，pregnancy rate etc.
1.3Statistical analysis using Rev System Man Cochraneevaluation software for Meta analysis. First，X2 test is used to analyze the heterogeneity between the studies，with P=0.1 as the cut-off point of statistical significance，and quantitative analysis of heterogeneity by I2.If P0.1，I250%. There is heterogeneity between studies and analysis of the heterogeneity which cannot be solved or unable to determine the sources of heterogeneity，the random effects model analysis of Meta，the stability of the sensitivity analysis result when necessary. Count data with odds ratio（OR）is effective dose，Measurement data with weighted mean difference（WMD）is effective dose. All effective dose are expressed in 95% confidence interval（CI）.
2. RESULTS
2.1 Search results are included in the study and methodological quality assessment through reading the title and abstract with initial inspection of 47 articles. By reading the text37 articles were removed that did not match with inclusion criteria，10 documents were finally selected[4-13].7 for rescue-ICSI with normal ICSI RCT studies，3 articles for early-ICSI with late-ICSI RCT research. The included literatures were prospectively studied and intervention measures are the same，the doctor is allocated according to the research purpose，all in the same center line of assisted reproduction treatment. The important prognostic factors including age，cause of infertility，the number ofoocytes. All were no mention of infertility or embryo quality. 5 references are the quality of class B and class C
2.2 rescue ICSI group and the normal ICSI group
Fertilization：7 papers reported the normal fertilization，the heterogeneity between the studies，2 papers [7-8] about the sensitivity analysis and exclusion，there is still a significant heterogeneity. 3 literature[4，6，9] homogeneity is better（X2=2.03，P>0.1），A total of 1026 rescue ICSI cycle ovumuse the Meta analysis，compared with the same period of 7778 normal ICSI cycle ovum，the rescue group normal fertilization rate is lower than the normal group，the difference is statistically significant[OR=0.37，95%CI（0.32，0.43）P<0.00001]，show as Figure 1.Abnormal fertilization is observed in 4 papers. There is heterogeneity in this study andthe results of 2 papers were analyzed by Meta analysisafter the apparent heterogeneity of the literature is ruled out. The results showed that the recovery rate of the remedial group is higher than that of the normal group，the difference is statistically significant [OR = 8. 03 95 % CI（5. 3512. 05），P< 0. 00001]，as Figure 2 shows.
cleavage：3 articles[4，7，9] were observed between the cleavage，heterogeneity，exclude literature [9] which has significant heterogeneity，Met analysis of the results of the 2 papers combined with [4，7]. The analysis results show that rescue group，the cleavage rate is lower than the normal group，the difference is statistically significant. [OR - 0. 18 95% CI（0. 120.28）P <0. 00001]，as Figure 3 shows.
Pregnancy：7 articles were reported in the pregnancy，4 of them were not pregnant，and the other 3 were 30 cases of pregnancy. In the 7 part of the literature，there is heterogeneity between the two，and the ICSI is acquired from the literature with the recovery of Met. The results showed that remedial group cleavage rate lower than the normal group，the difference is statistically significant[COR = 0. 55，95% CI（0. 34 0. 89），P <0. 01]，as Figure 4 shows. There were 30 cases of pregnancy，3 cases of twin pregnancy，16 cases of singleton pregnancy，10 cases of abortion，1 cases of unknown，and 378 cases of pregnancy.
other data：salvage group 4 cell embryo rate，the rate of embryo transfer，cycle rate and the number of cycles were lower than the normal group，the difference is statistically significant（P <0.05）.1 literatures were compared with two groups of embryo grading and fragment grading，the difference is not statistically significant（p>0.05）.
2.3 comparison of early recovery group and late recovery group
fertilization：3 reported in the literature of normal fertilization and abnormal fertilization，there is no heterogeneity between the studies，the results of Meta analysisshowed that the normal fertilization rate of early recovery group is higher than the late recovery group，the difference is statistically significant[OR=2.29，95%CI（1.69，3.10），P<0.00001] as Figure 6 shows.
Fig.5 The two groups of normal fertilization conditions in the early recovery and late recovery of the single sperm injection in the oocytes.
Fig. 6 The two groups of abnormal fertilization conditions in the early recovery and late recovery of the single sperm injection in the oocytes.
Cleavage：comparing the two sets of cleavage rate，no heterogeneity among the studies，Meta analysis showsthat two groups of cleavage rates are not statistically significant，[OR=1.3195%CI（0.57，3.01）P=0.52]，as Figure 7 shows.
High quality embryos have been reported in the literature：good quality embryo heterogeneity is in the studies，excluding significant heterogeneity in literature.Combined with 2 articles，the results of Met analysis showed that early rescue group is significantly higher than the rate of high quality embryos late rescue group，the difference is statistically significant[OR=4.62，95%CI（2.85，7.49）P<0.00001]，as Figure 8 shows.
Pregnancy：In the literature，the ovum of the same patient with identical period of the same period were studied by using MII phase ovum，Unable to compare pregnancy rate .The pregnancy rate of the two groups was compared，and the study was not different. Meta analysis results showed that early rescue group is higher than that of the late pregnancy rescue group，the difference is statistically significant[OR=9.46，95%，CI（2.43，36.83），P=0.001]，as Figure 9 shows. There are 20 cases of pregnancy，3 cases of twin pregnancy，8 cases of singleton pregnancy，1 cases of abortion，cases of abortion，and 3 cases of late recovery group are obtained.
Figure 9.The two groups of pregnant women in the early recovery and late recovery of the single sperm injection of the oocytes are injected into the forest.
Other data：Chen and Kattera reported that the early recovery group is higher than the late recovery group（20. 2% and 1.72%，P <0. 02）；The formation rate of early recovery group is significantly higher than that of late recovery group，and the difference is statistically significant（P < 0. 05）；Wang Meixian reported early rescue group of more than 5 cell embryos cryopreservation of embryos and the proportion is significantly higher than that in late rescue group，the differences are statistically significant（P < 0. 05）.
3. DISCUSSION
3.1Clinical significance of this study proves that oocytes that failed to fertilize through IVF can be fertilized by late-ICSI. TFF after IVF treatment can be frustrating for both patients and clinicians. Late-ICSI is an attempt to fertilize 1 or 2 day old oocyte. Though fertilization rate，cleavage rate，embryo quality and pregnancy rate are lower in late-ICSI than standard ICSI it is worth using. In recent years，rescue ICSI is widely applied in various infertility centers. Fertilization is conformed by checkingthe second polar body，if the first polar body not filling line of ICSI，this method can make the pregnancy rate of 30%. The results of this study also suggest that earlier the rescue-icsi performed better is the result.However，due to the less number of articles，small sample size，and the late-ICSI also has some abnormal fertilization rate，clinical value still need further observation. To judge the ovum cells in early stage of fertilization and to find the best time to repair the ICSI willneed further study.
3.2 research and improvement direction in future research should pay attention to the following aspects：increase the research sample content；the improvement of experimental design，improve the quality of research，the establishment of a unified procedure and evaluation system for the recovery of ICSI，Try to pay attention to the balance between groups，to minimize the deviation；to strengthen the research on the factors and the safety of the offspring outcomes of rescue-ICSI pregnancy；the rescue-ICSI on oocyte maturity is described，the analysis in order to rescue ICSI.
Conclusion
Late-ICSI does not have excellent result but it is a good option to salvage the oocytes after IVF failure.
REFERENCES
[1] YuzpeAA，LiuZ，FlukerMR.Rescueintracytoplasmic sperm injection（ICSI）salvaging in vitro fertilization（IVF）cycles after total or near-total fertilization failure. Fertility and Sterility . 2000
[2] Esfandiari N，，ClaessensEA，Burjaq H，et al.Ongoing twin pregnancy after rescue intracytoplasmic sperm injection of unfertilized abnormal oocytes. Fertility and Sterility . 2008
[3van der WesterlakenL，NaaktgeborenN，VerburgH，etal.Conventional in vitro fertilization versus intracytoplasmic sperm in-jection in patients with borderline semen：a randomized study using sibling oocytes. Fertility and Sterility . 2006
[4] Zini A，Lefebvre J，Kornitzer G，et al. Anti-sperm antibody levels are not related to fertilization or pregnancy rates after IVF or IVF/ICSI[J]. Journal of Reproductive Immunology，2011，88（1）：80-84.
[5]Gerris J. Reducing the Number of Embryos to Transfer After IVF/ICSI[M]// Essential IVF. 2004.
[6]Zini A，Fahmy N，Belzile E，et al. Antisperm antibodies are not associated with pregnancy rates after IVF and ICSI：systematic review and meta-analysis.[J]. Human Reproduction，2011，26（6）：1288-95.
[7]Li Z，Wang L，Cai J，et al. Correlation of sperm DNA damage with IVF and ICSI outcomes：a systematic review and meta-analysis.[J]. Journal of assisted reproduction and genetics，2006，23（9-10）：367-376.
[8] HirabayashilY，TawaralF，IshiilM，etal.Evaluationofrescue ICSI on oocytes without extrusion of the second polarbody in cases of moderately disturbed fertilization. JMamm Ova Res . 2006
[9] KuczynskiW，DhontM，GrygorukC，etal.Rescue ICSI of unfertilized oocytes after IVF. Human Reproduction . 2009
[10] KEE SANG PARK，HAI BUM SONG，SANG SIK CHUN. Late Fertilization of Unfertilized Human Oocytes in In Vitro Fertilization and Intracytoplasmic Sperm Injection Cycles：Conventional Insemination versus ICSI[J]. Journal of Assisted Reproduction and Genetics . 2000（8）
[11] Chen C，KatteraS.Rescue ICSI of oocytes that failed to extrude the second polar body 6 h post-insemination in IVF. Human Reproduction . 2003
[12]Demirol A，Gurgan T. Effect of treatment of intrauterine pathologies with office hysteroscopy in patients with recurrent IVF failure[J]. Reproductive Biomedicine Online，2004，8（5）：590-4.
[13]Craciunas L，Tsampras N. Bed rest following embryo transfer might negatively affect the outcome of IVF/ICSI：a systematic review and meta-analysis.[J]. BjogAn International Journal of Obstetrics &Gynaecology，2016，122：16-22.
[14]Liu W，Liu J，Zhang X，et al. Short co-incubation of gametes combined with early rescue ICSI：An optimal strategy for complete fertilization failure after IVF[J]. Human Fertility，2013，17（1）：50-55.
[15] Ming L，Liu P，Qiao J，Lian Y，Zheng X，Ren X，et al. Synchronization between embryo development and endometrium is a contributing factor for rescue ICSI outcome. Reprod Biomed Online 2012；24：527–31.
[16]. Nagy ZP，Joris H，Liu J，Staessen C，Devroey P，Van Steirteghem AC. Intracytoplasmic single sperm injection of 1-day-old unfertilized human oocytes. Hum Reprod 1993；8：2180–4.
[17]. Morton PC，Yoder CS，Tucker MJ，Wright G，Brochkman WDW，Kort HI. Reinsemination by intracytoplasmic sperm injection of 1-day-old oocytes after complete conventional fertilization failure. FertilSteril 1997；68：488 –91.
[18]. Bhattacharya S，Hamilton MP，Shaaban M，Khalaf Y，Seddler M，Ghobara T，et al. Conventional in-vitro fertilisation versus intracytoplasmic sperm injection for the treatment of non-malefactor infertility：a randomised controlled trial. Lancet. 2001；357：2075–9.
?YazhongJi，M.D.，Ph.D，Reproductive Medical Center，TongjiHospital，Tongji University，obstetrics and gynecology.
SamidhaArpit，master's degree，Reproductive Medical Center，TongjiHospital，Tongji University，obstetrics and gynecology.
论文作者:SamidhaArpit YazhongJi
论文发表刊物:《航空军医》2016年第21期
论文发表时间:2016/11/24
标签：SEARCH论文; RESULTS论文; RESULTS论文; Reading论文; title论文; methodological论文; assessment论文; 《航空军医》2016年第21期论文;