1) The document discusses sperm function and its contribution to embryo development, including morphology, DNA integrity, and various fertility markers beyond routine semen analysis. 2) Various techniques for improving sperm quality and health are reviewed, such as varicocele repair, antioxidant treatment, lifestyle modifications, and sperm selection methods like hyaluronic acid binding. 3) Studies on the effects of sperm quality on embryo development outcomes like fertilization rate, embryo cleavage and blastulation, as well as pregnancy rates are summarized.

1. Sandro Esteves, MD, PhD Director, ANDROFERT Center for Male Reproduction and Infertility Campinas, BRAZIL Esteves, 17 th International Congress of the Iranian Association for Fertility and Reproductive Medicine Tehran– March 2011

2. Objectives Esteves

3. Esteves Sperm function The paternal contribution

4. Oocyte Activating Factor Sofikitis et al ., 1996 Esteves Oocyte activating factor

5. Centrosome Bornens et al ., 1990 Esteves Microtubule organizing center Formation of an efficient mitotic spindle for syngamy and cleavage

6. Sperm contribution to the Embryo Summary Esteves

8. Strict Sperm Morphology and Embryo Quality French DM et al. Severe teratozoospermia and ICSI outcomes. Fertil Steril 93:1097, 2010 P>0.05 Esteves 0% 1% 2% 3% 4% 5-7% >7% N transfers 138 167 137 129 113 236 154 Maternal age (yrs.) 32.3 32.7 32.4 32.5 32.0 32.3 32.8 N oocytes injected (mean) 10.2 11.0 11.0 10.6 10.1 10.3 9.3 FR (%) 75 75 77 77 74 76 77 ET (n) 2.3 2.4 2.4 2.5 2.3 2.3 2.4 Blastulation (%) 50 43 44 47 41 42 45 % Top quality blastocysts 37 29 26 31 27 28 29 LBR (%) 56 54 47 44 52 49 52

9. Kruger Sperm Morphology and Embryo Quality Esteves

10. Case 1

11. Case 2

12. Menkveld R et al . Significance of sperm morphology. AJA (2011); 13:59-68 Tesarik J et al. Paternal effect on embryo development. Hum Reprod (2004); 19: 611-15 Sperm Defects and Embryo Quality Esteves Mid-piece defect Acrossomeless Double tail Tapered Cytoplasmic droplet Genetically determined Stress-induced (Elevated OS)

13. Sperm DNA Integrity Testing Esteves

14. Sperm DNA Integrity Testing & ART OR 0.07 (0.01-0.48) Esteves Adapted from Bungum et al., Hum Reprod 2007 Adapted from Bungum et al., Hum Reprod 2007 * <.05 *

15. Sperm DFI and Embryo Quality Esteves Reference Assay N ART Findings Larson KL et al (2000) SCSA 24 IVF; ICSI No impact (D3) Gandini et al (2004) SCSA 34 IVF; ICSI No impact (D3) Payne JF et al (2006) SCSA 100 IVF; ICSI No impact (D3) Sun JG et al (1997) TUNEL 236 IVF ↓ Cleavage (D3) Morris ID et al (2002) Comet 60 ICSI ↓ Cleavage; Morphology (D3) Virro MR et al (2004) SCSA 249 IVF; ICSI ↓ Blastulation rate Nasr-Esfahani et al. (2005) Comet, CMA 3 28 ICSI ↓ Blastocyst development

16. Sperm DFI, Pregnancy Loss & Baby Health Esteves

17. Zeta method Modified HOST IMSI PICSI Sperm head birefringence Laser-assisted sperm selection Esteves Magnetic- activated cell sorting Improving Sperm Health What to do ?

19. Watanabe S et al., J Mamm Ova Res 2008; 25:259-65 Tanaka A et al, ASRM 2009 (P-272) Esteves

21. Life-style modifications Antioxidant Treatment Varicocele Repair Leukocyte Reduction Esteves Improving Sperm Health What to do ?

22. Esteves

23. Microsurgical varicocele repair prior to ICSI (N=80) ICSI in the presence of varicocele (N=162) Clinical Outcome of Intracytoplasmic Sperm Injection in Infertile Men With Treated and Untreated Clinical Varicocele SC Esteves, FV Oliveira, RP Bertolla ANDROFERT, Center for Male Reproduction, Campinas, BRAZIL and Division of Urology, São Paulo Federal University, São Paulo, BRAZIL. The Journal of Urology Vol. 184,1442-6, October 2010 Esteves P<0.01

24. Esteves SC, Oliveira FV, Bertolla RP. Clinical Outcome of ICSI in Infertile Men with Treated and Untreated Clinical Varicocele. J Urol 2010;184:1442-1446 Esteves *P<0.05 Miscarriage (%) Odds ratio 1.87 0.43 95% CI 1.08 - 3.25 0.22 – 0.84 P-value 0.03 0.01

25. Pasqualotto et al., Fertil Steril 2000

26. Antioxidant Treatment Cochrane Review 2011 Outcome N studies N participants Effect size (OR; 95% CI) Live birth 3 214 4.85 [1.92, 12.24] Pregnancy rate 15 964 4.18 [2.65, 6.59] DNA fragmentation 1 64 -13.80 [-17.50, -10.10] Miscarriage, sperm count, sperm motility 6-16 242-700 No effect Adverse effects 6 426 No effect Showell MG, Brown J, Yazdani A, Stankiewicz MT, Hart RJ. Antioxidants for male subfertility. Cochrane Database of Systematic Reviews 2011, Issue 1. Art. No.: CD007411. DOI: 10.1002/14651858.CD007411.pub2.

28. Henkel R et al, AJA 2007; Alvarez et al. Fertil Steril 2002 Endtz Test

30. Caffeine Smoking Alcohol Psychological Stress Obesity

31. Klonoff-Cohen H. Human Reproduction Update, Vol.11, No.2 pp. 180–204, 2005

33. Esteves Varicocele Infection Lifestyle habits ICSI w/ejaculated and testicular sperm ICSI w/ejaculated sperm

34. Key Messages Esteves