Split Cohort Trial Comparing IVF Outcomes After the Use of Testicular vs. Ejaculated Sperm for ICSI

The experimental design for this study is as follows:

1. Couples with male partners who will be undergoing a TESA procedure secondary to elevated
DNA fragmentation (>25% DFI) as part of their routine IVF treatment will be contacted
for possible study participation.

2. Informed consent will be obtained

3. The primary investigator will be notified of the couple's participation.

4. The male partner will cryopreserve an ejaculated semen sample if there is no
cryopreserved ejaculated specimen in inventory. The male partner will undergo a surgical
sperm retrieval (TESA) and the specimen will be frozen per routine.

5. Serum will be collected from the male partner and preserved for future analysis.

6. The cryopreserved pre-TESA ejaculate and TESA specimen will be thawed on the day of
oocyte retrieval per protocol. After oocyte retrieval, oocytes will be analyzed per
routine and assessed for maturity. The oocytes will be divided into two groups per
embryologist discretion. One group will be labeled 'A' and the other will be labeled B.'
A random letter generator will create a list of 'A' and 'B's which will be placed in
sequentially numbered, sealed envelopes. The envelopes will be opened in sequence
according to patient enrollment. The first envelope opened by the embryologist will
reveal the letter of the oocyte group that will be inseminated with testicular sperm.
The other group will be inseminated with the frozen/ thawed ejaculated sperm. Therefore,
half of the oocytes will be inseminated using intracytoplasmic sperm injection (ICSI)
with testicular sperm and the other half will be inseminated via ICSI with ejaculated
sperm. If there are an odd number of oocytes, the extra oocyte will always belong to
group A for simplicity.

7. If fertilized, the group of zygotes created using testicular sperm will take the group
letter that corresponded to the testicular sperm. This will also be true of the zygotes
using ejaculated sperm. Both groups of zygotes will be cultured to the blastocyst stage
with culture conditions per standard laboratory procedures.

8. Fertilization and blastulation rates of the two groups will be recorded for each
patient.

9. Each blastocyst will be biopsied for comprehensive chromosome screening (CCS) in routine
fashion. Once comprehensive chromosomal screening results are available, if at least one
euploid embryo is available, patients will undergo a single embryo transfer in a
subsequent menstrual cycle.

10. Frozen embryo transfer cycles will be performed using either a programmed cycle
(exogenous estradiol with subsequent progesterone) or a natural cycle to prepare the
endometrium for embryo transfer.

11. If at least one euploid embryo is available from each group, a second randomization will
occur at the time of embryo selection. The embryologist selecting the embryo for
transfer will open a second sealed envelope, which contains the letter of the group from
which the embryo for transfer should reside. The best quality embryo (per embryologist
discretion) from the group corresponding to the letter in this envelope will be selected
for transfer. The embryologist selecting the embryo will be blinded as to which group of
embryos was created with ejaculated versus testicular sperm. The group from which the
embryo selected for transfer was derived will be recorded.

12. Both the patient and the physician performing the embryo transfer will be blinded with
regard to the group from which the embryo selected for transfer derived.

13. Pregnancy testing and follow up will proceed as per routine.

14. Approximately 8 weeks post-transfer, each participant will be assigned a cycle outcome
(i.e., no pregnancy, miscarriage, ongoing pregnancy). At that time, the study
participants can be notified of whether the sperm utilized for ICSI was derived from
testicular sperm or ejaculated sperm. This information could be shared via telephone or
in-person.

Inclusion Criteria:

- Willing to comply with all study procedures and be available for the duration of the
study

- Failed at least one IVF cycle (i.e., no live birth)

- Elevated DNA fragmentation noted in ejaculated sperm (>25% DFI according to the
American Society of Reproductive Medicine guidelines)

- Couple electing single embryo transfer

- Couples electing comprehensive chromosome screening (CCS) of embryos

- At least 4 oocytes retrieved in IVF cycle in order to randomize

Exclusion Criteria:

- Anything that would place the individual at increased risk or preclude the
individual's full compliance with or completion of the study.

- Contraindication to IVF

- Clinical indication for preimplantation genetic diagnosis (PGD) (i.e., screening for
single gene disorder, chromosomal translocation, or any other disorders requiring
detailed embryo genetic analysis)

- Male partner with azoospermia (<100,000 motile spermatozoa)

- Male partner with Y-chromosome microdeletion

- Male partner with any Karyotype other than 46,XY(normal male karyotype)

- Female partner history of hydrosalpinges or adnexal mass

- Female partner history of endometrial insufficiency (max endometrial thickness < 7mm)

- Female partner BMI < 35