Virology & Mycology Infectious Diseases
 
   Publications A-Z
A
»Accounting & Marketing
» Addiction Research & Therapy
» Advanced Chemical Engineering
»Advances in Automobile Engineering
»Advances in Crop Science and Technology
»Advances in Dairy Research
»Advancements in Genetic Engineering
»Advances in Pharmacoepidemiology & Drug Safety
»Advances in Robotics & Automation
»Advanced Techniques in Biology & Medicine
»Advance Research in Meteorological Sciences
»Aeronautics & Aerospace Engineering
»Aging Science
»Agrotechnology
»AIDS & Clinical Research
»Alcoholism and Drug Dependence
»Allergy & Therapy
»Alternative & Integrative Medicine
»Air & Water borne Diseases
»Alzheimers Disease & Parkinsonism
»Analytical & Bioanalytical Techniques
»Anaplastology
»Anatomy & Physiology
»Ancient Diseases & Preventive Remedies
»Andrology-Open Access
»Anesthesia & Clinical Research
»Angiology: Open Access
»Antivirals & Antiretrovirals
»Anthropology
»Applied & Computational Mathematics
»Applied Mechanical Engineering
»Aquaculture Research & Development
» Arabian Journal Business and Management Review
»Architectural Engineering Technology
»Arthritis
»Arts and Social Sciences Journal
» Astrobiology & Outreach
»Astrophysics & Aerospace technology
»Autacoids
»Automatic Control of Physiological State and Function
»Autism-Open Access
  
B
»Bacteriology & Parasitology
»Bioanalysis & Biomedicine
»Bioceramics Development and Applications
»Biochemistry and Analytical Biochemistry
»Biochemistry & Pharmacology: Open Access
»Biochips & Tissue Chips
»Biodiversity & Endangered Species
»Bioenergetics: Open Access
»Bioengineering & Biomedical Science
»Bioequivalence & Bioavailability
»Biosafety & Health Education
»Biofertilizers & Biopesticides
»Biometrics & Biostatistics
»Biomimetics Biomaterials and Tissue Engineering
»Biomolecular Research & Therapeutics
» Biomusical Engineering
»Biochemistry & Physiology: Open Access
»Biological Systems- Open Access
»Biology and Medicine
»Bioprocessing & Biotechniques
»Bioremediation & Biodegradation
»Biosafety
»Biosensors & Bioelectronics
» Biosensors Journal
»Biotechnology & Biomaterials
»Bioterrorism & Biodefense
»Blood Disorders & Transfusion
»Blood & Lymph
»Bone Marrow Research
»Brain Disorders & Therapy
»Business and Economics Journal
»Business and Financial Affairs
  
C
»Cancer Science & Therapy
»Climatology & Weather forecasting
»Carcinogenesis & Mutagenesis
»Cardiovascular Diseases & Diagnosis
»Cardiovascular Pharmacology: Open Access
»Cell & Developmental Biology
»Cell Science & Therapy
»Chemical Engineering & Process Technology
»Chemical Sciences Journal
»Chemotherapy: Open Access
»Child and Adolescent Behavior
»Chromatography & Separation Techniques
»Civil & Environmental Engineering
»Civil & Legal Sciences
»Clinical & Cellular Immunology
»Clinical Case Reports
»Clinical & Experimental Cardiology
»Clinical & Experimental Dermatology Research
»Clinical & Experimental Ophthalmology
»Clinical & Experimental Pathology
»Clinical & Experimental Pharmacology
»Clinical Microbiology: Open Access
»Clinical Pharmacology & Biopharmaceutics
»Clinical Research & Bioethics
»Clinical Research on Foot & Ankle
»Clinical Toxicology
»Clinical Trials
»Clinics in Mother and Child Health
»Cloning & Transgenesis
»Community Medicine & Health Education
»Communication Disorders, Deaf Studies & Hearing Aids
»Computer Science & Systems Biology
» Current Synthetic & Systems Biology
»Cytology & Histology
D
»Data Mining in Genomics & Proteomics
»Defense Management
»Dentistry
»Depression and Anxiety
»Developing Drugs
»Diabetes & Metabolism
»Drug Designing
»Drug Metabolism & Toxicology
  
E
»Earth Science & Climatic Change
»Ecosystem & Ecography
»Endocrinology & Metabolic Syndrome
»Entomology, Ornithology & Herpetology
»Environmental & Analytical Toxicology
»Epidemiology: Open Access
»Emergency Medicine
»Ergonomics
»Electrical & Electronics
»Enzyme Engineering
»Entrepreneurship & Organization Management
  
F
»Family Medicine & Medical Science Research
»Fermentation Technology
»Fertilization: In Vitro - IVF-Worldwide
»Fisheries and Aquaculture Journal
»Fisheries & Livestock Production
»Food Processing & Technology
»Forensic Biomechanics
»Forensic Research
»Forest Research: Open Access
»Fundamentals of Renewable Energy and Applications
»Fungal Genomics & Biology
  
G
»Gastrointestinal & Digestive System
»Genetic Syndromes & Gene Therapy
»Gene Technology
»Generalized Lie Theory and Applications
»Glycobiology
»Glycomics & Lipidomics
»Gynecology& Obstetrics
»General Medicine
»General Practice
»Geography & Natural Disasters
»Geology & Geosciences
»Geophysics & Remote Sensing
»Gerontology & Geriatric Research
»Global Economics
»Global Journal of Technology and Optimization
  
H
»Hair : Therapy & Transplantation
»Hematology & Thromboembolic Diseases
»Health Care : Current Reviews
»Health & Medical Informatics
»Hereditary Genetics
»Homeopathy & Ayurvedic Medicine
»Horticulture
»Hotel & Business Management
»Human Genetics & Embryology
»Hydrology: Current Research
»Hypertension- Open Access
  
I
»Industrial Engineering & Management
»Irrigation and Drainage Systems Engineering
»Infectious Diseases and Therapy
»Information Technology & Software Engineering
»Intellectual Property Rights: Open Access
»Integrative Oncology
»Internal Medicine
»International Journal of Accounting Research
»International Journal of Advanced Innovations, Thoughts & Ideas
»International Journal of Biomedical Data Mining
»International Journal of Economics and Management Science
»International Journal of Sensor Networks and Data Communications
»International Journal of Swarm Intelligence and Evolutionary Computation
»International Journal of waste resources
»International Journal of Genomic Medicine
»International Journal of Physical Medicine & Rehabilitation
»Innovative Energy Policies
»Immunome Research
  
J
»JBR Journal of Interdisciplinary Medicine and Dental Science
»JBR Journal of Clinical Diagnosis and Research
»JBR Journal of Young Scientist
  
L
»Liver
» Leukemia
» Lovotics
  
M
»Marine Science: Research & Development
»Malaria Chemotherapy, Control & Elimination
»Mass Communication & Journalism
»Material Sciences & Engineering
»Medicinal Chemistry
»Medicinal & Aromatic Plants
»Medical Diagnostic Methods
»Medical Microbiology & Diagnosis
»Medical & Surgical Urology
»Membrane Science & Technology
»Metabolic Syndrome
»Metabolomics:Open Access
»Microbial & Biochemical Technology
»Modern Chemistry & Applications
»Molecular Biology
»Molecular Biomarkers & Diagnosis
»Molecular and Genetic Medicine
»Molecular Imaging & Dynamics
»Molecular Pharmaceutics & Organic Process Research
»Mycobacterial Diseases
N
»Natural Products Chemistry & Research
»Nanomedicine & Biotherapeutic Discovery
»Nanomedicine & Nanotechnology
»Neonatal Biology
»Nephrology & Therapeutics
»Neurology & Neurophysiology
»Neuroinfectious Diseases
»Neurological Disorders
»Novel Physiotherapies
»Nuclear Medicine & Radiation Therapy
»Nutrition & Food Sciences
»Nutritional Disorders & Therapy
»Nursing & Care
  
O
»Obesity & Weight Loss Therapy
»Oceanography-Open Access
»Occupational Medicine & Health Affairs
»OMICS Journal of Radiology
»Osteoporosis and Physical Activity
»Oral Health and Dental Management
»Oral Hygiene & Health
»Organic Chemistry: Current Research
»Orthopedic & Muscular System: Current Research
»Otolaryngology
  
P
»Pain & Relief
»Palliative Care & Medicine
»Pancreatic Disorders & Therapy
»Pediatrics & Therapeutics
»Petroleum & Environmental Biotechnology
»Pharmaceutica Analytica Acta
»Pharmaceutical Regulatory Affairs: Open Access
»Pharmacogenomics & Pharmacoproteomics
»Pharmacovigilance
»Physical Chemistry & Biophysics
»Physical Mathematics
»Plant Pathology & Microbiology
»Plant Biochemistry & Physiology
»Pollution Effects & Control
»political Sciences & public affairs
»Poultry, Fisheries & Wildlife Sciences
»Powder Metallurgy & Mining
»Primatology
»Primary Health Care: Open Access
»Probiotics & Health
» Phylogenetics & Evolutionary Biology
»Proteomics & Bioinformatics
»Phylogenetics & Evolutionary Biology
»Psychology & Psychotherapy
»Psychological Abnormalities in Children
»Pulmonary & Respiratory Medicine
  
R
»Reproductive System & Sexual Disorders
»Research and Development
»Review of Public Adminstration and Management
»Rheumatology: Current Research
»Rice Research: Open Access
  
S
» Single Cell Biology
»Sleep Disorders & Therapy
»Socialomics
»Sociology and Criminology-Open Access
»Sports Medicine & Doping Studies
»Spine
»Stem Cell Research & Therapy
»Steroids & Hormonal Science
»Stock & Forex Trading
»Surgery: Current Research
  
T
»Telecommunications System & Management
»Textile Science & Engineering
»Theoretical and Computational Chemistry:Open Access
»Thermodynamics & Catalysis
»Thyroid Disorders & Therapy
»Tissue Science & Engineering
»Translational Medicine
»Transplantation Technologies & Research
»Transcriptomics: Open Access
»Trauma & Treatment
»Tropical Diseases
»Tropical Medicine and Surgery
»Tourism & Hospitality
  
V
»Vaccines & Vaccination
»Vascular Medicine & surgery
»Veterinary Science & Technology
»Virology & Mycology
»Vitamins & Minerals
»Vortex Science and Technology
  
W
»Women's Health Care
  
Y
»Yoga & Physical Therapy
 
   Browse by Subjects
Clinical
» AIDS & Clinical Research
» Anesthesia & Clinical Research
» Angiology
» Cancer Science & Therapy
» Carcinogenesis & Mutagenesis
» Cell Science & Therapy
» Chemotherapy
» Child & Adolescent Behavior
» Clinical & Cellular Immunology
» Clinical Case Reports
» Clinical & Experimental Cardiology
» Clinical & Experimental Dermatology Research
» Clinical & Experimental Ophthalmology
» Clinical & Experimental Pharmacology
» Clinical & Experimental Pathology
» Clinical Microbiology: Open Access
» Clinical Research & Bioethics
» Clinical Research on Foot & Ankle
» Clinical Toxicology
» Clinical Trials
»Clinics in Mother and Child Health
» Communication Disorders, Deaf Studies & Hearing Aids
» Cytology & Histology
» Forensic Research
»Forensic Biomechanics
» Integrative Oncology
»Immunome Research
»JBR Journal of Clinical Diagnosis and Research
» Neurology & Neurophysiology
» Pulmonary & Respiratory Medicine
» Stem Cell Research & Therapy
» Transplantation Technologies & Research
   
Pharmaceutical Sciences
» Advances in Pharmacoepidemiology & Drug Safety
» Alcoholism and Drug Dependence
» Bioanalysis & Biomedicine
» Biochemical Pharmacology
» Bioequivalence & Bioavailability
» Cardiovascular Pharmacology: Open Access
» Clinical Pharmacology & Biopharmaceutics
» Developing Drugs
» Drug Designing
» Drug Metabolism & Toxicology
» Medicinal & Aromatic Plants
» Molecular Pharmaceutics & Organic Process Research
» Pharmaceutica Analytica Acta
» Pharmaceutical Regulatory Affairs
» Pharmacovigilance
» Vaccines & Vaccination
   
Chemistry
» Advanced Chemical Engineering
» Analytical & Bioanalytical Techniques
» Chemical Sciences Journal
» Chromatography & Separation Techniques
» Medicinal Chemistry
» Modern Chemistry & Applications
» Natural Products Chemistry & Research
» Organic Chemistry
» Physical Chemistry & Biophysics
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» Thermodynamics & Catalysis
» Theoretical and Computational Chemistry:Open Access
   
Environmental
» Anthropology
» Aquaculture Research & Development
» Astrobiology & Outreach
» Biodiversity & Endangered Species
» Earth Science & Climatic Change
» Ecosystem & Ecography
» Environmental & Analytical Toxicology
» Fisheries & Livestock Production
»Fundamentals of Renewable Energy and Applications
» Geography & Natural Disasters
» Hydrology: Current Research
»Innovative Energy Policies
»International Journal of waste resources
» Oceanography-Open Access
» Petroleum & Environmental Biotechnology
» Pollution Effects & Control
» Poultry, Fisheries & Wildlife Sciences
   
Omics
» Data Mining in Genomics & Proteomics
»Ergonomics
» Glycomics & Lipidomics
» Health & Medical Informatics
»JBR Journal of Young Scientist
» Metabolomics:Open Access
» OMICS Journal of Radiology
» Pharmacogenomics & Pharmacoproteomics
» Phylogenetics & Evolutionary Biology
» Proteomics & Bioinformatics
» Transcriptomics
   
Life Sciences
» Advanced Techniques in Biology & Medicine
»Advancements in Genetic Engineering
»Advances in Crop Science and Technology
»Advances in Dairy Research
» Aging Science
» Agrotechnology
» Air & Water Borne Diseases
» Antivirals & Antiretrovirals
» Autism-Open Access
» Bacteriology & Parasitology
» Biochemistry & Physiology
» Biochemistry and Analytical Biochemistry
» Bioenergetics
» Bioengineering & Biomedical Science
» Biofertilizers & Biopesticides
» Biological Systems
» Biometrics & Biostatistics
»Biomimetics Biomaterials and Tissue Engineering
» Biomolecular Research & Therapeutics
» Bioremediation & Biodegradation
» Biosafety
» Biosafety & Health Education
» Biosensors & Bioelectronics
» Biosensors Journal
» Biotechnology & Biomaterials
» Bioterrorism & Biodefense
» Cell & Developmental Biology
» Current Synthetic & Systems Biology
» Entomology, Ornithology & Herpetology
» Enzyme Engineering
» Fermentation Technology
» Fertilization: In Vitro - IVF-Worldwide
» Fisheries and Aquaculture Journal
» Forest Research
» Fungal Genomics & Biology
» Gene Technology
» Glycobiology
» Horticulture
» Homeopathy & Ayurvedic Medicine
»International Journal of Swarm Intelligence and Evolutionary Computation
» Marine Science: Research & Development
» Membrane Science & Technology
» Microbial & Biochemical Technology
» Molecular Biology
» Molecular Imaging & Dynamics
» Nanomedicine & Biotherapeutic Discovery
» Nanomedicine & Nanotechnology
» Nutrition & Food Sciences
» Plant Pathology & Microbiology
» Primatology
» Probiotics & Health
» Rice Research: Open Access
» Single Cell Biology
» Sociology and Criminology-Open Access
» Tissue Science & Engineering
» Tropical Diseases
» Veterinary Science & Technology
» Vitamins & Minerals
»Virology & Mycology
   
Engineering
» Advances in Automobile Engineering
» Advances in Robotics & Automation
» Aeronautics & Aerospace Engineering
» Applied & Computational Mathematics
» Applied Mechanical Engineering
» Architectural Engineering Technology
» Astrophysics & Aerospace technology
» Biochips & Tissue Chips
» Bioprocessing & Biotechniques
» Chemical Engineering & Process Technology
» Civil & Environmental Engineering
» Computer Science & Systems Biology
» Electrical & Electronics
» Food Processing & Technology
» Geology and Geosciences
» Geophysics & Remote sensing
»Global Journal of Technology and Optimization
» Industrial Engineering & Management
» Information Technology & Software Engineering
» International Journal of Advance Innovations, Thoughts & Ideas
»International Journal of Sensor Networks and Data Communications
» Irrigation and Drainage Systems Engineering
»Generalized Lie Theory and Applications
» Lovotics
» Material Sciences & Engineering
»Physical Mathematics
» Powder Metallurgy & Mining
» Telecommunications System & Management
» Textile Science & Engineering
»Vortex Science and Technology
   
Medical Sciences
» Addiction Research & Therapy
» Allergy & Therapy
» Alternative & Integrative Medicine
» Alzheimers Disease & Parkinsonism
» Anaplastology
» Anatomy & Physiology
» Ancient Diseases & Preventive Remedies
» Andrology
» Arthritis
» Autacoids
»Automatic Control of Physiological State and Function
» Bioceramics Development and Applications
» Biology and Medicine
» Biomusical Engineering
» Blood & Lymph
» Blood Disorders & Transfusion
» Bone Marrow Research
» Brain Disorders & Therapy
» Cardiovascular Diseases & Diagnosis
» Cloning & Transgenesis
» Community Medicine & Health Education
» Dentistry
» Depression and Anxiety
» Diabetes & Metabolism
» Emergency Medicine
» Endocrinology & Metabolic Syndrome
» Epidemiology: Open Access
» Family Medicine & Medical Science Research
» Gastrointestinal & Digestive System
» General Medicine
» General Practice
» Genetic Syndromes & Gene Therapy
» Gynecology& Obstetrics
» Gerontology & Geriatrics Research
» Hematology & Thromboembolic Diseases
» Hair: Therapy & Transplantation
» Health Care : Current Reviews
» Hereditary Genetics
» Human Genetics & Embryology
» Hypertension-Open Access
» Infectious Diseases & Therapy
» International Journal of Genomic Medicine
» Internal Medicine
»International Journal of Biomedical Data Mining
» International Journal of Physical Medicine & Rehabilitation
»JBR Journal of Interdisciplinary Medicine and Dental Science
» Leukemia
» Liver
»Malaria Chemotherapy, Control & Elimination
» Medical & Surgical Urology
» Medical Diagnostic Methods
» Medical Microbiology & Diagnosis
» Metabolic Syndrome
» Molecular Biomarkers & Diagnosis
» Molecular and Genetic Medicine
» Mycobacterial Diseases
» Neonatal Biology
» Nephrology & Therapeutics
»Neuroinfectious Diseases
» Neurological Disorders
» Novel Physiotherapies
» Nuclear Medicine & Radiation Therapy
» Nursing & Care
» Nutritional Disorders & Therapy
» Obesity & Weight Loss Therapy
» Occupational Medicine & Health Affairs
» Oral Health and Dental Management
» Oral Hygiene & Health
» Orthopedic & Muscular System
» Osteoporosis & Physical Activity
» Otolaryngology
» Pain & Relief
» Palliative Care & Medicine
» Pancreatic Disorders & Therapy
» Pediatrics & Therapeutics
» Primary Health Care
» Psychological Abnormalities in Children
» Psychology & Psychotherapy
» Reproductive System & Sexual Disorders
»Research and Development
» Rheumatology: Current Research
» Sleep Disorders & Therapy
» Spine
» Sports Medicine & Doping Studies
» Steroids & Hormonal Science
» Surgery: Current Research
» Thyroid Disorders & Therapy
» Translational Medicine
» Trauma & Treatment
» Tropical Medicine and Surgery
» Vascular Medicine & surgery
» Women's Health Care
» Yoga & Physical Therapy
 
Management
» Accounting & Marketing
» Arabian Journal Business and Management Review
» Arts and Social Sciences Journal
» Business and Economics Journal
» Business and Financial Affairs
» Civil & Legal Sciences
» Defense Management
» Entrepreneurship & Organization Management
» Global Economics
» Hotel & Business Management
» Intellectual Property Rights: Open Access
»International Journal of Accounting Research
» International Journal of Economics & Management Sciences
» Mass Communication & Journalism
» political Sciences & public affairs
»Review of Public Adminstration and Management
» Socialomics
» Stock & Forex Trading
» Tourism & Hospitality
 
   Conferences
Upcoming Conferences
»3rd International Conference and Exhibition on Biosensors & Bioelectronics August 11-13, 2014 San Antonio, USA
»2nd World Associations Congress August 11-13, 2014 San Antonio, USA
»International Meeting on Space- Open Debate August 12-13, 2014 San Antonio, USA
»5th International Conference and Exhibition on Analytical & Bioanalytical Techniques August 18-20, 2014 Beijing, China
»2nd International Conference on Epidemiology and Evolutionary Genetics August 18-19, 2014 Beijing, China
»2nd International Conference and Exhibition on Pharmacognosy, Phytochemistry & Natural Products August 25-27, 2014 Beijing, China
»2nd International Conference and Exhibition on Traditional & Alternative Medicine August 25-26, 2014 Beijing, China
»2nd International Conference and Exhibition on Mechanical & Aerospace Engineering September 08-10, 2014 Philadelphia, USA
»2nd International Conference and Exhibition on Lasers, Optics & Photonics September 08-10, 2014 Philadelphia, USA
»3rd International Conference and Exhibition on Neurology & Therapeutics September 08-10, 2014 Philadelphia, USA
»4th International Conference on Pharmaceutical Regulatory Affairs September 08-10, 2014 Raleigh, USA
»2nd International Conference on Radiology and Imaging September 08-09, 2014 Raleigh, USA
»2nd International Conference on Genomics & PharmacogenomicsSeptember 08-09, 2014 Raleigh, USA
»2nd International Conference on Alzheimer's Disease and Dementia September 23-25, 2014 Valencia Convention Centre, Valencia, Spain
»3rd International Conference and Exhibition on Nutrition & Food Sciences September 23-25, 2014 Valencia, Spain
»3rd International Conference on Clinical Microbiology & Microbial Genomics September 24-26, 2014 Valencia, Spain
»3rd International Conference on Tissue Science & Regenerative Medicine September 24-26, 2014 Valencia, Spain
»4th International Conference on Vaccines & Vaccination September 24-26, 2014 Valencia, Spain
»3rd International Summit on GMP, GCP & Quality Control September 25-26, 2014 Valencia, Spain
»5th World Congress on Bioequivalence and Bioavailability: Pharmaceutical R&D Summit September 29-October 01, 2014 Baltimore, USA
»2nd International Conference on Hematology & Blood Disorders September 29-October 01, 2014 Baltimore, USA
»3rd International Conference and Exhibition on Clinical & Cellular Immunology September 29-October 01, 2014 Baltimore, USA
»3rd International Conference and Exhibition on Materials Science & Engineering October 06-08, 2014 San Antonio, USA
»3rd International Conference on Forensic Research and Technology October 06-08, 2014 San Antonio, USA
»4th World Congress on Virology October 06-08, 2014 San Antonio, USA
»2nd International Conference on Endocrinology October 20-22, 2014 Chicago, USA
»3rd 3rd International Summit on Toxicology & Applied Pharmacology October 20-22, 2014 Chicago, USA
»3rd 4th World Congress on Cancer Science and Therapy October 20-22, 2014 Chicago, USA
»3rd 3rd International Conference and Exhibition on Cell & Gene Therapy October 27-29, 2014 Las Vegas, USA
»2nd International Conference on HIV/AIDS, STDs & STIs October 27-29, 2014 Chicago, USA
»2nd World Congress on Petrochemistry and Chemical Engineering October 27-29, 2014 Las Vegas, USA
»3rd International Conference and Exhibition on Pharmacovigilance & Clinical Trials October 27-29, 2014 Hyderabad, India
»3rd International Conference and Exhibition on Biowaivers and Biosimilars October 27-29, 2014 Hyderabad, India
»3rd International Conference on Translational Medicine November 03-05, 2014 Las Vegas, USA
»2nd International Conference on Predictive, Preventive and Personalized Medicine & Molecular Diagnostics November 03-05, 2014 Las Vegas, USA
»5th International Conference on Diabetes & Metabolism November 03-05, 2014 Las Vegas, USA
»2nd International Congress on Bacteriology and Infectious Diseases November 17-19, 2014 Chicago, USA
»2nd International Conference on Nursing & Healthcare November 17-19, 2014 Chicago, USA
»3rd International Conference on Surgery and Anesthesia November 17-19, 2014 Chicago, USA
»4th International Conference on Nanotek & Expo December 01-03, 2014 San Francisco, USA
»3rd International Conference and Exhibition on Obesity & Weight Management December 01-03, 2014 San Francisco, USA
»2nd International Summit on Clinical PharmacyDecember 02-03, 2014 San Francisco, USA
»3rd International Conference on Medicinal Chemistry & Computer Aided Drug Designing December 08-10, 2014 San Francisco, USA
»3rd International Conference and Exhibition on Probiotics & Functional Foods December 08-10, 2014 San Francisco, USA
Previous Conferences Organized/Co-organized
»Health Informatics & Technology Conference July 28-29, 2014 Baltimore, USA
»3rd International Conference on Gastroenterology & Urology July 28-30, 2014 San Francisco, USA
»3rd International Conference on Earth Science & Climate Change July 28-30, 2014 San Francisco, USA
»3rd International Conference and Exhibition on Orthopedics & Rheumatology July 28-30, 2014 San Francisco, USA
»International Conference on Business Economics of Broadcasting Media & Film Industry July 28-30, 2014, Baltimore, USA
»4th International Conference on Proteomics & Bioinformatics August 04-06, 2014 Chicago, USA
»3rd International Conference and Exhibition on Addiction Research & Therapy August 04-06, 2014 Chicago, USA
»2nd International Conference on Integrative Biology Summit August 04-05, 2014 Chicago, USA
»3rd International Conference and Exhibition on Cosmetology & Trichology July 21-23, 2014 Las Vegas, USA
»3rd International Conference and Exhibition on Food Processing & Technology July 21-23, 2014 Las Vegas, USA
»2nd International Conference on Oceanography July 21-23 , 2014 Las Vegas USA
»4th International Conference on Clinical & Experimental Ophthalmology July 14-16, 2014 Baltimore, USA
»3rd International Conference & Exhibition on Biometrics & Biostatistics July 14-16, 2014 Baltimore, USA
»2nd International Conference and Exhibition on Physical Medicine & Rehabilitation July 14-16, 2014 Baltimore, USA
»International Conference on Geriatrics & Gerentology July 08-10, 2014 Chicago , USA
»International Conference on Women's Health, Gynecology & Obstetrics July 08-10, 2014 Chicago, USA
»International Conference on Computer Graphics and Media Design July 08-10, 2014 Chicago, USA
»4th International Conference on Clinical & Experimental Cardiology April 14-16, 2014 San Antonio, USA
»4th International Conference on Clinical & Experimental Dermatology April 14-16, 2014 San Antonio, USA
»3rd International Conference and Exhibition on Pathology April 14-16, 2014 San Antonio, USA
»5th International Conference on Biomarkers and Clinical Research April 15-17, 2014 University of Oxford, UK
»2nd International Conference on Business Economics and Management April 21-23, 2014 Dubai, UAE
»2nd International Conference on Dental and Oral Health April 21-23, 2014 Dubai, UAE
»4th World Congress on Cell Science & Stem Cell Research June 24-26, 2014 Valencia, Spain
»3rd International Conference on Biodiversity & Sustainable Energy Development June 24-26, 2014 Valencia, Spain
»3rd International Conference and Exhibition on Occupational Health & Safety June 24-25, 2014 Valencia, Spain
»5th World congress on Biotechnology June 25-27, 2014 Valencia, Spain
»3rd International Conference on Nephrology & Therapeutics June 26-27, 2014 Valencia, Spain
»2nd International Conference on Bioprocess and Engineering June 26-27, 2014 Valencia, Spain
»2nd International Conference on Dental and Oral Health April 21-23, 2014 Dubai, UAE
»5th International Conference on Biomarkers and Clinical Research April 15-17, 2014 University of Oxford, UK
»3rd International Conference and Exhibition on Pathology April 14-16, 2014 San Antonio, USA
»4th International Conference on Clinical & Experimental Dermatology April 14-16, 2014 San Antonio, USA
»4th International Conference on Clinical & Experimental Cardiology April 14-16, 2014 San Antonio, USA
»4th International Conference and Exhibition on Pharmaceutics & Novel Drug Delivery Systems March 24-26, 2014 San Antonio, USA
»3rd International Conference and Exhibition on Metabolomics & Systems Biology March 24-26, 2014 San Antonio, USA
»2nd International Conference on Agricultural & Horticultural Sciences, February 03-05, 2014 Hyderabad, India
»International Conference and Exhibition on Traditional & Alternative Medicine, December 09-11, 2013 Hyderabad, India
»2nd International Conference and Exhibition on Obesity & Weight Management, December 02-04, 2013 Las Vegas, USA
»International Conference on Nursing & Emergency Medicine, December 02-04, 2013 Las Vegas, USA
»3rd International Conference on Nanotek & Expo, December 02-04, 2013 Las Vegas, USA
»3rd World Congress on Virology, November, 20-22, 2013 Baltimore, USA
»International Congress on Bacteriology and Infectious diseases, November 20-22, 2013 Baltimore, USA
»3rd World Congress on Cell Science & Stem Cell Research, November 20-22, 2013 San Antonio, USA
»2nd International Conference and Exhibition on Pharmacovigilance & Clinical Trials, November 18-19, 2013 San Antonio, USA
»International Summit on Clinical Pharmacy & Dispensing, November 18-20, 2013 San Antonio, USA
»World Congress on Petrochemistry and Chemical Engineering, November 18-20, 2013 San Antonio, USA
»International Conference on Functional and Comparative Genomics & Pharmacogenomics, November 12-14, 2013 Chicago, USA
»2nd International Conference and Exhibition on Cosmetology & Trichology, November 12-14, 2013 Chicago, USA
»2nd International Summit on GMP, QA & QC, November 12-14, 2013 Chicago, USA
» International Conference on Fermentation Technology, Bioprocess and Cell Culture, October 28-30, 2013 Kansas City, USA
»2nd International Conference and Exhibition on Food Processing & Technology, October 28-30, 2013 Kansas City, USA
»International Conference on HIV/AIDS, STDs, & STIs, October 24-25, 2013 Orlando-FL, USA
»2nd International Conference and Exhibition on Cell & Gene Therapy, October 23-25, 2013 Orlando, USA
»2nd International Conference and Exhibition on Probiotics & Functional Foods, October 23-25, 2013 Orlando, USA
»International Conference and Exhibition on Pharmacognosy, Phytochemistry and Natural Products, October 21-23, 2013 Hyderabad, India
» 3rd World Congress on Cancer Science & Therapy, October 21-23, 2013 California, USA
»3rd International Conference on Pharmaceutical Regulatory Affairs, October 21-23, 2013 California, USA
»2nd International Conference on Clinical & Cellular Immunology, October 15-17, 2013 Las Vegas, USA
»2nd International Conference on Medicinal Chemistry & Computer Aided Drug Designing, October 15-17, 2013 Las Vegas, USA
»4th International Conference and Exhibition on Analytical & Bioanalytical Techniques, October 15-17, 2013 Las Vegas, USA
»2nd International Summit on Toxicology, October 07-09, 2013 Las Vegas, USA
»International Conference and Exhibition on Lasers, Optics & Photonics, October 7-9, 2013 San Antonio, USA
»2nd International Conference and Exhibition on Materials Science & Engineering, October 07-09, 2013 Las Vegas, USA
»International Conference and Exhibition on Biochemical & Molecular Engineering, October 07-08, 2013 San Antonio, USA
»International Conference on Psychology, Autism and Alzheimer's Disease, September 30-October 01, 2013 San Antonio, USA
»International Conference and Exhibition on Mechanical & Aerospace Engineering, September 30-October 02, 2013 San Antonio, USA
»2nd International Conference and Exhibition on Biowaivers & Biosimilars, September 23-25, 2013 Raleigh, USA
»4th World Congress on Biotechnology, September 23-25, 2013 Raliegh, USA
»International Conference on Hematology & Blood Disorders, September 23-25, 2013 Raliegh, USA
»2nd International Conference on Surgery and Anesthesia, September 16-18, 2013 Las Vegas, USA
»2nd International Conference on Clinical Microbiology & Microbial Genomics, September 16-18, 2013 Las Vegas, USA
» International Conference on Omics Studies, September 04-06, 2013 Orlando-FL, USA
»International Symposia on Entomology, September 04-06, 2013 Miami, USA
» World Congress on Endocrinology, August 26-28, 2013 Raleigh, USA
»2nd International Conference on Hydrology and Groundwater Expo, August 26-27, 2013 Raleigh, USA
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Review Article Open Access
Physiological IMSI (pIMSI) Improves Results Obtained with IMSI in Patients with Idiopathic Infertility
1Centro Fecondazione Assistita, Clinica Villa del Sole, Via Manzoni 15, 80122 Napoli, Italy
2Facolta di Medicina e Chirurgia, II Università degli Studi di Napoli,Via Costantinopoli, 16, 80100 Napoli, Italy
*Corresponding author: Dr. Martin Wilding
Centro Fecondazione Assistita
Clinica Villa del Sole, Via Manzoni 15
80122 Napoli, Italy
Tel: 081641689
Fax: 0815479251
Email: martinwilding@hotmail.com
 
Received October 17, 2011; Accepted February 09, 2012; Published February 15, 2012
 
Citation: Wilding M, Coppola G, Fabozzi G, Scotto di Frega A, Di Matteo L, et al. (2012) Physiological IMSI (pIMSI) Improves Results Obtained with IMSI in Patients with Idiopathic Infertility. Reproductive Sys Sexual Disord S3:001. doi:10.4172/2161-038X.S3-001
 
Copyright: 2012 Wilding M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
 
Abstract
 
Study Background: Intracytoplasmic morphology-selected sperm injection (IMSI) is a procedure in which spermatozoa are digitally analysed prior to injection into the oocyte. This increases the chance of selecting a good sperm, but physiological selection is not carried out. Here, we combine physiological pre-selection of spermatozoa with IMSI for patients with idiopathic infertility.
 
Methods: 290 patients, attending for assisted reproduction, were prepared for oocyte retrieval using standard controlled ovarian hyperstimulation protocols. Spermatozoa were preselected for ICSI with either digitalised morphological selection (IMSI) or IMSI combined with hyaluronic acid (HA) pre-selection techniques (pIMSI). Biological and clinical parameters were recorded and the clinical pregnancy rate noted.
 
Results: HA- pre-selection of mature spermatozoa led to a significant increase in pregnancy and implantation rates in patients treated with IMSI.
 
Conclusions: These data suggest that the combination of HA pre-determination of spermatozoa and advanced morphological analysis enables sperm selection on both a physiological and morphological basis and increases the probability of selecting a high quality spermatozoa.
 
Keywords
 
ICSI; IMSI; Idiopathic infertility; Assisted reproduction; Hyaluronic acid
 
Introduction
 
Idiopathic infertility is described as the failure to conceive after at least a year of unprotected intercourse in the absence of known pathologies. The proportion of patients attending for assisted reproduction that are diagnosed with idiopathic infertility is currently about 25-30%. As research and clinical techniques advance, this number tends to decline as causes are discovered. However, these groups of patients remain difficult to treat with assisted reproductive technologies.
 
A recent probable cause of male-factor infertility has been attributed to the presence of high levels of fragmented DNA in spermatozoa [1-4]. These data indicate that apparently normal spermatozoa often fertilise the oocyte creating an embryo in which the male genome is damaged to the extent that implantation and formation of a healthy foetus cannot occur. Although fragmented DNA in spermatozoa can be diagnosed, techniques enabling the selection of normal spermatozoa from the population contained within an ejaculate are still experimental.
 
Two techniques that enable to some extent the selection of physiologically normal spermatozoa have recently been developed. One of these is termed intracytoplasmic morphology-selected sperm injection (IMSI). Here, spermatozoa are selected for ICSI and analysed digitally prior to the microinjection procedure in order to deselect morphologically abnormal spermatozoa. With this technique, abnormalities not visible in standard ICSI procedures have been observed [5-11]. IMSI increases the pregnancy rate during ICSI cycles, and some data suggests that the level of pregnancy termination is also decreased [7,11-15]. Abnormalities in spermatozoa observed with MSOME have been correlated with the presence of fragmented DNA by TUNEL assay [16,17]. A second technique recently introduced to assisted reproduction is that of sperm selection with hyaluronic acid (HA). In this technique, mature sperm with HA receptors are distinguished from immature and abnormal sperm since these do not express such receptors. This technique is otherwise referred to as ‘physiological ICSI’ (pICSI) since the HA selection mimics the binding of spermatozoa to the zona pellucida of the oocyte – a physiological sperm selector [18-23]. It has been shown that HA-bound sperm have lower levels of persistent histones, fragmented DNA, apoptotic markers and aneuploidies than unbound spermatozoa [24-28].
 
The combination of HA sperm selection and IMSI are perfectly compatible in the assisted reproduction routine, and have been applied to the selection of spermatozoa for IMSI [29]. We applied this technique to couples affected by idiopathic infertility during IMSI procedures. We have termed this technique physiological IMSI (pIMSI). In this work, we compare pIMSI to the standard IMSI technique.
 
Materials and Methods
 
Patients
 
All patients in the present work were attending the Centro Fecondazione Assistita, Clinica Villa del Sole, Naples for assisted reproduction technology. Couples were characterised with idiopathic infertility when the female partner had no apparent cause of infertility after normal hysterosalpingography, hysteroscopy and ultrasound monitoring of the menstrual cycle; where hormonal values were within the normal range i.e. basal FSH <10IU/l, body mass index (BMI=weight (kg)/height (m)2) < 29, menstrual cycle range 24-35 days (intra-individual variability ± 3 days); if the karyotype of both subjects of the couple was normal and if the male partner was normospermic. Female patients were prepared using standard controlled ovarian hyperstimulation protocols including downregulation of the pituitary gland with a GnRH agonist (Decapeptyl, Ipsen, Italy) followed by ovarian stimulation with exogenous FSH (Gonal-F, Serono, Italy). A single member of the medical staff co-ordinated all stimulation protocols ensuring standardisation. Oocyte retrieval was performed 36 hours after the administration of 10,000 IU hCG when 2-3 follicles of 18-20 mm diameter were observed by ultrasound examination, and blood 17 β-oestradiol levels reached 150-200 pg/ml/follicle over 18 mm. Luteal phase supplementation was achieved with intramuscular injections of prontogest 50 mg/day. Sperm samples were collected by masturbation and examined after liquefaction. All samples were washed using a silicon-based gradient of 40% overlaid over an 80% silicon solution (COOK Sperm Gradient, Ireland). The sample was centrifuged for 20 minutes at 1000 G, followed by a wash in Hams F-10. The final precipitate was resuspended to a final concentration of 1 x 106 sperm/ml and conserved in an atmosphere of 37°C and 6% CO2 until required.
 
Intracytoplasmic sperm injection was performed on all patients diagnosed with idiopathic infertility to avoid the risk of failed fertilization. All oocytes in the present project were treated with ICSI 3 hours after oocyte retrieval (60 minutes after removal of the cumulus complex). A single team of biologists co-ordinated all biological work, ensuring that both culture protocols and embryo assessment were standardised. Oocytes were processed for ICSI using commercial IVF medium (COOK, Limerick, Ireland), pre-equilibrated to 37°C and 6% CO2.In standard procedures, spermatozoa previously selected by the IMSI or pIMSI technique were placed in a drop of PVP in a Falcon 1006 ICSI dish (Beckton Dickinson, New Jersey, USA), and microinjected using an ICSI setup consisting of a Nikon Eclipse Ti-U microscope, stage heated to 37°C and Hoffman contrast objectives. Micromanipulation was performed with Narishige micromanipulators and COOK microtools (ICSI and holding pipette, COOK, Ireland). Zygote quality was scored 16-17 hours after ICSI. Embryo quality on day 3 was assessed 64-65 hours after insemination. Zygote and embryo evaluation was performed according to previous data [30]. Two or three embryos were transferred in all cases on the third day after oocyte retrieval. The establishment of a pregnancy was considered as a positive β-hCG test of over 60 IU/l 14 days after embryo transfer. The implantation rate was calculated by the observation of foetal heart beats after ultrasound analysis, 8 weeks after the establishment of pregnancy.
 
Intracytoplasmic morphology-selected sperm injection (IMSI) was offered to patients after at least two cycles of ICSI in which pregnancy was not obtained. In the standard IMSI procedure, motile spermatozoa were preselected on the basis of morphology using a 40x Nomarski objective. Purified sperm samples were placed in a solution of 10% PVP in a Willco GWSt-5030 glass-bottomed petri dish (WillCo Wells BV, Amsterdan, Netherlands) and individual spermatozoa immobilised, captured and placed in groups of 10 in a separate drop of diluted PVP solution (5% final concentration) in the same dish and analysed under differential interference contrast optics using a 100x oil-immersion objective. The resolution (r) obtained with this system is defined as r=λ/2NA or 0.2 μm with λ defined as 560 nm. Computer-enhanced analysis and measurement of individual spermatozoa was achieved through digital recording of individual cells with a Nikon Digital Sight DS-2MBW camera followed by image analysis and measurement using the Nikon NIS-Elements image enhancement package (Nikon NISElements, Florence, Italy). Spermatozoa were considered morphologically suitable for ICSI procedures where the head of the sperm was a regular oval shape, 4.5-4.9 μm in length and 3.1-3.5 μm in width, and was characterised by a maximum of a single vacuole not more than 4% the total area of the sperm head (5). The midpiece was also required to be a regular, rectangular shape of between 4.0 and 5.0 μm in length (16). Upon selection of a sufficient number of spermatozoa to complete the technique, selected spermatozoa are replaced into the PVP drop of a standard prepared Falcon 1006 ICSI dish and subsequently injected into oocytes through standard ICSI procedures.
 
HA-binding of sperm samples
 
HA-binding of sperm samples was performed using the Sperm Slow kit (Origio, Denmark). A 1 μl drop of the prepared sperm samples was placed in a 10 μl drop of Gamete buffer (COOK, Ireland) on a Willco GWSt-5030 glass-bottomed petri dish (WillCo Wells BV, Netherlands). This was then gently fused with a 10 μl drop of Sperm Slow (Origio, Denmark) in order to maintain the integrity of the HA solution. Spermatozoa binding to the HA were characterised by vigorous tail beating with slow forward progression, whereas those that did not bind maintained rapid progression despite the presence of HA. The proportion of spermatozoa exhibiting HA binding was calculated by random selection of a pool of spermatozoa. Spermatozoa preselected by HA treatment were then placed in a drop of 5% PVP solution on the same dish and analysed for morphology as above.
 
Prospective, randomised trial
 
Two hundred and ninety couples diagnosed with idiopathic infertility agreed to be inserted into the trial during a cycle of assisted reproduction. These couples were assigned a number, and patients were selected for standard IMSI or pIMSI by picking numbers with random number tables. Couples were included in the trial after at least 1 year of unprotected intercourse, two cycles of assisted reproduction without pregnancy and a failed cycle of IMSI in our centre within the past year.
 
Statistical analysis
 
All data were plotted as mean ± standard deviation, or as percentages, unless stated. All plots and statistical analysis was calculated using Excel (Microsoft, USA) or web-based statistical analysis sites. Significance of data was tested with either Student’s t-test, ANOVA or the chi-squared test. The z-test with Yates correction was used to test the significance of proportions where necessary. Power of the test was calculated to be 98.6% in the present data.
 
Results
 
Statistical analysis of ICSI cycles in CFA Naples during the period 2007-2010 revealed a pregnancy rate of 29.8% for patients affected by idiopathic infertility (194/652 patients, maternal age 34.6 ± 5.5 years, Table 1). Since this group of patients, although apparently fertile, are difficult to treat successfully, we tested new techniques for the selection of spermatozoa. IMSI cycles in our laboratory have been previously shown to increase the pregnancy rate for a wide range of infertility diagnoses in patients where the male partner was affected by sub optimal semen characteristics [16]. However, in patients affected with idiopathic infertility, little benefit was observed. In a pool of 86 patients affected with idiopathic infertility treated with IMSI between 2009 & 2010, a pregnancy rate of 32.5% (28 couples), not significantly greater than that of ICSI in the same class of patients (Table 1) was achieved. We noted that in this patient population, the proportion of spermatozoa selectable for ICSI was higher than previous data (77.9%, [16], see Table 1), suggesting that the population of spermatozoa in idiopathic infertility is not highly affected by morphological abnormalities visible with high power optics.
 
Table 1: ICSI, IMSI and pICSI cycles for idiopathic infertility.
 
Physiological intracytoplasmic sperm injection (pICSI) is a technique in which physiologically mature spermatozoa are selected through their capacity to bind hyaluronic acid [18-20]. We compared the hyaluronic acid binding capacity parameters of spermatozoa from idiopathic and tubal factor infertility patients. In 15 control samples (no selection criteria), 53.5 ± 4.6% of spermatozoa analysed appeared bound to the HA (Figure 1). In a pool of 10 tubal factor infertility patients (in which there is no presumable male factor), 55.3 ± 4.8% of spermatozoa were bound to the HA, not significantly different from that of controls (Figure 1). Interestingly, a pool of 12 patients affected with idiopathic infertility were characterised by a significantly lower proportion of spermatozoa bound to HA (161/453 sperm examined, 35.5%, Figure 1). Individual patients were characterised by a wide range of HA binding capacities in idiopathic infertility patients (Figure 2). These data suggest that patients affected by idiopathic infertility are often characterised by low ratios of sperm binding to HA. We tested whether the pICSI technique could assist in sperm selection in patients affected by idiopathic infertility. In a group of 12 patients, 3 pregnancies were obtained (25%), not significantly higher than that of the control population (Table 1).
 
Figure 1: Proportions of hyaluronic acid bound semen in specific patient groups.
 
Figure 2: Variation of HA binding in individual patients affected by idiopathic infertility.
 
Recent work has suggested that HA-binding of spermatozoa does not select for normal morphology forms (28). We tested whether physiological selection of spermatozoa also selected sperm of good morphology by examining spermatozoa selected by HA binding in high power optics. A total of 1765 spermatozoa from 18 patient semen samples were analysed. Interestingly, no morphological selection appeared to have occurred. 16.28 ± 5.95% spermatozoa, examined from the control population (i.e. not bound to HA) were found to have good morphology after Kruger morphology analysis. After HA pre-selection, a total of 17.22 ± 6.42% (6.92 ± 23.27 % improvement) were found to have normal morphology. Again, a large variation in individual patients was noted (Figure 3). These data suggest that HA selection of spermatozoa does not enrich for normal morphology forms.
 
Figure 3: HA-binding and morphology enrichment in idiopathic infertility.
 
Since the IMSI technique selects spermatozoa on the basis of morphology alone, and pICSI selects spermatozoa on the basis of physiology without advanced morphological selection, we tested whether a combination of the techniques i.e. physiological selection of spermatozoa followed by morphological analysis, could improve the pregnancy rate in this group of patients. We therefore initiated a prospective, randomised trial to test this hypothesis. In total, 290 patients were selected for the trial after informed consent. Patients were divided into two groups of 145 patients (Table 2). After controlled ovarian hyperstimulation, 5 couples selected for IMSI, and 2 couples in the pIMSI group had their cycles cancelled due to poor response to the therapy (Table 2). Table 2 summarises the clinical data obtained during the trial. Interestingly, the percentage of fertilisation was not statistically significant between the two groups, 83.3 ± 9.1% of injected oocytes fertilised after IMSI, whereas 84 ± 11.1% of oocytes fertilised after pIMSI (Table 2). Furthermore, sufficient numbers of grade A embryos were produced to permit transfer of grade A embryos in all cases (Table 2). In the present trial, the group of patients undergoing IMSI achieved a total of 50 pregnancies out of the 140 transfers completed (35.6%). Cycles of pIMSI however resulted in 85 pregnancies (59.6%). The pregnancy rate was highly statistically significant between groups (p=0, z-test). The implantation rate of pIMSI patients was also significantly greater than that of IMSI patients. For the IMSI group, 55 gestational sacs were observed out of the 364 embryos transferred (15.1%). In the group of patients undergoing pIMSI, 107 gestational sacs were observed after the transfer of 355 embryos (30.1%). No significant differences were observed in patients undergoing IMSI and pIMSI treatments with respect to the number of pregnancies to term, or the percentage of gestational sacs that resulted in live births (Table 2).
 
Table 2: Clinical data for trial.
 
Discussion
 
Idiopathic infertility remains a ‘pathology’ which is difficult to treat with assisted reproduction. This is in large part due to the fact that the underlying cause of failure to conceive has not been diagnosed, leaving the couple untreated. In recent years, improvements in diagnostic techniques and the advancement of genetic testing has led to the reduction in the percentage of patients left undiagnosed. Tests on the physiology of spermatozoa such as the DNA fragmentation assay have been introduced to diagnose male factor infertility in cases where no apparent pathology is present [16]. One of the problems with males diagnosed with high levels of fragmented DNA is how to positively select for unfragmented DNA in a population of spermatozoa such as that obtained in an ejaculate. Gradients, glass wool filtration and other tests select for live spermatozoa, but no or little physiological selection is achieved.
 
IMSI is a technique whereby high resolution optics and digital analysis have revealed morphological abnormalities in spermatozoa [5-11]. This has aided in the selection of high quality spermatozoa for ICSI, and leads to an increase in pregnancy rates over classical ICSI techniques [7,11-15]. However, the technique does not detect physiological abnormalities or sperm maturity. Hyaluronic acid binding of spermatozoa detects physiological maturity of spermatozoa, but gives a low level of selection for morphology. However, this technique has been shown to increase pregnancy rates in assisted reproduction cycles.
 
In the present data, we found little increase in pregnancy rates after either IMSI or pICSI alone in patients affected by idiopathic infertility. However, our data suggests that the two techniques are based on mutually exclusive selection criteria i.e. IMSI selects for good morphology, but not necessarily mature spermatozoa and pICSI selects physiologically mature spermatozoa, but without enrichment for morphologically normal forms. Since the application of hyaluronic acid sperm selection techniques and morphological selection of spermatozoa with IMSI are not mutually exclusive, we combined them into a new technique which we termed ‘physiological intracytoplasmic morphology-selected sperm injection (pIMSI). This technique will enable the selection of morphologically normal, physiologically mature spermatozoa. We compared the clinical results obtained with this technique with IMSI alone in a group of patients diagnosed with idiopathic infertility. Couples in the two groups had previously attempted 2 cycles of IVF and a third cycle with IMSI without success prior to the pIMSI cycle. Couples were characterised by similar characteristics such as age, BMI and response to gonadotrophins. Couples were randomly selected for IMSI or pIMSI to exclude bias in the patient characteristics.
 
In this trial, patients treated by IMSI or pIMSI had similar clinical results with respect to fertilisation rate, percentage of grade I embryos, number of grade I embryos transferred, pregnancies and birth rates. However, the percentage of pregnancies achieved after pIMSI was significantly higher than the results achieved in standard IMSI cycles. Furthermore, the implantation rate of embryos produced with pIMSI was also significantly higher than that of IMSI.
 
The data suggest that the combination of physiological selection of spermatozoa with hyaluronic acid prior to the morphological examination of these spermatozoa for intracytoplasmic sperm injection improves results over either physiological or morphological selection alone in patients with no known infertility pathology. The data suggest that a population of spermatozoa contains both physiologically mature and morphologically normal subpopulations, but these do not necessarily correlate. The proportion of physiologically and morphologically normal spermatozoa in an ejaculate may therefore be a determinant of fertility in an otherwise normospermic male. Interestingly, the selection of physiologically and morphologically mature spermatozoa does not lead to an increase in either fertilisation rate of an improvement in embryo quality, suggesting that no quality classification criterion currently available to the major part of assisted reproduction laboratories can assist in the selection of embryos in these patients. We suggest that pIMSI could develop into a powerful tool for the treatment of patients affected by idiopathic infertility.
 
Acknowledgements
 
We thank Vincenzo Monfrecola for his contribution to the work.
 
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