Birth prevalence of genital anomalies among males conceived by intracytoplasmic sperm injection cycles: A cross-sectional study

Abstract Background Several studies have been conducted worldwide to evaluate the prevalence and relative risks of congenital anomalies associated with assisted reproductive technology cycles; however, there is limited data in Iran. Objective To investigate male genital anomalies among live births from assisted reproductive technology. Materials and Methods This cross-sectional study was conducted on children born after intracytoplasmic sperm injection (ICSI) at Royan Institute, Tehran, Iran from April 2013-December 2015. The prevalence of male genitalia disorders that included hypospadias, epispadias, cryptorchidism, micropenis, and vanishing testis were reported. The relationship between the cause of infertility and type of embryo transfer (fresh or frozen), gestational age at birth (term or preterm), and birth weight with these male genitalia anomalies were evaluated. Results In total, 4409 pregnant women were followed after their ICSI cycles to evaluate genitalia anomalies in their children. Out of 5608 live births, 2614 (46.61%) newborns were male, of which 14 cases (0.54%) had genital anomalies. The prevalence of various anomalies were cryptorchidism (0.34%), hypospadias (0.038%), micropenis (0.038%), vanishing testis (0.038%), and epispadias (0.077%). No relationship was found between the cause of infertility, type of embryo transfer (fresh or frozen), gestational age at birth (term or preterm), and male genital malformation (p = 0.33, p = 0.66, and p = 0.62, respectively). Conclusion The prevalence of each male genital anomaly after the ICSI cycle was rare and less than 0.5%; however, no significant infertility-related factor was observed with these anomalies.


Introduction
During the past 4 decades, assisted reproductive technology (ART) has been used as a standard worldwide medical practice to achieve pregnancy. ART is responsible for an estimated 1-5.9% of conceptions in some developed countries (1). In vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) are the 2 main ART modalities. Because sperm and oocytes are manipulated outside the body, there are concerns regarding embryos derived from these invasive procedures (2). The findings of several studies and meta-analyses indicate that ART is associated with an increased risk of congenital anomalies (1)(2)(3)(4)(5). Results of previous studies have suggested an association between ART and some specific cardiac birth defects (6,7), as well as some noncardiac defects such as cleft lip with or without cleft palate (8); hypospadias (9,10), neural tube defects (11), esophageal, anorectal (8,12), genitourinary defects (13), and large intestinal atresias (12). However, the magnitude of these associations and the spectrum of the involved defects remains unknown (14).
Presumed reasons to explain the higher risk of congenital malformations (CM) in ART infants include underlying subfertility, medications for ovulation induction, micromanipulation in ICSI and/or IVF, as well as increase in multiple gestations and prematurity (14). More CM have been observed in ICSI as a more invasive treatment method in cases where sperm could not pass through the natural route and physiologic deletion of abnormal sperms does not occur (oligospermia) (15). Similar interventions applied in IVF include the gonadotropin stimulator, oocyte aspiration, and culture media, which likely raise the incidence of CM (15). Some studies have investigated whether there is a higher risk of CM in offspring conceived by ICSI than IVF. However, they reported controversial results (9,(15)(16)(17). It was hypothesized that congenital genitourinary malformations, such as hypospadias, are more frequent after ICSI than after IVF. Moreover, they stated that there is a lack of robust data due to the rarity of these conditions (9). Hence, it was concluded that the increased prevalence of congenital genitourinary malformations was observed in singletons born after ART; however, more studies are warranted for confirmation (17). Only one study in Iran evaluated congenital anomalies and could not find a significant relationship between the type of infertility treatments and CM; however, the rate of CM after the ICSI cycles (11.7%) was slightly higher than after IVF cycles (5.9%) (15

Materials and Methods
This cross-sectional study was performed at Royan Institute, Tehran, Iran from April 2013-December 2015. After registering the ICSI cycles in Hakim's software system at Royan Institute, data regarding pregnancies were investigated, and all live births were monitored and followed retrospectively. The ICSI cycles and embryo transfer procedure were performed with standard protocols at Royan Institute. We collected the data regarding the cause of infertility and type of embryo transfer from participants' records.
The characteristics of newborns were also collected and recorded from the follow-up clinic.  (19). Micropenis was described as a penis 2.5 standard deviations (SD) smaller than the mean for the child's age and race. It was diagnosed by observing a stretched penis length of less than 1.9 centimeters at birth. Testicular regression syndrome or vanishing testis is reported to be due to the subsequent atrophy and disappearance in the fetal life of an initially normal testis, and its diagnosis is confirmed by surgery (20). Epispadias was defined by observing the opening of the urethra in the back of the penis (19).  Comparison of means for dichotomous variables was performed by the independent sample t test, and the Chi-square test was used to examine the relationship between categorical variables. A p-value < 0.05 was considered to be statistically significant.

Results
In this study, 4409 infertile couples with successful pregnancies after ICSI cycles were investigated to examine the male urogenital anomalies in their newborns.  newborns (0.98%). The most common anomaly was cryptorchidism (7 cases from 10 anomalies).
The prevalence of genitalia anomalies in male term newborns (> 37 wk) was 0.25%. The total prevalence of genitalia anomalies by gestational age in male newborns was 0.54%. The Chi-square test showed that the relationship between the prevalence of male genitalia anomalies and the gestational age was not statistically significant (p = 0.62).   (Table IV).
As a result, no significant link was discovered between azoospermia diagnosis and male genital anomalies in newborns following ICSI cycles.  In the present study, various genitalia anomalies had the following prevalences: cryptorchidism (0.34%), hypospadias (0.038%), micropenis (0.038%), vanishing testis (0.038%), and epispadias (0.077%). Due to our limitations, these children were almost entirely examined by pediatricians at the hospital's birth center.
The information collected was obtained from the parents via telephone and by assessment of medical records.
In the current study, the prevalence of cryptorchidism was 0.16% (9 out of 5608 live births) and 0.34% in boys. The prevalence of this disease was 0.2% in preterm neonates and 0.09% in term infants, which is approximately 20 times higher in premature infants and is consistent with the physiopathology description of this disease. The prevalence of cryptorchidism was 4.5% in live births from natural pregnancies, approximately 30% in premature infants, and 3.4% in term newborns. The difference in the prevalence of these 2 categories is that the normal time of testicular decline is between 28 and 32 wk of gestation. Although the cause of the testicle decline and its main mechanism is still unknown, it is undoubtedly affected by 2 hormonal changes, androgens and Müllerianinhibiting substance (21). In another study in Yazd, the prevalence of cryptorchidism in preterm and mature infants was reported as 29.5% and 3.27%, respectively (22). Mozafari Kermani and colleagues (15)

Conclusion
The results of the study indicated that the prevalence of each male urogenital anomalies including cryptorchidism, hypospadias, micropenis, and vanishing after the ICSI cycle was rare and less than 0.5%, and almost similar to those in infants from natural pregnancies which reported in Iranian scientific literature; however, we had no control group for better comparison.
Therefore, a prospective study with a control group should confirm the present results.