Defining Predictive Factors for Total Fertilization Failure and Embryo Development Arrest in Intracytoplasmic Sperm Injection Cycles

Defining Predictive Factors for Total Fertilization Failure and Embryo Development Arrest in Intracytoplasmic Sperm Injection Cycles | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Defining Predictive Factors for Total Fertilization Failure and Embryo Development Arrest in Intracytoplasmic Sperm Injection Cycles mustafa akşar, serdar dilbaz This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8701915/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 09 Mar, 2026 Read the published version in BMC Women's Health → Version 1 posted 13 You are reading this latest preprint version Abstract Purpose Total fertilization failure (TFF) and embryo development arrest (EDA) remain challenging outcomes in intracytoplasmic sperm injection (ICSI) cycles. This study aimed to identify predictive factors associated with TFF and EDA in ICSI treatments. Methods This retrospective study analyzed 1846 ICSI cycles performed between January 2016 and December 2019 at a tertiary assisted reproduction center. Patients were categorized into successful fertilization and unsuccessful fertilization groups (TFF and EDA). Demographic characteristics, ovarian reserve markers, stimulation parameters, semen characteristics, and embryological outcomes were compared. Univariate and multivariate logistic regression analyses were performed to determine independent predictors of fertilization success. Receiver operating characteristic (ROC) analysis was used to evaluate prognostic factors. Results Successful fertilization was achieved in 76.5% of cycles, while TFF and EDA occurred in 6.6% and 16.9%, respectively. Female age, basal FSH level, serum AMH level, antral follicle count, estradiol level on oocyte pick-up day, number of retrieved oocytes, and number of metaphase II oocytes were significantly associated with fertilization outcomes. In multivariate analysis, only the number of two-pronuclear (2PN) embryos was identified as an independent predictor of successful fertilization (OR = 12.016, 95% CI: 7.529–19.176, p < 0.001). ROC analysis demonstrated that a 2PN cut-off value of 2.5 predicted fertilization success with 75% sensitivity and 78% specificity (AUC = 0.845). Conclusion The number of 2PN embryos is the strongest independent prognostic factor for fertilization success in ICSI cycles. Identifying patients at risk for TFF and EDA may help optimize treatment strategies and improve clinical outcomes Figures Figure 1 INTRODUCTION Intracytoplasmic sperm injection (ICSI) is an effective method applied to increase fertilization rates in cycles that do not fertilize or have low fertilization rates after conventional in vitro fertilization (IVF) treatment [ 1 ]. The capacity of ICSI to fertilize oocytes with almost any type of spermatozoa has made this technique the most successful treatment for male infertility. ICSI for male infertility increased from 84% in 2003 to 93% in 2012 [ 2 ]. Fertilization rates of up to 80% and clinical pregnancy rates of up to 45% are observed with ICSI [ 3 ]. Although fertilization success rates seem high in ICSI, 1–4% total fertilization failure (TFF) and 15–16% embryo development arrest (EDA) occur in all ICSI cases [ 4 , 5 ]. Therefore, it is essential to identify the causes of TFF and EDA, the etiology of which has not yet been clarified, to reduce stressful consequences for both the patient and the clinician and maximize the success rate per cycle. Total fertilization failure (TFF) refers to the fertilization failure of all mature oocytes after oocyte retrieval. Failure rates increase in recurrent ICSI cycles and rise to 13% in second ICSI trials [ 4 ]. The causes of TFF are generally described as male infertility with impaired semen parameters and sperm morphologies and cycles with low oocyte count and quality [ 6 ]. Embryo developmental arrest (EDA) describes embryos that do not divide after 24 hours and stall at the single-cell stage. It has been shown that female age, insufficient in vitro culture conditions, and insufficient oocyte maturity and paternal factors may cause embryo development arrest [ 7 ]. The primary aim of this study is to reveal the factors that predict total fertilization failure and embryo development arrest. MATERIALS AND METHODS Data of patients admitted to Ankara Etlik Zübeyde Hanım Gynecology Training and Research Hospital Reproductive Assisted Therapy Clinic for infertility treatment. They underwent ICSI treatment between January 2016 and December 2019 (n = 1846) were analyzed retrospectively. Files of the patients were obtained from the clinical database with the permission of the university ethics committee. Patients who underwent conventional IVF, those with uncontrolled systemic disease, those with insufficient data, and those who could not obtain oocyte and sperm were not included in the study. In the study, 1846 cycles were included, GnRH agonist, GnRH antagonist, oral contraceptive (OCS) long luteal or microdose flare protocol used for controlled ovarian stimulation. recFSH and recLH were used as gonadotropins. The gonadotropin dose was individualized according to the patient. Follicle follow-up and cycle monitoring were performed by serial measurement of serum luteinizing hormone, estradiol (E2), and progesterone levels and evaluating the number and size of follicles with TVUSG. When the mean diameter of the three reached 17 mm, subcutaneous recombinant hCG (Ovitrelle, Serono, Istanbul, Turkey) was administered. Oocyte pick-up (OPU) was performed 36 hours after hCG administration, using an aspiration needle with TVUSG guidance. Oocytes were removed from the cumulus oophorus by soaking in hyaluronidase solutions (Vitrolife, Sweden). Oocytes were kept at 37°C, 5% carbon dioxide, and 95% humidity until the ICSI procedure (G-IVF medium, Vitrolife, Sweden). The sperm sample was obtained mainly from the ejaculate on the day of oocyte retrieval, after 2–7 days of sexual abstinence. Microdissection epididymal sperm aspiration (MESA) under local anesthesia with interventional methods in the absence of ejaculate or viable sperm; percutaneous epididymal sperm aspiration (PESA) or testicular sperm extraction (TESE) was performed. Semen was examined in terms of sperm count, motility and morphology. The examined sperm were prepared for fertilization. ICSI was applied to all patients included in the same embryologist for the fertilization study. A single sperm selected by the injection pipette was caught by the tail, kept from moving, and then drawn into the pipette. Collected oocytes were cleared of cumulus and granulosa cells. Polar bodies fixed. The zona pellucida and oolemma were passed with a pipette, and the sperm were placed directly into the ooplasm. Oocytes were examined for the presence of fertilization, approximately 18 hours after insemination, for pronucleus and polar bodies. Cycles did not show 2PN structure, and this condition was observed in all oocytes recorded with the result of TFF (n = 121). Embryo culture was performed using a sequential medium system, followed by daily development. Morphological criteria were used during evaluation [ 4 ]. Cell size, blastomere nuclear structure, and fragmentation status were evaluated and recorded per the development day. In addition, embryos that did not show division for 24 hours that paused at the single-cell stage were recorded with the result of EDA (n = 313). The group which quality embryos obtained for transfer (Group I, successful fertilization, n = 1412) and the results of EDA and TFF (Group II, unsuccessful fertilization, n = 434) compared by age, body mass index (BMI), follicle-stimulating hormone (FSH), and estradiol (E2) level in the early follicular phase, serum anti-mullerian hormone (AMH) level, antral follicle count, infertility duration, oocyte pick up (OPU) day estradiol level, number of oocytes collected in OPU, semen analysis parameters (advanced motile sperm count, Kruger ratio, total sperm count, motile sperm ratio), 2PN number, ovulation induction time, total administered gonadotropin dose. Data Analysis and Statistics Data for all patients included at the end of the study were performed using IBM SPSS version 22 (22.0, SPSS Inc., Chicago, IL, USA). The distribution of continuous data was determined using the Kolmogorov-Smirnov test of normality. Since continuous data did not show normal distribution, median, minimum, and maximum values ​​were calculated with descriptive statistics. Mann-Whitney U test was used to compare two groups of continuous data showing non-parametric distribution, and the Kruskal Wallis test was used to compare the three groups. Chi-square and Fisher exact test were used for categorical variables between groups. Bonferroni correction and Mann-Whitney U test were used for pairwise comparisons of data in which significant differences were detected in triple comparisons. Spearman correlation analysis was used for correlations between variables. Univariant and multivariant regression analyses evaluated the factors predicting fertilization success. Optimal cut-off, sensitivity, specificity values, and prognostic factors were calculated by ROC analysis​​. P < 0.05 was considered statistically significant. RESULTS The successful fertilization rate, in which quality embryos for transfer were obtained, was 76.5% (1412/1846). Total fertilization failure was detected in 6.6% (121/1846) and embryo development arrest in 16.9% (313/1846). Fertilization success was 97.5% in ovulatory dysfunction, 92.6% in male factor, 85% in unexplained infertility, and 59.2% in DOR cases; Fertilization success was 32.1% in endometriosis and only 35.3% in tubal factor. A statistically significant difference was found in the comparison according to infertility etiology (p < 0.001, Table 1 ). Table 1 Comparison of fertilization success according to infertility etiology Successful Fertilization (Group 1) n:1412 Embryo Development Arrest and Total Fertilization Failure (Group 2) N:434 p Unexplained infertility %85 (198/231) %15 (33/231) < 0,001 Male factor %92,6 (416/449) %7,4 (33/449) DOR %59,2 (134/226) %40,8 (92/226) Endometriosis %32,1 (45/140) %67,9 (95/140) Ovulatory Dysfunction %97,5 (527/540) %2,5 (13/540) Tubal factor %35,3 (92/260) %64,7 (168/260) Total 1412 434 DOR: Diminished ovarian reserve No statistically significant difference was found in terms of BMI, 3rd day E2 level, ovulation induction time and infertility duration between group 1 and 2 (p > 0.05). In Group I, age [(31 (19–46) vs 33 (18–47), p < 0.001, respectively] and on day 3 FSH level [(7.69 (0.48-62) vs 9.2 (0.71-42), p < 0.001, respectively] were significantly lower than Group II. Estradiol level on OPU day [1310 (97-7731) vs 785 (58-5959), p < 0.001, respectively], serum AMH level [1.81 (0.01-33) vs 0.7 (0.01-74), p < 0.001, respectively], antral follicle count [10 (0–30) vs 6 (0–30), p < 0.001, respectively], number of oocytes retrieved on OPU day [10 (1-144) vs 5 (1–31), p < 0.001, respectively] and 2PN number [4 (1–28) vs 1 (0–16), p < 0.001, respectively] were significantly higher in Group I than Group II (Table 2 ). Table 2 Comparison of cases according to fertilization success Successful Fertilization (Group 1) Embryo Development Arrest and Total Fertilization Failure (Group 2) p n:1412 N:434 Female Age, yıl 31 (19–46) 33 (18–47) < 0.001 BMI, kg/m 2 25,6 (15,7–44,8) 26 (17–45,4) 0,265 FSH, mIU/mL 7,69 (0,48–62) 9,2 (0,71 − 42) < 0.001 Estradiol, pg/mL 47,9 (11,8-482) 44 (11,6-596) 0,874 OPU day estradiol level, pg/mL 1310 (97-7731) 785 (58-5959) < 0.001 AMH, ng/mL 1,81 (0,01–33) 0,7 (0,01–74) < 0.001 Antral Follicle Count 10 (0–30) 6 (0–30) < 0.001 Administraeed gonodotropin total dose 2025 (675–7800) 2400 (688–5550) < 0.001 Ovulation induction time, day 10 (6–17) 10 (5–15) 0,062 OPU day collected oocyt count 10 (1-144) 5 (1–31) < 0.001 Obtained M2 oocyt count by OPU 8 (1–32) 3 (0–26) < 0.001 Infertility period, mounth 54 (1-288) 57 (2-276) 0,642 2PN count 4 (1–28) 1 (0–16) < 0.001 BMI: body mass index, FSH: follicle-stimulating hormone, OPU: oocyte pick up, AMH: anti-müllerian hormone When patients were grouped according to sperm retrieval techniques, it was seen that the most sperm was obtained from the ejaculate (1604/1746), second TESE procedure (132/1746) was performed. Fertilization success was found to be 75.4% (1211/1604) from the ejaculate, 70.4% (93/132) in TESE, and 80% (8/10) in the group in which other techniques were preferred (MESA, PESA, etc.). No statistically significant difference was found according to the sperm retrieval method (p = 0.771, Table 3). Total sperm count, motility rate [% (A + B)], total progressive motile sperm count, and Kruger rate (%) were compared, no statistically significant difference was found (p > 0.05). A statistically significant difference was found between the two groups only in terms of male age [33 (20–55) vs. 34 (22–67), p < 0.01, respectively] (Table 4 ). Table 3. The effect of sperm retrieval techniques on fertilization success Successful Fertilization (Group 1) Embryo Development Arrest and Total Fertilization Failure (Group 2) p n:1412 N:434 Ejaculate %75,4 (1211/1604) %24,6 (393/1604) 0,771 TESE %70,4 (93/132) %29,6 (39/132) Others %80 (8/10) %20 (2/10) Total 1312 434 TESE: testicular sperm extraction Table 4. Comparison of the included cases according to fertilization success as TFF, EDA, and successful fertilization TFF EDA Successful p n= 121 n= 313 Fertilization n= 1412 Female Age, yıl 35 (24-47) a 33 (18-46) b 31 (19-46) c <0,001 BMI, kg/m 2 26,9 (17-45) 25,75 (17-43) 25,8 (15,7-44,8) 0,153 FSH, mIU/mL 10,7 (2,48-22,92) a 8,9 (0,7-42) a 7,7 (0,42-62) b <0,001 Estradiol, pg/mL 43 (11,8-178) 45,1 (15-496) 47,5 (11,8-492) 0,983 OPU day estradiol level, pg/mL 589,8 (69,1-5256,5) a 821,5 (58,3-5852,9) b 1310,3 (97,3-7731,9) c <0,001 AMH, ng/mL 0,63 (0,1-13) a 0,7 (0,1-74) a 1,75 (0,1-33) b <0,001 Antral Follicle Count 5 (0-30) a 7 (0-30) b 10 (0-30) c <0,001 Administraeed gonodotropin total dose 2400 (1100-5250) a 2250 (688-5550) a 2025 (800-5250) b <0,001 Ovulation induction time, day OPU day collected oocyt count 4 (1-29) a 5 (1-31) b 10 (1-43) c <0,001 Obtained M2 oocyt count by OPU 2 (0-20) a 4 (0-26) b 8 (1-32) c <0,001 Infertility period, mounth 48 (7-228) 60 (2-276) 48 (1-264) 0,881 2PN count - 1 (0-16) a 4 (0-28) b <0,001 BMI: body mass index, FSH: follicle stimüle edici hormon, OPU: oosit pick up, AMH: anti-müllerian hormon a,b,c; groups indicated with different letters are statistically different among themselves When TFF, EDA and successful fertilization cases compared; female age [35 (24–47) vs 33 (18–46) vs 31 (19–46), p < 0.001, respectively], estradiol level on OPU day [589.8 (69.1-5256.5) vs 821 .5 (58.3-5852.9) vs. 1310.3 (97.3-7731.9), p < 0.001, respectively], antral follicle count [5 (0–30) vs 7 (0–30) vs. 10 (0–30), p < 0.001, respectively], number of oocytes collected on OPU day [4 (1–29) vs 5 (1–31) vs 10 (1–43), p < 0.001, respectively], number of M2 oocytes [2 (0–20) vs 4 (0–26) vs 8 (1–32), p < 0.001, respectively] and 2PN number [0 vs 1 (0–16) vs 4 (0–28), p < 0.001, respectively], there was a statistically significant difference between all three groups (p < 0.001). While serum AMH level was similar between TFF and EDA groups, it was significantly higher in the group with successful fertilization compared to the other two groups [0.63 (0.1–13) vs. 0.7 (0.1–74) vs. 1.75 (0.1–33), p < 0.001, respectively]. While the serum FSH level on the 3rd day was similar in the TFF and EDA groups, it was found to be significantly lower in the group with successful fertilization [10.7 (2.48–22.92) vs. 8.9 (0.7–42) vs. 7.7 (0,42–62), p0.001, respectively]. When the total dose of gonadotropin administered was compared, it was similar in the TFF and EDA groups. It was found to be significantly lower in successful fertilization [2400 (1100–5250) vs. 2250 (688–5550) vs. 2025 (800–5250), p 0.05). Table 4 summarizes the comparison of the three groups. In the multivariate logistic regression analysis prepared by including female age, serum AMH level, FSH level on day 3, estradiol level on day 3 of OPU, number of antral follicles, number of oocytes retrieved, and 2PN, only 2PN number was determined as an independent prognostic factor for successful fertilization [OR = 12.016 (7,529 − 19,176), p < 0.001]. Univariate and multivariate analyses are shown in Table 5 . Table 5. Univariate and multivariate logistic regression analysis of factors predicting fertilization success Univariate Analysis Multivariate Analysis Patients p Odds ratio 95% C.I.for EXP(B) p Lower Upper Female age, year <0,001 0,927 0,625 1,376 0,706 <32 773/956 ≥32 638/886 AMH, ng/mL <0.001 1,068 0,647 1,763 0,796 <1,46 296/440 ≥1,46 378/447 3. day FSH level, mIU/mL <0.001 0,878 0,592 1,303 0,52 <7,95 862/1040 ≥7,95 545/801 OPU day estradiol level, pg/mL <0.001 0,851 0,504 1,439 0,548 <1108 549/837 ≥1108 756/898 Antral follicle count <0.001 0,915 0,572 1,465 0,712 <8 423/652 ≥8 988/1193 OPU day collected oocyst count <0.001 1,356 0,788 2,332 0,272 <8 428/711 ≥8 885/1036 2PN number <0.001 12,016 7,529 19,176 <0.001 <3 332/671 ≥3 980/1073 AMH: anti-müllerian hormone, FSH: follicle-stimulating hormone, OPU: oocyst pick up In the ROC analysis, the number of 2PNs significantly predicted fertilization success. The optimal cut-off was calculated as 2.5 with 75% sensitivity and 78% specificity (AUC: 0.845, p < 0.001, Fig. 1 ). DISCUSSION Fertilization failure and embryo development arrest are still important stress factors for the clinician and the patient in ICSI applied cases. Considering IVF treatment's financial and moral burdens, maximizing our success rate per cycle is essential. After introducing ICSI, the fertilization failure rate decreased significantly compared to the conventional IVF technique. In the study conducted by Liu J. et al. in 1994, including 2732 cycles, the rate of TFF was found to be 3% [ 6 ]. In a study by Yanagida K., the rate of TFF was found to be 5.6% [ 8 ]. In another study by Shinar et al., the rate of TFF was found to be 4.3% [ 9 ]. However, the rate of EDA in patients undergoing ICSI was 15% in a study by Betts D. and Madan P. [ 10 ]. In the study conducted by Qi S. et al., EDA was 15.6% [ 5 ]. In our study, TFF 6.5% and EDA 16.8% occurred in all ICSI cases, with rates similar to those in the literature. In order to increase the success of fertilization, many new studies are carried out, and many new methods are tried. In previous studies, severe male factor was considered the leading cause of fertilization failure; Liu J. et al. described the causes of fertilization failure in general as impaired semen parameters, impaired sperm morphology, and cycles with low oocyte count and quality [ 6 ]. In a study by Gabrielsen et al., including 258 patients, it was reported that fertilization failure might occur due to oocyte defects [ 11 ]. Many studies have been conducted on the effect of infertility etiology on fertilization success. Previously, male infertility was shown as the primary cause, but recently, studies have shifted to unexplained infertility with the intensification of research at the molecular level. In a study conducted by Liu et al. in 2016, when patients were compared according to infertility etiology, embryo development arrest was found in most with unexplained infertility [ 12 ]. In a study conducted by Shinar et al., the rate of TFF was found to be higher in infertility due to male factors [ 9 ]. In our study, patients were compared according to the etiology of infertility; the highest fertilization success was observed in the group with ovulatory dysfunction. The group with the lowest fertilization success was accompanied by endometriosis. Due to the intertwining of infertility etiologies and the existence of cases with more than one disease, the results provide limited information. During ICSI, fertilization failure may develop due to the use of inappropriate techniques or the inexperience of the practitioner. In a study conducted by Vanderzwalmen et al., it was shown that the injection of sperm that is not fully immobilized, which is a situation caused by the practitioner, reduces the success of fertilization [ 13 ]. In a study to predict fertilization failure, Shen et al. identified sperm motility and ICSI practitioner as the two most important predictive factors. Again, in this study, the ICSI operator was an independent risk factor for the number of 2PN, which is one of the first indicators of fertilization [ 14 ]. Since the ICSI practitioner was the same throughout our study, the study cannot fully explain the effect of the practitioner on fertilization success. The basic principle of ICSI is to minimize the causes related to the malefactor. In contrast, it is thought that one of the most important predictive factors of fertilization failure in sperm morphology, in a study conducted in 2011, Sarıkaya et al. found that Kruger ratio and advanced motile sperm count were similar in the group with TFF and the group with successful fertilization [ 4 ]. In another study, Svalander et al. reported that sperm morphology was not associated with fertilization failure [ 15 ]. Furthermore, in a study by Liu et al., which included 1900 patients and 2732 ICSI cycles, no difference was found in sperm concentration and morphology [ 6 ]. Again, in a study conducted by Bulgurcuoğlu S. and Özsait B. in 2019, no difference was found in total sperm count, advanced motile sperm count, Kruger rate, and sperm concentration in those with embryo development arrest [ 7 ]. Similarly, no difference was found between the groups in terms of semen analysis results in our study. Sperm origin is thought to be a factor affecting the success of ICSI. For this reason, many studies have compared fertilization rates according to sperm origin. For example, a study by Aboulgar et al. in 1997 found no difference in fertilization rates [ 16 ]. However, in a study conducted by Göker et al. in 2002, fertilization and pregnancy rates were significantly lower in patients who underwent testicular biopsy [ 17 ]. Again, in a study conducted by Desai et al. in 2018, embryo development arrest was considerably higher in patients who underwent TESE [ 18 ]. However, our study found no statistically significant difference when the patients were compared according to the sperm origin. The number of retrieved oocytes, oocyte quality, and oocyte morphology are accepted as essential parameters affecting fertilization success. Many studies have been carried out to determine the optimal number of oocytes. OHSS and the risk of multiple pregnancies are considered limiting factors in oocyte count. Since only M2 oocytes are used in ICSI, the number of mature oocytes is essential. In 2003, Melie et al. TFF rate; found that ICSI applied significantly decreased when the number of oocytes increased [ 19 ]. In yet another study, Flaherty et al. found the TFF rate to be 37% in those who underwent ICSI with one oocyte, 13% in those with two oocytes, and 0.8% in those with five or more oocytes [ 20 ]. In a study conducted by Yanagida K., the rate of TFF was found to be 28.7% in patients who underwent ICSI with a single oocyte and < 7% in those who applied more than four oocytes [ 8 ]. In a study conducted by Alvarez et al. in 2013 and including 1400 ICSI cycles, it was shown that embryo development arrest increased due to the decrease in the number of M2 oocytes [ 21 ]. Contrary to all these studies, Liu et al. found that M2 oocyte and 2PN numbers were significantly higher in the group with embryo development arrest. In another study, Bulgurcuoğlu S. and Özsait B. found that the number of collected oocytes was high in the group with embryo development arrest [ 7 ]. They explain this result as in the deficient embryo group; oocytes are recruited from smaller, immature follicles, resulting in many embryos of insufficient quality but not mature enough due to low developmental potential [ 12 ]. In this study, the number of oocytes collected in OPU and applied ICSI was significantly lower in the group with fertilization failure. It is known that abnormal morphology, genetics, and fragility of the oocyte negatively affect fertilization. In the study by Liu et al., it was shown that significant anomalies in the oocyte cause fertilization failure [ 6 ]. As oocytes age, dysfunctional events during ovulation are more frequent. Such events at the first meiotic division are the most common cause of failure of assisted reproductive techniques [ 22 ]. In the study investigating the relationship of embryo development arrest with Age by Qi S. et al.; It has been shown that embryo development arrest increases significantly with age, which may be due to the increased risk of anapleuid [ 5 ]. In our study, female age was significantly higher in the group resulting in unsuccessful fertilization. Antral follicle count, FSH level in the early follicular phase, and serum AMH level are parameters used to show ovarian capacity and predict ovarian response. Fertilization success may increase due to higher ovarian power; more oocytes can be obtained, and the number of oocytes that can be performed ICSI increases. In a study conducted by Tomas C. et al. in 1997, it was determined that there was a positive and significant relationship between the number of antral follicles and fertilization success, and the response to gonadotropin was higher in this group [ 23 ]. In another study, Wen-Quin et al. reported that fertilization success was positively associated with serum AMH levels [ 24 ]. In our study, the number of antral follicles and serum AMH levels was higher in the group with successful fertilization. It has been shown that serum FSH level > 20 mU/ml and estradiol level > 80 pg/ml in the early follicular phase is associated with poor ovarian response. It is known that fewer oocytes can be obtained with poor ovarian response. Fewer oocyte retrieval was also associated with lower fertilization rates. In the study conducted by Taylor T. et al., 1363 IVF cycles were included in 2001–2006; no difference was found between the fertilized group in serum basal FSH and estradiol levels [ 25 ]. In another study by Bulguroğlu S. and Özsait B., no significant difference was found in the group with embryo development arrest in basal FSH and estradiol levels [ 7 ]. In a study by Liu L. et al., basal FSH level was significantly lower in the group with developmental arrest [ 12 ]. In our study, no difference was found in terms of basal estradiol level, but basal FSH level was significantly lower in the group with successful fertilization. In a study by Shen et al., a positive and significant correlation was found between estradiol level on the hCG day and fertilization success [ 14 ]. However, in a study conducted by Sarıkaya et al. in 2011, no significant difference was found between the group with total fertilization failure and estradiol level on the hCG day [ 4 ]. In our study, estradiol level on the hCG day was significantly lower in the group with total fertilization failure and embryo development arrest. Many studies have investigated the effect of the total dose of gonadotropin used during the treatment on fertilization success. High doses of gonadotropin are required to get a response to the treatment in the patient group with poor ovarian response. In a study conducted by Bulgurcuoğlu S. and Özsait B. in 2019, the total dose of gonadotropin used in the group with embryo development arrest was found to be significantly higher [ 7 ]. No difference was found in a study by Liu L. et al. [ 12 ]. A significant negative relationship was found between the total dose of gonadotropin used in our study and fertilization success. The retrospective nature of the study is one of its weaknesses. On the other hand, only the results of the patients who underwent ICSI were included in the evaluation. Therefore, a comparison with the conventional in vitro fertilization technique could not be performed. Furthermore, the effect of ICSI practitioners on fertilization success could not be fully explained because the ICSI practitioner was the same throughout the study. Therefore, it may be beneficial to expand the study in these aspects and conduct prospective studies in more case series. The number of 2PNs has been determined as an independent prognostic factor for fertilization success. In addition, it has been defined as a parameter that can predict good quality embryos suitable for transfer. Abbreviations ICSI Intracytoplasmic sperm injection TFF Total fertilization failure EDA Embryo development arrest IVF In vitro fertilization FSH Follicle-stimulating hormone AMH Anti-Müllerian hormone OPU Oocyte pick-up 2PN Two-pronucleus BMI Body mass index TESE Testicular sperm extraction PESA Percutaneous epididymal sperm aspiration MESA Microsurgical epididymal sperm aspiration Declarations Ethics approval and consent to participate This study was approved by the Ethics Committee of Ankara Etlik Zübeyde Hanım Training and Research Hospital , Ankara, Turkey (Approval No: [01-21 17.01.2020] ). The study was conducted in accordance with the ethical principles of the Declaration of Helsinki . Due to the retrospective nature of the study and the use of anonymized patient data, the requirement for informed consent was waived by the Ethics Committee . Consent for publication Not applicable. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests . Funding This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Authors’ contributions Mustafa Akşar conceived and designed the study, collected the data, performed the statistical analysis,and drafted the manuscript. Serdar Dilbaz contributed to study design, data interpretation, and critical revision of the manuscript. All authors read and approved the final manuscript. Acknowledgements Not applicable. References Moomjy M, et al. Implications of complete fertilization failure after intracytoplasmic sperm injection for subsequent fertilization and reproductive outcome. Hum Reprod (Oxford England). 1998;13(8):2212–6. Boulet SL, et al. Trends in use of and reproductive outcomes associated with intracytoplasmic sperm injection. JAMA. 2015;313(3):255–63. Palermo GD, et al. ICSI: where we have been and where we are going. Semin Reprod Med. 2009;27(2):191–201. Sarikaya E, et al. Analysis of 232 total fertilization failure cycles during intracytoplasmic sperm injection. Iran J Reproductive Med. 2011;9(2):105–12. Qi ST, Liang LF, Xian YX, Liu JQ, Wang W. Arrested human embryos are more likely to have abnormal chromosomes than developing embryos from women of advanced maternal age. J Ovarian Res. 2014;7:65. Published 2014 Jun 13. 10.1186/1757-2215-7-65 Liu J, et al. Analysis of 76 total fertilization failure cycles out of 2732 intracytoplasmic sperm injection cycles. Hum Reprod (Oxford England). 1995;10(10):2630–6. Sibel Bulgurcuoğlu BÖ. The Effect Of Preimplantation Embryo Development Arrest On Assisted Reproductive Treatment Results. J Ist Faculty Med 2019, 2019. Yanagida K. Complete fertilization failure in ICSI. Hum Cell. 2004;17(4):187–93. Shinar S, et al. Total fertilization failure in intra-cytoplasmic sperm injection cycles–classification and management. Gynecol Endocrinol. 2014;30(8):593–6. Betts DH, Madan P. Permanent embryo arrest: molecular and cellular concepts. Mol Hum Reprod. 2008;14(8):445–53. Gabrielsen A, et al. Intracytoplasmic sperm injection does not overcome an oocyte defect in previous fertilization failure with conventional in-vitro fertilization and normal spermatozoa. Hum Reprod. 1996;11(9):1963–5. Liu L et al. Clinical outcome of IVF/ICSI cycles with an arrested embryo on day 3. 2016. 9: pp. 16414–24. Vanderzwalmen P, et al. Two essential steps for a successful intracytoplasmic sperm injection: injection of immobilized spermatozoa after rupture of the oolema. Hum Reprod. 1996;11(3):540–7. Shen S, et al. Statistical analysis of factors affecting fertilization rates and clinical outcome associated with intracytoplasmic sperm injection. Fertil Steril. 2003;79(2):355–60. Vandervorst M, et al. Patients with absolutely immotile spermatozoa and intracytoplasmic sperm injection. Hum Reprod. 1997;12(11):2429–33. Aboulghar MA, et al. fertilization and pregnancy rates after intracytoplasmic sperm injection using ejaculate semen and surgically retrieved sperm. Fertil Steril. 1997;68(1):108–11. Göker EN, et al. comparison of the ICSI outcome of ejaculated sperm with normal, abnormal parameters and testicular sperm. Eur J Obstet Gynecol Reprod Biol. 2002;104(2):129–36. Desai N, et al. Azoospermia and embryo morphokinetics: testicular sperm-derived embryos exhibit delays in early cell cycle events and increased arrest prior to compaction. J Assist Reprod Genet. 2018;35(7):1339–48. Melie NA, et al. Predictive value of the number of oocytes retrieved at ultrasound-directed follicular aspiration with regard to fertilization rates and pregnancy outcome in intracytoplasmic sperm injection treatment cycles. Fertil Steril. 2003;80(6):1376–9. Flaherty SP, et al. Aetiology of failed and abnormal fertilization after intracytoplasmic sperm injection. Hum Reprod. 1995;10(10):2623–9. Álvarez C, et al. In vitro maturation, fertilization, embryo development & clinical outcome of human metaphase-I oocytes retrieved from stimulated intracytoplasmic sperm injection cycles. Indian J Med Res. 2013;137(2):331–8. Combelles CM, et al. Assessment of nuclear and cytoplasmic maturation in in-vitro matured human oocytes. Hum Reprod. 2002;17(4):1006–16. Tomas C, Nuojua-Huttunen S, Martikainen H. Pretreatment transvaginal ultrasound examination predicts ovarian responsiveness to gonadotrophins in in-vitro fertilization. Hum Reprod. 1997;12(2):220–3. Lin WQ, et al. The predictive value of anti-Mullerian hormone on embryo quality, blastocyst development, and pregnancy rate following in vitro fertilization-embryo transfer (IVF-ET). J Assist Reprod Genet. 2013;30(5):649–55. Taylor J, Grudzinskas BCG, Handyside AH, Shaw LM, Thornhill AR. Failed fertilisation: a review of approximately 6,000 cases of IVF/ICSI. Fertil Steril. 2007;88:S153. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 09 Mar, 2026 Read the published version in BMC Women's Health → Version 1 posted Editorial decision: Revision requested 20 Feb, 2026 Reviews received at journal 19 Feb, 2026 Reviewers agreed at journal 13 Feb, 2026 Reviewers agreed at journal 13 Feb, 2026 Reviews received at journal 12 Feb, 2026 Reviews received at journal 12 Feb, 2026 Reviewers agreed at journal 12 Feb, 2026 Reviewers agreed at journal 12 Feb, 2026 Reviewers invited by journal 12 Feb, 2026 Editor assigned by journal 12 Feb, 2026 Editor invited by journal 30 Jan, 2026 Submission checks completed at journal 29 Jan, 2026 First submitted to journal 29 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8701915","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":590749833,"identity":"2d9d3faa-302d-41f4-bed1-5b8900c25496","order_by":0,"name":"mustafa akşar","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9UlEQVRIiWNgGAWjYNACGwYGCRD9sQFEMjYeIKCesYEhDaKFcWYDiGZsIF4LM28DxDa8WnRnpD9/8CPBTl6y//Czz7Y7bOp02w8DbamxicalxexGjmFjT0Ky4WyJNOPZuWfSJMzOJAK1HEvLbcCthbGB9wcz4zwJBmPm3LbDEmYHgFoYGw7j0ZL+sPFPQr39PP7jn5ktQVrOPySkJcGwmSfhcOJshhxjZkaQlhuEbDnzxnC2TMLx5JkzcooZe9vSJLfdANqSgM8vx9MffHyTUG074/zxzQw/22z4zc6nP3zwocYGpxYcIIE05aNgFIyCUTAK0AAA/YFkgL8Yh0YAAAAASUVORK5CYII=","orcid":"","institution":"Etlik Zübeyde Hanım Kadın Hastalıkları Eğitim ve Araştırma Hastanesi","correspondingAuthor":true,"prefix":"","firstName":"mustafa","middleName":"","lastName":"akşar","suffix":""},{"id":590749834,"identity":"5523b30c-d63b-4f1c-841d-04d50f429345","order_by":1,"name":"serdar dilbaz","email":"","orcid":"","institution":"Etlik Zübeyde Hanım Kadın Hastalıkları Eğitim ve Araştırma Hastanesi","correspondingAuthor":false,"prefix":"","firstName":"serdar","middleName":"","lastName":"dilbaz","suffix":""}],"badges":[],"createdAt":"2026-01-26 15:38:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8701915/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8701915/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12905-026-04384-4","type":"published","date":"2026-03-09T15:59:41+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":102893954,"identity":"17e2c411-4472-4562-a6e3-c80a84d169bc","added_by":"auto","created_at":"2026-02-18 05:56:05","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":48616,"visible":true,"origin":"","legend":"\u003cp\u003eROC analysis in terms of prediction of fertilization success of 2PN number\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8701915/v1/f564be111e36f79c0fe7cab7.png"},{"id":104740295,"identity":"02e934ec-9bb0-4d30-9536-ddfb187dfa60","added_by":"auto","created_at":"2026-03-16 16:16:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1360123,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8701915/v1/7a0fe3cc-5c91-4702-805b-6193c13c67b0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Defining Predictive Factors for Total Fertilization Failure and Embryo Development Arrest in Intracytoplasmic Sperm Injection Cycles","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eIntracytoplasmic sperm injection (ICSI) is an effective method applied to increase fertilization rates in cycles that do not fertilize or have low fertilization rates after conventional in vitro fertilization (IVF) treatment [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The capacity of ICSI to fertilize oocytes with almost any type of spermatozoa has made this technique the most successful treatment for male infertility. ICSI for male infertility increased from 84% in 2003 to 93% in 2012 [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Fertilization rates of up to 80% and clinical pregnancy rates of up to 45% are observed with ICSI [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough fertilization success rates seem high in ICSI, 1\u0026ndash;4% total fertilization failure (TFF) and 15\u0026ndash;16% embryo development arrest (EDA) occur in all ICSI cases [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Therefore, it is essential to identify the causes of TFF and EDA, the etiology of which has not yet been clarified, to reduce stressful consequences for both the patient and the clinician and maximize the success rate per cycle.\u003c/p\u003e \u003cp\u003eTotal fertilization failure (TFF) refers to the fertilization failure of all mature oocytes after oocyte retrieval. Failure rates increase in recurrent ICSI cycles and rise to 13% in second ICSI trials [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The causes of TFF are generally described as male infertility with impaired semen parameters and sperm morphologies and cycles with low oocyte count and quality [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEmbryo developmental arrest (EDA) describes embryos that do not divide after 24 hours and stall at the single-cell stage. It has been shown that female age, insufficient in vitro culture conditions, and insufficient oocyte maturity and paternal factors may cause embryo development arrest [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe primary aim of this study is to reveal the factors that predict total fertilization failure and embryo development arrest.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003eData of patients admitted to Ankara Etlik Z\u0026uuml;beyde Hanım Gynecology Training and Research Hospital Reproductive Assisted Therapy Clinic for infertility treatment. They underwent ICSI treatment between January 2016 and December 2019 (n\u0026thinsp;=\u0026thinsp;1846) were analyzed retrospectively. Files of the patients were obtained from the clinical database with the permission of the university ethics committee.\u003c/p\u003e \u003cp\u003ePatients who underwent conventional IVF, those with uncontrolled systemic disease, those with insufficient data, and those who could not obtain oocyte and sperm were not included in the study.\u003c/p\u003e \u003cp\u003eIn the study, 1846 cycles were included, GnRH agonist, GnRH antagonist, oral contraceptive (OCS) long luteal or microdose flare protocol used for controlled ovarian stimulation. recFSH and recLH were used as gonadotropins. The gonadotropin dose was individualized according to the patient. Follicle follow-up and cycle monitoring were performed by serial measurement of serum luteinizing hormone, estradiol (E2), and progesterone levels and evaluating the number and size of follicles with TVUSG. When the mean diameter of the three reached 17 mm, subcutaneous recombinant hCG (Ovitrelle, Serono, Istanbul, Turkey) was administered. Oocyte pick-up (OPU) was performed 36 hours after hCG administration, using an aspiration needle with TVUSG guidance. Oocytes were removed from the cumulus oophorus by soaking in hyaluronidase solutions (Vitrolife, Sweden). Oocytes were kept at 37\u0026deg;C, 5% carbon dioxide, and 95% humidity until the ICSI procedure (G-IVF medium, Vitrolife, Sweden).\u003c/p\u003e \u003cp\u003eThe sperm sample was obtained mainly from the ejaculate on the day of oocyte retrieval, after 2\u0026ndash;7 days of sexual abstinence. Microdissection epididymal sperm aspiration (MESA) under local anesthesia with interventional methods in the absence of ejaculate or viable sperm; percutaneous epididymal sperm aspiration (PESA) or testicular sperm extraction (TESE) was performed. Semen was examined in terms of sperm count, motility and morphology. The examined sperm were prepared for fertilization.\u003c/p\u003e \u003cp\u003eICSI was applied to all patients included in the same embryologist for the fertilization study. A single sperm selected by the injection pipette was caught by the tail, kept from moving, and then drawn into the pipette. Collected oocytes were cleared of cumulus and granulosa cells. Polar bodies fixed. The zona pellucida and oolemma were passed with a pipette, and the sperm were placed directly into the ooplasm. Oocytes were examined for the presence of fertilization, approximately 18 hours after insemination, for pronucleus and polar bodies. Cycles did not show 2PN structure, and this condition was observed in all oocytes recorded with the result of TFF (n\u0026thinsp;=\u0026thinsp;121).\u003c/p\u003e \u003cp\u003eEmbryo culture was performed using a sequential medium system, followed by daily development. Morphological criteria were used during evaluation [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Cell size, blastomere nuclear structure, and fragmentation status were evaluated and recorded per the development day. In addition, embryos that did not show division for 24 hours that paused at the single-cell stage were recorded with the result of EDA (n\u0026thinsp;=\u0026thinsp;313).\u003c/p\u003e \u003cp\u003eThe group which quality embryos obtained for transfer (Group I, successful fertilization, n\u0026thinsp;=\u0026thinsp;1412) and the results of EDA and TFF (Group II, unsuccessful fertilization, n\u0026thinsp;=\u0026thinsp;434) compared by age, body mass index (BMI), follicle-stimulating hormone (FSH), and estradiol (E2) level in the early follicular phase, serum anti-mullerian hormone (AMH) level, antral follicle count, infertility duration, oocyte pick up (OPU) day estradiol level, number of oocytes collected in OPU, semen analysis parameters (advanced motile sperm count, Kruger ratio, total sperm count, motile sperm ratio), 2PN number, ovulation induction time, total administered gonadotropin dose.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis and Statistics\u003c/h2\u003e \u003cp\u003eData for all patients included at the end of the study were performed using IBM SPSS version 22 (22.0, SPSS Inc., Chicago, IL, USA). The distribution of continuous data was determined using the Kolmogorov-Smirnov test of normality. Since continuous data did not show normal distribution, median, minimum, and maximum values ​​were calculated with descriptive statistics. Mann-Whitney U test was used to compare two groups of continuous data showing non-parametric distribution, and the Kruskal Wallis test was used to compare the three groups. Chi-square and Fisher exact test were used for categorical variables between groups. Bonferroni correction and Mann-Whitney U test were used for pairwise comparisons of data in which significant differences were detected in triple comparisons. Spearman correlation analysis was used for correlations between variables. Univariant and multivariant regression analyses evaluated the factors predicting fertilization success. Optimal cut-off, sensitivity, specificity values, and prognostic factors were calculated by ROC analysis​​. P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe successful fertilization rate, in which quality embryos for transfer were obtained, was 76.5% (1412/1846). Total fertilization failure was detected in 6.6% (121/1846) and embryo development arrest in 16.9% (313/1846).\u003c/p\u003e \u003cp\u003eFertilization success was 97.5% in ovulatory dysfunction, 92.6% in male factor, 85% in unexplained infertility, and 59.2% in DOR cases; Fertilization success was 32.1% in endometriosis and only 35.3% in tubal factor. A statistically significant difference was found in the comparison according to infertility etiology (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of fertilization success according to infertility etiology\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSuccessful Fertilization (Group 1)\u003c/p\u003e \u003cp\u003en:1412\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEmbryo Development Arrest and Total Fertilization Failure (Group 2)\u003c/p\u003e \u003cp\u003eN:434\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUnexplained infertility\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e%85 (198/231)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%15 (33/231)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMale factor\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e%92,6 (416/449)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%7,4 (33/449)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDOR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e%59,2 (134/226)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%40,8 (92/226)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEndometriosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e%32,1 (45/140)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%67,9 (95/140)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOvulatory Dysfunction\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e%97,5 (527/540)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%2,5 (13/540)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTubal factor\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e%35,3 (92/260)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%64,7 (168/260)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1412\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e434\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eDOR: Diminished ovarian reserve\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eNo statistically significant difference was found in terms of BMI, 3rd day E2 level, ovulation induction time and infertility duration between group 1 and 2 (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). In Group I, age [(31 (19\u0026ndash;46) vs 33 (18\u0026ndash;47), p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respectively] and on day 3 FSH level [(7.69 (0.48-62) vs 9.2 (0.71-42), p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respectively] were significantly lower than Group II. Estradiol level on OPU day [1310 (97-7731) vs 785 (58-5959), p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respectively], serum AMH level [1.81 (0.01-33) vs 0.7 (0.01-74), p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respectively], antral follicle count [10 (0\u0026ndash;30) vs 6 (0\u0026ndash;30), p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respectively], number of oocytes retrieved on OPU day [10 (1-144) vs 5 (1\u0026ndash;31), p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respectively] and 2PN number [4 (1\u0026ndash;28) vs 1 (0\u0026ndash;16), p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respectively] were significantly higher in Group I than Group II (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of cases according to fertilization success\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSuccessful Fertilization (Group 1)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEmbryo Development Arrest and Total Fertilization Failure (Group 2)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en:1412\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN:434\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFemale Age, yıl\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (19\u0026ndash;46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (18\u0026ndash;47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI, kg/m\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25,6 (15,7\u0026ndash;44,8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (17\u0026ndash;45,4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,265\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFSH, mIU/mL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7,69 (0,48\u0026ndash;62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9,2 (0,71\u0026thinsp;\u0026minus;\u0026thinsp;42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEstradiol, pg/mL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47,9 (11,8-482)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44 (11,6-596)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,874\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOPU day estradiol level, pg/mL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1310 (97-7731)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e785 (58-5959)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAMH, ng/mL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,81 (0,01\u0026ndash;33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0,7 (0,01\u0026ndash;74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAntral Follicle Count\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (0\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (0\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAdministraeed gonodotropin total dose\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2025 (675\u0026ndash;7800)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2400 (688\u0026ndash;5550)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOvulation induction time, day\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (6\u0026ndash;17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (5\u0026ndash;15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,062\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOPU day collected oocyt count\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (1-144)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (1\u0026ndash;31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eObtained M2 oocyt count by OPU\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (1\u0026ndash;32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (0\u0026ndash;26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInfertility period, mounth\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54 (1-288)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57 (2-276)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,642\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2PN count\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (1\u0026ndash;28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0\u0026ndash;16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eBMI: body mass index, FSH: follicle-stimulating hormone, OPU: oocyte pick up, AMH: anti-m\u0026uuml;llerian hormone\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWhen patients were grouped according to sperm retrieval techniques, it was seen that the most sperm was obtained from the ejaculate (1604/1746), second TESE procedure (132/1746) was performed. Fertilization success was found to be 75.4% (1211/1604) from the ejaculate, 70.4% (93/132) in TESE, and 80% (8/10) in the group in which other techniques were preferred (MESA, PESA, etc.). No statistically significant difference was found according to the sperm retrieval method (p\u0026thinsp;=\u0026thinsp;0.771, Table\u0026nbsp;3). Total sperm count, motility rate [% (A\u0026thinsp;+\u0026thinsp;B)], total progressive motile sperm count, and Kruger rate (%) were compared, no statistically significant difference was found (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). A statistically significant difference was found between the two groups only in terms of male age [33 (20\u0026ndash;55) vs. 34 (22\u0026ndash;67), p\u0026thinsp;\u0026lt;\u0026thinsp;0.01, respectively] (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eTable 3. \u0026nbsp; The effect of sperm retrieval techniques on fertilization success\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"605\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuccessful Fertilization (Group 1)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 304px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmbryo Development Arrest and Total Fertilization Failure (Group 2)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en:1412\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 304px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN:434\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEjaculate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e%75,4 (1211/1604)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 304px;\"\u003e\n \u003cp\u003e%24,6 (393/1604)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0,771\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTESE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e%70,4 (93/132)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 304px;\"\u003e\n \u003cp\u003e%29,6 (39/132)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOthers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e%80 (8/10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 304px;\"\u003e\n \u003cp\u003e%20 (2/10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 169px;\"\u003e\n \u003cp\u003e1312\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 304px;\"\u003e\n \u003cp\u003e434\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 548px;\"\u003e\n \u003cp\u003eTESE: testicular sperm extraction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4. Comparison of the included cases according to fertilization success as TFF, EDA, and successful fertilization\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"652\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 150px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTFF\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEDA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 159px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuccessful\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en= 121\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en= 313\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 159px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFertilization\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 148px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 159px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en= 1412\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale Age, yıl\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e35 (24-47)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003e33 (18-46)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 159px;\"\u003e\n \u003cp\u003e31 (19-46)\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI, kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e26,9 (17-45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003e25,75 (17-43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 159px;\"\u003e\n \u003cp\u003e25,8 (15,7-44,8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e0,153\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFSH, mIU/mL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e10,7 (2,48-22,92)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003e8,9 (0,7-42)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 159px;\"\u003e\n \u003cp\u003e7,7 (0,42-62)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEstradiol, pg/mL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e43 (11,8-178)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003e45,1 (15-496)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 159px;\"\u003e\n \u003cp\u003e47,5 (11,8-492)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e0,983\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOPU day estradiol level, pg/mL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e589,8 (69,1-5256,5)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003e821,5 (58,3-5852,9)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 159px;\"\u003e\n \u003cp\u003e1310,3 (97,3-7731,9)\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAMH, ng/mL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e0,63 (0,1-13)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003e0,7 (0,1-74)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 159px;\"\u003e\n \u003cp\u003e1,75 (0,1-33) \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAntral Follicle Count\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e5 (0-30)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003e7 (0-30)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 159px;\"\u003e\n \u003cp\u003e10 (0-30)\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdministraeed gonodotropin total dose\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e2400 (1100-5250)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003e2250 (688-5550)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 159px;\"\u003e\n \u003cp\u003e2025 (800-5250)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOvulation induction time, day\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 148px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 159px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOPU day collected oocyt count\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e4 (1-29)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003e5 (1-31)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 159px;\"\u003e\n \u003cp\u003e10 (1-43)\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eObtained M2 oocyt count by OPU\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e2 (0-20)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003e4 (0-26)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 159px;\"\u003e\n \u003cp\u003e8 (1-32)\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInfertility period, mounth\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e48 (7-228)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003e60 (2-276)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 159px;\"\u003e\n \u003cp\u003e48 (1-264)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e0,881\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 150px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2PN count\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 111px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 148px;\"\u003e\n \u003cp\u003e1 (0-16)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 159px;\"\u003e\n \u003cp\u003e4 (0-28)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" style=\"width: 652px;\"\u003e\n \u003cp\u003eBMI: body mass index, FSH: follicle stim\u0026uuml;le edici hormon, OPU: oosit pick up, AMH: anti-m\u0026uuml;llerian hormon\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" style=\"width: 652px;\"\u003e\n \u003cp\u003ea,b,c; groups indicated with different letters are statistically different among themselves\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\u003cp\u003eWhen TFF, EDA and successful fertilization cases compared; female age [35 (24\u0026ndash;47) vs 33 (18\u0026ndash;46) vs 31 (19\u0026ndash;46), p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respectively], estradiol level on OPU day [589.8 (69.1-5256.5) vs 821 .5 (58.3-5852.9) vs. 1310.3 (97.3-7731.9), p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respectively], antral follicle count [5 (0\u0026ndash;30) vs 7 (0\u0026ndash;30) vs. 10 (0\u0026ndash;30), p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respectively], number of oocytes collected on OPU day [4 (1\u0026ndash;29) vs 5 (1\u0026ndash;31) vs 10 (1\u0026ndash;43), p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respectively], number of M2 oocytes [2 (0\u0026ndash;20) vs 4 (0\u0026ndash;26) vs 8 (1\u0026ndash;32), p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respectively] and 2PN number [0 vs 1 (0\u0026ndash;16) vs 4 (0\u0026ndash;28), p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respectively], there was a statistically significant difference between all three groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eWhile serum AMH level was similar between TFF and EDA groups, it was significantly higher in the group with successful fertilization compared to the other two groups [0.63 (0.1\u0026ndash;13) vs. 0.7 (0.1\u0026ndash;74) vs. 1.75 (0.1\u0026ndash;33), p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respectively]. While the serum FSH level on the 3rd day was similar in the TFF and EDA groups, it was found to be significantly lower in the group with successful fertilization [10.7 (2.48\u0026ndash;22.92) vs. 8.9 (0.7\u0026ndash;42) vs. 7.7 (0,42\u0026ndash;62), p0.001, respectively]. When the total dose of gonadotropin administered was compared, it was similar in the TFF and EDA groups. It was found to be significantly lower in successful fertilization [2400 (1100\u0026ndash;5250) vs. 2250 (688\u0026ndash;5550) vs. 2025 (800\u0026ndash;5250), p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respectively]. There was no statistically significant difference between the three groups regarding body mass index, 3rd-day estradiol level, ovulation induction time, and infertility time (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e4\u003c/span\u003e summarizes the comparison of the three groups.\u003c/p\u003e \u003cp\u003eIn the multivariate logistic regression analysis prepared by including female age, serum AMH level, FSH level on day 3, estradiol level on day 3 of OPU, number of antral follicles, number of oocytes retrieved, and 2PN, only 2PN number was determined as an independent prognostic factor for successful fertilization [OR\u0026thinsp;=\u0026thinsp;12.016 (7,529\u0026thinsp;\u0026minus;\u0026thinsp;19,176), p\u0026thinsp;\u0026lt;\u0026thinsp;0.001]. Univariate and multivariate analyses are shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e \n\u003cp\u003e\u003cstrong\u003eTable 5. Univariate and multivariate logistic regression analysis of factors predicting fertilization success\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"483\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnivariate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 256px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnalysis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 256px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMultivariate Analysis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 256px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 64px;\"\u003e\n \u003cp\u003ePatients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 64px;\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 64px;\"\u003e\n \u003cp\u003eOdds ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 128px;\"\u003e\n \u003cp\u003e95% C.I.for EXP(B)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 64px;\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eLower\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003eUpper\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale age, year\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026lt;0,001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0,927\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0,625\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 64px;\"\u003e\n \u003cp\u003e1,376\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0,706\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026lt;32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e773/956\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026ge;32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e638/886\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAMH, ng/mL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 64px;\"\u003e\n \u003cp\u003e1,068\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0,647\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 64px;\"\u003e\n \u003cp\u003e1,763\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0,796\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026lt;1,46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e296/440\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026ge;1,46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e378/447\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3. day FSH level, mIU/mL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0,878\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0,592\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 64px;\"\u003e\n \u003cp\u003e1,303\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0,52\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026lt;7,95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e862/1040\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026ge;7,95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e545/801\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOPU day estradiol level, pg/mL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0,851\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0,504\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 64px;\"\u003e\n \u003cp\u003e1,439\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0,548\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026lt;1108\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e549/837\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026ge;1108\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e756/898\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAntral follicle count\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0,915\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0,572\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 64px;\"\u003e\n \u003cp\u003e1,465\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0,712\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026lt;8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e423/652\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026ge;8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e988/1193\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOPU day collected oocyst count\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 64px;\"\u003e\n \u003cp\u003e1,356\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0,788\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 64px;\"\u003e\n \u003cp\u003e2,332\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 64px;\"\u003e\n \u003cp\u003e0,272\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026lt;8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e428/711\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026ge;8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e885/1036\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2PN number\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 64px;\"\u003e\n \u003cp\u003e12,016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 64px;\"\u003e\n \u003cp\u003e7,529\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 64px;\"\u003e\n \u003cp\u003e19,176\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026lt;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e332/671\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026ge;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e980/1073\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" style=\"width: 483px;\"\u003e\n \u003cp\u003eAMH: anti-m\u0026uuml;llerian hormone, FSH: follicle-stimulating hormone, OPU: oocyst pick up\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\u003c/br\u003e\u003cp\u003eIn the ROC analysis, the number of 2PNs significantly predicted fertilization success. The optimal cut-off was calculated as 2.5 with 75% sensitivity and 78% specificity (AUC: 0.845, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eFertilization failure and embryo development arrest are still important stress factors for the clinician and the patient in ICSI applied cases. Considering IVF treatment's financial and moral burdens, maximizing our success rate per cycle is essential. After introducing ICSI, the fertilization failure rate decreased significantly compared to the conventional IVF technique. In the study conducted by Liu J. et al. in 1994, including 2732 cycles, the rate of TFF was found to be 3% [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In a study by Yanagida K., the rate of TFF was found to be 5.6% [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In another study by Shinar et al., the rate of TFF was found to be 4.3% [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, the rate of EDA in patients undergoing ICSI was 15% in a study by Betts D. and Madan P. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In the study conducted by Qi S. et al., EDA was 15.6% [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In our study, TFF 6.5% and EDA 16.8% occurred in all ICSI cases, with rates similar to those in the literature.\u003c/p\u003e \u003cp\u003eIn order to increase the success of fertilization, many new studies are carried out, and many new methods are tried. In previous studies, severe male factor was considered the leading cause of fertilization failure; Liu J. et al. described the causes of fertilization failure in general as impaired semen parameters, impaired sperm morphology, and cycles with low oocyte count and quality [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In a study by Gabrielsen et al., including 258 patients, it was reported that fertilization failure might occur due to oocyte defects [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Many studies have been conducted on the effect of infertility etiology on fertilization success. Previously, male infertility was shown as the primary cause, but recently, studies have shifted to unexplained infertility with the intensification of research at the molecular level. In a study conducted by Liu et al. in 2016, when patients were compared according to infertility etiology, embryo development arrest was found in most with unexplained infertility [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In a study conducted by Shinar et al., the rate of TFF was found to be higher in infertility due to male factors [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In our study, patients were compared according to the etiology of infertility; the highest fertilization success was observed in the group with ovulatory dysfunction. The group with the lowest fertilization success was accompanied by endometriosis. Due to the intertwining of infertility etiologies and the existence of cases with more than one disease, the results provide limited information.\u003c/p\u003e \u003cp\u003eDuring ICSI, fertilization failure may develop due to the use of inappropriate techniques or the inexperience of the practitioner. In a study conducted by Vanderzwalmen et al., it was shown that the injection of sperm that is not fully immobilized, which is a situation caused by the practitioner, reduces the success of fertilization [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In a study to predict fertilization failure, Shen et al. identified sperm motility and ICSI practitioner as the two most important predictive factors. Again, in this study, the ICSI operator was an independent risk factor for the number of 2PN, which is one of the first indicators of fertilization [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Since the ICSI practitioner was the same throughout our study, the study cannot fully explain the effect of the practitioner on fertilization success.\u003c/p\u003e \u003cp\u003eThe basic principle of ICSI is to minimize the causes related to the malefactor. In contrast, it is thought that one of the most important predictive factors of fertilization failure in sperm morphology, in a study conducted in 2011, Sarıkaya et al. found that Kruger ratio and advanced motile sperm count were similar in the group with TFF and the group with successful fertilization [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In another study, Svalander et al. reported that sperm morphology was not associated with fertilization failure [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Furthermore, in a study by Liu et al., which included 1900 patients and 2732 ICSI cycles, no difference was found in sperm concentration and morphology [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Again, in a study conducted by Bulgurcuoğlu S. and \u0026Ouml;zsait B. in 2019, no difference was found in total sperm count, advanced motile sperm count, Kruger rate, and sperm concentration in those with embryo development arrest [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Similarly, no difference was found between the groups in terms of semen analysis results in our study.\u003c/p\u003e \u003cp\u003eSperm origin is thought to be a factor affecting the success of ICSI. For this reason, many studies have compared fertilization rates according to sperm origin. For example, a study by Aboulgar et al. in 1997 found no difference in fertilization rates [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, in a study conducted by G\u0026ouml;ker et al. in 2002, fertilization and pregnancy rates were significantly lower in patients who underwent testicular biopsy [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Again, in a study conducted by Desai et al. in 2018, embryo development arrest was considerably higher in patients who underwent TESE [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, our study found no statistically significant difference when the patients were compared according to the sperm origin.\u003c/p\u003e \u003cp\u003eThe number of retrieved oocytes, oocyte quality, and oocyte morphology are accepted as essential parameters affecting fertilization success. Many studies have been carried out to determine the optimal number of oocytes. OHSS and the risk of multiple pregnancies are considered limiting factors in oocyte count. Since only M2 oocytes are used in ICSI, the number of mature oocytes is essential. In 2003, Melie et al. TFF rate; found that ICSI applied significantly decreased when the number of oocytes increased [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In yet another study, Flaherty et al. found the TFF rate to be 37% in those who underwent ICSI with one oocyte, 13% in those with two oocytes, and 0.8% in those with five or more oocytes [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In a study conducted by Yanagida K., the rate of TFF was found to be 28.7% in patients who underwent ICSI with a single oocyte and \u0026lt;\u0026thinsp;7% in those who applied more than four oocytes [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn a study conducted by Alvarez et al. in 2013 and including 1400 ICSI cycles, it was shown that embryo development arrest increased due to the decrease in the number of M2 oocytes [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Contrary to all these studies, Liu et al. found that M2 oocyte and 2PN numbers were significantly higher in the group with embryo development arrest. In another study, Bulgurcuoğlu S. and \u0026Ouml;zsait B. found that the number of collected oocytes was high in the group with embryo development arrest [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. They explain this result as in the deficient embryo group; oocytes are recruited from smaller, immature follicles, resulting in many embryos of insufficient quality but not mature enough due to low developmental potential [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In this study, the number of oocytes collected in OPU and applied ICSI was significantly lower in the group with fertilization failure. It is known that abnormal morphology, genetics, and fragility of the oocyte negatively affect fertilization. In the study by Liu et al., it was shown that significant anomalies in the oocyte cause fertilization failure [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. As oocytes age, dysfunctional events during ovulation are more frequent. Such events at the first meiotic division are the most common cause of failure of assisted reproductive techniques [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In the study investigating the relationship of embryo development arrest with Age by Qi S. et al.; It has been shown that embryo development arrest increases significantly with age, which may be due to the increased risk of anapleuid [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In our study, female age was significantly higher in the group resulting in unsuccessful fertilization.\u003c/p\u003e \u003cp\u003eAntral follicle count, FSH level in the early follicular phase, and serum AMH level are parameters used to show ovarian capacity and predict ovarian response. Fertilization success may increase due to higher ovarian power; more oocytes can be obtained, and the number of oocytes that can be performed ICSI increases. In a study conducted by Tomas C. et al. in 1997, it was determined that there was a positive and significant relationship between the number of antral follicles and fertilization success, and the response to gonadotropin was higher in this group [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In another study, Wen-Quin et al. reported that fertilization success was positively associated with serum AMH levels [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In our study, the number of antral follicles and serum AMH levels was higher in the group with successful fertilization.\u003c/p\u003e \u003cp\u003eIt has been shown that serum FSH level\u0026thinsp;\u0026gt;\u0026thinsp;20 mU/ml and estradiol level\u0026thinsp;\u0026gt;\u0026thinsp;80 pg/ml in the early follicular phase is associated with poor ovarian response. It is known that fewer oocytes can be obtained with poor ovarian response. Fewer oocyte retrieval was also associated with lower fertilization rates. In the study conducted by Taylor T. et al., 1363 IVF cycles were included in 2001\u0026ndash;2006; no difference was found between the fertilized group in serum basal FSH and estradiol levels [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In another study by Bulguroğlu S. and \u0026Ouml;zsait B., no significant difference was found in the group with embryo development arrest in basal FSH and estradiol levels [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In a study by Liu L. et al., basal FSH level was significantly lower in the group with developmental arrest [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In our study, no difference was found in terms of basal estradiol level, but basal FSH level was significantly lower in the group with successful fertilization.\u003c/p\u003e \u003cp\u003eIn a study by Shen et al., a positive and significant correlation was found between estradiol level on the hCG day and fertilization success [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, in a study conducted by Sarıkaya et al. in 2011, no significant difference was found between the group with total fertilization failure and estradiol level on the hCG day [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In our study, estradiol level on the hCG day was significantly lower in the group with total fertilization failure and embryo development arrest.\u003c/p\u003e \u003cp\u003eMany studies have investigated the effect of the total dose of gonadotropin used during the treatment on fertilization success. High doses of gonadotropin are required to get a response to the treatment in the patient group with poor ovarian response. In a study conducted by Bulgurcuoğlu S. and \u0026Ouml;zsait B. in 2019, the total dose of gonadotropin used in the group with embryo development arrest was found to be significantly higher [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. No difference was found in a study by Liu L. et al. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. A significant negative relationship was found between the total dose of gonadotropin used in our study and fertilization success.\u003c/p\u003e \u003cp\u003eThe retrospective nature of the study is one of its weaknesses. On the other hand, only the results of the patients who underwent ICSI were included in the evaluation. Therefore, a comparison with the conventional in vitro fertilization technique could not be performed. Furthermore, the effect of ICSI practitioners on fertilization success could not be fully explained because the ICSI practitioner was the same throughout the study. Therefore, it may be beneficial to expand the study in these aspects and conduct prospective studies in more case series.\u003c/p\u003e \u003cp\u003eThe number of 2PNs has been determined as an independent prognostic factor for fertilization success. In addition, it has been defined as a parameter that can predict good quality embryos suitable for transfer.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eICSI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIntracytoplasmic sperm injection\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTFF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTotal fertilization failure\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEDA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEmbryo development arrest\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIVF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIn vitro fertilization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFSH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFollicle-stimulating hormone\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAMH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAnti-M\u0026uuml;llerian hormone\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOPU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOocyte pick-up\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e2PN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTwo-pronucleus\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBody mass index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTESE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTesticular sperm extraction\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePESA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePercutaneous epididymal sperm aspiration\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMESA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMicrosurgical epididymal sperm aspiration\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the \u003cstrong\u003eEthics Committee of Ankara Etlik Z\u0026uuml;beyde Hanım Training and Research Hospital\u003c/strong\u003e, Ankara, Turkey (Approval No:\u0026nbsp;\u003cem\u003e[01-21 17.01.2020]\u003c/em\u003e).\u003cbr\u003eThe study was conducted in accordance with the ethical principles of the \u003cstrong\u003eDeclaration of Helsinki\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eDue to the \u003cstrong\u003eretrospective nature\u003c/strong\u003e of the study and the use of anonymized patient data, the requirement for informed consent was \u003cstrong\u003ewaived by the Ethics Committee\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have \u003cstrong\u003eno competing interests\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMustafa Akşar conceived and designed the study, collected the data, performed the statistical analysis,and drafted the manuscript.\u003cbr\u003e\u0026nbsp;Serdar Dilbaz contributed to study design, data interpretation, and critical revision of the manuscript.\u003cbr\u003e\u0026nbsp;All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMoomjy M, et al. Implications of complete fertilization failure after intracytoplasmic sperm injection for subsequent fertilization and reproductive outcome. Hum Reprod (Oxford England). 1998;13(8):2212\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoulet SL, et al. Trends in use of and reproductive outcomes associated with intracytoplasmic sperm injection. JAMA. 2015;313(3):255\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePalermo GD, et al. ICSI: where we have been and where we are going. Semin Reprod Med. 2009;27(2):191\u0026ndash;201.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSarikaya E, et al. Analysis of 232 total fertilization failure cycles during intracytoplasmic sperm injection. Iran J Reproductive Med. 2011;9(2):105\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQi ST, Liang LF, Xian YX, Liu JQ, Wang W. Arrested human embryos are more likely to have abnormal chromosomes than developing embryos from women of advanced maternal age. J Ovarian Res. 2014;7:65. Published 2014 Jun 13. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/1757-2215-7-65\u003c/span\u003e\u003cspan address=\"10.1186/1757-2215-7-65\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu J, et al. Analysis of 76 total fertilization failure cycles out of 2732 intracytoplasmic sperm injection cycles. Hum Reprod (Oxford England). 1995;10(10):2630\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSibel Bulgurcuoğlu B\u0026Ouml;. The Effect Of Preimplantation Embryo Development Arrest On Assisted Reproductive Treatment Results. J Ist Faculty Med 2019, 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYanagida K. Complete fertilization failure in ICSI. Hum Cell. 2004;17(4):187\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShinar S, et al. Total fertilization failure in intra-cytoplasmic sperm injection cycles\u0026ndash;classification and management. Gynecol Endocrinol. 2014;30(8):593\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBetts DH, Madan P. Permanent embryo arrest: molecular and cellular concepts. Mol Hum Reprod. 2008;14(8):445\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGabrielsen A, et al. Intracytoplasmic sperm injection does not overcome an oocyte defect in previous fertilization failure with conventional in-vitro fertilization and normal spermatozoa. Hum Reprod. 1996;11(9):1963\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu L et al. Clinical outcome of IVF/ICSI cycles with an arrested embryo on day 3. 2016. 9: pp. 16414\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVanderzwalmen P, et al. Two essential steps for a successful intracytoplasmic sperm injection: injection of immobilized spermatozoa after rupture of the oolema. Hum Reprod. 1996;11(3):540\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShen S, et al. Statistical analysis of factors affecting fertilization rates and clinical outcome associated with intracytoplasmic sperm injection. Fertil Steril. 2003;79(2):355\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVandervorst M, et al. Patients with absolutely immotile spermatozoa and intracytoplasmic sperm injection. Hum Reprod. 1997;12(11):2429\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAboulghar MA, et al. fertilization and pregnancy rates after intracytoplasmic sperm injection using ejaculate semen and surgically retrieved sperm. Fertil Steril. 1997;68(1):108\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eG\u0026ouml;ker EN, et al. comparison of the ICSI outcome of ejaculated sperm with normal, abnormal parameters and testicular sperm. Eur J Obstet Gynecol Reprod Biol. 2002;104(2):129\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDesai N, et al. Azoospermia and embryo morphokinetics: testicular sperm-derived embryos exhibit delays in early cell cycle events and increased arrest prior to compaction. J Assist Reprod Genet. 2018;35(7):1339\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMelie NA, et al. Predictive value of the number of oocytes retrieved at ultrasound-directed follicular aspiration with regard to fertilization rates and pregnancy outcome in intracytoplasmic sperm injection treatment cycles. Fertil Steril. 2003;80(6):1376\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFlaherty SP, et al. Aetiology of failed and abnormal fertilization after intracytoplasmic sperm injection. Hum Reprod. 1995;10(10):2623\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u0026Aacute;lvarez C, et al. In vitro maturation, fertilization, embryo development \u0026amp; clinical outcome of human metaphase-I oocytes retrieved from stimulated intracytoplasmic sperm injection cycles. Indian J Med Res. 2013;137(2):331\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCombelles CM, et al. Assessment of nuclear and cytoplasmic maturation in in-vitro matured human oocytes. Hum Reprod. 2002;17(4):1006\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTomas C, Nuojua-Huttunen S, Martikainen H. Pretreatment transvaginal ultrasound examination predicts ovarian responsiveness to gonadotrophins in in-vitro fertilization. Hum Reprod. 1997;12(2):220\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLin WQ, et al. The predictive value of anti-Mullerian hormone on embryo quality, blastocyst development, and pregnancy rate following in vitro fertilization-embryo transfer (IVF-ET). J Assist Reprod Genet. 2013;30(5):649\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTaylor J, Grudzinskas BCG, Handyside AH, Shaw LM, Thornhill AR. Failed fertilisation: a review of approximately 6,000 cases of IVF/ICSI. Fertil Steril. 2007;88:S153.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8701915/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8701915/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eTotal fertilization failure (TFF) and embryo development arrest (EDA) remain challenging outcomes in intracytoplasmic sperm injection (ICSI) cycles. This study aimed to identify predictive factors associated with TFF and EDA in ICSI treatments.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis retrospective study analyzed 1846 ICSI cycles performed between January 2016 and December 2019 at a tertiary assisted reproduction center. Patients were categorized into successful fertilization and unsuccessful fertilization groups (TFF and EDA). Demographic characteristics, ovarian reserve markers, stimulation parameters, semen characteristics, and embryological outcomes were compared. Univariate and multivariate logistic regression analyses were performed to determine independent predictors of fertilization success. Receiver operating characteristic (ROC) analysis was used to evaluate prognostic factors.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSuccessful fertilization was achieved in 76.5% of cycles, while TFF and EDA occurred in 6.6% and 16.9%, respectively. Female age, basal FSH level, serum AMH level, antral follicle count, estradiol level on oocyte pick-up day, number of retrieved oocytes, and number of metaphase II oocytes were significantly associated with fertilization outcomes. In multivariate analysis, only the number of two-pronuclear (2PN) embryos was identified as an independent predictor of successful fertilization (OR\u0026thinsp;=\u0026thinsp;12.016, 95% CI: 7.529\u0026ndash;19.176, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). ROC analysis demonstrated that a 2PN cut-off value of 2.5 predicted fertilization success with 75% sensitivity and 78% specificity (AUC\u0026thinsp;=\u0026thinsp;0.845).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe number of 2PN embryos is the strongest independent prognostic factor for fertilization success in ICSI cycles. Identifying patients at risk for TFF and EDA may help optimize treatment strategies and improve clinical outcomes\u003c/p\u003e","manuscriptTitle":"Defining Predictive Factors for Total Fertilization Failure and Embryo Development Arrest in Intracytoplasmic Sperm Injection Cycles","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-18 05:55:54","doi":"10.21203/rs.3.rs-8701915/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-20T11:18:31+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-19T08:05:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"322978330254130704353705546052293760048","date":"2026-02-13T08:39:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"277153049310424318903257943370234041980","date":"2026-02-13T07:46:13+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-12T13:34:09+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-12T13:26:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"46580991317696689732169659616575389609","date":"2026-02-12T13:01:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"315967835758303560938898953877270672839","date":"2026-02-12T11:32:49+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-12T09:28:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-12T09:04:42+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-30T12:04:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-29T16:25:19+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2026-01-29T16:08:15+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3455d414-5073-46d0-a7ab-34d3e03fd43e","owner":[],"postedDate":"February 18th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-16T16:12:00+00:00","versionOfRecord":{"articleIdentity":"rs-8701915","link":"https://doi.org/10.1186/s12905-026-04384-4","journal":{"identity":"bmc-womens-health","isVorOnly":false,"title":"BMC Women's Health"},"publishedOn":"2026-03-09 15:59:41","publishedOnDateReadable":"March 9th, 2026"},"versionCreatedAt":"2026-02-18 05:55:54","video":"","vorDoi":"10.1186/s12905-026-04384-4","vorDoiUrl":"https://doi.org/10.1186/s12905-026-04384-4","workflowStages":[]},"version":"v1","identity":"rs-8701915","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8701915","identity":"rs-8701915","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}