Clinical outcome using the Q300™ device in a reproductive laboratory environment: an open-label, non-controlled and non-randomized study

Abstract

Background

Infertility affects a significant portion of the global population, with male factor infertility contributing to nearly half of all cases. The success of assisted reproductive technologies (ART), such as in vitro fertilization (IVF), depends on selecting high-quality sperm with optimal motility, morphology, and DNA integrity. The Q300™ device offers a novel approach for improving sperm selection. Utilizing an advanced optical imaging system, the Q300™ isolates the morphologically compliant sperm cells sperm for injection into the oocytes. This study aims to assess the usability and preliminary clinical outcome of the Q300™ device under “real-life conditions” in a fertility laboratory setting.

Methods

Preliminary clinical data collected from Barzilai Medical Center with or without using the technology were compared to the Key Performance Indicators (KPI) for ART laboratories according to the Vienna Consensus.

Results

The data suggest that the Q300™ significantly improved day-3 embryo development, blastulation, and cumulative pregnancy rates.

Conclusions

By offering a more refined and efficient selection process, the Q300™ has the potential to redefine clinical practice in infertility treatment, providing patients with a higher likelihood of achieving successful outcomes.

Trial registration

NCT06232720. Date of registration: 15 February 2023.

Enrollment of first subject: 20 August 2023. For more information, visit: https://clinicaltrials.gov/study/NCT06232720.

Background

Infertility represents a significant global health challenge, affecting millions and often leading to emotional and psychological stress [1]. While advances in reproductive medicine, such as in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI), have provided hope to many, the success of these treatments heavily relies on selecting the healthiest sperm [2, 3]. Traditional sperm selection methods, though effective to a degree, often lack precision in distinguishing between viable and non-viable sperm at a microscopic level. The sperm selection during ICSI is primarily based on manual and subjective morphological assessment and needs to be standardized for consistency and alignment between embryologists [4].

Advanced sperm selection techniques employ methods to enhance the accuracy and efficiency of selecting high-quality sperm. By focusing on key parameters such as motility, DNA integrity, and overall health [5], these technologies aim to improve fertilization rates, embryo quality [6], and ultimately the chances of a successful pregnancy [3].

Recent breakthroughs in sperm selection technology are poised to revolutionize infertility treatment. These innovations leverage cutting-edge techniques. Magnetic-activated cell sorting (MACS) employs a column containing annexin V microbeads that bind to the phosphatidylserine that is expressed in apoptotic sperm. Recent studies have confirmed the absence of a beneficial effect of MACS on pregnancy [7,8,9].

A microfluidics system, which contains micrometer-sized channels that enable sperm preparation without the need for centrifugation, has been shown to improve total motile sperm count, morphology, and DNA integrity [10,11,12], although it has yielded controversial results. Some studies presented positive effects of using microfluidics on live birth rate (LBR) [13], but others failed to support this conclusion [14].

Intracytoplasmic morphologically selected sperm injection (IMSI) involves the observation and selection of sperm based on the absence of vacuoles in the sperm head using high magnification (> 6000x) [15]. The latest reviews and meta-analyses showed that IMSI does not improve LBR [16,17,18].

Emerging technologies such as artificial intelligence (AI) and machine learning have gained traction recently. These technologies can assess progressive motility parameters to aid embryologists in sperm selection without causing damage or exposing the sperm to chemical stains [5, 6].

One of the newest techniques is the Q300™ device, an advanced optical imaging system designed for 3D morphological analysis of individual sperm [19]. This technology employs quantitative phase microscopy and principles of holographic imaging, enabling precise 3D refractive index measurement of live and motile sperm cells [20]. The device images live, motile sperm cells intended for subsequent injection into an oocyte for fertilization in ICSI procedures, and provides users with an automatic, objective, and recorded 3D morphological analysis of each sperm cell that the embryologist previously determined as normal and elected to inspect further. The Q300 provides a morphological map for each sperm cell that measures its refractive index at each point. The refractive index is an intrinsic property of cell material and indicates its dry mass. It has been shown that this map can be converted to a virtually stained version, making it possible to present the cell as if it is chemically stained [21, 22]; thus, allowing applying the WHO guidelines for chemically stained cells on live sperm cells during ICSI [23]. Based on this quantitative map of compliance with the WHO guidelines, the system indicates whether the inspected sperm cells should be selected or not. The green color indicates that the measured parameter (e.g., width, length, L/W, acrosome/head) fully complies with the WHO2021 range. The yellow range is a ± 10% borderline region, adjacent to the WHO2021 range. The red range is external to the yellow range. A green sperm cell means all four parameters are within the green range. A yellow sperm cell implies that at least one of its parameters is in the yellow range, but none are in the red range. A red sperm cell relates to a cell wherein at least one of its parameters is in the red range. The embryologist is advised to prefer green-marked sperm cells to yellow-marked sperm cells. While the Q300 device aids the clinical embryologist in selecting sperm cells, the embryologist can decide. This intervention aims to develop superior-quality embryos and achieve a successful pregnancy and live birth.

A previous multi-center double-blind study comparing sperm evaluation using the Q300™ system with chemical staining methods showed [24] the agreement between the QPM and the reference method was adequate with 85.2% sensitivity and 71.5% accuracy, however, the repeatability of the measurements was up to 10 × better when using the Q300™ system [24]. These results were obtained by having the embryologist select according to their current best clinical practice. Thus, these accuracy and sensitivity values relate to compliance with the WHO2021 metrics, a binary matching. It has previously been shown that 95–99% specificity and sensitivity can be obtained without the initial embryologist selection [25]. Another significant study revealed that less than 25% of the sperm cells chosen for ICSI through manual selection met the morphological criteria suggested by WHO 2021, despite this method being the current gold standard. This assessment was conducted by the same embryologists after the cells were fixed, stained, and analyzed offline at high digital magnification. This finding highlights the importance of improving the technology and techniques to identify the best sperm cell for injection into the oocyte.

We have compared the performance of the Q300 in sperm assessment to stain-based methods in our previous study [24]. Note that this directly compares to the commonly used morphological assessments that the WHO approves. Other comparisons to microfluidic-based methods are possible, but their quantification is problematic since they do not directly assess sperm morphology but motility.

This study aims to assess the usability and preliminary clinical outcomes of the Q300™ device in a real-world fertility laboratory setting. The assessment focuses on understanding how effectively the device can be integrated into routine laboratory workflows and its potential impact on clinical outcomes in assisted reproductive technology (ART).

To achieve this, preliminary clinical data were collected from Barzilai Medical Center, where ART procedures were conducted with and without using the Q300™ device. These datasets were then analyzed and compared against established Key Performance Indicators (KPIs) for ART laboratories, as outlined in the Vienna Consensus [26]. The Vienna Consensus provides standardized benchmarks for evaluating ART laboratory performance, ensuring that the study findings are assessed in the context of internationally recognized quality metrics.

By comparing clinical outcomes with and without the Q300™ device, the study aims to determine whether the technology contributes to improvements in key ART success parameters. The primary endpoints include fertilization rates, embryo development on day 2 and day 3, blastocyst, and good blastocyst development rates. The secondary endpoint consists of pregnancy outcomes.

Methods

Objectives

Thirty-four couples intended for ICSI, meeting specific inclusion and exclusion criteria (Table 1), were prospectively enrolled from the clinic’s patients. Eligibility criteria included female age ≤ 40, availability of fresh or frozen ejaculated motile sperm, and presence of motile sperm at the time of sperm selection for ICSI. No restrictions were imposed regarding the number of previous IVF/ICSI cycles per couple.

Table 1 Inclusion and exclusion criteria for participant selection

Sperm collection

Fresh semen samples were obtained by masturbation following a period of 2–5 days of sexual abstinence. The sample was allowed to liquefy at room temperature or 37 °C for 20–30 min.

Sperm preparation

For sperm preparation, the gradient of density and the swim-up technique were used. Gradient layers of 80% and 40% Isolate were used for the density gradient. The sample was centrifuged at 500 g for 20 min and washed using a multipurpose handling medium (MHM). The supernatant was discarded, and the pellet was resuspended in a small volume (20–50 µL) of sperm washing medium for the swim-up.

Sperm selection

Prepared sperm were transferred to a microdroplet of polyvinylpyrrolidone (PVP) solution in the ICSI dish for selection.

Each sperm cell selected by the embryologist was imaged using the Q300 device before microinjection to ensure morphological compliance. Initially, sperm cells were selected based on progressive motility and morphology. These cells were then imaged by the Q300 device to assess their morphological compliance according to WHO 2021 criteria.

ICSI procedure

Selected sperm were subsequently microinjected by electrohydraulic injectors (RI Integra micromanipulator, Cooper Surgical, USA). Non-compliant sperm cells were discarded. The ICSI procedure was performed as per standard protocols.

Embryo culture and vitrification

The oocytes were cultured in an Embryoscope using continuous single culture-NX complete medium (CSCM -NXC) (Irvine Scientific, California, USA) until day 3 or blastocyst stage. Subsequently, they were transferred or cryopreserved using a Kitazato vitrification kit (Kitazato, Japan).

Embryo thawing

Embryos or blastocysts were thawed using a Kitazato warming kit (Kitazato, Japan) and transferred to the CSCM-NXC dish.

Embryo transfer

Embryo transfer was performed using transabdominal ultrasound guidance employing a soft transfer catheter (Wallace, Cooper Surgical, USA).

Results

Thirty-four couples were recruited for the study from Barzilai Medical Center. Laboratory data from 34 couples using the Q300™ were compared to the results of a control group of 42 couples who did not use the Q300™ but met the same inclusion and exclusion criteria. These results were also compared to the KPIs for ART laboratories based on the Vienna Consensus (see Table 2).

Table 2 Clinical data comparison between the Q300™ group and the control group

The average age of females undergoing treatment was similar in both groups (33 vs. 34 years).

The average number of oocytes per couple was slightly lower in the Q300™ group (7.82 vs. 8.45), but this difference was not statistically significant (p = 0.62).

No statistically significant differences were found in sperm parameters between the groups, including sperm volume (3.04 mL vs. 3.3 mL, p = 0.53), sperm concentration (32.2 vs. 25.45 million cells/mL, p = 0.42), and sperm motility (57.5% vs. 44.8%, p = 0.16).

Among the Q300™ group, 61 sperm cells were classified as “green” (compliant with WHO criteria), and 205 were classified as “yellow” (at least one morphological parameter is within a 10% borderline range, outside the WHO criteria).

The percentage of injected cells relative to total sperm evaluated using the Q300™ device was 40.9% (266/650) (Table 2). These results underscore the challenges faced by embryologists in selecting the appropriate sperm for injection.

Fertilization and embryo development rates

The fertilization rate was comparable between the control group and the Q300™ group, with rates of 81.6% and 77.8%, respectively, showing no statistically significant difference (p = 0.65) (Vienna consensus competency: ≥ 65%) (Table 3). This difference was not statistically significant despite a slightly lower fertilization rate in the Q300™ group.

Table 3 Comparison of Q300™ results to control group results and KPIs for ART laboratories based on the Vienna Consensus

For Day 2 embryo development, the Q300™ group exhibited a slightly higher development rate (95.5%) compared to the control group (91.3%), although the difference was not statistically significant (p = 0.29). By Day 3, the embryo development rate showed a more pronounced improvement in the Q300™ group (91.7%) relative to the control group (84.3%), with this trend nearing statistical significance (p = 0.05).

The blastocyst development rate demonstrated a favorable trend in the Q300™ group (54.3%) compared to the control group (43.2%), though this difference was not statistically significant (p = 0.056). Similarly, the rate of good-quality blastocyst development was slightly higher in the Q300™ group (36.9%) versus the control group (31.5%) (Vienna consensus competency: ≥ 30%), but this difference did not reach statistical significance (p = 0.16).

The usable embryo rate per couple was slightly higher in the Q300™ group (59.1%) compared to the control group (54.8%), but this difference was not statistically significant (p = 0.20).

Pregnancy outcomes

The cumulative pregnancy rate per retrieval significantly improved in the Q300™ group, reaching 65% compared to 34.1% in the control group (p < 0.05).

Disscusion

Infertility impacts a considerable number of couples worldwide, with male factor infertility being a major contributor to conception difficulties [27]. ICSI is an advanced ART procedure designed to address infertility cases primarily caused by male factors [28]. This technique involves directly injecting a single sperm into an oocyte to enhance fertilization. In cases of male-factor infertility, ICSI has been shown to increase the likelihood of successful fertilization and pregnancy significantly [29].

Research has consistently shown that sperm morphology is critical in determining fertilization and pregnancy success in ICSI procedures [30]. Multiple studies have demonstrated a clear connection between sperm head morphology (including head size and shape, and acrosome size) and sperm DNA integrity. Abnormalities in sperm head shape or size are often linked to defective spermatogenesis, which results in poor chromatin condensation and elevated levels of DNA fragmentation [31, 32]. Men with teratozoospermia have been shown to exhibit significantly higher levels of reactive oxygen species (ROS), along with increased proportions of sperm exhibiting immature chromatin, denatured DNA, and DNA fragmentation. These parameters were positively correlated with abnormal sperm morphology, suggesting that impaired chromatin compaction can trigger DNA strand breaks and oxidative stress, thereby contributing to poor semen quality [33, 34]. Furthermore, research has identified a relationship between sperm head defects and incomplete chromatin condensation, a known contributor to increased DNA fragmentation [35, 36]. Due to the strong correlation between abnormalities in sperm head and acrosome morphology and compromised DNA integrity, and the practical challenges of assessing DNA integrity during sperm preparation for injection, evaluating sperm morphology remains the most effective approach for selecting the optimal sperm cell for injection. It is prudent to mention that most, if not all, such studies explored average semen parameters and did not compare individual sperm cell parameters on a cell-by-cell basis. The reason for that is that these semen assays date back to the time when classical IVF was solely used, so the general semen characteristics were more relevant than individual sperm cell parameters, and, also due to much higher technical complexity in measuring some of these parameters on a single-cell level, such as the extent of DNA fragmentation level.

Standardizing traditional sperm selection methods is essential to ensure uniformity and accuracy among embryologists [4]. The integration of emerging technologies into clinical practice expands the range of tools available to fertility specialists, offering renewed hope to couples struggling with infertility. Furthermore, this innovative 3D imaging tool lays the groundwork for AI-driven sperm selection, potentially introducing new criteria and improving standardization in sperm analysis and selection.

of Q300™ technology allowed for a quantitative, more precise and objective assessment of individual sperm-cell morphology, enabling embryologists to select highly compliant, the most viable sperm cells with greater accuracy than with conventional methods. This technique enhances sperm selection through virtual staining and automated evaluation of internal organelles, following WHO 2021 guidelines, without chemical staining. By prioritizing the healthiest and most viable sperm for fertilization, Q300™ technology aims to improve embryo quality and increase implantation success rates.

This study included 34 couples using QART compared to 42 couples without using QART. The baseline characteristics, including female age and sperm parameters, were similar between the two groups, ensuring that outcome differences were likely attributable to the sperm selection method rather than confounding variables.

A critical observation for consideration was embryologists’ difficulty in manually identifying high-quality sperm for ICSI. The Q300™ device classified only 40.9% of the embryologist-selected sperm as suitable for injection, underscoring the challenge of selecting optimal sperm cells by simple embryologist observation, the current gold standard. Similar results were shown in a previous study by Michailov et al.,2023 [24]. Sperm selection by embryologists relies on a subjective assessment of sperm morphology, despite the WHO defining normal reference ranges for parameters such as head width, head length, length-to-width ratio, and acrosome-to-head ratio—measurements that cannot be accurately determined through visual inspection alone. Despite this, fertilization rates remained comparable between groups (81.6% vs. 77.8%, p = 0.65), aligning with Vienna Consensus competency benchmarks (≥ 65%).

Embryo development rates exhibited positive trends in favor of the Q300™ group. Although Day 2 embryo development rates were similar between groups, Day 3 development rates were higher in the Q300™ group (91.7% vs. 84.3%, p = 0.05). Blastocyst development rates also trended favorably (54.3% vs. 43.2%, p = 0.056), suggesting a potential benefit of enhanced sperm selection on embryo quality. Likewise, the rate of good-quality blastocysts was slightly higher in the Q300™ group (36.9% vs. 31.5%), surpassing the Vienna Consensus competency threshold (≥ 30%), though not reaching statistical significance (p = 0.16).

The most striking result was the significantly improved cumulative pregnancy rate per retrieval in the Q300™ group (65% vs. 34.1%, p < 0.05). This suggests that refined sperm selection using the Q300™ technology may contribute to higher implantation success and overall pregnancy rates. The increased rate of usable embryos per couple (59.1% vs. 54.8%, p = 0.20) further supports the potential of Q300™ to enhance ART outcomes.

This is a pilot study that demonstrates the Q300 technology on full ICSI cycles for the first time on 34 patients, presenting promising results. One possible limitation of this study is a relatively small sample size with a natural tendency to random variations. Future studies will extend the sample size and increase the statistical power. Furthermore, long-term follow-up of pregnancies and live birth outcomes will provide essential insights into the safety and efficacy of this approach. Q300 is the only commercial quantitative phase imaging technology that will soon become available for clinical use. The prospective price of the device is approximately 60 K$.

In conclusion, this study is the first to explore the impact of using a new type of sperm cell imaging and selection workstation, utilizing quantitative phase imaging to acquire and analyze the structure of live and motile human sperm cells. The Q300™ calculates WHO morphological parameters and presents them to the operator in real time, enabling objective and quantitative sperm selection during ICSI.

This study was intended to provide an understanding of the practical usability and early clinical impact of using the Q300™ device in the IVF laboratory. Moreover, this study aimed to help design future, statistically powered RCTs that will further explore the impact of the Q300™ on laboratory and clinical results of ICSI procedures. The initial data suggest favorable outcomes, improving day-3 embryo development, blastocyst formation, and cumulative pregnancy rates. Further research is necessary to identify the patient subgroups that can benefit the most from this system. Additionally, validating and statistically powering the outcome measures in future studies is crucial. In the next generation of the product, incorporating an objective selection based on sperm motility may further improve its functionality.

Conclusion

This technique has the potential to improve the trends in embryo development and significantly increase pregnancy rates, thereby enhancing the success of reproductive treatments. Future research should focus on optimizing its application and evaluating its role in standardizing sperm selection criteria to improve reproductive outcomes.