A prospective pilot study comparing fertilization and embryo development between fresh and vitrified sibling oocytes

OBJECTIVE

To evaluate the outcome of a newly established oocyte vitrification program in women undergoing in vitro fertilization (IVF) within a short timeframe by simultaneously evaluating embryos derived from vitrified and fresh oocytes from the same stimulated cycle.

DESIGN

Cohort prospective controlled trial and case-control study.

SETTING

University-based tertiary fertility center.

PATIENT(S)

Fourteen women who fulfilled the inclusion criteria underwent controlled ovarian hyperstimulation and Intracytoplasmic sperm injection (ICSI) treatment.

INTERVENTION(S)

Oocyte vitrification.

MAIN OUTCOME MEASURE(S)

The primary outcome measures were oocyte survival, fertilization and cleavage rate, and subsequent embryo development, compared between vitrified and fresh oocytes. Secondary outcomes were implantation, clinical pregnancy, miscarriage and live birth rates using embryos derived from the vitrified oocytes for transfer. This was compared with age-matched controls who met similar inclusion criteria as the study patients and who underwent IVF during the same time period. Neonatal data on all newborns was also collected.

RESULTS

From October 2009 until November 2010, a total of 17 patients were enrolled in this study (mean age 31.9 +/- 2.9 years). Three subjects withdrew prior to retrieval and one subject did not have a transfer from vitrified oocytes. A total of 164 metaphase II (MII) oocytes were retrieved (mean 11.7 +/- 3.7), 83 were vitrified with 86.7% survival. Fertilization rate was similar between vitrified and fresh oocytes (69.4 vs 78.2%, P = 0.8). Cleavage on day two, however, was lowerin the vitrified oocytes (88% vs 100%, P = 0.004). Implantation rate (IR) was 25% (7/28) with a mean number of 2.0 +/- 0.5 embryos transferred. Live birth rate/embryo transfer (ET) was 46.1% (6/13) after transferring embryos derived only from vitrified oocytes, (six live births, seven babies,one set of twins). One additional ongoing pregnancy has been established after transfer of a cryopreserved blastocyst derived from a vitrified oocyte (combined pregnancy rate/ ET: 50%; 7/14).

CONCLUSIONS

This study provides a viable model to quickly assess the efficacy of a newly established egg vitrification program following American Society for Reproductive Medicine (ASRM) guidelines in an investigational protocol. Embryos resulting from oocyte vitrification resulted in optimal live birth and implantation rate. The lower cleavage rate noted in this study may indicate a possible detrimental effect of the vitrification process, which may be overcome with additional experience and refinement of the technique.

Factors that predict the probability of a successful clinical outcome after induction of oocyte maturation with a gonadotropin-releasing hormone agonist

OBJECTIVE

To determine factors predicting cycle success after in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) in high-risk patients undergoing controlled ovarian stimulation with a gonadotropin-releasing hormone (GnRH) antagonist protocol with a GnRH agonist to induce oocyte maturation.

DESIGN

Retrospective cohort study.

SETTING

University-based tertiary fertility center.

PATIENT(S)

Women who underwent a GnRH antagonist protocol during IVF-ICSI cycles and received a GnRH agonist for oocyte maturation.

INTERVENTION(S)

GnRH-agonist trigger.

MAIN OUTCOME MEASURE(S)

Clinical and ongoing pregnancy rates and any occurrence of ovarian hyperstimulation syndrome (OHSS).

RESULT(S)

The serum luteinizing hormone (LH) level on the day of trigger of oocyte maturation was the single most important predictor of clinical pregnancy. Patients with a peak estradiol (E(2)) level ≥4,000 pg/mL also had statistically significant higher serum LH on the day of the GnRH-agonist trigger and had a higher clinical pregnancy rate compared with those with a peak E(2) level <4,000 pg/mL, although the two groups had comparable numbers of oocytes retrieved. No patients developed OHSS.

CONCLUSION(S)

Serum LH and E(2) levels ≥4,000 pg/mL on the day of the GnRH-agonist trigger are important predictors of success in patients at high risk of OHSS development. As none of the patients in this high-risk population developed OHSS, the GnRH-agonist trigger is effective in the prevention of this iatrogenic complication.

The effect of luteal phase vaginal estradiol supplementation on the success of in vitro fertilization treatment: a prospective randomized study

OBJECTIVE

To determine whether the use of luteal phase vaginal E(2) supplementation improves clinical pregnancy rates in patients undergoing IVF treatment.

DESIGN

Prospective randomized controlled trial.

SETTING

University-based tertiary fertility center.

PATIENT(S)

One hundred sixty-six patients undergoing their first cycle of IVF treatment.

INTERVENTION(S)

Patients underwent three different protocols for controlled ovarian hyperstimulation for IVF treatment with long GnRH agonist suppression, use of GnRH antagonist, or a microdose GnRH agonist protocol. Luteal phase support was in the form of IM P. Patients randomized into the study group (n = 84) received E(2) supplementation in the form of vaginal estrace 2 mg twice a day starting on the day of ET. Patients randomized to the control group (n = 82) received no E(2) supplementation.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rates.

RESULT(S)

There were no significant differences in the implantation (56/210 [26.7%] vs. 64/203 [31.5%]), clinical pregnancy (42/84 [50%] vs. 52/82 [63.4%]), and ongoing pregnancy rates (40/84 [47.6%] vs. 46/82 [56.1%]) between the study and control groups, respectively. In the subgroup of patients who used the long GnRH agonist suppression protocol, there was a lower clinical pregnancy rate in the study group compared with the control group (27/55 [49.1%] vs. 42/59 [71.2%]). There were, however, no differences in clinical pregnancy rates between the two groups in patients who used either the GnRH antagonist or microdose GnRH agonist protocols.

CONCLUSION(S)

The addition of vaginal E(2) supplementation to routine P supplementation for luteal support does not improve the probability of conception after IVF treatment.

The use of gonadotropin-releasing hormone (GnRH) agonist to induce oocyte maturation after cotreatment with GnRH antagonist in high-risk patients undergoing in vitro fertilization prevents the risk of ovarian hyperstimulation syndrome: a prospective randomized controlled study

OBJECTIVE

To determine whether there are any differences in the incidence of ovarian hyperstimulation syndrome (OHSS) and implantation rates in high-risk patients undergoing IVF using a protocol consisting of GnRH agonist trigger after cotreatment with GnRH antagonist or hCG trigger after dual pituitary suppression protocol.

DESIGN

Prospective randomized controlled trial.

SETTING

University-based tertiary fertility center.

PATIENT(S)

Sixty-six patients under 40 years of age with polycystic ovarian syndrome, polycystic ovarian morphology, or previous high response undergoing IVF.

INTERVENTION(S)

Patients were randomized to an ovarian stimulation protocol consisting of either GnRH agonist trigger after cotreatment with GnRH antagonist (study group) or hCG trigger after dual pituitary suppression with a GnRH agonist (control group). Both groups received luteal phase and early pregnancy supplementation with IM progesterone (P), and patients in the study group also received E(2) patches and their doses were adjusted according to the serum levels.

MAIN OUTCOME MEASURE(S)

Incidence of OHSS and implantation rate.

RESULT(S)

None of the patients in the study group developed any form of OHSS compared with 31% (10/32) of the patients in the control group. There were no significant differences in the implantation (22/61 [36.0%] vs. 20/64 [31.0%]), clinical pregnancy (17/30 [56.7%] vs. 15/29 [51.7%]), and ongoing pregnancy rates (16/30 [53.3%] vs. 14/29 [48.3%]) between the study and control groups, respectively.

CONCLUSION(S)

The use of a protocol consisting of GnRH agonist trigger after GnRH antagonist cotreatment combined with adequate luteal phase and early pregnancy E(2) and P supplementation reduces the risk of OHSS in high-risk patients undergoing IVF without affecting implantation rate.

Impact of leuprolide acetate on luteal phase function in women undergoing controlled ovarian hyperstimulation and intrauterine insemination

OBJECTIVE

To determine if the combination of leuprolide acetate (LA) and human menopausal gonadotropin (hMG) results in luteal phase dysfunction.

DESIGN

A prospective, randomized clinical trial.

SETTING

A tertiary care university fertility center.

PATIENT(S)

One hundred thirty-five couples with various etiologies of infertility.

INTERVENTION(S)

Patients were prospectively randomized to receive either hMG and intrauterine insemination (IUI) or luteal phase down-regulation with LA, hMG, and IUI.

MAIN OUTCOME MEASURE(S)

Serum luteal phase progesterone (P) and luteal phase estradiol (E2) were obtained 9 days after hCG administration. Twenty-four-hour urinary P and luteinizing hormone (LH) were analyzed 9 days after human chorionic gonadotropin (hCG). Endometrial biopsies were performed 11 days after hCG and evaluated for luteal phase defects (LPD) using Noyes' criteria.

RESULT(S)

No significant differences in the incidence of LPD (11.9% vs. 13.9%), cycle fecundity (16.6% vs. 16.3%), or luteal phase hormone profiles were observed between the groups receiving and not receiving LA. A significant difference in E2 levels (on the day of hCG administration) between cycles with a luteal phase defect (967 pg/mL +/- 106) and without a luteal phase defect (1,422 pg/mL +/- 83) was observed (P<.05).

CONCLUSION(S)

Pituitary down-regulation with LA combined with hMG did not result in luteal phase dysfunction. The E2 levels on the day of hCG administration in both groups were lower in women with documented luteal phase defects.

GnRH agonist to induce oocyte maturation during IVF in patients at high risk of OHSS

The aim of this retrospective study was to evaluate the effectiveness of gonadotrophin-releasing hormone agonist (GnRHa) to trigger oocyte maturation in patients with polycystic ovarian syndrome (PCOS) or previous high response. The outcome of ovarian stimulation and IVF in patients using GnRHa to trigger oocyte maturation after co-treatment with GnRH antagonist (study group) was compared with patients using human chorionic gonadotrophin (HCG) to trigger oocyte maturation after a dual pituitary suppression protocol with oral contraceptive pill (OCP) and GnRHa overlap (control group). All patients received intramuscular progesterone for luteal support but patients in the study group received additional supplementation with oestradiol patches. The mean number of oocytes, proportion of mature oocytes and fertilization rate were similar between the study and control groups. Implantation rate (38.6% versus 45.1%), clinical pregnancy rate (69.6% versus 60.9%) and delivery rate (62.5% versus 56.5%) were similar in the study and control groups respectively. There was one case of moderate ovarian hyperstimulation syndrome (OHSS) in the control group and none in the study group. GnRHa is effective in triggering oocyte maturation in patients with PCOS or previous high response. Further randomized studies are required to evaluate its effectiveness in the prevention of OHSS in this group of patients.

Outcome of in vitro fertilization treatment in patients who electively inseminate a limited number of oocytes to avoid creating surplus human embryos for cryopreservation

OBJECTIVE

To determine whether the outcome of IVF treatment in patients who electively inseminate a limited number of oocytes is comparable to that in a group of good-prognostic or poor-prognostic patients.

DESIGN

Retrospective clinical study.

SETTING

University-based tertiary fertility center.

PATIENT(S)

Two hundred three women under the age of 40 years.

INTERVENTION(S)

Patients undergoing their first cycle of IVF who elected to have no more than four oocytes inseminated (study group) or who produced only four or fewer oocytes (poor-prognostic group) or who had excess embryos cryopreserved (good-prognostic group).

MAIN OUTCOME MEASURE(S)

Implantation rate, clinical pregnancy rate, and ongoing pregnancy rate.

RESULT(S)

There were no significant differences in the implantation rate for the study group when compared with the good-prognostic group or the poor-prognostic group. The clinical pregnancy rate (62.5% vs. 64%) and ongoing-pregnancy or birth rate (56.3% vs. 60.7%) were similar between the study group and the good-prognostic group. However, the clinical pregnancy rate (62.5% vs. 29.7%) and ongoing-pregnancy rate (56.3% vs. 24.3%) were higher in the study group compared with the poor-prognostic group.

CONCLUSION(S)

Inseminating fewer oocytes in patients who elect not to cryopreserve excess embryos does not adversely affect their probability of conception.

An unusual anatomic variation of a unicornuate uterus with normal external uterine morphology

OBJECTIVE

To describe a case of a unicornuate uterus with a normal external uterine morphology.

DESIGN

Case report.

SETTING

University-based fertility center.

PATIENT(S)

A 30-year-old nulligravid woman with a 1-year history of infertility found to have a right proximal tubal occlusion on hysterosalpingogram.

INTERVENTION(S)

Laparoscopy, hysteroscopy, and magnetic resonance imaging.

MAIN OUTCOME MEASURE(S)

External and internal morphology of the uterus.

RESULT(S)

Laparoscopy showed a normal external uterine morphology and normal fallopian tubes and ovaries, but chromopertubation failed to demonstrate a fill and spill from the right fallopian tube. Hysteroscopy showed a single tubular uterine cavity projecting to the left with a single left tubal ostium, consistent with a unicornuate uterus. Magnetic resonance imaging confirmed a normal external uterine fundal contour and an internal uterine morphology consistent with a unicornuate uterus.

CONCLUSION(S)

This is the first reported case of a unicornuate uterus presenting with a normal external uterine morphology and an internal morphology consistent with a unicornuate uterus, and we propose inclusion of this anomaly in the classification of mullerian anomalies.

Septate uterus with cervical duplication: a full-term delivery after resection of a vaginal septum

We report a full-term delivery after resection of a longitudinal vaginal septum in a patient with a septate uterus and cervical duplication.

Intracytoplasmic sperm injection overcomes previous fertilization failure with conventional in vitro fertilization

OBJECTIVE

To evaluate the outcome of intracytoplasmic sperm injection (ICSI) in patients with previous idiopathic fertilization failure (< or =20% fertilization rate) after conventional IVF.

DESIGN

Retrospective analysis.

SETTING

IVF program at a university medical center.

PATIENT(S)

Twenty-five patients who underwent 38 ICSI cycles after experiencing unexplained fertilization failure with conventional IVF (group A) and 87 patients who underwent 118 ICSI cycles for male factor indications during the same period (group B).

INTERVENTION(S)

Intracytoplasmic sperm injection was performed in a subsequent cycle after fertilization failure with conventional IVF.

MAIN OUTCOME MEASURE(S)

Outcomes of IVF were compared between groups A and B.

RESULT(S)

Fertilization was achieved with ICSI in all patients with previous fertilization failure. The mean (+/- SD) fertilization rate (68%+/-21% vs. 64%+/-22%), implantation rate per embryo (22.6% vs. 20%), and delivery rate per cycle (47.3% vs. 49.1%) did not differ significantly between groups A and B. Overall, 72% of patients with previous unexplained fertilization failure had a successful pregnancy after ICSI.

CONCLUSION(S)

Intracytoplasmic sperm injection can overcome unexplained fertilization failure caused by a potentially occult gamete abnormality, with the same fertilization, implantation, and pregnancy rates as are seen in patients with abnormal sperm parameters.

Cervical mucus changes in relationship to urinary luteinizing hormone

In order to evaluate the relationship between the urinary luteinizing hormone (LH) surge as detected by the OvuSTICK (Monoclonal Antibodies, Inc., Mountain View, CA) method and daily cervical mucus parameters, ten spontaneously ovulating women undergoing infertility evaluation were followed during their cycles with twice daily urinary LH testing as well as daily ultrasound, mucus evaluation, and hormonal assays of serum LH, progesterone (P), and estradiol (E2). Maximal cervical mucus scores, as determined using a modified Insler score, were noted to coincide consistently with the urinary LH surge as detected by twice daily testing and to precede ultrasound evidence of ovulation by 0 to 24 hours. Mucus scores rapidly declined in the 24-hour period following the urinary LH surge. Detection of the urinary LH surge may therefore help identify that period of time during which cervical mucus parameters are optimal and therefore facilitate the timing of artificial insemination, intercourse, or postcoital testing.

Single case study. Diazepam (Valium) detoxification

In the chronic abuser, diazepam (Valium) withdrawal can be a protracted event. In this report a case is presented of a 37-year-old Caucasian female who had been ingesting 60 to 80 mg of diazepam daily for 8 years. Twelve days following discontinuation of the drug, the patient continued to experience diarrhea, restlessness, emotional lability, and anxiety. Serial blood levels of diazepam and desmethyldiazepam were acquired and found to yield significant levels of desmethyldiazepam for 21 days and greater than trace amounts for 30 days. The results were interpreted as consistent with the slow release of the drug from peripheral storage sites. The prolonged period needed for detoxification in this patient raises important question regarding the appropriate length of hospitalization or close supervision required to withdraw the diazepam addict.