Strategies for the infertile man

Male infertility is one of the most common, identifiable causes of human reproductive failure. Although considerable progress has been made toward understanding sperm physiology and the biology of gamete interaction, still more work is needed to achieve objectivity and standardization of some of the andrological diagnostic methods used in the clinical setting. More information is needed to definitively establish which tests are more accurate predictors of sperm performance and how they correlate with pregnancy potential following in vivo and in vitro interventions. Infertile men can be successfully treated with defined urological and medical therapies or with assisted reproductive technologies (ARTs). Among the latter, intracytoplasmic sperm injection (ICSI) has become a validated means to overcome multiple sperm deficiencies. Nevertheless, it is expected that simplified and more cost-efficient therapeutic modalities will be developed as additional basic (cellular-molecular) and clinical knowledge is gained.

Use of human gametes obtained from anonymous donors for the production of human embryonic stem cell lines

OBJECTIVE

To investigate the use of donated gametes for the production of human embryonic stem cell lines.

DESIGN

Basic research study.

SETTING

Assisted Reproductive Technology (ART) program at an academic institution.

PATIENT(S)

Consenting oocyte and sperm donors.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Oocytes were aspirated from oocyte donors (n = 12) and inseminated with frozen-thawed donor (n = 2) sperm followed by culture of embryos to day 5 or 6 in sequential media. The inner cell masses of expanded blastocysts were isolated using immunosurgery and cultured for 4-11 days on irradiated primary mouse embryonic fibroblasts (PMEFs). Viable cell colonies were passed every 7-10 days onto fresh PMEFs in the presence of leukemia inhibitory factor (0.1 microg/mL) and evaluated for appropriate cell surface markers.

RESULT(S)

Immunosurgery of 40 blastocysts resulted in the culture of 18 inner cell masses, which have produced three cell lines. One of these cell lines has been shown to stain positive for alkaline phosphatase and stage-specific embryonic antigen (SSEA)-4 and negative for SSEA-1, express telomerase activity, and produce hCG when allowed to differentiate.

CONCLUSION(S)

These findings demonstrate that the future production of human embryonic stem cell lines for therapeutic use is possible with the use of donated gametes. Many ethical issues were considered before the initiation of this study, and it was our goal to ensure that both oocyte and sperm donors understood the nature and purpose of the research before their participating in the study.

Outcome of intracytoplasmic sperm injection in azoospermic patients: stressing the liaison between the urologist and reproductive medicine specialist

OBJECTIVES

To analyze the outcome of intracytoplasmic sperm injection (ICSI) cycles in infertile couples in whom the main diagnosis of infertility was azoospermia of obstructive and nonobstructive origin.

METHODS

Eighty-three consecutive ICSI cycles were carried out with retrieved testicular or epididymal spermatozoa, 60 cycles in 32 patients with obstructive azoospermia and 23 cycles in 12 patients with nonobstructive azoospermia. Fifty-four testicular biopsies (testicular sperm extraction) and 18 epididymal aspirations (microepididymal sperm aspiration) were performed.Results. Motile spermatozoa were recovered in 65 cycles (90.3%). In another 3 (4.2%), nonmotile spermatozoa were retrieved. In 4 patients (5.5%), sperm could not be recovered. In 11 cycles, frozen sperm from a previous procedure were used. A significantly lower fertilization rate (64% versus 73%, P = 0.02), clinical pregnancy rate (13% versus 47%, P <0.001), and good embryo quality rates (35% versus 56%, P = 0.009) were observed in patients with nonobstructive azoospermia. In patients with obstructive azoospermia, no significant differences were observed when the outcome was analyzed on the basis of the sperm origin (ie, from testicular sperm extraction or microepididymal sperm aspiration).

CONCLUSIONS

When combining testicular sperm extraction or microepididymal sperm aspiration with ICSI in patients with obstructive azoospermia, the results in terms of fertilization, implantation, and pregnancy rates were similar to those found in patients with nonazoospermic obstruction who underwent ICSI with ejaculated sperm. Patients with nonobstructive azoospermia had lower fertilization, embryo quality, and pregnancy rates than did those with obstructive azoospermia, probably because of severe defects in spermatogenesis, leading to poor gamete quality. The urologist and reproductive endocrinologist now have an excellent therapeutic option to offer men with previously intractable infertility.

Cryopreservation-Thawing of fractionated human spermatozoa is associated with membrane phosphatidylserine externalization and not DNA fragmentation

The objective of these studies was to evaluate the effect of cryopreservation-thawing of human spermatozoa on DNA fragmentation and membrane integrity. This was a prospective, controlled cohort study, performed at a university-based infertility center. Ejaculates were examined from 5 donors and 16 men undergoing infertility evaluation. Purified sperm populations were prepared by gradient centrifugation, cryopreserved using a manual method and TEST-yolk buffer and glycerol (TYB-G), followed by quick-thaw. Annexin V binding was used for assessing membrane translocation of phosphatidylserine, and terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) was utilized for the evaluation of DNA fragmentation. The results were as follows: the percentage of live cells with intact membranes (annexin V-, live) was significantly reduced after cryopreservation-thawing. On the other hand, the percentages of live cells with phosphatidylserine translocation (annexin V-, live) and of necrotic (dead) cells increased significantly after thawing. TUNEL revealed percentages of cells with DNA fragmentation in the prefreeze and postthaw samples that were not significantly different. In a further attempt to examine differences in response to various cryoprotection protocols, experiments were carried out using no cryoprotection, glycerol alone, or TYB-G. Samples frozen with TYB-G demonstrated significantly higher percentages of live cells without phosphatidylserine translocation than the other conditions. We concluded that cryopreservation-thawing of human sperm from patients and donors was associated with membrane change, as revealed by membrane translocation of phosphatidylserine, while having no major impact on DNA fragmentation.

Characterization of the biologic activities of a recombinant human zona pellucida protein 3 expressed in human ovarian teratocarcinoma (PA-1) cells

OBJECTIVE

This study was undertaken to clone and express a recombinant human zona pellucida protein 3 and to characterize its biologic activities as a sperm ligand and an inducer of the acrosome reaction.

STUDY DESIGN

Human ovarian teratocarcinoma (PA-1) cells were transfected with an expression vector containing human zona pellucida protein 3 complementary deoxyribonucleic acid with a sequence coding for a 6-histidine tail introduced into its 3' end. Purification of the secreted glycoprotein was performed by sequential affinity (lectin and nickel--nitrilotriacetic acid) and ion-exchange chromatography.

RESULTS

Western blot analysis confirmed a molecular weight of approximately 65 kd for the purified product. A cell-free translation system revealed a correctly sized protein backbone of 47 kd. The recombinant human zona pellucida protein 3 demonstrated specific, potent, and dose-dependent competitive inhibition of sperm-zona pellucida binding in vitro under hemizona assay conditions. Recombinant human zona pellucida protein 3 also stimulated the acrosome reaction of live sperm. This effect was fast, dose dependent, and capacitation time dependent. Furthermore, advance incubation with pertussis toxin, an inactivator of heterotrimeric G proteins, blocked recombinant human zona pellucida protein 3--induced acrosomal exocytosis.

CONCLUSION

The recombinant human zona pellucida protein 3 expressed in PA-1 cells manifested the full spectrum of expected biologic activities. It therefore represents a valuable tool for examination of human fertilization and the design of new strategies in diagnosis of male factor infertility and in contraception.

Molecular basis of human sperm-zona pellucida interaction

The recognition of carbohydrate sequences by complimentary receptors has been shown to be a critical factor in gamete interaction in many different animal species. We have proposed the hypothesis that, in the human, sperm binding to the zona pellucida requires a 'selectin-like' interaction. We have used the hemizona assay (a unique internally controlled bioassay that evaluates tight binding of human sperm to the homologous zona pellucida) and advanced methods of carbohydrate analysis to test this hypothesis. We provide compelling evidence that demonstrates that oligosaccharide recognition is also required for specific, tight human gamete binding. Hapten inhibition tests, zona pellucida lectin-binding studies and removal/modification of functional carbohydrates by chemical and enzymatic methods provide evidence for the involvement of defined carbohydrate moieties in initial binding. Our studies suggest the existence of distinct zona-binding proteins on human sperm that can bind to selectin ligands. Additionally, results suggest a possible convergence in the types of carbohydrate sequences recognized during initial human gamete binding and immune/inflammatory cell interactions. Full characterization of the glycoconjugates that manifest selectin-ligand activity on the human zona pellucida will allow for a better understanding of human gamete interaction in physiological and pathological situations.

Cryopreservation-thawing of fractionated human spermatozoa and plasma membrane translocation of phosphatidylserine

OBJECTIVE(S)

[1] To evaluate sperm membrane damage during cryopreservation-thawing by the assessment of phosphatidylserine (PS) translocation and [2] to examine the relationship between reactive oxygen species (ROS) and cryopreservation-related alterations.

DESIGN

Prospective cohort study.

SETTING

University-based center.

PATIENT(S)

Men consulting for infertility and fertile donors (controls).

INTERVENTION(S)

Semen processing was performed by density gradient separation followed by cryopreservation and thawing.

MAIN OUTCOME MEASURE(S)

Membrane PS translocation was evaluated with annexin V binding, generation of ROS was detected by chemiluminescence, and motion parameters were assessed by computer analysis.

RESULT(S)

Annexin V binding was detected in the prefreeze fractions with high and low sperm motility. In the patient group, there were significantly higher postthaw levels of annexin V binding in both fractions when compared with prefreezing values. However, such induction of PS translocation was significantly higher in the fractions with high sperm motility. Significantly higher ROS levels were detected in prefreeze samples of the fractions with low sperm motility.

CONCLUSION(S)

In the population of men studied, [1] cryopreservation-thawing was associated with induction of membrane PS translocation; [2] postthaw ROS levels were lower than before freezing; and [3] neither annexin V binding results nor the generation of ROS were able to accurately predict sperm cryosurvival rates.

Vaginal misoprostol enhances intrauterine insemination

This study examined whether the prostaglandin E(1) analogue misoprostol (400 microgram), when placed vaginally at the time of intrauterine insemination (IUI) improves pregnancy rates. A prospective, placebo-controlled, randomized and double-blind study involving 274 women in 494 IUI cycles resulted in a total of 64 pregnancies (13% per cycle). Misoprostol cycles totalled 253, with 43 pregnancies (17% per cycle), whereas placebo cycles totalled 241, with 21 pregnancies (9% per cycle). The cumulative pregnancy rate with misoprostol treatment was significantly greater than with placebo (P = 0.004, Cox proportional hazards regression). The benefit of misoprostol was seen in clomiphene cycles (14 versus 4%, P = 0.006), and was indicated in FSH cycles (33 versus 15%, borderline significance) and natural cycles (15.6 versus 7.7%, not significant), but was not seen in clomiphene/FSH cycles (18.2 versus 23.5%, not significant). Misoprostol treatment did not increase pain score on the day of IUI (1.1 versus 1.4) and at 1 day post IUI (0.6 versus 0.8). Complications were rare in both groups [six (2%) subject cycles in the misoprostol cycles compared with two (1%) in the placebo group]. It is concluded that the use of vaginal misoprostol may improve the chance for pregnancy in women having IUI in a wide variety of cycle types.

Effects of hydrogen peroxide on DNA and plasma membrane integrity of human spermatozoa

OBJECTIVE

To evaluate the effects of oxidative stress on DNA and plasma membrane integrity of human spermatozoa.

DESIGN

Prospective cohort study.

SETTING

University-based, tertiary-care infertility center.

PATIENT(S)

Men (n = 10) undergoing infertility investigation.

INTERVENTION(S)

Purified populations of sperm with high motility were separated using Percoll density gradients. Then, spermatozoa were incubated with 0, 10, 100, and 200 microM hydrogen peroxide (H(2)O(2)) under capacitating conditions.

MAIN OUTCOME MEASURE(S)

Motion parameters were assessed by computer analysis. Genomic integrity was examined by the terminal deoxynucleotidyl transferase (TdT)-mediated dUTP nick end-labeling (TUNEL) assay. Plasma membrane integrity was evaluated by the annexin V-binding assay, a measure of phosphatidylserine translocation.

RESULT(S)

Under basal conditions, there was a significant and negative relationship between sperm motility and the percentages of sperm with DNA fragmentation and membrane translocation of phosphatidylserine. After a 2-h incubation, there was a significant, dose-dependent effect of H(2)O(2) on motion parameters (decrease) and DNA fragmentation (increase). The percentage of annexin V(-) live (normal) cells declined significantly as the level of oxidative stress increased. Although the percentages of annexin V(+) live cells (sperm depicting translocation of phosphatidylserine) and necrotic cells increased at the highest H(2)O(2) levels, these changes were not significant.

CONCLUSION(S)

In vitro sperm incubation with H(2)O(2) induces DNA fragmentation in a dose-dependent fashion. The sublethal effects of oxidative stress on motion parameters were not significantly associated with membrane translocation of phosphatidylserine.

Impact of different clinical variables on pregnancy outcome following embryo cryopreservation

In our program's 13 years of experience, more than 9000 embryos have been cryopreserved in gonadotropin-stimulated IVF cycles. Over 1500 thaw and transfer cycles have yielded a pregnancy rate of approximately 25%. Different ovarian stimulation regimens (various preparations of FSH. alone or in combination with hMG, with or without concomitant use of a GnRH agonist) did not influence embryo survival or pregnancy rate. Likewise, the application of oocyte/embryo micromanipulation techniques for assisted fertilization (ICSI for male infertility) or assisted hatching (performed selectively) did not have an impact on pregnancy results. Survival and transfer rates of embryos cryopreserved at pronuclear or cleaving stage did not differ significantly. However, implantation and pregnancy rates were higher with pronuclear embryo freezing (day-2 transfers) when compared to embryos frozen at the cleavage stage (day-3 transfers). This may be the result of patient selection and transfer policies. Similar implantation and pregnancy results were achieved in natural and estrogen progesterone supplemented transfer cycles. Initial experience with pronuclear freezing followed by transfer at the blastocyst stage appears to offer a very successful alternative for selected patients.

Assessment of sperm cryodamage and strategies to improve outcome

Sperm cryopreservation still represents a valuable clinical aid in the management of infertility. Its current principal indications include (1) donor sperm insemination; (2) freezing before cancer therapy to maintain reproductive capacity; (3) patient's convenience; and (4) because of the outstanding success with ICSI, even patients with different degrees of oligo-asthenoteratozoospermia can now be offered the use of frozen/thawed sperm for oocyte micromanipulation. Although sperm cryopreservation/thawing and results of insemination and IVF have been consistently good using donor semen, results of infertile men (with or without various degrees of oligoasthenoteratozoospermia) have yielded remarkably lower rates of survival and pregnancy. Freezing/thawing techniques have not been subjected to major changes in the last years, Furthermore, the exact nature of sperm cryodamage still remains to be elucidated. Various aspects of sperm freezing are revisited here (1) development of new technical approaches for cryopreservation; (2) analysis of the stimulatory effect of putative cryoprotectant additives; (3) the use of intrauterine insemination-ready processed samples; and (4) selection and optimization of end-points for analysis of cryodamage. It is expected that advances in such areas will improve significantly the cryopreservation/thawing outcome particularly as related to semen samples of subfertile men.

Evaluation of outpatient hysteroscopy, saline infusion hysterosonography, and hysterosalpingography in infertile women: a prospective, randomized study

OBJECTIVE

To compare the diagnostic accuracy, pain scores, and procedure length of outpatient hysteroscopy (OHS), hysterosalpingography (HSG), and saline infusion hysterosonography (SIS) for evaluation of the uterine cavity of infertile women.

DESIGN

Prospective, randomized, investigator-blind study.

SETTING

Tertiary infertility clinic.

PATIENT(S)

Forty-six consecutive infertile women.

INTERVENTION(S)

Outpatient HSG, OHS, and SIS, followed by operative hysteroscopy (HS).

MAIN OUTCOME MEASURE(S)

Uterine abnormalities, procedure length, and subjective pain.

RESULT(S)

Fifty-nine percent of infertile subjects were found to have an abnormality on at least one of three outpatient uterine evaluations. When compared with the case of definitive operative HS, 60% of abnormalities were correctly classified by HSG, 72% by OHS, and 52% by SIS (P: NS). When comparing all combinations of 2 outpatient screening tests to operative hysteroscopy, 68% were correctly classified by HSG/OHS, 58% by HSG/SIS, and 64% by OHS/SIS (P: NS). The average time length for the OHS was 9.1 min., which was significantly greater than for both HSG (average, 5.3 min) and SIS (average, 6.1 min.) (P<.0001 for both). HSG and SIS were not statistically different regarding procedure time length. The average pain score (0-10) for SIS was 2.7, compared with 5.8 and 5.3 for HSG and OHS, respectively. Both HSG and OHS mean pain scores were significantly greater than the SIS mean.

CONCLUSION(S)

OHS, SIS, and HSG were statistically equivalent regarding evaluation of uterine cavity pathology in infertile women.

Semen treatment with progesterone and/or acetyl-L-carnitine does not improve sperm motility or membrane damage after cryopreservation-thawing

OBJECTIVE

To assess the effects of progesterone and acetyl-L-carnitine used before semen cryopreservation-thawing on sperm motility parameters and plasma membrane integrity.

DESIGN

Prospective cohort study.

SETTING

Academic tertiary center.

PATIENT(S)

Subfertile men undergoing semen evaluation.

INTERVENTION(S)

Before cryopreservation, spermatozoa were incubated with water-soluble progesterone (1 and 10 microM), acetyl-L-carnitine (2.5, 5, 10, and 20 mM), or both (progesterone, 1 microM; and acetyl-L-carnitine, 5 mM).

MAIN OUTCOME MEASURE(S)

Postthaw change of motility parameters (computer-assisted measurements) and vitality-membrane integrity (examined with eosin-Y staining and annexin V-Cy3 binding assay).

RESULT(S)

There were no statistically significant differences between control samples and samples treated with progesterone and/or acetyl-L-carnitine for cryosurvival rate, motility parameters, or membrane integrity. The percentages of postthaw cells identified as live showed significantly different results with use of the eosin-Y staining and annexin V binding assay.

CONCLUSION(S)

Neither progesterone nor acetyl-L-carnitine seemed to prevent cryodamage assessed by motility changes or membrane integrity in human spermatozoa of subfertile men. Annexin V binding, a reflection of membrane translocation of phosphatidylserine, provided more distinct information about postfreezing membrane integrity changes than eosin-Y staining.

Histochemical localization of endometrial insulin-like growth factor binding protein-1 and -3 during the luteal phase in controlled ovarian hyperstimulation cycles: a controlled study

OBJECTIVE

To determine if controlled ovarian hyperstimulation (COH) affects the endometrial expression of IGFBP-1 and IGFBP-3.

DESIGN

Prospective, controlled study.

SETTING

Tertiary infertility clinic.

PATIENT(S)

Eighteen oocyte donors undergoing COH cycles and 17 natural cycle controls.

INTERVENTION(S)

Controlled ovarian hyperstimulation, endometrial biopsies.

MAIN OUTCOME MEASURE(S)

Immunohistochemical scoring of endometrial IGFBP-1 and -3 expression, morphological endometrial dating, and serum estradiol (E(2)), LH, and progesterone (P(4)) concentrations.

RESULT(S)

No statistically significant difference was observed between natural and stimulated cycles in change in IGFBP-1 or -3 over standardized cycle days throughout the window of embryo implantation (days 17-24). The IGFBP-1 and -3 expression was zero or near zero for both the natural and COH cycles until day 12-13. Both IGFBPs showed increased production throughout the secretory phase. Advanced endometrial histology (>/=1 day) in glands and stroma was noted in COH cycles. Significant positive correlations of E(2) and P(4) were noted with IGFBP-1 and -3 but not with advanced endometrial morphology in the COH cycles.

CONCLUSION(S)

The COH cycles have no significantly increased endometrial IGFBP-1 or -3 expression throughout the implantation phase of the luteal cycle compared with normal menstrual cycles. Both IGFBPs were absent in the proliferative phase and increased throughout the secretory portion of the embryo implantation window.

Endometrial glycodelin-A expression in the luteal phase of stimulated ovarian cycles

OBJECTIVE

To determine if controlled ovarian hyperstimulation (COH) affects the endometrial expression of glycodelin-A (GdA).

DESIGN

Prospective, controlled study.

SETTING

Tertiary infertility clinic.

PATIENT(S)

Fifteen oocyte donors undergoing COH cycles and 19 natural-cycle control patients.

INTERVENTION(S)

COH, endometrial biopsies.

MAIN OUTCOME MEASURE(S)

Immunohistochemical scoring of endometrial GdA expression, morphologic endometrial dating, and serum E2, LH, and P4 concentrations.

RESULT(S)

GdA was detected in all subjects throughout the implantation window period. Immunolocalization was demonstrated in the endometrial glands and not in the stroma or on the surface. A significantly increased proportion of GdA-staining endometrial cells were noted in COH cycle patients as compared with natural-cycling control patients throughout the window of embryo implantation. Both cycle types demonstrated increasing GdA expression throughout the late luteal phase. A significant positive correlation was noted between GdA expression and serum E2 levels (r = 0.5, P<.001) in natural cycles and advanced histology in COH cycles (r = 0.63, P=.01). Neither LH nor P4 were correlated with endometrial GdA expression.

CONCLUSION(S)

COH cycles have a significantly increased endometrial GdA expression throughout the implantation phase of the luteal cycle when compared with normal menstrual cycles. The increased expression may affect implantation during COH cycles.

Analysis of DNA fragmentation, plasma membrane translocation of phosphatidylserine and oxidative stress in human spermatozoa

The objectives of this cross-sectional observational study were: (i) to detect DNA damage and plasma membrane translocation of phosphatidylserine in purified sperm populations of high and low motility, and (ii) to analyse their relationship with the endogenous generation of reactive oxygen species. Ejaculates from infertile men were examined following gradient centrifugation. The main outcome measures were: sperm motion parameters (assessed with a computer analyser), generation of reactive oxygen species (measured by chemiluminescence), DNA damage (detected by terminal deoxynucleotidyl transferase-mediated dUDP nick-end labelling and monoclonal antibody labelling of single-stranded DNA) and translocation of membrane phosphatidylserine (examined with annexin V staining). DNA fragmentation and membrane translocation of phosphatidyl-serine were observed in the fractions with low and high sperm motility in all patients. The fractions with low sperm motility had significantly higher proportion of cells with DNA damage and production of reactive oxygen species than the fractions with high sperm motility (P < 0.005). DNA fragmentation was significantly and positively correlated with the generation of reactive oxygen species (r = 0.42; P = 0.02).

IN CONCLUSION

(i) spermatozoa from infertile men display translocation of membrane phosphatidylserine as diagnosed by annexin V positive staining; (ii) DNA damage (fragmentation and presence of single-stranded DNA) can be detected in ejaculated spermatozoa from infertile men in fractions with low and high sperm motility, and (iii) there is a relationship between DNA damage and oxidative stress.

Sperm function assays and their predictive value for fertilization outcome in IVF therapy: a meta-analysis

The prevalence of male infertility and the availability of new, highly successful therapeutic options make the testing of sperm functional competence mandatory. An objective, outcome-based examination of the validity of the currently available assays was performed based upon the results obtained from 2906 subjects evaluated in 34 prospectively designed, controlled studies. The aim was carried out through a meta-analytical approach that examined the predictive value of four categories of sperm functional assays: computer-aided sperm motion analysis (CASA); induced-acrosome reaction testing; sperm penetration assay (SPA); and sperm-zona pellucida binding assays for IVF outcome. Results demonstrated a high predictive power of the sperm-zona pellucida binding and the induced-acrosome reaction assays for fertilization outcome. On the other hand, the findings indicated a poor clinical value of the SPA as predictor of fertilization and a real need for standardization and further investigation of the potential clinical utility of CASA systems. This analysis points out to limitations of the current tests and the need for standardization of methodologies and provides objective evidence on which clinical management and future research can be based.

Is the timing of implantation affected by zona pellucida micromanipulation?

PURPOSE

Our purpose was to examine the timing of implantation and early embryo development following uterine transfer of oocytes/embryos previously subjected to zona pellucida micromanipulation.

METHODS

A total of 68 singleton pregnancies resulting from IVF and embryo transfer with/without micromanipulation. Patients were divided into four groups according to the type of micromanipulation technique: assisted hatching, embryo biopsy, intracytoplasmic sperm injection, and no micromanipulation (control group). Serial serum beta-hCG levels were measured between 10 and 25 days after fertilization and log-transformed. Linear regression analyses were performed and extrapolated to hCG = 10 mIU/ml (hCG10) to estimate detectable implantation. The slopes of the regression lines were used to estimate the rising speed of hCG, an indirect sign of embryo development.

RESULTS

There were no significant differences among groups with respect to hCG10, the slopes or intercepts of the regression lines.

CONCLUSIONS

Various oocyte/embryo microsurgical procedures used in ART involving zona pellucida manipulation do not appear to affect the timing of implantation or early embryo development.