Pregnancy outcome following transfer of human blastocysts vitrified on electron microscopy grids after induced collapse of the blastocoele

Case report: two successful pregnancies following the transfer of re-vitrified human day 7 blastocysts developed from vitrified cleaved embryos

PURPOSE

To report successful pregnancies after the transfer of re-vitrified human day 7 blastocysts developed from vitrified cleaved embryos.

METHODS AND RESULTS

A total of five day 7 blastocysts developed from vitrified cleaved embryos were re-vitrified and re-warmed. All of five re-vitrified day 7 blastocysts (100%) survived after warming and were transferred to three patients. Two of the women became clinically pregnant. Of these women, one woman delivered a healthy baby and the other pregnancy is ongoing at 26 weeks of gestation.

CONCLUSIONS

This is the first report of successful pregnancies after the transfer of re-vitrified human day 7 blastocysts developed from vitrified cleaved embryos.

Effects of cancer treatment on ovarian function

Causes of primary ovarian failure are reviewed, focusing specifically on cancer treatment-related modalities. Strategies and future directions for protection of the ovaries during cancer therapy, including ovarian transposition, and conformal radiation techniques are presented.

Current aspects of blastocyst cryopreservation

Cryopreservation of human gametes and embryos has become an essential part of assisted reproduction. Successful cryopreservation of human blastocysts is increasingly relevant as extended in-vitro culture of human embryos becomes more common, permitting routine use of blastocyst transfer in IVF programmes. This reduces the number of embryos transferred, thereby reducing multiple pregnancies and maximizing cumulative pregnancy rates per oocyte retrieval. The superiority of blastocyst freezing over earlier stage freezing in terms of implantation per thawed embryo transferred improves overall expectations for the cryopreservation programme. Therefore, a reliable procedure for the cryopreservation of blastocysts is needed because, after transfer, only a small number of supernumerary blastocysts are likely to be available for cryopreservation. Since the early 1980s, two common techniques have been used in cryopreservation: the conventional slow cooling method and the more recent rapid procedure known as vitrification. Vitrification has become an attractive alternative to slow freezing, since it appears to result in significantly higher survival and pregnancy rates. The aim of this review is to focus on the cryopreservation of human blastocysts using slow and rapid protocols and to assess the impact of the crypreservation protocol used on the survival, implantation and pregnancy rates.

Cryopreservation of human embryos by vitrification or slow freezing: a systematic review and meta-analysis

OBJECTIVE

To examine the literature systematically in order to identify prospective comparative trials answering the following question: Is vitrification of human embryos associated with a higher postthawing survival rate as compared with slow freezing?

DESIGN

Systematic review and meta-analysis.

SETTING

University-based hospital.

PATIENT(S)

Not applicable.

INTERVENTION(S)

Vitrification versus slow freezing for cryopreservation of human embryos.

MAIN OUTCOME MEASURE(S)

Postthawing survival rate.

RESULT(S)

Four eligible studies were identified, three of which were randomized controlled trials. Overall, the current review summarizes information from 8,824 cryopreserved human cleavage stage embryos/blastocysts (vitrification: n = 7,482; slow freezing: n = 1,342). Survival rate of cleavage stage embryos was significantly higher after vitrification as compared with slow freezing (odds ratio 15.57, 95% confidence interval 3.68-65.82; random effects model). Postthawing survival rate of vitrified blastocysts was significantly higher compared with that observed with slow freezing (odds ratio 2.20, 95% confidence interval 1.53-3.16; fixed effects model).

CONCLUSION(S)

Vitrification appears to be associated with a significantly higher postthawing survival rate than slow freezing. Further prospective trials are necessary to confirm the above results and, in addition, allow the evaluation of the two cryopreservation methods in terms of pregnancy achievement.

Cryopreserved blastocyst transfer: impact of gonadotropin-releasing hormone agonist versus antagonist in the previous oocyte retrieval cycles

OBJECTIVE

To assess any detrimental effect of gonadotropin-releasing hormone (GnRH) antagonists on oocyte quality and embryo development by comparing the outcome of cryopreserved-thawed blastocyst transfers for cycles using a GnRH agonist or GnRH antagonist protocol for the controlled ovarian stimulation in the oocyte retrieval cycle.

DESIGN

Retrospective comparative study.

SETTING

Private IVF center.

PATIENT(S)

Seventy-seven women who underwent cryopreserved-thawed blastocyst transfer.

INTERVENTION(S)

The patients were divided into two groups based on whether they had been treated using a GnRH agonist long protocol (n = 44) or a GnRH antagonist multiple-dose protocol (n = 33) during the previous oocyte retrieval cycle. Cryopreserved-thawed blastocysts were transferred after endometrial preparation without pituitary suppression using a GnRH agonist.

MAIN OUTCOME MEASURE(S)

Implantation and clinical pregnancy rates.

RESULT(S)

The postthaw survival rate and numbers of good quality blastocysts transferred were similar for the GnRH agonist and GnRH antagonist groups. Implantation and pregnancy rates for cryopreserved-thawed blastocyst transfer for the GnRH agonist group versus the GnRH antagonist group were 21.0% (25 of 119) versus 29.0% (27 of 93) and 38.6% (17 of 44) versus 51.5% (17 of 33), respectively, which was not statistically significantly different.

CONCLUSION(S)

No difference was found in terms of implantation and pregnancy rates when a GnRH agonist or GnRH antagonist was used in the previous oocyte retrieval cycle. Our results suggest that GnRH antagonists do not have a detrimental effect on oocyte quality or embryo development.

Zona pellucida removal and vitrified blastocyst transfer outcome: a preliminary study

The objective of this study was to investigate whether a change in assisted hatching technique from partial opening to total removal of the zona pellucida improved the outcome of vitrified blastocyst transfer. This was a preliminary observational study conducted from November 2003 to April 2006. Partial opening using acid Tyrode's solution was performed in 45 cycles, while total removal using a laser and mechanical pipetting was performed in 57 cycles. The clinical pregnancy, implantation, and delivery rates were higher in the total removal group than in the partial opening group (67% versus 42%, P < 0.02; 55% versus 30%, P < 0.01; 56% versus 36%, P < 0.04, respectively). These results suggest that total removal of the zona pellucida is associated with higher pregnancy, implantation and delivery rates compared with partial opening for vitrified blastocyst transfer.

Vitrification of preimplantation genetically diagnosed human blastocysts and its contribution to the cumulative ongoing pregnancy rate per cycle by using a closed device

OBJECTIVE

To evaluate the survival rate and clinical results of our vitrification procedure on preimplantation genetic diagnosis (PGD) blastocysts and to calculate its actual contribution to the reproductive outcome per cycle.

DESIGN

Retrospective clinical study.

SETTING

University Institute IVI, Valencia, Spain.

PATIENT(S)

Patients who requested cryotransfer of surplus PGD blastocysts after failed fresh elective transfer.

INTERVENTION(S)

Retrospectively collected data during 2 years of experience with blastocyst vitrification.

MAIN OUTCOME MEASURE(S)

Primary outcome measures were the following: blastocyst recovery and survival; cryotransfer cancellation; and the implantation, pregnancy (PR), and ongoing-pregnancy rates. The secondary outcome measure was cumulative ongoing PR (COPR).

RESULT(S)

Cocultured vitrified PGD blastocysts were recovered and progressed in development after overnight culture (survival rate) at rates comparable to those of non-PGD blastocysts (49% and 42%, respectively). After transfer to 64% of patients, no statistical differences were found between PGD and non-PGD blastocyst groups concerning the following: PR (44% vs. 37%), implantation rate (40% vs. 27%), and ongoing-pregnancy rate (32% vs. 37%). Moreover, blastocyst vitrification significantly increased the COPR in both PGD and non-PGD cycles, from 47% (62/133) to 53% (70/133) and from 45% (24/53) to 53% (28/53), respectively.

CONCLUSION(S)

A preimplantation genetic diagnosis blastocyst vitrification procedure showed survival rates and improvements on the COPR that were comparable to those in non-PGD blastocyst cycles. Moreover, vitrification of biopsied and diagnosed embryos at the more advanced stages instead of at earlier cleavage stages is presented as an attractive strategy to consider in PGD programs.

Clinical-pregnancy outcome after vitrification of blastocysts produced from in vitro maturation cycles

This study was conducted to report the clinical-pregnancy outcome after vitrification of the blastocysts produced from in vitro maturation cycles. The survival rate after thawing was 92.0% (92/100). The clinical-pregnancy and implantation rates were 43.8% and 23.6%, respectively. These results suggest that the blastocyst-stage embryos produced from in vitro maturation cycles can be safely cryopreserved through vitrification.

Fertility preservation options for women with malignancies

Cancer is not rare in younger women. There has been a remarkable improvement in the survival rates due to progress in cancer treatment. The necessary treatment for most of the common cancer types occurring in younger women implies either removal of the reproductive organs or cytotoxic treatment that could partially or definitively affect reproductive function. Early loss of ovarian function not only puts the patients at risk for menopause-related complications at a very young age, but is also associated with loss of fertility. Further, women in the western hemisphere have been delaying initiation of childbearing to later in life. The results of these changes have led to an increase in patients facing the risk of premature ovarian failure, and therefore seeking help in preserving their fertility. This increase in demand has resulted in a proliferation of techniques to preserve fertility. Indeed, the number of options is increasing; some are more established procedures, such as embryo cryopreservation, and some are still experimental, such as ovarian cryopreservation. Because of the variations in type and dose of chemotherapy, the type of cancer, the time available before onset of treatment, the patient's age and the partner status, each case is unique and requires a different strategy of fertility preservation.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to recall the potential early loss of ovarian function secondary to radiotherapy and/or chemotherapy for cancer at a young age; explain the increasing demands for fertility preservation; and summarize the limited number of proven, safe, and efficacious methods.

High survival and hatching rates following vitrification of embryos at blastocyst stage: a bovine model study

Cryopreservation of embryos at the blastocyst stage may provide an effective method to increase the cumulative pregnancy rate for each treatment cycle of ovarian-stimulated IVF. The objective of this study was to evaluate the survival rate and hatching rate of bovine blastocysts following vitrification using a method designed for oocytes, with a view to introducing this methodology into human assisted reproduction technology and reproductive medicine. Bovine blastocysts were produced from abattoir materials subjected to in-vitro maturation and in-vitro fertilization. Survival rate of the bovine blastocysts was 100% (94/94) following vitrification using a method designed for oocyte cryopreservation. There was no difference in the hatching rate of the bovine blastocysts between control (62.5%: 60/96) and vitrified (61.7%: 58/94) groups. The number of dead cells in the blastocysts was not significantly different between control (5.0 +/- 2.9) and vitrified (9.5 +/- 4.0) groups. In conclusion, the results of this study indicate that bovine blastocysts can be vitrified successfully using a procedure designed for oocyte cryopreservation. It is possible that this method may also be successful for the cryopreservation of human embryos. A further study into this is currently being organized.

Gonadal damage and options for fertility preservation in female and male cancer survivors

It is estimated that in 2010, 1 in every 250 adults will be a childhood cancer survivor. Today, oncological surgery, radiotherapy and chemotherapy achieve relatively high rates of remission and long-term survival, yet are often detrimental to fertility. Quality of life is increasingly important to long-term survivors of cancer, and one of the major quality-of-life issues is the ability to produce and raise normal children. Developments in the near future in the emerging field of fertility preservation in cancer survivors promise to be very exciting. This article reviews the published literature, discusses the effects of cancer treatment on fertility and presents the options available today thanks to advances in assisted-reproduction technology for maintaining fertility in male and female patients undergoing this type of treatment. The various diagnostic methods of assessing the fertility potential and the efficacy of in vitro fertilization (IVF) after cancer treatment are also presented.

Cryopréservation des embryons humains par vitrification

Vitrification is a cryopreservation strategy where cells are converted into a glass-like amorphous solid which is free of any crystalline structure. Such process is achieved by a combination of high concentration of cryoprotectant and an extremely high cooling rate. In the last years, survival rates of up to 80% after thawing and pregnancy rates of almost 30% could be achieved after transfer of vitrified embryos at the zygote, cleavage, morula and blastocyst stages. Also deliveries of healthy babies have been reported numerous times. To this day, a limited interest in this technique can be noted. The explanation may lye in the apprehension of many ART units regarding exposure of embryos to high concentrations of cryoprotectants and storage in non sterile conditions. The aim of the first part of this article, is to analyse if such fears are justified on the basis that vitrification mimics conditions already in use for many years in slow-cooling procedures where cells are plunged into liquid nitrogen at around -30 degrees C and secondly since storage of embryos are now possible in high aseptic conditions. In the second part, results on survival after thawing, pregnancy rates and baby take home rates of vitrified embryos will be presented and the problems associated with vitrification of blastocysts will be discussed.

Artificial shrinkage of blastocoeles using either a micro-needle or a laser pulse prior to the cooling steps of vitrification improves survival rate and pregnancy outcome of vitrified human blastocysts

BACKGROUND

Since we reported the first successful birth from a blastocyst vitrified using a cryoloop technique, our results showed that the survival rate of vitrified blastocysts was negatively correlated with the expansion of the blastocoele. We speculated that a large blastocoele may disturb the efficacy of vitrification. Therefore, we evaluated the effectiveness of artificial shrinkage (AS) of blastocoeles before vitrification, on increasing the survival rate of vitrified blastocysts.

METHODS

Supernumerary expanded blastocysts on day 5 were vitrified after AS, which was performed by puncturing the blastocoele with a micro-needle, or by making a hole in the blastocoele with a laser pulse. After warming, viable blastocysts (confirmed by re-expansion of the blastocoele) were transferred to patients with hormone replacement cycle. We compared these data with those of our previous report where AS was not carried out.

RESULTS

The survival rate was significantly higher (97.2%, 488/502) in this study than that of the previous report (86%). After 266 transferable cycles, 160 patients became pregnant (60.2%), which was significantly higher than our previous results (34.1%, 29/85). The implantation rate was 46.7% (209/448).

CONCLUSIONS

Our results revealed that the survival rate and the pregnancy rate of vitrified expanded and hatching blastocysts can be improved by using AS to collapse the blastocele before vitrification.

Comparison of vitrification and conventional cryopreservation of day 5 and day 6 blastocysts during clinical application

OBJECTIVE

To evaluate implantation of day 5 and day 6 vitrified and slow-frozen blastocysts.

DESIGN

Retrospective analysis comparing two cryopreservation techniques.

SETTING

Private IVF clinic.

PATIENT(S)

Five hundred eight cryopreserved embryo transfer candidates.

INTERVENTION(S)

Supernumerary day 5 and day 6 blastocysts were vitrified or slow-frozen and transfered after warming or thawing.

MAIN OUTCOME MEASURE(S)

Comparison of two cryopreservation techniques with respect to survival rate, implantation, and pregnancy rates of day 5 and day 6 blastocysts.

RESULT(S)

In 254 vitrified transfer cycles, survival, embryonic implantation, and clinical pregnancy rates for day 5 blastocysts were 95.9%, 33.4%, 48.7%, respectively, and for day 6 blastocysts 97.5%, 25.9%, 42.8%. In 254 slow-frozen transfer cycles, survival, embryonic implantation, and clinical pregnancy rates for day 5 blastocysts were 91.4%, 29.6%, 42.8%, respectively, and for day 6 blastocysts 94.8%, 28.2%, 43.1%. Overall there was a slightly, but not significantly, higher outcome regarding implantation and clinical pregnancy with the use of day 5 blastocysts (31.3% and 45.4%, respectively) versus day 6 blastocysts (26.7, and 42.9%, respectively).

CONCLUSION(S)

Vitrification technique yields the same implantation and pregnancy rate as slow-frozen blastocyst transfers. Slow growing embryos can be cryopreserved on day 6, because they yield a satisfactory survival, implantation, and pregnancy rate.

Cryopreservation of Human Embryos

Cryopreservation of human embryos from the 2-cell stage up to the morula stage is a safe procedure which has been carried out for the last 25 years. Experience with blastocyst cryopreservation is still limited and pregnancy rates after the use of frozen, thawed blastocysts vary extremely. Vitrification has improved the success of embryo cryopreservation. However, this technique cannot yet be considered as a routine procedure. Despite all of the advantages for infertile couples, cryopreservation of human embryos creates severe ethical problems, because of surplus frozen embryos which either have to be destroyed or perhaps used for research. Embryo adoption may provide a solution to solve imminent medical, ethical and social problems.

Fertility preservation in cancer patients

Fertility preservation is an important but often neglected need of cancer patients. There are several options available but many are considered experimental or are unproven. Most require interventions that can postpone the initiation of cancer treatment. The options include surgical procedures to move the ovaries out of the path of a radiation field, prophylactic medical therapy with gonadotropin-releasing hormone agonists and storage of gametes, embryos or gonadal tissue. Embryo freezing after conventional in vitro fertilization has a high success rate. Experimental fertility preservation procedures such as oocyte freezing and ovarian tissue cryopreservation/transplantation should be offered to cancer patients only under institutional review board oversight. Laparoscopic ovarian transposition is a viable option if radiotherapy is to be used alone. Oncologists, reproductive endocrinologists and other healthcare professionals should be part of a multidisciplinary team that offers cancer patients options to preserve their reproductive potential if they desire to do so.

Survival of mouse embryos after vitrification depending on the cooling rate of the cryoprotectant solution

The aim of the study was to determine the relationship between the rate of cooling of eight-cell mouse embryos to the temperature of liquid nitrogen (-196 degrees C) and their developmental capacity after thawing on the basis of their ability to leave the zona pellucida ('hatching') during in vitro culturing. Eight-cell embryos were obtained from superovulated female mice and divided into three experimental and one control group. Embryos from the experimental groups were cryopreserved by the vitrification method using ethylene glycol as cryoprotectant. The vitrification protocols used in the study differed in the rate of cooling of the cryoprotectant solution. Embryos from the first group were frozen in conventional 0.25-ml plastic straws, those from the second group in pipetting 'tips', and embryos from the third group, placed in vitrification solution, were introduced dropwise directly into liquid nitrogen. The control group of embryos was cultured in vitro without freezing in a culturing medium in an environment consisting of 95% air and 5% CO2. The developmental capacity of thawed embryos was assessed on the basis of their ability to leave the zona pellucida ('hatching') after three days of in vitro culturing. In the control group 95.1% of embryos 'hatched'. A significantly higher number of embryos that 'hatched' after thawing was observed in the group introduced dropwise directly into liquid nitrogen (60.0%) compared to the group frozen in pipetting 'tips' (37.9%). The group frozen in straws yielded significantly the lowest proportion of 'hatching' embryos (8.1%). These results showed that increasing cooling rates during vitrification of embryos improved their survival.

Comparison of open and closed methods for vitrification of human embryos and the elimination of potential contamination

Survival and development of human embryos was compared following slow cooling versus vitrification involving more than 13,000 vitrified embryos. In addition, the efficacy of an open system, the Cryotop, and a closed vitrification system, the CryoTip(trade mark), were compared using human blastocysts. One hundred percent of vitrified human pronuclear stage embryos survived and 52% developed to blastocysts as compared with 89% survival and 41% blastocyst development after slow cooling. Similar survival rates were seen with vitrification of 4-cell embryos (98%) as compared with slow cooling (91%). Furthermore, 90% of vitrified blastocysts survived and resulted in a 53% pregnancy rate following transfer, as compared with 84% survival and 51% pregnancy rates following slow cooling. All corresponding values were significantly different. When the closed and open vitrification systems were compared, no difference was found with regard to supporting blastocyst survival (93 and 97% for CryoTip and Cryotop respectively), pregnancies (51 versus 59% respectively) and deliveries (48 versus 51% respectively). Vitrification is a simple, efficient and cost-effective way to improve cumulative pregnancy rates per cycle. The use of the closed CryoTip system eliminates the potential for embryo contamination during cryopreservation and storage without compromising survival and developmental rates in vitro and in vivo.

Optimization of a dilution method for human expanded blastocysts vitrified using EM grids after artificial shrinkage

PURPOSE

To verify a more effective dilution method that can be applied to human expanded blastocysts that are vitrified after artificial shrinkage.

METHODS

Surplus expanded blastocysts that remained after embryo transfer (ET) in in vitro fertilization (IVF) cycles, were cryopreserved. The blastocysts were vitrified on EM grids following artificial shrinkage. After thawing the blastocysts, cryoprotectants were diluted using either a 6- or 2-step method. We examined the survival rate and clinical outcome of blastocysts of 151 patients in our ET program after thawing.

RESULTS

The survival rate of blastocysts that were thawed using a 2-step method (91.6%, 239/261) was comparable with that of the 6-step method (89%, 186/209). The clinical pregnancy rate (45.9%, 39/85) and implantation rate (24.1%, 53/220) were slightly higher in the 2-step method than in the 6-step method (40.9%, 27/66; 19.4%, 33/170).

CONCLUSIONS

Our data indicate that the 2-step dilution method could be a simpler and more effective protocol for human expanded blastocysts that are vitrified using EM-grid following artificial shrinkage.

Microsuction of blastocoelic fluid before vitrification increased survival and pregnancy of mouse expanded blastocysts, but pretreatment with the cytoskeletal stabilizer did not increase blastocyst survival

OBJECTIVE

To ascertain effects of thermal change, size of blastocoele, artificial shrinkage, and cytoskeletal stabilizer on survival of blastocysts from vitrification.

DESIGN

In vitro and in vivo study.

SETTING

University infertility clinic and academic research laboratory.

ANIMAL(S)

Female mice of outbred ICR strain, aged 6 to 8 weeks.

INTERVENTION(S)

In experiment 1, various stages of mouse blastocysts were vitrified by using conventional straws or closed pulled straws (CPS). In experiment 2, microsuction was performed of blastocoelic fluid for blastocysts and expanded blastocysts before vitrification. In experiment 3, cytochalasin B (CCB) was used to treat embryos during vitrification. In experiment 4, vitrified expanded blastocysts were transferred to pseudopregnant mice.

MAIN OUTCOME MEASURE(S)

Survival and pregnancy.

RESULT(S)

The survival rates of early blastocysts were high and not different between the conventional straws and the CPS. The survival rates decreased for blastocysts and expanded blastocysts in both of the two methods. But the use of CPS achieved higher survival rates for blastocysts (83% vs. 70%) and expanded blastocysts (60% vs. 39%) than did the conventional straws. Microsuction before vitrification increased the survival rates for blastocysts (92% vs. 80%) and expanded blastocysts (89% vs. 59%). Survival of vitrified embryos was not distinct between CCB treatment and non-CCB treatment. The percentage of live young from vitrified expanded blastocysts using microsuction was greater than that from vitrified expanded blastocysts without microsuction (34% vs. 9%).

CONCLUSION(S)

The size of the blastocoeles influenced survival of blastocysts from vitrification. A rapid thermal change of CPS and effective reduction of blastocoelic fluid by microsuction may facilitate vitrification and reduce ice crystal damage for blastocysts and expanded blastocysts. The microfilament inhibitor of CCB treatment did not increase their survival rates.

Are programmable freezers still needed in the embryo laboratory? Review on vitrification

The predictable answer to the provocative question of whether programmable freezers are still needed in the embryo laboratory is an even more provocative 'no'. However, such a radical statement needs strong support. Based on the extensive literature of the past 5 years, the authors collected arguments either supporting or contradicting their opinion. After an overview of the causes of cryoinjuries and strategies to eliminate them, the evolution of vitrification methods is discussed. Special attention is paid to the biosafety issues. The authors did not find any circumstance in oocyte or embryo cryopreservation where slow freezing offers considerable advantages compared with vitrification. In contrast, the overwhelming majority of published data prove that the latest vitrification methods are more efficient and reliable than any version of slow freezing. Application of the proper vitrification methods increases the efficiency of long-term storage of stem cells and opens new perspectives in cryopreservation of oocytes, both for IVF and somatic cell nuclear transfer. However, lack of support from regulatory authorities, and conservative approachs regarding novel techniques can slow down the implementation of vitrification. The opinion of the authors is that vitrification is the future of cryopreservation. The public have the final say in whether they want and allow this future to arrive.

Vitrification of mouse pronuclear embryos after polar body biopsy without direct contact with liquid nitrogen

OBJECTIVE

To evaluate the viability of vitrified mouse pronuclear embryos after polar body biopsy by cooling directly in liquid nitrogen in comparison with cooling in closed 0.5 mL straw (aseptic system).

DESIGN

In vitro culture after vitrification.

SETTING

Department of Gynecological Endocrinology and Reproductive Medicine, University of Bonn, Germany.

PATIENT(S)

Superovulated mice.

INTERVENTION(S)

Biopsied embryos were vitrified, warmed, and cultured in vitro.

MAIN OUTCOME MEASURE(S)

Development after warming.

RESULT(S)

Development rates up to expanded blastocyst stage after in vitro culture were 25% in group with "direct" vitrification and 23% in group with "straw in straw" vitrification.

CONCLUSION(S)

Cryopreservation of biopsied mouse pronuclear embryos in open-pulled straws, which are placed inside a hermetically closed container, guarantees a complete isolation of embryos from liquid nitrogen and avoids potential contamination by pathogenic microorganisms. The combination of plunging this container into liquid nitrogen and rapid warming makes this process as efficient as conventional vitrification.

Fertilization, cleavage and blastocyst development according to the maturation timing of oocytes in in vitro maturation cycles*

BACKGROUND

This study was to examine the developmental capacity of oocytes collected from an in vitro maturation (IVM) programme according to their maturation time.

METHODS

The study included 47 IVM cycles that underwent blastocyst transfer. The patients (n = 38) were primed with 10 000 IU HCG 36 h before their oocyte retrieval. The oocytes were classified into three groups: group 1 (n = 139) where oocytes were matured on day of oocyte collection; group 2 (n = 627) where oocytes were matured on day 1 after IVM; group 3 (n = 163) where oocytes matured on day 2 after IVM. Fertilization, cleavage and blastocyst formation were compared between three groups.

RESULTS

Rates of cleavage and blastocyst development in group 3 (72.2%, 96/133; 19.0%, 15/133) were significantly lower than those of group 1 (100%, 108/108; 58.3%, 63/108) and group 2 (91.5%, 487/532; 50.4%, 268/532) respectively (P < 0.01). The number of freezable good quality blastocysts among blastocysts developed from group 1 (52.4%, 33/63) was significantly higher than those from group 2 (35.4%, 95/268) and group 3 (6.7%, 1/15) (P < 0.01). There were 24 clinical pregnancies (51.1%, 24/47) after transfer of the blastocysts and 29 healthy babies were delivered.

CONCLUSION

These results suggest that oocytes reaching metaphase II faster in an IVM programme have better embryonic developmental competence.

Fertility preservation options for female patients with malignancies

PURPOSE OF REVIEW

Preservation of fertility in female patients diagnosed with cancer has recently been an area of intensive investigation. This review summarizes available options and discusses recently published data concerning experimental methods. Specific strategies for fertility preservation in women with gynecologic malignancies are also presented.

RECENT FINDINGS

Success with ovarian stimulation protocols using tamoxifen or aromatase inhibitors has recently been reported for women with breast cancer who attempt embryo cryopreservation prior to chemotherapy. The first embryo transfer using oocytes retrieved from cryopreserved ovarian tissue implanted at a heterotopic location, the first pregnancy following orthotopic transplantation of cryopreserved ovarian tissue, and increasing success with oocyte cryopreservation were also reported.

SUMMARY

Fertility preservation in female patients with cancer has become an important health issue due to increasing survival rates and delayed childbearing especially in Western countries. Radical vaginal trachelectomy for cervical cancer, conservative surgery for ovarian tumors, and progestin treatment in endometrial cancers may be considered at early stages in order to preserve fertility. Embryo cryopreservation is an established technique that is available for fertility preservation, providing a delay in the initiation of chemotherapy or radiotherapy is acceptable, and a partner or donor sperm is available. Additional techniques that could be offered after counseling the patient about their experimental nature include oocyte cryopreservation, ovarian cryopreservation, and gonadotropin-releasing hormone agonist co-treatment with chemotherapy. Improvement of these techniques as well as better characterization of their success rates and risks await further investigation.

Fertility preservation and pregnancy outcome after malignancy

PURPOSE OF REVIEW

The overall survival and cure rates of patients with childhood and adult malignancies have improved dramatically, but cancer treatment can be associated with diminished reproductive potential. However, research on the preservation of fertility in these patients has given patients new options. This article discusses the mechanisms of reproductive failure after cancer therapy and the currently available fertility preservation strategies.

RECENT FINDINGS

Ovarian transposition is still a viable option if radiotherapy is to be used alone. Modifications in assisted reproductive technology that decrease peak estradiol levels are ideal for breast cancer survivors. Embryo freezing technology offers excellent pregnancy rates. Oocyte freezing is available for women without a partner, but there is more limited experience with this technique. Understanding the concepts of graft function after the autotransplantation of frozen-thawed ovarian tissue has resulted in great strides in the technical requirements for success.

SUMMARY

Gonadotropin-releasing hormone analogues are the only available medical protection means for gonadotoxic chemotherapy. Assisted reproductive technology offers excellent results, but the protocols require a delay in implementing chemotherapy. Despite recent reports of embryo development after the transplantation of cryopreserved-thawed ovarian tissue, clinical experience is limited and the technique remains experimental.

Aseptic technology of vitrification of human pronuclear oocytes using open-pulled straws

BACKGROUND

The aim of this study was to compare the viability of human pronuclear oocytes subjected to vitrification using cooling by direct submerging of open-pulled straws in liquid nitrogen versus vitrification by cooling of open-pulled straws located inside a closed 0.5 ml straw (aseptic system).

METHODS

Two- and three-pronuclei stage oocytes (n=114) were cryopreserved in super-open-pulled straws by vitrification in 20% ethylene glycol +20% dimethylsulphoxide (DMSO) + osmotic active and neutral non-permeable cryoprotectants with a four-step exposure in 20, 33, 50 and 100% vitrification solution for 2, 1 and 1 min, and 30-50 s, respectively at room temperature, and plunging into liquid nitrogen. Oocytes of group 1 (n=42) were rapidly cooled at a speed of 20,000 degrees C/min by direct plunging of open-pulled straws into liquid nitrogen. Oocytes of group 2 (n=44) were first located in 0.5 ml straws, which were closed at both sides by metal balls, and then plunged into liquid nitrogen. This method resulted in a cooling speed of 200 degrees C/min. For both groups, oocytes were thawed rapidly at a speed of 20 000 degrees C/min using an identical protocol. Oocytes subsequently were expelled into a graded series of sucrose solutions (1.0, 0.75, 0.5, 0.25 and 0.12 mol/l) at 2.5 min intervals.

RESULTS

Oocyte development up to expanded blastocyst stage after in vitro culture was 15% in group 1, 14% in group 2 and 29% in an untreated control group.

CONCLUSION

The deposition of human pronuclear oocytes in open-pulled straws which are placed inside a hermetically closed container guarantees a complete isolation of oocytes from liquid nitrogen and avoids potential contamination by pathogenic microorganisms. The combination of direct plunging of this container into liquid nitrogen and rapid warming makes this process as efficient as conventional vitrification.

Pregnancy resulting from transfer of repeat vitrified blastocysts produced by in-vitro matured oocytes in patient with polycystic ovary syndrome

This report describes a live birth produced from repeat vitrification and thawing of blastocysts derived from in-vitro matured (IVM) oocytes in a woman with polycystic ovarian syndrome. Immature oocyte retrieval was performed on day 12 of her induced menstrual cycle. The patient was administered 10,000 IU of human chorionic gonadotrophin s. c. 36 h before immature oocyte retrieval. A total of 47 immature oocytes were collected. Following IVM of these immature oocytes, 76.6% (36/47) become mature (at metaphase II stage). Thirty oocytes (30/36, 86.1%) were normally fertilized following insemination by intracytoplasmic sperm injection. The fertilized zygotes (two-pronuclear stage) were co-cultured with cumulus cells in YS medium supplemented with 10% human follicular fluid. On day 5 after insemination, three blastocysts were transferred. Unfortunately, fresh embryo transfer did not result in pregnancy. The remaining 10 embryos developed to the expanded blastocyst stage. These remaining blastocysts were vitrified with electron microscope grids following artificial shrinkage. Three months later, three blastocysts were thawed due to a clinical error. Consequently, the embryos were revitrified. After a week, the three blastocysts were warmed again. Two of them developed to hatched blastocysts. Following transfer, a full-term pregnancy resulted in the delivery of healthy twins.

Vitrification of hatching and hatched human blastocysts: effect of an opening in the zona pellucida before vitrification

Partially or completely hatched blastocysts were obtained from women with at least one previous cycle with failure of implantation. On day 5 after fresh embryo transfers, the remaining vitrification cycles (VC) were divided into three categories according to the types of blastocysts. The first group (20 VC) contained blastocysts (n = 38) with open zona pellucida (ZP), the second group of 34 VC contained blastocysts (n = 100) with both open and intact ZP, while the third group (14 VC) contained blastocysts with intact ZP (n = 39). Blastocysts were exposed to two mixtures of cryoprotectants. At 24 h after warming, survival rates of 82% (31/38), 72% (72/100) and 64% (25/39) were observed in the three groups respectively. Numbers of embryo transfers and blastocysts in the three groups respectively were 20, 31 and 13 transfers, and 31, 60 and 25 blastocysts, resulting in corresponding ongoing pregnancy rates per VC of 35, 26 and 21%. Blastocysts with a larger blastocoelic cavity survived vitrification better when they had partially or completely hatched. Survival rates significantly increased (P < 0.01) from 55 to 81% after warming expanded blastocysts with an intact ZP (n = 42) compared with an open ZP (n = 54) respectively. This study shows that partially or completely hatched blastocysts can be cryopreserved by a simple vitrification procedure using the hemi-straw as embryo carrier.

Blastocoele collapse by micropipetting prior to vitrification gives excellent survival and pregnancy outcomes for human day 5 and 6 expanded blastocysts

BACKGROUND

Manual puncture of the trophectoderm of human blastocysts with a needle before vitrification increases their survival rate, but the embryos take a long time to re-expand. This study examined whether causing human blastocysts to collapse by manual pipetting before vitrification would allow more rapid re-expansion and improve pregnancy rates.

METHODS

After embryo transfer in IVF cycles, surplus embryos that developed to the expanded blastocyst stage were placed in cryoprotectant and then artificially shrunk by mechanical pipetting with a fine hand-drawn glass pipette slightly smaller in diameter than the blastocyst. The shrunken embryos were placed in a small volume of vitrification solution and plunged into liquid nitrogen on a cryotop. The blastocysts were thawed by warming and then dilution in 1 mol/l sucrose.

RESULTS

Of 49 expanded vitrified blastocysts, 48 (98%) re-expanded within 3 h after warming. Following transfer (48 blastocysts in 28 cycles), 14 women (50%) became clinically pregnant, and the implantation rate was 33% (16/48). Eight healthy babies have been born in six deliveries, and the other eight pregnancies are ongoing. To date, there have been no spontaneous abortions.

CONCLUSIONS

The results suggest that artificial shrinkage with pipetting is a simple and effective technique to assist successful cryopreservation of expanded blastocysts by vitrification.

High Survival Rate of Bovine Oocytes Matured In Vitro Following Vitrification

Improving pregnancy rates associated with the use of cryopreserved human oocytes would be an important advance in human assisted reproductive technology (ART). Vitrification allows glasslike solidification of a solution without ice crystal formation in the living cells. We have attempted to improve the survival rates of oocytes by a vitrification technique using bovine models. In vitro matured oocytes with or without cumulus cells were vitrified with either 15.0% (v/v) ethylene glycol (EG) + 15% (v/v) dimethylsulfoxide (DMSO) + 0.5 M sucrose or 15% (v/v) EG + 15% (v/v) 1,2-propanediol (PROH) + 0.5 M sucrose, using 'Cryotop' or 'thin plastic sticker', respectively. The oocyte survival rates after vitrifying-warming, and the capacity for fertilization and embryonic development were examined in vitro. The rate of embryonic development to blastocyst was significantly higher (P<0.05) in the oocytes vitrified with 15% (v/v) EG + 15% (v/v) PROH + 0.5 M sucrose than in the oocytes vitrified with 15% (v/v) EG + 15% (v/v) DMSO + 0.5 M sucrose (7.4% +/- 4.1 vs. 1.7% +/- 3.0, respectively). Oocytes vitrified without cumulus cells had a higher survival rate after thawing and a superior embryonic developmental capacity compared with oocytes vitrified with cumulus cells. Prolonged pre-incubation time after thawing adversely affected the rates of embryonic cleavage and development. These results indicate that in vitro matured bovine oocytes can be vitrified successfully with the mixture of the cryoprotectants, EG + PROH, the absence of cumulus cells for vitrification does not affect oocyte survival rate after warming, and vitrified and warmed oocytes do not require pre-incubation before in vitro fertilization.

Cryopreservation of animal and human embryos by vitrification

Vitrification is a method in which not only cells but also the whole solution is solidified without the crystallization of ice. For embryo cryopreservation, the vitrification method has advantages over the slow freezing method. For example, injuries related to ice is less likely to occur, embryo survival is more likely if the embryo treatment is optimized, and embryos can be cryopreserved by a simple method in a short period without a programmed freezer. However, solutions for vitrification must include a high concentration of permeating cryoprotectants, which may cause injury through the toxicity of the agents. Since the development of the first vitrification solution, which contained dimethylsulphoxide, acetamide, and propylene glycol, numerous solutions have been composed and reported to be effective. However, ethylene glycol is now most widely used as the permeating component. As supplements, a macromolecule and/or a small saccharide are frequently added. Embryos of various species, including humans, can be cryopreserved by conventional vitrification using insemination straws or by ultrarapid vitrification using minute tools such as electron microscopic grids, thin capillaries, minute loops, or minute sticks, or as microdrops. In the ultrarapid method, solutions with a lower concentration of permeating cryoprotectants, thus having a lower toxicity, can be used, because ultrarapid cooling/warming helps to prevent ice formation.

Vitrification versus programmable rate freezing of late stage murine embryos: a randomized comparison prior to application in clinical IVF

A prospective randomized trial was performed to compare post-thaw development of murine blastocysts following programmable rate freezing and two methods of vitrification. Frozen 2-cell murine embryos (n = 429) thawed and cultured for 48 h, were randomly allocated by stage of development into four groups: control (not refrozen), programmable rate freezing (PR) in 0.25 ml straws, vitrification in flexible micropipettes by immersion in super-cooled (VSC) liquid nitrogen (LN2), and vitrification in flexible micropipettes by immersion in LN2 (VLN). Survival, developmental stage progression, presence or absence of an inner cell mass (ICM), and cell counts were recorded 24 h post-thaw. All measured outcomes were different between embryos from the control group and all freezing methods. Controlled-rate freezing resulted in the lowest total cell counts and fewest embryos with a distinct ICM. A higher percentage of embryos survived 24 h post-thaw, progressed to more advanced developmental stages and had higher total cell counts after VLN compared with PR. Moreover, fewer embryos, frozen by either PR or VSC, contained a detectable ICM compared with VLN. These data demonstrate that vitrification may be a better method for freezing murine blastocysts than PR, and may prove to be a superior method for freezing human blastocysts.

Outcome of blastocyst transfer according to availability of excess blastocysts suitable for cryopreservation

The purpose of this study was to assess the outcome of blastocyst transfer in relation to the presence or absence of excess blastocysts available for cryopreservation. The study was designed as a retrospective case series in a tertiary care private hospital. The study group consisted of 450 blastocyst stage embryo transfer cycles. In 139 cycles there were excess freezeable blastocysts (group 1), in 78 cycles there were excess but unfreezeable blastocysts (group 2), and in 233 cycles there were no excess blastocysts (group 3). A mean of three blastocysts was replaced in all groups. Treatment cycle characteristics, implantation and pregnancy rates following fresh and cryopreserved blastocyst transfer were assessed in each group. More embryos reached the blastocyst stage in group 1 and more blastocysts were of good quality. In group 1, clinical pregnancy and implantation rates (71 and 41%) were significantly higher compared with groups 2 (56 and 27%) and 3 (43 and 19%). Embryos that were selected for transfer among a cohort of good quality blastocysts yielded the highest implantation and pregnancy rates. Given a clinical pregnancy rate of 71%, an implantation rate per embryo of 41%, and a multiple pregnancy rate of 58%, serious consideration should be given to a single blastocyst transfer in these patients.

Recent developments in human oocyte, embryo and blastocyst vitrification: where are we now?

The target of any cryopreservation procedure should be to ensure high survival rates of living cells after thawing. Two important parameters determine the success of any cryopreservation protocol: the manner in which cells regain equilibrium in response to cooling, and the speed of freezing (cooling rate). Slow-rate freezing protocols result in the formation of ice crystals during cooling and warming. Vitrification, in which high cooling rates in combination with a high concentration of cryoprotectant are used, does not produce any ice crystals during cooling and warming. However, there is a practical limit to the attainable cooling speed, and also a biological limit to the concentration of cryoprotectant tolerated by the cells during vitrification. Although post-warming survival depends on the species, the developmental stage and the quality of the embryos being vitrified, it seems clear that vitrification methods are increasingly successful and might be a better method than slow cooling procedures in the field of cryobiology. Many of the potential problems and benefits underlying vitrification as a method of choice for embryo cryopreservation in clinical embryology will be discussed in this review.