The cumulative embryo score: a predictive embryo scoring technique to select the optimal number of embryos to transfer in an in-vitro fertilization and embryo transfer programme

A randomized clinical trial comparing embryo culture in a conventional incubator with a time-lapse incubator

PURPOSE

Time-lapse monitoring allows for a flexible embryo evaluation and potentially provides new dynamic markers of embryo competence. Before introducing time-lapse monitoring in a clinical setting, the safety of the instrument must be properly documented. Accordingly, the aim of this study was to evaluate the safety of a commercially available time-lapse incubator.

METHODS

In a two center, randomized, controlled, clinical trial 676 oocytes from 59 patients in their 2nd or third treatment cycle, age <38 years and ≥ 8 oocytes retrieved were cultured in the time-lapse incubator or in a conventional incubator. The primary outcome was proportion of 4-cell embryos on day 2. Secondary outcomes were proportion of 7-8 cell embryos on day 3 and proportion of blastocysts on day 5. Implantation pregnancy rates were registered based on presence of fetal heart activity visualized by ultrasound 8 weeks after embryo transfer.

RESULTS

No significant difference was found between the time-lapse incubator (TLI) and conventional incubator (COI) in proportion of 4-cell embryos on day 2 irrespective of whether data was analyzed according to ITT (RR(TLI/COI): 0.81 (0.65; 1.02)) or PP (RR(TLI/COI): 0.80 (0.63; 1.01)). Nor were any significant differences detected in the secondary endpoints; i.e. proportion of 7-8-cell embryos on day three ITT (RR(TLI/COI): 0.96 (0.73; 1.26)); PP (RR(TLI/COI): 0.95 (0.72; 1.26)) and proportion of blastocysts on day five ITT (RR(TLI/COI): 1.09 (0.84; 1.41)); PP (RR(TLI/COI): 1.09 (0.83: 1.41)). We found no differences in clinical pregnancy rate or implantation rate.

CONCLUSION

Culture in the time-lapse incubator supports embryonic development equally to a conventional incubator.

Release of superoxide dismutase-1 by day 3 embryos of varying quality and implantation potential

PURPOSE

To determine if the antioxidant superoxide dismutase-1 (SOD1 or Cu,Zn-SOD) is released by cultured human cleavage-stage embryos and to assess any link between SOD1 and implantation potential.

METHODS

Women (n = 91; ≤40 years old) undergoing IVF treatment with transfer of one or two 8-cell embryos that resulted in 0 or 100% implantation were included. Following individual embryo culture, spent medium samples (n = 122) were collected and levels of SOD1 protein were measured by an enzyme-linked immunosorbent assay. SOD1 detection and concentration in embryo spent medium were analyzed in relation to embryo fragmentation and symmetry scores, and implantation (viable fetus at >12 weeks).

RESULTS

Cleavage-stage embryos release SOD1 protein into the spent culture medium. Neither detection nor concentration of SOD1 was related to implantation. There was a positive relationship between increased embryo fragmentation scores and SOD1 release, with no apparent association with symmetry. In non-pregnant cycles, the release of SOD1 decreased with increasing maternal age.

CONCLUSIONS

While SOD1 does not predict implantation potential of select good-quality embryos, our data support the need to evaluate the biological significance of released SOD1 by embryos of varying quality and from patients of varying age.

Human spermatozoa vitrified in the absence of permeable cryoprotectants: birth of two healthy babies

Herein, we report the birth of two healthy babies to a woman following intracytoplasmic sperm injection (ICSI) using motile spermatozoa vitrified without permeable cryoprotectants. Spermatozoa (in a case of oligoasthenoteratozoospermia) were cooled in cut standard straws in human tubal fluid supplemented with 0.5% human serum albumin and 0.25 M sucrose. Sperm motility, capacitation-like changes, acrosome reaction and mitochondrial membrane potential (MMP) were compared in fresh and vitrified spermatozoa. Eight mature (MII) oocytes were microinjected with the vitrified–warmed motile spermatozoa. Although the motility of vitrified–warmed spermatozoa was markedly lower than that of fresh spermatozoa (60% v. 90%, respectively), there were no immediate visible differences in the percentages of capacitated and acrosome-reacted vitrified and fresh spermatozoa (10% v. 8% and 5% v. 8%, respectively). However, the MMP in vitrified spermatozoa was apparently adversely affected in the ejaculate used for ICSI compared with fresh spermatozoa (63% v. 96% spermatozoa with high MMP). Eighteen hours later, six oocytes showed signs of normal fertilisation. Two-pronuclear oocytes were cultured in vitro for 24 h and two four-blastomere embryos were transferred. Two healthy girls were born at term. Our findings suggest that permeable cryoprotectant-free vitrification can be applied successfully for some procedures in assisted reproduction, in particular in ICSI with motile vitrified spermatozoa, to achieve normal pregnancy and birth.

Effect of a supplementation with myo-inositol plus melatonin on oocyte quality in women who failed to conceive in previous in vitro fertilization cycles for poor oocyte quality: a prospective, longitudinal, cohort study

BACKGROUND

Several factors can affect oocyte quality and therefore pregnancy outcome in assisted reproductive technology (ART) cycles. Recently, a number of studies have shown that the presence of several compounds in the follicular fluid positively correlates with oocyte quality and maturation (i.e., myo-inositol and melatonin).

AIM

In the present study, we aim to evaluate the pregnancy outcomes after the administration of myo-inositol combined with melatonin in women who failed to conceive in previous in vitro fertilization (IVF) cycles due to poor oocyte quality.

MATERIALS AND METHODS

Forty-six women were treated with 4 g/day myo-inositol and 3 mg/day melatonin (inofolic® and inofolic® Plus, Lo.Lipharma, Rome) for 3 months and then underwent a new IVF cycle.

RESULTS

After treatment, the number of mature oocytes, the fertilization rate, the number of both, total and top-quality embryos transferred were statistically higher compared to the previous IVF cycle, while there was no difference in the number of retrieved oocyte. After treatment, a total of 13 pregnancies occurred, 9 of them were confirmed echographically; four evolved in spontaneous abortion.

CONCLUSION

The treatment with myo-inositol and melatonin improves ovarian stimulation protocols and pregnancy outcomes in infertile women with poor oocyte quality.

A review on automatic analysis of human embryo microscope images

Over the last 30 years the process of in vitro fertilisation (IVF) has evolved considerably, yet the efficiency of this treatment remains relatively poor. The principal challenge faced by doctors and embryologists is the identification of the embryo with the greatest potential for producing a child. Current methods of embryo viability assessment provide only a rough guide to potential. In order to improve the odds of a successful pregnancy it is typical to transfer more than one embryo to the uterus. However, this often results in multiple pregnancies (twins, triplets, etc), which are associated with significantly elevated risks of serious complications. If embryo viability could be assessed more accurately, it would be possible to transfer fewer embryos without negatively impacting IVF pregnancy rates. In order to assist with the identification of viable embryos, several scoring systems based on morphological criteria have been developed. However, these mostly rely on a subjective visual analysis. Automated assessment of morphological features offers the possibility of more accurate quantification of key embryo characteristics and elimination of inter- and intra-observer variation. In this paper, we describe the main embryo scoring systems currently in use and review related works on embryo image analysis that could lead to an automatic and precise grading of embryo quality. We summarise achievements, discuss challenges ahead, and point to some possible future directions in this research field.

Transfer of cryopreserved - thawed embryos in hCG induced natural or clomiphene citrate cycles yields similar live birth rates in normo-ovulatory women

INTRODUCTION

the purpose of this retrospective analysis is to compare the efficiency of hCG-induced natural and Clomiphene citrate (CC) cycles in normovulatory patients undergoing frozen embryo transfer (FET).

MATERIALS AND METHODS

it was retrospectively conducted in the Dutchspeaking Free University of Brussels and covered the period from April 2003 to August 2006. In particular, 428 day-three FET cycles belonging to the two comparative groups were recruited. Of these FET cycles, 261 were hCG-induced natural and 167 clomiphene citrate-induced cycles.

RESULTS

no statistically significant difference was observed in live birth rate between CC and natural group (22.2% versus 22.6%), respectively (P = 0.708). Except for the number of embryos transferred (1.72 ± 0.46 for cc group versus 1.63 ± 0.48 for natural group, p = 0.045), no other parameters seem to influence the outcome. discussion: To our knowledge, this is the first attempt to investigate which of the above mentioned regimens is optimal for normo-ovulatory women in FET cycles. A similar delivery outcome was observed for hCG-induced natural and CC-induced cycles used for endometrial preparation in FET.

Association between amino acid turnover and chromosome aneuploidy during human preimplantation embryo development in vitro

This study investigated the relationship between human preimplantation embryo metabolism and aneuploidy rates during development in vitro. One hundred and eighty-eight fresh and cryopreserved embryos from 59 patients (33.9 +/- 0.6 years) were cultured for 2-5 days. The turnover of 18 amino acids was measured in spent media by high-performance liquid chromatography. Embryos were either fixed for interphase fluorescent in situ hybridization analysis of chromosomes 13, 18, 19, 21, X or Y, or were assayed for mitochondrial activity. Amino acid turnover was different (P < 0.05) between stage-matched fresh and cryopreserved embryos due to blastomere loss following warming. The proportion of embryos with aneuploid cells increased as cell division progressed from pronucleate- (23%) to late cleavage stages (50-70%). Asparagine, glycine and valine turnover was significantly different between uniformly genetically normal and uniformly abnormal embryos on Days 2-3 of culture. By Days 3-4, the profiles of serine, leucine and lysine differed between uniformly euploid versus aneuploid embryos. Gender significantly (P < 0.05) affected the metabolism of tryptophan, leucine and asparagine by cleavage-stage embryos. Pronucleate zygotes had a significantly higher proportion of active:inactive mitochondria compared with cleavage-stage embryos. Furthermore, mitochondrial activity was correlated (P < 0.05) with altered aspartate and glutamine turnover. These results demonstrate the association between the metabolism, cytogenetic composition and health of human embryos in vitro.

A modified culture medium increases blastocyst formation and the efficiency of human embryonic stem cell derivation from poor-quality embryos

Human embryonic stem cells (HESCs) are defined as self-renewing cells that retain their ability to differentiate into all cell types of the body. They have enormous potential in medical applications and as a model for early human development. There is a need for derivation of new HESC lines to meet emerging requirements for their use in cell replacement therapies, disease modeling, and basic research. Here, we describe a modified culture medium containing human recombinant leukemia inhibitory factor and human basic fibroblast growth factor that significantly increases the number of human blastocysts formed and their quality, as well as the efficiency of HESC derivation from poor-quality embryos. Culturing poor-quality embryos in modified medium resulted in a two-fold increase in the blastocyst formation rate and a seven-fold increase over the derivation efficiency in conventional medium. We derived 15 HESC lines from poor-quality embryos cultured in modified culture medium and two HESC lines from quality embryos cultured in conventional culture medium. All cell lines shared typical human pluripotent stem cell features including similar morphology, normal karyotypes, expression of alkaline phosphatase, pluripotency genes, such as Oct4, and cell surface markers (SSEA-4, TRA-1-60, TRA-1-81), the ability to form teratomas in SCID mice, and the ability to differentiate into cells of three embryonic germ layers in vitro. Our data suggest that poor-quality embryos that have reached the blastocyst stage in our modified culture medium are a robust source for normal HESC line derivation.

Performance evaluation of microbead and ELISA assays for follicular G-CSF: a non-invasive biomarker of oocyte developmental competence for embryo implantation

G-CSF in individual follicular fluids correlates with the potential of the corresponding embryo to result in a live birth after transfer in IVF. To evaluate the requirements for routine follicular fluid G-CSF quantification, we compared follicular fluid G-CSF measurements made with two multiplexed microbead assays purchased from Bio-Rad Laboratories and R&D Systems, and a commercial G-CSF ELISA (R&D Systems). Individual follicular fluids (n=139) associated with transferred embryos were analysed to determine cytokine profile and the fate of each transferred embryo was recorded. The effect of multiplexing as well as comparison of the respective performances of the microbead assay with a flow cytometry assay was explored. Multivariable logistic regression analysis was performed and receiver operating characteristic (ROC) analysis was used to determine the performance and sensitivity/specificity of each method for individual follicular fluids. Covariate factors known to influence IVF outcome such as age, serum oestradiol and embryo score were systematically integrated in each analysis. The quantification of follicular fluid G-CSF using microbead assay methodologies, but not ELISA, yielded results showing the utility of follicular fluid G-CSF as a biomarker predictive of a successful delivery (Au(roc): 0.77 [0.68-0.84] (p=0.003) and 0.75 [0.66-0.82] (p=0.004) for Bio-Rad and R&D Systems microbead assays respectively), whereas follicular fluid G-CSF values quantified by ELISA were not predictive (Au(roc):0.61 [0.52-0.70] p=0.84). Microbead assay and flow cytometry appeared similarly efficient for quantifying follicular fluid G-CSF and multiplex versus single-plex assays did not influence the reliability of quantification.

The associated factors to endometrial cavity fluid and the relevant impact on the IVF-ET outcome

BACKGROUND

Endometrial cavity fluid (ECF) is a fluid accumulation within the endometrial cavity. The significance of ECF remains unclear during the program of in vitro fertilization-embryo transfer (IVF-ET). The aim of the present study was to investigate the associated factors to ECF, visualized through ultrasound at the day of oocyte retrieval, and the relevant impact on the outcome of IVF-ET.

METHODS

From the clinical data of 1557 infertility patients for IVF-ET program, 46 ECF patients were retrospectively selected as the ECF group; and another 134 patients with a bilateral salpingectomy and without ECF, selected as the control group. The demographics and the outcome of IVF-ET were compared between the two groups.

RESULTS

The incidence of ECF was 2.95% (46/1557). Over half (28/46, 60.87%) of ECF patients had tubal infertility. Only 12 Of 46 ECF patients (26.09%) had visible hydrosalpinx on ultrasonography before ovarian stimulation. The cycle cancellation rate (4/46, 8.69%) of ECF group was not significantly higher than that of the control group (6/134, 4.48%; P > 0.05). Reasons for cycle cancellation in both groups were all the high risk of ovarian hyperstimulation syndrome (OHSS). No significant difference was found in clinical pregnancy rate between the patients with their ECF <3.5 mm in the anterior-posterior diameter (APD) and the control group (35.48% versus 30.47%; P > 0.05). No clinical pregnancy was found among those patients with their ECF equal or higher 3.5 mm in APD.

CONCLUSIONS

It was tubal infertility, not hydrosalpinx, which was related to the development of ECF. Excessive ECF (equal or higher 3.5 mm in APD) at the day of oocyte retrieval would have a negative impact on the outcome of IVF-ET.

Embryo selection criteria based on morphology VERSUS the expression of a biochemical marker (sHLA-G) and a graduated embryo score: prediction of pregnancy outcome

PURPOSE

To compare pregnancy and implantation rates when embryos are selected based on a single Day 3 (D 3) morphology score vs. a GES score plus sHLA-G expression.

METHODS

A prospective randomized study (n = 214) undergoing fresh ICSI cycles. Embryos were selected for transfer based on either Day 3 morphology score (Group A) or GES-scoring plus sHLA-G expression (Group B).

RESULTS

Clinical [35/107 (33%) vs. 52/107 (49%)] and ongoing pregnancy [20/107 (19%) vs. 52/107 (49%)] rates were significantly different between Group A and Group B (p < 0.05). Implantation rates were not significantly different between Group A [52/353 (15%)] and Group B [73/417 (18%)] (p < 0.05). The number of pregnancies lost during the first trimester was nearly 12 times higher in Group A [25/52 (48%)].

CONCLUSION

The miscarriage rate was significantly lower in Group B than Group A and the pregnancy results were superior when embryos were selected based on GES plus sHLA-G expression.

Alkylation of sperm DNA is associated with male factor infertility and a reduction in the proportion of oocytes fertilised during assisted reproduction

Approximately one-third of IVF cases in the UK are attributed to male factor infertility and in the majority of cases the origin of male infertility is unknown. The integrity of sperm DNA is important both for the success of assisted reproduction and the implications for the off-spring. One type of DNA damage that has not been investigated with respect to fertility outcomes is the adduct N7-methyldeoxyguanosine (N7-MedG), a biomarker for exposure to alkylating agents. A prospective cohort of couples attending for IVF had their N7-MedG levels in sperm measured using an immunoslot blot technique to examine whether sperm N7-MedG levels are associated with male factor infertility, semen quality measures or assisted reproduction outcomes. Sufficient DNA for analysis was obtained from 67/97 couples and N7-MedG was detected in 94% of sperm samples analysed. Men diagnosed with male factor infertility had significantly higher mean levels of N7-MedG in their sperm DNA (P=0.03). Logistic regression analysis showed that N7-MedG levels were significantly negatively associated with the proportion of oocytes successfully fertilised irrespective of the method of fertilisation used (IVF or intra-cytoplasmic sperm injection; ICSI, P<0.001). Therefore exposure to DNA alkylating agents is significantly associated with male infertility and the proportion of oocytes fertilised during assisted reproduction. Reducing such exposure may improve male fertility but further work is required to determine the relative importance of exogenous and endogenous sources of exposure.

Effect of female nargile smoking on in vitro fertilization outcome

OBJECTIVE

Smoking is a significant health hazard that has been associated with poor reproductive outcome and reduced fertility in reproductive age women. The aim of this study was to assess the effect of nargile smoking on intra-cytoplasmic sperm injection (ICSI) outcome.

STUDY DESIGN

A prospective analysis of the outcomes of 297 women who underwent ICSI treatment at the ART Unit at the American University of Beirut Medical Center between January 1, and December 31, 2006 was done. The patients were divided into 3 groups based on their smoking status: cigarette smokers (n=42), nargile smokers (n=51) and non-smokers (n=204).

RESULTS

The mean age of nargile smokers was significantly lower than the other groups; however, the 3 groups were similar with respect to the cause of infertility, total dose of follicular stimulating hormone (FSH), number of oocytes and embryos obtained, and number and quality of embryos transferred. There was no significant difference in the clinical pregnancy rate between nargile smokers and non-smokers (51.0% vs 43.6%). However, cigarette smokers had a significantly lower clinical pregnancy rate compared to non-smokers (23.8% vs 43.6%, p=0.0238). On multiple logistic regression analysis, factors that decreased the clinical pregnancy rates were cigarette smoking and maternal age.

CONCLUSION

Although this study did not find a deleterious effect of nargile smoking on ICSI outcome, the results need to be confirmed in prospective studies that would include larger number of women with more objective measures of nargile smoke exposure.

A PolScope evaluation of meiotic spindle dynamics in frozen-thawed oocytes

In mature human oocytes, the metaphase II (MII) spindle presence and birefringence signal detected through the PolScope may vary before and after freezing. In particular, spindle dynamics during the first few hours after thawing is still under study. In this study, oocytes from stimulated ovaries were cryopreserved in 1.5 mol/l 1,2-propanediol with 0.3 mol/l sucrose using a slow freezing-rapid thawing method. Oocytes were examined with the PolScope for the presence, intensity of signal birefringence and size of the meiotic spindle before freezing and at 0, 1 and 2 h post-thaw (where 0 h = the time of the end of the thawing procedure). Of the 173 surviving oocytes exhibiting a spindle before freezing, 82.7% (143/173) showed spindle birefringence within 1 h of thawing. However, at the end of the thawing procedure the intensity of spindle birefringence (retardance) and the spindle length were smaller in comparison to the pre-freezing condition. These parameters increased after 1 h, although were not restored to the value observed before freezing. No significant changes were observed by extending the culture to 2 h.

Impact of female age and male infertility on ovarian reserve markers to predict outcome of assisted reproduction technology cycles

BACKGROUND

This study was designed to assess the capability of ovarian reserve markers, including baseline FSH levels, baseline anti-Müllerian hormone (AMH) levels, and antral follicle count (AFC), as predictors of live births during IVF cycles, especially for infertile couples with advanced maternal age and/or male factors.

METHODS

A prospective cohort of 336 first IVF/ICSI cycles undergoing a long protocol with GnRH agonist was investigated. Patients with endocrine disorders or unilateral ovaries were excluded.

RESULTS

Among the ovarian reserve tests, AMH and age had a greater area under the receiving operating characteristic curve than FSH in predicting live births. Furthermore, AMH and age were the sole predictive factors of live births for women greater than or equal to 35 years of age; while AMH was the major determinant of live births for infertile couples with absence of male factors by multivariate logistic regression analysis. However, all the studied ovarain reserve tests were not preditive of live births for women < 35 years of age or infertile couples with male factors.

CONCLUSION

The serum AMH levels were prognostic for pregnancy outcome for infertile couples with advanced female age or absence of male factors. The predictive capability of ovarian reserve tests is clearly influenced by the etiology of infertility.

Ovulation triggering with GnRH agonist vs. hCG in the same egg donor population undergoing donor oocyte cycles with GnRH antagonist: a prospective randomized cross-over trial

OBJECTIVE

To compare fertilization, implantation and pregnancy rates in donor oocyte cycles triggered for final oocyte maturation with either human chorionic gonadotropin (hCG) or gonadotropin releasing hormone (GnRH) agonist in the same donor population in two sequential stimulation cycles.

DESIGN

Prospective randomized cross-over trial.

SETTING

Private infertility clinic.

PATIENT(S)

Eighty-eight stimulation cycles in 44 egg donors.

INTERVENTIONS

Controlled ovarian hyperstimulation (COH) with GnRH antagonist protocol triggered with hCG or GnRH agonist (leuprolide acetate 0.15 mg) in the same egg donors in two consecutive cycles.

MAIN OUTCOME MEASURE(S)

The primary outcome measure was the proportion of mature and fertilized oocytes per donor cycle. Secondary outcome measures were implantation and pregnancy rates in the recipients and incidence of ovarian hyperstimulation syndrome (OHSS) in oocyte donors.

RESULT(S)

The proportion of mature oocytes, fertilized oocytes and mean embryo scores were comparable between the two triggering agents. While implantation (36.53% vs, 32.93%), pregnancy (69.08% vs. 68.81%) and clinical pregnancy (41.3% vs. 40.2%) rates were comparable for the groups, the incidence of OHSS was significantly lower in GnRH than in hCG triggered cycles.

CONCLUSION(S)

Fertilization, implantation and pregnancy rates from donor oocytes stimulated with GnRH antagonist protocol were identical for donor cycles triggered with hCG and GnRH agonist. GnRH antagonist triggering in egg donors was associated with lower rates of OHSS.

Derivation and characterization of human embryonic stem cell lines from poor quality embryos

Poor quality embryos discarded from in vitro fertilization (IVF) laboratories are good sources for deriving human embryonic stem cell (hESC) lines. In this study, 166 poor quality embryos donated from IVF centers on day 3 were cultured in a blastocyst medium for 2 days, and 32 early blastocysts were further cultured in a blastocyst optimum culture medium for additional 2 days so that the inner cell masses (ICMs) could be identified and isolated easily. The ICMs of 17 blastocysts were isolated by a mechanical method, while those of the other 15 blastocysts were isolated by immunosurgery. All isolated ICMs were inoculated onto a feeder layer for subcultivation. The rates of ICM attachment, primary ICM colony formation and the efficiency of hESC derivation were similar between the ICMs isolated by the two methods (P>0.05). As a result, four new hESC lines were established. Three cell lines had normal karyotypes and one had an unbalanced Robertsonian translocation. All cell lines showed normal hESC characteristics and had the differentiation ability. In conclusion, we established a stable and effective method for hESC isolation and culture, and it was confirmed that the mechanical isolation was an effective method to isolate ICMs from poor embryos. These results further indicate that hESC lines can be derived from poor quality embryos discarded by IVF laboratories.

Is there an advantage in scoring early embryos on more than one day?

BACKGROUND

This study was undertaken to determine what characteristics should be recorded on which days to build a predictive model for selection of Day 3 embryos.

METHODS

Embryos failing to form a clinical sac or that formed a viable fetus (to > or =12 weeks), and transferred singly (n = 269) or in pairs (n = 1326) were scored for early cleavage and pronuclear status on Day 1, and cell number, fragmentation, and symmetry on Days 2 and 3, with number of nuclei per blastomere also recorded on Day 2. Seven candidate models were identified using a priori clinical knowledge and univariate analyses. Each model was fit on a training-set and evaluated on a test-set with resampling, with discrimination assessed using the area under the ROC curve (AUC) and calibration assessed using the Hosmer-Lemeshow statistics.

RESULTS

Models built using Day 1, 2 or 3 scores independently on the 30 resampled data sets showed that Day 1 evaluations provided the poorest predictive value (median AUC = 0.683 versus 0.729 and 0.725, for Day 2 and 3). Combining information from Day 1, 2 and 3 marginally improved discrimination (median AUC = 0.737). Using the final Day 3 model fitted on the whole dataset, the median AUC was 0.732 (95% CI, 0.700-0.764), and 68.6% of embryos would be correctly classified with a cutoff probability equal to 0.3.

CONCLUSIONS

Day 2 or Day 3 evaluations alone are sufficient for morphological selection of cleavage stage embryos. The derived regression coefficients can be used prospectively in an algorithm to rank embryos for selection.

The effect of luteal phase support protocol on cycle outcome and luteal phase hormone profile in long agonist protocol intracytoplasmic sperm injection cycles: a randomized clinical trial

OBJECTIVE

To study the effect of luteal phase support protocol on cycle outcome and luteal phase hormone profile, in long agonist protocol intracytoplasmic sperm injection (ICSI) cycles.

DESIGN

Prospective randomized trial.

SETTING

Private infertility center.

PATIENT(S)

Two hundred seventy-four women undergoing first ICSI cycles were randomized after ovum pickup into three groups of luteal support.

INTERVENTION(S)

Group I received IM P (P(4)) only, group II received P(4) + oral E(2) valerate, group III received P(4) + hCG.

MAIN OUTCOME MEASURE(S)

Pregnancy rate (PR), implantation rate, rates of multiple pregnancy and miscarriage, and midluteal serum E(2) and P(4), and midluteal E(2):P(4) ratio.

RESULT(S)

The PR and implantation rates were significantly higher in group II compared to group I and the miscarriage rate was significantly lower in group II compared with group I. Midluteal E(2) was significantly higher in group II compared with group I. The decline in E(2) after ovum pickup was lowest in group II, highest in group I. The midluteal E(2):P(4) ratio was significantly higher in group II compared with groups I and III.

CONCLUSION(S)

The E(2) luteal phase supplementation in long GnRH-agonist (GnRH-a) protocol ICSI cycles resulted in better cycle outcome and better luteal phase hormone profile.

Prediction of embryonic developmental competence by time-lapse observation and 'shortest-half' analysis

Selecting an embryo with the highest probability of achieving a pregnancy is a major challenge. Early-cleavage embryos are considered to be of good quality; however, the exact developmental stage that predicts further development has not been defined. The aim of the study was to characterize cleavage rate and distribution of various stages of mouse preimplantation embryos using a time-lapse system. Mated mice were killed 20 h after human chorionic gonadotrophin administration and putative zygotes were recovered and cultured in an incubator-enclosed time-lapse imaging system. The 'shortest half' analysis was used to establish the period in which at least 50% of the embryonic population cleaved within the shortest time. Analysis indicated that through embryonic development, cleavage timing becomes less uniform and the 'shortest half' becomes longer with intervals of 2, 2.5, 3.5 and 5 h for 2-, 4-, 8-cell embryo and blastocyst stages, respectively. The 'shortest half' for the first cleavage was closely synchronized, with 80% of embryos developing to the blastocyst stage. Moreover, slow-cleaving embryos approaching the 2-cell stage expressed inferior developmental potential in comparison to those cleaving within the 'shortest half'. Thus, embryonic cleavage rate seems to be a biological indicator of developmental potential and may be useful for embryo selection.

Comparative study between slow freezing and vitrification of mouse embryos using different cryoprotectants

The objective of this study was to evaluate the effects of different cryoprotectants and different cryopreservation protocols on the development of mouse eight-cell embryos. Mouse eight-cell embryos were cryopreserved by using propylene glycerol (PROH), ethylene glycerol (EG), dimethyl sulfoxide (DMSO) or glycerol (G) as cryoprotectant with slow-freezing or Vit-Master vitrification protocol. After thawing, the survival rate, blastocyst formation rate and blastocyst hatching rate of the embryos were compared. When the mouse eight-cell embryos were cryopreserved by the slow-freezing, the survival rate, the blastocyst formation rate and the blastocyst hatching rate of the embryos with PROH were significantly higher than those of DMSO and G (p < 0.05, respectively), but not significantly different among those of DMSO, G and EG (p > 0.05, respectively), and not significantly different between those of PROH and EG (p > 0.05, respectively). When the mouse eight-cell embryos were cryopreserved by Vit-Master vitrification, the survival rate, the blastocyst formation rate and the blastocyst hatching rate of the embryos with EG were significantly higher than those of PROH, DMSO and G (p < 0.05, respectively). Yet, there were no significant differences among those of PROH, DMSO and G (p > 0.05, respectively). In conclusion, PROH was the optimal cryoprotectant for the cryopreservation of mouse eight-cell embryos by slow-freezing protocol. EG was the optimal cryoprotectant for the cryopresevation of mouse eight-cell embryos by Vit-Master vitrification protocol, which may be commonly used in clinical and laboratory practice.

How viable are zygotes in which the PN are still intact at 25 hours? Impact on the choice of embryo for transfer

OBJECTIVE

To evaluate the pertinence of kinetic observations of embryonic development 25 hours after IVF, with a view to optimizing the choice of embryos for transfer.

DESIGN

Retrospective study of 471 cycles with embryo transfer.

SETTING

University Hospital.

INTERVENTION(S)

Observations of changes in zygotes, in the 25th hour after insemination (25 h PI).

MAIN OUTCOME MEASURE(S)

Identification of three stages of development: two cells (2C), loss of the pronuclei (in syngamy; 0PN) and persistence of the two pronuclei (2PN). Embryonic morphology at 48 hours, according to the stages identified at 25 hours, was correlated with the rates of implantation and clinical pregnancy.

RESULT(S)

Two thousand four hundred seventy-eight day-2 embryos were observed. The number of blastomeres on day 2 differed significantly according to stage of development at 25 hours (2C: 69.8% vs. 0PN: 55% and 2PN: 24.6%). Implantation rates were significantly lower for cycles in which only 2PN embryos were produced (7%, n = 160) than for cycles with at least one 2C embryo and/or, preferably, a 0PN embryo (14.4%). The implantation rate was significantly lower for the transfer of only 2PN embryos (7.6%) than for the transfer of only embryos that had advanced further by 25 h PI (15.2%). If only one type of embryo was transferred (2PN vs. 2C or 0PN), for embryos with a similar morphology at 48 hours, four-blastomere embryos derived from 2PN embryos implanted less efficiently than those derived from 2C and/or 0PN embryos.

CONCLUSION(S)

Observation at 25 h PI is a simple, rapid, and cheap method for identifying the best embryos to transfer. A lack of zygote development at 25 hours is associated with a poor prognosis, unless the zygote concerned has two to three cells on day 2. The development of zygotes with 2PN at 25 h PI should be taken into account as a function of their development at 48 hours.

Three-dimensional power Doppler sonography of the (sub)endometrium and angiogenic cytokine concentrations

The aim of this study was to determine the correlation between three-dimensional power Doppler sonography (3D-PDS) of the (sub)endometrium and concentrations of angiogenic cytokines in patients attending an IVF programme. A total of 42 patients was included in a prospective, non-randomized clinical study. 3D-PDS of the (sub)endometrium was performed on the day of oocyte aspiration, with and without contrast agent. Quantitative assessment included the following 3D Doppler parameters: vascularization index, flow intensity, and vascularization flow index. On the same day, concentrations of oestradiol (serum only), vascular endothelial growth factor (VEGF), insulin-like growth factor (IGF) 1, IGF-binding protein 3 (IGFBP-3) and leptin were determined in the serum and in the follicular fluid. All 3D-PDS indices were significantly higher with contrast enhancement (P < 0.05). Follicular fluid concentrations of VEGF and IGFBP-3, as well as serum concentrations of leptin, showed significant P-values when correlated with (sub)endometrial Doppler indices. A weak linear dependency appeared between flow intensity and VEGF and leptin. Furthermore, weak dependencies were apparent between 3D Doppler parameters and high follicular fluid concentrations of VEGF and IGFBP-3. It is concluded that there is only little evidence for an association between (sub)endometrial Doppler indices as assessed by 3D-PDS and concentrations of angiogenic cytokines.

Affordable ART for developing countries: a cost benefit comparison of low dose stimulation versus high dose GnRH antagonist protocol

OBJECTIVE

Low dose stimulation (LS) is emerging as an alternative regime in assisted reproductive technology (ART). This study aimed to compare the cost-effectiveness of LS to the high dose GnRH antagonist (Atg) regime.

METHODS

An observational prospective study conducted at an academic infertility unit from January to June 2007. Outcome measures included the numbers of follicles, oocytes and embryos, morphological quality of oocytes and embryos, clinical pregnancy (PR) and complication rate.

RESULT

Ninety five first attempt ICSI cycles consisting of 54 LS and 41 Atg were analyzed. Subjects in both groups had comparable sociodemographics and reproductive characteristics. LS generated significantly fewer follicles, total oocytes, mature oocytes (all p < 0.0005) and immature oocytes (p = 0.009) than Atg but the number of excellent quality oocytes was similar. Significantly fewer embryos were available in LS although the proportion of usable embryos was higher, 83.2% vs. 67.0% for Atg. Mean embryos per transfer was 2.0 +/- 1.1 vs. 2.6 +/- 1.0 (p = 0.02) for a clinical PR per transfer of 43.2% vs. 50.0% for LS and Atg respectively. LS regime had a shorter gonadotrophin administration period with resultant COH cost one third of the Atg protocol (both, p < 0.0005). The cost per live birth per started cycle worked out to be USD 13,200 and 24,900 for LS and Atg respectively. Furthermore, LS had fewer incidences of OHSS compared to the Atg regime, 3.7% vs. 12.2%.

CONCLUSION

LS cost benefits included lower amounts of gonadotrophin used and fewer injections. It is a viable alternative regime in producing comparable clinical PR at lower cost and less complication in ART.