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

Obstetric outcomes following vitrification of in vitro and in vivo matured oocytes

OBJECTIVE

To evaluate obstetric outcomes with oocyte vitrification after ovarian stimulation (OS) and in vitro maturation (IVM) of immature oocytes.

DESIGN

A prospective trial from October 2003 to April 2007.

SETTING

University-based medical center.

PATIENT(S)

OS group: 38 patients undergoing intrauterine insemination who overresponded to OS. IVM group: 20 patients who had previous unsuccessful intrauterine insemination.

INTERVENTION(S)

Mature oocyte retrieval following OS. Immature oocyte retrieval and IVM. Oocyte vitrification, thawing, insemination, and transfer of the resulting embryos.

MAIN OUTCOME MEASURE(S)

Live-birth rates and obstetric outcomes.

RESULT(S)

The OS group was superior to the IVM group in terms of oocyte survival (81.4 +/- 22.6% vs. 67.5 +/- 26.1%), fertilization rate (75.6 +/- 22.5% vs. 64.2 +/- 19.9%), and cumulative embryo score (38.4 +/- 22.3 vs. 20.0 +/- 13.8). However, the differences in the implantation rate per embryo (19.1 +/- 25.8% vs. 9.6 +/- 24.1%), clinical pregnancy rate per cycle started (44.7%, vs. 20.0%), and live-birth rate per cycle started (39.5% vs. 20.0%) were not statistically significant. Twenty healthy babies were born in the OS group and four in the IVM group.

CONCLUSION(S)

Pregnancies achieved with vitrification of oocytes after OS and IVM treatments do not appear to be associated with adverse pregnancy outcomes. Vitrification of IVM oocytes represents a novel option for fertility preservation.

Effect of luteinized unruptured follicle cycles on clinical outcomes of frozen thawed embryo transfer in Chinese women

OBJECTIVE

To determine the effect of luteinized unruptured follicle (LUF) cycles on frozen thawed embryo transfer (FET).

DESIGN

A retrospective analysis comparing the clinical outcomes after FET among 144 cases of luteinized unruptured follicle (LUF) cycles and 866 cases of ovulation cycles.

SETTING

Reproductive medical center, Beijing China.

PATIENTS

Chinese infertile women who underwent FET.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Clinical pregnancy rate (PR), implantation rate.

RESULTS

The implantation rate, clinical pregnancy rate, on-going pregnancy rate and live birth rate in LUF group were 12.76% (49/384), 27.78% (40/144), 24.31% (35/144) and 19.44% (28/144), respectively, and in ovulation group, 14.74% (332/2251), 31.29% (271/866), 28.29% (245/866) and 22.23% (193/866), respectively (p > 0.05).

CONCLUSIONS

LUF does not affect the clinical outcomes of FET. Patients of LUF should be included in FET treatment.

Oocyte zona birefringence intensity is associated with embryonic implantation potential in ICSI cycles

A retrospective study recently showed that oocytes presenting with a high birefringence of the inner zona layer were more often associated with conception cycles. To further investigate these findings, a prospective study was conducted between September 2005 and September 2006 including intracytoplasmic sperm injection (ICSI) cycles presenting with at least two embryos for transfer. Using a polarization imaging system, oocytes were classified prior to ICSI treatment as having either a high zona birefringence (HZB) or a low zona birefringence (LZB) of the zona pellucida. Using zona birefringence as the only selection criterion, two fertilized oocytes, preferably derived from HZB oocytes, were selected for further culture and transfer. The required criteria were met by 135 ICSI cycles (124 patients; 34.9 +/- 4.1 years of age). Embryos for transfer were used in 20 cycles derived from HZB/HZB oocytes, in 50 cycles from HZB/LZB oocytes and in 65 from LZB/LZB oocytes. The corresponding implantation (P < 0.025), pregnancy (P < 0.005) and live birth (P < 0.025) rates were significantly different between HZB/HZB and HZB/LZB versus LZB/LZB group. Embryo development was superior in embryos derived from HZB oocytes. This study concludes that oocyte zona birefringence is a good selection criterion and a good predictive criterion for embryo implantation potential.

Serial uterine artery Doppler velocity parameters and human uterine receptivity in IVF/ICSI cycles

OBJECTIVE

To evaluate the predictive value of serial uterine artery Doppler ultrasound for embryo implantation in in-vitro fertilization (IVF)-intracytoplasmic sperm injection (ICSI) cycles.

METHODS

This was a prospective observational study at the VU University Medical Center, Amsterdam. Patients with an indication for IVF or IVF-ICSI according to departmental protocol underwent controlled ovarian hyperstimulation followed by IVF or IVF-ICSI and embryo transfer and had serial Doppler ultrasound performed during this treatment cycle. Patient and cycle characteristics, number of conceptions and ongoing pregnancies and pulsatility index (PI) of both uterine arteries on different cycle days were assessed and results were compared between patients who conceived and those who did not.

RESULTS

Of the 102 patients enrolled into the study, 83 underwent embryo transfer. Of these, 41 became pregnant and 42 did not (Group 1). Of the 41 pregnancies, 30 were ongoing (Group 2) and 11 miscarried (Group 3). Between Groups 1, 2 and 3, linear regression revealed no significant difference between any of the variables examined except in the quality of transferred embryos. There was no significant difference in the mean PI of the left and right uterine arteries on any day of the cycle, or in the change in PI during the cycle. Receiver-operating characteristics curves derived to determine the performance of PI to predict pregnancy outcome supported our findings that the uterine artery PI is not a suitable marker for identifying patients with implantation failure. Multivariate analysis showed no relationship between pregnancy and PI between groups, but it did show a relationship between pregnancy and some patient and cycle characteristics.

CONCLUSION

In an unselected group of patients undergoing IVF or IVF-ICSI and embryo transfer, serial Doppler ultrasound examination of the uterine artery does not discriminate between cycles resulting in ongoing pregnancy, miscarriage and no pregnancy.

The relationship between endometrial thickness and outcome of medicated frozen embryo replacement cycles

OBJECTIVE

To examine the relationship between endometrial thickness and outcome of medicated frozen-thawed embryo replacement (FER) cycles.

DESIGN

A retrospective observational study.

SETTING

Assisted conception unit at a university hospital.

PATIENT(S)

All patients who underwent an FER cycle between 1997 and April 2006 and met the inclusion criteria.

INTERVENTION(S)

For endometrial preparation, a daily dose of 6 mg of oral E(2) valerate was started on menstrual day 1, and P pessaries (800 mg daily) were administrated when the endometrial thickness had reached 7 mm or more, with ET taking place 2-3 days later. The FER cycles were categorized according to endometrial thickness measurement on the day of P supplementation.

MAIN OUTCOME MEASURE(S)

Implantation, clinical pregnancy, ongoing pregnancy, and live birth rates.

RESULT(S)

In all, 768 consecutive medicated FER cycles were analyzed. The lowest pregnancy rates were associated with endometrial thickness <7 mm (n = 13) and >14 mm (n = 12; 7% in both groups). Significantly higher implantation (19% vs. 12%), clinical pregnancy (30% vs. 18%), ongoing pregnancy (27% vs. 16%), and live birth (25% vs. 14%) rates were achieved in cycles where endometrial thickness was 9-14 mm (n = 386), compared with those in which endometrial thickness was 7-8 mm (n = 357). These differences remained significant after adjusting for confounding variables (adjusted odds ratio [OR] = 1.83 [confidence interval {CI} = 1.3-2.6] for clinical pregnancy, 1.8 [CI = 1.2-2.6] for ongoing pregnancy and 1.9 [CI = 1.3-2.8] for live birth).

CONCLUSION(S)

In medicated FER cycles, an endometrial thickness of 9-14 mm measured on the day of P supplementation is associated with higher implantation and pregnancy rates compared with an endometrial thickness of 7-8 mm.

Day 4 versus day 3 embryo transfer: a prospective study of clinical outcomes

OBJECTIVE

To compare the clinical outcomes after day 4 or day 3 embryo transfers in controlled ovarian hyperstimulation-IVF/intracytoplasmic sperm injection (ICSI) cycles.

DESIGN

Prospective randomized study.

SETTING

Center for Human Reproduction, 'Genesis Athens' Clinic (private gynecological and surgical clinic), Athens, Greece.

PATIENT(S)

Three hundred fifty women with primary infertility and indication for IVF/ICSI treatment. Patients were randomly allocated to day 4 or day 3 embryo transfer.

INTERVENTION(S)

Controlled ovarian hyperstimulation, oocyte retrieval, IVF/ICSI, embryo transfer.

MAIN OUTCOME MEASURE(S)

Implantation rate; clinical, ongoing, and multiple pregnancy rates.

RESULT(S)

A trend toward higher clinical and ongoing pregnancy rates was noted after day 4 embryo transfers. Implantation and multiple pregnancy rates were comparable after day 4 or day 3 embryo transfers.

CONCLUSION(S)

The transfer of day 4 embryos in IVF/ICSI cycles may result in favorable implantation and pregnancy rates which are at least comparable to those after the transfer of day 3 embryos.

Effect of increased body mass index on oocyte and embryo quality in IVF patients

Obesity may have an adverse effect on the outcome of IVF/intracytoplasmic sperm injection (ICSI) treatment. In this study, the effects of increased body mass index (BMI) on oocyte and embryo quality during IVF cycles were studied. A retrospective analysis of 426 IVF/ICSI cycles was performed. Cycles were classified according to the BMI: normal BMI (19-24.9 kg/m(2)), overweight (25-29.9 kg/m(2)) and obese (> or = 30 kg/m(2)). Cycles were further stratified based on age (group 1, < 35 years; group 2, > or = 35 years). Markers of oocyte quality (number of oocytes inseminated and fertilization rate) and embryo quality (utilization rate, number of embryos discarded and cryopreserved, and mean embryo grade) were examined. In group 1, obesity had a significant adverse effect on the mean embryo grade (P = 0.02), the embryo utilization rate (P = 0.01), number of embryos discarded (P = 0.007) and cryopreserved (P < 0.05). In group 2, there was no difference in markers of embryo quality between the three BMI ranks. Obesity did not have any significant effect on markers of oocyte quality or clinical pregnancy rates. In conclusion, obesity may adversely affect embryo quality in young women (<35 years) undergoing IVF/ICSI, while the oocyte quality is not affected.

The association between polypronucleate zygote formation with certain motion characteristics of sperm and IVF outcome

PURPOSE

To determine the efficiency of sperm motion characteristics as predictors for normal (2PN) and polypronulceate (PPN) zygotes in IVF.

METHODS

A retrospective cohort analysis for a total of 230 couples undergoing IVF treatment in a single infertility center.

RESULT(S)

Subsequent to semen analysis and hemizona assay, unexpected fertilization failure would appear to have occurred only extremely rarely (1/236, 0.4%). The rate of PPN, however, did arise and appeared to be related to certain sperm motion characteristics, such as lateral head displacement and concentration of progressive motile sperm. Interestingly, the patients featuring a high PPN rate (>20%) was associated with a greater pregnancy rate than those featuring a low PPN rate (<20%).

CONCLUSION

The sperm motion characteristics examined herein could be utilized to predict the rate of PPN in IVF. In order to enhance the rate of 2PN and maintain the relative high rate of clinical pregnancy, an efficient method needs further investigation and development.

Are endometrial parameters by three-dimensional ultrasound and power Doppler angiography related to in vitro fertilization/embryo transfer outcome?

OBJECTIVE

To evaluate whether endometrial parameters by three-dimensional ultrasonography and power Doppler angiography (3D US-PDA) can predict in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) outcome.

DESIGN

Prospective clinical study.

SETTING

Assisted reproduction unit in a referral hospital.

PATIENT(S)

Eighty women who underwent IVF cycles.

INTERVENTION(S)

Endometrial 3D US-PDA evaluated by VOCAL software (plane C and 9 degrees of rotational steps).

MAIN OUTCOME MEASURE(S)

Endometrial pattern, endometrial thickness (ET), endometrial volume (EV), and PDA indexes of vascularization index (VI), flow index (FI), and vascularization flow index (VFI) were measured on the day of human chorionic gonadotropin (hCG) administration. These measurements were related to IVF/ICSI and embryo transfer outcome.

RESULT(S)

In the pregnant group, EV, VI, FI, and FVI but not triple-line pattern and ET were statistically significantly higher. The area under receiver operating characteristic (ROC) curve was statistically significant for EV (0.746), VI (0.724), FI (0.828), and VFI (0.800) when no grade 1 embryos or only one were transferred (43 cycles, 14 pregnancies) but not when two or three grade 1 embryos were transferred. Moreover, these parameters were statistically significant in predicting a normal pregnancy outcome (no early pregnancy loss) but were not related to multiple pregnancies.

CONCLUSION(S)

In IVF/ICSI cycles, 3D US-PDA is useful for evaluating endometrial receptivity. Endometrial volume and 3D power Doppler indexes are statistically significant in predicting the cycle outcome when one grade 1 or no grade 1 embryos are transferred, which could be helpful data in a single-embryo transfer policy.

Cleavage stage versus blastocyst stage embryo transfer in assisted conception

BACKGROUND

Recent advances in cell culture media have led to a shift in IVF practice from early cleavage embryo transfer to blastocyst stage transfer. The rationale for blastocyst culture is to improve both uterine and embryonic synchronicity and self selection of viable embryos thus resulting in higher implantation rates.

OBJECTIVES

To determine if blastocyst stage embryo transfers (ETs) affect live birth rate and associated outcomes compared with cleavage stage ETs and to investigate what factors may influence this.

SEARCH STRATEGY

Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials, Cochrane Controlled Trials Register (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE and Bio extracts. The last search date was January 2007.

SELECTION CRITERIA

Trials were included if they were randomised and compared the effectiveness of early cleavage versus blastocyst stage transfers.

DATA COLLECTION AND ANALYSIS

Of the 50 trials that were identified, 18 randomised controlled trials (RCTs) met the inclusion criteria and were reviewed. The primary outcome was rate of live birth. Secondary outcomes were rates per couple of clinical pregnancy, multiple pregnancy, high order pregnancy, miscarriage, failure to transfer embryos and cryopreservation. Quality assessment, data extraction and meta-analysis were performed following Cochrane guidelines.

MAIN RESULTS

Evidence of a significant difference in live-birth rate per couple between the two treatment groups was detected in favour of blastocyst culture (9 RCTs; OR 1.35, 95% CI 1.05 to 1.74 (Day 2/3: 29.4% versus Day 5/6: 36.0%)). This was particularly for trials with good prognosis patients, equal number of embryos transferred (including single embryo transfer) and those in which the randomisation took place on Day 3. Rates of embryo freezing per couple was significantly higher in Day 2 to 3 transfers (9 RCTs; OR 0.45, 95% CI 0.36 to 0.56). Failure to transfer any embryos per couple was significantly higher in the Day 5 to 6 group (16 RCTs; OR 2.85, 95% CI 1.97 to 4.11 (Day 2/3: 2.8% versus Day 5/6: 8.9%)) but was not significantly different for good prognosis patients (9 RCTs; OR 1.50, 95% CI 0.79 to 2.84).

AUTHORS' CONCLUSIONS

This review provides evidence that there is a significant difference in pregnancy and live birth rates in favour of blastocyst transfer with good prognosis patients with high numbers of eight-cell embryos on Day three being the most favoured in subgroup for whom there is no difference in cycle cancellation. There is emerging evidence to suggest that in selected patients, blastocyst culture maybe applicable for single embryo transfer.

Limited importance of pre-embryo pronuclear morphology (zygote score) in assisted reproduction outcome in the absence of embryo cryopreservation

OBJECTIVE

To investigate the hypothesis that Z-score criteria represent a reliable predictor of implantation rate and pregnancy outcome in in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) cycles, excluding the possibility of embryo selection before the embryo transfer.

DESIGN

Retrospective clinical study.

SETTING

Centre of Reproductive Medicine, Department of Obstetrics and Gynecology, Arcispedale S. Maria Nuova (ASMN), Reggio Emilia, Italy.

PATIENT(S)

We analyzed 393 pregnancies obtained by IVF or ICSI cycles.

INTERVENTION(S)

Morphologic evaluations of Z-score in pre-embryos obtained from IVF or ICSI cycles.

MAIN OUTCOME MEASURE(S)

Evaluations of Z-scores, implantation rate, and clinical pregnancy outcome.

RESULT(S)

We did not find any statistically significant correlation between the Z-score of 1032 embryos transferred in 393 embryo transfers and the implantation rate or the pregnancy outcome. In particular, the best Z-score identified (Z1, 7.2%) did not seem to correlate with embryo implantation rate or pregnancy outcomes any better than those with worse scores (Z2, 6.9% and Z3, 85.9%).

CONCLUSION(S)

Our results seem to confirm that Z-score alone cannot be considered a better tool than standard morphologic criteria for identifying, controlling, or selecting embryos with a better chance of successful ongoing pregnancy.

Towards the elective replacement of a single embryo (eSET) in the United Kingdom

In the UK, the live birth rate after IVF in women aged less than 36 is >25%. The multiple birth rates in these women are excessive (20% to 25%). The perinatal mortality rate is increased significantly with IVF twins and triplets (8/1000 singletons, 20/1000 twins and 34/1000 triplets). Multiple pregnancies and births significantly increase the risks to the mother and the children, adversely affect family life and are economically disadvantageous to the couple and the wider community. The elective transfer of a single fresh embryo, followed if necessary by a single thawed embryo, in women at high risk of a multiple birth does not reduce the live birth rate and all but prevents the conception of twins and triplets.

Prediction of porcine blastocyst formation using morphological, kinetic, and amino acid depletion and appearance criteria determined during the early cleavage of in vitro-produced embryos

The determination for early cleavage-stage embryos of noninvasive morphologic and metabolic criteria that are predictive of blastocyst development and/or full-term viability remains an important research target. We describe the derivation of a logistic regression model that predicts the probability of porcine blastocyst formation in vitro. Pig zygotes, derived by in vitro maturation and fertilization of slaughterhouse oocytes, were cultured in NCSU-23 medium that was supplemented with a mixture of 20 amino acids (NCSU-23(aa)). On Day 1, at 21, 23, 25, 27, 29 and 31 h postinsemination, cleaving embryos were evaluated morphologically in terms of the: i) number of blastomeres, ii) evenness of division, and iii) degree of fragmentation. These embryos were then placed in 1.5-microl drops of NCSU-23(aa) for 24 h, after which time the three morphologic criteria were re-evaluated and 1.2 microl of spent medium were removed for analysis by HPLC, in order to determine the net rates of amino acid depletion and appearance. Embryos were then cultured singly in NCSU-23(aa) by placing them between the filaments of a woven polyester mesh until Day 6, in order to permit the identification of individual embryos. Of 256 cleaved embryos, 28.7 +/- 6.2% (n = 5 replicates) developed into blastocysts. Discriminant analysis was used to select a subset of amino acids (threonine, valine, lysine, and phenylalanine) that discriminated optimally between embryos that became blastocysts or degenerated. These discriminant scores were entered into the logistic regression. Significant univariate relationships were established between the probability of blastocyst development and amino acid score (odds ratio [OR] 0.53, 95% confidence interval [CI] 0.40-0.69, P < 0.001), cleavage time (OR 0.79, 95% CI 0.71-0.87, P < 0.001), degree of fragmentation on Day 1 (OR 0.55, 95% CI 0.35-0.84, P = 0.009) and Day 2 (OR 0.53, 95% CI 0.35-0.78, P = 0.002), evenness of division on Day 2 (OR 0.66, 95% CI 0.46-0.96, P = 0.028), and categorical values of blastomere number on Day 2 (all P < 0.02), although no single variate could accurately predict blastocyst formation. However, multivariate analysis of the cell numbers on Day 1 and Day 2 correctly classified 51.9% of the predicted blastocysts. The inclusion of cleavage time in the regression analysis raised this rate to 63.5%, which was increased to 66.2% by the addition of evenness of division and degree of fragmentation. Finally, the full logistic regression model, which incorporated amino acid score together with all the other morphologic and kinetic variables, correctly classified 80.8% of the predicted blastocysts. This represented 51.2% of the observed blastocysts. Our data are novel in that they not only define in a quantitative manner the influence of previously undescribed predictors of porcine blastocyst formation, but they also provide a simple model of preimplantation development with reasonable predictive accuracy. The present study also provides a basic model for the examination and incorporation of additional early morphologic and metabolic correlates of developmental competence and could potentially be applied to the selection of human embryos for transfer in clinical IVF.

Effect of 17alpha-hydroxyprogesterone caproate before embryo transfer on the outcome of in vitro fertilization and embryo transfer: a randomized trial

OBJECTIVE

To assess the effect of 17alpha-hydroxyprogesterone caproate (17-HPC) given before embryo transfer on the pregnancy outcome of IVF-embryo transfer (ET) cycles.

DESIGN

Randomized controlled study.

SETTING

A university-based hospital IVF unit.

PATIENT(S)

One hundred twenty-five consecutive patients undergoing IVF-ET were randomly assigned into treatment and control groups.

INTERVENTION(S)

In the treatment group, 63 patients received 17-HPC (250 mg, i.m.), 1 day before ET. The control group consisted of 62 patients who did not receive any injections.

MAIN OUTCOME MEASURE(S)

Pregnancy and multiple-pregnancy rates.

RESULT(S)

The two groups were similar with respect to the age of patients, total dose of FSH, number of oocytes and embryos obtained, and number and quality of embryos transferred. There was no significant difference in the pregnancy rate (34.9% vs. 38.7%) or in the rate of multiple gestation (15.9% vs. 9.7%) between cases and controls, respectively.

CONCLUSION(S)

The use of 17-HPC before ET does not appear to affect the outcome of IVF-ET.

Reducing the number of embryos transferred in Sweden-impact on delivery and multiple birth rates

BACKGROUND

Reduction of the number of embryos transferred has been introduced to decrease the multiple birth rates (MBRs) after IVF and the associated risks for the children. The aim of this report is to present the effect of two steps in reduction of the number of embryos transferred, when applied in the majority of the patients, on national data for delivery and MBR after IVF in Sweden.

METHODS

This observational study is based on annual reports from all IVF clinics in Sweden to the National Board of Health and Welfare for the time period 1991-2004.

RESULTS

The main finding is that despite a successive reduction in the number of embryos transferred, delivery rates were maintained at around 26% while MBR decreased dramatically, from about 35% to around 5%. The same pattern was noticed, independent of age, for all women below 40. In comparison with the USA, lower delivery and MBR were noted for Sweden whereas a higher 'birth per embryo transferred' was found.

CONCLUSIONS

Single embryo transfer (SET) results in satisfactory delivery rates and a dramatic decrease in the MBRs, also when applied on a broad scale. The experience from Sweden ought to encourage other countries to introduce SET more widely.

Assisted hatching is more effective when embryo quality was optimal in previous failed IVF/ICSI cycles

Assisted hatching (AH) was developed as a possible solution to repeated implantation failure. The aim of this analysis was to examine the relationship between the morphology of embryos in a previous cycle on outcome in a subsequent cycle with AH. A total of 175 AH cycles performed after previous failed ART without hatching were divided into group A with optimal and group B with suboptimal embryos transferred previously. The groups were similar in terms of demographic and cycle characteristics. In group A, there was a significant improvement (p<0.001) in implantation (28.8 vs 5.1%), clinical pregnancy (41.9 vs 12.1%) and live birth rate (38.5 vs 8.6%) compared with group B. The data suggest that the prognosis for treatment is better if AH is performed after failure despite optimal embryos compared with failure associated with suboptimal embryos and embryo quality is the most significant factor affecting outcome.

Pregnancy outcome and live birth after IVF and ICSI according to embryo quality

PURPOSE

The pregnancy outcome and the chances of birth were assessed according to embryo quality after IVF or ICSI.

METHODS

The implantation rate (IR), the loss of gestational sacs rate (LGSR), and birth rate (BR) were determined according to the cleavage stage and the integrity of blastomeres after day-2 homogeneous embryo transfers (n = 1812).

RESULTS

The LGSR was higher after transfers of 2-3-cell or 5-6-cell embryos and was significantly increased when more than 20% of the embryo volume was fragmented in 4-cell embryos. After transfers of 4-cell embryos without fragmentation, the BR was significantly higher than the BR after transfers of 4-cell embryos with 1-20% fragmentation (16.6% vs 13.1%). The difference was the consequence of a higher IR (20.4% vs 17.3%) but also of a lower LGSR (18.9% vs 24.2%).

CONCLUSIONS

Not only implantation and the ability to give a pregnancy, but also the capacity to give a live birth are dependent on the embryo quality.

Cryotop vitrification of human oocytes results in high survival rate and healthy deliveries

Vitrification, an ultra-rapid cooling technique, offers a new perspective in attempts to develop an optimal cryopreservation procedure for human oocytes and embryos. To further evaluate this method for human oocytes, 796 mature oocytes (metaphase II) were collected from 120 volunteers. Since Italian legislation allows the fertilization of a maximum of only three oocytes per woman, there were 463 supernumerary oocytes; instead of being discarded, they were vitrified. When, in subsequent cycles, these oocytes were utilized, 328 out of 330 (99.4%) oocytes survived the warming procedure. The fertilization rate, pregnancy rate and implantation rate per embryo were 92.9, 32.5 and 13.2% respectively. Thus, as already reported in the literature, the vitrification procedure seems to be highly effective, safe (since healthy babies have been born) and easy to apply. In situations where embryo cryopreservation is not permitted (as in Italy), there is now good indication for routine application of the method, once further standardization is achieved.

Elective cryopreservation of all pronuclear oocytes after GnRH agonist triggering of final oocyte maturation in patients at risk of developing OHSS: a prospective, observational proof-of-concept study

BACKGROUND

A bolus dose of GnRH agonist can substitute for hCG as a trigger for the resumption of meiosis in ovarian stimulation with GnRH antagonists, which has been suggested to reduce the risk of ovarian hyperstimulation syndrome (OHSS). As the efficacy of this measure in fresh embryo transfer (ET) cycles is unclear, we evaluated a new clinical concept of GnRH-agonist triggering.

METHODS

In this prospective, observational proof-of-concept study, 20 patients considered at increased risk of developing OHSS (> or = 20 follicles > or = 10 mm or estradiol > or = 4000 pg/ml, or a history of cycle cancellation due to OHSS risk or the development of severe OHSS in a previous cycle) after ovarian stimulation and concomitant GnRH-antagonist administration had final oocyte maturation triggered with 0.2 mg triptorelin s.c. All two pronucleate (2 PN) oocytes were cryopreserved by vitrification, and frozen-thawed ETs (FT-ETs) were performed in an artificial cycle. Main outcome measures were the cumulative ongoing pregnancy rate per patient and the ongoing pregnancy rate per first ET. Secondary outcomes included the incidence of moderate-to-severe OHSS.

RESULTS

Of the 20 patients triggered with GnRH agonist, 19 patients underwent 24 FT-ETs in the observational period. The cumulative ongoing pregnancy rate was 36.8% (95% confidence interval: 19.1-59.0%). The ongoing pregnancy rate per first FT-ET was 31.6% (15.4-54.0%). No cases of moderate or severe OHSS were observed.

CONCLUSIONS

The present study is the proof of the concept that GnRH-agonist triggering of final oocyte maturation in combination with elective cryopreservation of 2 PN oocytes offers OHSS risk patients a good chance of pregnancy achievement, while reducing the risk of moderate and severe OHSS.

Developmental stage on day-5 and fragmentation rate on day-3 can influence the implantation potential of top-quality blastocysts in IVF cycles with single embryo transfer

BACKGROUND

In IVF-ICSI cycles with single embryo transfer (SET), embryo selection for transfer is of crucial importance. The present study aimed to define which embryo parameters might be related to the implantation potential of advanced blastocysts.

METHODS

Overall, in 203 cycles with SET, developmental characteristics of 93 implanted (group A) and 110 non-implanted (group B) advanced blastocysts of good quality were compared. The following developmental parameters were assessed in the two groups: normal fertilization, developmental stage on day 5, number of blastomeres on day 2 and on day 3, fragmentation rate on day 3, compaction on day 4 and cleavage pattern on day 2 and day 3.

RESULTS

Expanded blastocysts compared to full blastocysts have higher implantation potential (56.5% vs. 29.3%, p < 0.05). In group B, a higher proportion of advanced blastocysts showed between 10% and 50% anucleated fragments on day 3 than in group A (23.6 vs 11.8, P = 0.03). Advanced blastocysts with >10-50% fragments on day 3 showed a significant lower implantation (29.7%) than those with < or = 10%fragments (49.4%, P = 0.03). All the other parameters analysed were comparable for the two groups.

CONCLUSION

Developmental stage on day 5 and fragmentation rate on day 3 were related to the implantation potential of advanced blastocysts and should also be taken into account in the selection of the best advanced blastocyst for transfer.

Meiotic spindle presence and oocyte morphology do not predict clinical ICSI outcomes: a study of 967 transferred embryos

With a view to correlating oocyte morphology and meiotic spindle presence to clinical intracytoplasmic sperm injection (ICSI) outcomes, 967 oocytes that led to 967 transferred embryos in 404 embryo transfers were studied. No relationship was found between oocyte morphology (ooplasm texture, perivitelline space largeness, perivitelline space granulation absence/presence and the first polar body shape) or meiotic spindle presence or absence and clinical pregnancy per transfer and implantation rates after ICSI. It was concluded that oocyte morphology and meiotic spindle presence or absence can only predict fertilization, cleavage rates and embryo quality, as previously described in the literature, but do not help in daily ICSI practice in the choice of the metaphase II oocyte that will lead to the embryo that starts clinical pregnancy.

Effect of reduced oxygen concentrations on the outcome of in vitro fertilization

We compared the effects of two standard oxygen concentrations, physiological (5% O(2), 5% CO(2), and 90% N(2)) and atmospheric (5% CO(2) with the balance as air), on fertilization, embryo development, and pregnancy rate in 106 patients undergoing IVF, excluding donor oocyte cycles and preimplantation genetic diagnosis cycles. The differences in oxygen concentration did not significantly affect fertilization rate, blastocyst formation, or pregnancy rate, but there was a significant difference in mean embryo score between physiological and atmospheric groups on day 3.

Relationship between even early cleavage and day 2 embryo score and assessment of their predictive value for pregnancy

The aim of this study was, firstly, to define the different patterns of early cleavage (EC) observed at 26 h after either IVF or intracytoplasmic sperm injection (ICSI) and, secondly, to assess the predictive value of one of these patterns, even EC (EEC), on pregnancy rate in combination with day 2 embryo score. In the first part of the study, the relationship between three different EC patterns (EEC, uneven EC and EC with fragmentation of the day 2 embryo) and embryo morphology was determined. EEC was shown to be strongly associated with good embryo morphology. In the second part of the study, it was shown that EEC used in combination with embryo score improved selection of embryos for transfer. The presence of EEC significantly (P < 0.001) enhanced mean implantation rate in all transfer categories involving identically scored embryos, in both compulsory single embryo transfers and elective single embryo transfers. Multivariate analysis demonstrated that EEC and embryo score had strong complementary predictive value for pregnancy. Based on these findings, it was concluded that even though they are associated, EEC and embryo score could be combined to increase pregnancy rate, especially in elective single embryo transfer programmes.

Three years of routine vitrification of human zygotes: is it still fair to advocate slow-rate freezing?

Cryopreservation of human oocytes and embryos is a necessary tool in assisted reproduction treatment that leads to an increased cumulative outcome while decreasing costs. Vitrification is a cryopreservation technique that leads to a glass-like solidification, with rapid cooling of cells or tissues. Nowadays vitrification is claimed to be the future of cryopreservation of human embryos due to improved survival rates and clinical outcomes. This study was conducted at a university clinic to assess the safety and efficiency of vitrification of human zygotes as a routine procedure. A total of 849 pronuclear-stage (PN) zygotes were vitrified between March 2004 and July 2006. During this period, 103 cycles of cryopreserved embryo transfer were completed. In total, 339 PN zygotes were thawed resulting in an 89% survival rate (302 PN zygotes). The mean number of embryos per transfer was 2.2. The pregnancy rate obtained was three times higher (36.9%) than that obtained with the slow-rate freezing method (10.2%) used previously in the same centre. In conclusion, vitrification of human zygotes at the pronuclear stage seems to be a successful and reliable method with favourable outcomes and can be recommended as a routine technique for cryopreservation of human embryos.

Predicting human embryo viability: the road to non-invasive analysis of the secretome using metabolic footprinting

Infertility affects an increasing number of couples and for many the treatment of choice is IVF. However, the success rate remains relatively low, and, as typically two or more embryos are implanted, successful pregnancy often leads to multiple pregnancies with attendant complications. The major limitation in clinical IVF is the inability to predict which embryos are most viable, with the highest chance of implantation and development to a live baby. In principle, embryos can be selected for transfer based on data obtained at the genomic, transcriptomic, proteomic and/or metabolomic levels; however, these measurements cannot always be made directly on the embryo without invasive biopsy of cells. Alternative strategies are needed and this review considers the range of possibilities, with a focus on the analysis of the secretome from human embryos using metabolic footprinting.

Relationship between sperm DNA damage, induced acrosome reaction and viability in ICSI patients

The DNA damage in human spermatozoa is a relevant predictor of prognosis in male infertility, whereby increased sperm DNA damage impairs the outcomes of artificial reproduction. Theoretically, DNA damage should alter the special cellular functions of human spermatozoa, and lead to diminished acrosome reaction with reduced fertilization rates. Nevertheless, intracytoplasmic sperm injection (ICSI) has been reported to alleviate such negative outcomes due to DNA damage. This study investigated the relationship between DNA fragmentation and acrosome reaction as well as viability in ICSI patients. The study enrolled 42 men undergoing ICSI due to poor sperm parameters. The DNA fragmentation indexes (DFI) were 4-10% in 38% of the cases, and > or = 10% in 19% of the cases. The results of both acrosome reaction and viability assays showed negative correlations with DFI values in all cases and especially in cases with fertilization rates <60% (P < 0.05). However, such correlations were not found in cases with fertilization rates >60%. There were no live deliveries in patients with high DFI levels (>10%). In conclusion, negative correlations were identified between increased DNA damage, and acrosome reaction and/or viability of human spermatozoa, especially in cases with reduced fertilization rates.

Effects of gonadotropin-releasing hormone agonist/recombinant follicle-stimulating hormone versus gonadotropin-releasing hormone antagonist/recombinant follicle-stimulating hormone on follicular fluid levels of adhesion molecules during in vitro fertilization

OBJECTIVE

To compare the effects of GnRH-agonist/recombinant rFSH versus GnRH-antagonist/recombinant FSH stimulation on follicular fluid levels of soluble intercellular adhesion molecule (sICAM)-1 and vascular cell adhesion molecule-1 (sVCAM-1) during in vitro fertilization (IVF).

DESIGN

Prospective, randomized study.

SETTING

University hospital.

PATIENT(S)

Seventy-three women underwent IVF.

INTERVENTION(S)

GnRH-agonist/rFSH or GnRH-antagonist/rFSH administration and collection of follicular fluid from 3 small (11-14 mm in diameter) and 3 large (18-21 mm in diameter) follicles on the day of oocyte retrieval.

MAIN OUTCOME MEASURE(S)

Follicular fluid levels of sICAM-1 and sVCAM-1 and intrafollicular estradiol and progesterone were also measured.

RESULT(S)

Women who underwent GnRH-agonist/rFSH showed higher concentrations of sICAM-1 in both small and large follicles were compared with patients who received GnRH-antagonist/rFSH treatment; follicular fluid levels of sVCAM-1 were similar between the 2 stimulation protocols. Content of sICAM-1 in small and large follicles positively correlated with the number of follicles of > or =15 mm and the number of oocytes that were retrieved in both study groups. Concentrations of follicular fluid sVCAM-1 and progesterone were higher in large than in small follicles and were correlated positively to each other in both follicular classes.

CONCLUSION(S)

In IVF, GnRH-agonist/rFSH is associated with higher follicular fluid levels of sICAM-1 compared with GnRH-antagonist/rFSH regimen. Intrafollicular sICAM-1 content may predict ovarian response, and sVCAM-1 appears as an indicator of the degree of follicular luteinization.

Similar outcome for cryopreserved embryo transfer following GnRH-antagonist/GnRH-agonist, GnRH-antagonist/HCG or long protocol ovarian stimulation

The pregnancy rates after triggering of final oocyte maturation with gonadotrophin-releasing hormone (GnRH) agonist in GnRH-antagonist ovarian stimulation protocols are lower than those following triggering with human chorionic gonadotrophin (HCG). Furthermore, lower pregnancy rates following GnRH-antagonist protocols compared with long GnRH-agonist protocols have been reported. The differences might be due to an impact on oocyte number and quality or on the endometrium. If any stimulation protocol had a negative impact on oocyte quality, then further evidence of this effect would be observed following frozen-thawed embryo transfer originating from that stimulation cycle. The outcome of frozen-thawed embryo transfer was retrospectively analysed using the long protocol with triptorelin depot 3.75 mg (n = 215) or 0.1 mg/day (n = 83), or GnRH-antagonist protocol with either HCG (n = 69) or GnRH-agonist (n = 25) for final oocyte maturation. The outcomes measured were implantation rate, clinical pregnancy rate, ongoing pregnancy rate and embryo survival rate. All outcomes were similar in the four groups. It is concluded that the potential for frozen-thawed embryos to implant and develop following transfer is independent of the GnRH-analogue and the final oocyte maturation protocol used in the collection cycle. Lower IVF embryo transfer success using GnRH-antagonist/GnRH-agonist protocol does not appear to be related to an adverse effect on oocyte quality.

Impact of the assessment of early cleavage in a single embryo transfer policy

The policy of single embryo transfer (SET) adopted for women <36 years old since 1 July 2003, strongly calls for improvement of embryo selection. A total of 196 cycles in which SET was performed were randomly allocated to two groups. In the first group, early cleavage was assessed (ECA) 25 h after insemination. The embryo with the best score that cleaved early, if present, was selected for transfer. In the second group, early cleavage was not assessed (ECNA) and embryo selection was based solely on the embryo score. Ninety-eight cycles were allocated in the ECA and ECNA group respectively. Early cleavage occurred in 64% of cycles and 32.2% of embryos. Patient population and embryo morphology were similar between the two groups, and similar delivery rates were observed (27.6 versus 24.5% respectively in the ECA and ECNA groups). The assessment of early cleavage as additional parameter did not improve the delivery rate in the single embryo transfer policy.

Interobserver and intraobserver variation in day 3 embryo grading

OBJECTIVE

Variations in pregnancy rates (PR) between IVF programs are due to multiple factors, including embryo quality. Standardized embryo grading systems have been developed to improve communication between embryologists and clinicians. However, these grading systems have not been validated. We sought to quantify both interobserver and intraobserver variability using a standardized day 3 embryo grading system (Veeck scale).

DESIGN

Prospective, sample-randomized, controlled, blinded study.

SETTING

University hospital.

PATIENT(S)

Twenty-six practicing embryologists.

INTERVENTION(S)

Observation and grading of 35 video clips of day 3 embryos.

MAIN OUTCOME MEASURE(S)

Interobserver and intraobserver variability. Embryologists were also assessed by education level, years of experience, size of IVF program, and type of grading system used. Kappa scores and intraclass correlation coefficients were calculated.

RESULT(S)

Practicing embryologists differed from control (Lucinda Veeck) by as much as two grades, despite using the same grading system (Kappa = 0.24, interclass correlation coefficient = 0.98). There was also variability in grading the same embryo (Kappa = 0.69, interclass correlation coefficient = 0.88). Programs with higher cycle numbers per year had lower variability.

CONCLUSION(S)

There is substantial interobserver variability and moderate intraobserver variability among embryologists. Such variability could alter both the expected quality of embryos transferred, as well as the number transferred, both of which directly impact IVF program success.

Effect of traditional Chinese herbs combined with low dose human menopausal gonadotropin applied in frozen thawed embryo transfer

OBJECTIVE

To assess embryo implantation rate (IR) and pregnancy rate (PR) in women who received Bushen Wengong Decoction (BSWGD), a Chinese herbal formula, combined with low dose of human menopausal gonadotropin (hMG) prior to frozen-thawed embryo transfer (FET).

METHODS

A total of 262 subjects (674 transferred embryos) who received FET were analyzed retrospectively. In them, 122 women were under 30 years old, 106 between 30 - 35 years and 32 over 35 years. The 85 subjects with normal ovulation were assigned to Group A, the natural menstruation cycling group, on whom no pre-transfer treatment was applied. The other 177 subjects with abnormal ovulation were assigned to Group B, and subdivided, according to the pre-transfer treatment they received, into three groups, Group B1 (50 cases) received BSWGD, Group B2 (58 cases) received hMG and Group B3 (69 cases) received both BSWGD and low dose hMG. The IR and PR of FET in the four groups were compared, and the effect of the embryo cryotime on PR of FET were compared also. Besides, the influencing factors to FET were analyzed.

RESULTS

IR and PR were significantly higher in all age sects of Group B3 than those in Group A, showing significant difference (P< 0.05). IR and PR in subjects in age sects of <30 years and > 35 years in group B3 were significantly higher than those in Group B1 ( P<0.05), but no significant difference was shown in the two parameters between Group B 2 and Group B3 (P>0.05). PR in the subjects who received embryos with cryo-time of > 200 days was significantly lower than that in those with cryo-time of < 100 days ( P<0.05). Embryo cryo-time, endometrial thickness, use of BSWGD and use of hMG were of significance in FET ( P 0.05).

CONCLUSION

A programmed cycle of BSWGD combined with low dose of hMG could improve the embryo IR and PR of FET. Embryo cryo-time, endometrial thickness, and the use of BSWGD and hMG are of significance for FET.

Construction of an evidence-based integrated morphology cleavage embryo score for implantation potential of embryos scored and transferred on day 2 after oocyte retrieval

BACKGROUND

Evidence-based morphological embryo scoring models for ranking of implantation potential are still scarce, and the need for a precise model increases when aiming for singleton pregnancies.

METHODS

Prospectively, 2266 IVF/ICSI double-embryo, day 2 transfers were studied. The five variables scored in 3- to 5-step scales for the embryos transferred are blastomere number (BL), fragmentation, blastomere size variation ('equality', EQ), symmetry of the cleavage and mononuclearity in the blastomeres (NU). The scoring results of embryos with an individual traceability from scoring to implantation, i.e. treatments resulting in either no implantation (n=1385) or twin implantation (n=228), were studied for prognostic potential.

RESULTS

Although all five variables correlated highly with implantation potential, only BL, NU and EQ remained independently significant after regression analysis. The equation thus derived formed the basis for a 10-point integrated morphology cleavage (IMC) embryo score. A table with the scoring point for each possible combination of the embryo variables is presented. The scoring model was statistically validated on the singleton pregnancy group (n=653).

CONCLUSIONS

We suggest that this IMC embryo scoring, incorporating cleavage stage and information on the variation in blastomere size and the number of mononucleated blastomeres, may optimize embryo ranking and selection for day 2 transfers.

Early compaction on day 3 may be associated with increased implantation potential

OBJECTIVE

To determine whether day 3 embryos exhibiting early compaction have an improved implantation potential compared to embryos without compaction.

DESIGN

A retrospective cohort study.

SETTING

Hospital-based academic medical center.

PATIENT(S)

Women <38 years of age undergoing IVF cycles between November 2001 and December 2004 having a day 3 transfer of one or two embryos with >8 cells.

INTERVENTION(S)

Standard IVF protocol.

MAIN OUTCOME MEASURE(S)

Compaction grading and implantation rates of 1,047 embryos as related to fragmentation of >or= 8-cell embryos in patients with either 0% or 100% implantation.

RESULT(S)

Compaction grading was strongly associated with implantation potential; however, the direction of this effect depended on the degree of fragmentation. In embryos with <10% fragmentation, implantation rates increased with the degree of compaction (grade 1, 25%; grade 2, 33%; and grade 3, 47%); in embryos with >or=10% fragmentation, the effect was reversed (grade 1, 38%; grade 2, 20%; and grade 3, 9%).

CONCLUSION(S)

Assessing the degree of compaction can be a valuable addition to traditional morphologic assessment in identifying optimal embryos for transfer on day 3.

Association of a single dose of gonadotropin-releasing hormone antagonist with nitric oxide and embryo quality in in vitro fertilization cycles

The patients undertaking a single-dose protocol for GnRH antagonist were associated with elevated serum and follicular levels of nitric oxide (NO) and decreased embryo quality scores compared with those who underwent the long protocol for GnRH agonist. The relatively poor embryo quality may be NO related instead of Fas related.

Effect of dehydroepiandrosterone on oocyte and embryo yields, embryo grade and cell number in IVF

BACKGROUND

The aim of this study was to investigate the effect of treatment with dehydroepiandrosterone (DHEA) on fertility outcomes among women with diminished ovarian reserve.

MATERIALS AND METHODS

This is a case-control study in an academically affiliated private infertility centre. Twenty-five women with significantly diminished ovarian reserve had one IVF cycle before and after DHEA treatment, with otherwise identical hormonal stimulation. Women received 75 mg of DHEA daily (25 mg three times daily) for an average of 17.6 +/- 2.13 weeks. We performed a comparison of IVF outcome parameters, before and after DHEA treatment, including peak estradiol (E(2)) levels, oocyte and embryo numbers, oocyte and embryo quality and embryo transfer statistics.

RESULTS

Paired analysis of IVF cycle outcomes in 25 patients, who underwent cycles both before and after DHEA supplementation, demonstrated significant increases in fertilized oocytes (P < 0.001), normal day 3 embryos (P = 0.001), embryos transferred (P = 0.005) and average embryo scores per oocyte (P < 0.001) after DHEA treatment.

CONCLUSION

This study confirms the previously reported beneficial effects of DHEA supplementation on ovarian function in women with diminished ovarian reserve.

Factors determining early pregnancy loss in singleton and multiple implantations

BACKGROUND

The incidence of first trimester pregnancy loss is much lower in IVF twin pregnancies than in IVF singleton pregnancies. The objective of this study was to determine which embryonic and maternal factors contribute to this finding.

METHODS

Retrospective data analysis of the outcome of 1593 pregnancies after day 3 double-embryo transfer (DET) after IVF or ICSI treatment.

RESULTS

Of 1148 single implantations at 6 weeks, 936 (81.5%) were ongoing pregnancies. Of 445 multiple implantations at 6 weeks, 354 (79.6%) were ongoing multiple pregnancies, 80 (17.9%) were ongoing singleton pregnancies and 11 (2.5%) ended in a spontaneous abortion. Total pregnancy loss was 18.5 and 2.5% (P < 0.001) in singleton and twin gestations, respectively. Loss per gestational sac was 18.5 and 11.46% (P < 0.001), respectively. Determinants contributing to the continuation of gestation beyond 6 weeks were young maternal age, possibility to cryopreserve embryos and short GnRH agonist flare-up stimulation protocol. Whereas factors promoting multiple implantation at 6 weeks of gestation were young maternal age, high cumulative embryo score (CES), male infertility, long stimulation protocol and thick endometrium.

CONCLUSIONS

Although multiple implantation at 6 weeks is predominantly determined by (morphological) embryo quality, the continuation of pregnancy beyond 6 weeks becomes more dependent on the combination of genetic and developmental potential of the embryo(s) and an optimal uterine milieu.

Comment améliorer nos résultats en AMP ? La France est-elle en retard ? Stratégie de transfert de l'embryon unique : la place du choix de l'embryon et de la congélation embryonnaire

Multiple embryo transfer is associated with a high frequency of twin pregnancies with costly complications involving both mother and child. As a result high priority is currently being given to the development of single embryo transfer (SET) programs. France seems to be lagging behind Northern European countries in the development of SET and widespread use of SET will depend on convincing physicians that this policy will not have a negative impact on success rate, as has been the case for many protocols described in the literature as well as in our own experience. Our SET program includes patients less than 36 years of age undergoing their first FIV-ICSI. If two embryos showing satisfactory morphology are obtained, one is selected transferred and the other is systematically frozen. Selection for transfer is based on two criteria, i.e. observation of even early cleavage 26 hours after FIV-ICSI and evaluation of embryo morphology score on day 2. Embryo morphology score is based on the presence of four blastomeres and absence of blastomere irregularities and anucleated fragmentation. Last, a prerequisite for SET is an effective freezing program. A pregnancy rate of 13% per thawing was sufficient enough to obtain a cumulative pregnancy rate after SET (N = 205) and subsequent frozen embryo transfer (FET) similar to the cumulative pregnancy rate obtained after double embryo transfer (N = 394) and subsequent FET (46.3 vs 46.7%, NS). Twin delivery rate were respectively 2,6% after SET and 26,6% after double embryo transfer (P < 0.01).

Smoking impairs angiogenesis during maturation of human oocytes

OBJECTIVE

This study determines whether smoking influences ovarian vascularization which thus may impair follicular development.

DESIGN

Prospective laboratory study of follicular fluids and granulosa cells from patients undergoing in vitro fertilization.

SETTING

University Hospital Aachen, Germany.

PATIENT(S)

Fifty smoking women and 50 nonsmoking women.

INTERVENTION(S)

Cultivation of human granulosa cells. Cultivation of human umbilical vein endothelial cells (HUVECs) with either granulosa cell-conditioned medium or follicular fluid. Determination of clinical parameters.

MAIN OUTCOME MEASURE(S)

Quantification of soluble vascular endothelial growth factor receptor 1 (sVEGFR-1) and cotinine.

RESULT(S)

Mean sVEGFR-1 concentration in follicular fluid of smokers was 499.6 pg/mL compared with 159.2 pg/mL in nonsmokers. Correspondingly, supernatant of HUVECs cultured with follicular fluid from smoking and nonsmoking women showed, respectively, 1,174.1 pg/mL versus 794.2 pg/mL sVEGFR-1. The HUVECs incubated with conditioned medium from smokers' granulosa cells at culturing days 5, 9, 13, and 17 secreted, respectively, 1,712.4, 1,560.6, 1,619.0, and 1,635.0 pg/mL sVEGFR-1, whereas nonsmokers showed, respectively, 1,147.6, 1,067.2, 1,135.9, and 1,206.3 pg/mL sVEGFR-1. Mean cotinine concentration in smoking women was 83.9 ng/mL and in nonsmoking was 2.8 ng/mL. In all four comparisons, differences between groups reached statistical significance.

CONCLUSION(S)

This study showed that smokers secrete significantly higher amounts of sVEGFR-1 than nonsmokers, which may result in decreased ovarian vascularization and reduced oocyte maturation.

Efficiency of changing the embryo transfer time from day 3 to day 2 among women with poor ovarian response: A prospective randomized trial

OBJECTIVE

To compare the outcome of day 2 and day 3 embryo transfers in women demonstrating poor ovarian response.

DESIGN

Prospective randomized clinical trial.

SETTING

Private assisted reproductive technology center.

PATIENT(S)

Two hundred eighty-one women demonstrating poor ovarian response to controlled ovarian hyperstimulation.

INTERVENTION(S)

Women who were poor responders were randomly allocated to day 2 or day 3 embryo transfer following oocyte retrieval.

MAIN OUTCOME MEASURE(S)

Implantation rates and pregnancy rates per oocyte retrieval and embryo transfer.

RESULT(S)

The clinical pregnancy rates per oocyte retrieval (37.2% vs. 21.4%, respectively; P<.05) and per embryo transfer (38.9% vs. 24.1%, respectively; P<.05) were significantly higher in the day 2 embryo transfer group compared with day 3. On the other hand, implantation rates were not different between groups (23.9% vs. 17.2%, respectively; P=.08).

CONCLUSION(S)

Our results demonstrated that transfering embryos on day 2 could provide an alternative to the management of poor responder patients.