Ultrastructural evaluation of human metaphase II oocytes after vitrification: closed versus open devices

A comprehensive review and update on human fertility cryopreservation methods and tools

The broad conceptualization of fertility preservation and restoration has become already a major concern in the modern western world since a large number of individuals often face it in the everyday life. Driven by different health conditions and/or social reasons, a variety of patients currently rely on routinely and non-routinely applied assisted reproductive technologies, and mostly on the possibility to cryopreserve gametes and/or gonadal tissues for expanding their reproductive lifespan. This review embraces the data present in human-focused literature regarding the up-to-date methodologies and tools contemporarily applied in IVF laboratories' clinical setting of the oocyte, sperm, and embryo cryopreservation and explores the latest news and issues related to the optimization of methods used in ovarian and testicular tissue cryopreservation.

The effects of vitrification on oocyte quality

Vitrification, is an ultra-rapid, manual cooling process that produces glass-like (ice crystal free) solidification. Water is prevented from forming intercellular and intracellular ice crystals during cooling as a result of oocyte dehydration and the use of highly concentrated cryoprotectant. Though oocytes can be cryopreserved without ice crystal formation through vitrification, it is still not clear whether the process of vitrification causes any negative impact (temperature change/chilling effect, osmotic stress, cryoprotectant toxicity, and/or phase transitions) on oocyte quality that translate to diminished embryo developmental potential or subsequent clinical outcomes. In this review, we attempt to assess the technique's potential effects and the consequence of these effects on outcomes.

DNA damage in cumulus cells generated after the vitrification of in vitro matured porcine oocytes and its impact on fertilization and embryo development

Background

The evaluation of the DNA damage generated in cumulus cells after mature cumulus-oocyte complexes vitrification can be considered as an indicator of oocyte quality since these cells play important roles in oocyte developmental competence. Therefore, the aim of this study was to determine if matured cumulus-oocyte complexes exposure to cryoprotectants (CPAs) or vitrification affects oocytes and cumulus cells viability, but also if DNA damage is generated in cumulus cells, affecting fertilization and embryo development.

Results

The DNA damage in cumulus cells was measured using the alkaline comet assay and expressed as Comet Tail Length (CTL) and Olive Tail Moment (OTM). Results demonstrate that oocyte exposure to CPAs or vitrification reduced oocyte (75.5 ± 3.69%, Toxicity; 66.7 ± 4.57%, Vitrification) and cumulus cells viability (32.7 ± 5.85%, Toxicity; 7.7 ± 2.21%, Vitrification) compared to control (95.5 ± 4.04%, oocytes; 89 ± 4.24%, cumulus cells). Also, significantly higher DNA damage expressed as OTM was generated in the cumulus cells after exposure to CPAs and vitrification (39 ± 17.41, 33.6 ± 16.69, respectively) compared to control (7.4 ± 4.22). In addition, fertilization and embryo development rates also decreased after exposure to CPAs (35.3 ± 16.65%, 22.6 ± 3.05%, respectively) and vitrification (32.3 ± 9.29%, 20 ± 1%, respectively). It was also found that fertilization and embryo development rates in granulose-intact oocytes were significantly higher compared to denuded oocytes in the control groups. However, a decline in embryo development to the blastocyst stage was observed after CPAs exposure (1.66 ± 0.57%) or vitrification (2 ± 1%) compared to control (22.3 ± 2.51%). This could be attributed to the reduction in both cell types viability, and the generation of DNA damage in the cumulus cells.

Conclusion

This study demonstrates that oocyte exposure to CPAs or vitrification reduced viability in oocytes and cumulus cells, and generated DNA damage in the cumulus cells, affecting fertilization and embryo development rates. These findings will allow to understand some of the mechanisms of oocyte damage after vitrification that compromise their developmental capacity, as well as the search for new vitrification strategies to increase fertilization and embryo development rates by preserving the integrity of the cumulus cells.

Development of Optimized Vitrification Procedures Using Closed Carrier System to Improve the Survival and Developmental Competence of Vitrified Mouse Oocytes

The open carrier system (OC) is used for vitrification due to its high efficiency in preserving female fertility, but concerns remain that it bears possible risks of cross-contamination. Closed carrier systems (CC) could be an alternative to the OC to increase safety. However, the viability and developmental competence of vitrified/warmed (VW) oocytes using the CC were significantly lower than with OC. We aimed to improve the efficiency of the CC. Metaphase II oocytes were collected from mice after superovulation and subjected to in vitro fertilization after vitrification/warming. Increasing the cooling/warming rate and exposure time to cryoprotectants as key parameters for the CC effectively improved the survival rate and developmental competence of VW oocytes. When all the conditions that improved the outcomes were applied to the conventional CC, hereafter named the modified vitrification/warming procedure using CC (mVW-CC), the viability and developmental competence of VW oocytes were significantly improved as compared to those of VW oocytes in the CC. Furthermore, mVW-CC increased the spindle normality of VW oocytes, as well as the cell number of blastocysts developed from VW oocytes. Collectively, our mVW-CC optimized for mouse oocytes can be utilized for humans without concerns regarding possible cross-contamination during vitrification in the future.

Ultrastructure of mitochondria of human oocytes in different clinical conditions during assisted reproduction

Infertility affects around 8% of couples with a slight change in percentage in the last years. Despite the significant efforts made in Assisted Reproductive Technologies (ARTs) in handling this disorder, oocyte quality remains a crucial factor for a positive outcome. A better understanding of the dynamics underlying oocyte maturation, fertilization, and embryo development remains one of the main areas for progress in the ARTs field. Mitochondria are believed to play an essential role in these processes. Mitochondria have a crucial part in producing energy for oocyte maturation and embryo development throughout precise cellular functions comprising Ca²⁺ homeostasis regulation, glycolysis, amino acid and fatty acid metabolism, and regulation of apoptosis. Recent studies suggest that mitochondrial structure, content, and function may be related to oocyte competence, embryo viability, and implantation success during ARTs. Their defects could lead to low fertilization rates and embryonic development failure. This review aimed to provide an overview of the available literature data surrounding the correlation between changes at ultrastructural level of mitochondria or correlated-mitochondrial aggregates and oocyte quality and ARTs treatments. Our reported data demonstrated that oocyte mitochondrial ultrastructural alterations could be partial or complete recovery during the early embryo stages. However, these changes could persist as quiescent during the pre-implantation embryo development, causing abnormalities that become evident only during fetal and postnatal life. These factors led to consider the mitochondria as a crucial marker of oocyte and embryo quality, as well as a strategic target for further prospective therapeutical approaches.

Cryopreservation of equine oocytes: looking into the crystal ball

Invitro embryo production has evolved rapidly in the horse over the past decade, but blastocyst rates from vitrified equine oocytes remain quite poor and further research is needed to warrant application. Oocyte vitrification is affected by several technical and biological factors. In the horse, short exposure of immature oocytes to the combination of permeating and non-permeating cryoprotective agents has been associated with the best results so far. High cooling and warming rates are also crucial and can be obtained by using minimal volumes and open cryodevices. Vitrification of invivo-matured oocytes has yielded better results, but is less practical. The presence of the corona radiata seems to partially protect those factors that are necessary for the construction of the normal spindle and for chromosome alignment, but multiple layers of cumulus cells may impair permeation of cryoprotective agents. In addition to the spindle, the oolemma and mitochondria are also particularly sensitive to vitrification damage, which should be minimised in future vitrification procedures. This review presents promising protocols and novel strategies in equine oocyte vitrification, with a focus on blastocyst development and foal production as most reliable outcome parameters.

Oocyte cryopreservation - current scenario and future perspectives: A narrative review

Oocyte cryopreservation is a boon for women undergoing assisted reproductive technology. With the evolution in the technique of cryopreservation over the last three decades, there has been an exponential rise in the number of oocyte cryopreservation cycles for diverse indications. Apart from cancer patients, it has also been promoted as a mode of fertility insurance to overcome the age-related decline in fertility as well as post-surgical decline following endometriosis surgery. The objective of the review is to evaluate its clinical applications, ideal age at freezing, optimal oocyte number, freezing method of choice, efficacy, safety and recent advances. In the last decade, vitrification has surpassed slow freezing for oocyte cryopreservation. Although closed system of vitrification provides the aseptic environment, open vitrification is commonly followed in practice. Early to mid-thirties is a reasonable age group for planned oocyte cryopreservation, although it might be recommended at a younger age, in patients with diminished ovarian reserve. The patients should be motivated to preserve around 14–20 mature oocytes for successful live birth. Various studies have shown comparable fertilisation and pregnancy rates between Intracytoplasmic sperm injection with fresh and frozen-thawed oocytes. The available evidence has shown no increase in the incidence of congenital abnormalities in babies born through vitrified oocytes. In the future, image analysis using artificial intelligence, and spindle visualisation using poloscope may further enhance the outcome of oocyte cryopreservation.

Comparison of two different oocyte vitrification methods: a prospective, paired study on the same genetic background and stimulation protocol

STUDY QUESTION

Can two different methods for oocyte vitrification, one using an open tool and the other a closed tool, result in similar oocyte survival rates?

SUMMARY ANSWER

The oocyte survival rate was found to be higher in the closed method.

WHAT IS KNOWN ALREADY

Open vitrification is performed routinely in oocyte donation cycles. Closed oocyte vitrification may result in slower cooling rates and thus it is less used, even though it has been recommended in order to avoid the risk of cross-contamination between material from different patients.

STUDY DESIGN, SIZE, DURATION

This is a prospective cohort study with sibling oocytes carried out in a fertility center between July 2014 and January 2016. The study included 83 oocyte donors each providing a minimum of 12 mature oocytes (metaphase II: MII) at oocyte retrieval. Oocyte survival rate and fertilization rate, as well as reproductive outcomes (biochemical, clinical, ongoing pregnancy and live birth rates) per embryo transfer and also cumulatively between the two methods were compared by Chi2 tests.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Donor oocytes were denuded and six MII oocytes from each donor were vitrified using an open method and later assigned to one recipient, while another six MII oocytes were vitrified using a closed method and assigned to a different recipient (paired analysis). ICSI was used in all cases and embryo transfer was performed on Day 2-3 in all cases.

MAIN RESULTS AND THE ROLE OF CHANCE

Oocyte donors were 24.8 years old on average (SD 4.7). Recipient age (average 41.2 years, SD 4.7) and BMI (mean 23.8 kg/m2, SD 4.0) were similar between recipient groups. Oocytes vitrified using the closed method had higher survival rate (94.5% versus 88.9%, P = 0.002), but lower fertilization rate (57.1% versus 69.8%, P < 0.001) compared to the open method. The number of fresh embryos transferred in the two groups was 1.8 on average (SD 0.4). Biochemical (45% closed versus 50% open), clinical (40% versus 50%) and ongoing (37.5% versus 42.5%) pregnancy rates were not different between groups (P > 0.05) and neither were live birth rates (37.5% versus 42.5%, P > 0.05). Cumulative reproductive results (obtained after the transfer of all the embryos) were also similar between groups.

LIMITATIONS, REASONS FOR CAUTION

The participants of this study were oocyte donors, i.e. young women in good health, and care should be exerted in extending our results to other populations such as infertility patients, oncofertility patients and women freezing oocytes to delay childbearing.

WIDER IMPLICATIONS OF THE FINDINGS

Our results suggest that, in spite of different survival and fertilization rates, closed and open oocyte vitrification methods should offer similar reproductive outcomes up to cumulative live birth rates.

STUDY FUNDING/COMPETING INTEREST(S)

The authors report no conflict of interest. Vitrolife provided the media and the closed method tool needed for the study at no cost.

Vitrification negatively affects the Ca2+-releasing and activation potential of mouse oocytes, but vitrified oocytes are potentially useful for diagnostic purposes

RESEARCH QUESTION

To what extent does vitrification affect the Ca²⁺-releasing and activation potential of mouse oocytes, which are commonly used to determine the oocyte activation potential of human spermatozoa?

DESIGN

The effect of mouse oocyte vitrification on Ca²⁺ dynamics and developmental competence after oocyte activation was assessed and compared with fresh mouse oocytes. Moreover, the Ca²⁺ store content of the endoplasmic reticulum was determined at different time points during the vitrification-warming procedure. Finally, the Ca²⁺ pattern induced by cryoprotectant exposure was determined.

RESULTS

After human sperm injection into mouse oocytes, Ca²⁺ dynamics but not fertilization rates were significantly altered by vitrification warming (P < 0.05). Ca²⁺ dynamics in response to SrCl₂ or ionomycin were also altered by oocyte vitrification. In contrast, activation and blastocyst rates after SrCl₂ exposure were not affected (P > 0.05), whereas activation rates after ionomycin exposure were significantly lower in vitrified-warmed oocytes (P < 0.05); blastocyst rates were not affected (P > 0.05). Cryoprotectant exposure was associated with a strong drop in endoplasmic reticulum Ca²⁺ store content. Oocytes rapidly recovered during warming and recovery in Ca²⁺-containing media; a threshold area under the curve of Ca²⁺ dynamics to obtain activation rates above 90% was determined.

CONCLUSIONS

Vitrified-warmed mouse oocytes display reduced Ca²⁺-releasing potential upon oocyte activation, caused by cryoprotectant exposure. With adapted classification criteria, these oocytes could be used for diagnosing oocyte activation deficiencies in patients. Evaluating the Ca²⁺-signalling machinery in vitrified-warmed human oocytes is required.

Dynactin pathway-related gene expression is altered by aging, but not by vitrification

The storage of surplus oocytes by cryopreservation (OC) is a widely used tool in assisted reproductive technology, but there is a great debate about the effects of cryopreservation on oocyte competence. It is known that OC may affect meiotic spindles but remains unclear if OC may increase the risk of aneuploidy. The aim of this study was to test the effects of OC and women aging on the expression of cytokinesis-related genes playing an important role in the segregation of chromosomes (DCTN1, DCTN2, DCTN3, DCTN6 and PLK1). Results highlighted that OC do not modify the expression of the selected genes, whereas women aging modulate the expression of all transcripts, confirming that aging is the crucial factor affecting meiosis and aneuploidy risk. A new role for Dynactin and PLK1 was shed in light, providing information on the ageing process in the oocyte which may be associated to reduced fertility.

Sensing Cell Membrane Biophysical Properties for Detection of High Quality Human Oocytes

Oocyte quality plays a crucial role in the early development and implantation of the embryos, and consequently has a profound impact on the accomplishment of assisted reproductive technology (ART). A simple and efficient method for detecting high-quality human oocytes is urgently needed. However, the clinically used morphological method is time-consuming, subjective, and inaccurate. To this end, we propose a practical and effective approach for detecting high-quality oocytes via on-chip measurement of the oocyte membrane permeability. We found that oocytes can be divided into two subpopulations (high-quality versus poor-quality oocytes) according to their membrane permeability differences, and as was further confirmed by subsequent in vitro fertilization (IVF) and development experiments (the blastocyst rates of high-quality and poor-quality oocytes were 60% and 0%, respectively). This approach shows great potentials in improving the success of ART, including both the fertilization and development rates, and thus it may have wide applications in the clinic.

Oocyte freezing: reproductive panacea or false hope of family?

Advanced technology now allows young women to freeze and store oocytes with a realistic chance of future pregnancy. Vitrification has revolutionized oocyte preservation, with comparable pregnancy rates to fresh oocyte use. Traditionally used for women who were about to undergo sterilizing oncology treatment, now the opportunity has been extended for 'social freezing'. A steady rise in all women accessing freezing continues. Despite this, there is a lack of understanding of natural fertility and the impact of age on pregnancy outcomes. The optimum time for freezing is before a woman reaches her late 30s, which unfortunately is not reflected in those accessing egg freezing. The underlying message prevails that planning for fertility is best done early, whether that be by physical completion of family size or storing oocytes before the passage of time and age prevents it.

Survival Rates in Closed and Open Vitrification for Human Mature Oocyte Cryopreservation: A Meta-Analysis

BACKGROUND/AIMS

Survival of warmed oocytes is the first part and is one of the most important aspects of in vitro fertilization following oocyte cryopreservation. There is no definite conclusion about the difference in survival rates between closed and open vitrification for oocyte cryopreservation. This study aimed to investigate whether there is a difference in survival rates between closed and open vitrification for cryopreservation of human mature oocytes.

METHODS

A literature search was performed using the MEDLINE, Cochrane Central Register of Controlled Trials, and Embase databases. A total of 4 studies were included in the meta-analysis.

RESULTS

In the frequentist meta-analysis, the random effects model showed no statistically significant difference in survival rates between closed and open vitrification (risk ratio [RR] 0.8873, 95% confidence interval [CI] 0.7658-1.0280). However, an effect size deviation of the RR from 1.0 and a borderline trend of the 95% CI were noted. In the Bayesian meta-analysis, the posterior probability that closed vitrification would decrease the survival rate when compared to that with open vitrification was 83.04% for the random effects model.

CONCLUSION

It is not yet possible to conclude that closed vitrification is an aseptic alternative to open vitrification in human mature oocyte cryopreservation.

Vitrification of human immature oocytes before and after in vitro maturation: a review

The use of immature oocytes subjected to in vitro maturation (IVM) opens interesting perspectives for fertility preservation where ovarian reserves are damaged by pathologies or therapies, as in PCO/PCOS and cancer patients. Human oocyte cryopreservation may offer some advantages compared to embryo freezing, such as fertility preservation in women at risk of losing fertility due to oncological treatment or chronic disease, egg donation and postponing childbirth. It also eliminates religious and/or other ethical, legal, and moral concerns of embryo freezing. In addition, a successful oocyte cryopreservation program could eliminate the need for donor and recipient menstrual cycle synchronization. Recent advances in vitrification technology have markedly improved the oocyte survival rate after warming, with fertilization and implantation rates comparable with those of fresh oocytes. Healthy live births can be achieved from the combination of IVM and vitrification, even if vitrification of in vivo matured oocytes is still more effective. Recently, attention is given to highlight whether vitrification procedures are more successful when performed before or after IVM, on immature GV-stage oocytes, or on in vitro matured MII-stage oocytes. In this review, we emphasize that, even if there are no differences in survival rates between oocytes vitrified prior to or post-IVM, reduced maturation rates of immature oocytes vitrified prior to IVM can be, at least in part, explained by underlying ultrastructural and biomolecular alterations.

Safety and efficiency of oocyte vitrification

As the oocyte is the starting point for a new life, artificial reproductive technology (ART) techniques should not affect the (ultra) structural and functional integrity, or the developmental competence. Oocyte vitrification -one of the most significant achievements in human ART during the past decade- should therefore be a safe and efficient technique. This review discusses the principles and developments of the existing and future techniques, applications possibilities and safety concerns. The broad range of vitrification media and devices that are currently available, show differences in their effects on the oocyte ultrastructure and preimplantation development. It is not yet fully decided whether this has an influence on the obstetric and neonatal outcome, since only limited information is available with different media and devices. For autologous oocytes, the obstetric and neonatal outcomes appear promising and comparable to pregnancies obtained with fresh oocytes. This however, is not the case for heterologous fresh or vitrified oocytes, where the immunological foreign foetus induces adverse obstetric and neonatal outcomes. Besides the oocyte vitrification process itself, the effect of multiple stimulations (for oocyte banking or for oocyte donors), seems to influence the possibility to develop gynaecological cancers further in life. Automated vitrification/warming should offer a consistent, cross-contamination free process that offers the highest safety level for the users. They should also produce more consistent results in survival, development and clinical pregnancies between different IVF clinics.

Influence of storage time on vitrified human cleavage-stage embryos froze in open system

BACKGROUND

During in vitro fertilization, rapid growth of vitrification and liquid nitrogen storage of embryos have been well characterized. However, the effect of storage time on vitrified cleavage-stage embryos in an open system is poorly understood.

AIMS

To investigate the influence of storage time on the survival and pregnancy outcomes of vitrified human cleavage-stage embryos froze and stored in an open system.

METHODS

A retrospective study of 786 vitrified-warmed cycles of 735 patients was performed from January 2013 to October 2013. The cycles were divided into five groups according to storage time: 1-3 months, 4-6 months, 7-12 months, 13-24 and 25-60 months. The clinical outcomes of cycles with different storage time were analyzed.

RESULTS

There were no significant differences of the survival rate, clinical pregnancy outcomes, birth rate, gestational weeks and singleton birthweights at various storage times.

CONCLUSION

For vitrified embryos froze and stored in an open system, the storage time would not influence the survival rate and pregnancy outcomes by storage time up to 5 years.

Freeze/thaw stress induces organelle remodeling and membrane recycling in cryopreserved human mature oocytes

PURPOSE

Our aim was to evaluate the ultrastructure of human metaphase II oocytes subjected to slow freezing and fixed after thawing at different intervals during post-thaw rehydration.

METHODS

Samples were studied by light and transmission electron microscopy.

RESULTS

We found that vacuolization was present in all cryopreserved oocytes, reaching a maximum in the intermediate stage of rehydration. Mitochondria-smooth endoplasmic reticulum (M-SER) aggregates decreased following thawing, particularly in the first and intermediate stages of rehydration, whereas mitochondria-vesicle (MV) complexes augmented in the same stages. At the end of rehydration, vacuoles and MV complexes both diminished and M-SER aggregates increased again. Cortical granules (CGs) were scarce in all cryopreserved oocytes, gradually diminishing as rehydration progressed.

CONCLUSIONS

This study also shows that such a membrane remodeling is mainly represented by a dynamic process of transition between M-SER aggregates and MV complexes, both able of transforming into each other. Vacuoles and CG membranes may take part in the membrane recycling mechanism.

Successful slush nitrogen vitrification of human ovarian tissue

OBJECTIVE

To study whether slush nitrogen vitrification improves the preservation of human ovarian tissue.

DESIGN

Control vs. treatment study.

SETTING

University research laboratory.

PATIENT(S)

Ovarian biopsies collected from nine women (aged 14-35 years) during laparoscopic surgery for benign gynecologic conditions.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Ovarian cortical strips of 2 × 5 × 1 mm were vitrified with liquid or slush nitrogen. Fresh and vitrified cortical strips were analyzed for cryodamage and viability under light, confocal, and transmission electron microscopy.

RESULT(S)

Compared with liquid nitrogen, vitrification with slush nitrogen preserves [1] follicle quality (grade 1 follicles: fresh control, 50%; liquid nitrogen, 27%; slush nitrogen, 48%); [2] granulosa cell ultrastructure (intact cells: fresh control, 92%; liquid nitrogen, 45%; slush nitrogen, 73%), stromal cell ultrastructure (intact cells: fresh control, 59.8%; liquid nitrogen, 24%; slush nitrogen, 48.7%), and DNA integrity (TUNEL-positive cells: fresh control, 0.5%; liquid nitrogen, 2.3%; slush nitrogen, 0.4%); and [3] oocyte, granulosa, and stromal cell viability (oocyte: fresh control, 90%; liquid nitrogen, 63%; slush nitrogen, 87%; granulosa cells: fresh control, 93%; liquid nitrogen, 53%; slush nitrogen, 81%; stromal cells: fresh control, 63%; liquid nitrogen, 30%; slush nitrogen, 52%).

CONCLUSION(S)

The histology, ultrastructure, and viability of follicles and stromal cells are better preserved after vitrification with slush nitrogen compared with liquid nitrogen.

Assessment of aneuploidy formation in human blastocysts resulting from cryopreserved donor eggs

Background

Increased embryo implantation rates were reported after transfer of euploid embryos selected by preimplantation genetic screening (PGS). Egg cryopreservation by vitrification has become one of the most important assisted human reproduction technologies. Although reports indicate that development and implantation of human embryos derived from frozen donor eggs are comparative to fresh eggs, it is still unknown whether egg vitrification increases chromosomal abnormalities in eggs, which in turn causes formation of embryonic aneuploidy. Therefore, in this study, we evaluated the aneuploidy formation in the blastocysts derived from frozen donor eggs and also evaluated the efficiency of egg vitrification as an advanced technology for egg cryopreservation.

Results

In this study, donated human eggs from young women were cryopreserved by vitrification and PGS was performed in the resulted blastocysts by DNA microarray. A total of 764 frozen eggs from 75 egg thawing cycles were warmed and 38 blastocysts were biopsied for PGS before embryo transfer. A 97.1% of egg survival rate was obtained and 59.1% of embryos developed to blastocyst stage. After biopsy and PGS, it was found that 84.2% of blastocysts were euploid and 15.8% were aneuploid. Aneuploidy rates varied among donors. Transfers of blastocysts without PGS resulted in higher clinical pregnancy and implantation rates as compared with transfer of blastocysts with PGS.

Conclusions

Although the overall aneuploidy rate was low in the blastocysts derived from frozen donor eggs, high aneuploidy rates were observed in the embryos resulting from some donated eggs. Clinical pregnancy rate was not improved by PGS of embryos resulting from donor eggs, indicating that PGS may not be necessary for embryos derived from donor eggs in most cases.

Electronic supplementary material

The online version of this article (doi:10.1186/s13039-015-0117-8) contains supplementary material, which is available to authorized users.

Fine morphological assessment of quality of human mature oocytes after slow freezing or vitrification with a closed device: a comparative analysis

BACKGROUND

Human mature oocytes are very susceptible to cryodamage. Several reports demonstrated that vitrification might preserve oocyte better than slow freezing. However, this is still controversial. Thus, larger clinical, biological and experimental trials to confirm this concept are necessary. The aim of the study was to evaluate and compare fine morphological features in human mature oocytes cryopreserved with either slow freezing or vitrification.

METHODS

We used 47 supernumerary human mature (metaphase II) oocytes donated by consenting patients, aged 27-32 years, enrolled in an IVF program. Thirtyfive oocytes were cryopreserved using slow freezing with 1.5 M propanediol +0.2 M sucrose concentration (20 oocytes) or a closed vitrification system (CryoTip Irvine Scientific CA) (15 oocytes). Twelve fresh oocytes were used as controls. All samples were prepared for light and transmission electron microscopy evaluation.

RESULTS

Control, slow frozen/thawed and vitrified/warmed oocytes (CO, SFO and VO, respectively) were rounded, 90-100 μm in diameter, with normal ooplasm showing uniform distribution of organelles. Mitochondria-smooth endoplasmic reticulum (M-SER) aggregates and small mitochondria-vesicle (MV) complexes were the most numerous structures found in all CO, SFO and VO cultured for 3-4 hours. M-SER aggregates decreased, and large MV complexes increased in those SFO and VO maintained in culture for a prolonged period of time (8-9 hours). A slight to moderate vacuolization was present in the cytoplasm of SFO. Only a slight vacuolization was present in VO, whereas vacuoles were almost completely absent in CO. Amount and density of cortical granules (CG) appeared abnormally reduced in SFO and VO, irrespective of the protocol applied.

CONCLUSIONS

Even though, both slow freezing and vitrification ensured a good overall preservation of the oocyte, we found that: 1) prolonged culture activates an intracellular membrane "recycling" that causes the abnormal transformation of the membranes of the small MV complexes and of SER into larger rounded vesicles; 2) vacuolization appears as a recurrent form of cell damage during slow freezing and, at a lesser extent, during vitrification using a closed device; 3) premature CG exocytosis was present in both SFO and VO and may cause zona pellucida hardening.

Vitrification versus slow freezing for women undergoing oocyte cryopreservation

BACKGROUND

Oocyte cryopreservation is a technique with considerable potential in reproductive medicine, including  fertility preservation, as a way of delaying childbearing and as part of oocyte donation programs. Although the technique was relatively ineffective at first more recently numerous modifications have led to higher success rates.

OBJECTIVES

To compare the effectiveness and safety of vitrification and slow freezing as oocyte cryopreservation techniques for fertility outcomes in women undergoing assisted reproduction.

SEARCH METHODS

We searched electronic databases, trial registers and websites, including the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and PsycINFO (date of search 3 March 2014).

SELECTION CRITERIA

Two review authors independently selected randomised controlled trials (RCTs) comparing vitrification and slow freezing for oocyte preservation in women undergoing assisted reproduction.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data from eligible studies and assessed their risk of bias. Any disagreements were resolved by discussion or by a third review author. Data extracted included study characteristics and outcome data. The overall quality of the evidence was assessed using GRADE methods.

MAIN RESULTS

Two RCTs were included in the review (106 participants). Neither study reported live birth rate. Vitrification was associated with an increased clinical pregnancy rate compared to slow freezing (RR 3.86, 95% CI 1.63 to 9.11, P = 0.002, 2 RCTs, 106 women, I(2) = 8%, moderate quality evidence). The effect of vitrification compared to slow freezing on ongoing pregnancy rates was only reported in one small study, with inconclusive findings (RR 6.07, 95% CI 0.86 to 43.04, P = 0.07, one RCT, 28 women, low quality evidence).No data were reported on adverse effects, nor were any other outcomes reported in the included trials. The evidence was limited by imprecision. We assessed the included studies as at low to unclear risk of bias as the methods were not well described.

AUTHORS' CONCLUSIONS

Oocyte vitrification compared to slow freezing probably increases clinical pregnancy rates in women undergoing assisted reproduction. However, the total number of women and pregnancies were low and the imprecision is high which limits applicability. The effect on ongoing pregnancy is uncertain as data were sparse. No data were available on live births or adverse effects.

Ultrastructure of immature and mature human oocytes after cryotop vitrification

In vitro maturation of vitrified immature germinal vesicle (GV) oocytes is a promising fertility preservation option. We analyzed the ultrastructure of human GV oocytes after Cryotop vitrification (GVv) and compared it with fresh GV (GVc), fresh mature metaphase II (MIIc) and Cryotop-vitrified mature (MIIv) oocytes. By phase contrast microscopy and light microscopy, the oolemmal and cytoplasmic organization of fresh and vitrified oocytes did not show significant changes. GVv oocytes showed significant ultrastructural alterations of the microvilli in 40% of the samples; small vacuoles and occasional large/isolated vacuoles were abnormally present in the ooplasm periphery of 50% of samples. The ultrastructure of nuclei and mitochondria-vesicle (MV) complexes, as well as the distribution and characteristics of cortical granules (CGs), were comparable with those of GVc oocytes. MIIv oocytes showed an abnormal ultrastructure of microvilli in 30% of the samples and isolated large vacuoles in 70% of the samples. MV complexes were normal, but mitochondria-smooth endoplasmic reticulum aggregates appeared to be of reduced size. CGs were normally located under the oolemma but presented abnormalities in distribution and matrix electron density. In conclusion, Cryotop vitrification preserved main oocyte characteristics in the GV and MII stages, even if peculiar ultrastructural alterations appeared in both stages. This study also showed that the GV stage appears more suitable for vitrification than the MII stage, as indicated by the good ultrastructural preservation of important structures that are present only in immature oocytes, like the nucleus and migrating CGs.

Cryopreservation of embryos and oocytes in human assisted reproduction

Both sperm and embryo cryopreservation have become routine procedures in human assisted reproduction and oocyte cryopreservation is being introduced into clinical practice and is getting more and more widely used. Embryo cryopreservation has decreased the number of fresh embryo transfers and maximized the effectiveness of the IVF cycle. The data shows that women who had transfers of fresh and frozen embryos obtained 8% additional births by using their cryopreserved embryos. Oocyte cryopreservation offers more advantages compared to embryo freezing, such as fertility preservation in women at risk of losing fertility due to oncological treatment or chronic disease, egg donation, and postponing childbirth, and eliminates religious and/or other ethical, legal, and moral concerns of embryo freezing. In this review, the basic principles, methodology, and practical experiences as well as safety and other aspects concerning slow cooling and ultrarapid cooling (vitrification) of human embryos and oocytes are summarized.

Cryopreservation in ART and concerns with contamination during cryobanking

The cryopreservation of gametes and embryos is vital to numerous fields of reproductive biology, including assisted human reproduction. With improved culture conditions, there are an increasing number of embryos to cryopreserve for potential use in subsequent cycles. Many of the gametes and embryos in human IVF are cryopreserved in open systems. Because liquid nitrogen is not sterile, concerns have been raised with regard to contamination from the liquid nitrogen and also cross-contamination between patients' germplasm. Human gamete and embryo cryopreservation are discussed, with recommendations on how to minimize and eliminate contamination, emphasizing the benefits of closed vitrification devices.

Cryopreservation of eggs

Oocyte cryopreservation is playing an increasingly important role in the field of human infertility treatment. The ability to store viable oocytes for later use has given many women the option to delay childbearing in order to pursue other ventures in life, without the concern of losing the opportunity to have a family. Furthermore, oocyte cryopreservation is very valuable for diseased patients who have to undergo treatments that may compromise fertility. Also, infertility patients who produce large numbers of oocytes during a retrieval cycle now have the option of storing some eggs prior to fertilization, thereby reducing the number of embryos that have to be managed. Lastly, oocyte cryopreservation enables egg donation programs that are independent of fresh donations, which makes it possible for numerous recipients to benefit from a single donor.Traditionally, slow freezing was the only method available for oocyte cryopreservation. However, recent years have shown that ultrarapid cooling of oocytes results in higher survival and developmental rates. Thus, vitrification is today's preferred method of oocyte cryopreservation and therefore the only technique described.In this chapter, we present two reliable methods of oocyte vitrification that have been in use for several years and that have been experimentally validated. Since no single vitrification method is clearly superior to the rest, other systems are also briefly described to give the reader options when deciding which methods to utilize in their practice.

Clinical pregnancy after uterus transplantation

OBJECTIVE

To present the first clinical pregnancy after uterus transplantation.

DESIGN

Case study.

SETTING

Tertiary center.

PATIENT(S)

A 23-year-old Mayer-Rokitansky-Kuster-Hauser syndrome patient with previous vaginal reconstruction and uterus transplantation.

INTERVENTION(S)

Eighteen months after the transplant, the endometrium was prepared for transfer of the thawed embryos.

MAIN OUTCOME MEASURE(S)

Implantation of embryo in an allografted human uterus.

RESULT(S)

The first ET cycle with one day 3 thawed embryo resulted in a biochemical pregnancy. The second ET cycle resulted in a clinical pregnancy confirmed with transvaginal ultrasound visualization of an intrauterine gestational sac with decidualization.

CONCLUSION(S)

We have presented the first clinical pregnancy in a patient with absolute uterine infertility after uterus allotransplantation. Although the real success is the delivery of a healthy near-term baby, this clinical pregnancy is a great step forward and a proof of concept that the implantation phase works.

Optimized protocol for cryopreservation of human eggs improves developmental competence and implantation of resulting embryos

Background

Successful egg cryopreservation has many potential benefits to a variety of patients. However, a superior standard protocol describing all aspects of oocyte cryopreservation has not yet been identified. Oocyte cryopreservation is still a technical challenge for many infertility clinics. To maintain satisfactory clinical outcomes, there is a need to develop an easy to use, yet efficient laboratory protocol. The present study was designed to examine if human embryos resulting from eggs frozen with an optimized vitrification protocol have similar developmental competence as those from fresh eggs.

Methods

Twenty recipients received donated eggs vitrified with a protocol in which short exposure time to the vitrification solution was used and 23 recipients received donated eggs and 6 patients had their own eggs vitrified with a modified protocol in which long exposure time to the vitrification solution was used. After warming, egg survival, fertilization, cleavage, blastocyst formation, clinical pregnancy and implantation rates were compared. The developmental competence of eggs vitrified with the optimized protocol was further compared with fresh eggs donated from the same donors.

Results

There was no difference in the oocyte survival, fertilization, cleavage, clinical pregnancy or implantation rates between the short and long protocol groups. However, blastocyst formation rate was significantly (P < 0.001) higher in the long protocol group (50.8%) than that in short protocol group (26.5%), resulting in more blastocysts being transferred and frozen. When frozen eggs vitrified with long protocol and fresh eggs from the same donors (12) were compared in 39 recipients, no differences were observed in terms of fertilization (86.4 vs 80.1%), blastocyst formation (50.0 vs 59.2%), clinical pregnancy (63.2 vs 60.0%) and implantation (41.7 vs 44.7%) rates. Four out of 6 patients had ongoing pregnancy after transfer of embryos from their own frozen eggs with a 46.2% implantation rate.

Conclusions

These results indicate that blastocyst development is an appropriate measure for egg survival after cryopreservation and frozen eggs have similar developmental potential as fresh eggs if they are frozen with an optimized method.

Survival and post-warming in vitro competence of human oocytes after high security closed system vitrification

PURPOSE

To compare two vitrification methods and two warming methods for human oocyte vitrification using a high security closed device in terms of survival, fertilization and embryo development.

METHODS

For vitrification, oocytes were (1) immediately placed in equilibration solution or (2) they were gradually exposed to the cryoprotectants. For warming, oocytes were placed (1) in a 25 μl preheated (37 °C) thawing solution droplet that was put at room temperature for 1 min once the oocytes were inside or (2) in a 150 μl droplet for 1 minute at 37 °C.

RESULTS

Survival and preimplantation development were significantly lower when warming was performed in a small preheated droplet. There was no significant difference in survival and embryo development between the gradual or direct exposure to cryoprotectants.

CONCLUSIONS

Using this high security closed vitrification device a 90 % survival rate can be achieved when the oocytes are immediately warmed in a large volume at 37 °C.

Optimising vitrification of human oocytes using multiple cryoprotectants and morphological and functional assessment

Oocyte vitrification is a clinical practice that allows preservation of fertility potential in women. Vitrification involves quick cooling using high concentrations of cryoprotectants to minimise freezing injuries. However, high concentrations of cryoprotectants have detrimental effects on oocyte quality and eventually the offspring. In addition, current assessment of oocyte quality after vitrification is commonly based only on the morphological appearance of the oocyte, raising concerns regarding its efficiency. Using both morphological and functional assessments, the present study investigated whether combinations of cryoprotectants at lower individual concentrations result in better cryosurvival rates than single cryoprotectants at higher concentrations. Surplus oocytes from IVF patients were vitrified within 24 h after retrieval using the Cryotop method with several cryoprotectants, either individually or in combination. The morphological and functional quality of the vitrified oocytes was investigated using light microscopy and computer-based quantification of mitochondrial integrity, respectively. Oocyte quality was significantly higher using a combination of cryoprotectants than vitrification with individual cryoprotectants. In addition, the quality of vitrified oocyte varied depending on the cryoprotectants and type of combination used. The results of the present study indicate that observations based purely on the morphological appearance of the oocyte to assess the cryosurvival rate are insufficient and sometimes misleading. The outcome will have a significant implication in the area of human oocyte cryopreservation as an important approach for fertility preservation.

Preliminary results of the first human uterus transplantation from a multiorgan donor

OBJECTIVE

To describe the first-year results of the first human uterus transplantation case from a multiorgan donor.

DESIGN

Case study.

SETTING

University hospital.

PATIENT(S)

A 21-year-old woman with complete müllerian agenesis who had been previously operated on for vaginal reconstruction.

INTERVENTION(S)

Uterus transplantation procedure consisting of orthotopic replacement and fixation of the retrieved uterus, revascularization, end to site anastomoses of bilateral hypogastric arteries and veins to bilateral external iliac arteries and veins was performed.

MAIN OUTCOME MEASURE(S)

Resumption of menstrual cycles.

RESULT(S)

The patient had menarche 20 days after transplant surgery. She has had 12 menstrual cycles since the operation.

CONCLUSION(S)

We have described the longest-lived transplanted human uterus to date with acquirement of menstrual cycles.

Ultrastructure of human mature oocytes after vitrification

Since the introduction of human assisted reproduction, oocyte cryopreservation has been regarded as an attractive option to capitalize the reproductive potential of surplus oocytes and preserve female fertility. However, for two decades the endeavor to store oocytes has been limited by the not yet optimized methodologies, with the consequence of poor clinical outcome or of uncertain reproducibility. Vitrification has been developed as the promising technology of cryopreservation even if slow freezing remains a suitable choice. Nevertheless, the insufficiency of clinical and correlated multidisciplinary data is still stirring controversy on the impact of this technique on oocyte integrity. Morphological studies may actually provide a great insight in this debate. Phase contrast microscopy and other light microscopy techniques, including cytochemistry, provided substantial morpho-functional data on cryopreserved oocyte, but are unable to unraveling fine structural changes. The ultrastructural damage is one of the most adverse events associated with cryopreservation, as an effect of cryo-protectant toxicity, ice crystal formation and osmotic stress. Surprisingly, transmission electron microsco py has attracted only limited attention in the field of cryopreservation. In this review, the subcellular structure of human mature oocytes following vitrification is discussed at the light of most relevant ultrastructural studies.

A critical appraisal of cryopreservation (slow cooling versus vitrification) of human oocytes and embryos

BACKGROUND

Vitrification is now a commonly applied technique for cryopreservation in assisted reproductive technology (ART) replacing, in many cases, conventional slow cooling methodology. This review examines evidence relevant to comparison of the two approaches applied to human oocytes and embryos at different developmental stages.

METHODS

Critical review of the published literature using PubMed with particular emphasis on studies which include data on survival and implantation rates, data from fresh control groups and evaluation of the two approaches in a single setting.

RESULTS

Slow cooling is associated with lower survival rates and compromised development relative to vitrification when applied to metaphase II (MII) oocytes, although the vitrification results have predominantly been obtained using direct contact with liquid nitrogen and there is some evidence that optimal protocols for slow cooling of MII oocytes are yet to be established. There are no prospective randomized controlled trials (RCTs) which support the use of either technique with pronuclear oocytes although vitrification has become the method of choice. Optimal slow cooling, using modifications of traditional methodology, and vitrification can result in high survival rates of early embryos, which implant at the same rate as equivalent fresh counterparts. Many studies report high survival and implantation rates following vitrification of blastocysts. Although slow cooling of blastocysts has been reported to be inferior in some studies, others comparing the two approaches in the same clinical setting have demonstrated comparable results. The variation in the extent of embryo selection applied in studies can lead to apparent differences in clinical efficiency, which may not be significant if expressed on a 'per oocyte used' basis.

CONCLUSIONS

Available evidence suggests that vitrification is the current method of choice when cryopreserving MII oocytes. Early cleavage stage embryos can be cryopreserved with equal success using slow cooling and vitrification. Successful blastocyst cryopreservation may be more consistently achieved with vitrification but optimal slow cooling can produce similar results. There are key limitations associated with the available evidence base, including a paucity of RCTs, limited reporting of live birth outcomes and limited reporting of detail which would allow assessment of the impact of differences in female age. While vitrification has a clear role in ART, we support continued research to establish optimal slow cooling methods which may assist in alleviating concerns over safety issues, such as storage, transport and the use of very high cryoprotectant concentrations.

Raman microspectroscopy as a non-invasive tool to assess the vitrification-induced changes of ovine oocyte zona pellucida

Cryopreservation-induced modifications of zona pellucida (ZP) have been explored to a lesser extent compared to other oocyte compartments. Different methods have been applied to identify ZP changes, but most of them are invasive and measure only few properties of ZP. Raman microspectroscopy (RMS) is a powerful technique for studying the molecular composition of cells but to date few studies have been performed on the oocytes using this method. The aim of the present study is to investigate the structural modifications of ZP of vitrified/warmed in vitro matured ovine oocytes by means of RMS. Cumulus-oocyte complexes were recovered from the ovaries of slaughtered adult sheep, matured in vitro and vitrified following the Minimum Essential Volume method using cryotops. ZPs of vitrified/warmed oocytes (VITRI), were exposed to vitrification solutions but not cryopreserved (CPA-exp) and untreated oocytes (CTR) were analyzed by RMS. We focused our analysis on the ZP protein and carbohydrate components by analyzing the 1230-1300 cm(-1) amide III region and the 1020-1140 cm(-1) spectral range in RMS spectra, respectively. The spectral profiles in the ranges of proteins and carbohydrates were comparable between CTR and CPA-exp ZPs, whereas VITRI ZPs showed a significantly altered protein secondary structure characterized by an increase in β-sheet content and a decrease in the α-helix content. A significant modification of the carbohydrate components was also observed. This study demonstrates that vitrification of ovine oocytes induces biochemical changes of ZP related to the secondary structure of proteins and carbohydrate residues. Cryoprotectants do not strongly alter the molecular composition of ZP which is affected mainly by cooling. Raman technology offers a powerful and non-invasive tool to assess molecular modifications induced by cryopreservation in oocytes.

Implantation rates of embryos generated from slow cooled human oocytes from young women are comparable to those of fresh and frozen embryos from the same age group

Previous reports of slow cooling of human mature oocytes have shown a reduced clinical efficiency relative to fresh oocytes. This study reports that equivalent fertilization and implantation rates to those obtained using fresh oocytes and cryopreserved embryos can be achieved with human mature oocytes dehydrated in 1.5 M propanediol and 0.2 M sucrose at 37°C and cryopreserved using slow cooling rates.

Relevance and Methodology for the Morphological Analysis of Oocyte Quality in IVF and ICSI

Oocytes collected from patients following ovarian stimulation exhibit varying qualities. The quality of oocytes has an effect on its subsequent fertilization, developmental competence post-fertilization and the viability of resultant embryos. The aim of this article was to review the morphological criteria devised for assessment of oocyte quality by ordinary light and polarized light microscopy before IVF or ICSI. The parameters employed in the evaluation of oocyte morphology include the appearance of: structure of the cumulus–oocyte complex, oocyte cytoplasm, perivitelline space, zona pellucida, polar body and meiotic spindle.