Effect of hCG priming on embryonic development of immature oocytes collected from unstimulated women with polycystic ovarian syndrome

A fresh start for IVM: capacitating the oocyte for development using pre-IVM

BACKGROUND

While oocyte IVM is practiced sporadically it has not achieved widespread clinical practice globally. However, recently there have been some seminal advances in our understanding of basic aspects of oocyte biology and ovulation from animal studies that have led to novel approaches to IVM. A significant recent advance in IVM technology is the use of biphasic IVM approaches. These involve the collection of immature oocytes from small antral follicles from minimally stimulated patients/animals (without hCG-priming) and an ∼24 h pre-culture of oocytes in an advanced culture system ('pre-IVM') prior to IVM, followed by routine IVF procedures. If safe and efficacious, this novel procedure may stand to make a significant impact on human ART practices.

OBJECTIVE AND RATIONALE

The objectives of this review are to examine the major scientific advances in ovarian biology with a unique focus on the development of pre-IVM methodologies, to provide an insight into biphasic IVM procedures, and to report on outcomes from animal and clinical human data, including safety data. The potential future impact of biphasic IVM on ART practice is discussed.

SEARCH METHODS

Peer review original and review articles were selected from PubMed and Web of Science searches for this narrative review. Searches were performed using the following keywords: oocyte IVM, pre-IVM, biphasic IVM, CAPA-IVM, hCG-triggered/primed IVM, natural cycle IVF/M, ex-vivo IVM, OTO-IVM, oocyte maturation, meiotic competence, oocyte developmental competence, oocyte capacitation, follicle size, cumulus cell (CC), granulosa cell, COC, gap-junction communication, trans-zonal process, cAMP and IVM, cGMP and IVM, CNP and IVM, EGF-like peptide and IVM, minimal stimulation ART, PCOS.

OUTCOMES

Minimizing gonadotrophin use means IVM oocytes will be collected from small antral (pre-dominant) follicles containing oocytes that are still developing. Standard IVM yields suboptimal clinical outcomes using such oocytes, whereas pre-IVM aims to continue the oocyte's development ex vivo, prior to IVM. Pre-IVM achieves this by eliciting profound cellular changes in the oocyte's CCs, which continue to meet the oocyte's developmental needs during the pre-IVM phase. The literature contains 25 years of animal research on various pre-IVM and biphasic IVM procedures, which serves as a large knowledge base for new approaches to human IVM. A pre-IVM procedure based on c-type natriuretic peptide (named 'capacitation-IVM' (CAPA-IVM)) has undergone pre-clinical human safety and efficacy trials and its adoption into clinical practice resulted in healthy live birth rates not different from conventional IVF.

WIDER IMPLICATIONS

Over many decades, improvements in clinical IVM have been gradual and incremental but there has likely been a turning of the tide in the past few years, with landmark discoveries in animal oocyte biology finally making their way into clinical practice leading to improved outcomes for patients. Demonstration of favorable clinical results with CAPA-IVM, as the first clinically tested biphasic IVM system, has led to renewed interest in IVM as an alternative, low-intervention, low-cost, safe, patient-friendly ART approach, and especially for patients with PCOS. The same new approach is being used as part of fertility preservation in patients with cancer and holds promise for social oocyte freezing.

Novel predictors for livebirth delivery rate in patients with idiopathic non-obstructive azoospermia based on the clinical prediction model

Objective

To build a prediction model for live birth delivery per intracytoplasmic sperm injection (ICSI) in iNOA patients by obtaining sperm by microdissection testicular sperm extraction (mTESE).

Methods

A retrospective cohort study of 377 couples with iNOA male partners treated with 519 mTESE-ICSI cycles was conducted from September 2013 to July 2021 at the Reproductive Medical Centre of Peking University Third Hospital. Following exclusions, 377 couples with iNOA male partners treated with 482 mTESE-ICSIs were included. A prediction model for live birth delivery per ICSI cycle was built by multivariable logistic regression and selected by 10-fold cross-validation. Discrimination was evaluated by c-statistics and calibration was evaluated by the calibration slope.

Results

The live birth delivery rate per mTESE-ICSI cycle was 39.21% (189/482) in these couples. The model identified that the presence of motile sperm during mTESE, bigger testes, higher endometrial thickness on the day of human chorionic gonadotrophin (hCG) administration (ET-hCG), and higher quality embryos are associated with higher live birth delivery success rates. The results of the model were exported based on 10-fold cross-validation. In addition, the area under the mean ROC curve was 0.71 ± 0.05 after 10-fold cross-validation, indicating that the prediction model had certain prediction precision. A calibration plot with an estimated intercept of -1.653 (95% CI: -13.403 to 10.096) and a slope of 1.043 (95% CI: 0.777 to 1.308) indicated that the model was well-calibrated.

Conclusion

Our prediction model will provide valuable information about the chances of live birth delivery in couples with iNOA male partners who have a plan for mTESE-ICSI treatment. Therefore, it can improve and personalize counseling for the medical treatment of these patients.

The spectrum of in vitro maturation in clinical practice: the current insight

In vitro oocyte maturation (IVM) has been used worldwide. Despite the long-term implementation, the uptake of this procedure to complement current in vitro fertilization (IVF) remains low. The main reason is likely due to the non-synchronization of protocol and definition criteria, leading to difficulty in collective proper outcome data worldwide and, thus, lack of understanding of the exact IVM procedure. The review aims to consolidate the current clinical practice of IVM by dissecting relevant publications to be tailored for a current spectrum of clinical practice. Nevertheless, the background theories of oocyte maturation were also explored to provide a comprehensive understanding of the basis of IVM theories. Additional discussion of other potential uses of IVM in the future, such as in ovarian tissue cryopreservation known as OTO-IVM for fertility preservation and among women with diminished ovarian reserve, was also explored. Otherwise, future collaboration among all IVM centers is paramount for better collection of clinical data to provide valid recommendations for IVM in clinical practice, especially in molecular integrity and possible DNA alteration if present for IVM offspring outcome safety purposes.

IVM of human immature oocytes for infertility treatment and fertility preservation

Background

Thousands of healthy babies are born from in vitro maturation (IVM) procedures, but the rate of efficiency differs with the source of immature oocytes obtained. Recently, there are different IVM protocols proposed for infertility treatment and fertility preservation.

Methods

Based on the literature, the clinical application for IVM of immature oocytes was summarized.

Main findings Results

Immature oocytes may be retrieved from women after priming with or without the use of follicular stimulation hormone (FSH), human chorionic gonadotrophin (hCG) or a combination of both FSH and hCG. Successful pregnancy rates with IVM technology seem to be correlated with the number of immature oocytes obtained. With the source and culture course of immature oocytes, there are various IVM protocols. IVM of immature oocytes is profoundly affected by the culture conditions, but no breakthrough has been made by improving the IVM medium itself. Thus, the clinical application of IVM technology continues to evolve.

Conclusion

IVM technology is a useful technique for infertile women and fertility preservation. Mild stimulation IVF combined with IVM of immature oocytes is a viable alternative to the conventional stimulation IVF cycle treatment as it may prove to be an optimal first-line treatment approach.

Clinical Outcomes of In Vitro Maturation After Oocyte Retrieval With Gynecological Surgery for Refractory Polycystic Ovary Syndrome: A Retrospective Cohort Study

OBJECTIVE

To explore the clinical outcomes of unstimulated in vitro maturation (IVM) after oocyte retrieval with gynecological surgery (IVM-surgery) for refractory polycystic ovary syndrome (PCOS) and analyze the influencing factors.

METHODS

Patients with refractory PCOS who underwent unstimulated IVM-surgery from June 2014 to September 2018 were included in this retrospective cohort study. Matured IVM oocytes were freshly fertilized and subsequently frozen at the blastocyst stage. Frozen-thawed embryo transfer was then conducted according to the desire of patients. Oocytes and embryological outcomes, reproductive outcomes were evaluated. Influencing factors of oocytes and embryological outcomes were analyzed by univariate analysis and multivariate analysis. Receiver operating characteristic curves were used to evaluate the predict value of serum hormone levels for oocytes and embryological outcomes.

RESULTS

A total of 93 patients with refractory PCOS who underwent unstimulated IVM-surgery were included in this study.13 patients (13/85, 15.3%) had spontaneous pregnancy and live birth after surgery. 34 patients (34/93, 36.6%) obtained blastocysts and received embryo transfer, of which 13 patients (13/34, 38.2%) eventually achieved live birth by IVM. Higher anti-Mullerian hormone, antral follicle count and basal serum luteinizing hormone (LH) levels were strongly correlated with higher number of oocytes retrieved (P = 0.004, 0.004, 0.040, respectively). Higher basal serum follicle-stimulating hormone (FSH) and LH were significantly associated with higher oocyte maturation rate (P = 0.001 and P = 0.004, respectively) and blastocyst formation (P = 0.036 and P = 0.003, respectively). There was a significant linear correlation between basal serum FSH and LH (r = 0.500, P <0.001). What is more, basal serum FSH and LH had predictive value for oocytes and embryological outcomes.

CONCLUSION

Unstimulated IVM-surgery provided the opportunity for both spontaneous pregnancy and assisted reproductive technology. Basal FSH and LH were significantly associated with oocyte maturation rate and blastocyst formation of unstimulated IVM-surgery.

Lipid Metabolism Was Associated With Oocyte in vitro Maturation in Women With Polycystic Ovarian Syndrome Undergoing Unstimulated Natural Cycle

Objective

Hyperlipidemia are common polycystic ovarian syndrome (PCOS)-related metabolic dysfunctions and can adversely affect assisted reproductive technology (ART) outcomes in controlled ovarian hyperstimulation (COH) cycles. The objective of this study is to analyze the relationship between lipid metabolism and ART outcomes in unstimulated natural cycles without the utilization of ovarian induction drugs, which is still uncertain.

Methods

This retrospective study included infertile women with PCOS between 21 and 40 years old undergoing unstimulated natural cycles from January 01, 2006 to December 31, 2019. Lipid metabolism was measured by body mass index (BMI) and serum biochemical parameters including total cholesterol (TC), triglycerides (TG), high and low density lipoprotein cholesterol (HDL-C and LDL-C). ART outcomes were measured by number of oocytes retrieved, oocyte maturation quality and developmental potential, clinical pregnancy and live birth.

Results

A total of 586 patients were included in this study. Multivariate Poisson log-linear analysis showed that high TC (≥5.18 mmol/L), triglycerides (TG) (≥1.76 mmol/L), LDL-C (≥3.37 mmol/L) levelsand low HDL-C levels (≤1.04 mmol/L) were significantly (P_TC = 0.001, P_TG < 0.001, P_HDL–C < 0.001, P_LDL–C < 0.001) associated with increased number of oocytes retrieved. BMI was significantly negatively associated with maturation rate (P < 0.001), fertilization rate (P < 0.001) and transferrable embryo rate (P = 0.002). High TG levels and low HDL-C levels were also associated with decreased maturation rate (P_TG < 0.001, P_HDL–C = 0.026). Logistic regression analysis showed statistically significant association between obesity (≥28.0 kg/m²) and decreased live birth rate (P = 0.004) as well as cumulative live birth rate (P = 0.007).

Conclusion

This is the first study that focused on the relationship between basal lipid metabolism and ART outcomes in women with PCOS undergoing unstimulated natural cycles. The results showed that high levels of lipid metabolic parameters were associated with increased number of oocytes retrieved and obesity was closely associated with impaired oocyte maturation quality and developmental potential as well as poor live birth outcomes.

Enhancing the scope of in vitro maturation for fertility preservation: transvaginal retrieval of immature oocytes during endoscopic gynaecological procedures

STUDY QUESTION

Could in vitro maturation (IVM) following transvaginal oocyte retrieval during gynaecological surgery (IVM-surgery) be an effective and safe strategy for fertility preservation?

SUMMARY ANSWER

IVM-surgery on unstimulated ovaries is a novel option that can be considered for fertility preservation for women requiring gynaecological surgery, but more research is needed to identify appropriate patients who may benefit and to determine the cost-effectiveness of such an approach.

WHAT IS KNOWN ALREADY

IVM followed by oocyte/embryo cryopreservation has been useful as a safe reproductive strategy for some infertile women.

STUDY DESIGN, SIZE, DURATION

This prospective cohort study comprised 158 consecutive women with polycystic ovary syndrome (PCOS) who underwent laparoscopy or hysteroscopy for other reasons and had concomitant transvaginal oocyte retrieval followed by IVM between 2014 and 2016.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 158 women with anovulatory PCOS who underwent IVM-surgery in our infertility centre were recruited for this study. Matured IVM oocytes obtained from these women were either freshly fertilized and subsequently frozen at the blastocyst stage (fresh oocyte group, n = 46) or the oocytes were frozen (frozen oocyte group, n = 112) for fertility preservation followed by later thawing for insemination and cleavage embryo transfer (ET) (n = 33). The following outcomes were then evaluated: embryological data, clinical pregnancy rate, live birth rate (LBR), neonatal outcomes, post-operative complications and post-operative ovarian function.

MAIN RESULTS AND THE ROLE OF CHANCE

Among all the women who underwent IVM-surgery, the clinical pregnancy rate and LBR per initiated IVM cycle were 9.5% (15/158) and 6.9% (11/158), respectively. Women (40.6%, 20/33) who underwent the procedure with frozen-thawed oocytes (oocyte survival rate, 83.0%) obtained a high quality of cleaved embryos. In the fresh oocyte group, the clinical pregnancy rate and LBR per ET cycle were 69.2 and 53.8%, respectively. In the frozen oocyte group, the clinical pregnancy rate and LBR per ET cycle were 28.6 and 19.1%, respectively. No adverse neonatal outcomes were recorded. IVM-surgery was not associated with post-operative complications, a longer hospital stay, or impaired ovarian function.

LIMITATIONS, REASONS FOR CAUTION

Because of the small sample size and the low utilization rate and cost-effectiveness per retrieval, the present findings should be interpreted with caution, and further studies are needed for the long-term follow-up of live births.

WIDER IMPLICATIONS OF THE FINDINGS

This strategy can also help patients with normal ovulation to obtain available oocytes and embryos for cryopreservation and subsequent use.

STUDY FUNDING/COMPETING INTEREST(S)

This research was supported by the Joint Research Fund for Overseas Natural Science of China (No. 31429004), the National Key Research and Development Program of China (No. 2017YFC1002000, 2017YFC1001504, 2016YFC1000302), the Ministry of Science and Technology of China Grants (No. 2014CB943203), the Chinese Society of Reproductive Medicine Fund (No. 16020400656) and the National Natural Science Foundation of China (No. 81300456). All the authors have nothing to disclose in terms of conflicts of interest.

TRIAL REGISTRATION NUMBER

chictr-ONC-17011861.

Poor intracytoplasmic sperm injection outcome in infertile males with azoospermia factor c microdeletions

OBJECTIVE

To explore whether the presence of azoospermia factor c (AZFc) microdeletions adversely affects intracytoplasmic sperm injection (ICSI) outcome.

DESIGN

Retrospective cohort.

SETTING

University hospital.

PATIENT(S)

A total of 293 patients with azoospermia or severe oligozoospermia AZFc deletions underwent 345 ICSI cycles, and 363 idiopathic patients with normal Y chromosome underwent 462 ICSI cycles.

INTERVENTION(S)

Testicular sperm aspiration, microdissection testicular sperm extraction.

MAIN OUTCOME MEASURE(S)

The main clinical outcome parameters were cumulative clinical pregnancy rate, cumulative live birth delivery rate, and no embryo suitable for transfer cycle rate.

RESULT(S)

Compared with the control group, the AZFc deletion group exhibited poorer ICSI outcome, with significant differences between the 2 groups for cumulative clinical pregnancy rate (45.39% vs. 67.49%; odds ratio [OR], 2.843; 95% confidence interval [CI]), cumulative live birth delivery rate (35.15% vs. 53.44%; OR, 2.234; 95% CI), no embryo suitable for transfer cycle rate (15.07% vs. 8.23%; OR, 0.565; 95% CI), fertilization rate (46.80% vs. 53.37%; adjusted β, -0.074; 95% CI), implantation rate (28.63% vs. 31.26%; adjusted β, -0.075; 95% CI) separately. The poor ICSI outcome of the AZFc deletion group was related to AZFc microdeletions by linear and logistic regression analyses.

CONCLUSION(S)

AZFc microdeletions adversely affect ICSI outcome; patients with AZFc deletion should be informed that they have reduced opportunities to be biological fathers.

Association between mild stimulated IVF/M cycle and early embryo arrest in sub fertile women with/without PCOS

BACKGROUND

The in vitro maturation (IVM) technique has physical and financial benefits, but a lower efficiency and outcome that is still unclear whether it is related to polycystic ovary syndrome (PCOS) itself or the IVM procedure. In this study, we analyzed the clinical and laboratory outcomes of an optimized IVM protocol in patients with and without PCOS. We also discussed the possible reasons for early embryo arrest in the IVM cycle.

METHODS

This prospective study involved 58 PCOS patients and 56 non-PCOS patients who underwent mild stimulated IVF combined IVM (IVF/M) cycles. The clinical and laboratory outcomes were compared between the two groups. Also, metaphase II (MII) oocytes were obtained after IVM from the two groups, and in vivo MII oocytes randomly collected from IVF patients were examined for mitochondrial function using a laser scanning confocal microscope (LSCM). The aneuploidy rate for arrested cleavage embryos from IVM and IVF oocytes were screened using Next Generation Sequencing (NGS).

RESULTS

Mildly stimulated IVF/M resulted in cumulative clinical pregnancy and implantation rates (40.2, 28.7% in the PCOS group vs. 41.9, 36% in the non-PCOS group), respectively. The blastocyst formation rates were comparable (28% vs. 28.2%) in PCOS and non-PCOS groups, respectively. Using LSCM, there was a significant decrease in the mitochondrial membrane potential of IVM oocytes compared with the control IVF oocytes (P < 0.001), but no significant difference between the PCOS and non-PCOS groups. The NGS showed that the aneuploidy rates were comparable (75, 75, and 66.6%) in IVM-PCOS, IVM-non-PCOS, and control IVF arrested embryos, respectively.

CONCLUSIONS

The mildly stimulated IVF/M protocol produced acceptable clinical outcomes in PCOS and non-PCOS patients. IVM itself rather than the PCOS condition adversely affected the embryo development through its effect on mitochondrial function, which appeared to be a possible cause for the embryo arrest in the IVM cycles rather than chromosomal aneuploidy.

Human Chorionic Gonadotropin Priming Does Not Improve Pregnancy Outcomes of PCOS-IVM Cycles

Background: Influence of pre-retrieval human chorionic gonadotropin (HCG) priming on outcomes of in vitro maturation (IVM) remains controversial. This study aimed to evaluate the effect of HCG priming before oocyte retrieval on clinical outcomes of IVM cycles in patients with polycystic ovarian syndrome (PCOS). Methods: This was a retrospective cohort study analyzing data from the first IVM cycles of unstimulated PCOS patients in a reproductive center of university affiliated hospital from January 2006 to December 2017. Patients received HCG injection before oocyte retrieval were assigned to HCG priming group and those without HCG administration were categorized as none HCG priming (Non-HCG) group. Main outcomes included oocyte maturation rate, number of embryos available, clinical pregnancy rate, and live birth rate. Candidate factors of clinical pregnancy rate was explored by univariate analysis and multivariate logistic regression analysis. Results: There were 324 patients meeting the inclusion and exclusion criteria. Among them, 129 women received HCG priming and 195 other did not. Women in HCG group had significantly lower basal FSH level (5.17 ± 1.63 vs. 5.80 ± 2.38) than Non-HCG group. Both FSH levels were <10 IU/L and the absolute difference was 0.63 IU/L. Other basic characteristics were similar between groups with or without HCG priming. Oocyte maturation rate was trend to be higher in HCG group (52.68 vs. 48.56%) but no statistical significance was found (P = 0.097). No significant difference in clinical pregnancy rate was found between HCG and Non-HCG groups (31.37 vs. 35.67%). Miscarriage rates (31.25 vs. 34.43%) and live birth rates were also similar between groups. HCG priming was not correlated with clinical pregnancy rate in both univariate analysis (P = 0.468) and multivariate logistic regression analysis (P = 0.538; OR = 1.212; 95%CI: 0.657-2.237). Conclusion: HCG priming before oocyte retrieval may not improve clinical outcomes of IVM in patients with PCOS.

Aberrant endometrial steroid receptor expression in in-vitro maturation cycles despite hormonal luteal support: A pilot study

Clinical outcomes of fresh embryo transfer in non-hCG triggered in vitro maturation (IVM) cycles are inferior compared to vitrified-warmed embryo transfer. This is a prospective observational pilot study in a consecutive cohort of 31 polycystic ovary syndrome (PCOS) patients and 37 normo-ovulatory egg donors who underwent IVM without fresh embryo transfer between July 2009 and June 2014. All subjects received 150 IU of highly purified menotropin (HP-hMG) daily for three days. On cycle day 6, all patients started transdermal oestradiol (E2) at a daily dose of 9 mg. There was no human chorionic gonadotropin (hCG) trigger before oocyte retrieval (OR). Vaginal micronized progesterone was commenced on the evening after OR, at a daily dose of 600 mg. Additional luteal phase support (LPS) was administered as follows: Group A: no additional LPS; Group B: 1500 IU of hCG administered 4 h after OR and Group C: 5000 IU of hCG administered 4 h after OR + an additional injection of 5000 IU of hCG 1 day before endometrial biopsy. Endometrial biopsy for histology and immunohistochemistry (IHC) was performed on day 5 or 6 after OR. Instead of being downregulated, both PR-B and ERα in endometrial glands and stroma were moderately to strongly expressed in all three protocols, suggesting that the mid-luteal histological signature of endometrial receptivity is deficient in a non-hCG-triggered IVM cycle. Poor clinical outcomes after fresh embryo transfer following IVM are probably related to inappropriate endometrial development which may be linked to the short follicular phase of IVM cycles.

Successful in vitro maturation for urgent fertility preservation despite hormonal contraception by continuous progestin application

We report a unique case of a rare utilization of IVM. This case shows the successful retrieval of immature oocytes followed by in vitro maturation (IVM) for fertility preservation in a patient undergoing chronic progestin contraception. A 24-year-old patient with anaplastic astrocytoma requiring chemotherapy with temozolomide for 12 cycles as soon as possible with wish for fertility preservation while using a long acting etonogestrel birth control implant presented in our unit for fertility preservation in May 2017. The currently used implant should be preserved for further contraception. As the ovaries presented with a high, pco-like, antral follicle count, IVM was offered; the patient agreed. A transvaginal follicular puncture in general anesthesia without any hormonal intervention and IVM of gained oocytes was performed. As the patient actually had no spouse, she decided to freeze unfertilized metaphase II stage oocytes (MII). Thirteen oocytes were obtained, eight of them could be matured and cryopreserved. IVM could be a possibility for fertility preservation in patients with polycystic ovaries when no time is available for stimulation for conventional in vitro fertilization. Even use of continuous progestin application for contraception is no obstacle.

Advances in Fertility Preservation for Young Women With Cancer

Female patients of reproductive age with cancer often require treatment that can compromise their future fertility. Treatment-related infertility is an important cancer survivorship issue and is associated with depression and diminished quality of life. Recent advances in reproductive health care provide the opportunity to preserve fertility prior to the initiation of cancer therapy. Clinical guidelines recommend that oncology providers counsel patients about the risk of treatment-related infertility and fertility preservation options, and that they refer those who are interested in fertility preservation to fertility specialists. Guidelines endorse the use of assisted reproductive techniques (ART) provided by reproductive endocrinologists to preserve fertility in young female patients with cancer. In addition, ovarian suppression with gonadotropin-releasing hormone (GnRH) agonists may be considered for ovarian protection during chemotherapy. This article reviews currently available and emerging ART for fertility preservation in female patients of reproductive age with cancer and current data supporting the use of ovarian suppression for ovarian protection during chemotherapy in this population. We also review the uptake of fertility services and discuss barriers to fertility preservation in female patients of reproductive age with cancer.

In vitro maturation in subfertile women with polycystic ovarian syndrome undergoing assisted reproduction

BACKGROUND

Polycystic ovarian syndrome (PCOS) occurs in 4% to 7% of all women of reproductive age and 50% of women presenting with subfertility. Subfertility affects 15% to 20% of couples trying to conceive. A significant proportion of these women ultimately need assisted reproductive technology (ART). In vitro fertilisation (IVF) is one of the assisted reproduction techniques employed to raise the chances of achieving a pregnancy. For the standard IVF technique, stimulating follicle development and growth before oocyte retrieval is essential, for which a large number of different methods combining gonadotrophins with a gonadotrophin-releasing hormone (GnRH) agonist or antagonist are used. In women with PCOS, the supra-physiological doses of gonadotrophins used for controlled ovarian hyperstimulation (COH) often result in an exaggerated ovarian response, characterised by the development of a large cohort of follicles of uneven quality, retrieval of immature oocytes, and increased risk of ovarian hyperstimulation syndrome (OHSS). A potentially effective intervention for women with PCOS-related subfertility involves earlier retrieval of immature oocytes at the germinal-vesicle stage followed by in vitro maturation (IVM). So far, the only data available have derived from observational studies and non-randomised clinical trials.

OBJECTIVES

To assess the effectiveness and safety of IVM followed by IVF or ICSI versus conventional IVF or ICSI among women with PCOS undergoing assisted reproduction.

SEARCH METHODS

This is the second update of this review. We performed the search on 17 April 2018.The search was designed with the help of the Cochrane Gynaecology and Fertility Group Information Specialist, for all published and unpublished randomised controlled trials (RCTs).We searched the the Cochrane Gynaecology and Fertility Group Specialised Register of controlled trials, CENTRAL via the Cochrane Central Register of Studies Online, MEDLINE, Embase, CINAHL, and the trial registers for ongoing and registered trials and the Open Grey database for grey literature from Europe. We made further searches in the National Institute for Health and Care Excellence (NICE) fertility assessment and treatment guidelines. We handsearched reference lists of relevant systematic reviews and RCTs, together with PubMed and Google for any recent trials that have not yet been indexed in the major databases.

SELECTION CRITERIA

All RCTs on the intention to perform IVM before IVF or ICSI compared with conventional IVF or ICSI for subfertile women with PCOS, irrespective of language and country of origin.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed risk of bias, extracted data from studies, and attempted to contact the authors of studies for which data were missing. Our primary outcomes were live birth per woman randomised and miscarriage. We performed statistical analysis using Review Manager 5. We assessed evidence quality using GRADE methods.

MAIN RESULTS

We found two RCTs suitable for inclusion in the review and six ongoing trials that have not yet reported results. Both included studies were published as abstracts in international conferences.Both studies were at unclear or high risk of bias for most of the seven domains assessed. Common problems were unclear reporting of study methods and lack of blinding. The main limitations in the overall quality of the evidence were high risk of bias and serious imprecision.There were no data on the primary outcomes of this review, namely live birth per woman randomised and miscarriage.Both studies reported clinical pregnancy rate: there was evidence of an effect between IVM and IVF, favouring the former (odds ratio 3.10, 95% confidence interval 1.06 to 9.00; 71 participants; 2 studies; I2 = 0%; very low-quality evidence). The incidence of OHSS was zero in both studies in both groups.There were no data for the other outcomes specified in this review.

AUTHORS' CONCLUSIONS

Though promising data on the in vitro maturation (IVM) technique have been published, unfortunately there is still no evidence from properly conducted randomised controlled trials upon which to base any practice recommendations regarding IVM before in vitro fertilisation (IVF) or intracytoplasmic sperm injection for women with polycystic ovarian syndrome. Regarding our secondary outcomes, very low-quality evidence showed that clinical pregnancy was higher with IVM when compared to IVF, whereas the incidence of ovarian hyperstimulation syndrome was zero in both studies in both groups. We are awaiting the results of six ongoing trials and eagerly anticipate further evidence from good-quality trials in the field.

Live birth rate after human chorionic gonadotropin priming in vitro maturation in women with polycystic ovary syndrome

BACKGROUND

In vitro maturation (IVM) has some advantages over conventional in vitro fertilization (IVF), particularly in polycystic ovary syndrome (PCOS) where the risk of ovarian hyperstimulation is high. We studied the live birth rate in a large series of PCOS women undergoing human chorionic gonadotropin (hCG)-priming IVM.

METHODS

This retrospective study included women with PCOS aged 18-42 years undergoing IVM with hCG priming. We reported live birth rate after the first embryo transfer and cumulative live birth rate from embryos obtained in the IVM cycle. We also performed logistic regression to assess which factors predicted number of oocytes and live birth.

RESULTS

We included 921 women (age 28.9±3.5 years, body mass index 21.8±3.1 kg/m2, infertility duration 3.7±2.6 years, 81% primary infertility, 88% first IVF attempt, 94% ovulation induction failure). Live birth rate after the first embryo transfer was 31.7%, with a cumulative live birth rate from the cycle of 33.7%. High anti-Müllerian hormone levels predicted a high number of oocytes and a high oocyte maturation rate while the opposite was the case when luteinizing hormone levels were high.

CONCLUSIONS

In women with PCOS, hCG priming IVM was feasible and resulted in acceptable live birth rates.

Current perspectives on in vitro maturation and its effects on oocyte genetic and epigenetic profiles

In vitro maturation (IVM), the maturation in culture of immature oocytes, has been used in clinic for more than 20 years. Although IVM has the specific advantages of low cost and minor side effects over controlled ovarian stimulation, the prevalence of IVM is less than 1% of routine in vitro fertilization and embryo transfer techniques in many reproductive centers. In this review, we searched the MEDLINE database for all full texts and/or abstract articles published in English with content related to oocyte IVM mainly between 2000 and 2016. Many different aspects of the IVM method may influence oocyte potential, including priming, gonadotrophin, growth factors, and culture times. The culture conditions of IVM result in alterations in the oocyte or cumulus cell transcriptome that are not observed under in vivo culture conditions. Additionally, epigenetic modifications, such as DNA methylation or acetylation, are also different between in vitro and in vivo cultured oocytes. In sum, current IVM technique is still not popular and requires more systematic and intensive research to improve its effects and applications. This review will help point our problems, supply evidence or clues for future improving IVM technique, thus assist patients for fertility treatment or preservation as an additional option.

In vitro maturation of human immature oocytes for fertility preservation and research material

Aim

In recent years, the importance of fertility preservation (FP) has increased. In vitro maturation (IVM), an important technique in FP, has started to be used in the clinic, but controversies persist regarding this technique. Here, a survey of IVM for FP is provided.

Methods

Based on a literature review, the applications of FP, methods of FP, IVM of oocytes that had been collected in vivo and ex vivo, maturation of oocytes after IVM for FP, cryopreservation of oocytes for FP, explanation of the procedures to patients, and recent research on FP using IVM were investigated.

Results

Although IVM for FP remains controversial, the application of FP is expected to expand. Depending on the age and disease status of the patient, various methods of oocyte collection and ovarian stimulation, as well as various needle types and aspiration pressures, have been reported. The maturation rate of IVM in FP ranges widely and requires optimization in the future. In regard to cryopreservation for matured oocytes, the vitrification method is currently recommended.

Conclusion

Regarding FP for patients with cancer, the treatment of cancer is prioritized; thus, the time and use of medicines are often constrained. As several key points regarding IVM remain unclear, well‐designed and specific counseling for patients is necessary.

Strategies for improving outcome of assisted reproduction in women with polycystic ovary syndrome: systematic review and meta-analysis

OBJECTIVES

To identify, appraise and summarize the current evidence regarding the efficacy of strategies aimed at improving assisted reproductive techniques in women with polycystic ovary syndrome (PCOS).

METHODS

A comprehensive literature search of the standard medical databases was performed. The last electronic search was run in July 2015. The primary outcome measures were live birth/ongoing pregnancy and ovarian hyperstimulation syndrome (OHSS). The secondary outcome measures were clinical pregnancy and miscarriage.

RESULTS

We screened 1021 records and completely assessed 173, finally including 66 studies in the quantitative analysis. Many different interventions were assessed, however the overall quality of the studies was low. We observed moderate-quality evidence that there is no clinically relevant difference in live birth/ongoing pregnancy rates (relative risk (RR), 0.95 (95% CI, 0.84-1.08)), or clinical pregnancy (RR, 1.02 (95% CI, 0.91-1.15)) when comparing antagonist and agonist protocols for ovarian stimulation. Additionally, we found low-quality evidence that metformin improves live birth/ongoing pregnancy (RR, 1.28 (95% CI, 1.01-1.63)) and clinical pregnancy rates (RR, 1.26 (95% CI, 1.04-1.53)) when compared with placebo or no intervention. We further found low-quality evidence that there is no clinically relevant difference in live birth/ongoing pregnancy rates (RR, 1.03 (95% CI, 0.80-1.34)) and clinical pregnancy rates (RR, 0.99 (95% CI, 0.81-1.22)) when comparing human menopausal gonadotropin for inducing ovulation and artificial preparation with estradiol valerate for endometrial preparation for frozen embryo transfer (FET). Low-quality evidence suggests that mannitol compared with no intervention (RR, 0.54 (95% CI, 0.39-0.77)) and antagonist protocols compared with agonist protocols (RR, 0.63 (95% CI, 0.49-0.80)) reduce rates of OHSS.

CONCLUSION

There is low- to moderate-quality evidence suggesting that antagonist protocols are preferable to agonist ones, because they reduce the incidence of OHSS without interfering with clinical pregnancy and live birth for women with PCOS. Additionally there is low-quality evidence pointing to a benefit of metformin supplementation on clinical pregnancy and live birth; and that ovulation induction and administration of estradiol seem to be equally effective for endometrial preparation before FET for women with PCOS. For all other interventions, the evidence is of very low quality, not allowing any meaningful conclusions to be drawn. Estrategias para mejorar el resultado de la reproducción asistida en mujeres con síndrome de ovario poliquístico: revisión sistemática y metaanálisis RESUMEN OBJETIVOS: Identificar, evaluar y resumir la evidencia actual sobre la eficacia de las estrategias para mejorar las técnicas de reproducción asistida en mujeres con síndrome de ovario poliquístico (SOP). MÉTODOS: Se realizó una búsqueda exhaustiva de literatura en las bases de datos médicas estándar. La última búsqueda electrónica se realizó en julio de 2015. Las medidas de resultado primarias fueron los nacimientos vivos/embarazos en curso y el síndrome de hiperestimulación ovárica (SHO). Las medidas de resultado secundarias fueron el embarazo confirmado ecográficamente y el aborto.

RESULTADOS

Se cribaron 1021 registros, de los que se evaluaron por completo 173, para finalmente incluir 66 estudios en el análisis cuantitativo. Aunque se evaluaron muchas intervenciones diferentes, en general la calidad de los estudios fue baja. Se observó evidencia de calidad moderada de que no hay diferencias relevantes clínicamente en las tasas de nacimientos vivos/embarazos en curso (riesgo relativo (RR): 0,95 (IC 95%, 0,84-1,08)), o de embarazos confirmados ecográficamente (RR: 1,02 (IC 95%, 0,91-1,15)), cuando se comparan los protocolos de antagonistas y agonistas para la estimulación ovárica. Además, se encontró evidencia de baja calidad en que la metformina mejora las tasas de nacimientos vivos/embarazos en curso (RR: 1,28 (IC 95%, 1,01-1,63)) y de embarazos confirmados ecográficamente (RR: 1,26 (IC 95%, 1,04-1,53)) en comparación con un placebo o la no intervención. Se encontró también evidencia de baja calidad en que no hay diferencias relevantes clínicamente en las tasas de nacimientos vivos/embarazos en curso (RR: 1,03 (IC 95%, 0,80-1,34)) y las tasas de embarazos confirmados ecográficamente (RR: 0,99 (IC 95%, 0.81-1,22)) al comparar la gonadotropina menopáusica humana para la inducción de la ovulación y la preparación artificial con el valerato de estradiol para preparar el endometrio para la transferencia de embriones congelados (TEC). La baja calidad de la evidencia sugiere que el manitol, en comparación con la no intervención (RR: 0,54 (IC 95%, 0,39-0,77)), y los protocolos de antagonistas, en comparación con los protocolos de agonistas (RR: 0,63 (IC 95%, 0,49-0,80)), reducen las tasas de SHO. CONCLUSIÓN: Hay evidencia de calidad baja a moderada que sugiere que los protocolos de antagonistas son preferibles a los de agonistas, ya que reducen la tasa de SHO sin interferir con el embarazo confirmado ecográficamente y los nacimientos vivos en las mujeres con SOP. Además, existe evidencia de baja calidad que indica un beneficio del uso de metformina como aporte suplementario en embarazos confirmados ecográficamente y en nacimientos vivos; y que la inducción de la ovulación y la administración de estradiol parecen ser igualmente eficaces para la preparación del endometrio antes de la TEC en mujeres con SOP. Para el resto de procedimientos, la evidencia es de muy baja calidad, y por ello no permite extraer conclusiones importantes.

Human chorionic gonadotrophin priming for fertility treatment with in vitro maturation

BACKGROUND

In vitro maturation (IVM) is a fertility treatment that involves the transvaginal retrieval of immature oocytes, and their subsequent maturation and fertilisation. Although the live birth rate is lower than conventional in vitro fertilisation (IVF) with ovarian stimulation, it is a useful treatment, as it avoids the risk of ovarian hyperstimulation syndrome (OHSS). Women with polycystic ovaries (PCO) or polycystic ovarian syndrome (PCOS) are at an increased risk of OHSS. Thus, IVM may be a more useful treatment in this patient group.Strategies to maximise the maturation rates of the immature oocytes are important. This review focuses on the administration of human chorionic gonadotrophin (hCG) prior to immature oocyte retrieval.

OBJECTIVES

To determine the effectiveness and safety of hCG priming in subfertile women who are undergoing IVM treatment in the context of assisted reproduction.

SEARCH METHODS

We searched the following electronic databases up to 29 August 2016: Cochrane Gynaecology and Fertility Group Specialised Register of controlled trials, CENTRAL, MEDLINE, Embase, PsycINFO, and CINAHL. We also searched the trial registries ClinicalTrials.gov and WHO ICTPR to identify ongoing and registered trials. We sought recently published papers not yet indexed in the major databases, and reviewed the reference lists of reviews and retrieved studies as sources of potentially relevant studies. There were no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared hCG priming with placebo or no priming in women undergoing IVM. We also included RCTs that compared different doses of hCG, or the timing of oocyte retrieval. The primary outcomes were live birth rate and miscarriage rate per woman randomised.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, and with a third author, assessed risk of bias and extracted data. We contacted the original authors where data were missing. For dichotomous outcomes, we used the Mantel-Haenszel method to calculate odds ratios (OR). For continuous outcomes, we calculated the mean differences (MD) between treatment groups. We assessed statistical heterogeneity using the I² statistic. We assessed the overall quality of the evidence using GRADE methods.

MAIN RESULTS

We included four studies, with a total of 522 women, in the review. One of these studies did not report outcomes per woman randomised, and so was not included in formal analysis. Three studies investigated 10,000 units hCG priming compared to no priming. One study investigated 20,000 units hCG compared to 10,000 units hCG priming. Three studies only included women with PCOS (N = 122), while this was an exclusion criteria in the fourth study (N = 400).We rated all four studies as having an unclear risk of bias in more than one of the seven domains assessed. The quality of the evidence was low, the main limitations being lack of blinding and imprecision.When 10,000 units hCG priming was compared to no priming, we found no evidence of a difference in the live birth rates per woman randomised (OR 0.65, 95% confidence intervals (CI) 0.24 to 1.74; one RCT; N = 82; low quality evidence); miscarriage rate (OR 0.60, 95% CI 0.21 to 1.72; two RCTs; N = 282; I² statistic = 21%; low quality evidence), or clinical pregnancy rate (OR 0.52, 95% CI 0.26 to 1.03; two RCTs, N = 282, I² statistic = 0%, low quality evidence). Though inconclusive, our findings suggested that hCG may be associated with a reduction in clinical pregnancy rates; 22% of women who received no priming achieved pregnancy, while between 7% and 23% of women who received hCG priming did so.The study comparing 20,000 units hCG with 10,000 units hCG did not report sufficient data to enable us to calculate odds ratios.No studies reported on adverse events (other than miscarriage) or drug reactions.

AUTHORS' CONCLUSIONS

This review found no conclusive evidence that hCG priming had an effect on live birth, pregnancy, or miscarriage rates in IVM. There was low quality evidence that suggested that hCG priming may reduce clinical pregnancy rates, however, these findings were limited by the small number of data included. As no data were available on adverse events (other than miscarriage) or on drug reactions, we could not adequately assess the safety of hCG priming. We need further evidence from well-designed RCTs before we can come to definitive conclusions about the role of hCG priming, and the optimal dose and timing.

Random start or emergency IVF/in vitro maturation: a new rapid approach to fertility preservation

There is a need to develop rapid protocols for ovarian stimulation for women who wish to preserve their fertility following diagnosis of cancer. Conventional gonadotropin stimulation protocols are lengthy and are delayed until the start of the next menstrual period, potentially compromising cancer treatments. The development of random start IVF/in vitro maturation has made significant strides for enabling couples undergoing cancer therapy to achieve a family. However, several unanswered questions still remain. What do we know about the endocrinology of stimulating ovarian follicular activity outside the established protocols of stimulation during the follicular phase? This article explores what is known about antral follicle development during the menstrual cycle, novel ovarian stimulation proposals for optimizing assisted reproductive therapies in women, and direction.

Impact of hepatitis B virus carrier serostatus on neonatal outcomes after IVF-ET

An increasing number of infertile, hepatitis B virus-infected individuals have opted for assisted reproductive technology. However, the impact of the hepatitis B virus carrier serostatus on neonatal outcomes has not been evaluated. Data from 504 patients who delivered singletons were analyzed. In females, hepatitis B surface antigen, hepatitis B e antigen, and antibody to hepatitis core antigen seropositivity significantly decreased the gestational age at delivery. In contrast, the male hepatitis B virus serostatus did not affect the gestational age at delivery. Multiple linear regression analysis showed that maternal weight, gestational age at delivery, and infant gender were significantly related to birth weight. The present retrospective study showed that in females, hepatitis B surface antigen, hepatitis B e antigen, and antibody to hepatitis core antigen seropositivity was significantly associated with the gestational age at delivery after in vitro fertilization-embryo transfer (IVF-ET).

[In vitro oocyte maturation for female fertility preservation]

Recovering immature oocytes from unstimulated ovaries, followed by in vitro maturation (IVM) was initially proposed to avoid the risks and side effects of exogenous gonadotropin administration. Therefore, during the past decades, IVM was mainly offered to patients with polycystic ovary syndrome at high risk of ovarian hyperstimulation syndrome. However, the development of fertility preservation has recently opened new perspectives in the field of IVM. The present review reports the possible indications of IVM, in the strategy of female fertility preservation.

Pioneering contributions by Robert Edwards to oocyte in vitro maturation (IVM)

The history of in vitro maturation (IVM) of mammalian oocytes, especially of human oocytes, holds a special place for Robert Edwards. He was the first to comprehensively examine and demonstrate maturation of human oocytes in vitro and in so doing he changed the course of medicine by fertilizing them in vitro. In reviewing his contribution, we have examined the state of the field at the time and discuss his pioneering insights into mammalian oocyte biology. We will also discuss how some of the major concepts and challenges identified by Edwards 50 years ago remain among the major challenges facing IVM today.

In vitro maturation in subfertile women with polycystic ovarian syndrome undergoing assisted reproduction

BACKGROUND

Polycystic ovarian syndrome (PCOS) occurs in 4% to 7% of all women of reproductive age and 50% of women presenting with subfertility. Subfertility affects 15% to 20% of couples trying to conceive. A significant proportion of these women ultimately need assisted reproductive technology (ART). In vitro fertilisation (IVF) is one of the assisted reproduction techniques employed to raise the chances of achieving a pregnancy. For the standard IVF technique, stimulating follicle development and growth before oocyte retrieval is essential, for which a large number of different methods combining gonadotrophins with a gonadotrophin-releasing hormone (GnRH) agonist or antagonist are used. In women with PCOS, the supra-physiological doses of gonadotrophins used for controlled ovarian hyperstimulation (COH) often result in an exaggerated ovarian response, characterised by the development of a large cohort of follicles of uneven quality, retrieval of immature oocytes, and increased risk of ovarian hyperstimulation syndrome. A potentially effective intervention for women with PCOS-related subfertility involves earlier retrieval of immature oocytes at the germinal-vesicle stage followed by in vitro maturation (IVM). So far, the only data available have derived from observational studies and non-randomised clinical trials.

OBJECTIVES

To compare outcomes associated with in vitro maturation (IVM) followed by vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) versus conventional IVF or ICSI, among women with polycystic ovarian syndrome (PCOS) undergoing assisted reproductive technologies (ART).

SEARCH METHODS

We searched the Menstrual Disorders and Subfertility Group (MDSG) Specialised Register of controlled trials to May 2013 for any relevant trials identified from the title, abstract, or keyword sections. This was followed by a search of the electronic database MEDLINE, EMBASE, LILACS and CINAHL, without language restriction. We also performed a manual search of the references of all retrieved articles; sought unpublished papers and abstracts submitted to international conferences, searched the clinicaltrials.gov and WHO portal registries for submitted protocols of clinical trials, and contacted experts. In addition, we examined the National Institute of Clinical Excellence (NICE) fertility assessment and treatment guidelines and handsearched reference lists of relevant articles (from 1970 to May 2013).

SELECTION CRITERIA

All randomised trials (RCTs) on the intention to perform IVM before IVF or ICSI compared with conventional IVF or ICSI for subfertile women with PCOS.

DATA COLLECTION AND ANALYSIS

Three review authors (CS, MK and NV) independently assessed eligibility and quality of trials. Primary outcome measure was live birth rate per randomised woman.

MAIN RESULTS

There were no RCTs suitable for inclusion in the review, although there are currently three ongoing trials that have not yet reported results.

AUTHORS' CONCLUSIONS

Though promising data on the IVM technique have been published, unfortunately there is still no evidence from RCTs upon which to base any practice recommendations regarding IVM before IVF or ICSI for women with PCOS. Meanwhile, the results of the above-mentioned ongoing trials are awaited and, of course, further evidence from good quality trials in the field is eagerly anticipated.

No effect of embryo culture media on birthweight and length of newborns

STUDY QUESTION

Does the type of media used to culture embryos for IVF influence the birthweight and length of neonates?

SUMMARY ANSWER

No significant differences were observed in birthweight and length among the three embryo culture media used for in vitro embryo culture.

WHAT IS KNOWN ALREADY

Since the establishment of IVF as an assisted reproductive technology (ART), many different culture systems have been used for the development of human embryos. Some studies have shown that the types of culture media influence the newborn birthweight; however, other studies have shown no effect. To further explore this contradictory issue, we compared the birthweight and length of neonates born after the transfer of embryos cultured in one of three commercially available media.

STUDY DESIGN, SIZE AND DURATION

This retrospective analysis of birthweight and length of newborns included 1201 women who delivered singletons and 445 women who delivered twins. The following three commercially available culture media were used: G5™, Global and Quinn's advantage media. Women who underwent IVF-ET cycles between 2008 and 2010 were analyzed.

PARTICIPANTS/MATERIALS, SETTING AND METHODS

Patients younger than 40 years of age with a body mass index (BMI) <30 kg/m(2) were analyzed. Only data from singletons and twins born alive after the 20th week of gestation were included in the data analysis. Patients who received preimplantation genetic diagnosis (PGD) and donor oocytes were excluded.

MAIN RESULTS AND THE ROLE OF CHANCE

The analysis of 1201 singletons and 445 sets of twins showed no significant association between mean birthweight or mean birth length and the type of embryo culture medium. Inter-twin mean birthweight and length disparities were analyzed, but were not shown to be significantly different. Multiple linear regression analysis showed that maternal weight, maternal height, gestational age and infant gender were significantly related to birthweight, and paternal height, gestational age and newborn complications were significantly associated with birth length.

LIMITATIONS AND REASONS FOR CAUTION

The current study showed that birthweight and length of newborns were not associated with the embryo culture medium. More research needs to be performed to analyze the effects of other culture medium formulations and to evaluate the long-term effects of embryo culture medium on the health of children conceived through ART. WIDER IMPLICATIONS OF THESE FINDINGS: Our retrospective study suggests that embryo culture medium does not influence neonatal birthweight and length; however, the effects of culture medium on epigenetic variation of embryos need to be studied further.