IVF outcome in azoospermic cancer survivors

OBJECTIVE

To assess clinical outcome among infertile couples treated by in vitro fertilization (IVF) and intra cytoplasmic sperm injection (ICSI) using testicular sperm from azoospermic cancer survivors.

STUDY DESIGN

This clinical retrospective study included infertile couples treated in a single tertiary referral center between 1996 and 2013. All male partners were cancer survivors who were diagnosed with azoospermia due to previous gonadotoxic treatments and referred to testicular sperm extraction (TESE). Retrieved sperm was used for IVF-ICSI among patients' spouses. Sperm retrieval rate and IVF-ICSI outcome were evaluated.

RESULTS

Sperm was successfully retrieved in 12 out of 36 patients (33.3%) on initial TESE, with an overall sperm retrieval rate of 38.6% (17 of 44). Female patients were 29.8±5.1 years old. The average number of retrieved oocytes was 14.0±4.0 per cycle, with clinical pregnancy and live birth rates per successful TESE of 64% (11 of 17) and 58.8% (10 of 17), respectively. Age, serum FSH, testicular volume and time from chemotherapy to TESE were not significantly different between patients with successful TESE to those without. Patients suffering from seminomas had significantly higher sperm retrieval rate, as compared to patients who had Hodgkin's lymphoma (P=0.024).

CONCLUSIONS

Post-chemotherapy azoospermia can be successfully treated with TESE and ICSI, and should be offered to azoospermic cancer survivors who did not cryopreserve sperm prior to their gonadotoxic treatments.

Does controlled ovarian stimulation prior to chemotherapy increase primordial follicle loss and diminish ovarian reserve? An animal study

BACKGROUND

Storage of embryos for fertility preservation before chemotherapy is widely practiced. For multiple oocyte collection, the ovaries are hyperstimulated with gonadotrophins that significantly alter ovarian physiology. The effects of ovarian stimulation prior to chemotherapy on future ovarian reserve were investigated in an animal model.

METHODS

Cyclophosphamide (Cy) in doses of 0, 50 or 100 mg/kg was administered to 38 adult mice (control, unstimulated). A second group of 12 mice were superovulated with equine chorionic gonadotrophin (eCG, 10 IU on Day 0) before Cy administration; hCG (10 IU) was administered (Day 2) followed by 0, 50 or 100 mg/kg Cy (Day 4). In both groups ovaries were removed, serially sectioned (7-day post-Cy), primordial follicles were counted and differences between groups evaluated.

RESULTS

Follicle number dropped from 469 +/- 24 (mean +/- SE) to 307 +/- 27 and 234 +/- 19 with 50 or 100 mg/kg Cy, respectively (P < 0.0001). In the eCG pretreated group, follicle count dropped from 480 +/- 31 to 345 +/- 16 and 211 +/- 26 when 50 or 100 mg/kg Cy were administered (P < 0.0001). There were no significant differences in follicle count between the pretreated eCG group and controls for each chemotherapy dose.

CONCLUSIONS

This animal study indicates that ovarian stimulation before administration of Cy does not adversely affect ovarian reserve post-treatment. These results provide support for the safety of fertility preservation using ovarian stimulation and IVF-embryo cryopreservation procedures prior to chemotherapy.

Cortical fibrosis and blood-vessels damage in human ovaries exposed to chemotherapy. Potential mechanisms of ovarian injury

BACKGROUND

Chemotherapy destroys primordial follicles and can lead to ovarian atrophy. Although reports indicate that apoptosis is the mechanism responsible for follicle loss, additional pathways can be involved. This study investigates the damage in human ovaries after administration of non-sterilizing doses of chemotherapy.

METHODS

In a blind study, pathological changes in ovarian tissue harvested for cryopreservation were evaluated. The study group comprised young non-sterile cancer patients, previously exposed to chemotherapy who were (mean +/- SD), when compared with non-exposed patients.

RESULTS

Thirty-five cancer patients aged 28.7 +/- 6.74; 17 were previously exposed to non-sterilizing chemotherapy and 18 were not. In all samples, primordial follicles were present. In previously exposed patients, damage to cortical blood vessel and proliferation of small vessels was observed. The cortex showed focal areas of fibrosis with disappearance of follicles (sensitivity 76%, positive predictive value 75% for <37 years old patients). Older patients, not exposed to chemotherapy (5/7) showed similar pathological changes.

CONCLUSIONS

Injury to blood vessels and focal ovarian cortical fibrosis are aspects of ovarian damage caused by chemotherapy. These findings indicate a potential additional mechanism of damage to the direct apoptotic effect of chemotherapy on follicles. The possibility that these changes are involved in ageing ovaries should be further investigated.

Outcome of pregnancies complicated by severe ovarian hyperstimulation syndrome (OHSS): a follow-up beyond the second trimester

The main aim of this study was to assess the obstetric complications for those pregnancies that are complicated by ovarian hyperstimulation syndrome (OHSS) and continue beyond the first trimester. We checked also for other related serious events that occurred during the first trimester.

METHODS

We included only patients whose pregnancies continued beyond the first trimester and compared them with IVF-treated patients displaying moderate ovarian response.

RESULTS

We studied 165 patients with OHSS (101 singletons and 64 twins) and 156 IVF control patients (85 singletons and 71 twins). Two serious complications, gestational diabetes mellitus (GDM) and pregnancy-induced hypertension (PIH), were noted in both groups. However, the incidence of these two complications did not differ significantly between the groups. In the OHSS group, GDM presented with an incidence of 9.9% for singletons and 9.4% for twins, and 12.9% and 7.0%, respectively, for the control group. PIH presented as 6.9% for singletons and 10.9% for twins in the OHSS group, and 8.2% and 7.0%, respectively, for the control groups. During the first trimester laparoscopies for suspected ovarian torsion were performed in 13 patients, and in 10 patients the diagnosis were confirmed.

CONCLUSIONS

Although patients with OHSS-complicated pregnancies previously reported a relatively high risk of GDM and PIH, the occurrence rates do not differ from a matched control group of normally responding patients who conceived after IVF.

The effect of prolonged cryopreservation on embryo survival

The purpose of this study was to assess the effects of long-term cryopreservation on the survival and implantation rates of embryos. We performed a matched case-control study comparing 101 women whose embryos were transferred after cryopreservation for 2-9 years, with 101 control women whose embryos were transferred after 6 months or less of cryopreservation. A multiple step-wise logistic regression was performed to determine the independent effect of the duration of cryopreservation, patient age and embryo quality on pregnancy and live birth rates. In the study group, 673 embryos were frozen for 24-108 months and of these 451 were thawed. In the control group, 513 embryos were cryopreserved for up to 6 months and 456 were thawed. The implantation rate was similar (4.5% vs. 5.5%) in both groups. We concluded that the duration of cryopreservation did not adversely affect embryo survival, and prolonged cryopreservation appeared to be a safe treatment option.

Studies on sperm chromosomes in patients with severe male factor infertility undergoing assisted reproductive technology treatment

The aim of the study was to determine the rate of chromosome abnormalities in testicular sperm after intracytoplasmic sperm injection due to severe male factor infertility. The study groups included patient with non-obstructive azoospermia (n=9), obstructive azoospermia (n=10), Klinefelter's syndrome (n=5) and normal controls (n=6, groups I-VI, respectively). The mean serum levels of FSH 17.5+/-8.2 (P<0.05), 3.5+/-2.6, 29.8+/-13.0 (P<0.05) and 3.1+/-0.4 mIU/ml, respectively. The rates of chromosome abnormalities were 19.6% (P<0.001), 8.2% (P<0.001), 6.3 and 1.6%, respectively. Chromosomes X and Y were significantly more involved in the aneuploidy than chromosome 18 in groups I and II. The present findings demonstrate a linkage between gonadal failure (high serum FSH levels) and sperm chromosome abnormalities. Our findings may explain the increased incidence of perinatal sex chromosome abnormalities found in severe male factor patients. Patients with non-mosaic Klinefelter's syndrome have comparable risk for sex chromosomes aneuploidy as the rest of the patients with azoospermia. Therefore, genetic screening during pregnancy or before embryo replacement should be carefully considered in severe male factor patient following in vitro fertilization (IVF).

In vitro fertilization following natural cycles in poor responders

This prospective study was designed to examine the feasibility of natural cycle in vitro fertilization (IVF) in poor responders, and the clinical factors that may predict successful outcome. Twenty-two poor responders underwent IVF treatment with 44 unstimulated cycles. The results of the natural cycles were compared with those of the 55 low-response stimulated cycles of these patients during the 12 months prior to the study. Eighteen (82%) patients had at least one oocyte retrieved, while nine (41%) had at least one cycle with embryo transfer. Two (9%) patients each gave birth to a healthy term baby. These results are comparable with those of the stimulated cycles. Serum early follicular follicle stimulating hormone (FSH) level was found to be the only reliable predictor of oocyte recovery and overall outcome in each specific natural cycle. However, because of great variability in basal FSH levels among different cycles of the same patient, this is not a reliable predictor of outcome in future cycles. We conclude that poor responders are a unique group of patients who may benefit from natural-cycle IVF treatment.

Sperm chromosome abnormalities in men with severe male factor infertility who are undergoing in vitro fertilization with intracytoplasmic sperm injection

OBJECTIVE

To investigate the potential paternal contribution to the risk of fetal chromosomal anomalies after intracytoplasmic sperm injection (ICSI).

DESIGN

Spermatozoa isolated from testicular tissue and ejaculated specimens of consenting patients undergoing testicular biopsy and ICSI were analyzed for chromosomes X, Y, and 18 by FISH.

SETTING

Assisted reproductive technology program.

PATIENT(S)

Consenting patients undergoing testicular biopsy and ICSI, severe oligozoospermic patients, and normal fertile donors.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The rate of chromosome abnormalities in testicular sperm with regard to the type of azoospermia and ejaculated sperm compared to healthy men.

RESULT(S)

The mean serum levels of FSH in the groups with nonobstructive azoospermia (n = 9), obstructive azoospermia (n = 10), severe oligozoospermia (n = 9), and the normal donors (n = 6) were 17.5 +/- 8.2 (P<.05), 3.5 +/- 2.6, 14.6 +/- 3.5 (P<.05), and 3.1 +/- 0.4 IU/mL, respectively. The corresponding rates of sperm chromosome abnormalities among these groups were 19.6% (P<.001), 8.2% (P<.001), 13.0% (P<.001), and 1.6%, respectively. The corresponding rates of disomy among these groups were 7.8% (12 of 153 spermatozoa), 4.9% (18 of 367), 6.2% (109 of 1,751), and 1% (5 of 500 spermatozoa), respectively. Errors in chromosomes X and Y were significantly more common than in chromosome 18.

CONCLUSION(S)

The present findings demonstrate a linkage between gonadal failure (high serum FSH levels) and the occurrence of sperm chromosome aneuploidies. Our findings may explain the increased incidence of sex chromosome abnormalities found after IVF in the severe male factor patient population. Genetic screening during pregnancy or before embryo replacement should be considered carefully.

Sperm chromosome analysis and outcome of IVF in patients with non-mosaic Klinefelter's syndrome

OBJECTIVE

The aim of the study was to determine the potential risk for fetal chromosomal anomalies in non-mosaic Klinefelter's syndrome patients undergoing IVF and intracytoplasmic sperm injection.

DESIGN

Individually collected spermatozoa were isolated from wet testicular tissue preparations and fixed on glass slides using micromanipulation. Their nuclei were analyzed for chromosomes X, Y, and 18 by fluorescent in situ hybridization.

SETTING

Assisted reproductive technology program.

PATIENT(S)

Consenting patients with non-mosaic Klinefelter's syndrome undergoing testicular biopsy and IVF (fresh specimens) or following such treatment (cryopreserved specimens).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The rates of numerical chromosome abnormalities for chromosomes X, Y, and 18 among spare testicular sperm and the pregnancy outcome following treatment.

RESULT(S)

Testicular sperm were found in 8 of 20 patients. Four couples became pregnant following embryo replacement. Sperm chromosomes were analyzed in five patients. One hundred and five sperm of 112 analyzed (93.7%) were normal with X to Y ratio of 50:55 (NS) respectively. Among the 112 sperm tested, seven (6.3%) demonstrated chromosomal abnormalities, of which five were related to the sex chromosomes and two to chromosome 18. One set of triplets, one set of twins, and two singletons (four males and three females) with normal karyotypes were born.

CONCLUSION(S)

Most of the testicular sperm retrieved from Klinefelter's syndrome patients demonstrates a normal pattern of sex chromosome segregation. Therefore, the risk of transmitting numerical sex chromosome abnormalities is relatively low and probably comparable with the rates found in other severe male factor infertility patient groups.

Incidence and perinatal outcome of multiple pregnancies after intracytoplasmic sperm injection compared to standard in vitro fertilization

PURPOSE

Our purpose was to assess the incidence of multiple pregnancies and their obstetric outcome after intracytoplasmic sperm injection.

METHODS

The study group comprised women who delivered twins or triplets after intracytoplasmic sperm injection and standard in vitro fertilization. The incidence and main perinatal outcome of 140 multiple pregnancies resulting from intracytoplasmic sperm injection or standard in vitro fertilization treatment were analyzed.

RESULTS

A total of 60 multiple pregnancies was obtained after intracytoplasmic sperm injection (3.4 +/- 1.1 embryos/cycle) and 80 after standard in vitro fertilization (3.3 +/- 2.0 embryos/cycle). The incidence of multiple pregnancy, i.e., 22.6 compared to 20.7%, respectively, was calculated. The obstetric outcome of 47 multiple pregnancies after intracytoplasmic sperm injection was 39 twin deliveries at between 27 and 37 weeks of gestation (mean, 36 +/- 3.3) and 8 successful triplet deliveries between 26 and 36 weeks of gestation (mean 32.6 +/- 2.4). The outcome after regular in vitro fertilization was similar. No major malformations were observed.

CONCLUSIONS

The results of this study showed that the incidence of multiple pregnancies after intracytoplasmic sperm injection was similar to that after standard, conventional in vitro fertilization. The perinatal outcome did not differ between both groups.

In-vitro fertilization treatment for severe male factor: the fertilization potential of immotile spermatozoa obtained by testicular extraction

A retrospective analysis in 50 couples of 53 cycles of intracytoplasmic sperm injection (ICSI) with immotile spermatozoa from testicular-retrieved spermatozoa was performed to evaluate whether total immotile spermatozoa achieved after testicular sperm extraction could fertilize ova and result in pregnancies. We assessed the efficacy of ICSI with totally immotile testicular spermatozoa extracted from the testes of azoospermic patients with severe spermatogenic failure (group 1) and compared these results with those from spermatozoa which were recovered after several hours of incubation and were motile (group 2) at the time of injection. In 19 cycles, only totally immotile spermatozoa were injected at the time of ICSI. For the remaining 34 cycles, at least one motile spermatozoon was found for injection. The oocyte fertilization rates were 51% for group 1 and 62% for group 2 (P < 0.02). Eighteen of 19 cycles in group 1 (90%) and all 34 (100%) cycles in group 2 had embryos for replacement. The mean number of embryos per cycle was 5.2 +/- 0.8 and 7.5 +/- 0.9 in groups 1 and 2 respectively; this and the embryo quality (cumulative embryo scoring = 40 +/- 8 for group 1 and 50 +/- 7 for group 2), and clinical pregnancy rates (15.8% per oocyte retrieval in group 1 and 23.5% in group 2) were not significantly different between groups. Fertilization, cleavage and pregnancy can be achieved with intracytoplasmic testicular sperm injection from patients with immotile spermatozoa, at levels comparable with those of ICSI using motile spermatozoa.

Testicular sperm aspiration and intracytoplasmic sperm injection for persistent infection of the ejaculate

OBJECTIVE

To report the successful use of testicular sperm aspiration and intracytoplasmic sperm injection in the presence of an Escherichia coli-infected ejaculate that previously caused repeated embryo degeneration.

DESIGN

Case report.

SETTING

University medical center.

PATIENT(S)

A 38-year-old woman who did not conceive for 6 years with repeated IVF attempts. Escherichia coli was isolated from both the oocyte culture dish and her male partner's ejaculate.

INTERVENTION(S)

Testicular sperm aspiration and intracytoplasmic sperm injection followed by ET.

MAIN OUTCOME MEASURE(S)

Clinical outcome.

RESULT(S)

Establishment of a pregnancy delivered at term.

CONCLUSION(S)

Patients undergoing IVF treatment who have repeated embryo degeneration caused by bacterial infection originating in the ejaculate may be treated successfully with testicular sperm aspiration and intracytoplasmic sperm injection.

Rapid visualization of metaphase chromosomes in single human blastomeres after fusion with in-vitro matured bovine eggs

The present study was aimed to facilitate karyotyping of human blastomeres using the metaphase-inducing factors present in unfertilized eggs. A rapid technique for karyotyping would have wide application in the field of preimplantation genetic diagnosis. When cryopreserved in-vitro matured bovine oocytes were fused with human blastomeres, the transferred human nuclei were forced into metaphase within a few hours. Eighty-seven human blastomeres from abnormal or arrested embryos were fused with bovine oocytes in a preclinical study. Fusion efficiency was 100%. In 21 of the hybrid cells, no trace of human chromatin was found. Of the remaining 66, 64 (97%) yielded chromosomes suitable for analysis. The method was used to karyotype embryos from two patients with maternal translocations. One embryo which was judged to be karyotypically normal was replaced in the first patient, resulting in one pregnancy with a normal fetus. None of the second patient's embryos was diagnosed as normal, and hence none was transferred. The results of the present study demonstrated that the ooplasmic factors which induce and maintain metaphase in bovine oocytes can force transferred human blastomere nuclei into premature metaphase, providing the basis for a rapid method of karyotyping blastomeres from preimplantation embryos and, by implication, cells from other sources.

Cryopreservation of activated mouse oocytes and zygote reconstitution after thaw

A new approach to cryopreservation of unfertilized oocytes is proposed using techniques of artificial egg activation combined with nuclear transplantation. Matured mouse oocytes were released from metaphase II arrest by brief exposure to alcohol, allowed to progress to the pronuclear stage and then frozen according to a standard freezing protocol in propandiol. After thaw the female pronuclei were enucleated and fused with a male karyoplasts that were divided from in-vivo fertilized zygotes. Reconstituted zygotes, fresh and cryopreserved culture control zygotes were cultured to the blastocyst stage and transferred to pseudopregnant recipients. The rate of blastocyst formation was 75.8, 91.6 and 44.1% respectively. A total of 110, 215 and 70 blastocysts were transferred to pseudopregnant females respectively. The implantation rates were 36.4, 72.0 and 75.7% while the rates of fetal viability at mid-gestation were 15.5 (P < 0.0001), 51.1 and 37.1% respectively.

Difficult or repeated sequential embryo transfers do not adversely affect in-vitro fertilization pregnancy rates or outcome

In order to assist the medical team in the decision-making process and in adequate counselling of patients when encountering technical difficulties at the time of embryo transfer, we investigated the effect of difficult embryo transfer, with or without the need for cervical dilatation or repeated sequential attempts because of retained embryos in the catheter system, on in-vitro fertilization (IVF) pregnancy rates and outcome. A total of 854 consecutive embryo transfer procedures were prospectively categorized as (i) easy (smooth, unforced), (ii) difficult (requiring uterine manipulation or increased force or cervical grasping and/or accompanied by trauma), (iii) requiring cervical dilatation, or (iv) multiple (two or three) sequential attempts because of embryos retained in the catheter system. Embryo transfer was easy in 734 cases (85.9%). It was difficult in 72 (8.4%), cervical dilatation was required in 21 (2.5%), and one or two repeated attempts were needed in 27 cases (3.2%). Pregnancy rates for the different categories of embryo transfer were 23.3, 23.6, 23.8 and 29.6% respectively. There were no significant differences in the percentage of the ongoing/delivered pregnancies for the different categories of embryo transfer (69, 64.6, 60 and 62.5% respectively). There were no significant differences in the distribution of embryo transfer types among the six infertility specialists who performed the procedures. To conclude, embryo transfers that are difficult to perform or that require cervical dilatation or repeated attempts do not adversely affect pregnancy rates and outcome following IVF. Cervical dilatation, if needed for patients with cervical stenosis, should be performed at the time of the embryo transfer and not earlier. Surgical transmyometrial embryo transfer or rescheduling patients for delayed embryo transfer could be avoided in most patients. This information is important for patient management and counselling in cases of embryo transfer that are not easy to perform.

In vitro fertilization treatment for severe male factor: a comparative study of intracytoplasmic sperm injection with testicular sperm extraction and with spermatozoa from ejaculate

PURPOSE

Our purpose was to evaluate whether the source of spermatozoa influences the results of intracytoplasmic sperm injection (ICSI) treatment in couples with severe male-factor infertility.

METHODS

A retrospective analysis of 40 cases of ICSI with testicular-retrieved spermatozoa, matched with 40 cases of ICSI with ejaculated spermatozoa, was performed. We included only couples with normoovulatory females younger than 37 years who were matched according to the day of ovum pickup with the patients in the study group.

RESULTS

Eighty cycles were analyzed: 40 cycles using testicular spermatozoa and 40 cycles using ejaculated spermatozoa. In 32 (80%) of the 40 ICSI transcutaneous needle aspiration cycles, we obtained enough spermatozoa to inject all the mature oocytes retrieved. In eight (20%) cases there were not enough spermatozoa to inject all the oocytes. Only 76 (54%) of 141 available oocytes were injected in these eight patients. The oocyte fertilization rates were 42% for the study group and 55.5% for the controls (P < 0.005). Thirty-six (90%) patients in the group with nonobstructive a zoospermia (NOA) and 37 (92.5%) patients in the oligoteratoasthenospermia (OTA) group had embryos for replacement. The mean cleavage rates per cycle (96% with testicular and 93% with ejaculated spermatozoa), the mean number of embryos per transfer (3.72 +/- 1.6 in the NOA group and 4.24 +/- 1.5 in the OTA group), the embryo quality (cumulative embryo scoring = 34.03 +/- 22.62 in the testicular sperm group and 36.08 +/- 19.28 in the ejaculated sperm group), and the clinical pregnancy rates (22.5% in the NOA patients and 20% in the ejaculate group) were not significantly different between groups.

CONCLUSIONS

High fertilization, cleavage, and pregnancy rates can be achieved with intracytoplasmic testicular sperm injection from patients with NOA, reaching levels comparable with those of ICSI using ejaculated spermatozoa.

Outcome of in vitro fertilization and intracytoplasmic injection of epididymal and testicular sperm extracted from patients with obstructive and nonobstructive azoospermia

OBJECTIVE

To evaluate IVF outcome after epididymal and testicular sperm retrieval in patients with obstructive or nonobstructive azoospermia.

DESIGN

Retrospective clinical analysis.

SETTING

Public university-affiliated IVF unit.

PATIENT(S)

One hundred twenty-three azoospermic patients (178 cycles).

INTERVENTION(S)

Sixty-three patients (103 cycles) with obstructive azoospermia (group 1) underwent either epididymal or testicular sperm retrieval, and 60 patients (75 cycles) with nonobstructive azoospermia (group 2) underwent testicular sperm retrieval combined with IVF treatment. Mature oocytes were fertilized using intracytoplasmic sperm injection. After sperm preparation, supernumerary spermatozoa were cryopreserved.

MAIN OUTCOME MEASURE(S)

Oocyte fertilization rate and clinical pregnancy rate (PR).

RESULT(S)

The oocyte fertilization rate was 48.4% (534/1,104) in group 1 and 41.5% (312/751) in group 2 (not significant [NS] difference). A total of 100 cycles (97.1%) and 62 cycles (82.7%) in the obstructive and nonobstructive groups, respectively, had embryos for replacement (NS difference). The clinical PRs per ET cycle were 24% (24/100) and 17.7% (11/62) in the two groups, respectively. Oocyte fertilization rates, when fresh (46.4%) or frozen-thawed (41.8%) spermatozoa were used, were not significantly different in the two groups. The PR when fresh sperm were used was 23.6% (30/127), versus 14.3% (5/35) when frozen sperm were used (NS difference). The PR for women aged < or = 35 years was similar to that for women >35 years of age (20.7% or 29/140 and 18.2% or 4/25, respectively).

CONCLUSION(S)

Epididymal and testicular sperm obtained in azoospermic patients can fertilize oocytes successfully and may lead to high fertilization rates and PRs. Freezing of these spermatozoa does not reduce the outcome of treatment significantly.

Ooplasmic transfer in mature human oocytes

Ooplasmic transplantation aimed at restoring normal growth in developmentally compromised oocytes and embryos was evaluated in seven couples (eight cycles) with multiple implantation failures. Two approaches were investigated to transfer ooplasm from donor eggs at metaphase II (MII) stage into patient MII eggs: (i) electrofusion of a ooplasmic donor fragment into each patient egg (three cycles), and (ii) direct injection of a small amount of ooplasm from a donor egg into each patient egg (five cycles). Some donor eggs were used multiple times. Donor eggs were divided into two groups, one being used for ooplasmic extraction and the other one for egg donation. Cleaved embryos resulting from the latter were cryopreserved, where numbers and satisfactory development permitted. A second control group consisted of embryos derived from patient eggs after intracytoplasmic sperm injection without ooplasmic transfer. This was performed when sufficient number of eggs were available (n = 5). Donor eggs (n = 40) were evaluated cytogenetically after micromanipulation in order to confirm the presence of chromosomes. One egg was anuclear and the recipient embryos were not transferred. Normal fertilization was significantly higher after injection of ooplasm (63%) in comparison with fusion (23%). Pronuclear anomalies appeared enhanced after fusion with ooplasts. Embryo morphology was not improved in the three cycles with electrofusion and patients did not become pregnant. An improvement in embryo morphology was noted in two patients after injection of ooplasm and both became pregnant, but one miscarried. A third pregnancy was established in the repeat patient, without obvious embryo improvement. One baby was born and the third pregnancy is ongoing with a normal karyotype. Two other patients with male factor infertility had poor embryos after ooplasmic injection, but the donor embryo controls were also poor. The patients did not become pregnant and had no donor embryos frozen. Ooplasmic transfer at the MII stage may be promising in patients with compromised embryos; however, evaluation of ooplasmic anomalies and optimization of techniques will require further investigation prior to widescale application.

Cortisol concentrations in follicular fluid of 'low responder' patients

The study was undertaken to examine any differences existing in total cortisol concentrations in the follicular fluid (FF) of pre-ruptured follicles between 'low responder' patients (group 1, n = 20) and 'good responder' patients (group 2, n = 15). The groups were defined according to how many oocytes had been retrieved during the previous in-vitro fertilization procedure (group 1: three or fewer; group 2: more than three) and total oestradiol concentration at previous in-vitro fertilization (IVF) (group 1: < or = 500 pg/ml; group 2: > 500 pg/ml). All patients were aged 36-43 years (group 1 mean +/- SD: 38.2 +/- 4.7; group 2: 32.1 +/- 3.8 years) and were diagnosed with tubal or unexplained infertility. The total FF cortisol concentrations obtained in conjunction with an IVF procedure were assayed and related to oocyte fertilization. Follicular fluid was analysed for total cortisol content. Only follicles between 19 and 20 mm diameter were analysed in both groups. After aspiration of blood-free FF, total cortisol concentrations were measured by radioimmunoassay, designed for the quantitative measurement of cortisol, and related to oocyte fertilization. Total cortisol concentration in FF from fertilized oocytes was 9.7 +/- 0.6 microg/ml (mean +/- SD) in group 1 compared to 9.2 +/- 4.4 microg/ml in group 2 (not statistically significant). Total cortisol concentrations were not associated with oocyte fertilization and no difference between the groups was found in total cortisol concentrations in the FF of unfertilized oocytes or empty follicles.

Zygote intrafallopian transfer may improve pregnancy rate in patients with repeated failure of implantation

OBJECTIVE

To evaluate the efficacy of zygote intrafallopian transfer (ZIFT) on implantation rates and pregnancy rates (PRs) in patients with repeated failure of implantation in IVF-ET cycles.

DESIGN

A case-control study.

PATIENT(S)

Criteria for patient selection included male factor or unexplained infertility, normal uterine cavity, and at least three failures of implantation in IVF-ET cycles in which at least three embryos were placed per transfer. Data on 70 patients who underwent 92 ZIFT cycles are presented. A control group consisted of patients with the same selection criteria who underwent an additional standard IVF-ET cycle during the same time period.

INTERVENTION(S)

Ovulation induction consisted of down-regulation with GnRH analogue followed by ovarian stimulation with FSH and hMG. Intracytoplasmic sperm injection was performed on the oocytes of all patients with male factor infertility. Zygotes were transferred by laparoscopy into the fallopian tube 24-26 hours after oocyte retrieval.

MAIN OUTCOME MEASURE(S)

Implantation rates and PRs in the ZIFT and control groups were compared.

RESULT(S)

The PRs and implantation rates were significantly higher in the ZIFT group than in the control group: 34.2% (24/70) and 8.7% (29/333) versus 17.1% (12/70) and 4.4% (13/289), respectively (P = 0.002 and P = 0.04). The cumulative conception rate for two ZIFT cycles was 59.3%.

CONCLUSION(S)

Zygote intrafallopian transfer should be considered a beneficial mode of treatment for patients with repeated failure of implantation in IVF and transcervical ET. More prospective randomized studies are needed to support this observation.

Concurrent use of flow cytometry and fluorescence in-situ hybridization techniques for detecting faulty meiosis in a human sperm sample

Routine semen analysis in an infertile patient revealed severe teratospermia associated with malformation of head and tail in 100% of the sperm cells. Flow cytometry and fluorescence in-situ hybridization (FISH) were shown to supplement routine semen analysis by providing information on the sperm chromatin. Using flow cytometry, propidium iodide-stained spermatozoa from the same sperm sample were compared with a normal reference pool, and with human lymphocytes. The results point to a population of diploid sperm cells rather than to mature haploid spermatozoa. Numerical chromosomal abnormalities of the spermatozoa were subsequently evaluated using FISH. A total of 1000 sperm cells were scored for X and Y chromosomes, and an additional 1128 sperm cells for chromosome 18. Aneuploidy of chromosomes X and Y was revealed in 96.9% of the cells and of chromosome 18 in 90.3% of the cells. Non-disjunction of chromosome X and Y in meiosis I and II occurred in 54.8 and 2.7% of the sperm cells respectively. Non-disjunction in both meiosis I and II occurred in 39.4% of the sperm cells. A normal haploid pattern for chromosomes X and Y was observed in only 3.1%, and for chromosome 18 in 9.7%, of the cells. Using three colour FISH for the sex chromosomes and for chromosome 18, diploidy was demonstrated in 19.4% of 500 sperm cells and aneuploidy in virtually all sperm cells (99.2%). The use of flow cytometry and FISH in cases where genetic and developmental chromatin abnormalities are suspected is a valuable adjunct to other available techniques, and can guide the clinicians to decide which samples are unsuitable for intracytoplasmic injection.

Gonadotropins and glucocorticoid therapy for "low responders"--a controlled study

PURPOSE

A randomized, nonplacebo controlled study was conducted to determine the effect of dexamethasone supplementation to a protocol of gonadotropin therapy in 42 "low-responder patients" aged 32 to 43 years.

METHODS

All underwent at least two previous cycles treated by gonadotropins for unexplained infertility, or anovulation. Human menopausal gonadotropin was started on day 4 of the menstrual cycle combined with dexamethasone 0.5 mg administered nightly, as an adjuvant. A group of "low responders" who did not receive dexamethasone served as the controls. The number of follicles, total amount of gonadotropins used, time required for stimulation, fertilization, peak estradiol levels and pregnancy rate were evaluated.

RESULTS

The number of developing follicles, estradiol levels, fertilization rate and pregnancy rate did not differ significantly.

CONCLUSIONS

Although certain beneficial effects were observed in the literature in some of the infertile patients treated with corticosteroids, the overall results did not support daily, low-dose dexamethasone (long-acting corticosteroid) as a clinically useful adjuvant therapy for "low responders" during gonadotropin therapy.

The development of mouse zygotes after fusion with synchronous and asynchronous cytoplasm

Cytoplasts with diameters of 40-45, 50-55 and 70-75 microm, derived from mouse oocytes at the germinal vesicle, metaphase II and zygote stages were incorporated into zygotes by electrofusion. Manipulated (n = 867) and culture-control (n = 1114) embryos were cultured in vitro and transferred to pseudo-pregnant recipients at the blastocyst stage. When synchronous cytoplasts measuring 40-45 and 50-55 microm in diameter were incorporated into 138 and 86 zygotes respectively, only one embryo in each group (not significant) became arrested at the 1-cell stage. A total of 124 (89.9 compared with 91. 6% for controls) and 69 embryos (80%, P < 0.001 compared with 91.6% for controls) reached the blastocyst stage respectively. In the first group, 66 out of 106 blastocysts implanted (62.2 compared with 54.9% for controls; not significant), however, only 24 (22.6 compared with 40.2% for controls, P < 0.001) were viable in comparison with controls. There were four groups of zygotes that received metaphase II cytoplasts. In the first group, 200 zygotes were fused with 40-45 microm cytoplasts. The second group of 145 zygotes were fused with cytoplasts of the same size derived from aged oocytes. In the third and fourth groups, 38 and 36 zygotes were fused with 50-55 and 70-75 microm cytoplasts respectively. In the first two groups, none of the embryos arrested at the 1-cell stage, but in the other groups the rates were 15 out of 38 (39.5%) and 36 out of 36 (100%) respectively. These zygotes remained arrested at the pronuclear stage and contained large inflated pronuclei. The blastocyst formation rates were 183 out of 200 (91.5 compared with 91.6% for controls, not significant), 109 out of 145 (75.2% lower than controls, P < 0.05) and 14 out of 38 (39.5% lower than controls, P < 0.0001) respectively. In the first two groups 109 and 25 blastocysts were transferred, of which 76 (69.7%) and 15 (60.0%) implanted. This was higher than control embryos (54.9%, P < 0.01) for the first group and similar to controls for the second group. In the first group, 60 embryos (55%) were viable on day 10 of transfer in comparison with controls (40.2%, P < 0.05) while in the second group, 11 embryos (44.0%, not significant) were viable on day 10 of transfer. Zygotes that received germinal vesicle stage cytoplasts developed poorly and the implantation rate was significantly reduced. The present study confirms the importance of the ooplasmic domain in meiotic maturation and preimplantation development. Our results suggest that implantation may be enhanced by transfer of a small amount of metaphase II cytoplasm to the mouse embryo during the 1-cell stage; however, fusion of intact zygotes with cytoplasts > 45 microm appeared largely detrimental. The mechanisms responsible for these changes are yet unknown.

Formation of male pronuclei in partitioned human oocytes

Ninety-five metaphase II human oocytes, aged in vitro for either one day or for two days, and five fresh immature oocytes with no visible germinal vesicle nucleus were partitioned into small cytoplasts after removal of the zona pellucida and exposure to cytochalasin B. Seventy-one metaphase II and four immature oocytes were used as intact zona-free controls. The cytoplasts derived from each partitioned oocyte and all the zona-free whole oocytes were exposed to normal or subfertile donor sperm and later assessed for signs of male pronucleus development. A total of 711 fragments (an average of 8 fragments per partitioned egg) with a mean diameter of about 50 microns were produced from the 100 partitioned oocytes. When exposed to normal sperm, 76% of the 1-day-old metaphase II fragments, 67% of the 2-day-old metaphase II fragments, and 83% of the immature oocyte fragments were fertilized. The mean number of decondensing nuclei per partitioned oocyte was 11.9 for the 1-day-old metaphase II oocytes, 6.4 for the 2-day-old metaphase II oocytes, and 13 for the immature oocytes. The mean number of decondensing nuclei per a whole zona-free oocyte was 5.6 for the 1-day-old metaphase II oocytes (p < 0.05), 6.7 for the 2-day-old metaphase II oocytes (NS), and 13 for the immature oocytes. When exposed to subfertile sperm, 54% of the 1-day-old metaphase II fragments and 28% of the 2-day-old metaphase II fragments were fertilized.(ABSTRACT TRUNCATED AT 250 WORDS)

Highly effective method of human oocyte activation

Fresh and aged unfertilised human oocytes were activated by electroporation and by exposure to isotonic solution of mannitol supplemented with low concentrations of calcium, magnesium and chloride. Over 95% of the fresh oocytes were activated, all showing formation of one pronucleus and extrusion of the second polar body. Oocytes activated 1 and 2 days post-collection showed activation rates of 66.6% and 64.1%, respectively; however, the proportion of one-pronucleate oocytes in these groups was significantly lower (61.6% and 23.5%, respectively). There was no difference in the activation efficiency between the two activation modes. Twelve activated oocytes from the freshly collected group cleaved when left in culture. It is concluded that, in the human, a brief exposure to isotonic solution of mannitol with low concentrations of calcium, magnesium and chloride is a very effective activation stimulus.

Male and female genomes associated in a single pronucleus in human zygotes

The ploidy of single-pronucleated human zygotes obtained after conventional in vitro fertilization was determined by fluorescent in situ hybridization (FISH) using multiple simultaneous probes for gonosomes and autosomes. After zona removal the single-pronucleated zygotes were exposed to cytochalasin B, and the pronucleus, surrounded by scant cytoplasm and the plasma membrane (karyoplast), was divided from the rest of the egg (cytoplast). The karyoplasts and the corresponding cytoplasts were analyzed separately by FISH. Of the 16 zygotes analyzed, 10 had haploid pronuclei and 6 were diploid. Four diploid pronuclei contained XY chromosomes, and 2 contained XX chromosomes. These results suggest that during the course of their interaction, human gamete nuclei can associate together and form diploid, single-pronucleated zygotes. These findings confirm a newly recognized variation of human pronuclear interaction during syngamy.

Estradiol- and progesterone-related increases in the renin-aldosterone system: studies during ovarian stimulation and early pregnancy

To investigate the degree to which endogenous increases in estradiol (E2) and progesterone (P4) are associated with changes in the renin system, we studied eight patients undergoing ovarian stimulation for in vitro fertilization (FSH/human menopausal gonadotropin or clomiphene citrate for 5-11 days, followed by hCG). Three conceived and were followed for up to 62 days after hCG treatment. The others were followed until the end of the luteal phase. During the follicular phase, E2 increased 10-fold, PRA increased 2-fold, and absolute levels of E2 and P4 were positively correlated (r = 0.63; P < 0.05). After ovulation, which was induced by hCG, E2 fell by 50% (day 7), but there was a 50-fold increase in P4 and a further 5-fold increase in PRA. By day 14, E2 increased again in the women who conceived, to levels even higher than those in the follicular phase, and both P4 and PRA increased 2- to 3-fold between days 7 and 14. In contrast, E2, P4, and PRA returned toward baseline levels in the nonpregnant women. On day 21, E2, P4, and PRA remained very high in the pregnant women [E2, 2297 +/- 255 pg/mL (8430 pmol/L); P4, 103 +/- 22 pg/mL (328 pmol/L); PRA, 33 +/- 8 ng/mL.h (9.17 ng/L.s)]. During the luteal phase and early pregnancy, there was a positive relationship between PRA and P4 (r = 0.68; P < 0.05). There was also a positive relationship between PRA and E2 (r = 0.54; P < 0.05); compared to the follicular phase level, PRA was 4-fold higher in the luteal phase at any E2 level. Like renin, urinary aldosterone excretion (UA) increased 5-fold during the luteal phase (day 7) and by a further 3-fold between days 7 and 21 in the pregnant women, reaching very high levels [135 +/- 28 micrograms/day (375 nmol/day); n = 3]. PRA and UA positively correlated (r = 0.59; P < 0.08). Plasma angiotensinogen increased from 2146 +/- 283 ng angiotensin-I/mL (n = 8) to 3682 +/- 607 (n = 8) on day 7 and to 5353 +/- 799 (n = 3) on day 21. Urinary sodium excretion did not fall, and urinary potassium did not increase in coordination with the changes in renin and aldosterone. There was no hypokalemia. These results demonstrate marked increases in plasma renin and UA in coordination with increases in plasma E2 and P4 during ovarian stimulation and early pregnancy, and coordinated falls during luteolysis.(ABSTRACT TRUNCATED AT 400 WORDS)

Use of gonadotropin-releasing hormone agonist to cause ovulation and prevent the ovarian hyperstimulation syndrome

The physiologic basis and clinical applications of the use of GnRHa, rather than hCG, to induce the final stage of oocyte maturation and ovulation in gonadotropin-treated cycles were reviewed. A single mid-cycle dose of GnRHa is able to trigger a preovulatory LH/FSH surge, leading to oocyte maturation and pregnancy in women undergoing ovarian stimulation for IVF/ET or induction of ovulation in vivo. The limited information currently available suggests there are similar pregnancy rates in patients treated with either GnRHa or hCG. The potential clinical advantages of GnRHa over hCG in gonadotropin-treated cycles include 1) the ability to titrate the amplitude and duration of the LH surge, 2) better control of luteal steroid hormone levels, 3) a higher implantation rate, 4) a lower rate of multiple pregnancy, and 5) a reduced risk of OHS. To date, the GnRHa regimen has been effective in preventing OHS in patients at high risk for having this complication.

The natural history of multiple pregnancies after assisted reproduction: is spontaneous fetal demise a clinically significant phenomenon?

OBJECTIVE

To determine the rate of spontaneous fetal demise after heartbeats are demonstrated in multiple pregnancies conceived after IVF-ET.

DESIGN

Retrospective case series.

SETTING

University-based IVF-ET program.

PATIENTS

Eighty-one patients in whom initial transvaginal ultrasound (US) study, performed at 5 to 6 weeks of gestation, identified more than one gestational sac. Total number of sacs was 191.

INTERVENTION

Patients were followed by serial US examinations.

MAIN OUTCOME MEASURE

Outcome of pregnancies.

RESULTS

Twenty-four empty gestational sacs were identified in 21 patients, of whom 15 delivered, 2 miscarried, and 4 are currently ongoing beyond first trimester. Of the 167 initially viable embryos, 9 (5%) underwent spontaneous fetal demise. In 5 of these 9 pregnancies, initial US identified significant interfetal size variation.

CONCLUSIONS

The rate of spontaneous fetal demise for a specific embryo in multiple gestation, after fetal heartbeats have been identified in early pregnancy, is 5%. This rate is similar to that seen in spontaneous conceptions. The chance of future fetal demise increases if first trimester interfetal size variation is significant.

Assessment of ovarian and uterine blood flow by transvaginal color Doppler in ovarian-stimulated women: correlation with the number of follicles and steroid hormone levels

OBJECTIVE

To study the changes that occur in vascular resistance to flow in the utero-ovarian circulation and their correlation with the number of follicles and steroid hormone levels in patients undergoing ovarian stimulation with gonadotropin.

DESIGN

In a prospective study, the impedance to flow in the intraovarian and uterine vessels was measured by means of transvaginal color flow Doppler imaging throughout the cycle.

SETTING

University-based IVF program.

PATIENTS

Eleven infertile patients undergoing ovarian stimulation with gonadotropin in preparation for IVF and ET.

MAIN OUTCOME MEASURES

Intraovarian, uterine, and arcuate artery blood flow velocity waveforms, follicular growth, and serum E2 and P concentrations throughout the cycle.

RESULTS

Pulsatility index (PI) of the intraovarian blood vessels and uterine artery decreased gradually during the follicular and luteal phase. The PI of the arcuate artery did not change significantly. The PI of the intraovarian blood vessels correlated with the number of follicles (> 15 mm; day of hCG). Serum E2 concentrations but not P demonstrated negative linear correlation with the PI of the intraovarian vessels and uterine artery.

CONCLUSIONS

Induced cycles are associated with decreased impedance to blood flow in the utero-ovarian circulation. Intraovarian PI correlates negatively at each stage of the cycle with the eventual number of preovulatory follicles. Little or no changes are observed when the response to ovarian stimulation is poor.

Presence of sperm in the perivitelline space predicts fertilization rate after partial zona dissection

OBJECTIVE

To examine the association of the number of spermatozoa present in the perivitelline space and sperm parameters with fertilization after partial zona dissection in male factor patients.

DESIGN

Partial zona dissection was applied in 62 couples (84 cycles). A total of 524 oocytes underwent partial zona dissection (1/8 of the zona circumference) (partial zona dissection group) and 171 sibling oocytes were not manipulated (control group). A total of 326 manipulated oocytes were examined for the presence of spermatozoa in the perivitelline space.

SETTING

University-based in vitro fertilization (IVF) program.

PATIENTS

Fifty-four (87%) couples had at least one complete failure of fertilization, and 8 (13%) couples had low fertilization rate (< 10%) in previous routine IVF attempts.

MAIN OUTCOME MEASURES

Fertilization rate, cleavage rate, and the number of spermatozoa present in the perivitelline space after partial zona dissection.

RESULTS

Monospermic and polyspermic fertilization rates were 22.3% and 6.7% in the partial zona dissection oocytes and 8.8% and 0.6% in the nonmanipulated oocytes, respectively. The cleavage rate was similar in the partial zona dissection and control group (69.2% and 66.6%, respectively). A total of 81 partial zona dissection embryos and 10 nonmanipulated embryos were transferred to the uterus of 34 women (39 cycles), resulting in four pregnancies. In 46% (18 of 39) of the patients who had both partial zona dissection and control oocytes, only the manipulated oocytes fertilized. In only 48.8% of partial zona dissection oocytes, spermatozoa were detected in the perivitelline space; in this group of oocytes the fertilization rate was 56.6%. Sperm count and morphology were not clearly correlated with the outcome of partial zona dissection.

CONCLUSIONS

The partial zona dissection technique enhances fertilization of subfertile sperm. However, the low efficiency of the procedure, apart from being associated with a high polyspermic rate, is related to the failure of sperm to traverse the slit in the zona pellucida in approximately one half of the manipulated oocytes.

No beneficial effects of human growth hormone therapy in normal ovulatory patients with a poor ovarian response to gonadotropins

We studied the effects of human growth hormone (hGH) in 7 in vitro fertilization (IVF) patients with normal ovulatory menstrual cycles who showed a low response to ovarian stimulation with follicle-stimulating hormone (FSH) and human menopausal gonadotropin (hMG). Human growth hormone therapy had no significant effect on the number of days of gonadotropic stimulation, on the total amount of hMG administered, on the serum estradiol level on the day of human chorionic gonadotropin injection, or on the IVF outcome. Our preliminary results do not encourage the routine use of hGH to improve IVF outcome in normogonadotropic ovulatory patients who respond poorly to the standard FSH/hMG protocol.

Pregnancy after subzonal insertion of cryopreserved spermatozoa from a patient with testicular seminoma

The first pregnancy established after subzonal insertion of frozen-thawed sperm obtained from a patient with seminoma and severe oligoasthenospermia is reported. A total of 800,000 sperm with a poor progressive motility were recovered after thawing. Three to seven motile spermatozoa were injected into the perivitelline space of each of 10 oocytes, and seven sibling oocytes were coincubated and inseminated with 200,000 motile sperm/mL. Only 1 of the manipulated oocytes fertilized and was transferred to the uterus 65 hours after insemination at the eight-cell stage. A healthy boy weighing 3,600 g was delivered spontaneously at 38 weeks of pregnancy. This report gives hope to patients with testicular malignancy and severely impaired sperm function to maintain their reproductive potential through sperm banking and assisted fertilization techniques.

Highest concentrations of prorenin and human chorionic gonadotropin in gestational sacs during early human pregnancy

Prorenin is not only the biosynthetic precursor of renin; under certain circumstances in vitro prorenin exhibits reversible intrinsic renin activity and can form angiotensin from renin substrate with or without cleavage of the prosequence. Prorenin is the predominant form of renin synthesized by reproductive organs (ovary, chorion laeve of the placenta, uterine decidua). Its plasma concentrations increases 10-fold throughout pregnancy to 10-100 times that of renin; amniotic fluid prorenin concentration is even higher. No data are available of gestational fluid prorenin concentrations during early pregnancy. For the first 10 weeks there are two gestational cavities; the chorionic cavity then disappears and the smaller amniotic cavity becomes predominant. In this study we measured prorenin, renin, renin substrate and hCG in fluid aspirated from gestational sacs during the first trimester of gestation (predominantly chorionic) and during the second and third trimesters (amniotic). Seventeen patients had amniocentesis during the second or third trimester. Nine patients underwent selective abortion of multiple pregnancy at 7-12 weeks gestation. One patient underwent surgery at 5 5/7 weeks (26 days after conception) for a tubal pregnancy. Second and third trimester amniotic fluid prorenin maximum velocity (Vmax) (16 and 3 sacs, respectively) averaged 6,100 +/- 1,700 (SD) and 1,930 +/- 760 ng/mL.h, respectively (i.e. 1,700 and 540 ng/L.s). In gestational fluid collected before 8 weeks, prorenin Vmax was 10-fold higher, averaging 62,500 +/- 40,000 ng/mL.h (17,000 ng/L.s). The concentration was 140,000 ng/mL.h (39,000 ng/L.s) in the 5 5/7 week tubal pregnancy. In sharp contrast, at 10-12 weeks gestation (n = 3) prorenin Vmax was only 260 +/- 114 ng/mL.h (72 ng/L.s); human CG was also highest before 8 weeks (276,500 +/- 110,900 IU/L) and lowest at 10-12 weeks (1210 +/- 540 IU/L) with intermediate levels occurring later in pregnancy. This study shows that the highest biological levels of prorenin yet detected (close to 1 micrograms protein/mL) occur in gestational sacs in early pregnancy, consistent with a role for the renin-angiotensin system in embryonic development or placentation.

Transvaginal embryo aspiration--a safe method for selective reduction in multiple pregnancies

OBJECTIVE

To evaluate pregnancy outcome after transvaginal selective embryo aspiration and to compare the results with those reported previously with other techniques for selective abortion.

DESIGN

Retrospective case series.

SETTING

University-based in vitro fertilization (IVF) program.

PATIENTS

Nineteen women with multiple pregnancy who conceived after ovulation induction or IVF/gamete intrafallopian transfer.

INTERVENTION

Transvaginal ultrasound-guided aspiration of the embryo(s) was performed at 7 to 8 weeks of gestation.

MAIN OUTCOME MEASURES

Early and late complications related to the procedure, outcome of pregnancy, and birth weight.

RESULTS

In 18 cases, the initial number of embryos (3 to 7) was reduced to two. In 1 case, the number of embryos was reduced from 4 to 3. None of the remaining fetuses vanished after the procedure. One patient delivered at 25 weeks and all other patients delivered healthy, viable infants (a pregnancy loss rate of 5.3%).

CONCLUSIONS

Transvaginal embryo aspiration in early gestation appears to be a simple and relatively safe procedure for selective termination in patients with high-order multiple pregnancy. The cumulative loss rate of selective termination procedures previously reported by others is three times higher than the loss encountered in our series. This earlier procedure may be more acceptable to patients from emotional and religious points of view.

Induction of preovulatory luteinizing hormone surge and prevention of ovarian hyperstimulation syndrome by gonadotropin-releasing hormone agonist

OBJECTIVE

To use gonadotropin-releasing hormone agonist (GnRH-a) instead of human chorionic gonadotropin (hCG) to induce oocyte maturation for in vitro fertilization (IVF).

DESIGN

Pituitary and ovarian responses to GnRH-a and the outcome of IVF were studied prospectively. Data from patients injected with hCG were analyzed retrospectively.

SETTING

Program of IVF at the Rambam (Governmental) Hospital, Haifa, Israel.

PATIENTS AND INTERVENTIONS

One or two doses of buserelin acetate 250 to 500 micrograms were administered to six patients with moderate response (Estradiol [E2], 1,494 +/- 422 [+/- SD] pg/mL) and 8 patients with exaggerated response (E2, 7,673 +/- 3,028 pg/mL) to gonadotropin stimulation. Progesterone (P) and E2 were administered for luteal support.

MAIN OUTCOME MEASURES

Gonadotropin-releasing hormone agonist effectively triggered luteinizing hormone (LH)/follicle-stimulating hormone (FSH) surge. Mature oocytes were recovered in all patients. Luteal E2 and P were lower than in patients injected with hCG. No signs of ovarian hyperstimulation syndrome were observed.

RESULTS

Serum LH and FSH rose over 4 and 12 hours, respectively, and were significantly (P less than 0.05) elevated for 24 hours. Of all mature oocytes, 67% fertilized and 82% cleaved. Four pregnancies were obtained.

CONCLUSIONS

A bolus of GnRH-a is able to trigger an adequate midcycle LH/FSH surge, resulting in oocyte maturation and pregnancy. Our preliminary results also suggest that it allows a more accurate control of ovarian steroid levels during the luteal phase and may prevent the clinical manifestation of ovarian hyperstimulation syndrome.

Human sperm and hamster oocyte interaction: a model system to assess sperm entry into the oocyte after partial zona dissection

A model system of hamster oocyte and human sperm interaction was used to assess sperm entry into the perivitelline space after partial zona dissection. The procedure of zona dissection was standardized by creating slits which included one fourth, one eighth, one eighth X 2, or one sixteenth of the zonal circumference. Manipulated eggs were allowed to interact with 1 X 10(6) sperm/mL for 3 hours. A single large or medium slit was equally effective in permitting sperm entry into 46% and 47% of the manipulated eggs, respectively. However, the longer slit doubled the average number of sperm detected in the perivitelline space. A second medium-sized slit increased the rate of sperm entry into the perivitelline space to 76%, but the incidence of damaged oocytes also increased. A small slit did not permit sperm entry into any of the manipulated oocytes. This heterologous system of gamete interaction provides a model to evaluate requirements for successful partial zona dissection or other related procedures for assisted fertilization in the human.