Sex ratio and birth weights of infants born as a result of blastocyst transfers compared with early cleavage stage embryo transfers

OBJECTIVE

To analyze the birth weights and sex ratio of infants born as a result of blastocyst transfer and compare them with data resulting from the transfer of early-cleavage stage embryos.

DESIGN

Retrospective analysis.

SETTING

Monash IVF (private in vitro fertilization clinic).

PATIENTS(S)

One hundred twenty-five infertile patients who became pregnant after IVF procedures involving blastocyst transfer.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Sex ratio and birth weights of infants born after blastocyst transfer.

RESULT(S)

The sex ratio of 129.6 for infants born after blastocyst transfer was not significantly different from the sex ratio calculated from data compiled by NPSU for births resulting from early cleavage stage embryo transfers at Monash IVF (100.6) and all other assisted conception units in Australia and New Zealand (97.9). No differences were observed in the combined mean birth weight of male and female infants born as a result of blastocyst transfers and early-cleavage stage embryo transfers.

CONCLUSION(S)

There is no evidence of abnormal fetal growth or a shift in the sex ratio for infants born as a result of blastocyst transfer when compared with the case of births resulting from early cleavage stage embryo transfers within our unit or all other assisted conception units in Australia and New Zealand.

Is the acrosome reaction a prerequisite for sperm incorporation after intra-cytoplasmic sperm injection (ICSI)?

There is debate as to whether the acrosome reaction is necessary for sperm incorporation after intra-cytoplasmic sperm injection (ICSI). Ultrastructural evidence is presented to show that the acrosome reaction could occur in the ooplasm before sperm incorporation in mature human oocytes or the acrosome could be discarded intact before sperm incorporation in immature oocytes, matured in vitro. Both germinal vesicle and growing follicular oocytes showed sperm chromatin decondensation, with discarded acrosomes close to the sites of incorporation, and were able to form male pronuclei. This is probably the first report of microfertilization of a growing oocyte with a reticulate nucleolus by ICSI. The acrosome reaction, when it occurs, is preceded by acrosome swelling and is followed by vesiculation of surface membranes exposing the inner acrosome membrane, as observed on the surface of the zona during IVF or in the perivitelline space after subzonal sperm injection. These sperm were probably capacitated at the time of ICSI. There was subtle evidence of leaching of the acrosomal matrix from intact discarded acrosomes and from partially depleted acrosomes attached to decondensing spermheads. These sperm were probably not fully capacitated at the time of ICSI. It is concluded that both the acrosome reaction and acrosome deletion are possible prerequisites to sperm incorporation after ICSI.

Oocyte maturation

Primary oocytes recovered from small and growing follicles of > or = 3 mm in the ovaries of untreated women, can be matured in vitro, will fertilize and develop in vitro, and when transferred to the patient, develop to term. However, the implantation rate of cleaved embryos has been disappointingly low and when embryos are allowed to develop beyond the 4-cell in vitro, retardation of development and blockage is frequently observed, with relatively few embryos developing to blastocysts. We have devised new culture systems for human embryos to enable high rates of development of in-vivo matured oocytes to blastocysts within 5-6 days of culture, and high implantation rates of these blastocysts when they are transferred to the patients' uterus. These culture systems are now being used for in-vitro matured oocytes. In order to determine whether embryo developmental competence could be improved, a number of factors were examined. Treatment of patients with pure follicle stimulating hormone (FSH) early in the follicular phase, or treatment with oestrogen prior to oocyte recovery, had no apparent effect on any parameters of oocyte developmental competence. There was no indication that a medium made specifically for human oocyte maturation improved oocyte developmental competence. Nuclear and cytoplasmic changes in oocytes matured in vitro appear to be similar to that in vivo, although some lack of synchronization in completing maturation is evident. It is possible that follicles of < 10 mm diameter in the human contain developmentally-incompetent oocytes. However, the development to term and birth of normal babies from germinal vesicle stage oocytes recovered from small follicles and matured in vitro, suggests that further research will identify the factors necessary to improve embryo developmental competence. The application of immature oocyte collection (IOC) and in vitro maturation (IVM) as an alternative to ovulation stimulation with high doses of gonadotrophins for in-vitro fertilization (IVF), remains a priority for research in human medicine.

Evolution of a culture protocol for successful blastocyst development and pregnancy

A cell-free culture system was designed for human embryo development to the blastocyst stage by testing a range of culture conditions in a series of protocols. The culture system that was evolved has a brief 1 h exposure to spermatozoa and then culture of the pronucleate zygote for 2 days in IVF-50 medium. Two or three embryos were cultured together in 20 microl microdrops of medium under oil. Embryos were then regrouped and two or three at a similar stage were cultured together in 50 microl microdrops of Gardner's G2 medium under oil from days 3 to 5. Embryos were transferred to fresh G2 medium on day 5 and cultured for a further 1 or 2 days (day 6 or 7). No serum was used in any of the cultures. The embryo transfer medium and G2 medium were supplemented with human serum albumin. The zonae of all blastocysts to be transferred to patients were completely removed enzymatically. Using this protocol, 52% of zygotes developed to blastocysts and 34 out of 35 patients treated received 82 blastocysts and 11 morulae on day 5 or 6. Twenty-one fetal sacs with positive heartbeats (23% implantation rate) were detected in 13 ongoing pregnancies (38% pregnancy rate/transfer or 37%/patient treated). We anticipate that further improvements in embryo development and the selection of viable embryos can be achieved using this simple and effective culture system.

Production of embryos from in vitro-matured primary human oocytes

OBJECTIVE

To determine the factors that influence the number and quality of embryos produced from primary oocytes collected from untreated regularly ovulating and irregular or anovulatory polycystic women.

DESIGN

A direct comparison between two patient groups whose oocytes were matured in vitro and a comparison of the embryo development of in vitro-matured oocytes from untreated patients with in vivo-matured oocytes of superovulated IVF-ET patients obtained during the same period.

SETTING

The Monash IVF Clinic, involving patients who expressed the desire to avoid super-ovulation with fertility drugs.

MAIN OUTCOME MEASURES

The completion of nuclear maturation of oocytes after 36 or 48 hours culture, fertilization in vitro, and embryo development ratio.

RESULTS

Oocytes from regular cycling patients matured and fertilized at significantly higher rates than irregular cycling and anovulatory women and their embryos had significantly higher mean embryo development ratio. The mean embryo development ratio of embryos of regular cycling patients was similar to superovulated IVF patients but irregular cycling and anovulatory patients had a significantly lower embryo development ratio. Culture of oocytes for 48 hours increased maturation of oocytes from 57% to 82% but did not affect fertilization or cleavage rates. Embryo development was not affected significantly by the grade of follicular cell cover of oocytes.

CONCLUSIONS

The developmental capability of primary oocytes is higher in regular cycling women than in irregular cycling and anovulatory women with polycystic ovary disease.

Blastocyst development and birth after in-vitro maturation of human primary oocytes, intracytoplasmic sperm injection and assisted hatching

Immature oocyte recovery followed by in-vitro oocyte maturation and in-vitro fertilization is a promising new technology for the treatment of human infertility. The technology is attractive to potential oocyte donors and infertile couples because of its reduced treatment intervention. Immature oocytes were recovered by ultrasound-guided transvaginal follicular aspiration. Oocytes were matured in vitro for 36-48 h followed by intracytoplasmic sperm injection (ICSI). Embryos were cultured in vitro for 3 or 5 days before replacement. Assisted hatching was performed on a day 5 blastocyst stage embryo. Embryo and uterine synchrony were potentially enhanced by luteinization of the dominant follicle at the time of immature oocyte recovery. Mature oocyte and embryo production from immature oocyte recovery were similar to the previous IVF results of the patients. A blastocyst stage embryo, produced as a result of in-vitro maturation, ICSI, in-vitro culture and assisted hatching, resulted in the birth of a healthy baby girl at 39 weeks of gestation.

In vitro maturation and the fertilization and developmental competence of oocytes recovered from untreated polycystic ovarian patients

OBJECTIVE

To determine the maturational and developmental competence of immature oocytes recovered in situ from anovulatory and ovulatory patients with polycystic ovaries (PCO).

DESIGN

A newly designed method for recovery of immature oocytes from 2 to 10 mm follicles by transvaginal ultrasound or laparoscopy was used to compare the recovery and maturation of oocytes from 9 anovulatory polycystic ovarian syndrome (PCOS) patients and 10 ovulatory patients without polycystic ovaries (PCO) (experiment 1). In a second study (experiment 2), we compared the maturation, fertilization, and development of oocytes recovered from another 10 anovulatory PCOS and 13 ovulatory PCO patients. Two types of culture methods and time intervals for maturation were also examined.

RESULTS

In experiment 1, a significantly higher number of immature oocytes were recovered from PCOS patients (15.3) compared with non-PCO patients (2.8). Sixty-five percent of oocytes cultured in medium with gonadotropins, estrogen, and fetal calf serum matured to metaphase II by 43 to 47 hours, and 81% were mature at 48 to 54 hours of culture. Thirty-four percent of the inseminated oocytes fertilized and 56% of the cultured pronuclear oocytes cleaved to eight cells or more. In experiment 2, there was no significant difference between anovulatory PCOS and ovulatory PCO patients in the number of oocytes recovered or their maturation, fertilization, and development. There was no difference between oocytes matured in medium or in coculture with mature granulosa cells, with or without added hCG. However, significantly fewer oocytes were immature and more fertilized when oocytes were inseminated after 34.5 to 35.5 hours of maturation than 29.5 to 32.5 hours of maturation. A pregnancy and the birth of a normal baby occurred in one of the anovulatory PCOS patient receiving an abbreviated steroid replacement protocol after ET.

CONCLUSION

Immature oocyte recovery could be developed as a new method for the treatment of women with infertility due to PCO because the oocytes of these patients retain their maturational and developmental competence.