Spermatid injection into human oocytes. II. Clinical application in the treatment of infertility due to non-obstructive azoospermia

We have reported recently the first birth after intrauterine transfer of embryos obtained by injection of round spermatids into oocytes in cases of unexpected azoospermia. Here we provide a complete documentation of the series of 11 cases in which this novel method of infertility treatment was employed. In four of these cases, elongated spermatids were identified in the ejaculate, and it was decided to perform elongated spermatid injection (ELSI). In the other six cases, only round spermatids were present, and round spermatid injection (ROSI) was done. In one case, ROSI was given preference to ELSI because of a very poor viability status of elongated spermatids present in the ejaculate. Fertilization of at least one oocyte was achieved in 10 of the 11 treatment cycles; the fertilization rate in these 10 cycles ranged between 7 and 100% with a mean value of 45%. All of the two-pronucleated zygotes cleaved and were transferred to the patient's uterus. A singleton pregnancy was achieved in two ROSI cycles. Both pregnancies developed uneventfully and resulted in the birth of normal infants. These data show the intra-ooplasmic injection of spermatids obtained from the ejaculate may become the treatment of first choice in patients with non-obstructive azoospermia.

Comparison of plasma and follicular fluid hormone profiles following stimulation with HMG, with or without LHRH agonists, for in-vitro fertilization

Plasma and follicular fluid (FF) hormone assays for follicle stimulating hormone (FSH), luteinizing hormone (LH), prolactin (PRL), oestradiol (E2), progesterone (P), delta-4-androstenedione (A4) and testosterone (T) were performed on the day of oocyte retrieval in two groups of normo-ovulatory women enrolled in an in-vitro fertilization (IVF) programme: 24 were treated using the decapeptyl agonists DTRP6, of luteinizing hormone-releasing hormone (LHRH) in the long protocol associated with human menopausal gonadotrophin (HMG) (49 FF) and 14 were stimulated with HMG alone (33 FF). In both FF and plasma the mean concentration of P was greater, and the E2/P ratios as well as the LH levels were lower in the agonist-treated group. In this group the follicular concentration of P was greater and the E2/P ratio lower when pregnancy occurred following IVF. The hormonal modifications may be due to greater functional maturity of the granulosa cells.

Ovarian stimulation using human menopausal gonadotrophins with or without LHRH analogues in a long protocol for in-vitro fertilization: a prospective randomized comparison

In order to evaluate the exact role of GnRH agonists, we have undertaken a randomized prospective study comparing two groups of 90 normo-ovulatory patients, aged less than 38 years and with tubal infertility with no male factor. Luteinizing hormone releasing hormone analogue (DTRP6 administered in a long protocol, for at least 15 days) was associated with human menopausal gonadotrophin (HMG) induction in group I. In group II, stimulation was performed using HMG alone (three ampoules per day in general, from days 2 to 7 of the cycle). Apart from the well known results demonstrated in the literature of a reduced incidence of inadequate responses, an absence of premature luteinization and a greater number of oocytes per retrieval (8.8 +/- 4.9 versus 6.8 +/- 3.2, P less than 0.01 in group II), this study confirms the higher pregnancy rate (21.1 versus 12.2% per cycle and 24.7 versus 17.1% per oocyte retrieval, not significant) and underlines the higher plasma progesterone levels and lower E2/P ratio in group I from D - 1 to D + 5, which could explain a better maturation of the oocytes and the endometrium.

Pregnancies following ovum donation in gonadal dysgenesis

Between February 1987 and February 1989, 13 women with primary ovarian failure due to gonadal dysgenesis were treated with embryo transfer following ovum donation in 22 cycles. Eight pregnancies were obtained (36.7% per transfer); four births of normal children, two spontaneous abortions and two other pregnancies currently ongoing (between 5 and 8 months). An association of percutaneous oestradiol, oestradiol valenate and intravaginal progesterone was used as hormone substitution and embryo transfer was only performed following assessment of the endometrium during a previous cycle. Apart from the day of embryo transfer, which was the same for all patients (the 2nd day after initiation of progesterone) various prognostic factors were analysed. These were the type of gonadal dysgenesis (45 XO, 46 XX or 46 XY), the number of embryos replaced, whether they had been frozen, whether the egg donor was anonymous and finally the influence of the hormone substitution protocol. Only the number of embryos replaced and the substitution protocol seemed to influence the implantation rate. The other parameters, and in particular the type of gonadal dysgenesis, seemed to have no effect on the results. The pregnancy rate per transfer was 30% for 45 XO (10 transfers), 25% for 46 XX (eight transfers) and 75% for 46 XY (four transfers).

Treatment of hyperstimulation during in-vitro fertilization

In 33 patients treated with a combination of an LHRH agonist (LHRH-A) and gonadotrophin in a long protocol, a biological hyperstimulation occurred (E2 greater than 2500 pg/ml on the day of HCG administration and 4722 +/- 1190 pg/ml the day after, with greater than 10 follicles greater than 12 mm on each ovary). The replacement of fresh embryos were deferred and LHRH-A was continued, and an endometrial biopsy was performed on the theoretical day of replacement (2 days after oocyte recovery). With this technique, we obtained a mean number of 17.9 +/- 7 oocytes, a fertilization rate of 49% and a replacement rate of 87% in a deferred cycles. The overall pregnancy rate of frozen-thawed embryos was 27% in the seven spontaneous cycles, 12 induced cycles and 10 artificial cycles. Only one severe hyperstimulation occurred and this case emphasizes that caution remains necessary even with this technique.

[Treatment of ovarian polycystic syndrome in vitro. Physiopathogenetic considerations]

More than 60% of patients with polycystic ovary disease (PCO) cannot conceive after repeated ovulation inductions with Clomifene citrate although there is ovulation or more frequently follicle luteinization. Because of hyperstimulation, therapy with hMG has been superseded by low doses of purified FSH with variable results according to authors. It has been even claimed that there was no benefit to replace hMG with FSH. However, on the basis of the PCO physico-pathology, namely LH hypersecretion and androgen hyperproduction, it would be rational to associate the desensitization of the pituitary with LH-RH agonist and the ovary stimulation with variable doses of hMG or purified FSH. In the series where such therapy associating LH-RH agonists with purified FSH was applied, the results concerning suppression of LH and androgen secretion, and the occurrence of pregnancy were interesting. However, the risk of hyperstimulation still occurred. Thus, the first part concerns the critical review of these results while, in the second part, our experience in in vitro fecundation will be reported.

[Evaluation criteria of the condition of the endometrium in relation to the presence of ovocytes]

18 patients with ovarian failure received cyclic steroid replacement therapy including estrogens and progesterone for embryo transfer. Hormonal results and endometrial histology are reported. The temporal window of endometrial receptivity 13 discussed, shedding some light on the respective role of embryo and endometrium in the implantation process.

[Solutions provided by the freezing of embryos and questions posed by the freezing of human ovocytes]

The major questions raised by frozen embryos are reviewed: how to freeze? which embryos to freeze? how to replace the frozen embryos? What is he contribution of frozen embryos in a program of fertilization in-vitro. The cryopreservation of human ovocytes is also discussed.

Programmed ovulation induction and oocyte retrieval for in vitro fertilization

Forty-two patients underwent programmed ovulation induction for oocyte retrieval. They were treated in the preceding cycles with a progestagen, ethynodiol diacetate, at a dose of 2 mg twice daily. Two groups were defined based upon the stimulation protocol: Group A1 was stimulated with clomiphene citrate and human menopausal gonadotropin (hMG), and Group A2 with follicle-stimulating hormone (FSH) and hMG. They were compared to two randomized control groups of patients who received the same induction but were classically monitored. There was a high proportion of spontaneous ovulations in the programmed group (8/42) compared to the nonprogrammed group (0/42). There was a nonsignificant difference in the number of oocytes obtained or embryos replaced per cycle. Four pregnancies were obtained in the programmed group (24% per transfer), against 10 in the nonprogrammed patients (32% per transfer). The results of this method seem to be better using FSH for ovulation stimulation and a verification of the serum estradiol on the day of induction with human chorionic gonadotropin (hCG) and the following day (semiprogrammed method).

Comparison between long and short protocols of LHRH agonist in the treatment of polycystic ovary disease by in-vitro fertilization

Two groups of patients with polycystic ovary disease were treated with analogues of LHRH to compare long and short protocols of pituitary desensitization. In group 1 (n = 15), decapeptyl was administered for 30 days associated with stimulation by pure FSH. In group 2 (n = 12) Buserelin was given for 15 days with the same ovarian stimulation. Patients were randomly assigned to the two groups. Six patients in each group had received treatment, for at least 4 months, to induce ovulation with clomiphene citrate or HMG and failed to conceive, despite the absence of a tubal factor. The best results were obtained using the long protocol. Androgen concentrations, particularly delta 4-androstenedione, were significantly lower on the day of oocyte retrieval in group 1 than in group 2 (2.52 +/- 0.73 ng/ml versus 4.44 +/- 2.62, respectively (P less than 0.02). Polycystic follicular formation was less pronounced in group 1 and no clinical hyperstimulations occurred in this group. The pregnancy rate was comparable in the two groups (six ongoing pregnancies in 21 cycles in the 15 patients in group 1 versus three pregnancies in 12 cycles in the 12 patients in group 2).

Pregnancies after replacement of frozen-thawed embryos in a donation program

Eighteen patients with primary (n = 8) or secondary (n = 10) ovarian failure were enrolled in a donation program. In 15 cases, the oocytes were donated anonymously; in 3 cases, they were donated by the sister of the recipient. All the recipients had cyclic steroid replacement therapy that included estrogens and progesterone administered by the transdermal and tranvaginal routes, respectively. The embryos obtained were cryopreserved and replaced with no attempt at synchronization between donor and recipient. Steroid hormonal patterns were within the range for the normal menstrual cycle and endometrial biopsies taken on day 21 or 22 of the treatment cycles were independently assessed as being representative of day 21 +/- 2. Four of 12 transfers were successful (31%): 1 patient aborted at 6 weeks, and the three others were delivered, one normally and two by cesarian sections. The authors' practice suggests the following: (1) steroid supplementation by transdermal and transvaginal routes is effective, (2) synchronization between donor and recipient is no longer required with the use of frozen-thawed embryos, and (3) the "temporal window" is large since all the replacements were done on day 14 of the cycle.

Prognostic value of pre-ovulatory serum progesterone, LH and oestradiol-17 beta levels in stimulated cycles for in-vitro fertilization

The prognostic value of a decrease in oestradiol-17 beta (E2) on the day after HCG injection in stimulated cycles has been related to a premature increase in plasma progesterone (P) on the day before HCG injection. This retrospective study was carried out on 363 patients who were divided into four groups. Patients in group A were given clomiphene citrate plus human menopausal gonadotrophin (HMG) to stimulate follicle growth, and they were subdivided into subgroups A1 and A2 who showed an increase or a decrease in E2 levels after HCG injection. The changes in E2 were greater than 10% of the levels on the previous day. Patients in group B were stimulated by HMG and were similarly subdivided into subgroups B1 and B2 according to their E2 levels. The number of oocytes recovered and the incidence of pregnancy was significantly higher in A2 as compared with A1, and higher but not significantly so in B2 versus B1. Moreover, in subgroups A1 and B1 the day before the decrease of E2 was marked by a significant rise in LH before the HCG injection. We suggest that oocyte recovery is deferred in these cases.

Results of IVF in the treatment of polycystic ovary disease

Sixteen patients with polycystic ovarian syndrome (PCO) were treated by in-vitro fertilization (IVF), 11 suffered from definitive tubal infertility and five had previously undergone multiple unsuccessful attempts at ovulation induction after conventional therapy. They were randomly allocated into two groups: A1 (six patients) treated with 'pure FSH' and A2 (10 patients) whose ovarian stimulation was performed by a combination of LHRH agonist and pure FSH. More oocytes were recovered in group A1 (7.5 +/- 2.2) and group A2 (10.3 +/- 5.8) than in a control group (B) but this difference was not significant. There was no difference between groups A and B in the number of immature oocytes, the oocyte fertilization rate (60%) and the number of embryos replaced per patient (2.8). Four pregnancies were achieved in the six patients in group A1, 5/9 in group A2 and 3/6 in group B. One severe hyperstimulation was recorded in group A1 but this patient developed a pregnancy which was normal at term. This small study suggests that IVF may be a solution to the treatment of PCO resistant to clomiphene citrate and HMG treatment and that the combination of pure FSH with an analogue of LHRH (in a short protocol of 15 days) does not seem to have an advantage over FSH stimulation alone and does not reduce the frequency of hyperstimulation.

Cryopreservation of human embryos and oocytes

The success rate of human embryo cryopreservation depends on technical and embryonic parameters. First of all, the cryoprotectant can affect embryo survival as we found by comparing two freeze-thaw procedures using propanediol (PROH) (1.5 mol) alone or with sucrose (0.1 mol). Embryo survival was significantly enhanced with sucrose (62 versus 32%). Embryo quality is another major parameter involved in the success of freezing; the rates of positive survival were found to be 67% for morphologically normal embryos versus 49% for embryos with fragments (P less than 0.001). The efficiency of embryo cryopreservation in an IVF programme could be estimated in 1986: a woman with extra embryos, stored after transfer of 3-4 fresh embryos (16% of all cycles), can expect a 22% pregnancy rate per transfer of fresh embryos and a 32% pregnancy rate per collection after transfer of the stored eggs. A comparative study of the cryopreservability of immature or mature oocytes was performed in humans. Human oocytes have a low survival rate (36%) whatever the cryopreservation protocol or the initial maturation stage. Immature human oocytes could survive freezing and thawing, mature and be fertilized in vitro, but with a very low efficiency.