Ahmet Zeki Isik

Gonadotrophin-releasing hormone agonist trigger and freeze-all strategy does not prevent severe ovarian hyperstimulation syndrome: a report of three cases

Ovarian hyperstimulation syndrome (OHSS) is the most serious iatrogenic complication of IVF cycles. Although the development of effective treatment strategies for this syndrome is important, preventing OHSS is more crucial. Triggering ovulation with a gonadotrophin-releasing hormone (GnRH) agonist is one method used to avoid OHSS. In this paper, three patients who developed severe OHSS after undergoing GnRH agonist triggering and freezing of all embryos in a GnRH antagonist protocol are described. A review of the literature is also provided. This report highlights the ongoing risk of severe OHSS even after GnRH agonist triggering combined with freezing all embryos in GnRH antagonist cycles. Other prevention strategies might be considered for extreme hyper-responders.

Development of blastocyst-stage embryos after round spermatid injection in patients with complete spermiogenesis failure.

Purpose: Our purpose was to evaluate the progression of embryos derived from round spermatid injection to the blastocyst stage and compare the results with those obtained by the use of testicular or epididymal spermatozoa.Methods: Thirty-eight patients with azoospermia enrolled in this study. In 29 patients with obstructive or nonobstructive azoospermia, spermatozoa were recovered from epididymis or testis. In the remaining nine cases with nonobstructive azoospermia, only round spermatids were found in seven, whereas in two of the patients, there were no elongated or round spermatids. Six of these cases underwent round spermatid injection.Results: Twenty-one of 29 patients with injection of spermatozoa underwent embryo transfer on day 3, and 10 pregnancies (47.6%) were obtained. In eight cycles, embryos were further cultured for delayed transfer. In six cases undergoing round spermatid injection, no transfer was performed on day 3 and extended culture with delayed embryo transfer was applied. The mean number of fertilized oocytes and mean number of embryos on day 3 and also the fertilization rate and mean number of good-quality embryos on day 3, mainly grade 1 or 2, were statistically significantly higher in the spermatozoa group than the round spermatid injection group. Compared to the spermatozoa group, the number of arrested embryos was significantly higher and the number of blastocyst-stage embryos and number of good-quality blastocysts were significantly lower in the spermatid injection group. No blastocysts developed in two spermatid cycles and embryo transfer was not possible, and in the remaining four cycles, after at least one blastocyst transfer, no pregnancies were achieved. However, in eight cycles with extended culture in the spermatozoa group, embryo transfers were achieved in all and three pregnancies, for a pregnancy rate of 37.5%, were obtained after blastocyst transfer.Conclusions: Our preliminary results showed that round spermatid injection was associated with a significantly lower fertilization and embryo development rate and a significantly higher developmental arrest rate compared with the injection of spermatozoa. Extended culture and delayed embryo transfer did not improve the clinical outcome after round spermatid injection, and these results suggested a developmental failure in embryos preventing successful implantation after round spermatid injection.

Comparison of Zona Manipulated and Zona Intact Blastocyst Transfers: A Prospective Randomized Trial

AbstractPurpose: In this prospective randomized study the effectsof enzymatic treatment of zona pellucida of blastocysts onimplantation and pregnancy rates were evaluated in a groupof patients who had more than five embryos on day 3. Methods: Forty-six patients with a mean age of 29.8 ± 4.5years and mean duration of infertility of 6.72 ± 0.63 yearshad blastocyst stage transfers, with a mean number of2.9 ± 0.1 embryos replaced per patient. Patients were randomlydivided into two groups. The first group consisted ofpatients (n = 22) who had zona intact blastocyst stagetransfers and the second group consisted of patients (n = 24)who had zona manipulated (enzymatic treatment) blastocyststage transfers. Patient and cycle characteristics were similarin both groups. A commercial cell and serum-free sequentialculture system was used for all embryos. Results: Overall blastocyst formation rate was 50.3%.Transfer could be done in all patients. The positive β-humanchorionic gonadotropin rate in the zona intact group was50% (11/22) and in the zona-manipulated group was 70.8%(17/24). Clinical pregnancy, ongoing pregnancy, andimplantation rates in zona intact and manipulated groupswere 45.5%, 27.3%, and 19%, and 62.5%, 45.8%, and 24%respectively. Although implantation and pregnancy rates inthe zona-manipulated group were higher, there were nostatistically significant differences in terms of these variablesbetween two groups. No triplet pregnancy was obtained ineither group, and the twin pregnancy rate was 20% (2/10)in the zona intact group and 13.3% (2/15) in thezonamanipulated group. Conclusions: With further improvements in the embryoculture systems it will become possible in the near future toachieve high implantation rates even with single blastocysttransfers. Enzymatic treatment of the zona pellucida seemsthat it does not alter the pregnancy and implantation rates,but further studies with larger group of patients are neededto clarify the real effect of this zona manipulation onpregnancy outcome.

Combined approach as an effective method in the prevention of severe ovarian hyperstimulation syndrome

The purpose of this study was to evaluate the effectiveness of combined approach on the prevention of severe ovarian hyperstimulation syndrome (OHSS) in high risk patients undergoing controlled ovarian hyperstimulation for IVF. The combined approach consisted of: (1) step-down administration of gonadotropins; (2) lowering the dose of human chorionic gonadotropin; (3) intravenous albumin infusion at the time of oocyte retrieval and (4) progesterone use for luteal support. Total of 87 high risk patients with a serum estradiol level >11,010 pmol/l or 3000 pg/ml on HCG day were managed by this combined approach and their results were compared with 274 low risk patients. In all high risk patients, the gonadotrophin dose were decreased starting as early as on day 4 of ovarian stimulation as necessary, ovulation was triggered by a decreased HCG dose of 5000-7000 IU according to the level of estradiol, intravenous infusion of 20% human albumin, 50-100ml were given just 1h before the oocyte retrieval and luteal support was provided either by 50mg progesterone in oil, IM or 600 mg micronized progesterone orally or vaginally until the day of beta-HCG determination. All patients were followed by serial ultrasonographic examinations and complete blood count analysis after embryo transfer to detect the early signs of OHSS and to allow early intervention. Age and duration of infertility were similar in both groups. Although the number of gonadotrophin ampoules used (22.7 +/- 4.7 versus 27.8+/-3.7; P<0.05) was significantly lower, estradiol levels (16,764 +/- 6936 pmol/l versus 8870 +/- 2456 pmol/l; P<0.05) and mean number of oocytes (18.3 +/- 5.9 versus 10.6+/-5.4; P<0.05) were significantly higher in study group. There was no significant difference between groups in terms of the mean number of transferred embryos (3.2 +/- 1.1 versus 3.4+/-1.1) and rate of pregnancies (50.5% versus 40.1%). There was only one moderate and no severe OHSS case in the high risk group, while five moderate and one severe OHSS cases developed in the control group consisting of low risk patients. In conclusion, intravenous albumin combined with low dose HCG, early step-down administration of gonadotropins and progesterone use for luteal support, so called combined approach, proved to be effective in the prevention of severe ovarian hyperstimulation syndrome in documented high risk patients.

Luteal phase hormonal profile in prediction of pregnancy outcome after assisted reproduction.

The clinical efficacy of luteal phase hormones including estradiol and progesterone in the prediction of pregnancy and its outcome in ICSI-ET cycles was evaluated. In 121 ICSI-ET cycles, serial estradiol and progesterone levels were measured in the luteal phase. The day of ovum pick-up was designated as day 0. All the patients had luteal support with vaginal progesterone suppositories after embryo transfer (ET). Serial estradiol measurements were performed on days 8, 11 and 13 and progesterone level on day 11. A single dose of hCG was given for corpus luteum rescue 5000 IU, if day 8 estradiol level <200pg/ml; 2000IU, if estradiol between 200 and 800pg/ml; no hCG if estradiol level >800pg/ml). On day 15, beta-hCG level was measured to detect pregnancy and if positive, injected on day 17. Fifty-seven pregnancies were achieved in 121 cases after ET (47%). Clinical pregnancy rate and ongoing pregnancy rate per ET were 37.1 and 30%, respectively. While there was no difference between progesterone levels measured on day 11, estradiol levels on days 11 and 13 were significantly higher in women who became pregnant. In 40 patients taking only progesterone and in 81 cases taking hCG plus progesterone, estradiol levels on days 11 and 13 were significantly higher in women who became pregnant. Progesterone levels on day 11, in progesterone treated groups, did not differ between pregnant and non-pregnant patients. Estradiol and progesterone levels on day 11 and estradiol levels on day 13 showed a big overlap between pregnant and non-pregnant patients. The efficacy of serial testing was evaluated. An increase in estradiol level from day 11 to 13 was associated with 71% pregnancy rate (72% ongoing). In the case of a decrease in estradiol level, the pregnancy rate was 18% of which 80% had to implant. Rising estradiol in the late luteal phase is associated with higher pregnancy rate and more successful pregnancy outcome.

Borderline form of empty follicle syndrome: is it really an entity?

We report two patients who were administered erroneously 1000 IU HCG instead of 10,000 IU for ovulation triggering in an assisted reproductive technology (ART) cycle. In one case no oocyte was retrieved from eight mature follicles after several washing attempts and retrieval day serum beta-HCG level was 21 mIU/ml. As there was no follicle in the other ovary we did not try a rescue protocol. In the other case two immature and one mature oocytes were retrieved from 15 mature follicles located in both ovaries. Retrieval day serum beta-HCG level was 12 mIU/ml. ICSI was performed in one mature and two in vitro maturated oocytes and the embryo transfer that was done 72 h after the retrieval yielded a healthy singleton pregnancy. Our experience shows that a borderline form of EFS may be an entity and it may be possible to see the formation of periovulatory events and even to obtain a pregnancy in an ART cycle where the ovulation was triggered by 1000 IU HCG.

Fertilization and development of a blastocyst-stage embryo after selective intracytoplasmic sperm injection of a mature oocyte from a binovular zona pellucida : A case report

Purpose:Our purpose is to describe the development of a blastocyst-stage embryo after the selective fertilization of a mature oocyte from a binovular zona pellucida by intracytoplasmic sperm injection (ICSI).Method:A 34-year-old woman underwent intracytoplasmic sperm injection due to severe male-factor infertility. After oocyte retrieval, a binovular zona pellucida including one mature metaphase II oocyte and one immature oocyte at the germinal vesicle stage as well as nine metaphase II oocytes was injected with spermatozoa using a one-to-one approach.Results:The injected mature oocyte of the binovular zona pellucida showed fertilization as evidenced by the presence of two pronuclei and cleaved to a four-cell embryo on the second day, while the uninjected oocyte showed signs of degeneration. On the third day, this embryo further cleaved to six blastomeres with slight fragmentation and it reached the blastocyst stage on the sixth day.Conclusions:Selective fertilization of one oocyte from a binovular zona pellucida by ICSI may lead to the development of a morphologically normal blastocyst-stage embryo which can be used for embryo transfer in the presence of a limited number of embryos.

Pregnancies achieved by testicular sperm recovery in male hypogonadotrophic hypogonadism with persistent azoospermia

Hypogonadotrophic hypogonadism is characterized by oligospermia or azoospermia and low testosterone, FSH and LH concentrations. In such cases, treatment with gonadotrophins is required to produce or increase spermatozoa in the ejaculate but few achieve normal spermatogenesis. After long periods of medical treatment, if the patients still have a low sperm count or azoospermia, assisted reproductive technologies in addition to hormone administration can be offered. Four cases of hypogonadotrophic hypogonadism with persistent azoospermia after at least 10 months of medical treatment are reported. In all four cases, spermatozoa retrieved by testicular sperm extraction and intracytoplasmic sperm injection (ICSI) were used to achieve fertilization. Excess spermatozoa were frozen in all cases. Six ICSI cycles using fresh testicular spermatozoa in four and thawed testicular spermatozoa in two were performed. Although there was no pregnancy in cycles where thawed spermatozoa were used, three clinical pregnancies were achieved in four cycles using fresh testicular spermatozoa. One of them ended with spontaneous abortion at 10 weeks of gestation and the two others resulted in the delivery of three normal offspring. If azoospermia persists after medical treatment, spermatozoa can be obtained surgically from testes and can be used successfully to achieve pregnancy in cases of hypogonadotrophic hypogonadism.

The association between coenzyme Q10 concentrations in follicular fluid with embryo morphokinetics and pregnancy rate in assisted reproductive techniques

PurposeThis study seeks to evaluate the association between follicular fluid (FF) coenzyme Q10 (CoQ10) levels, embryo morphokinetics, and pregnancy rate.MethodsSixty infertile patients who underwent intracytoplasmic sperm injection (ICSI) cycles were included in the study. For each patient, CoQ10 level of the follicular fluid was measured by high-performance liquid chromatography system. After the ICSI of each oocyte, the relationship between the level of CoQ10 content of each follicular fluid, the subsequent embryo quality, and embryo morphokinetics was investigated. The relationship between the level of CoQ10 content of each follicle and optimal time-lapse parameters for the embryos of these follicles including t5, s2, and cc2 was also analyzed. The embryos were further classified into four categories, namely, grades A, B, C, and D, according to morphokinetic parameters using t5–t2 and t5–t3 (cc3). Each follicular fluid analysis was performed for a single oocyte of a single embryo which was transferred to the patients. Additionally, follicular fluid CoQ10 levels and pregnancy rates were evaluated.ResultsFollicular fluid CoQ10 levels were significantly higher in grades A and B than grades C and D embryos (p < 0.05). The concentration of CoQ10 levels was significantly higher in the pregnant group (p < 0.05). There was no significant correlation between optimal t5 and s2 morphokinetic parameters and CoQ10 levels. However, CoQ10 levels were significantly higher in follicular fluid of embryos which had optimal cc2 (p < 0.05).ConclusionHigh follicular fluid CoQ10 level is associated with optimal embryo morphokinetic parameters and higher pregnancy rates.

Comparison of the morphokinetic parameters of embryos according to ovarian reserve in IVF cycles

Abstract The aim of this study is to evaluate the impact of ovarian reserve and age of women on early morphokinetic parameters of embryos with a time-lapse monitoring system. In total, 197 infertile couples with poor ovarian reserve (Group 1, n = 41), normal ovarian reserve (Group 2, n = 59), or polycystic ovaries (Group 3, n = 97) were included. The time from insemination to the following events were analyzed: pronuclear fading (Pnf) and cleavage to 2, 3, 4 and 5 cells. The optimal ranges for morphokinetic parameters of t5, s2 and cc2 in each group were also evaluated. In total, 1144 embryos were evaluated. Morphokinetic parameters did not differ statistically between the groups. Data were analyzed according to different age groups (20–30, 30–40, >40). The morphokinetic parameters did not differ statistically in Group 1 and 3. In Group 2, the times from insemination to tPnf, t2, t3, t4 were significantly shorter in the younger age group than the older age group (p < 0.05). The percentages of optimal embryos, according to t5, s2 and cc2, did not differ statistically between the groups. In conclusion, ovarian reserve did not seem to affect the morphokinetic parameters of embryos.