Christo Zouves

The effect of embryo quality on subsequent pregnancy rates after in vitro fertilization

OBJECTIVE To determine if a simple morphological classification of embryos was predictive of subsequent pregnancy. DESIGN Prospective case series. SETTING University-based in vitro fertilization (IVF) program. PATIENTS, PARTICIPANTS Consecutive embryo transfer (ET) cycles (n = 206). INTERVENTIONS Embryos were classified into three grades: (1) equal-size blastomeres with no fragmentation; (2) unequal-size blastomeres; and (3) evidence of fragmentation. MAIN OUTCOME MEASURES Embryo quality, age, indication for IVF, and stimulation protocol were evaluated for their effect on pregnancy rates (PRs). RESULTS In cycles in which the best embryo transferred was grade 3, 2, or 1, the clinical PRs per ET were 0% (0/11 cycles), 12.8% (6/47 cycles, P less than 0.05), and 21.8% (32/148 cycles, P less than 0.05), respectively. When one, two, or three or more grade 1 embryos were replaced, the clinical PRs per ET were 15.6%, 16.3%, and 40% (P less than 0.05), respectively. Using logistic regression, embryo quality (P = 0.0011) and patients age (P = 0.0044) were the only variables that affected PRs. CONCLUSION The transfer of more than two good quality embryos had a positive effect, patients age had a negative effect on PRs after IVF-ET.

Tubal ectopic pregnancy after in vitro fertilization and embryo transfer: a role for proximal occlusion or salpingectomy after failed distal tubal surgery?

OBJECTIVE To assess predisposing factors to tubal pregnancy after in vitro fertilization-embryo transfer (IVF-ET). DESIGN Retrospective analysis of 891 ET cycles. SETTING University-based IVF program. PATIENTS, PARTICIPANTS All ET cycles performed in the study period were included; the indication for IVF was tubal factor in 640 (72%) and other (nontubal) factors in 251 (28%) cycles. INTERVENTIONS None. MAIN OUTCOME MEASURE Observing a higher than expected number of tubal pregnancies in our program; we examined subgroups to determine those at highest risk. RESULTS Tubal pregnancies comprised 12% of clinical pregnancies in the tubal factor group but only 2.6% in the cycles nontubal factor group (P less than 0.05). Of 640 ET cycles in the tubal factor group, 359 were performed in patients who had prior tubal reconstructive surgery; tubal pregnancies comprised 15.6% of the clinical gestations in this subgroup. In the remainder of the tubal factor group (no prior tubal surgery), 281 ET cycles yielded a tubal pregnancy rate of only 5.5% (P less than 0.05). CONCLUSIONS Women with prior reconstructive surgery for distal tubal disease are at highest risk of developing tubal pregnancy after IVF.

The outcome of in vitro fertilization and embryo transfer in women with polycystic ovary syndrome failing to conceive after ovulation induction with exogenous gonadotropins

OBJECTIVE To assess the outcome of in vitro fertilization and embryo transfer (IVF-ET) in women with refractory polycystic ovarian syndrome (PCOS). DESIGN Retrospective case series with an age-matched control group. SETTING Ovulation induction and IVF programs in a tertiary referral center. PATIENTS AND INTERVENTIONS Nine patients with PCOS who failed standard ovulation induction treatment (clomiphene citrate plus greater than or equal to 6 ovulatory human menopausal gonadotropin [hMG] cycles) underwent 19 cycles of IVF-ET. Forty age-matched tubal factor patients who completed 40 cycles of IVF-ET served as a control group. OUTCOME MEASURES Demographic features and IVF-ET cycle characteristics were compared using Students t-test and Fishers exact test. RESULTS Cycles of IVF-ET in patients with PCOS were associated with higher estradiol levels (5,222 versus 4,009 pmol/L), lower hMG requirements (15.8 versus 19.6 vials), greater numbers of oocytes (7.6 versus 5.6), and lower fertilization rates (56% versus 75%) compared with tubal factor cycles (P less than 0.05). However, the number of embryos transferred (3.9 versus 4.0) and the clinical pregnancy rate per embryo transfer (24% versus 25%) did not differ significantly between the two groups. CONCLUSION These results suggest that conception failure after six or more ovulatory hMG cycles in patients with PCOS does not adversely affect subsequent IVF performance.

A prospective randomized comparison of zygote intrafallopian transfer and in vitro fertilization-embryo transfer for nontubal factor infertility

OBJECTIVE To evaluate the efficacy of zygote intrafallopian transfer (ZIFT) versus standard IVF-ET for the treatment of nontubal factor infertility. DESIGN A prospective randomized trial. PARTICIPANTS Fifty-nine couples undergoing oocyte retrieval for nontubal infertility in a university hospital-based IVF-ET program. INTERVENTIONS A maximum of four cleaving embryos were transferred into the fallopian tube or uterine cavity 48 or 55 hours after oocyte retrieval, respectively. MAIN OUTCOME MEASURES Rates of implantation, pregnancy, and spontaneous abortion (SAB) were compared. RESULTS Clinical pregnancies occurred after 26.5% versus 12% of retrievals and 29% versus 14.3% of transfers in IVF-ET versus ZIFT cycles, respectively. Pregnancy, implantation, and SAB rates did not differ between the groups. CONCLUSIONS This prospective randomized trial failed to demonstrate any therapeutic improvement associated with the increased complexity of ZIFT as compared with standard IVF-ET.

Hypospadias after assisted reproduction incorporating in vitro fertilization and gamete intrafallopian transfer

OBJECTIVE To determine incidence of hypospadias in infants born as a result of assisted reproductive technology (ART). DESIGN Prospective data collection. SETTING Parents with various forms of infertility attended an in-hospital in vitro fertilization program. PATIENTS Two of the 53 male infants, conceived as a result of ART over a 3-year period, were born with hypospadias. INTERVENTIONS Patient no. 1 underwent follicular stimulation (17 ampules of human menopausal gonadotropin (hMG), followed by 10,000 IU of human chorionic gonadotropin (hCG) 60 hours after the last hMG). Patient no. 2 underwent follicular stimulation with clomiphene citrate 100 mg/d from days 3 to 7, followed by 14 ampules of hMG starting day 6, and 10,000 IU of hCG 30 hours after her last hMG. MAIN OUTCOME MEASURES All infants were examined in the immediate postpartum period for congenital anomalies. RESULTS Infant no. 1, one of a set of dizygotic twins, had penoscrotal hypospadias, with normal renal sonogram and chromosomal studies. Infant no. 2 had glandular hypospadias with the urinary meatus displaced to the border of the glans. CONCLUSION This high incidence raises concern about possible links between assisted reproduction and hypospadias.

The chromosomal complements of cleaved human embryos resulting from in vitro fertilization.

Chromosome preparations were made from 25 cleaved abnormal human embryos at the two-to eight-cell stage after in vitro fertilization. Morphologically, these embryos showed either variable degrees of degeneration or an abnormal number of pronuclei before first cleavage. Among 14 successfully karyotyped embryos, only 3 had a normal chromosomal complement. Eleven showed chromosomal abnormalities, including triploidy, hapioidy, and mosaicism. This finding documents a high incldence of chromosomal errors in morphologically abnormal early preimplantation embryos.

Emotional experiences of in vitro fertilization participants

Data were collected from self-administered question-naires returned by 33 female participants and 18 of their partners in the University of British Columbias in Vitro Fertilization/Gamete Intrafallopian Transfer (IVF/GIFT) Program during a 2-month period. Emotional reactions to each of the stages of IVF/GIFT by treatment phase were measured. Responses were then grouped into the following categories: anxiety, depression, loss of control, and positive feelings. For female participants, anxiety was reported most frequently throughout the treatment process and loss of control was highest following embryo replacement. Male and female participants reported high rates of depression at the completion of the treatment cycle. The findings from this pilot study outline the emotional experiences of male and female participants under-going IVF/GIFT by treatment phase and indicate their desire for support services.

The combined use of vibrostimulation and in vitro fertilization: Successful pregnancy outcome from a retrograde specimen obtained from a spinal cord-injured male

SummaryWhile pregnancies have been documented through the independent use of the vibrator method (12–14,18), from other methods of procuring ejaculate from spinal cord injured men (6–12), and from artificial insemination using a retrograde specimen (3–5), we believe that this is the first case report of a live birth resulting from a retrograde ejaculate obtained by vibration from a spinal cord-injured male whose partner underwent in vitro fertilization.Vibrostimulation may well be successful in the two-thirds of men whose spinal cord lesions are at the T10 neurological level and above, who have an intact bulbocavernosus reflex and anal tone but no pain or temperature sensation of the genitalia (17). Blood pressure monitoring, prevention of autonomic dysreflexia, alkalinization, dilution and infection control of urine, and retrograde specimen retrieval are all important techniques to ensure patient safety and optimal ejaculates.The timing of ovulation and insemination is the crucial factor for the partner of a SCI male whose sperm quality is poor. A complete gynecological workup, including studies of tubal patency, should be done before embarking on a series of artificial inseminations. Stimulation of ovulation and well-timed inseminations should optimize the chance of conception. Depending on semen analysis, female partner factors, and emotional and financial costs, IVF can appropriately be either an early or a final option.

Mitochondrial DNA quantitation—making sense of contradictory reports

Sir, We read the article by Ravichandran et al., which appeared in the June 2017 issue of Human Reproduction, with interest (Ravichandran et al., 2017). The manuscript reports the findings of a retrospective analysis of mitochondrial DNA (mtDNA) levels in blastocyst transfers, and concludes that ‘mtDNA quantity can serve as an independent biomarker for the prediction of euploid blastocyst implantation potential’. In the article, the authors mention our study, which in contrast to theirs did not show a statistically significant correlation between mtDNA levels and implantation (Victor et al., 2017). Ravichandran et al. question the conclusions of our study asserting that it was ‘hampered by a variety of technical issues’. We would like to take the opportunity to comment on the points listed as technical concerns. First, the authors claim that the Next Generation Sequencing (NGS) technique used in our study is incapable of accurately quantifying mtDNA levels as it is ‘known to provide insufficient coverage of the mitochondrial genome’. This assertion is not followed by a reference. To the best of our knowledge, there is no published report that leads to such a conclusion. To be able to make this claim, it is necessary to perform a proper analysis such as by comparing different detection platforms in samples with known mtDNA quantities. We carried out such a cross-platform validation in our study (Victor et al., 2017). Second, the authors point out that the absolute quantitation we performed fails to account for sample-to-sample variation due to technical batch effect and biopsy sample size. Here, the authors clearly had a misconception about the method employed in our study. We carried out absolute quantitation of a locus in the mtDNA ‘as well’ as a locus in the nuclear DNA, and calculated the ratio between the two in order to normalize for the variables stated above. Third, the use of a single copy locus in the nuclear DNA for normalization is declared to lead to ‘almost meaningless results’ due to alleledrop-out during whole genome amplification, something the authors test experimentally in the manuscript. It is unclear how well the qRTPCR assays used in their experiment were validated, as no standard curves or serial dilutions are shown testing the efficiencies of the various assays. We would like to point to a more recent study that makes use of a nuclear multi-copy locus and still concludes that mtDNA quantitation has no predictive power in regards to implantation (Treff et al., 2017). On a different note, we are generally puzzled by the authors’ focus on our technical methods, when there is a clear explanation how our studies could be reconciled and both be ‘right’, as explained below. All data in our paper stemmed from transfers at a single IVF center, thereby controlling for possible inter-clinic variables such as culture conditions, biopsy techniques, or equipment. In their manuscript, Ravichandran et al. indicate that multiple clinics provided data to their study, and they show stark differences in percentage of embryos that contain elevated mtDNA levels at each site (Table I). In fact, approximately half (17 out of 35) of the clinics that contribute data to their study did not show any blastocysts with elevated mtDNA amounts. The most logical conclusion is that our center is one of those that do not produce embryos with high mtDNA levels. From this, we gather that the phenomenon of elevated mtDNA is not a universal biological occurrence that happens stochastically in a percentage of embryos in any given setting, but is rather a center-induced event. We feel that a much more intriguing and fundamental question is what could be eliciting these large deviations in mtDNA levels across clinics.

Chromosome analysis of human oocytes failing to fertilize in vitro***Supported by grants from the Medical Research Council (MA-7298), Ottawa, Ontario and the British Columbia Health Care Research Foundation (5-52477), Burnaby, British Columbia, Canada.

To assess the contribution of chromosome anomalies to the high failure of in vitro fertilization (IVF), 94 unfertilized eggs from 43 women participating in the IVF program were cytogenetically investigated. The mean age of the oocyte donors was 33.6 years. Chromosome karyotypes were obtained in 65 of 94 oocytes: 34 oocytes (52.3%) had a normal haploid chromosome complement; 10 (15.4%) were hypohaploid; 7 (10.8%) were hyperhaploid; 8 were diploid; and 6 were hypodiploid or hyperdiploid (from 36 to 53). Eleven eggs showed prematurely condensed chromosomes of the G1-phase from sperm, as well as a set of maternal metaphase II chromosomes. These results are compared to similar reports in the literature.