Fabienne Devreker

Live birth after autograft of ovarian tissue cryopreserved during childhood

Ovarian insufficiency is a major long-term adverse event, following the administration of a myeloablative conditioning regimen, and occurring in >80% of children and adolescents receiving such treatment for malignant or non-malignant disease. Cryopreservation of ovarian tissue is currently offered to preserve the fertility of these young patients. At least 35 live births have been reported after transplantation of cryopreserved ovarian tissue in adult patients, but the procedure remains unproven for ovarian tissue harvested at a prepubertal or pubertal age. We report here the first live birth after autograft of cryopreserved ovarian tissue in a woman with primary ovarian failure after a myeloablative conditioning regimen as part of a hematopoietic stem cell transplantation performed for homozygous sickle-cell anemia at age 14 years. This first report of successful fertility restoration after the graft of ovarian tissue cryopreserved before menarche offers reassuring evidence for the feasibility of the procedure when performed during childhood.

Short-term medical complications of 1500 oocyte retrievals for in vitro fertilization and embryo transfer

OBJECTIVE To evaluate the different short-term complications after in vitro fertilization and embryo transfer. DESIGN a retrospective study on 7 years in the fertility clinic of an university hospital. MATERIALS AND METHODS Short-term medical complications were analysed after 1500 transvaginal ultrasonographically guided oocyte retrievals. RESULTS Ovarian hyperstimulation syndrome (1.8%), pelvic infections (0.4%), intraperitoneal bleeding (0.2%) and adnexal torsions (0.13%) were observed. One case of adnexal torsion occurred during pregnancy (0.18%). Two unusual case of bowel endometriosis were encountered (0.13%). CONCLUSIONS Short-term medical complications after in vitro fertilization and embryo transfer are rare (2.8%). This contrast with the high rate of multifetal pregnancies which increases maternal and perinatal morbidity and mortality and must be considered as the major complication of in vitro fertilization treatment.

Effect of Insulin-Like Growth Factor-I During Preantral Follicular Culture on Steroidogenesis, In Vitro Oocyte Maturation, and Embryo Development in Mice

Abstract Insulin-like growth factor-I (IGF-I) is involved in the regulation of ovarian follicular development and has been shown to potentiate the FSH responsiveness of granulosa cells from preantral follicles. The aim of the present study was to investigate the effect of IGF-I during preantral follicular culture on steroidogenesis, subsequent oocyte maturation, fertilization, and embryo development in mice. Preantral follicles were isolated mechanically and cultured for 12 days in a simplified culture medium supplemented with 1% fetal calf serum, recombinant human FSH, transferrin, and selenium. In these conditions, follicles were able to grow and produce oocytes that could be matured and fertilized. The first experiment analyzed the effect of different concentrations of IGF-I (0, 10, 50, or 100 ng/ml) added to the culture medium on the follicular survival, steroidogenesis, and the oocyte maturation process. The presence of IGF-I during follicular growth increased the secretion of estradiol but had no effect on the subsequent oocyte survival and maturation rates. In the second experiment, IGF-I (0 or 50 ng/ml) was added to the culture medium during follicular growth, oocyte maturation, or both, and subsequent oocyte fertilization and embryo development rates were evaluated. Oocyte fertilization rates were comparable in the presence or absence of IGF-I. However, the blastocyst development rate was enhanced after follicular culture in the presence of IGF-I. Moreover, the total cell number of the blastocysts observed after differential labeling staining was also higher when follicles were cultured or matured in the presence of IGF-I.

Safety and usefulness of cryopreservation of ovarian tissue to preserve fertility: a 12-year retrospective analysis

STUDY QUESTION Do the benefits of ovarian tissue cryopreservation outweigh the risks for patients seeking to preserve fertility before gonadotoxic treatment in various indications? SUMMARY ANSWER In >90% of the patients undergoing cryopreservation of ovarian tissue, oncological treatment was associated with a reduced ovarian reserve and in 30% of patients, premature ovarian failure (POF) occurred within 5 years. WHAT IS KNOWN ALREADY Ovarian tissue cryopreservation is an effective fertility preservation option, especially for pre-pubertal patients and patients who have a short time between diagnosis of a disease and gonadotoxic treatment. STUDY DESIGN, SETTING, DURATION This study retrospectively analysed ovarian function and fertility recovery rates, as well as ovarian tissue characteristics, of patients who underwent ovarian tissue cryopreservation at Erasme Hospital between 1999 and 2011. PARTICIPANTS/MATERIALS, SETTINGS, METHODS A total of 225 patients referred from 15 Belgian oncological units underwent cryopreservation of ovarian tissue before gonadotoxic therapy for malignant or benign diseases. There were 28 patients (12.4%) who died during follow-up due to recurrence of disease. One severe adverse event occurred during anaesthesia for ovarian tissue collection, leading to the death of the patient. Ovarian function and fertility outcomes were available for 114 patients including 13 girls who were pre-pubertal at the time of the procedure. Eight patients had undergone ovarian tissue transplantation in order to restore their fertility after remission of the disease. MAIN RESULTS AND THE ROLE OF CHANCE Breast cancer and haematological disease were the most frequent indications for ovarian tissue cryopreservation. Overall, 90% of post-pubertal patients were diagnosed with poor ovarian reserve (AMH < 0.5 ng/ml) after a mean of 50 months of follow-up (11-125 months), including 30% with POF (FSH > 40 IU/ml). Breast cancer patients had a lower rate of POF than did post-pubertal patients with haematological diseases (11 versus 34.5%, respectively), despite the older age (mean 31 versus 23.5 years old, respectively) of the breast cancer patients. Ovarian function returned in 71 post-pubertal patients without the need for grafts of cryopreserved tissue. Spontaneous pregnancies were reported for 33 of them, leading to 34 live births. Among the 13 pre-pubertal patients who reached pubertal age during the follow-up, 10 had POF. Eight patients received cryopreserved ovarian grafts to reverse POF and three of them have already become pregnant. LIMITATIONS, REASONS FOR CAUTION This study is a retrospective analysis. The cohort was not compared with a control group of patients who did not undergo the procedure. WIDER IMPLICATIONS OF THE FINDINGS After careful evaluation of the surgical risks, ovarian tissue cryopreservation can be proposed as an efficient option to preserve the fertility of children and young adults facing gonadotoxic therapies. However, alternative procedures such as oocyte or embryo cryopreservation should be considered as first options especially for older patients or if there is high risk of neoplastic cells within the ovaries. STUDY FUNDING/COMPETING INTEREST This study was supported by the Télévie, FNRS-FRSM and Fondation Belge contre le cancer. There are no competing interests to report.

Glutamine improves human preimplantation development in vitro

OBJECTIVE To study the effect of glutamine on human preimplantation embryo development in vitro. DESIGN A randomized, controlled, prospective study of 138 normally fertilized and nontransferred human embryos. On day 2 after fertilization, the embryos were allocated randomly to glucose-free medium with or without 1 mM of glutamine. SETTING A university hospital-based IVF-ET program. PATIENT(S) Couples undergoing IVF treatment. INTERVENTION(S) Embryo culture. MAIN OUTCOME MEASURE(S) Blastocyst formation, trophectoderm and inner cell mass numbers, and pyruvate uptake and lactate production by individual embryos. RESULT(S) A higher proportion of embryos reached the morula (89% versus 68%, respectively) and blastocyst (71% versus 54%, respectively) stages when cultured with glutamine compared with embryos cultured without glutamine. Blastocyst cell numbers were not statistically significantly different for embryos grown in the presence or absence of glutamine. Pyruvate uptake and lactate production were higher in the presence of glutamine throughout development; these increases were statistically significant at the blastocyst stage. CONCLUSION(S) This study demonstrates that supplementation of the culture medium with glutamine is beneficial for human preimplantation embryo development in vitro, increasing the proportion of embryos that develop to the morula and blastocyst stages.

In vitro development and metabolism of the human embryo up to the blastocyst stage

The preimplantation period begins with the fertilisation of the oocyte and ends with the formation of the blastocyst. During this period, several major events occur resulting in an embryo composed of pluripotent cells. These morphological changes correspond to changes in the embryonic metabolism. The cleavage stages are characterised by a low metabolism and the inability of the embryo to metabolise glucose. After the activation of the embryonic genome, there is a surge in the embryonic metabolism with increased demand for ATP. The embryo is then able to metabolise glucose. Recently, the importance of amino acids has been highlighted by experiments with mouse, hamster and bovine embryos. Amino acids have also been reported to benefit human embryo development in vitro. Some growth factors have been shown to play a role in human embryo development too. The importance of lipids or vitamins, however, is poorly investigated. Culture media have been developed to improve preimplantation development, but more information is required for adapting culture condition to embryonic requirements which hopefully will improve the outcome of in vitro fertilisation (IVF).

The long-acting gonadotropin-releasing hormone analogues impaired the implantation rate.

OBJECTIVES To determine the efficacy and innocuousness of long-acting versus short-acting GnRH analogues (GnRH-a) in long protocol for in IVF-ET. DESIGN Prospective randomized study. SETTING The IVF unit at an academic hospital. PATIENTS One hundred couples admitted for their first IVF-ET attempt. MAIN OUTCOME MEASURES Serum concentrations of LH, E2, and P during the all cycles and duration of pituitary desensitization were assessed, as well as fertilization rate, embryo quality, and implantation and pregnancy rates. RESULTS Significantly more days (10.8 +/- 1.8 versus 9.2 +/- 1.7 days) of stimulation and more ampules of hMG (47 +/- 22 versus 33 +/- 16) were necessary to obtain similar numbers of embryos of quality with the long-acting GnRH-a. Implantation and delivery rates were significantly lower with the long-acting GnRH-a (32.8% versus 21.1%; 48.9% versus 29.1%, respectively). CONCLUSIONS As the long-acting GnRH-a might interfere with the luteal phase and embryo development, short-acting GnRH-a should be preferred for ovarian hyperstimulation in IVF-ET.

Noninvasive assessment of glucose and pyruvate uptake by human embryos after intracytoplasmic sperm injection and during the formation of pronuclei

OBJECTIVE To improve in vitro culture conditions and human embryo selection before transfer after IVF with intracytoplasmic sperm injection (ICSI). DESIGN A controlled, randomized, prospective study. SETTING University hospital-based IVF-ET program. PATIENT(S) Couples undergoing ICSI. INTERVENTION(S) Culture of human embryos in the presence of 1 mM or 5.56 mM glucose and metabolic measurements with the use of noninvasive microfluorescence assays immediately after ICSI to the time of transfer. MAIN OUTCOME MEASURE(S) Embryo development, implantation rate, and glucose and pyruvate uptake. RESULT(S) Fertilization rates, early embryo development, and implantation rates were not significantly different between 1 mM and 5.56 mM glucose. Pyruvate uptake was significantly higher during the formation of the pronuclei, at 15 +/- 0.7 and 11.4 +/- 1.3 pmol/embryo/h for fertilized and unfertilized oocytes, respectively. Pyruvate uptake did not correlate with cleavage stage or embryo morphology. However, during the second day of incubation, pyruvate uptake was significantly higher for the untransferred embryos of pregnant women compared with nonpregnant women, at 17.9 +/- 1.5 and 10.8 +/- 1.0 pmol/embryo/h, respectively. CONCLUSION(S) The increased level of pyruvate uptake during fertilization reflects the increased demand for energy necessary for the formation of the pronuclei. However, the metabolic measurements could not improve the selection of embryos with the best implantation potential. Finally, the reduction of glucose concentration in the culture medium failed to improve embryo viability.

Embryo–maternal interactive factors regulating the implantation process: implications in assisted reproductive treatment

The embryo-maternal dialogue that starts very early in the life of the embryo is crucial for its own implantation. A disturbance in this dialogue is the major reason for which 60% of all pregnancies are terminated at the end of the periimplantation period. Many studies have been performed to improve the understanding of the molecular mechanisms involved in this dialogue. Both partners, the mother and the embryo, are equally involved in this exchange of signals. Much progress has been done in understanding the role of (i) chorionic gonadotrophin, (ii) growth factors and cytokines, and (iii) steroid hormones and other mediators, produced either by the embryo, by the mother, or by both, during the peri-implantation period. Today it is clear that their production dictates changes in the endometrium, in the immunological system of the mother and in embryo metabolism, that enable the embryo to implant. Knowledge of the molecular mechanisms involved in the embryo-maternal interaction are reviewed in this article.

Impact of the assessment of early cleavage in a single embryo transfer policy

The policy of single embryo transfer (SET) adopted for women <36 years old since 1 July 2003, strongly calls for improvement of embryo selection. A total of 196 cycles in which SET was performed were randomly allocated to two groups. In the first group, early cleavage was assessed (ECA) 25 h after insemination. The embryo with the best score that cleaved early, if present, was selected for transfer. In the second group, early cleavage was not assessed (ECNA) and embryo selection was based solely on the embryo score. Ninety-eight cycles were allocated in the ECA and ECNA group respectively. Early cleavage occurred in 64% of cycles and 32.2% of embryos. Patient population and embryo morphology were similar between the two groups, and similar delivery rates were observed (27.6 versus 24.5% respectively in the ECA and ECNA groups). The assessment of early cleavage as additional parameter did not improve the delivery rate in the single embryo transfer policy.