Jin-Tsung Su

Poor Response of Ovaries with Endometrioma Previously Treated with Cystectomy to Controlled Ovarian Hyperstimulation

AbstractPurpose: To compare ovarian response to controlled ovarian hyperstimulation (COH) between normal ovaries and ovaries previously treated surgically for unilateral ovarian endometrioma. Methods: From January 1996 to December 2001, 32 patients with unilateral ovarian endometrioma previously treated surgically underwent 38 cycles of COH. Their records were reviewed retrospectively. The number of dominant follicles observed on the day of hCG injection and the number of eggs retrieved from the diseased and the normal ovaries in each patient were compared. Results: The numbers of dominant follicles from diseased and normal ovaries were 1.9 ±1.5 and 3.3 ± 2.1, respectively (P < 0.001). During ovum pick up, the numbers of eggs retrieved from diseased and normal ovaries were 2.9 ± 2.6 and 6.1 ± 4.1, respectively (P < 0.0001). For diseased ovaries, 21.1% (8/38) had no dominant follicles, while only 7.9% (3/38) of normal ovaries lacked dominant follicles. The clinical pregnancy rate and the implantation rate per embryo transfer were 33.3 and 17.6%. Conclusions: Surgery for ovarian endometrioma may damage ovarian reserve. It potentially results in poor ovarian response to COH, compared to the response of the contralateral normal ovary in the same individual.

Cessation of Low-Dose Gonadotropin Releasing Hormone Agonist Therapy Followed by High-Dose Gonadotropin Stimulation Yields a Favorable Ovarian Response in Poor Responders

AbstractPurpose: This study is a prospective nonrandomized study to determine the effect of a new protocol of controlled ovarian hyperstimulation (COH) using low doses and a half-period of gonadotropin releasing hormone agonist (GnRHa) followed by high doses of gonadotropin in patients who were supposed to be poor responders to standard long protocols of GnRHa administration. Methods: From Dec 1996 to Nov 1998, 50 patients who were classified as “poor responders” were scheduled for 52 cycles of a modified controlled ovarian hyperstimulation protocol. They were categorized into 3 groups: a group of poor responders to COH in the previous IVF or IUI cycles, a group with elevated Day 3 FSH levels, and a group over the age of 40 years. All patients received GnRH agonist from the midluteal phase of the previous cycle to the onset of menstruation in the next cycle. Then high doses of gonadotropins (HMG/FSH) were given. The patients then had standard courses of in vitro fertilization and embryo transfer (IVF-ET) or transfallopian embryo transfer (TET). Results: Six of the 52 cycles of the modified protocols were cancelled because of poor ovarian response. One premature ovulation was noted before ovum retrieval was performed. In the other 45 cycles, an average of 6.3 mature oocytes were retrieved. The total pregnancy rate and implantation rate were 20.5 and 11.5%, respectively. Conclusions: The low dose and half duration of GnRHa therapy lessened the suppression of the response of the ovaries to COH compared with the regular long protocol of GnRHa down regulation therapy. This resulted in a low cancellation rate (11.8%), a favorable embryo implantation rate (11.5%), and an acceptable clinical pregnancy rate (20.5%).

The Effects of Brief Gamete Co-incubation in Human In Vitro Fertilization

AbstractPurpose: To investigate whether very short exposure ofmature oocytes to sperm in vitro may affect the fertilizationrates, embryo cleavage rates, and embryo quality betweensibling oocytes in the same patient. Methods: Sibling oocytes of the same patient from 23 oocytecollection cycles were randomly allocated to the study group,with a 1-hr or 3-hr sperm—oocyte incubation, or the controlgroup with the standard overnight gamete co-incubation.The fertilization rates, cleavage rates, and subsequentembryo quality were evaluated. Results: Our results showed no statistically significant differencesin fertilization rates, embryo cleavage rates, andquality of the embryos between the study group and thecontrol group. Conclusions: Since the present study showed that long exposureof the oocyte to sperm has no advantage over shortexposure, we prefer shortening the oocyte—sperm incubationperiod for reducing the negative effect induced bynonphysiologically high concentrations of spermatozoa.

Relationship of Follicular Size to the Development of Intracytoplasmic Sperm Injection-derived Human Embryos

OBJECTIVE To compare the embryonic development of oocytes obtained from follicles of different sizes. MATERIALS AND METHODS Oocytes (n = 819) were retrieved from women at 40 years of age or younger during 86 in vitro fertilization cycles and categorized as small, medium, or large based on the estimated volume of follicular fluid at the time of retrieval. RESULTS The rates of good quality embryos from the large, medium, and small groups on days 2 and 3 were 76.85% and 66.20%, 74.00% and 61.33%, and 69.81% and 58.49%, respectively. There were no significant differences in the rates of good quality embryos between the three follicular volume groups. CONCLUSION Even though fewer oocytes completed maturation in the small follicle group than in the other two groups, the quality of the embryos in all three groups was the same on days 2 and 3. These findings suggest that follicles of all sizes should be aspirated during the intracytoplasmic sperm injection cycle as follicles of every size were a good source of embryos.

Distinction Between Paternal and Maternal Contributions to the Tripronucleus in Human Zygotes Obtained after In Vitro Fertilization

OBJECTIVE The aim of this study was to determine the genetic composition of tripronuclear (3PN) zygotes. Fluorescence in situ hybridization (FISH) was used to quantify the sperm tails in human 3PN zygotes. MATERIALS AND METHODS Ovarian hyperstimulation was performed using a standard long protocol consisting of gonadotropin-releasing hormone agonist (GnRHa) with human menopausal gonadotropins (HMG) and/or recombinant follicle stimulating hormone (rFSH). Human chorionic gonadotropin (hCG) was administered when at least two leading follicles reached 18 mm in mean diameter. Oocytes were retrieved from the follicles transvaginally under ultrasound guidance 34-36 hours after administration of hCG. The oocytes were examined 16-18 hours after fertilization for the presence and number of pronuclei. The 3PN zygotes were then fixed and extracted in buffer at 37 degrees C for 60 minutes. After washing in a blocking solution, the 3PN zygotes were prepared for indirect immunofluorescence using monoclonal antibody and Hoechst dye 33342 to visualize the number of pronuclei. RESULTS Twenty-one 3PN zygotes were randomly collected for evaluation. The number of 3PN zygotes containing one, two or four sperm tails were two (10%), 18 (85%) and one (5%), respectively. CONCLUSION Based on our observations, additional pronuclei are mainly of paternal origin.

A comparison of the effects of different degrees of zona pellucida damage followed by cryopreservation on the postthaw development of mouse embryos

Purpose:The totally intact zona pellucida is not essential for the development of embryos. It is still unclear how much effect the degree of damages to the zona pellucida will have on the developmental potential of postthaw embryos after cryopreservation. We compared the developmental potential of cryopreserved mouse embryos after induction of two degrees of mechanical damage to the zonae pellucidae by micromanipulation.Methods:In experiment I, the development of 124 cryopreserved ICR mouse embryos to the blastocyst stage after zona pellucida penetration of two-cell embryos as in the procedures of subzonal sperm insertion (SUZI) was compared with the development of zona-intact cryopreserved embryos. In experiment II, the zonae pellucidae of 93 two-cell mouse embryos were dissected as in the procedures of partial zonal dissection (PZD), following which the embryos were frozen. This postthaw development was also compared with that of zona-intact two-cell cryopreserved embryos. All the embryos were thawed and cultured to the blastocyst stage. Additional controls were provided by culturing zonaintact and zona-penetrated or zona-dissected embryos without cryopreservation.Results:The development of unfrozen mouse embryos was not affected by either zona penetration (P=0.433) or zona dissection (P=0.659). The developmental potential of cryopreserved mouse embryos was significantly affected after zona dissection (blastocyst rate, 31% ZD vs 72%, control; P<0.001) but not after zona penetration (blastocyst rate, 59% ZP vs 64% control; P=0.441).Conclusions:The quality of cryopreserved embryos was affected by a large hole on the zona pellucida created by zona dissection but not by simple zona penetration.

Uterine Position Change Between Mock and Real Embryo Transfers

OBJECTIVE This study was designed to assess the change in uterine position between mock and real embryo transfers. MATERIALS AND METHODS A total of 386 embryo transfer cycles were reviewed, and the uterine position was recorded at the time of mock embryo transfer and then again at the time of real embryo transfer. RESULTS Of 254 patients with an anteverted uterus at mock transfer, only 3 (1.2%) were found to have a retroverted uterus at actual embryo transfer. Of 132 patients with a retroverted uterus at mock transfer, 24 (18%) had an anteverted uterus at actual embryo transfer (p < 0.0001). CONCLUSION Routine ultrasound-guided embryo transfer is suggested when a retroverted uterus is found at mock embryo transfer, as there is a significant chance that the uterine position will change.

Poor Ovarian Response with High Cancellation Rate during Controlled Ovarian Hyperstimulation after Enucleation of Ovarian Endometriomas

Objective: To evaluate ovarian response during controlled ovarian hyperstimulation (COH) in patients with endometriomas previously treated surgically. Material(s) and Method(s): The medical records of patients under 40 years old undergoing IVF from January 1992 to December 1999 were retrospectively reviewed. In group 1 (51 patients, 71 cycles), all patients had undergone cystectomy for ovarian endometriomas prior to IVE. A control group 2 (48 patients, 52 cycles) had had male factor infertility and had undergone ICSI. The ovarian response and cancellation rates of these two groups during COH were compared. Result(s): The cancellation rate in group 1 was significantly higher than in group 2 (28.2% vs. 7.7%, P＜0.05). The estradiol level and number of dominant follicles on the day of hCG injection, the number of mature oocytes retrieved, and the number of embryos available were all significantly lower in group 1. There were no statistical differences in the clinical pregnancy rate (32.0% vs. 42.6%), implantation rate (13.1% vs. 15.1%) or live birth rate (30.0% vs. 31.9%). Conclusion(s): Ovarian surgery may damage ovarian reserve, resulting in poor ovarian response and increased cancellation rate during COH.

Comparison of Day 2 Tubal Embryo Transfer with Day 3 Embryo Transfer into the Uterus of Intracytoplasmic Sperm Injection Derived Human Embryos

OBJECTIVE To compare the results of embryo transfer into the uterus (ET) performed on day 3 vs. tubal embryo transfer (TET) on day 2 in couples diagnosed with male factor infertility. MATERIALS AND METHODS We collected data from 34 and 110 patients who underwent intracytoplasmic sperm injection (ICSI) followed by either TET on day 2 or ET on day 3 (January 2001-June 2005), respectively. All couples were diagnosed with male factor infertility; there were no tubal or uterine factors, diminished ovarian reserve, pelvic adhesions, history of polycystic ovary syndrome or previous ovarian surgery. RESULTS The clinical pregnancy rates of day 2 TET and day 3 ET following ICSI were 64.71% and 57.27% (p > 0.05), respectively. The corresponding implantation rates were 35.47% and 29.58% (p > 0.05), respectively. CONCLUSION The implantation and clinical pregnancy rates of ET on the 3rd day following ICSI were similar to the rates obtained with TET 2 days after ICSI. Therefore, ET performed 3 days after ICSI should be the first choice for couples with male factor infertility, while day 2 TET remains a good alternative, especially for women with normal tubal function and known difficulties of transcervical ET.

Tubal Pregnancy Following Tubal Embryo Transfer into the Contralateral Fallopian Tube

Ectopic and heterotopic pregnancy may occur with increased frequency following assisted reproductive technology (ART) procedures. In addition, there may be unusual sites of implantation, which may cause atypical and confusing clinical manifestations. We present a case of tubal pregnancy after tubal embryo transfer (TET) to the contralateral fallopian tube. Four embryos were transferred to the left fallopian tube by laparoscopy, but the patient developed a right tubal pregnancy, possibly as a result of intrauterine or intra-abdominal migration of the embryo. ART patients must be followed closely soon after the procedure, and there should be a high index of suspicion for an unusual implantation site.