P. Drakakis

Oocyte morphology correlates with embryo quality and pregnancy rate after intracytoplasmic sperm injection

OBJECTIVE To evaluate the relation of oocyte morphology with embryo quality and pregnancy rates (PRs) after intracytoplasmic sperm injection (ICSI). DESIGN Retrospective study of patients undergoing ICSI. SETTING University Hospital IVF Center. PATIENT(S) Sixty-eight patients who underwent ICSI and had transfer of good-quality embryos (grade 3), 60 patients with transfer of both good- and poor-quality embryos (grade 3 and grade 2), and 18 patients with transfer of poor-quality embryos (grade 2). INTERVENTION(S) Comparison of the outcome of ICSI in the three groups of patients and the relation of oocyte morphology to embryo quality. MAIN OUTCOME MEASURE(S) Oocyte morphology and embryo quality (grade). Fertilization, cleavage, and pregnancy rates. Serum E2 on the day of hCG administration. RESULT(S) Oocytes with poor morphology (dark cytoplasm; many vacuoles or fragments in cytoplasm) led to poor-quality embryos and consequently to lower PRs (5.5% versus 29.4%). Serum E2 on the day of hCG administration was significantly higher in the group with good-quality embryos compared with that with poor-quality embryos (2,047 +/- 135.7 versus 1,651 +/- 164.8 pg/mL, respectively). CONCLUSION(S) Serum E2 on the day of hCG administration is a marker of embryo quality. Oocyte morphology correlates well with embryo quality and PRs after ICSI.

Birth of two infants who were seronegative for human immunodeficiency virus type 1 (HIV-1) after intracytoplasmic injection of sperm from HIV-1-seropositive men

OBJECTIVE To report two cases of live births after intracytoplasmic sperm injection (ICSI) in two women who were seronegative for human immunodeficiency virus type 1 (HIV-1) after the use of processed semen from their seropositive husbands. DESIGN Case reports. SETTING University hospital IVF center. PATIENT(S) Two HIV-1 seropositive men and their HIV-1 seronegative female partners; all gave their informed consent in writing before undergoing the ICSI procedures. INTERVENTION(S) The men provided semen samples that were processed with the use of Percoll and swim-up techniques. Ovarian stimulation in the women was performed with the long protocol using GnRH analogs and recombinant FSH. ICSI was performed. MAIN OUTCOME MEASURE(S) Oocytes were fertilized by ICSI, and the resulting embryos were transferred to the patients. The mothers and babies were tested for HIV-1 antibodies. RESULT(S) In the first case, seven mature oocytes were collected and fertilized with ICSI, and three embryos were transferred; the woman became pregnant and gave birth to a healthy boy. Six months after the birth, testing for HIV-1 antibodies in the woman and the baby gave negative results. In the second case, 10 mature oocytes were collected and fertilized with ICSI, and four embryos were transferred; the second woman became pregnant and also gave birth to a healthy boy. Testing for HIV-1 antibodies at the babys delivery also gave negative results. CONCLUSION(S) In women who are infertile because of fallopian tube obstruction or in men who have poor quality semen for artificial insemination, ICSI can be performed using processed semen. This method, which involves the use of only one spermatozoon per oocyte, provides HIV-1 seropositive men with the opportunity to have children with a minimal risk-if any-of infecting their female partners.

Biological Factors in Culture Media Affecting in Vitro Fertilization, Preimplantation Embryo Development, and Implantation

Abstract: Optimal culture conditions are of paramount importance for in vitro fertilization of gametes, preimplantation embryo development, and implantation for all species. Water is the basis of all culture media, and ultrapure water should be employed. The main energy sources of a medium are lactate, pyruvate, and glucose. The concentrations of the first two vary in different media, whereas the latter is necessary mainly for the later stages (morula to blastocyst) of development. A fixed nitrogen source is essential for implantation embryo development whether this is provided by amino acids, albumin, or serum. Suboptimal culture conditions can block development. Pronuclear zygotes of most species (but not human) arrest at some point between the two‐cell and the 16‐cell stage. Modifying culture conditions can lead the embryos to develop through this block. Hypoxanthine also causes a two‐cell block to mouse pronuclear zygotes, and this again depends largely on culture conditions. Simple culture media are bicarbonate‐buffered systems with pyruvate, lactate, and glucose. Complex media, such as Hams F‐10, contain in addition amino acids and other elements found in serum. Human tubal fluid simulates the fallopian tube microenvironment. EDTA, gonadotropins, growth factors, and other substances can be included in the media to stimulate development. Coculture of embryos with oviductal cells has shown promising results.

Different ovarian stimulation protocols for women with diminished ovarian reserve.

PurposeTo review the available treatments for women with significantly diminished ovarian reserve and assess the efficacy of different ovarian stimulation protocols.MethodsLiterature research performed among studies that have been published in the Pubmed, in the Scopus Search Machine and in Cohrane database of systematic reviews.ResultsA lack of clear, uniform definition of the poor responders and a lack of large-scale randomized studies make data interpretation very difficult for precise conclusions. Optimistic data have been presented by the use of high doses of gonadotropins, flare up Gn RH-a protocol (standard or microdose), stop protocols, luteal onset of Gn RH-a and the short protocol. Natural cycle or a modified natural cycle seems to be an appropriate strategy. Low dose hCG in the first days of ovarian stimulation has promising results. Molecular biology tools (mutations, single nucleotide polymorphisms (SNPs)) have been also considered to assist the management of this group of patients.ConclusionsThe ideal stimulation for these patients with diminished ovarian reserve remains a great challenge for the clinician, within the limits of our pharmaceutical quiver.

Alternative Approaches in the Management of Poor Response in Controlled Ovarian Hyperstimulation (COH)

Abstract: Improving pregnancy rates in patients with many failed attempts remains a challenge during IVF‐ET or ICSI‐ET programs. The availability of good‐quality oocytes is a prerequisite for good results in such programs. The use of a personalized protocol for controlled ovarian hyperstimulation (COH) that gives the best possible results for the specific patient is a main factor for the success in IVF or ICSI. The response of many patients to the ovarian stimulation used is very poor, giving fewer oocytes than expected, resulting in much lower, if any, pregnancy rates. The definition of a poor responder is not clear and differs among researchers. A variety of strategies have been used to improve response in these patients, regardless of the definition used. These include various ovulation induction protocols that we believe might assist these patients achieve a pregnancy. The difficulty is greater due to the fact that poor responders are not a homogeneous group and each patient may have a different cause. More studies with large numbers of patients are needed in order to find those protocols that could provide these couples with an acceptable pregnancy rate.

Oocyte donation to women over 40 years of age: pregnancy complications

Recently, oocyte donation to women of advanced age has led to a considerable number of conceptions, thus increasing the age limit for becoming pregnant. A main consideration encountered by physicians, though, is the potential medical and obstetric complications of a pregnancy at an advanced age. In this study, the obstetric complications, as well as the perinatal outcome, of pregnancies of aged recipients (above 40) are presented and compared to those of younger recipients. A significantly higher incidence of gestational diabetes (P < 0.001), an increased incidence of pre-eclampsia (at the 10% level of significance) and an increased risk for thrombophlebitis (again at the 10% level) was observed in the older patients, but a careful follow-up during their pregnancy led to a highly satisfactory obstetric and perinatal outcome. A rigorous precycle medical screening (especially for cardiovascular diseases and diabetes) and a careful follow-up during pregnancy is, therefore, imperative so that oocyte donation to older women is not withheld and continues to provide fertility possibilities to otherwise sterile patients.

A preliminary study of the effect of growth hormone on mouse preimplantation embryo development in vitro

The role of growth hormone (GH) in follicular development, ovulation and embryo development is currently under reconsideration. In this study, we have tried to investigate the effect of GH on preimplantation development of mouse embryos in vitro. Zygotes and two-cell mouse embryos were cultured without (control) or with GH. For zygotes, the addition of 0.2 micrograms/ml of GH resulted in 77 +/- 1% of blastocysts formed and 66 +/- 3% rate of hatching (control 64 +/- 4 and 31 +/- 3%, p < 0.05 and p < 0.01, respectively). For two-cell embryos, the addition of 0.2 micrograms/ml of GH resulted in 87 +/- 2% of blastocysts formed and 60 +/- 4% hatching rate (control 76 +/- 4 and 47 +/- 5%, p < 0.05 for both). This positive effect of GH addition implies that the latter can support mouse preimplantation development in vitro and it suggests, along with its local action on the ovary and its possible effects, via the insulin-like growth factor system, on the tubal and uterine epithelium, a continuous role of this hormone in reproductive physiology from follicular maturation to embryonic development and, possibly, implantation.

Follicle-Stimulating Hormone Receptor Gene Mutations Are Not Evident in Greek Women with Premature Ovarian Failure and Poor Responders

Background/Aims: This clinical and molecular study aimed to investigate the presence of follicle-stimulating hormone (FSH) receptor gene mutations in women with premature ovarian failure (POF) and poor responders to in vitro fertilization treatment. Methods: DNA was extracted from blood samples for subsequent polymerase chain reaction (PCR). PCR was followed by restriction fragment length polymorphism and direct sequencing. Results: No inactivating mutations reported so far were identified in exons 6, 7, and 10 in women with POF and poor responders. Conclusion: FSH receptor gene mutations are not frequent in Greek patients with POF as is the case in the rest of the world except for cases with ovarian dysgenesis in Finland.

Factors affecting postoperative pregnancy rate after endoscopic management of large endometriomata

Objective: To identify factors influencing postoperative pregnancy rate in women with extensive endometriosis and large endometriomata as the only identified cause of infertility that were treated by laparoscopy. Method: Sixty‐four infertile patients with endometriomata (≥3 cm) and no other apparent cause of infertility. The latter were removed by operative laparoscopy. Life table calculations, the Students t‐test and the χ2 test were used where appropriate. Result: Thirty‐four patients (53%) became pregnant during the 2‐year follow‐up period. A significantly increased pregnancy rate was found for the first year compared to the second (76 vs. 24%). The existence of adhesions affected adversely the outcome of the operation only as far as early achievement of pregnancy is considered. The number and size of endometriomata and the existence of peritoneal implants have not been found to affect pregnancy rates. The severity of the disease did not affect pregnancy rate, but in the cases with moderate disease most of the pregnancies were achieved during the first postoperative year. The duration of infertility was significantly associated only at the 10% level with decreased pregnancy rates. Conclusion: Extensive endometriosis with large endometriomata can be safely and effectively treated with laparoscopy using the traditional laparoscopic tools providing the infertile patient with a high chance to conceive in a relatively short period of time postoperatively.

THE ROLE OF STEROID HORMONES IN ART

Steroid hormones hold a major role in female fertility and their proper utilisation and monitoring in modern assisted reproduction protocols is important. Oocyte maturation and endometrial receptivity are the two major factors that appear to be related to a successful outcome in Assisted Reproductive Technology (ART). Many reports suggest that oocyte immaturity accounts for a considerable loss of efficiency in ART, mainly due to the poor quality of the obtained embryos and their inability to develop normally. Oestrogen appears to exert its effects on the cytoplasmic maturation of the oocyte, while progesterone has been shown to accelerate meiotic resumption. Moreover, ovarian stimulation appears to affect the normal luteal function and shifts in the window of implantation as a response to hormonal supplementation have also been observed. The ethical limitations in conducting in vivo studies of human implantation, have led to an indirect hormonal- and morphologic-oriented assessment of endometrial receptivity. The two main protocols of luteal support involve either progesterone supplementation or hCG administration, whereas the combined supplementation with oestradiol remains controversial. This brief review aims to summarize the current knowledge on steroidal actions during the above processes and to address their potential use in the improvement of current ART protocols.