S.L. Tan

Obstetric outcome of in vitro fertilization pregnancies compared with normally conceived pregnancies.

OBJECTIVE To compare the obstetric outcome of in vitro fertilization pregnancies with normally conceived pregnancies. STUDY DESIGN The obstetric outcome of in vitro fertilization pregnancies achieved in 763 British residents at two in vitro fertilization clinics resulting in the births of 961 babies were compared by means of the relative risk statistic with a control group of naturally conceived primiparous pregnancies matched by maternal age and multiplicity of pregnancy. RESULTS Twenty-five percent of in vitro fertilization pregnancies were multiple pregnancies. The incidence of singleton term breech presentation was similar to that among controls. As compared with controls there was an increased incidence among in vitro fertilization pregnancies of vaginal bleeding and hypertension requiring hospitalization (p less than 0.001) and cesarean births (p less than 0.001) and, among in vitro fertilization singleton pregnancies, an increased incidence of intrauterine growth retardation (p less than 0.05), placenta previa (p less than 0.05), and preterm delivery (p less than 0.001). The congenital malformation, stillbirth, and perinatal mortality rates were comparable with maternal age-standardized national rates. CONCLUSIONS Although the majority of in vitro fertilization pregnancies have a satisfactory obstetric outcome, there are a number of increased obstetric risks that may reflect the history of infertility, the relatively high incidence of poor obstetric history, and the lower threshold for obstetric intervention in in vitro fertilization patients.

In-vitro maturation of human oocytes

Immature human oocytes can be matured and fertilized in vitro. However, subsequent embryonic development is different when the immature oocytes are retrieved in different situations. Exposure to the LH surge in vivo may be important for the oocytes to acquire the competence for maturation and subsequent embryonic development. The size of the follicles may also be an important feature for subsequent embryonic development. However, the developmental competence of oocytes derived from small antral follicles does not seem to be adversely affected by the presence of a dominant follicle. Oocyte maturation in vitro is profoundly affected by culture conditions. Gonadotrophins are required for oocyte maturation in vivo, but any requirement in vitro is still unclear. Recent clinical results from in-vitro matured (IVM) human oocytes are promising, although further research remains to be done in order to address the mechanisms of oocyte maturation and to improve culture conditions and also the implantation rate of embryos generated from IVM oocytes.

Priming with human chorionic gonadotropin before retrieval of immature oocytes in women with infertility due to the polycystic ovary syndrome.

To the Editor: Women who have infertility due to anovulation in association with the polycystic ovary syndrome are particularly difficult to treat. A substantial proportion have no response to the ...

Transvaginal three-dimensional ultrasound: accuracy of follicular volume measurements*

OBJECTIVES To evaluate the accuracy of three-dimensional (3-D) ultrasound (US) follicular volume measurements. DESIGN Prospective clinical study. SETTING A tertiary referral center for assisted reproduction. PATIENTS Twenty-five patients undergoing ovarian stimulation for IVF-ET using the long protocol of GnRH agonist. INTERVENTION Transvaginal two-dimensional (2-D) and 3-D ovarian scan performed immediately before US-directed follicle aspiration. MAIN OUTCOME MEASURES The volume of follicular fluid aspirated was compared with the corresponding volume of the follicle measured by 3-D US and with the conventional 2-D US volume measurement calculated using the formula pi/6 (D1 x D2 x D3). Limits of agreement and 95% confidence intervals were calculated and systematic bias between the methods was analyzed. RESULTS The limits of agreement between the volume of follicular aspirate and follicular volume determined by US were +0.96 to -0.43 mL for 3-D measurements and +3.47 to -2.42 mL for 2-D measurements. CONCLUSIONS The true volume of ovarian follicles, within the clinically useful range for IVF-ET cycles, is measured more accurately by a 3-D US system than by 2-D US techniques.

The long protocol of administration of gonadotropin-releasing hormone agonist is superior to the short protocol for ovarian stimulation for in vitro fertilization

Objective To investigate whether pituitary desensitization with the gonadotropin-releasing hormone agonist (GnRH-a), buserelin acetate, before the administration of human menopausal gonadotropin (hMG) for ovarian stimulation in in vitro fertilization (IVF) is superior to the simultaneous administration of both hormones at the beginning of the treatment cycle. Design Prospective randomized study. Patients Ninty-one patients having their first attempt at IVF. Interventions Patients in group 1 (long protocol) were administered subcutaneous (SC) buserelin acetate 200 μ g/d from day 1 of the menstrual cycle, and hMG was started only after pituitary desensitization had been achieved at least 14days later. Patients in group 2 (short protocol) were administered SC buserelin acetate 200 μ g/d from day 2 and the same dose of hMG used in the long protocol from day 3 of the menstrual cycle. Results The median total amount of hMG required in both groups was comparable. There were significantly more follicles ( P =0.0001), oocytes ( P =0.0008), fertilized oocytes ( P =0.0001), and cleaved embryos ( P =0.0001), and a higher fertilization rate ( P =0.0047) in patients in group 1. The pregnancy rates per initiated cycle and per embryo transfer were 19.57% and 25.71% in group 1 compared with 8.89% and 16.67% in group 2. Conclusions The long protocol is superior in terms of significantly greater follicular recruitment, oocyte recovery and fertilization rates, and significantly greater number of embryos available for transfer. In general, it is the preferred method when GnRH-a are used for ovarian stimulation in IVF.

Pregnancies resulting from in vitro matured oocytes retrieved from patients with polycystic ovary syndrome after priming with human chorionic gonadotropin.

OBJECTIVE To describe pregnancies that resulted from in vitro matured oocytes derived from two unstimulated, anovulatory patients with polycystic ovary syndrome after priming with hCG before oocyte retrieval. DESIGN Case series. SETTING McGill Reproductive Center, Royal Victoria Hospital, McGill University. PATIENT(S) Two women with polycystic ovary syndrome. INTERVENTION(S) Progesterone induction of a withdrawal bleeding episode. The administration of subcutaneous hCG 36 hours before oocyte retrieval in a natural menstrual cycle. In vitro maturation of immature oocytes, fertilization, and ET. Luteal support with oral estrogen and progesterone. MAIN OUTCOME MEASURE(S) Pregnancy outcome. RESULT(S) Two clinical pregnancies were confirmed after oocyte maturation in vitro, fertilization with intracytoplasmic sperm injection, and ET. CONCLUSION(S) The administration of hCG 36 hours before harvesting of immature oocytes may improve the maturational and developmental competence of the oocytes and the pregnancy rates of unstimulated patients with polycystic ovary syndrome.

Production of steroids from human cumulus cells treated with different concentrations of gonadotropins during culture in vitro

OBJECTIVE To evaluate the output of E2 and progesterone produced by cumulus cells, derived from mature and immature oocytes, in culture medium. DESIGN Prospective randomized study. SETTING McGill Reproductive Center, Royal Victoria Hospital, McGill University, Montreal, Quebec, Canada. PATIENT(S) Twenty-one women, <38 years of age and with normal menstrual cycles, who were undergoing intracytoplasmic sperm injection for assisted reproduction. INTERVENTION(S) Culture medium with or without fetal bovine serum (FBS) supplemented with either a physiologic (75 mIU/mL) or a supraphysiologic (7,500 mIU/mL) concentration of gonadotropins. MAIN OUTCOME MEASURE(S) Comparison of steroid levels in culture medium. RESULT(S) Estradiol secretion was significantly increased in the culture medium with FBS supplemented with both concentrations of FSH alone compared with control. However, E2 secretion was inhibited by both concentrations of FSH with LH. The level of E2 was undetectable in the medium without FBS even after supplementation with both concentrations of FSH alone, hCG alone, and FSH with LH. Progesterone production was increased in the medium with FBS supplemented with FSH alone, hCG alone, and FSH with LH compared with control. There was no difference in progesterone levels in the culture medium without FBS supplemented with both concentrations of FSH alone and hCG alone compared with control. However, progesterone secretion was increased in the medium without FBS supplemented with a physiologic concentration of FSH with LH. CONCLUSION(S) Culture medium with FBS supplemented with a physiologic and a supraphysiologic concentration of FSH stimulates E2 secretion from cumulus cells derived from mature and immature oocytes. This suggests that it may be not necessary to add E2 to the culture medium for maturation in vitro of immature human oocytes retrieved from patients undergoing stimulated cycles.

The efficiency of male fertility restoration is dependent on the recovery kinetics of spermatogonial stem cells after cytotoxic treatment with busulfan in mice

BACKGROUND Spermatogonial stem cells (SSCs) are the foundation of spermatogenesis and represent a crucial resource for male fertility restoration. It has not been well documented, however, whether the recovery of SSC population size after cytotoxic damage associates with the kinetics of male fertility restoration. We addressed this issue using the mouse as a model. METHODS Following single injections of busulfan at 15, 30 or 45 mg/kg into male mice, we examined their ability to sire offspring at different times by natural mating and determined SSC numbers using spermatogonial transplantation. We measured testis physiological parameters (testis weights, sperm counts, serum and intratesticular testosterone levels, and histological assessments of spermatogenic recovery) and quantified the expression of glial-cell-line-derived neurotrophic factor (GDNF) transcripts. RESULTS Regardless of busulfan doses, fertility was lost within 4 weeks after treatment, while more than 95% of SSCs were lost within 3 days. Fertility and SSC numbers gradually recovered with time, but the recoveries were delayed at higher busulfan doses. Interestingly, SSC numbers reached ∼30% of before-treatment levels by 4 weeks prior to the time of fertility restoration, across the dose groups. Sperm counts were ∼20% of before-treatment levels at the onset of fertility restoration, regardless of busulfan doses. We detected a significant increase in total GDNF mRNA per testis immediately after busulfan treatment. CONCLUSIONS The loss and restoration of fertility after busulfan treatment are direct consequences of SSC loss and expansion. Our data suggest that there is a threshold in SSC numbers that allows for male fertility restoration and that the testicular somatic environment responds rapidly and temporarily to the loss of spermatogonia, including SSCs, by altering GDNF mRNA levels. This study provides fundamental information to clinically apply SSCs for male fertility restoration in the future.

Maturational and developmental competence of cumulus-free immature human oocytes derived from stimulated and intracytoplasmic sperm injection cycles

The present experiments compared the maturational and developmental competence of immature oocytes derived from stimulated cycles, following culture in a newly designed in-vitro maturation medium (IVM-medium) or in standard tissue culture medium (TCM-199; control). The results indicated that maturation and fertilization rates were comparable when the cumulus-free M-I stage oocytes were matured in the IVM-medium (78.6%) or the control medium (70.8%). However, there was a significant difference in blastocyst development (P < 0.05) when M-I oocytes were matured in these two media (19.6 versus 7.7%). Both maturation and early embryonic development rates of GV-stage oocytes were significantly higher (P < 0.01) in the IVM-medium (maturation: 75.7%; blastocyst: 12.9%) compared with control (maturation 55.7%; blastocyst: 0.0%). Moreover, embryos developed to the blastocyst stage at a higher rate in both media if GV-stage oocytes had matured within 24 h compared with 48 h of culture. These results demonstrate that immature human oocytes derived from stimulated ovaries can achieve maturation and early embryonic development in vitro, especially in the new IVM-medium, which may allow additional embryos to be produced for clinical use at embryo transfer.

Fertility preservation treatment for young women with autoimmune diseases facing treatment with gonadotoxic agents

OBJECTIVE To describe a case series of seven women with SLE and other systemic autoimmune rheumatic diseases (SARDs) who required cyclophosphamide therapy and underwent fertility preservation treatments. METHODS Of the seven patients reported here, five women had SLE with nephritis, the sixth had immune thrombocytopenia purpura (ITP) and the seventh had microscopic polyangiitis (MPA) with renal involvement. All women were nulliparous and younger than 35 yrs. RESULTS Patients with SLE underwent in vitro maturation (IVM) of immature oocytes aspirated during a natural menstrual cycle followed by vitrification of the matured oocytes if a male partner was not available, or vitrification of embryos if one was available. The patient with ITP and the patient with MPA underwent gonadotropin ovarian stimulation followed by oocyte or embryo vitrification. All women completed fertility preservation treatment successfully and mature oocytes or embryos (36 and 13, respectively) were vitrified. No complications were associated with this treatment and cytotoxic therapy was initiated as scheduled in all cases. CONCLUSIONS Oocyte or embryo cryopreservation should be considered for fertility preservation in young women with SARDs who face imminent gonadotoxic treatment. In patients, where gonadotropin ovarian stimulation is deemed unsafe, IVM of immature oocytes, aspirated during a natural menstrual cycle, followed by vitrification or fertilization of the mature oocytes, seems to be safe and feasible. For patients in whom hormonal ovarian stimulation is not contraindicated, this method may be considered depending on the urgency to start cytotoxic therapy.