Shoshana Amit

Assisted hatching by partial zona dissection of human pre-embryos in patients with recurrent implantation failure after in vitro fertilization*

OBJECTIVE To examine the potential of the partial zona dissection technique to promote successful implantation by assisting embryo hatching after IVF. DESIGN The study and the control group included 72 and 82 patients, respectively, each had undergone at least three failed IVF-ET attempts. Assisted hatching was performed on four- to six-cell stage embryos by creating a slit in the zona pellucida using the partial zona dissection technique. After 90 minutes incubation (5% CO2, 37 degrees C), the embryos were transferred to the uterus. SETTING Infertility and IVF Unit of an academic tertiary referral medical center. RESULTS In the assisted hatching group, 230 micromanipulated embryos were replaced (3 or 4 treated embryos per patient) compared with 295 nonmanipulated embryos in the control group. Clinical pregnancy rates (PRs) were similar in the assisted hatching and control groups (n = 15; 20.8% and n = 12; 14.6%, respectively). However, the contribution of assisted hatching by partial zona dissection to successful implantation was related to the patientss age: patients older than 38 years showed a markedly higher PR after assisted hatching: 23.9% in the study group compared with only 7% of the controls. CONCLUSIONS These results demonstrate that assisted hatching by partial zona dissection is a quick and efficient method that does not induce any visible damage to the embryos replaced. In a selected group of patients (aged over 38 years, who have failed to conceive in at least three previous IVF attempts) it significantly increases the chances for pregnancy after ET.

The relationship between sperm parameters and fertilizing capacity in vitro: a predictive role for swim-up migration.

The relationship between sperm parameters and fertilizing capacity in vitro was examined retrospectively, with the aim of finding predictive criteria for successful in vitro fertilization. Three hundred thirty semen samples were used to inseminate 1462 oocytes. Conventional parameters of sperm concentration and percentage motility in the ejaculate as well as swim-up migration were analyzed in relation to fertilization rate. It was shown that the probability of fertilizing human oocytes in vitro decreases significantly when (a) the sperm concentration is below 20×106 spermatozoa/ml ejaculate (P=0.006), (b) motility is lower than 80% (P=0.002), or (c) less than 4×106 motile spermatozoa/ml are concentrated in the swim-up fraction (P<0.0001). It was also demonstrated that nonfertilizing sperm could not be distinguished from fertilizing sperm by the conventional criteria but rather by the average concentration of motile spermatozoa in the swim-up fraction [12.5±1.5 and 22.3±2.3×106/ml for the 0 and the 100% fertilization groups, respectively (mean±SE;P<0.01)]. Thus, the swim-up migration technique can serve as a predictive test for the in vitro fertilizing capacity of sperm.

Cutaneous graft-versus-host-like reaction after paternal lymphocyte immunization for prevention of recurrent abortion

We have presented an immunocompetent patient who, after paternal lymphocyte immunization, developed a GVH-like skin reaction; she recovered spontaneously. This complication is rarely seen. This was the only case observed in our series of over 70 patients immunized. A similar phenomenon was not reported in a larger series by Carp and colleagues (1). However, the case deserves special attention because this reaction can be life-threatening. Therefore, we suggest that paternal lymphocyte immunization should be recommended only for those patients who have undergone a thorough work-up and in whom all causes, other than immunological, for recurrent abortion have been excluded. Even then, this treatment should be given with utmost caution. In view of the above described complication, we believe that more data are still required to justify offering such a treatment modality on a routine basis.

Treatment variables in relation to oocyte maturation: lessons from a clinical micromanipulation-assisted in vitro fertilization program.

Objective: In an effort to understand the mechanism underlying the improved pregnancy rate observed in IVF cycles when gonadotropin-releasing hormone analogues (GnRH-a) are applied, we investigated a possible relationship between treatment variables and oocyte-nuclear maturity.Design: Nuclear maturity was retrospectively assessed in cumulus-free, denuded oocytes, obtained from women undergoing micromanipulation-assisted IVF treatment following controlled ovarian hyperstimulation with GnRH-a and menotropins.Setting: The setting was the infertility and IVF unit of a tertiary academic medical center.Participants: Two hundred twenty-one patients underwent 435 treatment cycles.Main Outcome Measure: This was the proportion of germinal vesicle-intact immature (GVII) oocytes.Results: One hundred fifty-four of the 3520 oocytes studied (4.4%) were in the GVII stage. These oocytes were found in 66 of the treatment cycles (15.2%) and in 54 of the patients (24.4%). Cycles in which GVII oocytes were detected did not differ from those in which all the aspirated oocytes were mature in the following respects: patient age, type and duration of infertility, controlled ovarian hyperstimulation protocol and time of ovum pickup. However, the GVII group was characterized by a significantly higher peak estradiol level, as well as a higher number of mature follicles visualized sonographically (diameter, >14 mm) and oocytes retrieved.Conclusions: Comparing the present findings with previously published data, it appears that the inclusion of GnRH-a in the stimulation regimen is associated with a lower proportion of immature oocytes. A higher occurrence of oocyte-nuclear immaturity is apparently associated with a significantly better ovarian response to stimulation. The high incidence of immature oocytes observed in patients with normospermic partners and low fertilization rates in previous cycles may suggest that the fertilization failure in some of these cases is due to oocyte, rather than sperm, dysfunction.

The initial flare-up induced by gonadotropin releasing hormone agonist may serve as a predictor of ovarian response in the current IVF-ET treatment cycle in normogonadotropic women aged 40-48 years.

AbstractObjective: Our purpose was to assess the potential role of the baseline hormone profile in combination with the initial pattern of response to gonadotropin releasing hormone (GnRH) analogue in predicting ovarian function and hence reproductive outcome in normogonadotropic patients aged 40 years or older undergoing IVF treatment. Patients and Methods: A retrospective analysis of 394 controlled ovarian hyperstimulation (COH) cycles that reached the stage of oocyte retrieval was conducted. The study included 163 normogonadotropic (serum FSH ≤15 IU/L) patients aged between 40 and 48 years who had regular menstrual cycles. Superovulation was achieved using menotropins in combination with GnRH analog (short protocol, beginning on menstrual day 2). The ovarian response was monitored on the third cycle day, the day following the first GnRH analogue administration. Results: Cycle distribution by patient age was 175 (44.4%), 122 (30.9%), and 97 (24.7%), while the patient distribution was 85 (52.2%), 48 (29.5%), and 30 (18.3%) for age groups 40–41, 42–43, and 44–48 years, respectively. The mean total dose of menotropins needed for optimal COH was 1787 IU (range, 600–6000 IU). This dose increased with age, while the yield of oocytes and embryos declined (P<0.05; ANOVA). A positive correlation was demonstrated between the E2 level on day 3 (GnRH analogue flare effect) and the outcome of the treatment cycle (number of oocytes and embryos). Using multiple stepwise regression analysis, it was demonstrated that the initial (day 3) serum E2 levels, combined with baseline FSH levels, patients age and body mass index enabled early prediction of the ovarian response in the current IVF-ET treatment cycle (oocytes=8.2−0.18×Age+0.17×BMI−0.12×FSH+0.0042×E2). Conclusions: Multiple-parameter analysis demonstrated that the use of the initial E2 response to GnRH analogue stimulation combined with basic clinical data may assist in the prediction of ovarian function and hence the reproductive outcome in normogonadotropic IVF patients aged 40 years or older. This may serve as a clinical tool for improving patient selection and treatment outcome in IVF-ET.

Immunosuppressive activity in culture media containing human oocytes fertilized in vitro.

A possible cause for implantation failure following embryo transfer is the rejection of pre-embryos by the maternal immune system. To elucidate the mechanisms underlying the rescue of the pre-embryo from maternal rejection, immunosuppressive activity was investigated in culture media containing human oocytes fertilized in vitro by employing the graft-versus-host reaction and the active rosette test. Normal donor lymphocytes were incubated with culture medium containing either fertilized or nonfertilized oocytes. Control experiments were carried out using lymphocytes incubated in culture medium only, as well as in culture medium containing human sperm. In 67% of the tests (12 out of 18), graft-versus-host reaction was inhibited, as compared to 29% of those performed with medium in which oocytes failed to fertilize (p less than .03), and 33% with medium in which only sperm was present. The frequency of an inhibitory active rosette test was similar in both groups. It is possible that immunosuppressive properties are acquired by the human pre-embryo as it grows in culture. Detection of such substances, which could contribute to the establishment of pregnancy, may improve monitoring of embryo quality prior to transfer.

Viscosity and refractive index of follicular fluid in relation to in vitro fertilization

AbstractPurpose: To set the standard values of follicular fluid viscosity and refractive index, and to investigate a possible relationship between these physiological parameters and the outcome of in vitro fertilization treatment. Design and Results: 128 samples of follicular fluid were collected from 40 in vitro fertilization patients. Viscosity determinations (centipoise; mean ± SD) for shear rates of 23, 46, 115, and 230 were 2.04±0.86, 1.84±0.49, 1.48±0.27, and 1.38±0.22, respectively. The average (± SD) refractive index was 1.030±0.002. There was no significant difference between the values of thawed frozen fluids and fresh samples of the same specimens. The data showed no correlation between follicular fluid viscosity or refractive index and the presence of oocytes, their maturation grade or their fertilizing capacity. Conclusions: For the first time, values of the viscosity and refractive index of follicular fluid obtained during in vitro fertilization have been determined. However, these preliminary results did not reveal any relationship between the physiological parameters examined and the outcome of in vitro fertilization treatment.

Practical and informative charts for in vitro fertilization and embryo transfer

ConclusionWe have attempted to provide IVF-ET programs with an information management system which is complementary to the patients infertility file. It can be used alone or as an entry format for computer storage. At present, two different computer programs (one on Digital VAX 11/780, another on Apple MacIntosh) based upon these forms have been written and are being simultaneously assessed. They can be easily modified to fit the needs of any program. As with all other aspects of IVFET, it will require frequent revisions and updates to retain its usefulness.