Timothy J. Gelety

The impact of sperm morphology evaluated by strict criteria on intrauterine insemination success

OBJECTIVE To determine the relationship between IUI success and the level of morphologically normal sperm, evaluated using strict criteria, in the raw semen. DESIGN Evaluation of semen quality characteristics and pregnancy results for 538 stimulated IUI cycles. SETTING University medical center infertility clinic. PATIENT(S) Women undergoing IUI with their partners semen as treatment for infertility (n = 193). INTERVENTION(S) Ovulation induction using clomiphene citrate, hMG, or both; preparation of raw semen using wash and swim-up or Percoll; deposition of prepared semen at the uterine fundus. MAIN OUTCOME MEASURE(S) Pregnancy status after IUI. Percentage morphologically normal sperm in raw semen, evaluated using strict criteria. Sperm concentration and percentage motile sperm in raw and prepared semen. RESULT(S) Pregnancy rates (PRs) per cycle were not different when the percentage of morphologically normal sperm in raw semen was < 5%, 5% to 9%, 10% to 19%, 20% to 29%, and > or = 30% (6.5% +/- 3.9%, 13.6% +/- 3.2%, 8.8% +/- 2.4%, 7.1% +/- 2.5%, and 9.7% +/- 3.3%, respectively). Pregnancy rates did not differ among age groups, infertility diagnoses, ovarian stimulation protocols, or semen preparation methods. CONCLUSION(S) The percentage of morphologically normal sperm in the raw semen, as judged by strict criteria, did not affect IUI PR. Intrauterine insemination appears to be a successful treatment modality for male factor infertility, even when the percentage of morphologically normal sperm in raw semen is very low.

Optimal use of fresh and frozen-thawed testicular sperm for intracytoplasmic sperm injection in azoospermic patients

Purpose: To optimize the use of fresh and frozen-thawed testicular biopsy specimens from patients with azoospermia.Methods: Fifty-one patients suffering from obstructive and non-obstructive azoospermia underwent testicular sperm extraction (TESE). The specimens were divided and used for either in vitro maturation or freezing for a future intracytoplasmic sperm injection (ICSI) cycle.Results: At initial testicular sperm extraction, very few motile spermatozoa were seen. After 24 h of in vitro maturation, sperm motility increased remarkably, with a maximum motility rate seen between 48 and 72 h of culture. Motile spermatozoa were observed up to 120 h in culture. In the 22 fresh ICSI cycles, a total of 294 oocytes were injected using motile sperm and 212 oocytes demonstrated normal 2PN formation (fertilization rate, 72.1%). In 36 frozen-thawed ICSI cycles, a total of 454 oocytes were injected and 302 oocytes became 2PN (66.5%). On day 3, high quality embryos were observed in 54.2% of fresh cycles and 54.1% of frozen cycles (P > 0.05). The clinical pregnancy rate did not show a significant difference between using fresh (59%) and frozen (55.5%) testicular biopsy sperm for ICSI (P > 0.05), but the embryo implantation rates did differ significantly between fresh (29.5%) and frozen-thawed (22.2%) cycles (P < 0.05). A total of 33 healthy babies have been born from 22 women, giving birth after 58 embryo transfer attempts (38%).Conclusion: The freezing and in vitro culturing of testicular biopsy tissue is a very reliable approach for the management of testicular biopsy specimens from azoospermic patients, and offers the possibility of several treatments of IVF/ICSI from a single sample.

Prematurely condensed chromosomes and meiotic abnormalities in unfertilized human oocytes after ovarian stimulation with and without gonadotropin-releasing hormone agonist

OBJECTIVE To investigate the incidence of meiotic abnormalities, aneuploidy, and prematurely condensed sperm chromosomes in failed fertilized oocytes after controlled ovarian hyperstimulation (COH). DESIGN Retrospective analysis of air-dried preparations of unfertilized oocytes. SETTING University hospital-based infertility clinic. PATIENT(S) Thirty-three patients undergoing IVF having only tubal factor as the cause of infertility. Twelve patients (13 cycles) underwent treatment with hMG alone (-GnRH agonist [GnRH-a]), and 21 patients (24 cycles) underwent treatment with leuprolide acetate (LA) and hMG (+GnRH-a group). INTERVENTION(S) Standard IVF-ET treatment cycle for ovarian stimulation using hMG with or without LA. MAIN OUTCOME MEASURE(S) The meiotic stage, ploidy, and the presence of prematurely condensed sperm chromosomes were determined in 161 air-dried preparations of unfertilized oocytes. RESULT(S) Significantly more unfertilized oocytes were at metaphase II in the -GnRH-a group as compared with the +GnRH-a group, with significantly fewer exhibiting meiotic aberrations. Aneuploidy rates did not differ between groups. However, significantly more oocytes in the +GnRH-a group revealed prematurely condensed sperm chromosomes than in the -GnRH-a group. CONCLUSION(S) The use of GnRH-a for COH does not have an impact on aneuploidy rates in failed fertilized oocytes. However, the higher incidence of meiotic aberrations and prematurely condensed sperm chromosomes in the unfertilized population indicates that some retrieved oocytes exhibit incomplete nuclear and cytoplasmic maturation after the use of this agonist.

Maternal serum dehydroepiandrosterone sulfate levels and the efficiency of labor in young nulliparas

Objective To evaluate the maternal serum dehydroepiandrosterone (DHEA) sulfate level as a factor influencing labor “efficiency” at term. Methods On admission to the labor and delivery unit, blood was collected from 55 term nulliparous women up to 25 years of age in active labor. Following delivery, umbilical venous cord blood was also collected. Pregnancies complicated by diabetes mellitus, hypertension, fetal growth restriction, tobacco use, corticosteroid use, or chorioamnionitis were excluded. Serum DHEA sulfate levels were measured by radioimmunoassay. Dehydroepiandrosterone sulfate levels and other obstetric variables were correlated retrospectively with the clinically determined requirement for oxytocin augmentation of labor. The unpaired Student t test, Mann-Whitney test, and linear correlation were used for statistical analysis. P < .05 was considered statistically significant. Results Oxytocin augmentation followed standard indications in 29 of the 55 patients. The mean (± standard error) maternal serum DHEA sulfate level was significantly lower in these patients than in the remaining 26 who progressed spontaneously through labor (99.31 ± 8.92 versus 135.05 ± 12.30 μg/dL, respectively; P = .02). With the exception of cervical dilation on admission, no significant demographic differences were identified between the two groups. The maternal serum DHEA sulfate level did not correlate significantly with cervical dilation on admission (r = 0.03, P = .81). Conclusion Among term nulliparous women, maternal serum levels of DHEA sulfate are significantly lower in those clinically requiring pharmacologic augmentation than in those progressing spontaneously through labor. Dehydroepiandrosterone sulfate may be an important factor in efficient labor.

Understanding reproducibility of human IVF traits to predict next IVF cycle outcome

PurposeEvaluating the failed IVF cycle often provides useful prognostic information. Before undergoing another attempt, patients experiencing an unsuccessful IVF cycle frequently request information about the probability of future success. Here, we introduced the concept of reproducibility and formulae to predict the next IVF cycle outcome.MethodsThe experimental design was based on the retrospective review of IVF cycle data from 2006 to 2013 in two different IVF centers and statistical analysis. The reproducibility coefficients (r) of IVF traits including number of oocytes retrieved, oocyte maturity, fertilization, embryo quality and pregnancy were estimated using the interclass correlation coefficient between the repeated IVF cycle measurements for the same patient by variance component analysis. The formulae were designed to predict next IVF cycle outcome.ResultsThe number of oocytes retrieved from patients and their fertilization rate had the highest reproducibility coefficients (r = 0.81 ~ 0.84), which indicated a very close correlation between the first retrieval cycle and subsequent IVF cycles. Oocyte maturity and number of top quality embryos had middle level reproducibility (r = 0.38 ~ 0.76) and pregnancy rate had a relative lower reproducibility (r = 0.23 ~ 0.27). Based on these parameters, the next outcome for these IVF traits might be accurately predicted by the designed formulae.ConclusionsThe introduction of the concept of reproducibility to our human IVF program allows us to predict future IVF cycle outcomes. The traits of oocyte numbers retrieved, oocyte maturity, fertilization, and top quality embryos had higher or middle reproducibility, which provides a basis for accurate prediction of future IVF outcomes. Based on this prediction, physicians may counsel their patients or change patient’s stimulation plans, and laboratory embryologists may improve their IVF techniques accordingly.

Improving ART pregnancy rates using culture with two kinds of media and two types of incubators

OBJECTIVE: Culture media and incubator systems have played a key role in IVF. Improved commercial culture media show little significant difference for embryo culture. However, we have observed individual patient’s embryos to have different responses for two media and two incubators. The objective of this study is to determine patient’s embryo response to culture medium and incubation. DESIGN: Prospective control study. MATERIALS AND METHODS: 1850 2PN zygotes from 220 patients were studied. In the same dish, patient’s embryos were divided. One sibling was placed in global medium and another in P1 medium. Each microdroplet contained a single embryo for culture. If patients had more than 4 embryos, they were cultured in two incubators with single CO2 gas or triple-gas. The cleavage rate and embryo quality on Day 2 and day 3 was recorded and the response of embryos to medium was determined based on embryo quality. Finally, pregnancy rates were determined in each group. RESULTS: The cleavage (global vs P1: 97.5% vs 98.7%), top quality embryos on Day 2 (74.1% vs 74.7%) and Day 3 (65.1% vs 60.4%) were not statistically different between media. However, different patient’s embryos had different responses to media. 40% (70/174) patient’s embryos grew very well in either global medium or P1 medium. 29% (50/174) patient’s embryos grew well only in P1with poor quality in global, while 20% (35/174) grew well in the global but poorly in the P1. 12% (21/ 174) did not grow well in both. The pregnant rate was 40% (10/25) in P1and 42.5% (9/21) in global (P>0.05). However, when two media were used simultaneously, the pregnant rate increased to 70.1% (122/ 174). Also, when two media were cultured in two incubators, it had a significant higher pregnant rate than in single incubator (73.2% vs. 60%, P<0.05). CONCLUSION: The favorable response of individual patient’s embryos to media and incubation suggest that in IVF clinical practice, using two media and two incubators for embryo culture could significantly improve IVF/ ICSI pregnant rates.

Chapter 4 The Biology of the ovary

The mammalian ovary provides an ideal example of a dynamic organ that evolves through a characteristic life cycle which closely follows the life cycle of the female. This cycle is initiated during prenatal life and progresses through the neonatal interval to reach the climax of its activity during the period of sexual maturity prior to entry into a phase of gradual senescence before reaching menopause. The prenatal period is characterized by ovarian differentiation, germ cell formation, and the entry of a finite number of germ cells into oogenesis. While follicle formation begins prenatally, so also does the process of follicular atresia, whereby there is a gradual attrition of the predetermined pool of germ cells. During the neonatal interval, the cycle of folliculogenesis and atresia continues resulting in a progressive decrease in the number of germ cells, and thus the reproductive potential of the individual. Superimposed on the period of sexual maturity is the menstrual cycle which, in contrast to the other phases of the ovarian cycle, is measured in days, rather than in months or years. It is during the menstrual cycle that the ovary fulfills its two primary physiological responsibilities: the release of a meiotically mature haploid egg with foil developmental competency, and the production of the two steroid hormones, estradiol and progesterone. Both these activities are accomplished in an integrated, repetitive fashion involving a variety of heterogenous cell types organized into follicular units embedded within the ovarian stroma. The regulation of these activities is predominantly via the hormonal interplay between the ovary and the hypothalamic-pituitary axis, but is defined by a single, transitory subunit, the domi nant follicle. During the perimenopausal period, follicular function wanes, diminishing steroid production and overall reproductive potential. An accelerated attrition of the germ cell pool, as well as a decline in the quality of the remaining oocytes, are also major factors in the decline in fecundity. Such decline culminates, following the menopause, in exhaustion of the germ cell pool and cessation of ovarian steroid function.