Beta-Endorphin levels in the preovulatory follicles and the outcome of in vitro fertilization

The level of immunoreactive beta-endorphin-like (IR--EP) material(s) was determined in follicular fluid samples obtained from patients treated for in vitro fertilization (IVF). Follicles containing morphologically mature oocytes had slightly lower concentrations of IR--EP. The total IR--EP content was similar in follicles with oocytes at different degrees of maturity. A smaller amount of IR--EP in the follicle fluid was associated with a greater developmental potential of the oocytes, which formed embryos that reached the three- to six-cell stage at 40–44 hr after insemination (r=–0.35, P<0.026). A higher IR--EP content was seen in fluid samples containing oocytes that remained uncleaved after fertilization (P<0.05 by Duncan's multiple-range test).     

Oocyte fertilizability and hormonal environment of human preovulatory follicles in hyperstimulated cycles in an in vitro fertilization program: Are mature preovulatory follicles undergoing atresia?

Steroid hormones in preovulatory follicular fluid, maturity of the oocyte-corona-cumulus complex (OCCC), and oocyte fertilizability were studied in 55 hyperstimulated cycles in 40 patients who were indicated for in vitro fertilization and embryo transfer due to tubal infertility. Aspirated follicles were categorized into four groups according to the degree of oocyte maturation and fertilizability, i.e. follicle (Fol)-1 (non-fertilized, intermediate maturation), Fol-2 (fertilized, intermediate maturation), Fol-3 (fertilized, full maturation), and Fol-4 (non-fertilized, full maturation). Estradiol (E2), progesterone (P), and delta 4- androstenedione (delta 4A) concentrations were highest in Fol-3, being lower in Fol-2 and Fol-1 sequentially. Fol-3 contained significantly more E2 and P than did Fol-1, showing that the degree of oocyte maturation and fertilizability correlate with concentrations of E2 and P in the follicles. A comparison of Fol-3 and Fol-4 revealed significantly higher concentrations of delta 4A in Fol-4, whereas differences in E2 and P concentrations were not significant although Fol-4 values were lower. This comparison indicated that Fol-4 were already undergoing atresia at the time of oocyte retrieval, containing morphologically mature OCCC which had lost fertilizability. This study shows that steroid hormones in the follicular fluid reflect oocyte viability and fertilizability, and suggests that preovulatory follicles with mature oocytes can also undergo atresia.     

Hysteroscopy in a program of in vitro fertilization

Two hundred twenty-four women underwent hysteroscopic evaluation without anesthesia after at least two failed attempts of in vitro fertilization and embryo transfer. One hundred fifty-three (68%) women were diagnosed as having mechanical infertility, and abnormal hysteroscopic findings were observed in 32 (21%). Forty-one women were diagnosed as having unexplained infer-tility (18%) and six (15%) had abnormal findings with hysteroscopy. Of the 30 couples who entered the in vitro fertilization regimen program because of male infertility, 4 (13%) had abnormal findings. The overall rate of abnormal findings was 19%; cervical canal and intrauterine abnormalities were found in 10 and 32 patients, respectively. Ten patients were treated during hysteroscopic evaluation procedure, and four patients subsequently underwent operative hysteroscopy under general anesthesia. We suggest that diagnostic hysteroscopy should be a routine procedure before in vitro fertilization and embryo transfer therapy.     

Office hysteroscopy in an in vitro fertilization program

Objective. In the present paper we evaluate the incidence of intrauterine pathologies in a population undergoing in vitro fertilization (IVF) treatment. Moreover, we compare the IVF outcome between patients with normal and abnormal uterine findings to determine if office hysteroscopy (OH) is of any clinical significance.

Methods. The hysteroscopic findings in 866 consecutive patients were analyzed. The study group included 555 patients at the first IVF attempt and 311 patients with two or more failed IVF cycles.

Results. All hysteroscopic parameters were considered normal in 514 cases (59.4%); in 352 cases (40.6%) various pathological conditions were found. Patients were divided into two groups according to the hysteroscopic findings. The implantation and pregnancy rates were similar between the groups. Comparing the clinical outcomes in patients with repeated IVF failure who had hysteroscopy with no pathology and with pathology, we did not find any statistical differences.

Conclusions. This study suggests that hysteroscopy as a routine infertility examination should be performed in all patients, owing to the elevated incidence of hysteroscopic pathological findings (59.4%); hysteroscopy also seems to be the best way to repair the uterine cavity when pathological conditions are present. However, performing OH before IVF–embryo transfer is of no significant value in improving pregnancy outcomes.     

Follitropin-alpha versus human menopausal gonadotropin in an in vitro fertilization program

OBJECTIVE: To compare the efficacy of recombinant FSH and urinary-derived hMG for ovarian stimulation during IVF. DESIGN: Retrospective analysis of data from IVF cycles conducted over 15 months. SETTING: University hospital IVF unit. PATIENT(S): Three hundred twenty-four women undergoing their first to sixth IVF cycle. INTERVENTION(S): After pituitary down-regulation, patients received recombinant FSH or hMG, according to personal choice. After hCG administration, patients underwent oocyte retrieval, oocyte fertilization, and embryo transfer. MAIN OUTCOME MEASURE(S): Implantation rate and clinical ongoing pregnancy rate per oocyte retrieval. RESULT(S): Patients who chose recombinant FSH were slightly younger than those who chose hMG (34.1 vs. 35.1 years, respectively). Although more embryos were transferred in the hMG group (3.6 vs. 3.2), the ongoing pregnancy and implantation rates were significantly higher in the recombinant FSH group (ongoing pregnancy rate, 50.0% vs. 36.2%). CONCLUSION(S): Recombinant FSH is more effective than hMG for ovarian stimulation in IVF cycles. This increased efficacy, which is achieved with fewer ampoules, is likely to offset the higher acquisition costs of recombinant FSH.     

The relationship of semen parameters to fertilization in patients participating in a program of in vitro fertilization

Approximately 80% of the patients in a program of in vitro fertilization (IVF) will fertilize an oocyte. The purpose of this study was to determine which parameters of the semen analysis influence fertilization in vitro. Of 120 patients participating in an in vitro fertilization program, 98 achieved fertilization of at least one mature oocyte and 22 did not. Ovulation induction was standardized and patients whose sperm was exposed to at least one mature oocyte (by light microscopy) were included in the study. Semen washing was accomplished using a swim-up technique. Semen parameters were assessed both before (raw) and after washing. Following insemination with 100,000 motile sperm, fertilization was determined by the presence of pronuclei or cleavage. Mean sperm count and motility were higher in patients who fertilized. However, morphology was similar. Fertilization was more likely to occur with a raw density>104 million/ml and a motility>64%, as well as with a density>18 million/ml and a motilkity>86% following washing. Furthermore, washing lowered sperm counts by 75% and increased motility by 25% but had no effect on morphology. This study demonstrates that sperm count and motility, but not morphology, influence fertilization in a program of in vitro fertilization and that patients with higher counts and motility have and greater probability of fertilization.Presented at the Third Annual Congress of Andrology, April 27–May 2, 1985, Boston, Massachusetts.     

Outcome of patients with one ovary in an in vitro fertilization program

To determine whether the absence of one ovary would influence adversely the outcome of in vitro fertilization, the results of 60 laparoscopic oocyte retrieval procedures in 34 single-ovary patients were compared with the outcome for all laparoscopic retrieval cycles during the same period (January 1984–August 1986) in patients with tubal infertility and two accessible ovaries (559 cycles in 335 patients). The median age was younger in the one-ovary group (31 vs 32) (P < 0.05). The group with two accessible ovaries had significantly more follicles aspirated (median, 7 vs 5; P < 0.001) and more oocytes obtained (median, 5 vs 4; P < 0.001) per retrieval compared with the single-ovary group. However, the single-ovary group had a higher percentage fertilization (69 vs 62%; P < 0.05) so that the number of embryos transferred per transfer patient (median, 3 vs 3) and pregnancy rate per cycle (9.7 vs 15.6%) did not differ significantly between groups. We conclude that patients with a single ovary have a compensatory increase in the ability to produce oocytes which may have greater potential for fertilization and subsequent development.     

The prevalence of human immunodeficiency virus in patients and their spouses entering a large in vitro fertilization program

Between September 1987 and August 1989, all patients and their spouses entering our in vitro fertilization (IVF) program were screened for the human immunodeficiency virus (HIV) using the enzyme-linked immunosorbent assay (ELISA). Of 848 patients and 848 spouses tested, all but 4 patients and 1 husband tested negative. Of those who tested positive on repeat testing with ELISA, only one was positive on Western blotting (HIV prevalence, 0.59 per 1000). During this same time period 1187 samples of human cord blood were used to make tissue culture medium for the IVF embryology laboratory. One sample was discarded because of positive HIV on ELISA and Western blotting; two other samples were discarded because of positivity to the hepatitis B surface antigen. While we believe that routine HIV screening of IVF patients and their spouses is indicated, this population is of low risk for HIV positivity. Furthermore, continued screening of human sera used to make tissue culture media for IVF is mandatory.Presented at the 45th Annual Meeting of the American Fertility Society, November 11–16, 1989, San Francisco, California.     

Oocyte pickup by laparoscopy replaced by transvaginal aspiration in an in vitro fertilization program

The results of laparoscopic (lap) and transvaginal (TV) oocyte pickups (OPUs) performed concurrently for in vitro fertilization in 232 consecutive treatment cycles have been reviewed. The patients were compared for age, preoperative estradiol concentration, luteal-phase support, and number of follicles aspirated and were found to be similar but were not matched for cause of infertility. The lap OPU group had more oocytes recovered per follicle aspirated (P<0.001), but because of a lower fertilization rate (P<0.01), the number of embryos transferred was similar. Nevertheless, more (P<0.05) pregnancies occurred in the TV OPU group. Patients were subgrouped so that comparisons of patients with the same cause of infertility, tubal disease alone, were considered. This showed that the pregnancy rate was still higher in the TV OPU group (P<0.05). TV OPU was less painful and not associated with increased morbidity, and since the data suggest that TV OPU was at least as successful as lap OPU, it is recommended that all oocyte pickups in the future be performed transvaginally.     

Satellite in vitro fertilization: The Oregon experience

Objective: This study was designed to compare the results of preliminary evaluation, ovarian hyperstimulation, and monitoring of patients at a distant in vitro fertilization satellite center with those treated at the main campus of the program.Study design: Fifty-four patients completing oocyte retrieval cycles at the Eugene satellite Oregon Health Sciences University in vitro fertilization program for the period Jan. 1, 1991, through Dec. 31, 1993, were compared with 222 patients at the main campus for age, peak estradiol level, number of oocytes, retrieved, number of embryos, clinical pregnancy rate, and pregnancy outcome.Results: There were no statistically significant differences between the Eugene in vitro fertilization satellite center and the main campus for any of the factors analyzed with the exception of clinical pregnancy rate. The clinical pregnancy rate per cycle at the Eugene satellite center was 39% while the Portland main campus rate was 23% (p = 0.027), presumably because of a larger number of couples with severe male factor infertility at the central site.Conclusion: A distant in vitro fertilization satellite program was highly successful in the Oregon experience. In addition to greater convenience to the patients, the program was highly comparable to main campus program in measured parameters of ovarian hyperstimulation, oocyte retrieval, number of embryos, and pregnancy rate.     

Folate serum levels in Italian women entering an in vitro fertilization program

Italian public health authorities recommend women of childbearing age to assume a daily dose of 0.4?mg of folic acid (FA) from at least one month before conception in order to reduce the risk of having children affected by neural tube defects (NTDs). In this study, folate, homocysteine and vitamin B12 serum levels were determined in 77 women entering an in vitro fertilization program. About 75% of patients had serum folate values compatible with the intake of the recommended dose of FA for at least three months, whereas only the 61% of them reached or exceeded the serum folate concentration regarded as the optimal concentration during the periconceptional period. Mean vitamin B12 serum levels and mean homocysteine plasma levels resulted in normal range in all the women with mean values of 381.2?±?2.2?pg/ml and 8.48?±?2.2?μmol/l, respectively. In conclusion, only a portion of women entering an IVF program presents proper folate levels.     

Prognostic value of objective semen parameters in an in vitro fertilization program

Purpose: The basic semen parameters seem to have a limited predictive value in male fertility. Could other objective sperm analyses be helpful in the choice of the most adapted assisted procreation technique?Methods: This study concerns 78 infertile couples with insemination failures. For each semen, 21 objective parameters are analyzed in fresh semen and after sperm selection procedure. The 78 couples are then included in an IVF protocol and classified into two groups: fertile (at least one cleaved embryo is obtained) and infertile.Results: Using multiple variant discriminant factorial analysis, we have found nine nonconventional parameters which induce us to define two classes of semen. These two classes fit with the classification into fertile and infertile groups in 74.4% of the cases.Conclusions: So these parameters allow us to predict the chance of obtaining embryos during an IVF trial and to choose for each couple the most appropriate technique: IVF or ICSI.Key words: acrosome reaction, hyperactivated motility, in vitro fertilization, intracytoplasmic sperm injection, sperm kinetics     

The association between chlamydial-specific IgG and IgA antibodies and pregnancy outcome in an in vitro fertilization program

Chammydial-specfic IgG and IgA antibodies were determined by a single serovar (L2) immunoperoxidase assay (IPA) in the serum of all patients that have conceived in an in vitro fertilization and embryo transfer (IVF & ET) progrom (n=106) and in a group of patients that went through the program at the same period of time and did not conceive (n=94). The prevalence rate of elevated IPA IgG (titers1128) and IPA IgA (titers116) specific to chlamydiae was significantly higher (P<0.001) in the IVF&ET pregnancy loss and nonconception groups (failures) versus the IVF&ET term pregnancy group (successes) (74 vs 47%, odds ratio=4.1, and 34 vs 14%, odds ratio=4.3, respectively). Stepwise discriminant analysis revealed that elevated specific chlamydial IgG had the greatest effect on the variance between successes and failures in this study group. Our study indicates the possible role of past or chronic active chlamydiae infection on the take-home baby rate in an IVF&ET program.     

Chromosomal analysis of unfertilized oocytes and morphologically abnormal preimplantation embryos from an in vitro fertilization program

In vitro fertilization cycles yield a low percentage of pregnancies. Eighty-five to ninety percent of the transferred embryos do not implant, and the abortion rate approaches 30%. Aneuploidy is assumed to be responsible for a major portion of this pregnancy wastage. The purpose of this study was to determine if there was any correlation between morphology and chromosomal content of unfertilized oocytes and rejected embryos. To assess the chromosomal content of oocytes and embryos, we used the method described by Tarkowski in 1966. Sixty oocytes from 28 women, aged between 27 and 41 years, were analyzed. Sixty-seven percent were aneuploid; of these, 23.35% were hyperhaploid, 23.35% were hypohaploid, 8.35% were hyperdiploid, 3.35% were diploid, and 8.35% showed premature chromosome condensation. Of 20 preimplantation embryos analyzed, 80% were aneuploid, 10% were diploid, 5% were haploid, and 5% showed structural anomaly. Correlation was found between maternal age and aneuploidy in oocytes and between morphology and genetic balance in preimplantation embryos.     

Toxicity testing for human in vitro fertilization programs

Using a mouse embryo culture system, several procedures and materials associated with human in vitro fertilization protocols were tested for potential toxicity. Also, quality-control assays were performed for media prepared by nine different human in vitro fertilization programs. Detrimental effects upon embryo development were observed when culture media were exposed to the following substances: surgical instruments sterilized with Cidex or Cidex-7 or sterilized with ethylene oxide after packaging in Nest Protector Packs, various brands of surgical gloves, and various synthetic materials being evaluated as possible needle or catheter liners. Results from comparative testing of media and serum supplements prepared by different in vitro programs indicated a wide range in culture medium quality, as assayed by the ability of the reagents to support mouse embryo development. The importance of an animal model system available to all human in vitro programs for routine quality-control analysis and testing of novel uses of materials and innovative methods is discussed.     

Analysis of human spermatozoa before and after processing for in vitro fertilization

Washed incubated spermatozoa processed for in vitro fertilization were compared to the spermatozoa from the same unprocessed ejaculate in 31 randomly selected normal males (Group 1) and 7 subfertile moles (Group 2). In Group I there was a significant increase in motility (P=0.001) as well as a significant increase in normal morphology (P=0.001). All categories of morphologically abnormal sperm decreased, with a significant decrease in those exhibiting small heads (P=0.01), tapered heads (P=0.01), cytoplasmic droplets (P=0.001), bent midpieces (P=0.01), or coiled tails (P=0.02). There was also a significant decrease in immature germ cells (P=0.001) as well as white blood cells (P=0.02). Group 2 also showed a significant increase in motility (P=0.01). and a significant increase in normal morphology (P=0.01). There was a decrease in various categories of abnormal sperm, with a significant decrease in sperm with cytoplasmic droplets (P=0.02).     

The application of the zona-free hamster egg test for the prognosis of human in vitro fertilization

The zona-free hamster egg test was carried out using spermatozoa from 15 men which consistently failed to fertilize their wives' oocytes in vitro. Spermatozoa from nine of these men fertilized hamster eggs in vitro, indicating that positive results in this assay are an unreliable guide to human in vitro fertilization. Donor spermatozoa were needed to fertilize the wife's oocytes in three of these cases. Nevertheless, the proportion of hamster egg penetration was significantly lower compared with spermatozoa from 15 men who could fertilize their wives' oocytes in vitro. The hamster assay also failed to indicate the establishment of pregnancy.     

Follicular-phase response in two clomiphene-human menopausal gonadotropin regimes for an in vitro fertilization program

Two clomiphene-human menopausal gonadotropin regimes were assessed for our in vitro fertilization and embryo replacement (IVF and ER) program since September 1983. Clomiphene, 50 mg bd, was taken from day 2 for 5 days. Human menopausal gonadotropin (hMG) was given from day 6; for the first regime, 75 IU/day was given for the first 3 days, and for the second, 150 IU/day. The subsequent dosages were dependent on the estradiol response. There were 9 cases for the first regime and 10 cases for the second. The mean number of hMG ampoules given was 16.5 and 19.25, respectively. The number of follicles seen on ultrasound was 3.0±0.5 and 3.4±1.2 (mean±SD), respectively. There was no statistical difference in the estradiol response up to the day of laparoscopic ova recovery for the two regimes. However, a spontaneous luteinizing hormone (LH) surge was observed in 4 of 9 cases in the first group and 6 of 10 cases in the second group. When a comparison was made between cases that had a spontaneous LH surge and cases that were given human chorionic gonadotropin (hCG), there was a higher estradiol level on the day of the laparoscopy in the hCG group with the lower hMG regime (P<0.05). There were no other differences. Our small series shows a 52.6% incidence of spontaneous LH surge with clomiphene-hMG. Hence such stimulated regimes can result in a high proportion of spontaneous LH surges; this may be an index of satisfactory endocrinological control in spite of an increase in the number of follicles.     

The chromosome complement of first-cleavage mouse embryos after in vitro fertilization

A comparison of the first cleavage-stage chromosome complements of 1022 in vivo fertilized mouse embryos and 1033 in vitro fertilized mouse embryos is reported. The chromosome analysis of first-cleavage embryos allows us to study directly the chromosome complement of the sperm and oocyte that contribute to the embryo, since both chromosome clusters remain separate when an antimitotic agent is used to prevent syngamy. In this paper we show that the sex ratio and the incidence of aneuploidy are similar, irrespective of the fertilization system used. Male and female gametes have the same levels of aneuploidy. Triploidy is more frequent in the in vitro fertilized embryos and the difference can be ascribed to a higher incidence of polyspermy and diploid spermatozoa.     

Relationship between anticomplement in seminal plasma and complement in follicular fluid associated with outcome in an in vitro fertilization program

Purpose: The study was conducted to evaluate levels of anticomplement in seminal plasma and levels of complement in follicular fluid, in correlation with fertilization and pregnancy rate after in vitro fertilization and intracytoplasmic sperm injection programs. Materials and Methods: Anticomplement levels were determined in 70 couples undergoing in vitro fertilization therapy. In 15 of these couples, complement levels were measured. Anticomplement and complement levels were also determined in an additional 21 couples (apart from the 70 couples) undergoing intracytoplasmic sperm injection treatment. Results: A correlation was found between fertilization rate and anticomplement levels in the seminal plasma (r=0.4,P<0.01) after standard in vitro fertilization. No correlation was found in the intracytoplasmic sperm injection group, or observed between complement levels and any parameter examined in both groups. Pregnancy occurred only in those couples with an anticomplement: complement ratio below 0.49. Conclusions: Determination of anticomplement and complement levels may contribute to the assessment of a successful outcome of in vitro fertilization/intracytoplasmic sperm injection.Presented in Part at the IXth World Congress on In Vitro Fertilization and Alternate Assisted Reproduction, April 3–7, 1995, Vienna, Austria.