Low-dose prednisolone does not improve the outcome of in-vitro fertilization in male immunological infertility

Early reports of male immunological infertility suggested adecline in antisperm antibody concentrations in some patientsafter even short-term (10 day) therapy with lowdose prednisolone.In the present study, 53 men with positive results in spermatozoalmixed antiglobulin reaction (MAR) and serum tray agglutinationtests (TAT), were randomized to receive either 20 mg of prednisoloneor placebo daily for 2 weeks prior to in-vitro fertilization(IVF) treatment. The antibody levels were also monitored byflow cytometry (FCM). There were no significant differencesbetween these groups as regards fertilization rates (35% withprednisolone; 39% with placebo) and pregnancy rates (29%; 32%).No significant changes occurred in either MAR or FCM resultsin relation to therapy. Patients with fertilization rates of<10% had significantly higher immunoglobulin G (IgG) MARvalues compared with those with better fertilization, whereasthere was no relationship between IgA levels and fertilizationresults. As regards FCM, the results were similar, but withoutstatistical significance. In conclusion, IVF is a good courseof action in severe male immune infertility, but low-dose prednisolonetherapy does not lower the sperm-bound antibody numbers anddoes not improve the IVF outcome.     

Sperm treatment with extracellular ATP increases fertilization rates in in-vitro fertilization for male factor infertility

Previous work from our laboratory has revealed that extracellular ATP is a rapid and potent activator of human sperm acrosome reaction and fertilizing ability. In the present study, we assessed the effects of in-vitro sperm incubation with ATP on fertilization and embryo development in couples undergoing in-vitro fertilization (IVF) for male factor infertility. Oocytes from 22 women undergoing ovulation induction were divided in two groups and inseminated in vitro either with selected spermatozoa from the corresponding partner suffering from male factor infertility pre-incubated with ATP (2.5 mM) for 1 h, or with spermatozoa incubated with 0.9% NaCl solution (control group). After insemination, fertilization was assessed by the presence of pronuclei and then by embryo cleavage. The fertilization rate in the group of oocytes inseminated with ATP-treated spermatozoa improved significantly with respect to the control group (65.7 versus 42.5%, P < 0.01). No significant differences were observed in embryo cleavage and embryo quality. Embryos from both treated and control groups were transferred together in 20 transfer procedures, and in two couples fertilization was not obtained. Nine pregnancies occurred: one biochemical, one miscarriage, and seven patients delivered 9 healthy babies. Two pregnancies were twin with an overall pregnancy rate of 40.9% per cycle and of 45% per transfer. In conclusion, the results of the present study demonstrate that, in humans, extracellular ATP induces a significant increase of sperm fertilizing potential, as these findings are a rationale for the use of ATP for in-vitro treatment of human spermatozoa during IVF.     

Comparison of pregnancy outcome after intracytoplasmic sperm injection and in-vitro fertilization

The aim of this study was to compare pregnancy characteristics and perinatal outcome of intracytoplasmic sperm injection (ICSI) pregnancies with pregnancies obtained after in-vitro fertilization (IVF). Retrospectively, 145 ICSI pregnancies were matched with 145 IVF pregnancies using the last menstruation data. The main outcome measures were preclinical and clinical abortions, ectopic pregnancies, multiple gestations, prenatal morbidity, prematurity, Caesarean section, birthweight, perinatal mortality and malformations for singletons, twins and triplets. Although patients were significantly younger (P < 0.001) in ICSI (31 years) than in IVF (33 years), their infertility duration (5 years) was similar. The mean number of transferred embryos (2.7 embryos per transfer) was similar in IVF and ICSI. The rates of preclinical (15%) and clinical abortions (11% in ICSI versus 15% in IVF) were not different. Four ectopic pregnancies were observed in the IVF group and none in the ICSI group. In ICSI, two minor malformations were detected and two therapeutic abortions were performed respectively for polymalformations and suspicion of cystic fibrosis. The rate of congenital malformation was 2.8% in ICSI and 2.2% in IVF. In this last group, one therapeutic abortion for malformation of neural tube was performed and two minor malformations were detected. The rate of aborted embryonic sacs before 16 weeks of gestation was not significantly lower in ICSI compared with IVF (13.7% versus 20%). The rate of multiple gestations was similar in both groups (31% in IVF and 35% in ICSI). The number of Caesarean sections was similar in IVF and in ICSI and was twice as frequent for twins versus singletons. The number of singletons born by Caesarean section was 21% after ICSI and 17% after IVF. Mean birthweights and gestational ages at birth for twins were significantly higher (P < 0.05) in ICSI than in IVF (2488 versus 2281 g and 36.5 versus 35.5 weeks). This difference was not observed for singletons. In conclusion, pregnancy characteristics and perinatal outcome after ICSI showed no increase in the number of pathologies in comparison with IVF.      

Comparison between stimulated in-vitro fertilization and stimulated intrauterine insemination for the treatment of unexplained and mild male factor infertility

A prospective trial was undertaken to evaluate the efficacy of stimulated in-vitro fertilization (SIVF) and stimulated intrauterine insemination (SIUI) in couples with unexplained and mild male factor infertility. In all, 80 couples were allocated to treatment with SIVF or SIUI, both treatments following the same protocol [clomiphene citrate and follicle stimulating hormone (FSH) injection], except that higher doses of FSH were used in the SIVF treatment cycles. Initially, 41 couples were allocated to and started treatment with SIVF but eight cases were eventually converted to SIUI because of under-response. Similarly, although 39 couples were initially allocated to SIUI treatment, five of these converted to SIVF because of over-response. The treatment cycles that were converted either to SIUI or to SIVF were not considered as treatment failures but as treatment changes and so were included in the analyses. Of the final 38 SIVF cycles, four were cancelled (dysfunctional response), failed fertilization occurred in five cycles and 29 subjects reached embryo transfer. There were two biochemical pregnancies [positive human chorionic gonadotrophin (HCG) only], two clinical abortions and seven live births. Of the final 42 SIUI cycles, only two were cancelled, insemination being performed in the remaining 40 cases. The result was one clinical abortion, three ectopics and eight live births. The proportion of cycles with positive HCG was identical (28.9% per cycle treated for SIVF and 28.6% for SIUI) and the livebirth rates were also not different (18.4% per cycle treated for SIVF and 19.0% for SIUI). The cost per maternity of SIUI was approximately half that of SIVF (Pounds Sterling 1923 versus Pounds Sterling 4611) and so we conclude that, as SIUI had an efficacy that was not significantly different from SIVF (using similar protocols) but was more cost-effective, it must be considered the more appropriate form of management for the treatment of unexplained and mild male factor infertility. Indeed, it is hard to justify the routine use of IVF, as a first approach, in unexplained infertility.      

Male factor as determinant of in-vitro fertilization outcome.

The effect of different semen parameters was evaluated in 200 consecutive couples in an in-vitro fertilization (IVF) programme. All semen analyses were performed on the native aliquot of semen which was subsequently prepared and used for in-vitro insemination. Morphology evaluation using strict criteria (kappa 0.46 and r = 0.565) was compared with progressive motile sperm density (kappa 0.37 and r = 0.333) and the conventional World Health Organisation (WHO) evaluation of morphology (kappa 0.31 and r = 0.378). Results show that morphology evaluation using strict criteria is the best predictor of IVF and density of progressively motile spermatozoa can be an optional method. The combined results of strict morphology and motile concentration progressively showed that if both parameters were below the cut-off points of 5% and 3 x 10(6)/ml respectively, the fertilization rate per oocyte was very low (18%). No pregnancies were achieved in this group. When both parameters were above the cut-off points, the fertilization rate per oocyte was high (72%) (P less than 0.005) and the pregnancy rate per embryo transfer was 27%. Predictive values indicate that morphology evaluation using strict criteria and the number of progressive motile spermatozoa can be used as patient selection criteria for infertility clinics.     

Ubiquitin-based sperm assay for the diagnosis of male factor infertility

Sperm morphology is correlated with fertility in men, yet the existing, subjective sperm morphology assays provide only a limited insight into patients' infertility. Here, we provide the experimental background for a new, objective and automated semen assay, based on the cross-reactivity of defective human spermatozoa with antibodies against a proteolytic marker peptide, ubiquitin. Using immunofluorescence and flow cytometry, we screened the spermatozoa from 17 infertility patients and two fertile donors for their cross-reactivity with anti-ubiquitin antibodies. Thirteen out of 17 patients, but neither of two fertile donors, displayed an increased binding of anti-ubiquitin antibodies to sperm surface, that reflected the occurrence of abnormalities in these samples and was corroborated by available clinical data. Highest correlation coefficient (r = -0.432) was obtained with the cleavage rate after IVF. The contribution of male factor was revealed in several couples previously diagnosed with idiopathic infertility. Ubiquitin-cross-reactive sperm-surface proteins thus seem to be a universal marker of semen abnormalities, including sperm head and tail defects and semen contaminants such as spermatids, leukocytes and cellular debris. We propose that the sperm-ubiquitin tag immunoassay (SUTI) may be a valuable diagnostic tool in treatment of male factor and idiopathic infertility.     

Differential evaluation of human sperm hypoosmotic swelling test and its relationship with the outcome of in-vitro fertilization of human oocytes

The hypoosmotic swelling test is a simple laboratory test to measure the functional integrity of the human sperm membrane. Its in-vivo and in-vitro applicability needs to be evaluated before it can be accepted as a useful routine test for the fertilizing potential of human semen. We studied the standard semen analysis results and differential sperm tail swelling patterns of seminal and swim-up sperm after hypoosmotic treatment in 97 semen samples used for in-vitro fertilization of human oocytes. Semen samples were classified as infertile (0% fertilization rate; n = 27) or fertile (greater than 0% fertilization rate; n = 70) before statistical analyses. There was a significant difference (P less than 0.005) in percentage normal morphology of seminal sperm between the fertile and infertile semen samples. The percentage normal morphology of seminal sperm correlated (r = 0.4250; P less than 0.005) with the in-vitro fertilization rate of human oocytes and this parameter was selected by the multivariate stepwise discriminant analysis as the discriminator capable of predicting the in-vitro fertilization rate with 57.7% accuracy. The percentage total swelling of seminal and swim-up sperm after hypoosmotic treatment was not correlated with the in-vitro fertilization rate. The percentage swelling pattern g (the open type) of seminal sperm was also selected by the multivariate stepwise discriminant analysis as the discriminator to predict the in-vitro fertilization rate. This parameter correlated with the percentage normal morphology of seminal sperm (r = 0.3014; P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

Comparison of in-vitro fertilization in male and tubal infertility: a 3 year survey.

The in-vitro fertilization and embryo transfer (IVF-ET) procedure was compared in 175 couples with male infertility and 480 couples with tubal infertility. In cases of male infertility, more oocytes were recovered but fewer oocytes were fertilized. Although the cleavage rate was decreased, no difference in embryo quality was found. In male infertility, fewer transfers were performed and the average number of embryos per transfer was lower. The total pregnancy rate was also lower per cycle (12.8 versus 22.9%), but not per transfer (25.4 versus 25.7%). The further obstetrical outcome was similar in both groups. We conclude that male infertility can be treated by IVF-ET but results are still disappointing when compared to a control group with normal spermatozoa.     

Experience with assisted fertilization in severe male factor infertility and unexplained failed fertilization in vitro

We present results of in-vitro fertilization (IVF) cycles usingassisted fertilization at our centre. Assisted fertilizationwas performed in those couples who had failed to fertilize oocyteswith conventional IVF, or where this was predicted by the presenceof severe male factor infertility. In 20 consecutive assistedfertilization cycles 223 oocyted were subjected exclusivelyto subzonal insemination (SUZI). Subsequently in 32 consecutiveassisted fertilization cycles 418 oocytes were subjected tointra-cytoplasmic sperm injection (ICSI). More oocytes weredamaged by ICSI (8.9%) than by SUZI (2.3%) (p = 0.03), but normalfertilization resulted more often after ICSI (56.9%) than SUZI(35.8%) (p = 0.004). Sperm parameters, other than sufficientnumbers to perform the procedures, had no effect on fertilizationor pregnancy rates. Every cycle led to the transfer of at leastone embryo. Pregnancy resulted from eight of the SUZI cycles(40%) and nine of the ICSI cycles (28%). Implantation rateswere calculated as 25 and 12% for SUZI and ICSI respectively.The presence of living spermatozoa is the only semen parameterlimiting assisted fertilization. At present more centres areable to perform SUZI than ICSI and we feel it is premature toabandon SUZI altogether. Local conditions and success ratesshould be considered when decisions are made in assisted fertilizationcycles.     

Quality control in an in-vitro fertilization laboratory: use of human sperm survival studies

A bioassay procedure is described for quality control testingof various disposable items used in routine IVF procedures.This biosassay is performed over 4 days and uses the survivalof human sperm in vitro at room temperature to assess whichproducts are suitable for use. New products were tested forcytotoxicity using a general screening method and subsequenthatches of every suitable item tested to detect interbatch variation.Products were considered suitable or unsuitable for use dependingupon a calculated sperm survival index. Two main types of productwere found to be cytotoxic, namely certain brands of syringeand surgical gloves, the common feature of both being the presenceof rubber components. The bioassay was also used to investigatefurther the cytotoxic effect of the powdered and starch-freesurgical gloves. The cytotoxic substances from both types ofsurgical glove were readily transferred to an embryo replacementcatheter by touch, and washing of the gloves reduced this effectonly moderately. The bioassay has proved inexpensive and convenientbut more importantly it has been invaluable for detecting potentialsources of cytotoxicity before they are introduced into a standardIVF protocol.     

A self-migration method for preparation of sperm for in-vitro fertilization

Human sperm samples (n = 211) were prepared for in-vitro fertilization(IVF) and embryo transfer by a self-migration procedure in Earle'smedium containing highly purified hyaluronic acid (Hya) (MW3 000 000) included to increase the viscosity of the medium.The method resulted in the recovery of a significantly higherpercentage of motile spermatozoa compared with the traditionalcentrifugation method, 87.5 ± 0.9% versus 76.1 ±1.3% (P < 0.001). When comparing media with and without Hyain the selfmigration method for preparation of normal spermsamples, the media containing Hya resulted in the recovery ofa significantly higher percentage of motile spermatozoa, 89.0± 0.8% versus 73.8 ± 2.0% (P < 0.001). In agroup of 80 consecutive couples entering our IVF programme,sperm samples from 44 of the men were allocated at random forthe self migration method in medium containing Hya and spermsamples from 36 men for preparation by centrifugation and swim-up.Significantly more pregnancies were achieved in the group preparedin medium containing Hya. It is concluded that self-migrationof sperm in a medium containing Hya is simple and rapid, andresults in a high recovery of motile spermatozoa which can beused for in-vitro insemination of human oocytes with favourableresults.     

Natural cycle in-vitro fertilization in couples with unexplained infertility: impact of various factors on outcome

This study evaluated outcome in 117 couples with unexplained infertility who underwent 162 attempts at natural cycle in-vitro fertilization (NIVF) between 1991 and 1993. An egg was obtained in 138 cycles and a single embryo was transferred in 89 cycles. There were 16 implantations (four biochemical pregnancies, three clinical abortions and nine live births). The implantation rate per embryo was 16/89 (18.0%), which translated into a live birth rate per egg collection of 9/138 (6.5%). The impact factors that were assessed included oocyte quality, sperm quality, embryo quality and woman's age. The outcome measures used were fertilization/inseminated egg and implantation/replaced embryo. All embryo transfers were of single embryos. We conclude that, in couples with unexplained infertility, outcome following NIVF is affected by both egg and sperm quality and by the age of the woman. Embryo quality was independent of the above factors but was also critical for successful implantation.      

Relationship between human in-vitro fertilization and intracytoplasmic sperm injection and the zona-free hamster egg penetration test

The zona-free hamster egg penetration test (HEPT) is widely used for evaluating the fertilizing ability of human spermatozoa. However, the relationship between the HEPT and microassisted fertilization has yet to be determined. To evaluate the efficiency of HEPT in selecting the most appropriate method of in-vitro fertilization (IVF), including intracytoplasmic sperm injection (ICSI) in couples with male factor infertility, clinical laboratory data was analysed retrospectively. The patients were divided into groups according to the sperm penetration index as determined by the HEPT: group A (sperm penetration index = 0), group B (sperm penetration index < 15) and group C (sperm penetration index > or = 15). A total of 405 oocytes were collected and inseminated by conventional methods in 69 couples with male factor infertility. In all, 31 out of 148 (20.9%) oocytes fertilized in group A; 35 out of 117 (29.9%) in group B; and 73 of 140 (52.1%) in group C. The clinical pregnancy rates per transfer in groups A, B and C were 0% (0/13), 0% (0/14) and 25.9% (7/27) respectively. Both the fertilization rate and pregnancy rate in group C was significantly higher than in groups A and B. ICSI was carried out in a total of 57 couples and 334 oocytes in metaphase II stage were manipulated. The normal fertilization (2 pronuclear) rate per oocyte was 65.6 +/- 26.0% (mean +/- SD). Out of 127 oocytes, 76 (59.8%) fertilized in group A, 57 out of 87 oocytes (65.5%) in group B and 86 out of 120 oocytes (71.7%) in group C. Of the 56 transfers, 17 clinical pregnancies were obtained, giving an average pregnancy rate of 30.4% per transfer. The clinical pregnancy rates per transfer in groups A, B and C were 17.4% (4/23), 40.0% (4/10) and 39.1% (9/23) respectively. No significant differences were observed in the fertilization rates or in the pregnancy rates between the three groups. In addition, there were no differences in the fertilization and pregnancy rates between the ICSI and IVF patients in group C. These findings suggest that the results of the HEPT are well correlated with the fertilizing ability of human spermatozoa in the patients treated by conventional IVF. Couples suffering from male factor infertility with a sperm penetration index of < 15 (as determined by HEPT) should consider treatment with ICSI, while those with a sperm penetration index of > or = 15 should attempt conventional IVF.      

Efficacy of the sperm survival test for the prediction of oocyte fertilization in culture

The present study was carried out to investigate the predictivevalue of the sperm survival test (SST) with respect to the fertilizationof oocytes in culture. In general, our laboratory uses a totalof 50 000–150 000 motile spermatozoa to inseminate eachoocyte. The remaining material is evaluated for motility beforeand after 24 h of incubation at 37°C in a 5% CO₂ atmosphere.A total of 250 oocytes from 50 cases (mean ± SD, 5.0± 2.4 oocytes per retrieval) were inseminated and thefinal rate of cleaved embryos obtained was 52.5%. The SST (%)was considered normal when the ratio (final density of progressingspermatozoa after 24 h x 100/initial density of progressingspermatozoa) was 50% or more. Any other result was consideredabnormal. Cases presenting one or more cleaved embryos (n =40) were separated from those in which no embryo formation occurred(n = 10) and the results were compared in terms of the respectivesperm survival rates over a period of 24 h: normal SST (oneor more cleaved embryos, 37; none, five), abnormal SST (oneor more cleaved embryos, three; none, five). The specificityof the SST was 0.92 and sensitivity 0.50, the predictive valueof the abnormal test was 0.62 and the predictive value of thenormal test 0.88. The efficacy of the test was estimated at0.71, which was better than the conventional parameters of spermanalysis. A receiver — operating characteristics curvefor SST confirmed that the test can be useful for the predictionof fertilizability of oocytes in the laboratory.     

Human and bovine cervical mucus penetration as a test of sperm function for in-vitro fertilization

Human and bovine cervical mucus penetration tests (n = 57) wereperformed preceding IVF to test their prognostic value as spermfunction tests for IVF. This evaluation also induded resultsfrom conventional semen analysis and from a computerized spermanalysis system. The bovine cervical mucus penetration testwas shown to be at least as valuable as the human cervical mucuspenetration test in evaluating sperm function. The migrationdistance of the vanguard sperm (P < 0.001) and the spermdensity at a fixed migration distance in the mucus column (P< 0.05) correlated most closely with the IVF results. A clearparallelism with the out come of the ‘swim up’ techniquewas also found. Of the sperm parameters examined, only spermmotility In the ejaculate (P < 0.05) correlated significantlywith the results of IVF. It is concluded that the outcome ofa bovine cervical mucus penetration test depends on the samesperm functions as re quired for IVF. Therefore, this test maybe of predictive value in an IVF programme.     

Cancer and male infertility: Gamete intra-Fallopian transfer or in-vitro fertilization after failed ovarian stimulation and intrauterine insemination in unexplained infertility?

A prospective randomized study was designed to compare gameteintra-Fallopian transfer (GIFT) and in-vitro fertilization (IVF)and embryo transfer in the treatment of couples who have failedto conceive after at least three cycles of ovarian stimulationand intrauterine insemination (IUI). A total of 69 couples withprimary unexplained infertility of at least 2 years' durationplus at least three failed cycles of ovarian stimulation andIUI were randomly allocated to either GIFT or IVF/embryo transfer.The clinical pregnancy rate was 34% after GIFT treatment and50% after IVF/embryo transfer. This difference was not statisticallysignificant. The twin rate in the IVF/embryo transfer groupwas higher than in the GIFT group (53 versus 17%, P = 0.005).We conclude that patients with unexplained infertility and failedovarian stimulation and IUI can still achieve encouraging pregnancyrates with IVF/embryo transfer or GIFT. Since IVF/embryo transferis the least invasive of the two procedures and may yield diagnosticinformation, we would favour this therapy; however, the numberof embryos transferred should be reduced to two to reduce therisk of twin pregnancy.     

Comparison of clinical outcome after cryopreservation of embryos obtained from intracytoplasmic sperm injection and in-vitro fertilization

The impact of intracytoplasmic sperm injection (ICSI) on cryopreservedzygotes and embryos was evaluated by comparing embryo survivaland implantation between embryos derived from ICSI and thosederived from standard insemination procedures. The study includedpatients whose excess zygotes and embryos were cryopreservedbetween September 1993 and December 1994 and who subsequentlyunderwent a frozen embryo transfer. Embryo survival, clinicalpregnancy rates per transfer and pregnancy outcome were compared.Three hundred and thirty eight cryopreservation cycles, duringwhich 1471 embryos were cryopreserved, were included in thisstudy. Of those, 961 were derived from oocytes fertilized byinsemination in vitro and 510 were derived from oocytes fertilizedby ICSI. A total of 690 of the embryos (451 in the inseminationgroup and 239 in the ICSI group) have since undergone a thawcycle. The embryo survival rates were similar between the twogroups (70.5 and 73.2%, insemination and ICSI respectively)and were not significantly affected by the stage at cryopreservation.There was no significant difference in pregnancy rates per transfer(31.8 and 32.3%), the preclinical pregnancy loss rate (16.7and 23.8%), or the clinical miscarriage rate (16.7 and 23.8%)between the insemination and the ICSI groups respectively. Itis concluded that ICSI does not have an adverse impact on thesurvival and successful implantation of cryopreserved and thawedembryos.     

Modified sperm stress test: a simple assay that predicts sperm-related abnormal in-vitro fertilization

Loss of sperm motility is associated with the process of sperm senescence and occurs at different rates within a given normal or abnormal sperm population. Reactive oxygen species attack cell membrane phospholipids, generating fatty acid peroxides and other degradation products, that also have deleterious effects on sperm motility and fertilizing ability. The objective of this investigation was to study a modification of the original sperm stress test (MOST), changing the culture medium to one offering transitional metals and shortening the total test time, to ascertain whether it can predict fertilization under these laboratory conditions. A total of 41 semen samples was obtained from patients undergoing in-vitro fertilization (IVF) at our institution. Semen samples were grouped into those producing total fertilization rates (FR) within normal limits (>50%) and those showing low total FR (<50%). The normal FR group had a significantly greater MOST mean value than the low FR group (0.71 versus 0.44). Furthermore, there was a statistically significant correlation between the MOST score and ungrouped fertilization rates (r = 0.53, P = 0.0004). Diagnostic statistics for MOST ratio values predicting <50% FR showed an optimal threshold of 0.39. Collectively, sensitivity, specificity, positive predictive value and negative predictive value have their largest values at this threshold. Taking into account the above mentioned threshold figures, there is a significant association between MOST and FR categories (P = 0.0009). In conclusion, MOST is a simple assay that has significant predictive value for sperm related IVF abnormalities.      

Oocyte donation programme: results obtained with intracytoplasmic sperm injection in cases of severe male factor infertility or previous failed fertilization

Intracytoplasmic sperm injection was carried out in 15 oocytedonation cycles of 15 infertile couples where oocytes had failedto fertilize after in-vitro fertilization (IVF) procedures orwhere the male partner had severe male factor infertility. Atotal of 62 oocytes were donated, but only 46 of these, in metaphaseEl, were injected. Of the injected oocytes, 31 (673%) had twopronuclei the morning after the injection procedure. On thefollowing day, 29 embryos were obtained (93% of the fertilizedoocytes) and 25 were transferred. Two patients were not successfuland consequently did not undergo embryo transfer. A total offive clinical pregnancies were obtained, giving pregnancy ratesof 333 and 38.4% per started cycle and embryo transfer respectively.