Infertility: CASE REPORT Astonishing fertility from a single oocyte recovery

A 36 year old patient underwent in-vitro fertilization (IVF)and embryo transfer. Three embryos were transferred to her uterusand eight spare embryos were cryopreserved. The patient conceiveda quadruplet pregnancy and delivered two boys and two identicaltwin girls by Caesarean section at 30 weeks gestation. The couplesubsequently donated their cryopreserved embryos to the embryodonation programme for the use of other couples. Two agonadalpatients received these cryopreserved-thawed embryos, each ina hormone replacement cycle. Both conceived, one has safelydelivered twins and the other conceived a twin pregnancy, oneof the fetuses has vanished and the otter is progressing normally.The overall embryo implantation rate was seven out of nine (78%).     

Birth of a healthy infant after in vitro oocyte maturation and ICSI in a woman with diminished ovarian response: case report

In vitro maturation of oocytes (IVM) has been developed as a treatment option for subjects with good prognosis in assisted reproduction. We present successful IVM treatment in connection with a woman from whom low numbers of embryos were obtained after repeated failed conventional IVF cycles. A 35 year old woman, after 5 years infertility and two intrauterine insemination and three conventional IVF cycles, underwent first an IVM cycle with low dose FSH stimulation, and after failure, another natural IVM cycle. Three oocytes were obtained. After 36 h of IVM the oocytes had reached metaphase II stage, and fertilization using ICSI resulted in one 4-cell stage embryo, which was transferred 2 days later. The result was an uneventful pregnancy and birth of a healthy female infant weighing 4150 g. IVM may be an option for women from whom only low numbers of oocytes are obtained after gonadotrophin stimulation.     

Embryo quality in natural versus stimulated IVF cycles

BACKGROUND: The impact of controlled ovarian stimulation (COS) on oocyte and subsequent embryo quality remains controversial. In the present study we have compared embryo quality in natural and stimulated cycles in the same group of patients. METHODS: This retrospective study was comprised of patients with a regular menstrual cycle who had IVF after COS using rFSH in a long GnRH agonist protocol. In all stimulated cycles the patients had fresh embryos transferred and surplus good quality embryos cryopreserved. Subsequently the same patients were treated with a modified FER cycle (mFER) where thawing of the frozen embryos was combined with aspiration of the dominant follicle in the natural cycle. The embryo cleavage stage and quality score were compared between the stimulated and the natural cycle for the patients having an embryo in the natural cycle. RESULTS: In 177 cases patients returned for mFER in a natural cycle. Spontaneous ovulation had occurred in 35 cycles. In 17 cycles no oocyte was retrieved at aspiration and in 125 cycles 128 oocytes were aspirated. In the stimulated cycles from these patients we had obtained 950 embryos (cleavage rate 70.4%) versus 85 embryos (cleavage rate 66.4%) (P = 0.34) in the natural cycles. Comparing the embryos in the natural and stimulated cycles in all patients having an embryo in the natural cycle, we found no difference in the distribution between the different cleavage stages. Of the cleaved embryos, 53% in the stimulated cycles had >or=4 cells versus 59% in the natural cycles after 2 days culture (P = 0.31). In the stimulated cycles 61% of the embryos had <10% fragmentation at the time of transfer on day 2, compared to 69% in the natural cycles (P = 0.15). CONCLUSION: The administration of exogenous gonadotrophins was not reflected in cleavage capacity or quality assessment of the resulting embryos.     

In-vitro fertilization in a spontaneous cycle: easy, cheap and realistic

The results of in-vitro fertilization in natural cycles (NIVF) in women with tubal infertility at our department are presented. The study had a prospective design. We needed 75 cycles in 50 patients to obtain one oocyte from each patient. Successful oocyte recovery rate was 67% per started cycle and 82% per oocyte retrieval. Thirty-five embryos were transferred and resulted in four ongoing pregnancies (5.3% per cycle, 6.5% per oocyte retrieval, 11.4% per embryo transfer and 11.4% per embryo). Six patients who participated in the study made a second attempt at NIVF. Five of them conceived of which four were ongoing. Cumulative ongoing pregnancy rates are 9. 8% per cycle, 11.9% per oocyte retrieval, 19.5% per embryo transfer and 19.5% per embryo. We conclude that NIVF is an easy, cheap and realistic method to obtain a pregnancy for patients with tubal infertility.     

Chromosomal aneuploidy in embryos conceived with unstimulated cycle IVF

There is an ever increasing trend in reproductive medicine to reduce the intensity of ovarian stimulation for in vitro fertilization (IVF) and to restrict the number of embryos that are transferred into the uterine cavity. Recent findings suggest that the magnitude of ovarian stimulation affects the proportion of euploid embryos. As a result of the restriction in the number of embryos transferred, it becomes even more important to select the embryo with optimum implantational and developmental potential. Our aim was to asses the prevalence of numerical chromosomal abnormalities (aneuploidy) in unstimulated cycle IVF embryos. Thirty patients (mean age 31.4 years) underwent oocyte retrieval in a natural cycle without any form of ovarian stimulation, followed by intracytoplasmic sperm injection and Preimplantation genetic aneuploidy screening (PGS) for chromosomes X, Y, 13, 16, 18, 21 and 22. Out of 30 cycles, 21 oocytes were retrieved, 15 of which fertilized successfully. Eleven embryos developed sufficiently in order to undergo the PGS analysis, and four embryos proved to be aneuploid (36.4%; 95% CI: 10.9-69.2%). Six normal embryos were transferred in utero, resulting in three ongoing pregnancies. Two healthy girls were born and one patient miscarried. Numerical chromosomal abnormalities (aneuploidy) are present even in embryos of young women, and in the absence of ovarian stimulation.     

Salpingectomy improves the pregnancy rate in in-vitro fertilization patients with hydrosalpinx

The objective of this study was to assess the impact on pregnancyoutcome of excising hydrosalpinx(ges) in patients with repeatedin-vitro fertilization (IVF) failures. A group of 15 patientswho had previously undergone failed IVF attempts and had unilateralor bilateral hydrosalpinx was subjected to an operative laparoscopywith excision of the affected tube(s). Of these, 10 patientsunderwent a unilateral salpingectomy and five had a bilateralsalpingectomy. Stimulated cycles of IVF and/or cryo-thaw cycleswere then carried out post-salpingectomy and the results werecompared to those of pre-salpingec-tomy cycles. There was nostatistically significant difference between the number of matureeggs retrieved, peak oestra-diol concentrations, number of daysto human chorionic gonadotrophin administration, or number ofpre-zygotes frozen in the stimulated cycles pre- versus post-salpingectomy.Pre-salpingectomy, 15 patients underwent 38 stimulated cyclesand eight patients underwent 14 cycles with cryopreserved-thawedembryos, achieving one pregnancy from a fresh transfer thatresulted in a miscarriage. Post-salpingectomy, eight patientsunderwent 12 stimulated cycles, achieving five clinical pregnancies(two miscarriages and three ongoing pregnancies, i.e. eitherdelivered or a pregnancy >20 weeks), and nine patients underwent10 cycles with cryopreserved-thawed embryos, achieving fourclinical pregnancies (one miscarriage and three ongoing). Weconclude that excision of hydrosalpinx(ges) improves the pregnancypotential after IVF, and that new and repeat IVF patients shouldbe counselled accordingly.     

Fertility preservation in breast cancer patients: IVF and embryo cryopreservation after ovarian stimulation with tamoxifen

BACKGROUND: Breast cancer chemotherapy commonly causes premature ovarian failure and infertility. Because increased estrogen levels are thought to be potentially risky in breast cancer patients, natural cycle IVF (NCIVF) has been used to preserve fertility and treat infertility in these women. METHODS: Twelve women with breast cancer received 40-60 mg tamoxifen for 6.9 +/- 0.6 days beginning on days 2-3 of their menstrual cycle (15 cycles), and had IVF (TamIVF) with either fresh embryo transfer (six cycles) or cryopreservation (nine cycles). They were compared to a retrospective control group (n = 5) who had natural cycle IVF (NCIVF, nine cycles). RESULTS: Cycle cancellation was significantly less frequent in TamIVF, compared with NCIVF (1/15 versus 4/9, P < 0.05). Compared with NCIVF, TamIVF patients had a greater number of mature oocytes (1.6 +/- 0.3 versus 0.7 +/- 0.2, P = 0.03) and embryos (1.6 +/- 0.3 versus 0.6 +/- 0.2, P = 0.02) per initiated cycle. TamIVF resulted in the generation of embryo(s) in every patient (12/12) while only three out of five patients had an embryo following NCIVF. Two out of six patients in TamIVF, and 2/5 in NCIVF conceived. One patient in the TamIVF group delivered a set of twins. After a mean follow up of 15 +/- 3.6 months (range 3-54), none of the patients had a recurrence of cancer. CONCLUSIONS: Tamoxifen stimulation appears to result in a higher number of embryos and may provide a safe method of IVF and fertility preservation in breast cancer patients.     

Pregnancy and birth resulting from transfer of a blastocyst observed to have one pronucleus at the time of examination for fertilization.

This case report describes a successful full-term pregnancy and birth after the transfer of a zona-free blastocyst derived from an oocyte observed at fertilization check as having only one distinct pronucleus (PN). The patient had previously undergone four in-vitro fertilization (IVF) cycles and three frozen embryo transfer cycles, with one pregnancy resulting. In this IVF cycle, 7/19 oocytes were fertilized exhibiting two distinct PN; however, all these oocyctes failed to develop in culture and had arrested or totally fragmented by day 6 after insemination. One oocyte (1/19) displayed only one PN 18 h after insemination, but culture of this oocyte led to development of an early cavitating blastocyst by day 6. Since no other embryos were available for transfer to the patient, this embryo was transferred, resulting in a full-term pregnancy with delivery of a normal healthy boy. Observation of a single PN at the normal time of fertilization assessment would not appear to be an absolute indicator of developmental incompetence. In-vitro culture to 6 days post-insemination provides the opportunity to assess embryological development after activation of the embryonic genome. Formation of a morphologically normal blastocyst may be an indicator of a fertilized embryo with normal developmental capacity.     

A comparison of four different techniques of assisted hatching

BACKGROUND: Assisted hatching (AH) has been proposed as a means to increase the implantation rate in patients with poor prognosis for pregnancy. The procedure appears to be effective when used selectively. Several different methods for AH have been introduced over the years but comparative studies are lacking. The aim of the current study was to compare retrospectively the efficacy of AH performed with four different methods in patients undergoing IVF or ICSI. METHODS: AH was performed prior to day 3 embryo transfer in 794 IVF/ICSI cycles. Indications for AH were females aged >35 years and/or elevated follicular phase FSH levels, previous failed IVF/ICSI cycles, poor embryo quality, and thick zona pellucida (>15 microm). Assignment to one of the four methods of AH was according to the availability of the particular method during the study period. The study was not randomized. RESULTS: Partial zona dissection was used in 239, acid Tyrode in 191, diode laser in 219 and pronase thinning of the zona pellucida in 145. Mean female age, mean number of previous failed IVF/ICSI cycles, number of oocytes retrieved, fertilization and cleavage rates, good quality embryos and zona thickness on day 3 did not differ between groups. Mean number of embryos transferred, implantation rate, clinical pregnancy rate, and abortion rates were likewise similar. CONCLUSIONS: Selective AH using four different methods yields similar implantation and pregnancy rates.     

Successful pregnancy following blastocyst vitrification: case report

A 32 year old woman and her 32 year old spouse were referred to our IVF programme. Following recovery of 12 mature oocytes, nine were fertilized following conventional IVF. Three fresh embryos were transferred to the uterus, but all failed to result in pregnancy. Six supernumerary embryos were cultured in vitro until day 5 in order to create blastocysts. Two grew to the blastocyst stage and were vitrified using a modification of a previous method. Two blastocysts survived the freeze-thaw process and were transferred to the patient's uterus during a natural cycle, 3 months after the previous retrieval cycle. Implantation resulted in a healthy pregnancy; delivery is expected in June 2000. This report documents the first successful pregnancy in Japan, achieved via blastocyst vitrification.     

Birth from cryopreserved embryos following in-vitro maturation of oocytes and intracytoplasmic sperm injection

This case report describes the birth of a baby following the transfer of cryopreserved embryos generated from intracytoplasmic sperm injection (ICSI) carried out on the second day after oocyte pick-up of in-vitro-matured metaphase I and germinal vesicle stage oocytes. The couple had a history of three failed intrauterine insemination attempts and reduced fertilization rates in two previous in-vitro fertilization (IVF) cycles. In the IVF-ICSI treatment cycle, 6/11 mature oocytes became fertilized following ICSI on the first day. However, the patient failed to conceive following the transfer of three embryos. Five oocytes were immature (two at metaphase I stage and three with a germinal vesicle) and these were cultured overnight. All had extruded a polar body by the following day and ICSI was therefore performed; four oocytes became fertilized, and were cryopreserved at the pronulear stage in propanediol. In the next treatment cycle, transfer of frozen embryos was planned. The pronuclear zygotes were thawed and cultured for 24 h prior to the transfer of two embryos in a cycle stimulated with low doses of follicle stimulating hormone. This resulted in a pregnancy and the delivery of a healthy baby boy. In-vitro maturation of metaphase I and germinal vesicle oocytes which are routinely collected in IVF-ICSI cycles, followed by second day ICSI fertilization, may provide a valuable source of embryos for infertile couples.      

Embryo quality and uterine receptivity in in-vitro fertilization cycles with or without agonists of gonadotrophin-releasing hormone

The proportion of abnormal oocytes or embryos per recovered oocyte in in-vitro fertilization (IVF) cycles had no influence on the occurrence of pregnancy following the transfer of normal embryo(s) derived from oocytes capable of fertilization. There were more implantations per transferred embryo in stimulated IVF cycles using long-acting buserelin (30.0%) compared with short-acting decapeptyl (17.3%) or no gonadotrophin-releasing hormone agonist (GnRHa, 15.2%) treatments. However, the chances of implantation per embryo transferred being in excess of one in patients who became pregnant tended to be higher in non-GnRHa (23.5%) compared to buserelin- (16.4%) or decapeptyl- (13.3%) treated IVF cycles. Moreover, frozen--thawed embryos had a higher implantation rate (P less than 0.05) when originating from IVF cycles without GnRHa (11.7%) compared to GnRHa-treated cycles (buserelin, 4.3%; decapeptyl, 5.9%). It can be concluded that GnRHa associated with gonadotrophins produced embryos of a poorer aptitude for development than stimulation treatments without GnRHa. The clinical efficacy of GnRHa in IVF--ET cycles could be the result of an improved uterine receptivity to the transferred embryos.     

Quadruplet pregnancy following transfer of two embryos: Case report

Following a long period of secondary unexplained infertility, a couple had assisted conception treatment with IVF and transfer of two embryos 2 days later. The woman conceived and was found to have a quadruplet pregnancy. Following spontaneous labour onset at 34 weeks gestation, she was delivered by immediate Caesarean section. All four babies (three boys, one girl) were eventually discharged home with the mother. All the boys were found to be of differing zygosity. The quadruplet pregnancy was attributed to natural conception following intercourse and fertilization of oocytes not collected at the time of IVF. The wisdom of intercourse during a cycle of IVF is discussed.     

Autoimmune disorders: another possible cause for in-vitro fertilization and embryo transfer failure

This study was undertaken to investigate the role of autoantibodiesin association with in-vitro fertilization (IVF) and embryotransfer failure. Anticardiolipin, lupus anticoagulant, anti-deoxyribonucleicacid and antinuclear antibody, rheumatoid factor and antithyroidantibody concentrations were measured. The study group comprised50 IVF patients with three or more previously failed cyclesafter embryo transfer. The control group comprised 80 computer-matchedwomen: 40 who had conceived and delivered following three orless IVF and embryo transfer cycles, and 40 who were healthynulligravidas. The incidence of autoantibodies in the studygroup was 22.0%, compared with 2.5% in the IVF control group(P < 0.05) and 7.5% in the nulligravida group (P < 0.05).In the study group, no statistical difference was found betweenthe patients with unexplained infertility and those with mechanicalinfertility (23.0 and 20.8% respectively). The high occurrenceof autoantibodies found in patients who failed at least threeIVF and embryo transfer cycles could imply that these autoantibodiesmay be one of the possible causes of IVF failure in either mechanicalor unexplained infertility. Further investigations are requiredto indicate the autoantibody profile as part of the work-upafter three or more failed IVF and embryo transfer attempts.     

Andrology: Successful treatment of severe male factor infertility in 100 consecutive cycles using intracytoplasmic sperm injection

In this report, we present the results of our first 100 consecutivecycles of intracytoplasmic sperm injection (ICSI). Overall,fertilization occurred in 98% of cycles and embryos were transferredin 94% (2.6 embryos per cycle). About 50% of patients had embryosfrozen. The overall fertilization rate was 71%, of which 4%were abnormally fertilized (three pronuclei). A total of 30clinical pregnancies were established (32% per transfer), resultingin 18 singleton, six twin and one triplet ongoing pregnancies.The implantation rate per embryo was 15%. There were no significantdifferences in the fertilization or pregnancy rates betweenpatients Who had only occasional motile spermatozoa in the ejaculate,semen that was too poor for routine in-vitro fertilization (IVF),or who had failed routine IVF and/or subzonal sperm injection(SUZI). A group of 18 patients were treated with both ICSI androutine IVF on their first cycle because of the high likelihoodof failed fertilization due to poor sperm morphology (<20%normal). In this group, ICSI oocytes had a fertilization rateof 76% compared to only 15% for the routine IVF (control) oocytes,and six patients conceived after transfer of ICSI embryos (33%),indicating that ICSI can be used successfully on 50% of theoocytes if fertilization failure is expected. Similarly, patientswho had failed to become pregnant with SUZI achieved excellentresults after ICSI. There were no significant differences betweenICSI and routine IVF in the proportions of grade 1, 2 or 3 embryoson day 3 post-oocyte recovery. In conclusion, we have achievedresults comparable to those reported from Belgium and we havefound that ICSI is universally applicable to all forms of severemale factor infertility. ICSI produces fertilization, pregnancyand freezing rates comparable to routine IVF with normozoospermicsamples and has none of the drawbacks of other assisted fertilizationtechniques.     

Case report: successful pregnancy after vitrification of a human blastocyst that had completely escaped from the zona pellucida on day 6

This case report describes a successful pregnancy after vitrification of a human hatched blastocyst. A 31-year-old woman, after failed stimulated and thaw cycles, underwent short-treatment protocol stimulation, and oocytes were recovered transvaginally with ultrasound guidance. Eight mature oocytes were obtained and six were fertilized with conventional IVF. Consecutive embryo transfer was performed, in which two cleaved embryos were transferred on day 3 and a single blastocyst was transferred on day 5, but no implantation occurred. On day 6, one of the non-transferred embryos developed into a blastocyst that had completely escaped from the zona pellucida. The zona-free hatched blastocyst was vitrified using a cryotop procedure after artificial shrinkage, which in our clinical experience has proved to be effective for zona-intact blastocysts. Six months after the previous retrieval cycle, the cryopreserved hatched blastocyst survived the warming process and was transferred to the patient's uterus. Implantation resulted in a healthy pregnancy; the pregnancy is ongoing at 33 weeks. This is the first report of a pregnancy after vitrification of a human blastocyst that had completely escaped from the zona pellucida.     

Live-birth rates and multiple-birth risk of assisted reproductive technology pregnancies conceived using thawed embryos,USA 1999-2000

BACKGROUND: Increasing use of assisted reproductive technology treatments has been associated with the current rise in multiple births in the USA. Embryo cryopreservation and subsequent thawed embryo transfer may favourably impact the multiple-birth risk by relieving some pressure that patients and providers may feel to transfer several embryos in a single cycle. The study objective was to examine both live-birth rates and multiple-birth risk in thawed cycles. METHODS: The authors used a population-based sample of 21 555 assisted reproductive technology procedures performed in US clinics in 1999 and 2000 that used thawed embryos derived from the patient's oocytes. RESULTS: Both patient age and the number of embryos transferred were independent predictors of live birth. Even among women aged 20-29 years, the transfer of three embryos resulted in an increase in the live-birth rate compared with cycles in which one or two embryos were transferred. This increase in success was accompanied by an increased multiple-birth risk. In all age groups up to 40 years, the transfer of just two embryos resulted in a multiple-birth risk of 16-17%. The multiple-birth risk increased with the number of embryos transferred. CONCLUSIONS: Patient age and the number of embryos transferred significantly affect live-birth and multiple-birth rates among women who use thawed embryos.     

Selection of patients suitable for one-embryo transfer may reduce the rate of multiple births by half without impairment of overall birth rates

The aim of the present study was to identify a subset of patients at high risk of multiple birth after IVF and hence suitable for one-embryo transfer, which undoubtedly would reduce the multiple birth rate. This retrospective study included 2107 IVF cycles in which two embryos were transferred. Factors with possible correlation to multiple birth were studied in a multivariate analysis. The factors included background data (female age, previous pregnancies and births, previous IVF cycles, indication for IVF) and IVF cycle characteristics. The following factors were independently predictive of multiple birth: female age expressed a negative correlation while number of good quality embryos transferred was positively correlated. A subset of patients was identified as being at high risk of multiple birth by including age, cycle number and presence of tubal infertility in a model derived from a logistic regression analysis. The rate of multiple births can be reduced from 26% to 13% of all births if one-embryo transfer is performed in selected cases. The total birth rate will decrease from 29% to 25% but may be completely restored by performing one additional one-embryo freeze transfer in high risk patients who do not achieve a term pregnancy.     

Selection of good embryos for transfer depends on embryo cohort size: implications for the 'mild ovarian stimulation' debate

Embryo quality evaluated by the embryo morphology is a critical parameter in human in-vitro fertilization (IVF) and embryo transfer. It determines which and how many embryos will be replaced, as pregnancy rates are directly related to number and quality of transferred embryos. This retrospective analysis included 1301 IVF and embryo transfer cycles to identify which factors influenced embryo quality. Embryo quality did not correlate with maternal age, causes of infertility, ovarian stimulation parameters or embryo cohort size. However, the mean score of transferred embryos was significantly higher for patients with more than five embryos compared to fewer than five embryos (P < 0.001), irrespective of maternal age. Patients tended to produce a similar embryo quality from cycle to cycle, r = 0.33 (P < 0.001) for the embryo cohort and r= 0.47 (P < 0.001) for the transferred embryos. Poor embryo morphology probably reflects oocytes with compromised development competence and could be an independent factor of infertility. Furthermore, a large embryo cohort was the main factor increasing the chances of at least one good embryo in the cohort.     

Cryo-thawed embryos obtained from conception cycles have double the implantation and pregnancy potential of those from unsuccessful cycles

BACKGROUND: The purpose of this study was to evaluate the influence of fresh IVF/ICSI cycle outcome on the prognosis of the related frozen embryo replacement (FER) cycle. METHODS: 459 FER cycles, involving 2049 cleavage stage embryos with no or up to 10% fragmentation, were performed for which the outcome of the fresh cycle was recorded. The cycles were divided into two groups; group A included cycles in which cryopreserved embryos were obtained from fresh cycles in which conception occurred. Group B were cycles in which cryopreserved embryos originated from unsuccessful fresh cycles. RESULTS: Groups A and B were comparable with respect to mean (+/- SD) age at cryopreservation (33 +/- 3.9 versus 33.2 +/- 4 years, P = not significant), mean number of oocytes retrieved and fertilized normally in the fresh cycle (11 +/- 5.2 versus 11.2 +/- 4.8, P = not significant) and mean age at the cryo-thawed transfer (34.5 +/- 4.2 versus 33.9 +/- 4 years, P = not significant). No significant difference was found between the two groups with regard to mean number of embryos cryopreserved (6.5 +/- 3.9 versus 6.2 +/- 3.6) and subsequently thawed (4.5 +/- 2.5 versus 4.5 +/- 1.8) per cycle and number of cryo-thawed embryos transferred per cycle (2.0 +/- 0.7 versus 2.1 +/- 0.8). However, the implantation rate per transferred embryo in group A was double that in group B (23 versus 11.2%, P < 0.0001). Moreover, the clinical pregnancy and ongoing pregnancy rates per cycle were significantly higher in group A compared with group B (34.8 and 27.3% versus 15.6 and 13.1%, P < 0.0001 and P = 0.0003 respectively). The difference in FER cycle outcome could not be explained by confounding variables. CONCLUSIONS: After thawing, cryopreserved embryos originating from conception IVF/ICSI cycles achieve double the implantation and pregnancy rates of those obtained from unsuccessful cycles.