The outcome of ICSI of immature MI oocytes and rescued in vitro matured MII oocytes

BACKGROUND: The use of immature oocytes is limited to cases where these are the only available oocytes, and they are usually only microinjected with sperm after having undergone maturation in vitro. This study compares the outcome of injection of sperm into metaphase I oocytes immediately after their denudation (MI) performed 2 h after their retrieval, with the outcome of injection of sperm into rescued in vitro matured metaphase II (IVM MII) oocytes after their short incubation in routine laboratory conditions. METHODS: ICSI was performed on MI oocytes, rescued IVM MII oocytes and on MI oocytes that were incubated but failed to extrude their first polar body (arrested IVM MI). Fertilization and cleavage rates were compared with those achieved in mature metaphase II oocytes (MII). RESULTS: ICSI of MI oocytes showed impaired performance compared with ICSI of rescued IVM MII oocytes and MII oocytes, in terms of oocyte degeneration rate (11 versus 6 versus 4%; P < 0.0001), fertilization rate (28 versus 44 versus 68%; P < 0.0001) and multipronucleated fertilization (10 versus 4 versus 4%; P < 0.01). The cleavage rate was lower in rescued IVM MII oocytes compared with MII oocytes (86 versus 95%; P < 0.01). Arrested IVM MI oocytes showed similar results to those of MI oocytes but had a lower cleavage rate (72 versus 96%; P < 0.01). CONCLUSIONS: The injection of rescued IVM MII oocytes is preferred to the injection of MI oocytes.     

Factors influencing the outcome of ICSI in patients with obstructive and non-obstructive azoospermia: a comparative study

BACKGROUND: Factors influencing success of sperm retrieval in azoospermic patients and outcome of ICSI were evaluated. METHODS AND RESULTS: Uni- and multifactorial analysis were performed using logistic and stepwise analysis, following surgical sperm retrieval by percutaneous epididymal sperm aspiration (55 cycles) or testicular sperm extraction (142 cycles) in 52 and 123 patients with obstructive azoospermia (OA) and non-obstructive azoospermia (NOA) respectively. ICSI cycles using fresh or cryopreserved-thawed sperm were included. Sperm were retrieved to allow ICSI in 100 and 41% of OA and NOA patients, with no significant correlation with patients' age or FSH level. Occurrence of pregnancy was significantly correlated with female age (90th quantile: 38 years), number of oocytes retrieved (10th quantile: five oocytes) and number of oocytes injected (10th quantile: four oocytes). Sperm origin (epididymal versus testicular), status (fresh or thawed), male partner's age, and serum FSH had no significant effect upon implantation rate, pregnancy rate per embryo transfer or spontaneous miscarriage rate. CONCLUSIONS: In OA patients ICSI should be planned in conjunction with surgical sperm retrieval. In contrast, the lack of efficient non-invasive parameters to predict sperm retrieval in NOA suggests that elective surgical sperm retrieval may be offered to these patients prior to ovarian stimulation of their partners, especially when donor back-up is not an alternative. Female factors such as age and ovarian reserve have significant impact upon clinical success rates.     

Testicular sperm retrieval by percutaneous fine needle sperm aspiration compared with testicular sperm extraction by open biopsy in men with non-obstructive azoospermia

The efficiency of testicular sperm retrieval by testicular fine needle aspiration (TEFNA) was compared with open biopsy and testicular sperm extraction (TESE), in 37 rigorously selected patients with non- obstructive azoospermia. All patients underwent TEFNA and TESE consecutively. Thus, each patient served as his own control. The case was regarded as successful if at least one testicular spermatozoon was found allowing intracytoplasmic sperm injection (ICSI) of at least one oocyte. The mean age of the male patients was 32.7 years (range 24-47). Whereas by TEFNA spermatozoa enabling performance of ICSI were found in only four patients out of 37 (11%), open biopsy and TESE yielded spermatozoa in 16 cases (43%). The negative predictive value of high serum follicle stimulating hormone (FSH) concentrations (> or =10 IU/l) (predicting failure to find spermatozoa for ICSI) was low (38.4%). The positive predictive value (predicting the chance to find spermatozoa for ICSI) of normal-sized testicle was not different from that of small- sized (<15 ml) testicle (50%). Complications included one case of testicular bleeding following fine needle aspiration, treated locally, and two cases of extratunical haematomata following TESE requiring no intervention. In patients with non-obstructive azoospermia, TEFNA has a significantly lower yield compared to TESE. Performance of ICSI with testicular sperm in these cases resulted in satisfactory fertilization and high embryo transfer rates. The implantation and pregnancy rates per embryo transfer were 13 and 29% respectively. Neither serum FSH values nor testicular size were predictive of the chances to find spermatozoa for ICSI. Some complications may occur even following TEFNA.      

Controlled intravenous bicarbonate and fetal-maternal acid-base balance. I. The primipara.

The effects of a controlled sodium bicarbonate (SB) infusion on the acid-base balance of the primiparous mother and fetus at labor and delivery were evaluated. Two identical groups of primiparas with normal labor and delivery were studied. According to acid-base parameters observed in the mothers and fetuses of a control group, the pharmacologic dynamics, and the space of distribution of SB, 2 mEq/1 kg of total body weight were administered to the mothers of the study group, beginning at a cervical dilation of 6 cm until full dilation occurred. Highly significant changes in pH, base excess (BE), and plasma bicarbonate were observed in both the mothers and fetuses. In the latter, the significant changes appeared after a time lag of about 2 hours. No adverse effects in the mothers and fetuses were observed. The significant reduction of the relative fetal acidosis by the controlled SB infusion justifies further studies on the therapy potentials of this method in high-risk deliveries and during intrapartum fetal distress.     

The value of simultaneous hysterectomy during Burch colposuspension for urinary stress incontinence

The effect of concomitant hysterectomy during colposuspension on the cure rate of genuine stress incontinence was evaluated prospectively in 45 patients. Twenty-two women underwent a colposuspension only (no-hysterectomy group) and 23 had a concomitant abdominal hysterectomy and cul-de-sac obliteration (hysterectomy group). Twenty-five months postoperatively, no differences were found in the cure rate for urinary stress incontinence between the two groups (95.5 and 95.7% for the no-hysterectomy and the hysterectomy group, respectively). In the no-hysterectomy group, three patients (13.6%) had enterocele formation after surgery; this complication did not occur in any of the patients in the hysterectomy group.     

Overstimulated cycles under low-dose gonadotrophins in patients with polycystic ovary syndrome: characterization and management

Among 30 patients with polycystic ovary syndrome, treated withlow-dose gonadotrophins, 75 cycles were analysed in order tocharacterize overstimulated cycles that were at increased riskof developing ovarian hyperstimulation. Optimal response (oneor two follicles 14 mm diameter) was observed in 59 cycles(79%). The remaining 16 cycles (21%) exhibited an overstimulatedresponse characterized either by growing more than two folliclesor having an oestradiol level > 850 pg/ml (2 SD above themean observed in optimal cycles). Six of the latter were handledprospectively when oestradiol levels were found to be too highaccording to the size of the leading follicle. This stage wastermed as developing overstimulation and its identificationwas based on objective criteria obtained from the optimal group.Following the withholding of gonadotrophin, the follicles continuedto grow; however, the final oestradiol level was lower comparedwith six other matched overstimulated cycles. Overall, 14 patientsconceived (47%) of whom three (21%) had multiple pregnancies.Mild or moderate ovarian hyperstimulation syndrome occurredin three cases; all of which involved overstimulated cycles.Low-dose gonadotrophin treatment is associated with a substantialdegree of overstimulated response. All cycles should be monitoredcarefully in order to recognize the overstimulated response,which deserves cautious management.     

Prerequisite work-up of the couple before in-vitro fertilization.

Prerequisite examinations, including immune status for rubella and hepatitis B antigens, cultures for Chlamydia trachomatis and mycoplasmas, Pap smear and hystersalpingogram were performed in 227 couples before their enrollment into an in-vitro fertilization (IVF) programme. The examinations were completed in 187 couples. Immune status for rubella had already been documented in 45% of the women: of the remainder, 11 patients were not immune (6%). A screening test for hepatitis B antigens had already been documented in only 10% of the patients; eight of the remaining women (5%) were carriers of hepatitis B antigen. C. trachomatis and Mycoplasma hominis were each isolated from 14% of the patients and Ureaplasma urealiticum from 16%. Pap smears had been previously performed in only 35% of the enrolled women. Six (5%) of the 122 newly referred cases had cervical intra-epithelial dysplasia. In 21 (11%) cases some pathology in the uterine cavity was demonstrated. One patient conceived after diagnostic hysteroscopy; another two patients conceived following lysis of adhesions and before IVF treatment. The results of this study show the importance of the preparatory examinations before the IVF and embryo transfer procedure, and raise the medical and medico-legal aspects of this prerequisite work-up.     

Eight years' experience with an IVF surrogate gestational pregnancy programme

The aim of this study was to retrospectively audit eight years' experience of an IVF surrogate gestational programme and to compare the outcome of surrogacy due to absence of the uterus with surrogacy indicated for repeated IVF failure and recurrent abortions. A total of 60 cycles of IVF surrogate pregnancy were initiated in 19 treated couples. Absence of the uterus was the indication for surrogacy in 10 cases: Rokitansky syndrome (eight cases) and post-hysterectomy (two cases) designated as group A. The indications in the remaining nine patients (group B) were: IVF implantation failure (three cases), habitual abortions (four cases) and deteriorating maternal diseases (two cases). IVF performance and subsequent pregnancy outcome of groups A and B were compared. There was no difference in ovarian stimulation parameters and in IVF performance between the groups A and B. The overall pregnancy rate per transfer was 10/60 (17%). The pregnancy rates per patient and per transfer were 7/10 (70%) and 7/35 (20%) in group A compared with 3/9 (33%) and 3/25 (12%) in group B. A median number of three treatment cycles were needed to achieve pregnancy. In conclusion, the existence or absence of the uterus in the commissioning mothers is irrelevant for their IVF performance and conception rates. In patients who conceived after more than three IVF cycles, an additional 'oocyte factor' might be present.