Sperm selection strategies and their impact on assisted reproductive technology outcomes

The application of assisted reproductive technologies (ART) has revolutionised the treatment of human infertility, giving hope to the patients previously considered incapable of establishing pregnancy. While semen analysis is performed to access whether a sample has an adequate number of viable, motile and morphologically normal sperm cells able to achieve fertilisation, sperm selection techniques for ART aim to isolate the most competent spermatozoon which is characterised by the highest fertilising potential. Based on the semen analysis results, the correct sperm selection technique must be chosen and applied. In this review, different sperm selection strategies for retrieving spermatozoa with the highest fertilising potential and their impact on ART outcomes are discussed. In addition, advantages and disadvantages of each method and the best suited techniques for each clinical scenario are described.     

In vitro maturation

In vitro maturation (IVM) is an in vitro fertilisation (IVF) technique modified to collect immature oocytes from antral follicles, with the final stages of meiosis completed during in vitro culture. The primary benefit of IVM is that it reduces gonadotrophin stimulation in the patient, thereby eliminating the risk of ovarian hyperstimulation syndrome (OHSS) in high-risk patients such as those with polycystic ovaries (PCO) and polycystic ovary syndrome (PCOS). IVM has additional benefits for fertility preservation, particularly in oncofertility patients. IVM research has progressed in recent years to significantly improve success rates and to provide evidence of safety in terms of neonatal and childhood outcomes. More recently, pre-maturation protocols and the discovery of new culture media additives have demonstrated potential to maximise maturation and oocyte developmental competence. In this chapter, we discuss current methodologies used in clinics routinely performing IVM, target patient populations and areas of future research that may improve IVM success.     

血清及卵泡液中抑制素B动态变化及其与促排卵结局的相关性研究

目的:探讨不同控制性超促排卵(controlled ovarian hyperstimulation,COH)方案中血清及卵泡液(follicular fluid,FF)中抑制素B(inhibin B,INHB)的动态变化及其与COH结局的相关性。方法:收集因输卵管因素和/或男方因素首次接受体外受精/卵细胞质内单精子注射-胚胎移植(IVF/ICSI-ET)助孕患者COH过程各时间节点的血清及取卵(ovum pick up,OPU)日不同大小卵泡的FF,按筛选要求选取长方案组(A组,n=38)及非降调节方案组(B组,n=38)患者,对其血清及FF中INHB水平进行检测并行相关性分析。结果:①降调节过程中,血清INHB水平显著下降(P0.01),且Gn启动日A组血清INHB水平较B组明显下降(P=0.000)。②A组和B组Gn启动后血清INHB水平呈上升趋势,至h CG注射日达高峰后下降,OPU后2 d显著下降(P0.01);A组和B组基础及Gn启动后的血清INHB水平无统计学差异(P0.05)。③ Gn第5日血清INHB水平与COH结局相关性最强,且Gn启动日血清INHB水平与Gn用量呈高度负相关(P0.01)。④A组和B组FF中血清INHB水平随卵泡直径增大而升高,大卵泡的FF中INHB水平无统计学差异(P0.05),但A组中小卵泡的FF中INHB水平显著高于B组(P0.01);且大卵泡的FF中INHB水平与COH结局相关性最好。结论:①降调节后血清INHB水平预示降调节对卵泡同步化作用较好;②COH过程中血清及大中卵泡的FF中INHB水平能很好地预测卵巢反应性及COH结局。     

Obstetric and perinatal outcomes of pregnancy in patients with repeated implantation failure

ObjectiveDespite the great advance of assisted reproductive technology (ART) in recent decades, many IVF patients failed to achieve a pregnancy even after multiple IVF-ET attempts. These patients are considered to have repeated implantation failure (RIF). While exhausting efforts have been devoted to the improvement of pregnancy rate in RIF patients, it is not clear whether RIF patients have aberrant obstetric or perinatal outcomes after they eventually achieved a pregnancy.Materials and methodsTaking advantage of a relatively large database of IVF-ET cycles at the Chang Gung Memorial Hospital, we compared obstetric and perinatal outcomes of RIF patients who have a successful pregnancy after IVF-ET treatment(s) to those of control IVF-ET patients.ResultsBecause multiple pregnancies are associated with a high risk of obstetric complications, we restricted the analysis to patients who had singleton pregnancies. Analysis of a total of 596 control and 46 RIF cases showed the rates of almost all obstetric and perinatal outcomes investigated are not different between the two groups. However, the rate of placental abruption in the RIF group (4.35%) appeared to be significantly higher than that of controls (0.50%; OR = 8.99). This difference is still statistically significant after adjustment with the age (adjusted OR = 8.2).ConclusionWhile the rates of a spectrum of obstetric and perinatal outcomes are normal in RIF patients, these patients could have an enhanced risk of placental abruption. However, investigations with a large sample size are needed to substantiate this inference.     

A novel approach to infertility treatment of advance-age patient with prominent intramural fibroid

We report for the first time on a case of infertile advance-age patient with large intramural fibroid, who conceived following a course of Ulipristal. The patient underwent two fresh fertility preserving IVF cycles, with cryopreservation of 9?day-3 embryos, followed by a 12?weeks course of Ulipristal (5?mg per day) and a subsequent frozen-thawed embryo transfer with her own previously cryopreserved embryos. We, therefore, believe that Ulipristal is a valuable addition to treatment armamentarium of advance-age infertile patient with prominent intramural fibroid.     

Good oocytes for successful IVF cycles

Human fertility is mainly related to the egg quality both in spontaneous and IVF induced cycles.     

Comparison of the Effects and Safety of Mild Ovarian Stimulation and Conventional Ovarian Stimulation with A Long GnRH Agonist Protocol on IVF Outcomes

Objective To conduct a Meta-analysis of studies that compared the efficacies of mild ovarian stimulation and conventional long GnRH agonist protocol in patients under- going IVF or intracytoplasmic sperm injection （ICSI）. Methods Meta-analysis was performed. All studies were published by July 2012 with data related to outcomes following mild ovarian stimulation compared with the conventional protocol. Odds ratios （ORs） and weighted/standardized mean difference （WMD/SMD） from individual study were pooled in fixed and random effect models. Main outcome measure was the efficacy of mild ovarian stimulation. Results Six articles were included in this Meta-analysis. The number of oocytes retrieved was lower, the cycle cancellation rate was higher and the incidence of ovarian hyperstimulation syndrome （OHSS） was lower in the mild stimulation group than in conventional ovarian stimulation group. Clinical pregnancy rates were similar in both mild and conventional stimulation groups. Conclusions The level of evidence supporting the use of mild stimulation protocols in IVF is low, considering the fewer oocytes retrieved and the higher rates of cycle cancellation.