The reproductive outcome following a superhigh response to stimulation in gamete intrafallopian transfer program

Cumulative experience of percutaneous epididymal sperm aspiration (PESA) with intracytoplasmic sperm injection

OBJECTIVE

Our objective was to evaluate the recovery rate of spermatozoa from the epididymis using a percutaneous aspiration technique and to assess the fertilisation rate after intracytoplasmic sperm injection.

MATERIALS AND METHODS

Fifty-four patients with azoospermia had a total of 59 cycles at IVF with intracytoplasmic sperm injection (ICSI). The cause of the azoospermia was failed vasectomy reversal in 23 cases, congenital absence of the vas in 22 cases, partial testicular failure in 5 cases, and retrograde ejaculation in 2 cases, while the remaining 2 patients had erectile disorders.

RESULTS

A total of 741 oocytes was collected and 521 metaphase II oocytes were subsequently microinjected. Normal fertilisation occurred in 274 oocytes (52.6%), and of these, 234 cleaved (85.4%). In 54 cycles, embryo transfer of more than one embryo occurred (91.5%) and a total of 155 embryos was replaced. The pregnancy rate was 30.5% per cycle and 33.3% per embryo transfer. The implantation rate was 14.2%; failure of fertilisation occurred in two cycles, while in three other cycles the embryos did not cleave.

CONCLUSIONS

Percutaneous epididymal sperm aspiration can be used successfully to retrieve sperm in men with azoospermia due to obstructive, or nonobstructive, disorders. The technique is simple, cost-effective, and associated with fewer complications than an open microsurgical operation.

Percutaneous epididymal sperm aspiration and intracytoplasmic sperm injection in the management of infertility due to obstructive azoospermia

OBJECTIVE

To evaluate the recovery rate of spermatozoa from the epididymis using a percutaneous aspiration technique and to examine the fertilization rate after intracytoplasmic sperm injection.

DESIGN

Prospective observational study.

SETTING

Private infertility clinic, London.

SUBJECTS

Twenty patients with obstructive azoospermia who each had an attempt at IVF. The sperm used for intracytoplasmic sperm injection was retrieved by percutaneous epididymal sperm aspiration in 16 patients. In one patient, microepididymal sperm aspiration was performed in addition because the quality of the sperm obtained by percutaneous epididymal sperm aspiration was not considered suitable for microinjection. In the remaining three patients, neither percutaneous epididymal sperm aspiration nor microepididymal sperm aspiration resulted in the recovery of sperm, which was obtained by testicular biopsy in one of them.

INTERVENTION

Assisted fertilization with intracytoplasmic sperm injection.

MAIN OUTCOME MEASURES

Normal fertilization and pregnancy rates.

RESULTS

A total of 179 eggs were collected and 157 subsequently were microinjected. Normal fertilization occurred in 22 oocytes (14%) and the total number of embryos cleaved was 30. Twelve patients underwent ET in which three conceived (pregnancy rate 25% per transfer). The implantation rate was 10% and failed fertilization occurred in four cycles.

CONCLUSION

Percutaneous epididymal sperm aspiration can be used successfully to recover sperm in men with obstructive azoospermia for use in assisted fertilization IVF cycles. The technique is simple, effective, and less traumatic compared with an open microsurgical operation.

Late intracytoplasmic sperm injection in unexpected failed fertilization in vitro: diagnostic or therapeutic?

OBJECTIVE

To evaluate fertilization potential of 24-hour-old unfertilized oocytes using intracytoplasmic sperm injection and the pregnancy potential of resultant embryos.

DESIGN

Prospective observational study.

SETTING

Private infertility clinic, London, United Kingdom.

PATIENTS

Fifteen patients with a history of infertility who underwent treatment with IVF and showed failure of fertilization on the day after oocyte retrieval.

INTERVENTION

Assisted fertilization with intracytoplasmic sperm injection was carried out at 24 hours after oocyte retrieval.

RESULTS

A total of 121 metaphase II oocytes were subjected to intracytoplasmic sperm injection. Of these, 9 were damaged (7%), 2 were polyploidic (2%), and 58 showed normal fertilization (48%). Of the latter, 47 cleaved normally (81%). Forty embryos were transferred and three were cryopreserved. One patient conceived (7%) but in this case only one of three embryos transferred was from intracytoplasmic sperm injection.

CONCLUSION

Late (24 hours) intracytoplasmic sperm injection can give good fertilization and cleavage rates but the potential of the generated embryos to achieve pregnancy seems to be low.

Appraisal of gamete intrafallopian transfer

OBJECTIVE

To collect results of gamete intrafallopian transfer on a large scale in order to compare treatment indications, results, and factors which influence the success rates; to evaluate whether gamete intrafallopian transfer is well-established and what the real place of this procedure is among other assisted reproduction techniques.

DESIGN

Data relating to gamete intrafallopian transfer were collected from World Reports, national registries of different countries and meta-analysis of medical publications during the years 1986-1991.

SUBJECT

Official registries reported 47,200 treatment cycles and 18,759 treatment cycles were analysed from ten medical publications.

RESULTS

The procedure accounts for 13.5% of all assisted reproduction techniques but its popularity varies significantly among countries. The same indications for gamete intrafallopian transfer are followed by all countries, but great differences exist with regard to the proportional share of each etiology. Also, the share has changed considerably over the years. TREATMENT OUTCOME: 10,667 clinical pregnancies were reported which represent 24% of treatment cycles and 29% of ovum pick-up. The live birth rate was 23.3%; abortion rate, 22%; and ectopic pregnancy rate, 5.5%. The stillbirth rate was 2.3% and the malformation rate was 2.8%, not confined to specific organs or systems. There were 19.5% twins, 4.6% triplets and 0.3% quadruplets or more. The number of transferred oocytes influenced pregnancy rates: 28% for transfer of four oocytes and only 10% following transfer of one oocyte. The cause of infertility might influence the results and the poorest results are obtained for male factor infertility. In most cases correlation of success rates reported by leading units through medical publications closely resembles the overall national registries results. Indications for this treatment were broadened over the years, but its role among other assisted reproduction technologies is not agreed upon, especially for male factor and unexplained infertility.

CONCLUSIONS

Gamete intrafallopian transfer carries an overall higher pregnancy rate than in vitro fertilization. Quality control by professional or public associations should be established and more research employed over indications for treatment and results in order to establish when GIFT is the treatment of choice and when other modes of treatment should be preferred.

Assisted fertilization with intracytoplasmic sperm injection

OBJECTIVE

To evaluate the significance of intracytoplasmic sperm injection in severe male factor infertility and previous failed fertilization.

DESIGN

Prospective observational study.

SETTING

Private infertility clinic, London.

SUBJECTS

Sixty-nine patients with a long-standing history of infertility of which 48 had previous failed fertilization, 15 had < 1 million progressive motile sperm per ejaculate, and the remaining 6 had obstructive azoospermia.

INTERVENTION

Assisted fertilization with primary intracytoplasmic sperm injection was carried out in 69 IVF.

OUTCOME

Normal (two pronuclei [2PN]) fertilization and pregnancy rates.

RESULTS

A total of 967, oocytes were collected and 785 were subsequently microinjected. Normal fertilization (2PN) occurred in 410 oocytes (52%) and 90.5% of those cleaved. Sixty-four patients underwent ET, with a total of 181 embryos transferred. Twenty-five patients conceived with a pregnancy rate of 39% per transfer. The implantation rate was 16% and the total pregnancy loss rate 24%. Failed fertilization after intracytoplasmic sperm injection occurred in four cases.

CONCLUSIONS

Intracytoplasmic sperm injection is increasingly becoming the treatment of choice in infertile couples where assisted fertilization is indicated. The high fertilization and pregnancy rates observed with this technique, together with a low risk of abnormalities, has revolutionized treatment of male factor infertility.

Experience with subzonal insemination (SUZI) and intracytoplasmic sperm injection (ICSI) on unfertilized aged human oocytes

OBJECTIVE

The aim of this study was to assess the fertilizability of unfertilized aged human oocytes from failed in vitro fertilization (IVF) cycles using SUZI and ICSI.

METHODS

A total of 363 oocytes which showed no fertilization after conventional IVF was subjected to assisted fertilization using SUZI or ICSI. The microinjected oocytes which were derived from 72 patients undergoing their first IVF treatment had an intact polar body and no signs of degeneration. SUZI was carried out in 265 oocytes and ICSI in the remaining 98.

RESULTS

Significantly more oocytes were damaged after ICSI (9 vs 0.3%, P < 0.01). Normal fertilization rates were higher at 24 hr in both groups and occurred more frequently after ICSI, although the difference did not reach statistical significance. Abnormal fertilization occurred significantly more often after SUZI at 48 hr (P < 0.005), but not at 24 hr. Cleavage rates were significantly higher after ICSI (94.4 vs 57.1%, P < 0.025) at 24 hr, but this was not observed at 48 hr, although the ICSI group still showed better cleavage rates (33.3 vs 19.1%). There was no difference in embryo quality in either group.

CONCLUSIONS

Our results indicate that micromanipulation rather than reinsemination should be carried out on unfertilized human oocytes from failed IVF attempts. Both techniques can be used to achieve fertilization which occurs more often after ICSI. However, the trauma from the former technique on the microinjected oocytes may impair the potential of the generated embryos to achieve pregnancy compared to SUZI. Prospective randomized trials are necessary to address the problem.

Transfer of embryos into the uterus: how much do technical factors affect pregnancy rates?

OBJECTIVE

Our objective was to identify the effect on outcome of (a) ultrasound-assisted embryo transfer, (b) the use of different embryo transfer catheters, and (c) the length of time the patients remain in the supine position after embryo transfer.

SETTING

The setting was a private fertility center.

SUBJECTS

This was a prospective study of 178 in vitro fertilization and embryo transfers (IVF-ET) and 63 frozen embryo replacements (FER).

RESULTS

The pregnancy rate was 28.7% following IVF-ET and 31.8% for FER. Ultrasound-assisted transfer did not affect the outcome (29 vs 30.3%). There was no difference in the performance of the Wallace and Frydman catheters with regard to outcome (30.3 vs 30.7%). Although there was an increase in pregnancy rate as the time interval in the supine position after ET increased, this needs a larger study.

CONCLUSION

The parameter studies did not affect the outcome of IVF/ET or FER. Some factors encouraged us to recommend ultrasound-assisted transfer in some cases, and the use of a Frydman catheter for transfer and to encourage the supine position after transfer for longer periods.