Reduction of perifollicular arterial blood flow resistance after hCG administration is a good indicator of the recovery of mature oocytes in ART treatment

Measurement of oxidative stress in the follicular fluid of infertility patients with an endometrioma

PURPOSE

Follicular fluid (FF) might reflect the environment during follicle and oocyte growth, and an evaluation of oxidative stress in the FF might be useful in predicting oocyte quality. In order to measure the oxidative stress (OS) in the FF from a single follicle of patients with endometrioma (EM), we evaluated whether an EM might affect the environment of follicular growth.

METHODS

Between December 2011 and July 2013, 26 patients with a unilateral EM (EM group) and 29 without EM (control group) were enrolled in this study. The FF was obtained during the first puncture of follicular aspiration, and was stored at -30 °C until it was assayed. A Free Radical Elective Evaluator (WISMERLL, USA) was used to perform d-ROM and BAP tests to measure oxidative stress (U.CARR) and antioxidant power (μmol/L).

RESULTS

The d-ROM values in the EMC and control groups were 328.7 ± 97.8 and 414.9 ± 84.2, respectively, and the BAP values for the two groups were 2474.3 ± 432.0 and 2552.8 ± 435.58, respectively. These values were similar between the two groups (mean ± SD). The number of patients with a modified BAP/d-ROM ratio of <1.0 in the EM group was similar to that for the control group at 16 and 15, respectively (61.5 and 51.7 %).

CONCLUSIONS

The oxidative stress and antioxidant potential in the FF of the patients with unilateral EM showed values similar to those without an EM. Therefore, we concluded that EMs do not affect the environment for follicle growth during ART treatment.

Hyaluronan-enriched transfer medium improves outcome in patients with multiple embryo transfer failures

PURPOSE

To ascertain whether the use of hyaluronan-enriched transfer medium (HETM) improves pregnancy and implantation rates among embryo transfer patients with a history of multiple implantation failures.

METHODS

Patients (n = 314) under the age of 40 and with a history of multiple unsuccessful embryo transfers were enrolled. There were three groups of patients: those undergoing fresh embryo transfer (fresh ET [n = 111]), those undergoing vitrified-warmed ET in the natural cycle (WET-N [n = 101]) and those undergoing WET in a hormone replacement cycle (WET-H [n = 102]). On the day of ET, patients were randomized to HETM (0.5 mg/ml hyaluronan) or control medium containing no hyaluronan. Only patients with good quality embryos on day 3 were included.

RESULTS

For all three patients groups (fresh ET, WET-N and WET-H) pregnancy rates (37.5 %, 31.4 % and 41.2 %, respectively) were significantly higher when using HETM compared with control medium (10.9 %, 10.0 % and 15.7 %, respectively; p < 0.05), and implantation rates when using HETM were also significantly higher compared with control medium (p < 0.05). Miscarriage rates were similar in both groups.

CONCLUSION

HETM significantly increased pregnancy and implantation rates among embryo transfer patients with a history of multiple unsuccessful implantations-regardless of method used to prepare the endometrium.

A programmed schedule of oocyte retrieval using mild ovarian stimulation (clomiphene citrate and recombinant follicle-stimulating hormone)

PURPOSE

The purpose was to establish a mild ovarian stimulation protocol that would help assisted reproductive technology (ART) units to avoid scheduling on weekends.

METHODS

This protocol directed patients to take 50 mg/day of clomiphene citrate between days 3 and 7 of the menstrual cycle: 225 IU of recombinant follicle-stimulating hormone (rec-FSH) were administered on days 3, 5 and 7; human chorionic gonadotropin (hCG) was administered on day 9; and, oocyte pick-up (OPU) was planned for day 11. From October 2008 through October 2009, 514 women underwent ART treatment with mild stimulation at the Sugiyama Clinic, and we evaluated whether OPU was accomplished on the planned day.

RESULTS

Of all the treatment cycles, 419 (81.5%) underwent OPU on day 11 (scheduled group). Additional rec-FSH administration was needed in 83 cycles, in which case OPU was performed on day 12 or later. In 12 cycles, OPU was canceled. The unscheduled group (n = 95) consisted of delayed OPU cycles and canceled cycles. Of all treatment cycles, 332 cycles in the scheduled group and 68 cycles in the unscheduled group underwent embryo transfer, with 81 and 16, respectively, resulting in pregnancies.

CONCLUSIONS

Using this protocol, OPU was performed on the scheduled day in about 80% of the cycles. Most weekend scheduling of OPU can be avoided using this mild stimulation.

Elective single cleavage-stage embryo transfer need not result in lower pregnancy rates compared to double cleavage-stage embryo transfer

AIM

To confirm whether women who choose to have one fresh embryo transferred and one frozen-and-thawed embryo when needed can dramatically reduce the possibility of a multifetal pregnancy while giving themselves a better chance of achieving pregnancy.

METHODS

We enrolled 685 patients who were undergoing assisted reproductive technology (ART) treatment at our clinic between January 2005 and December 2008. None of the patients had a history of ART treatment, and they received either a double-embryo transfer (DET) or single-embryo transfer (SET) during this period. The outcomes of the ART and the pregnancy rates per patient were evaluated for both groups and comparisons were made.

RESULTS

The mean age was 35.7 +/- 0.2 years (mean +/- standard error of the mean) for all patients (n = 583) who received a fresh embryo cycle of DET. In contrast, the mean age (34.3 +/- 0.4) of all patients (n = 102) who received a fresh- or thawed-embryo transfer cycle of SET was significantly younger than the average age in the DET group (P < 0.05). The per-patient overall pregnancy rate in the SET group was an estimated 35.3%, which was significantly higher than that in the DET group (P = 0.02). However, the multifetal pregnancy rate for the DET group was significantly higher than that for the SET group (P < 0.01).

CONCLUSION

We demonstrated that women who choose to have one fresh embryo transferred and one frozen-and-thawed embryo when needed, can dramatically reduce their possibility of a multifetal pregnancy while giving themselves a better chance of achieving pregnancy.

A study of the effect of an extremely low oxygen concentration on the development of human embryos in assisted reproductive technology

Purpose

To determine whether embryos cultured with a low oxygen level (2%) brought about beneficial effects on the outcome of ART.

Methods

This is a sequential case-control embryo-culture study. Embryos were cultured either with a gas mixture containing 2% O₂, 5% CO₂, and 93% N₂ (low-oxygen group) or 5% O₂, 5% CO₂, and 90% N₂ (conventional group). From January 2008 to September 2008, 873 fertilized oocytes were obtained from 250 patients in the low-oxygen group and from October 2008 to March 2009, 730 fertilized oocytes were obtained from 213 patients in the conventional group. The outcomes of ART were compared between two groups.

Results

The cleavage rate in the low-oxygen group (94.4%) was similar to that (94.7%) in the conventional group. The mean number of blastomeres on Day 3 in the low-oxygen group (mean ± SE) was 6.5 ± 1.9, and this was significantly lower than in the conventional group (6.8 ± 1.9, p < 0.05). Moreover, the low-oxygen group produced worse quality embryos, on the basis of the significantly higher embryo grade 2.1 ± 0.6 versus 1.9 ± 0.6, p < 0.001, in 5% oxygen. The pregnancy and miscarriage rates in the low-oxygen group were 22.3 and 20.8%, respectively, which were statistically similar to the outcomes in the conventional group.

Conclusions

Overall, culture of embryos at the low oxygen level did not significantly improve ART results compared with embryos grown in 5% oxygen. The study suggests that a low oxygen level worsens embryo morphology but does not impair embryo viability.

Clinical outcomes resulting from the transfer of vitrified human embryos using a new device for cryopreservation (plastic blade)

PURPOSE

We attempted clinical application of a plastic blade, which is a novel cryopreservation device, for vitrification of human embryos and blastocysts.

METHODS

Between February 2003 and December 2007, a total of 4,430 Day 3 embryos from 898 patients (Day 3 group) and 55 blastocysts from 29 patients (blastocyst group) were vitrified and cryopreserved with a plastic device, and subsequently thawed for embryo transfer. Clinical outcomes after thawing and transfer of vitrified embryos and blastocysts were evaluated.

RESULTS

In the Day 3 group, all embryos resulting from 1,441 oocyte retrieval cycles were recovered, and the thawed embryo survival rate was 98.4%. In the blastocyst group, the survival rate after thawing was 100%. A total of 3,026 day 3 embryos and 46 blastocysts were transferred. The pregnancy and implantation rates in the Day 3 group were 25.0% and 15.5%, respectively, and in the blastocyst group the rates were 24.2% and 26.1%, respectively. The miscarriage rates in the Day 3 and blastocyst groups were 18.3% and 50.0%, respectively.

CONCLUSIONS

A plastic blade is a useful novel device in cryopreservation of vitrified human embryos.

Laparoscopically-assisted transabdominal oocyte retrieval in an infertility patient with ovarian malposition

Infertility patients with malpositioned ovaries have considerable difficulty conceiving naturally because of extended fallopian tubes and ovarian malposition; such patients turn for help to assisted reproductive technology (ART) treatment. For most of these patients, ovarian malposition prevents transvaginal oocyte retrieval, so the transabdominal approach for oocyte retrieval is required. One of our infertility patients presented with ovarian malposition, and laparoscopy-assisted transabdominal oocyte retrieval was performed. We performed a Gonadotropin-releasing hormone agonist (GnRH-a) long protocol with human menopausal gonadotropin (hMG) ovarian stimulation, and used a standard transvaginal probe through the anterior abdominal wall for ovarian imaging and monitoring of the growing follicles. The patient underwent laparoscopically-assisted transabdominal oocyte retrieval-9 oocytes were recovered, and 5 were fertilized, and 2 embryos were transferred to the patient's uterus. The patient became pregnant and a gestational sac was detectable by transvaginal ultrasonography, but she spontaneously miscarried. The patient then received several laparoscopically-assisted transabdominal oocyte retrievals and finally became pregnant following a thawed embryo transfer during a hormone replacement cycle, and now her pregnancy is going well.

Laparoscopic proximal tubal division can preserve ovarian reserve for infertility patients with hydrosalpinges

AIM

To investigate whether laparoscopic proximal tubal division for the treatment of hydrosalpinges could preserve ovarian function.

METHODS

From June 2002 to October 2006, before assisted reproductive treatment (ART), a total of 17 infertile patients with bilateral hydrosalpinges were studied--11 patients underwent laparoscopic proximal tubal division (PTD group), and six underwent laparoscopic salpingectomy (salpingectomy group). In both groups, the basal follicle-stimulating hormone (FSH) values before and after surgery, the operation time and outcome of ART treatment were retrospectively evaluated.

RESULTS

The mean FSH value before laparoscopic PTD was similar to that after surgery. The FSH value before laparoscopic salpingectomy significantly increased after surgery (6.8 +/- 1.1 vs 14.1 +/- 9.3). The operation time in the PTD group was significantly shorter than in the salpingectomy group. The outcomes of ART were similar in both groups. The pregnancy rate per patient in the PTD and salpingectomy groups were 45.5% and 50%, respectively.

CONCLUSIONS

Laparoscopic proximal tubal division preserved ovarian function and was an optimal operation method for infertility patients with hydrosalpinges. The basal FSH values after laparoscopic proximal tubal division were comparable to those before surgery.

The dilemma faced by patients who undergo single embryo transfer

Purpose

The aim of this study was to identify the factors that contribute to the decision to choose single embryo transfer (SET).

Methods

Two hundred and nine patients who underwent ART treatment in our clinics between April 2006 and May 2007 were enrolled in this study. All patients had elected to undergo SET before the start of each treatment cycle; a questionnaire was administered to all patients prior to the SET procedure.

Results

The mean age of the patients was 34.6 years old (range: 24-45 years). The mean number of redundant embryos was 3.7 (range: 1-17), and the pregnancy rate per embryo transfer was 25.7%. A total of 121 patients (57.9%) who underwent SET returned their questionnaires. Based on the results of questionnaire, 56.2% of patients who received SET waived their right to choose between single and double embryo transfer. Among patients who selected SET, 67.6% believed that the pregnancy rate resulting from double embryo transfer (DET) is significantly greater than that associated with SET, and 25% of patients wanted to have twins. The majority of patients (80.9%) who underwent SET understood that multi-fetal pregnancy increases the risk of complications during gestation and delivery. Among all patients who completed the questionnaire, 72.8% believed that the number of transferred embryos should not be controlled by law.

Conclusions

The results of the present study show that greater than one-half of patients who underwent SET were faced with a dilemma--the difficult choice between their own desires and their clinician's recommendation.

The ratio of late-follicular to mid-follicular phase LH concentrations efficiently predicts ART outcomes in women undergoing ART treatment with GnRH-agonist long protocol and stimulation with recombinant FSH

PURPOSE

To establish an index to predict ART outcomes and to identify infertile patients who need LH supplementation during ovarian stimulation.

METHODS

Serum LH concentrations were measured during the mid- and late-follicular phase in 86 normogonadotropic infertile patients who underwent ART treatment using GnRH-agonist long protocol with recombinant-FSH. The relationships between serum LH concentrations at both time points and ART outcomes were retrospectively analyzed, and the relationships between the ratio of late-follicular to mid-follicular LH concentrations and ART outcomes were also evaluated.

RESULTS

There were no significant correlations between the mid- or late-follicular LH concentrations and ART outcomes. The ratio of late-follicular to mid-follicular LH concentrations <1.0 was considered the relatively LH decreased group (RD group) and ratio >or= 1.0 was considered the relatively LH increased group (RI group). The number of usable embryos in RD group was similar to that in RI group, but the pregnancy and implantation rates in the RD group (9.7% and 5.8%) were significantly lower than those in the RI group (31.1% and 17.2%; p < 0.05).

CONCLUSIONS

Relatively decreased LH concentrations during ovarian stimulation using GnRH-agonist long protocol with rec-FSH had a negative effect on ART outcomes. Therefore, the ratio of mid- to late-follicular phase LH concentrations is suggested to be an efficient index to identify patients who might benefit from LH supplementation.

Elevated basal FSH levels, if it is under 15 IU/L, will not reflect poor ART outcomes

PURPOSE

For this study, the impact of basal FSH levels on ART outcomes was assessed.

METHODS

From June 2003 to May 2006, 191 ART cycles were performed in our hospital. All cases were treated with GnRH-a long protocol. The patients were classified according to their basal FSH level as follows: group A: FSH <10 IU/l, group B: 10 <or= FSH <15 IU/l, and group C: 15 IU/l <or= FSH. ART outcomes were compared among the three groups.

RESULTS

The number of retrieved oocytes in group A was significantly higher than in group B, but fertilized oocytes and the pregnancy rates were comparable. The pregnancy rate in group C was not significantly lower than those found in either group A or B, but the trend was lower.

CONCLUSION

Oocytes retrieved from the patients who showed basal FSH levels below 15 IU/l were found to possess significant pregnancy potential.

Impact of laparoscopic cystectomy on fecundity of infertility patients with ovarian endometrioma

AIM

To clarify the effect of laparoscopic cystectomy for ovarian endometrioma in infertility patients, the pregnancy outcome was evaluated.

METHODS

This was a retrospective study. From August 2002 to February 2006, 33 infertility patients with ovarian endometrioma underwent laparoscopic cystectomy at our center. According to the laparoscopic findings 33 were divided into two groups; 10 were evaluated as the patients who need assisted reproductive technologies (ART) treatment (IVF subgroup) and 23 were evaluated as the patients who do not need ART treatment but conventional infertility treatment (non-IVF subgroup). During the same period, 70 patients who were age-matched and received ART treatment without laparoscopy were defined as control (control group). Following up to 12 months after laparoscopy, the cumulative pregnancy rate in the non-IVF subgroup was calculated.

RESULTS

The patients age, duration of infertility and size of endometrioma were equal in the IVF and the non-IVF subgroups. The revised-American Society of Reproductive Medicine (r-ASRM) score in the IVF subgroup was significantly higher than that in the non-IVF group (P < 0.05). The pregnancy rates after laparoscopic cystectomy in IVF and non-IVF subgroups were 50.0% and 60.9%, respectively. These rates in the IVF and the non-IVF groups were slightly higher than that in control group (41.4%), but these differences were not significant. The cumulative pregnancy rate in the non-IVF group reached 52.2%, 12 months after laparoscopic surgery.

CONCLUSIONS

Laparoscopic surgery should be performed prior to ART treatment not only for making a decision about the treatment course but also for establishing a good pelvic condition to induce a pregnancy during ART treatment in infertility treatment with ovarian endometrioma.

Relationships of Follicle Versus Oocyte Maturity to Ultrasound Morphology, Blood Flow, and Hormone Concentrations of the Preovulatory Follicle in Mares1

The effects of ultrasound morphology, vascularity, and follicular-fluid hormones of the preovulatory follicle on oocyte recovery rate and on follicle and oocyte maturity rates were studied for 60 spontaneous and solitary preovulatory follicles in mares. An ovulation-inducing dose of hCG was given when the follicle was >or=32 mm (Hour 0), and a procedure for oocyte recovery was done 30 h later (Hour 30). Between Hours 0 and 30, diameter of the follicle increased less and circulating estradiol (E2) concentrations decreased more in groups with successful versus nonsuccessful oocyte recovery and in groups with mature versus immature recovered oocytes, as indicated by significant interactions of group and hour. Significant differences in blood-flow end points between groups were not detected. At Hour 30, the frequency of granulosa serration, an indicator of impending ovulation, was higher (P < 0.001), and the number and expansion of granulosa cells in the lavaging fluid, indicators of follicle maturity, were greater in the oocyte-recovery group and in the oocyte-mature group. Follicular-fluid concentrations of E2, progesterone, and free insulin-like growth factor (IGF) 1 were not different between the oocyte-recovery and -nonrecovery groups. Concentration of progesterone was significantly greater, and E2 and free IGF1 were less in the oocyte-mature than in the immature groups. Results indicated that the post-hCG oocyte-recovery and oocyte-maturity rates were positively affected by follicle maturity. Greater follicular-fluid progesterone and lower E2 and free IGF concentrations were associated temporally with maturation of the oocyte but not with maturation of the follicle.