Endometrial biopsy during hormone replacement cycle in donor oocyte recipients before in vitro fertilization-embryo transfer

Is there a role for preparatory cycle in ovum donation recipients?

PURPOSE OF REVIEW

In ovum donation cycles, the role of preparatory cycles to ensure proper endometrial development in the recipient remains controversial. As evidenced in the literature, endometrial receptivity is critical in conception. Therefore, endometrial preparation with exogenous hormones in addition to synchronization of the recipient and donor are essential in achieving a successful outcome.

RECENT FINDINGS

There are very limited data specifically examining the benefit of recipients undergoing preparatory cycles prior to their actual egg donation cycle. One study concluded that trial hormone replacement treatment cycles with endometrial biopsies may be useful in older reproductive-age women but not in younger women. Another study showed no difference in pregnancy rates between those who did and did not undergo preparatory cycles.

SUMMARY

Since one of the integral elements of preparatory cycles is determining endometrial dating, with relatively conflicting data, these mock cycles may not be as beneficial as expected. Therefore, for those who routinely use preparatory cycles, the potential risks, benefits, and costs of these cycles, increased hormonal exposure, the relatively invasive nature of the procedure, and time prior to performing them must be considered.

Oocyte and embryo donation 2006: reviewing two decades of innovation and controversy

For over 21 years, oocyte and embryo donation have been used to treat infertility caused by a variety of conditions affecting the ovary. Many disorders, including premature ovarian failure, advanced reproductive age, unexplained recurrent implantation failure and inherited conditions, are amenable to gamete donation, with high pregnancy rates and good obstetrical outcomes observed in recipients. Protocols for the medical screening of recipients and donors, as well as infectious disease and genetic testing, have become relatively uniform and well accepted. Established guidelines allow synchronization of the menstrual cycles of both women to ensure that embryos are transferred to a receptive endometrium. The high demand for donor services has led to escalating costs and long waiting lists. American programmes bid against each other to secure the participation of young women often motivated as much by financial reward as altruism. In the United States, where the majority of oocyte donation is practised, more than 100,000 treatment cycles have occurred. However, to date no meaningful longitudinal studies detailing the long term effects of treatment on donors, recipients, children born, or families created have been published. Throughout its history, oocyte and embryo donation has proven to be both efficacious and clinically innovative, yet remains highly controversial.

Oocyte donation

Oocyte donation affords women with ovarian failure, advanced reproductive age, heritable conditions or recurrent implantation failure the ability to conceive. Recipients must be medically screened carefully prior to attempting pregnancy. Egg donors should also be healthy and pose no infectious or genetic risk to the recipient or offspring. Donor and recipient menstrual cycles are synchronized so that embryos are transferred to a receptive endometrium. Donors are prescribed injectible gonadotrophins to achieve multifollicular growth. Recipient endometrial priming begins with 2 weeks (or more) of oestradiol, with progesterone added to the regimen 3-4 days prior to the transfer of embryos. Pregnancy rates following egg donation are among the highest observed following assisted reproduction. Despite advanced reproductive age, perinatal and obstetric outcomes are generally good. Techniques (i.e. germinal vesicle transfer, donor ooplasm, and ovarian cryopreservation and transplantation techniques) may permit the recipient to provide some genetic contribution to offspring and are currently under investigation.

A successful pregnancy following SEM fine tuning of hormonal priming

BACKGROUND: Manipulation of the uterine epithelium utilising standard dose exogenous oestrogen (E2) and progesterone (P4) has been shown to achieve a mature secretory morphological response. However, in an in vitro fertilisation (IVF) setting, frozen embryo transfer (ET) has had a low success rate. We propose that in patients with previously failed ET attempts, the uterine epithelium can be directly visualised by biopsy and Scanning Electron Microscopy (SEM) and that with an individualised fine tuning of the hormone supplementation regime, based on the SEM examination of sequential uterine biopsies, it is possible to provide a uterine environment conducive to successful ET. METHODS: A 47 year old women was chosen for endometrial biopsy, histopathological dating and endometrial observation utilising SEM to determine the integrity of her secretory uterine epithelium because of her age and several previously failed attempts at frozen ET. Exogenous E2 and P4 supplementation was administered in modified doses according to the SEM result, in consecutive cycles until the epithelial response appeared satisfactory for potential implantation. RESULTS: This case study demonstrates the dramatic change in epithelial characteristics that can be achieved as a response to these altered doses of E2 and P4. The uterine morphology changed from a hypotrophic to a mature, receptive epithelium such that ET resulted in the birth of healthy twin boys. CONCLUSION: The comparison between the consecutive biopsies in direct response to the SEM analysis and tailored modification of E2 and P4 dose clearly demonstrates, in this case, the effectiveness of individual morphological monitoring to maximise the successful outcome of ET.