The influence of in-vitro development upon post-thaw survival and implantation of cryopreserved human blastocysts

The Effect of Post warming Culture Period Between Thawing and Transfer of Cryopreserved Embryos on Reproductive Outcomes After In Vitro Fertilization (IVF): A Systematic Review and Meta-analysis

Background

The purpose of this study was to evaluate the effect of post warming culture period between thawing and transfer of cryopreserved embryos on reproductive outcomes after in vitro fertilization (IVF).

Methods

An extensive literature search was performed using PubMed, EmBase, and the Cochrane library from January 2000 to August 2019. A systematic review and meta-analysis of clinical trials was performed in this manuscript. The trials represented patients with embryo transfers of at least one previously cryopreserved good quality embryo. Main outcome measures of the study included clinical pregnancy rate, live birth rate, miscarriage rate, and ectopic pregnancy rate.

Results

A total of 5338 trial/abstracts were identified through a literature search. Totally, five studies were included in the systematic review, and three in the final meta-analysis. The studies included 1717 embryo transfers, 605 after short culture, and 1112 after long culture. The clinical pregnancy rate (CPR) was the most consistent outcome reported. The CPR was slightly better after short time culture with a RR of 1.09 (0.95-1.26, 95%CI) but this difference was not statistically significant. The great heterogenicity in the results reported in the included studies made it impossible to compare all planned outcomes.

Conclusion

There are no differences in reproductive outcomes if cryopreserved embryos are transferred after overnight culture or after two hours of culture following thawing. Due to small number and the poor quality of trials reported on this topic, the results of this review should be treated with caution.

Clinical pregnancy is significantly associated with the blastocyst width and area: a time-lapse study

In order to maintain pregnancy rates following single embryo transfer, optimisation of embryo culture and selection is vital. Time-lapse monitoring (TLM) has the potential to play a crucial role by providing sequential images of embryo development and minimal disturbance. Therefore, in this study morphometric assessment of blastocyst area and maximum width was performed in order to evaluate if these parameters are associated with pregnancy outcomes in IVF/ICSI cycles. This is a retrospective study of 664 patients who had elective single blastocyst transfer (eSBT). The EmbryoScope drawing tools were used to measure specific variables such as the maximum blastocyst width and blastocyst area. Our results show that women who were pregnant had significantly (P < 0.01) larger blastocyst width [median (range) μm] 184 (125-239) versus non-pregnant, 160 (120-230)] and area [median (range) μm²] 26099 (12101-45,280) versus non-pregnant women, 22,251 (10992-37,931)]. A univariate logistic regression performed showed that blastocyst width [(OR = 1.026, 95% CI = (1.019, 1.033)] was significant (P < 0.01) and for every μm increase of blastocyst width, the odds of clinical pregnancy increase by 2.6%. A univariate logistic regression performed showed that blastocyst area [(OR = 1.00008, 95% CI = (1.00006, 1.00011)] was significant with P < 0.01. For every μm² increase of blastocyst area, our data showed the odds of clinical pregnancy increase by 0.008%. Hosmer-Lemeshow tests of calibrations were performed to verify calibration. Although our findings show a clear correlation between blastocyst dimensions and the clinical pregnancy rate, further studies are necessary to confirm these observations.

Techniques for slow cryopreservation of embryos

The slow cryopreservation of embryos has been used for nearly three decades as a means of storing surplus conceptuses from single IVF (in vitro fertilization) cycles. Doing so has allowed caregivers to maximize pregnancy rates without wastage of precious biological materials. Very detailed methods are described here using a popular biological freezing unit manufactured by Planer PLC (Middlesex, UK). Culture media preparation and tranfer protocols, including replacement in both natural and stimulated cycles, are included.

Vitrification of oocytes, embryos and blastocysts

In assisted reproductive technology, cryopreservation of human oocytes and embryos has been significantly improved by refined slow-cooling and the new vitrification method. The slow-cooling method requires a programmed cryo-machine, and usually takes several hours. It is, however, difficult to eliminate injuries resulting from ice formation completely. Vitrification has become a reliable strategy because it is simple, can lead to high survival rates and viability, and has better clinical outcome. Vitrification transforms cells into an amorphous glassy state inside and outside the vitrified cell with ultra-rapid cooling and warming steps by plunging the oocytes and embryos into liquid nitrogen, instead of ice-crystal formation. Over the past decade, several advances in vitrification technologies have improved clinical efficiency and outcome. In this chapter, we focus on vitrification technologies for cryopreservation in human assisted reproductive technology.

Comparing thaw survival, implantation and live birth rates from cryopreserved zygotes, embryos and blastocysts

CONTEXT:

Most in vitro fertilization (IVF) programs employ embryo cryopreservation to enhance pregnancies from a single ovarian stimulation. More embryos are created, some of which are not transferred to the uterus immediately, generating a need for improved cryopreservation protocols. One protocol may involve growing embryos to a further stage of development, allowing only embryos with proven developmental capabilities to be cryopreserved. Here we examined thaw survival, implantation and live birth rates of embryos cryopreserved at different stages.

AIMS:

We examined thaw survival, implantation and live birth rates of embryos cryopreserved at the zygote, day 3 (D3) embryos or blastocyst stage.

SETTINGS AND DESIGN:

This is a retrospective study from a single academic IVF program.

PATIENTS AND METHODS:

A retrospective study of all patients who had frozen embryos transferred to their uteri from year 2002 to 2008 at a single academic IVF program was conducted.

STATISTICAL ANALYSIS USED:

Analysis of variance followed by Fisher's Exact Test was performed to compare the survival after thaw, implantation and live birth rates between the three groups.

RESULTS:

One thousand nine hundred and ninety-one zygotes, 2880 D3 embryos and 503 blastocysts were frozen using a slow freeze technique, thawed and transferred. Significantly more D3 embryos and blastocysts survived the thawing process compared to zygotes and significantly higher implantation rate per number of thawed blastocysts was achieved than that for zygotes. Live birth rates were similar between the three groups.

CONCLUSIONS:

Growing embryos to blastocyst stage prior to cryopreservation is associated with fewer frozen embryos but does not appear compromise patients’ chance of achieving pregnancy

Current aspects of blastocyst cryopreservation

Cryopreservation of human gametes and embryos has become an essential part of assisted reproduction. Successful cryopreservation of human blastocysts is increasingly relevant as extended in-vitro culture of human embryos becomes more common, permitting routine use of blastocyst transfer in IVF programmes. This reduces the number of embryos transferred, thereby reducing multiple pregnancies and maximizing cumulative pregnancy rates per oocyte retrieval. The superiority of blastocyst freezing over earlier stage freezing in terms of implantation per thawed embryo transferred improves overall expectations for the cryopreservation programme. Therefore, a reliable procedure for the cryopreservation of blastocysts is needed because, after transfer, only a small number of supernumerary blastocysts are likely to be available for cryopreservation. Since the early 1980s, two common techniques have been used in cryopreservation: the conventional slow cooling method and the more recent rapid procedure known as vitrification. Vitrification has become an attractive alternative to slow freezing, since it appears to result in significantly higher survival and pregnancy rates. The aim of this review is to focus on the cryopreservation of human blastocysts using slow and rapid protocols and to assess the impact of the crypreservation protocol used on the survival, implantation and pregnancy rates.

Cryopreservation of Human Embryos

Cryopreservation of human embryos from the 2-cell stage up to the morula stage is a safe procedure which has been carried out for the last 25 years. Experience with blastocyst cryopreservation is still limited and pregnancy rates after the use of frozen, thawed blastocysts vary extremely. Vitrification has improved the success of embryo cryopreservation. However, this technique cannot yet be considered as a routine procedure. Despite all of the advantages for infertile couples, cryopreservation of human embryos creates severe ethical problems, because of surplus frozen embryos which either have to be destroyed or perhaps used for research. Embryo adoption may provide a solution to solve imminent medical, ethical and social problems.

Randomized comparison of two different blastocyst grading systems

A more detailed blastocyst grading system provides a better selection of blastocysts with the highest implantation potential. Grading systems will help to decrease the number of blastocysts to be transferred without compromising high implantation and pregnancy rates.

Clinical experiences of ICSI-ET thawing cycles with embryos cryopreserved at different developmental stages

PURPOSE

The aim of our study was to analyze factors including survival, implantation and pregnancy rate, patients' age and BMI, abortions and extra uterine pregnancies that might influence the outcome of ICSI-ET thawing cycles.

METHODS

A total of 147 cycles with embryos cryopreserved at different developmental stages were retrospectively evaluated.

RESULTS

No difference was found in the survival, implantation and pregnancy rates of embryos cryopreserved on Day 2-3 and 5. However, in the pregnant group significantly higher implantation rate was observed with Day 5 blastocysts then with Day 2 or 3 early embryos. We found no difference in the number of abortions and extra uterine pregnancies between fresh and frozen ICSI-ET cycles. Higher BMI was found in the pregnant than in the nonpregnant group. However, the age of patient had no effect on the results.

CONCLUSIONS

Developmental stage of embryo and patients' BMI influences the success of ICSI-ET thawing cycles.

Pregnancy rates after transfer of cryopreserved blastocysts cultured in a sequential media

OBJECTIVE

This study was undertaken to determine the pregnancy rate after transfer of cryopreserved blastocysts.

STUDY DESIGN

Retrospective review of 61 patients from January 1, 2002, to December 31, 2003, who were transferred with blastocyst embryos cryopreserved on day 5 or 6 after culture in a sequential media. The cryopreserved blastocysts were thawed by using a 7-step dilution process after rapid thawing half hour to 2 hours before embryo transfer.

RESULTS

The pregnancy rate after transfer of 61 patients with cryopreserved blastocysts was 66%, with 49% having cardiac activity. The pregnancy rate after transfer of 3 blastocysts was 71% and after transfer of 2 blastocysts was 66%. The pregnancy rate of blastocysts cryopreserved after intracytoplasmic sperm injection was 56%.

CONCLUSION

Cryopreservation and transfer of blastocysts appears to be a reliable procedure, and that the human blastocyst can be cryopreserved and thawed without a significant loss of viability.

Successful pregnancy following blastocyst cryopreservation using super-cooling ultra-rapid vitrification

BACKGROUND

Blastocysts were cryopreserved by a new two-step ultra-rapid cooling in super-cooled liquid nitrogen (-205 degrees C).

METHODS

There were 308 mouse blastocysts collected from fertile B6CBF1 mice and 249 human blastocysts collected from 51 couples treated with IVF. The blastocysts were super-cooled by a Vit-Master and cryoloops after treatment in 50 and 100% vitrification solution (VS) for 2 min and 30 s, respectively. The 100% VS was composed of 20% ethylene glycol, 20% dimethylsulphoxide and 0.5 mol/l sucrose in human tubular fluid medium with 20% human serum albumin. The embryos were warmed after treatment in 0.25 and 0.125 mol/l sucrose for 2 and 3 min, respectively. The survival of embryos was observed after re-swell.

RESULTS

The survival rate (SR) and hatching rate (HR) of mouse blastocysts in the super-cooled, the cryosolution-treated and control groups were not significantly different (SR, 87, 95.5 and 100%; HR, 50, 33 and 44.6%, respectively; P>0.05). After 96 super-cooled human blastocysts were warmed, 60 survival blastocysts were transferred into 13 patients. The successful SR and pregnancy rate (PR) for the super-cooled blastocyst group were 77.1% (74 out of 96) and 53.8% (seven out of 13).

CONCLUSION

The ultra-rapid vitrification of blastocysts with a successful SR and PR could be used to replace classical slow cooling.

Examination of frozen cycles with replacement of a single thawed blastocyst

This investigation examined frozen cycle outcomes with the transfer of a single thawed blastocyst. It also aimed to determine if the suggested model could aid in achieving a better understanding of factors that influence success with frozen blastocyst transfer. A retrospective analysis was conducted of single frozen embryo transfer cycles carried out at the Cleveland Clinic Fertility Centre in Beachwood, OH. Between January 2001 and March 2004, 88 thaw procedures were initiated that resulted in 75 frozen cycles in which only a single thawed blastocyst was transferred. In 66 of these 88 thaw procedures, only a single embryo was available for thawing. The post-thaw survival rate of a single frozen blastocyst was 85% (56/66). These 56 frozen transfers with a single thawed blastocyst resulted in a clinical pregnancy rate per transfer of 27% (15/56) and a live birth rate of 18%. Blastocyst post-thaw morphology at transfer was found to be an important prognostic factor associated with success. The ability to re-expand within a few hours of the thaw appeared to be a strong indicator of blastocyst potential. Blastocyst age at cryopreservation did not impact outcomes. The single frozen embryo transfer model can yield valuable information and help gauge the effectiveness of a laboratory's cryopreservation protocol.

High pregnancy rates can be achieved after freezing and thawing human blastocysts

OBJECTIVE

To examine the results of a 3-year trial using blastocyst cryopreservation to limit multiple pregnancy and optimize overall pregnancy per cycle.

DESIGN

Retrospective clinical evaluation of pregnancy rates after freezing and thawing human blastocysts.

SETTING

Tertiary-care academic center.

PATIENT(S)

Seven hundred fifty-three different patients treated in 783 IVF cycles with blastocysts frozen from July 2000 to June 2003.

INTERVENTION(S)

Two thousand, two hundred fifty-nine blastocysts were frozen in cycles in which only blastocysts were cryopreserved (cycles with pronuclear stage oocytes or pre-embryos also cryopreserved were excluded from the analysis). Of these, 628 (27.6%) were thawed in 218 cycles.

MAIN OUTCOME MEASURE(S)

Pregnancy rate per cycle with thaw.

RESULT(S)

Four hundred seventy-nine (76.3%) blastocysts survived thawing, and 440 (92.0%) were transferred after exhibiting evidence of survival (most commonly, blastocoele reexpansion). In cycles with a thaw, 211 (96.8%) of 218 underwent intrauterine transfer. An average of 2.09 blastocysts was transferred per replacement. One hundred twenty-five (59.2%) clinical pregnancies were established, which included 23 sets of twins and 5 triplet gestations. Two sets of monozygotic twins were identified after the replacement of a single thawed blastocyst (1.6%). The age of the patient at the time of cryopreservation (<37 years) was an important factor in the establishment of clinical and ongoing pregnancy. The mode of ovarian stimulation, replacement method, and whether blastocysts were frozen on day 5 or day 6 of development did not demonstrate clinical significance.

CONCLUSION(S)

Cryopreserved and thawed blastocysts demonstrated a similar potential for implantation when compared with fresh pre-embryos on day 3. On the basis of these results, the blastocyst stage of development appears to be optimal for clinical freeze-thaw trials.

Overnight incubation improves selection of frozen–thawed blastocysts for transfer: preliminary study using supernumerary embryos

A study was undertaken to determine whether the interval between thawing and transfer influences both biological and clinical outcomes of cryopreserved blastocysts, using supernumerary embryos cultured in sequential media. One hundred and seventy-two patients who underwent blastocyst thawing without any exclusion criteria were included in this single center prospective study of blastocyst thawing cycles. Outcome of 338 blastocysts originating from culture of supernumerary embryos in sequential media was analyzed after 4 or 20 h of culture between thawing and transfer. Survival rate, re-expansion and hatching rates for surviving blastocysts, implantation rates (IRs), pregnancy and miscarriage rates were studied. Blastocyst survival was not influenced by the incubation time after thawing; however both re-expansion and hatching rates were increased after 20-h incubation. Moreover, the IR per thawed or transferred blastocyst was increased three-fold after 20-h incubation compared to 4-h incubation. Increasing the interval between thawing and transfer appears to be beneficial in order to better select for transfer frozen-thawed blastocysts.

Successful freezing and thawing of blastocysts cultured in sequential media using a modified method

OBJECTIVE

To evaluate the clinical role of blastocyst freezing and thawing after prolonged culturing in sequential media.

DESIGN

Retrospective analysis of 293 blastocyst freeze-thawing cycles.

SETTING

University hospital infertility unit.

PATIENT(S)

Nonselected couples undergoing IVF.

INTERVENTION(S)

Blastocysts were frozen and thawed by a modified method.

MAIN OUTCOME MEASURES

Blastocyst recovery after freeze-thawing and pregnancy rates after the transfer. Evaluation of the effect of the number of transferred blastocysts, the method of IVF, and of the woman's age on the results achieved by frozen-thawed blastocysts.

RESULT(S)

Frozen-thawed blastocysts provided a 29.5% clinical pregnancy rate per transfer. After the transfer of three blastocysts the pregnancy rate was 42.0%, and after the transfer of one or two blastocysts it was approximately the same (25.0% and 28.0%, respectively). The method of IVF did not affect pregnancy rates, but the increasing age of the woman did. Pregnancies were characterized by a low abortion rate (8.0%) regardless of the age of the woman.

CONCLUSION(S)

A modified method for blastocyst freeze-thawing provides good clinical results. It offers the possibility for a single-thawed blastocyst transfer and represents a good alternative for older women because of its lower risk of spontaneous abortion.

Transfer of frozen-thawed blastocysts that underwent quarter laser-assisted hatching at the day 3 cleaving stage before freezing

OBJECTIVE

To examine the pregnancy potential of frozen-thawed blastocysts that underwent quarter laser-assisted hatching (AH) at the cleaving stage before freezing and to compare clinical and embryo characteristics between the groups that succeeded in and failed to achieve pregnancy.

DESIGN

Prospective observational study.

PATIENT(S)

Thirty-four of 112 patients with frozen blastocysts requiring transfer of thawed embryos between January 2000 and December 2001.

SETTING

Assisted reproductive technology unit in a tertiary medical center.

INTERVENTION(S)

Embryos of patients undergoing blastocyst transfers routinely underwent quarter AH using a nontouch 1.48-microm diode laser. Blastocysts not transferred were cryopreserved using a six-step freezing protocol with glycerol as the cryoprotectant.

MAIN OUTCOME MEASURE(S)

Postthaw embryo survival and zona pellucida (ZP) maintenance, implantation rate, and clinical pregnancy rate per transfer of thawed blastocysts.

RESULT(S)

A total of 118 frozen blastocysts was thawed. Of these, 89 (75.4%) embryos survived and were transferred in 35 cycles. Assisted hatching-manipulated ZP tolerated the freeze-thaw procedures without shape distortion in surviving embryos. Eleven (31.4%) clinical pregnancies with 15 intrauterine gestational sacs occurred, for an implantation rate of 16.9%. Those who succeeded in pregnancy tended to have more embryos available before freezing, more original blastocysts of good quality for freezing, and more surviving blastocysts after thawing for transfer than did those who failed to achieve pregnancy.

CONCLUSION(S)

An acceptable clinical pregnancy rate was obtained from transfer of thawed blastocysts that underwent laser AH on the ZP at the day 3 cleaving embryo stage in fresh cycles in selected patients. Embryo characteristics before freezing played major roles in determining implantation potential of thawed embryos.

Does the developmental stage at freeze impact on clinical results post-thaw?

The value of cryopreserving prezygotes, pre-embryos or blastocysts for future thaw and transfer is an important consideration of every IVF program. The convergence of two factors, a higher pregnancy rate and a lower multiple gestation rate, can be managed effectively through the establishment of a successful cryopreservation programme. In this article, freezing and thawing results from pronuclear oocytes, pre-embryos, and blastocysts are compared.

Outcome of blastocyst transfer according to availability of excess blastocysts suitable for cryopreservation

The purpose of this study was to assess the outcome of blastocyst transfer in relation to the presence or absence of excess blastocysts available for cryopreservation. The study was designed as a retrospective case series in a tertiary care private hospital. The study group consisted of 450 blastocyst stage embryo transfer cycles. In 139 cycles there were excess freezeable blastocysts (group 1), in 78 cycles there were excess but unfreezeable blastocysts (group 2), and in 233 cycles there were no excess blastocysts (group 3). A mean of three blastocysts was replaced in all groups. Treatment cycle characteristics, implantation and pregnancy rates following fresh and cryopreserved blastocyst transfer were assessed in each group. More embryos reached the blastocyst stage in group 1 and more blastocysts were of good quality. In group 1, clinical pregnancy and implantation rates (71 and 41%) were significantly higher compared with groups 2 (56 and 27%) and 3 (43 and 19%). Embryos that were selected for transfer among a cohort of good quality blastocysts yielded the highest implantation and pregnancy rates. Given a clinical pregnancy rate of 71%, an implantation rate per embryo of 41%, and a multiple pregnancy rate of 58%, serious consideration should be given to a single blastocyst transfer in these patients.

Fundamentals of human embryonic growth in vitro and the selection of high-quality embryos for transfer

Knowledge of the nature of embryo growth, and the handling and scoring of quality in human embryos are significant aspects for embryologists in IVF clinics. This review describes the formation, growth and maturation of human oocytes, many aspects of fertilization in vitro, embryonic transcription during preimplantation stages, and the formation of polarities, timing controls, role of mitochondria and functions of endocrine and paracrine systems. Modern concepts are fully discussed, together with their significance in the practice of IVF. This knowledge is essential for the correct clinical care of human embryos growing in vitro, especially in view of their uncharacteristic tendency to vary widely in implantation potential. Underlying causes of such variation have not been identified. Stringent tests must be enforced to ensure human embryos develop under optimal conditions, and are scored for quality using the most advanced techniques. Optimal methods of culture are described, including methods such as co-culture introduced to improve embryo quality but less important today. Detailed attention is given to quality as assessed from embryonic characteristics determined by timers, polarities, disturbed embryo growth and anomalous cell cycles. Methods for classification are described. Approaches to single embryo transfers are described, including the use of sequential media to produce high-quality blastocysts. These approaches, and others involved in surgical methods to remove fragments, transfer ooplasm or utilize newer approaches such as preimplantation diagnosis of chromosomal complements in embryos are covered. New outlooks in this field are summarized.

Quantitative grading of a human blastocyst: optimal inner cell mass size and shape

OBJECTIVE

To investigate the predictive value of quantitative measurements of blastocyst morphology on subsequent implantation rates after transfer.

DESIGN

Prospective observational study.

SETTING

Private assisted reproductive technology center.

PATIENT(S)

One hundred seventy-four IVF patients receiving transfers of expanded blastocyst-stage embryos on day 5 (n = 112) or day 6 (n = 62) after oocyte retrieval.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Blastocyst diameter, number of trophectoderm cells, inner cell mass (ICM) size, ICM shape, and implantation and pregnancy rates.

RESULT(S)

Blastocyst diameter and trophectoderm cell numbers were unrelated to implantation rates. Day 5 expanded blastocysts with ICMs of >4,500 microm(2) implanted at a higher rate than did those with smaller ICMs (55% vs. 31%). Day 5 expanded blastocysts with slightly oval ICMs implanted at a higher rate (58%) compared with those with either rounder ICMs (7%) or more elongated ICMs (33%). Implantation rates were highest (71%) for embryos with both optimal ICM size and shape. Pregnancy rates were higher for day 5 transfers of optimally shaped ICMs compared with day 5 transfers of optimally sized ICMs.

CONCLUSION(S)

Quantitative measurements of the inner cell mass are highly indicative of blastocyst implantation potential. Blastocysts with relatively large and/or slightly oval ICMs are more likely to implant than other blastocysts.

Cryoloop vitrification yields superior survival of Rhesus monkey blastocysts

BACKGROUND

Vitrification using the cryoloop procedure was evaluated for preservation of non-human primate blastocysts by comparing survival results from two different cryoprotectant mixtures with prior results from controlled rate cooling.

METHODS

Rhesus monkey blastocysts were produced by intracytoplasmic sperm injection of mature oocytes from cycling females stimulated with recombinant human hormones. Morphologically well-formed blastocysts were divided between Procedure A (2.8 mol/l dimethylsulphoxide and 3.6 mol/l ethylene glycol with 0.65 mol/l sucrose and 25 micromol/l Ficoll in TALP-HEPES with 20% fetal bovine serum (TH20)) and Procedure B (3.4 mol/l glycerol and 4.5 mol/l ethylene glycol in TH20). After >48 h in liquid nitrogen, the removal of cryoprotectants was accomplished in the presence of a 3-step series of decreasing sucrose concentrations in TH20. Surviving embryos were co-cultured on buffalo rat liver cells.

RESULTS

Of 16 blastocysts vitrified via Procedure A, 38% survived with minimal lysis and only one hatched in culture; in contrast, of 33 blastocysts vitrified by Procedure B, 85% survived and 71% hatched. Of 22 blastocysts cryopreserved by conventional slow cooling, 36% survived and 6% hatched. Transfer into three recipients, each with two embryos vitrified with Procedure B, resulted in a successful twin-term pregnancy.

CONCLUSION

Modified cryoloop vitrification with a final solution of 3.4 mol/l glycerol and 4.5 mol/l ethylene glycol is a promising procedure for preserving Rhesus monkey blastocysts that is simple, rapid, and inexpensive.

Vitrification of mouse and human blastocysts using a novel cryoloop container-less technique

OBJECTIVE

To vitrify mouse and human blastocysts with use of the cryoloop procedure and to assess subsequent development.

DESIGN

Controlled study of vitrification of mouse and human blastocysts.

SETTING

Research department of a private assisted reproductive technology unit.

PATIENT(S)

Blastocysts that were not suitable to be frozen were donated from patients.

INTERVENTION(S)

Culture of pronucleate embryos in sequential media to the blastocyst stage.

MAIN OUTCOME MEASURE(S)

Survival of the vitrification procedure was assessed by reexpansion, hatching, and outgrowth in culture. In addition, the viability of mouse blastocysts was assessed after transfer to pseudopregnant recipients.

RESULT(S)

Vitrification of mouse blastocysts did not affect the ability to reexpand, hatch, or outgrow in culture. Furthermore, implantation rates and fetal development were equivalent for nonfrozen and vitrified blastocysts. Vitrified human blastocysts were able to hatch and outgrow in culture at rates similar to nonfrozen controls.

CONCLUSION(S)

Cryoloop vitrification was able to cryopreserve mouse and human blastocysts without any reduction in the ability to reexpand and hatch in culture. Furthermore, viability was not reduced by the cryoloop vitrification of mouse blastocysts.

Developmental potential of frozen-thawed human blastocysts

PURPOSE

To examine the possibility of freezing human embryos at late cleaved stages (morula or blastocyst stage), we cryopreserved human embryos 5 days (day 5) or 6 days (day 6) after insemination and investigated their developmental potential after thawing.

MATERIALS AND METHODS

One hundred nineteen morphologically good-quality human embryos from 43 women undergoing in vitro fertilization treatment between 1991 and 1992 were frozen using dimethylsulfoxide as a cryoprotectant. The embryos were cryopreserved for 5 to 30 months. After thawing they were then cultured in vitro for 24 hr to investigate their developmental potential. Survival rates and developmental rates were morphologically assessed after 24 hr of in vitro culture.

RESULTS

Developmental rates were significantly (P < 0.01 or P < 0.05) lower than survival rates at every developmental stage. There was no difference in total survival rates between embryos frozen 5 days after insemination (78.2%; 54/69) and embryos frozen 6 days after insemination (70.0%; 35/54). However, the developmental rates after 24 hr of culture was significantly (P < 0.05) lower for embryos frozen 6 days after insemination (6.0%; 3/50) than for embryos frozen 5 days after insemination (18.8%; 13/69). Only two embryos developed into fetuses after transfer into the uterus (1.7%; 2/119).

CONCLUSIONS

From the results, the developmental potential of frozen-thawed human blastocysts was found to be significantly reduced, even though the blastocysts were of morphologically good quality. Longer in vitro exposure of embryos appears to reduce their developmental potential.

Rescue of human embryos by micromanipulation

This chapter evaluates clinical micromanipulation techniques aimed at rescuing abnormally developing zygotes and cleaved embryos. First, the possibility of reversing dispermic zygotes to a normal biparental diploid state was evaluated by extracting the distal pronucleus (that furthest from the polar body). The ratio of X:Y was determined in both groups of embryos by assessing a minimum of two blastomeres using duplex PCR or multiple colour FISH. The ratio of embryos containing only an X chromosome and those with X as well as Y chromosomes in the intact dispermic zygotes was 1.0:2.6, which is similar to the theoretical ratio of 1:3. This ratio was 1.0:1.5 in dispermic zygotes from which the distal pronuclei were removed. Although the ratio of X:Y was altered following removal of distal pronuclei, suggesting frequent targeting of male pronuclei, accidental removal of the female pronucleus could not be excluded. In a second set of mouse experiments, it was shown that the hatching process of embryos that develop with excessive amounts of degenerate material is adversely affected. It was shown that removal of such extracellular material by micromanipulation potentially reverted the hatching process. It was also indicated that immediate removal of the degenerate tissue was more beneficial than that following prolonged co-culture. Assisted hatching is probably the most frequently applied clinical embryo micromanipulation procedure. The outcome of assisted hatching is dependent largely on the mode by which the zona pellucida is breached, the size of the artificial gap and the thickness of the zona pellucida. Embryos with zonae thicker than 17 microns rarely implant. Zona drilling could be detrimental in embryos with thin zonae (< 12 microns). Superficial zona thinning has not enhanced implantation. These observations led to a routine procedure called selective assisted hatching, which involves measuring the zonae before zona drilling and replacement on day 3 of development. This appears to be most successful in older women and those with elevated basal FSH levels. Selective assisted hatching is routinely applied in consenting patients whose embryos have thick zonae, slow development or excessive fragmentation (> 20%). Zona drilling of all embryos, regardless of zona thickness, is being performed in patients aged over 40 years and in those with repeated failures or elevated basal FSH levels. Results in the first group of more than 900 patients indicate that nearly one-quarter of human embryos have the ability to implant.

Pre-embryo: therapeutic approaches

There are potential interventions in the pre-embryo stage in order to improve the clinical results of assisted reproductive technology, live-birth per cycle of treatment, and to prevent the birth of offspring with genetic aberrations. The following therapeutic measures can be potentially applied to the pre-embryo: improvement of culture conditions, pre-embryo cryopreservation, assisted hatching, genetic diagnosis and gene therapy. In order to discuss the parents' rights and duties in applying therapeutic measures to the pre-embryo, it is essential to clarify the ethical and legal dilemmas concerning the status of the pre-embryo.

The effects of cryopreservation on early development and chromosome constitution in Chinese hamster embryos

The effects of cryopreservation on early embryonic development were investigated in Chinese hamster embryos. Embryos were randomly divided into 3 groups, as follows: the control group, embryos which were simply cultured; the DMSO group, embryos which were exposed to dimethyl sulfoxide (DMSO) and then cultured; the cryopreservation group, embryos which were cryopreserved and then cultured. The percentages of embryos which developed into blastocysts after 40 hours of cultivation were high in all groups. However, there were significant differences in the mean number of blastomeres with lower values after an exposure to DMSO and cryopreservation (73.2 in the control group, 62.0 in the DMSO group, and 40.2 in the cryopreservation group). No significant differences in chromosome abnormality rate were evident and there was no distinct tendency for variation in karyotype among the 3 groups. These results indicate that DMSO adversely affects the division of blastomeres, and that cryopreservation with DMSO as a cryoprotectant might aggravate these adverse effects.

The implantation window

The implantation window is defined as that period when the uterus is receptive for implantation of the free-lying blastocyst. This period of receptivity is short and results from the programmed sequence of the action of oestrogen and progesterone on the endometrium. Implantation itself is a process that commences with apposition, continues through attachment to trophoblast outgrowth and decidualization. For maximal effectiveness of assisted reproductive technologies in women, it is important to know the optimal time for embryo transfer which implies a need to predict the period of uterine receptivity. At present there are no good markers of, or for prediction of, uterine receptivity. In cycles where endogenous hormonal activity is suppressed or absent, the optimal time for embryo transfer can be easily defined and lies between luteal days +3 to +5, where luteal day +1 is the first day of exogenous progesterone treatment. In the human, it is suggested that blastocyst apposition begins about LH day +6 and is complete by LH +10. Human embryos survive in vitro manipulation well, and the stage of development at which they are placed in the uterus seems less critical than in other species, provided they are at an earlier stage of development than that of the endometrium.

Culture of human spare preembryos: association between blastocyst formation and pregnancy

The rate of blastocyst development was studied in cultures of human fertilized eggs. A total of 195 spare embryos from 86 cycles in 73 in vitro fertilization (IVF) patients resulted in a total of 77 expanded blastocysts, corresponding to an overall blastocyst development of 39%. In the group of patients where pregnancy occurred, at least one of the spare embryos developed into the blastocyst stage in 100% of the patients, while the corresponding figure for nonpregnant patients was 53%. Superficially these results seem to indicate that blastocyst development could be of decisive importance for the success rate in IVF. A detailed analysis revealed, however, that this is not the case as long as in vitro culture before replacement is limited to 2-3 days.

Role of embryonic factors in implantation: recent developments

The embryonic factors influencing implantation have been studied extensively in laboratory and domestic animals, but not in primates, including humans. Species differences make extrapolation inadvisable. Embryonic factors affecting implantation include intrinsic features of the embryo, such as its genetic constitution, morphology and hatching. Abnormal genetic constitutions or unsuccessful transitions from maternal to embryonic transcription could account for many failures of early embryonic growth and implantation. Morphology per se does not greatly influence implantation, except when it reflects an abnormal genetic constitution, e.g. in severe fragmentation, although subtle effects may be detected as experimental techniques are refined. The initiation of differentiation and intraembryonic communication between cells and cell types has been studied in animal embryos. Signals must be exchanged between the embryo and the mother to ensure satisfactory implantation. These could include platelet activating factor, prostaglandins, histamine related factors, steroids, proteins, metabolic products and immune-active factors. No one factor seems to be totally responsible for alerting the mother to the presence of an embryo, and a concerted action of these and other agents is probably responsible. The process of implantation itself is poorly understood because of a lack of adequate experimental models. The expression of complementary proteins and the role of specific enzymes and markers of endometrial and embryonic competence are factors well worthy of further study. Knowledge about human implantation is increasing because of recent developments in assisted reproductive technology, and concepts arising from many years of research in animals should find clinical applications in understanding and controlling human reproduction.