In vitro maturation may prevent the cancellation of in vitro fertilization cycles in poor responder patients: A case report

In vitro maturation of oocytes: what is already known?†

Assisted reproductive technologies (ARTs) involve the laboratory manipulation of gametes and embryos to help couples with fertility problems become pregnant. One of these procedures, controlled ovarian stimulation, uses pharmacological agents to induce ovarian and follicular maturation in vivo. Despite the effectiveness in achieving pregnancy and live births, some patients may have complications due to over-response to gonadotropins and develop ovarian hyperstimulation syndrome. In vitro maturation (IVM) of oocytes has emerged as a technique to reduce the risk of ovarian hyperstimulation syndrome, particularly in women with polycystic ovary syndrome, and for fertility preservation in women undergoing oncological treatment. Although there are some limitations, primarily due to oocyte quality, recent advances have improved pregnancy success rates and neonatal and infant outcomes. Different terms have been coined to describe variations of IVM, and the technique has evolved with the introduction of hormones to optimize results. In this review, we provide a comprehensive overview of IVM relating hormonal priming, culture system and media, and clinical indications for IVM with its reproductive outcomes during ARTs.

Effects of combination of melatonin and L-carnitine on in vitro maturation in mouse oocytes: An experimental study

Background

Melatonin and L-carnitine are free radical scavengers with antiapoptotic and antioxidant properties that improve oocyte development.

Objective

This study aimed to find the possible effect of combining 2 antioxidant agents of melatonin and L-carnitine on oocyte morphology, maturation, apoptosis, and expression of bone morphogenetic protein 15 (BMP-15) and growth differentiation factor 9 (GDF-9) genes in a mice model.

Materials and Methods

To overstimulation, 60 female NMRI mice were injected intraperitoneally using mare serum gonadotropin. On day 2 post-injection, 70 cumulus-oocyte complexes were collected from each mouse. The collected oocytes randomly were then divided into 4 groups including, the control, melatonin, L-carnitine, and melatonin + L-carnitine groups. The morphology and maturation rate of the oocytes was evaluated using a light microscope. Apoptosis was identified by terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling assay and the expression of BMP-15 and growth and differentiation factor GDF-9 genes was also evaluated by real-time polymerase chain reaction.

Results

Oocyte diameter significantly was increased in combination treatment of L-carnitine and melatonin compared to other groups (p < 0.05). L-carnitine group showed the highest mean percentage of oocyte cytoplasmic pattern. Results of the terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling indicated that the lowest apoptosis rate belonged to the melatonin + L-carnitine group. Moreover, the combination groups showed the highest number of oocytes and maturation rate. The BMP-15 and GDF-9 genes were significantly upregulated in all treatment groups compared to the control group.

Conclusion

Our results suggested a combination of melatonin + L-carnitine administration as a more effective choice for in vitro promotion of oocyte maturation.

Early oocyte triggering followed by in vitro maturation is a good approach in women with resistance ovary syndrome: A case-series

Background

Some women represent the inability to respond to endogenous and exogenous gonadotropins during in vitro fertilization/intracytoplasmic sperm injection cycles leading to the follicular developmental arrest. The women with resistant ovaries could benefit from in vitro maturation.

Case

This case-series presents pregnancies resulting from initially scheduled conventional in vitro fertilization which led to arrested cycles because of resistant ovary syndrome. The protocol was changed to early oocyte triggering for 15 women due to the small follicles ≤ 12 mm in diameter on day 15 after stimulation with high doses of exogenous gonadotrophins instead of cycle cancellation. Germinal vesicle and metaphase I oocytes that were retrieved from follicles were matured in vitro and inseminated by intracytoplasmic sperm injection. Twenty formed embryos were transferred on day 3 after oocyte retrieval. This resulted in a 30.76% chemical pregnancy out of which no abortion occurred. Therefore, we reported a 30.76% singleton ongoing pregnancy.

Conclusion

It seems that early oocyte triggering followed by in vitro maturation may be considered as a good modality in women experiencing follicular resistance to gonadotropins. These cycles can be rescued from cancellation with satisfactory clinical outcomes.

Transvaginal ovarian drilling followed by controlled ovarian stimulation from the next day improves ovarian response for the poor responders with polycystic ovary syndrome during IVF treatment: a pilot study

BACKGROUND

Poor response patients with PCOS who are not susceptible to gonadotropin stimulation are more likely to have canceled cycles or poor clinical outcomes during IVF treatment. However, some limitations exist in the present therapies. In this study, we evaluated the effects of using the transvaginal ovarian drilling (TVOD) followed by controlled ovarian stimulation (COS) from the second day of these poor responders.

METHODS

During IVF, 7 poor responders with PCOS and 28 PCOS patients (14 normal and 14 high responders) were recruited. All patients received COS with the gonadotropin-releasing hormone antagonist protocol. For the poor responders, after undergoing 10 to 14 days of ovulation induction with no response, the TVOD was applied and then ovarian stimulation was performed from the next day at the same gonadotropin dose. Serum samples during COS and follicular fluid samples from the dominant follicles on the oocyte pick-up (OPU) day in all three groups were collected. Besides, follicular fluid from small follicles (diameter < 1 cm) in the normal and high responders on the OPU day and those in the poor responders on the TVOD day were gathered. Hormonal levels were examined in all samples using immunometric assays.

RESULTS

All the poor responders restored ovary response after receiving TVOD. There was no significant difference in the stimulation duration, total gonadotrophin dose used and the clinical outcomes among the three groups. The body mass index, serum and follicular levels of anti-Müllerian hormone (AMH) and testosterone in poor responders were higher than those in the other two groups, and the application of TVOD significantly decreased the levels of AMH and testosterone in both serum and follicular fluid.

CONCLUSIONS

TVOD followed by ovulation induction from the next day is effective and convenient for poor responders with PCOS. The decline of AMH and testosterone resulted from TVOD may be the main reason resulting in the recovery of ovary sensitivity to gonadotropins. The small sample size is the primary limitation of this study, future studies using a large population cohort and monitoring the long-term outcomes of this strategy will be required.

TRIAL REGISTRATION

ChiCTR1900023612. Registered 04 June 2019-Retrospectively registered.

The use of in vitro maturation in stimulated antagonist in vitro fertilization cycles of normo-hyperresponder women due to arrested follicular development: A rescue procedure

Objective

To evaluate the impact of rescue in vitro maturation (IVM) on the clinical outcomes of women with arrested follicular development in stimulated in vitro fertilization (IVF) cycles.

Materials and Methods

This is a retrospective review of 13 patients who were evaluated as normo-hyperresponders for ovarian stimulation. The main outcome measure was the clinical pregnancy and livebirth rates. The purpose of gonadotropin stimulation in patients undergoing IVF is to retrieve multiple oocytes by avoiding multifetal gestation and Ovarian Hyperstimulation syndrome (OHSS). The ovarian response to stimulation ranges from poor response to OHSS, which is related to the follicular number and the dose of the gonadotropins used. However, in some cycles of normo-hyperresponder women, follicular development decelerates or ceases. Close follow-up in a daily manner and increasing the dose of gonadotropins did not change the follicular arrest. This clinical situation has two edges; one is cycle cancellation, which has undesired psychological outcomes for women and the IVF team, and second one is the prolongation of the IVF cycle. For such circumstances, IVM may be a valuable option. Stimulated IVF cycles were converted to IVM as a rescue IVM procedure following detailed informed consent of the women who were close to cycle cancellation.

Results

Thirteen 13 IVM cycles and their clinical outcomes are presented. Six women achieved pregnancies, but only 4 delivered 5 healthy live born. The other two women had biochemical loss during follow-up.

Conclusion

Based on the data obtained, it can be concluded that gonadotropin-stimulated cycles with follicular arrest at the edge of cancellation can be shifted to rescue IVM procedures with reasonable clinical outcomes.