A Successful Live Birth From a Vitrified Oocyte for Fertility Preservation of a Patient With Borderline Ovarian Tumor Undergoing Bilateral Ovarian Surgery: A Case Report

This article reports the live birth of a healthy newborn using vitrified-warmed oocytes from fertility preservation before ovarian surgery. The patient in our case underwent two cycles of controlled ovarian stimulation before laparoscopic bilateral ovarian cystectomy for endometriosis, and a total of 23 mature oocytes were vitrified. After surgery, her pathologic reports revealed a serous borderline tumor and endometrioma. Fifteen months after her second surgery of laparoscopic right salpingo-oophorectomy and left ovarian cystectomy owing to recurrence, she had been married by then, and three of the frozen oocytes were thawed for intracytoplasmic sperm injection. These oocytes were cryopreserved for 2.5 years. All three were fertilized, and two grade-A cleavage-stage embryos were transferred. A singleton pregnancy was achieved, resulting in the delivery of a healthy baby boy at 39.3 weeks of gestation. Oocyte cryopreservation is an effective method for fertility preservation prior to ovarian surgery when ovarian function decline is predictable.

Assessment of Expression Levels and Localization Patterns of Phospholipase C zeta in Different Grades of HOST in Human Sperm

BACKGROUND

Phospholipase C zeta (PLC-ζ) deficiency in sperm can underlie oocyte activation failure after intracytoplasmic sperm injection (ICSI). The aim of this study was to determine PLC-ζ expression and location in individual spermatozoa in each host score so that a hypo-osmotic swelling test (HOST) may be used to help routine sperm selection for ICSI.

MATERIALS AND METHODS

In this experimental study, fresh semen samples were randomly obtained from 30 men who were referred to the Andrology Unit of the Infertility Center. Samples were processed by density gradient centrifugation (DGC) and exposed to hypotonic conditions. Seven different tail patterns, classified from 'a' to 'g' can be detected according to World Health Organization (WHO) criteria. Then, the PLC-ζ protein localization pattern was assessed by quantitative Immunofluorescence in individual sperm Host grades. Moreover, the sperm content of PLC-ζ protein was evaluated by flow cytometry correlated with semen analysis parameters.

RESULTS

In the present study, quantitive immunofluorescence analysis indicated that sperm from different host grades exhibited seven localization patterns of PLC-ζ of acrosomal (A); equatorial (EQ), and postacrosomal (PA) patterns. A+EQ=acrosomal and equatorial, A+PA=acrosomal and post-acrosomal, EQ+PA=equatorial and post-crosomal, and A+EQ+PA. The sperm from HOST grade 'd' exhibited significantly higher PLC-ζ (A+PA) and (A+EQ+PA) staining compared to sperm from other grades (P=0.006). The sperm from grade 'd' exhibited higher PLC-ζ (EQ+PA) compared with other grades (P=0.001). However, grade 'd' was not significantly different from 'c' (P=0.087). Analysis of the combined results confirmed that there was a clear reduction in PLC-ζ immunofluorescence in Host grades 'a', 'f' and 'g' sperms.

CONCLUSION

Our data suggest that HOST may represent a useful diagnostic tool for the selection of sperms exhibiting a higher level of PLC-ζ expression.

Assisted Oocyte Activation following Intracytoplasmic Sperm Injection: A Sensible Option for Infertile Couples with Severe Teratozoospermia

The intracytoplasmic sperm injection (ICSI) has significantly improved male factor infertility treatment; however, complete fertilization failure still occurs in 1-5% of ICSI treatment cycles mainly due to oocyte activation failure. It is estimated that around 40-70% of oocyte activation failure is associated with sperm factors after ICSI. Assisted oocyte activation (AOA) as an effective approach to avoid total fertilization failure (TFF) has been proposed following ICSI. In the literature, several procedures have been described to overcome failed oocyte activation. These include mechanical, electrical, or chemical stimuli initiating artificial Ca²⁺ rises in the cytoplasm of oocytes. AOA in couples with previous failed fertilization and those with globozoospermia has resulted in varying degrees of success. The aim of this review is to examine the available literature on AOA in teratozoospermic men undergoing ICSI-AOA and determine whether the ICSI-AOA should be considered as an adjunct fertility procedure for these patients.

Sperm DNA Fragmentation and Sperm-Borne miRNAs: Molecular Biomarkers of Embryo Development?

The evaluation of morpho-functional sperm characteristics alone is not enough to explain infertility or to predict the outcome of Assisted Reproductive Technologies (ART): more sensitive diagnostic tools are needed in clinical practice. The aim of the present study was to analyze Sperm DNA Fragmentation (SDF) and sperm-borne miR-34c-5p and miR-449b-5p levels in men of couples undergoing ART, in order to investigate any correlations with fertilization rate, embryo quality and development. Male partners (n = 106) were recruited. Semen analysis, SDF evaluation and molecular profiling analysis of miR-34c-5p and miR-449b-5p (in 38 subjects) were performed. Sperm DNA Fragmentation evaluation- a positive correlation between SDF post sperm selection and the percentage of low-quality embryos and a negative correlation with viable embryo were found. SDF > 2.9% increased the risk of obtaining a non-viable embryo by almost 4-fold. Sperm miRNAs profile—we found an association with both miRNAs and sperm concentration, while miR-449b-5p is positively associated with SDF. Moreover, the two miRNAs are positively correlated. Higher levels of miR-34c-5p compared to miR-449b-5p increases by 14-fold the probability of obtaining viable embryos. This study shows that SDF, sperm miR-34c-5p, and miR-449b-5p have a promising role as biomarkers of semen quality and ART outcome.

How Could One Sperm and One Oocyte Proceed To Molar Pregnancy? Prevalence of Molar Pregnancy during ICSI Procedure in Over 25,000 Fresh Embryo Transfers: A Retrospective Cross-Sectional Study

BACKGROUND

Gestational trophoblastic disease (GTD) is a heterogeneous group of diseases characterized by excessive proliferating trophoblastic tissue. The prevalence of GTD has a varied geographical distribution. However, its frequency following intracytoplasmic sperm injection (ICSI) cycles has not yet been reported. This study aimed to estimate GTD frequency and prevalence after ICSI cycles.

MATERIALS AND METHODS

This retrospective cross-sectional study included all patients diagnosed with GTD subsequent to ICSI and segmental embryo transfer procedure during 2011-2019 at Royan Institute. GTD diagnosis was established for patients who met all three criteria: beta-human chorionic gonadotropin (β-hCG) levels greater than 100,000 mIU/mL, vesicular ultrasonographic pattern, and presence of pathologic features of hydatidiform mole. Although we assessed the GTD frequency in all ICSI cycles, GTD cases were only observed following fresh embryo transfer ICSI procedures.

RESULTS

We evaluated 25,667 fresh embryo transfer ICSI procedures out of 41,540 ICSI cycles. This study identified a total of 10 GTDs confirmed by all criteria which were mentioned previously. Of these 10 GTDs, nine cases had hydatidiform mole, and one had gestational trophoblastic neoplasia. The frequency of GTD was calculated 10 cases in 41,540 (0.240 per 1000) ICSI procedures and 10 in 25,667 (0.389 per 1000) fresh embryo transfers following ICSI cycles. Also, we detected 10 GTD cases in 8,196 (1.220 per 1000) clinical pregnancies.

CONCLUSION

We discuss that the possibility of GTD after ICSI procedure is not as low as expected. Thus, the previous theses are insufficient to explain all aspects of molar pregnancy, and more research is required.

Unexplained Total Fertilization Failure after Intracytoplasmic Sperm Injection Cycles: A Case-Control Study on Predictive Factors and Retreatment Prognosis

BACKGROUND

The aim of our study was to detect the rate of unexplained total fertilization failure (TFF) after intracytoplasmic sperm injection (ICSI) and identify its risk factors and retreatment prognosis.

MATERIALS AND METHODS

In this retrospective case-control study, we searched the computerized database of the Royan Institute (Tehran, Iran) from March 2015 to March 2019 and retrieved all cases diagnosed with TFF after ICSI. TFF cases that did not have any recognized risk factors were classified as unexplained (subgroup A). Cases with recognized risk factors were classified as subgroup B. The control group was randomly selected from infertile couples who underwent ICSI cycles with fertilization of at least one oocyte during the same time interval. Characteristics and treatment outcomes of the cases with unexplained TFF (subgroup A) were compared to the control group, and to the other TFF cases (subgroup B).

RESULTS

Out of 18,750 couples who underwent ICSI cycles, 296 (1.58%) experienced TFF for the first time. Of these, 49 (16.5%) couples were diagnosed as unexplained TFF (subgroup A) and 247 (83.5%) were placed in subgroup B, TFF with expected risk factors. Multivariable logistic regression analysis showed that the total number of mature oocytes (P<0.001), duration of infertility (P=0.043), and women's body mass index (BMI, P<0.001) were significant predictive factors for unexplained TFF. In the ICSI cycle after TFF, clinical pregnancy and live birth rates in subgroup A were higher than subgroup B. Although differences between these groups were not statistically significant (P=0.14 and P=0.07, respectively), this finding could be clinically important.

CONCLUSION

Unexplained TFF following ICSI is a rare event significantly related to a lower number of mature oocytes, longer duration of infertility and higher female BMI. It has a good prognosis in retreatment cycles in comparison with expected TFF cases. Clinicians should take this into consideration for patient counseling and management.

The Effect of Recombinant Human Follicle-Stimulating Hormone on Sperm Quality, Chromatin Status and Clinical Outcomes of Infertile Oligozoospermic Men Candidate for Intracytoplasmic Sperm Injection: A Randomized Clinical Trial

Background

Follicle-stimulating hormone (FSH) plays a crucial role in spermatogenesis; in this study, we assessed the effect of recombinant human FSH (rhFSH) on sperm parameters, chromatin status and clinical outcomes of infer- tile oligozoospermic men candidates for intracytoplasmic sperm injection (ICSI).

Materials and Methods

This interventional randomized clinical trials (IRCT) included 40 infertile oligozoospermic men undergoing ICSI. These individuals were randomized into two groups: 20 men received rhFSH drug for three months and the other 20 men who did not receive rhFSH drug were considered the control group. Before and 3 months after treatment initiation, sperm parameters (using computer-assisted semen analysis) and chromatin status [using chromomycin A3, aniline blue, and sperm chromatin dispersion (SCD) tests] were assessed in these individuals. Fur- thermore, hormonal profile was assessed using enzyme-linked immunosorbent assay (ELISA). Clinical outcomes of ICSI were also compared between the two groups.

Results

The rhFSH treated group showed a significant increase in the level of FSH, luteinizing hormone (LH), tes- tosterone (T) and prolactin (PRL), as well as significant improvements in sperm parameters compared to the control group. Also, after administration of rhFSH, there was asignificant reduction in the percentage of sperm DNA damage, protamine deficiency and chromatin immaturity, while such a reduction in these parameters was not observed in the control group. Moreover, the percentage of embryos with grade Aquality, was significantly higher in the rhFSH group compared to the control group. The pregnancy rate in the rhFSH group was higher than the control group but the dif- ference was insignificant.

Conclusion

Administration of rhFSH improves sperm quality in infertile oligozoospermic men and results in higher rates of good quality embryos post-ICSI (Registration number: IRCT20170923036334N2).

Effect of Metformin on Premature Luteinization and Pregnancy Outcomes in Intracytoplasmic Sperm Injection-Fresh Embryo Transfer Cycles: A Randomized Double-Blind Controlled Trial

BACKGROUND

Premature luteinization (PL) is not unusual in in vitro fertilization (IVF) and could not be wholly avoided by using either gonadotropin-releasing hormone (GnRH) agonists or GnRH antagonist regimens. The study aims to evaluate metformin's efficacy in preventing PL in fresh GnRH antagonist intracytoplasmic sperm injection (ICSI) cycles with cleavage-stage embryo transfer.

MATERIALS AND METHODS

This randomized, double-blind, placebo-controlled trial was conducted in a tertiary university IVF center. We recruited infertile women who were scheduled to perform their first or second ICSI trial. Eligible women were recruited and randomized in a 1:1 ratio into two groups. Metformin was administered in a dose of 1500 mg per day since the start of contraceptive pills in the cycle antecedent to stimulation cycle until the day of ovulation triggering, while women in the placebo group received a placebo for the same regimen and duration. The primary outcome was the incidence of PL, defined as serum progesterone (P) on the triggering day ≥1.5 ng/mL. Secondary outcomes comprised the live birth, ongoing pregnancy, implantation, and good-quality embryos rates.

RESULTS

The trial involved 320 eligible participants (n=160 in each group). Both groups had comparable stimulation days, endometrial thickness, peak estradiol levels, number of oocytes retrieved, and number of mature oocytes. Metformin group experienced lower level of serum P (P<0.001) and incidence of PL (10 vs. 23.6%, P=0.001). Moreover, lower progesterone/estradiol (P/E) ratio and progesterone to mature oocyte index (PMOI) (P=0.002 and P=0.002, respectively) were demonstrated in women receiving metformin. Metformin group generated a better rate of goodquality embryos (P=0.005) and ongoing pregnancy (43.8 vs. 31.8%, P=0.026). A similar trend, though of borderline significance, was observed in the live birth rate in favor of metformin administration (38.15 vs. 27.5%, P=0.04).

CONCLUSION

Metformin could be used in patients with potential PL to improve fresh cycle outcomes by preventing PL (Registration number: NCT03088631).

Treatment with Calcium Ionophore Improves The Results in Patients with Previous Unsuccessful Attempts at The Fertilization: A Cohort Study

BACKGROUND

The objective of this study is to evaluate artificial oocyte activation (AOA) with calcium ionophore (CaI) in a subsequent attempt at fertilisation in patients after extremely low or failed fertilisation. We assessed improvements in fertilisation, implantation and pregnancy rates as well as cancellation rates in these patients. Finally, was evaluated the result testing in addition to delivery rate and obstetric outcomes in children born after AOA.

MATERIALS AND METHODS

This was a retrospective observational study conducted in an IVF laboratory of an IVI clinic (IVIRMA Valencia, Spain). One group (509 mature oocytes from 66 patients) received a first intracytoplasmic sperm injection (ICSI) without AOA, which resulted in either a failed fertilisation or very low values (<30%). This group was compared with a second group (616 mature oocytes from the same 66 patients) that used AOA. Outcome was compared by McNemar's test and the dependent t tests.

RESULTS

AOA plus CaI resulted in enhanced fertilisation (51 vs. 13.1%), ongoing pregnancy (47 vs. 21.7%), and implantation (31.1 vs. 13.1%) rates, and less chances for cancelling the cycle (22.7 vs. 69.3%). There were no observed adverse effects in obstetric and perinatal outcomes after the use of AOA.

CONCLUSION

Our findings support the use of AOA for a given population of patients where fertilisation was affected during previous attempts. After AOA, we observed a significant increase in reproductive success due to the increased number of embryos available for embryo selection and, therefore, enhanced chances for success. The use of this artificial technique is comforting after checking non-existence of detrimental effects on the offspring.

Assisted oocyte activation with calcium ionophore 44 hours after intracytoplasmic sperm injection resulting in successful pregnancy

Assisted Oocyte Activation (AOA) with Calcium Ionophore, is possible to manually activate the oocytes and cure globozoospermia, thus leading to successful pregnancy in 1 h after ICSI. But in this case, we report a case that 44 h after ICSI, the arrest zygotes assisted oocyte activation with calcium ionophore, obtained clinical pregnancy and live birth. Accordingly, AOA may provide us with an immediate treatment for embryonic arrest in the future.

Use of Artificial Neural Networks and PCA to Predict Results of Infertility Treatment in the ICSI Method

Background:

Intracytoplasmic sperm injection (ICSI) or microinjection is one of the most commonly used assisted reproductive technologies (ART) in the treatment of patients with infertility problems. At each stage of this treatment cycle, many dependent and independent variables may affect the results, according to which, estimating the accuracy of fertility rate for physicians will be difficult

Objective:

This study aims to evaluate the efficiency of artificial neural networks (ANN) and principal component analysis (PCA) to predict results of infertility treatment in the ICSI method

Material and Methods:

In the present research that is an analytical study, multilayer perceptron (MLP) artificial neural networks were designed and evaluated to predict results of infertility treatment using the ICSI method. In addition, the PCA method was used before the process of training the neural network for extracting information from data and improving the efficiency of generated models. The network has 11 to 17 inputs and 2 outputs.

Results:

The area under ROC curve (AUC) values were derived from modeling the results of the ICSI technique for the test data and the total data. The AUC for total data vary from 0.7670 to 0.9796 for two neurons, 0.9394 to 0.9990 for three neurons and 0.9540 to 0.9906 for four neurons in hidden layers

Conclusion:

The proposed MLP neural network can model the specialist performance in predicting treatment results with a high degree of accuracy and reliability

PhiC31-based Site-Specific Transgenesis System for Production of Transgenic Bovine Embryos by Somatic Cell Nuclear Transfer and Intracytoplasmic Sperm Injection

OBJECTIVES

The Streptomyces phage phiC31 integrase offers a sequence-specific method of transgenesis with a robust long-term gene expression. PhiC31 has been successfully developed in a variety of tissues and organs for purpose of in vivo gene therapy. The objective of the present experiment was to evaluate PhiC31-based site-specific transgenesis system for production of transgenic bovine embryos by somatic cell nuclear transfer and intracytoplasmic sperm injection.

MATERIALS AND METHODS

In this experimental study, the application of phiC31 integrase system was evaluated for generating transgenic bovine embryos by somatic cell nuclear transfer (SCNT) and sperm mediated gene transfer (SMGT) approaches.

RESULTS

PhiC31 integrase mRNA and protein was produced in vitro and their functionality was confirmed. Seven phiC31 recognizable bovine pseudo attachment sites of phage (attP) sites were considered for evaluation of site specific recombination. The accuracy of these sites was validated in phic31 targeted bovine fibroblasts using polymerase chain reaction (PCR) and sequencing. The efficiency and site-specificity of phiC31 integrase system was also confirmed in generated transgenic bovine embryo which successfully obtained using SCNT and SMGT technique.

CONCLUSIONS

The results showed that both SMGT and SCNT-derived embryos were enhanced green fluorescent protein (EGFP) positive and phiC31 integrase could recombine the reporter gene in a site specific manner. These results demonstrate that attP site can be used as a proper location to conduct site directed transgenesis in both mammalian cells and embryos in phiC31 integrase system when even combinaed to SCNT and intracytoplasmic sperm injection (ICSI) method.

The Effects of In Vitro Maturation Technique on The Expression of Genes Involved in Embryonic Genome Activation of Human Embryos

Objective

In vitro maturation technique (IVM) is shown to have an effect on full maturation of immature oocytes and the subsequent embryo development. Embryonic genome activation (EGA) is considered as a crucial and the first process after fertilization. EGA failure leads to embryo arrest and possible implantation failure. This study aimed to determine the role of IVM in EGA-related genes expression in human embryo originated from immature oocytes and recovered from women receiving gonadotrophin treatment for assisted reproduction.

Materials and Methods

In this experimental study, germinal vesicle (GV) oocytes were cultured in vitro. After intracytoplasmic sperm injection of the oocytes, fertilization, cleavage and embryo quality score were assessed in vitro and in vivo. After 3-4 days, a single blastomere was biopsied from the embryos and then frozen. Afterwards, the expression of EGA-related genes in embryos was assayed using quantitative reverse transcriptase-polymerase chain reaction (PCR).

Results

The in vitro study showed reduced quality of embryos. No significant difference was found between embryo quality scores for the two groups (P=0.754). The in vitro group exhibited a relatively reduced expression of the EGA- related genes, when compared to the in vivo group (all of them showed P=0.0001).

Conclusion

Although displaying the normal morphology, the IVM process appeared to have a negative influence on developmental gene expression levels of human preimplanted embryos. Based on our results, the embryo normal morphology cannot be considered as an ideal scale for the successful growth of embryo at implantation and downstream processes.

Comparison of In Vitro Fertilization/Intracytoplasmic Sperm Injection Cycle Outcome in Patients with and without Polycystic Ovary Syndrome: A Modified Poisson Regression Model

Background

Polycystic ovary syndrome (PCOS) is a frequent condition in reproductive age women with a prevalence rate of 5-10%. This study intends to determine the relationship between PCOS and the outcome of assisted reproductive treatment (ART) in Tehran, Iran.

Materials and Methods

In this historical cohort study, we included 996 infertile women who referred to Royan Institute (Tehran, Iran) between January 2012 and December 2013. PCOS, as the main variable, and other potential confounder variables were gathered. Modified Poisson Regression was used for data analysis. Stata software, version 13 was used for all statistical analyses.

Results

Unadjusted analysis showed a significantly lower risk for failure in PCOS cases compared to cases without PCOS [risk ratio (RR): 0.79, 95% confidence intervals (CI): 0.66-0.95, P=0.014]. After adjusting for the confounder variables, there was no difference between risk of non-pregnancy in women with and without PCOS (RR: 0.87, 95% CI: 0.72-1.05, P=0.15). Significant predictors of the ART outcome included the treatment protocol type, numbers of embryos transferred (grades A and AB), numbers of injected ampules, and age.

Conclusion

The results obtained from this model showed no difference between patients with and without PCOS ac- cording to the risk for non-pregnancy. Therefore, other factors might affect conception in PCOS patients.

Predicting Implantation Outcome of In Vitro Fertilization and Intracytoplasmic Sperm Injection Using Data Mining Techniques

Background

In vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) are two important subsets of the assisted reproductive techniques, used for the treatment of infertility. Predicting implantation outcome of IVF/ICSI or the chance of pregnancy is essential for infertile couples, since these treatments are complex and expensive with a low probability of conception.

Materials and Methods

In this cross-sectional study, the data of 486 patients were collected using census method. The IVF/ICSI dataset contains 29 variables along with an identifier for each patient that is either negative or positive. Mean accuracy and mean area under the receiver operating characteristic (ROC) curve are calculated for the classifiers. Sensitivity, specificity, positive and negative predictive values, and likelihood ratios of classifiers are employed as indicators of performance. The state-of-art classifiers which are candidates for this study include support vector machines, recursive partitioning (RPART), random forest (RF), adaptive boosting, and one-nearest neighbor.

Results

RF and RPART outperform the other comparable methods. The results revealed the areas under the ROC curve (AUC) as 84.23 and 82.05%, respectively. The importance of IVF/ICSI features was extracted from the output of RPART. Our findings demonstrate that the probability of pregnancy is low for women aged above 38.

Conclusion

Classifiers RF and RPART are better at predicting IVF/ICSI cases compared to other decision makers that were tested in our study. Elicited decision rules of RPART determine useful predictive features of IVF/ICSI. Out of 20 factors, the age of woman, number of developed embryos, and serum estradiol level on the day of human chorionic gonadotropin administration are the three best features for such prediction.

Kisspeptin: A Potential Factor for Unexplained Infertility and Impaired Embryo Implantation

Background

Kisspeptin (KP) is a neuropeptide that causes the release of the gonadotropin releasing hormone, which controls hypothalamo pituitary ovarian axis and exerts a number of peripheral effects on reproductive organs. The primary objective of this study was to compare baseline KP levels in females with different types of infertility and identify possible correlations with risk of failure to conceive, preclinical abortion and pregnancy after intracytoplasmic sperm injection (ICSI).

Materials and Methods

A longitudinal cohort study was carried out from August 2014 until May 2015 by recruiting 124 female patients undergoing ICSI, after obtaining ethical approval from the Australian Concept Infertility Medical Center. Cause of infertility due to male, female and unexplained factors was at a frequency of 32 (24%), 33 (31%) and 59 (45%) among the individuals respectively. KP levels were measured by ELISA assay before the initiation of the ICSI treatment protocol. Outcome of ICSI was categorized into three groups of non-pregnant with beta-human chorionic gonadotropin (β-hCG)<5-25 mIU/ml, preclinical abortion with β-hCG>25 mIU/ml and no cardiac activity, and clinical pregnancy declared upon confirmation of cardiac activity. Results based on cause of infertility and outcome groups were analyzed by one-way ANOVA.

Results

Females with unexplained infertility had significantly lower levels of KP when compared with those with male factor infertility (176.69 ± 5.03 vs. 397.6 ± 58.2, P=0.001). Clinical pregnancy was observed in 28 (23%) females of which 17 (71%) had a female cause of infertility. In the non-pregnant group of 66 (53%) females, common cause of infertility was unexplained 56(85%). A weak positive correlation of KP levels with fertilized oocytes and endometrial thickness was observed (P=0.04 and 0.01 respectively).

Conclusion

Deficiency of KP in females with unexplained infertility was associated with reduced chances of implantation after ICSI.

Renal and Hepatic Functions after A Week of Controlled Ovarian Hyperstimulation during In Vitro Fertilization Cycles

BACKGROUND

One the main aspects of in vitro fertilization (IVF) cycle is to avoid any possible systemic damage on women undergoing a controlled ovarian hyperstimulation (COH). The aim of this work is to evaluate renal and hepatic function blood tests in patients undergoing controlled ovarian hyperstimulation during IVF cycles.

MATERIALS AND METHODS

We performed a prospective cohort analysis. All patients re- ceived a long stimulation protocol with gonadotropin-releasing hormone (GnRH) analogues by daily administration, since the twenty-first day of the previous ovarian cycle followed by COH with recombinant follicle-stimulating hormone (FSH). The daily dose of exogenous gonadotropins for every single patient was modified according to her follicular growth. The oocytes were retrieved during the oocyte pick up and fertilized by standard procedures of intracytoplasmic sperm injection (ICSI). The blood samples to evaluate renal and hepatic functions were taken at the 7^th day of ovarian stimulation.

RESULTS

We enrolled 426 women aged between 19 and 44 years, with a mean body mass index (BMI) of 24.68 Kg/m². The mean value of blood urea nitrogen was 14 ± 3.16 mg/ dl, creatinine: 1 ± 0.45 mg/dl, uric acid: 4 ± 1.95 mg/dl, total proteins: 7 ± 3.93 mg/dl, aspartate aminotransferase: 18 ± 6.29 mU/ml, alanine aminotransferase: 19 ± 10.41 mU/ ml, alkaline phosphatase: 81 ± 45.25 mU/ml, total bilirubin 1 ± 0.35 mg/dL. All of the results were considered as a normal range following the Medical Council of Canada.

CONCLUSION

Our data suggest that, unlike ovarian hyperstimulation syndrome (OHSS), COH patients did not show any alteration to renal and hepatic functions.

Use of Follicular Output Rate to Predict Intracytoplasmic Sperm Injection Outcome

BACKGROUND

The measurement of follicular output rate (FORT) has been proposed as a good indicator for evaluating follicular response to the exogenous recombinant folliclestimulating hormone (rFSH). This places FORT as a promising qualitative marker for ovarian function. The objective of the study was to determine FORT as a predictor of oocyte competence, embryo quality and clinical pregnancy after intracytoplasmic sperm injection (ICSI).

MATERIALS AND METHODS

This prospective study was carried out on a group of infer- tile females (n=282) at Islamabad Clinic Serving Infertile Couples, Islamabad, Pakistan, from June 2010 till August 2013. Downregulated females were stimulated in injection gonadotropins and on ovulation induction day, pre-ovulatory follicle count (PFC) was determined using transvaginal ultrasound scan (TVUS), and FORT was determined as a ratio of PFC to antral follicle count (AFC)×100. Group I consisted of females with a negative pregnancy test, while group II had a positive pregnancy test that was confirmed with the appearance of fetal cardiac activity. Linear regression analyses of categorical variables of clinical pregnancy along with other independent variables, including FORT, were performed using SPSS version 15.0.

RESULTS

Pregnancy occurred in 101/282 women who were tested, recording a clinical pregnancy rate of about 35.8%. FORT values were higher in group II as compared to group I females (P=0.0001). In multiple regression analysis, 97.7, 87.1, 78.2, and 83.4% variations were explained based on the number of retrieved oocytes per patients, number of metaphase II oocytes retrieved, number of fertilized oocytes, and number of cleaved embryos, respectively, indicating FORT as an independent predictor.

CONCLUSION

FORT is a predictor of oocyte competence in terms of a number of retrieved, mature and fertilized oocytes. It also gives information about the number of cleaved embryos and clinical pregnancy rate.

Comparison of Metformin and Simvastatin Administration in Women With Polycystic Ovary Syndrome Before Intra-Cytoplasmic Sperm Injection Cycle: A Prospective, Randomized, Clinical Trial Study

Background:

Drugs administration as a pretreatment regiment before ICSI cycle in PCOs patients could enhance the success rate.

Objectives:

The aim of this study was to compare the effectiveness of metformin with Simvastatin in patients with polycystic ovary syndrome (PCOs) candidates for intra-cytoplasmic sperm injection (ICSI) before starting the cycle.

Patients and Methods:

In this prospective, double blind, randomized clinical trial the efficacy of these drugs was evaluated in 40 women with PCO syndrome (20 patients in each group; A: simvastatin and B: metformin) candidates for ICSI. In the both groups, metformin and simvastatin administrated for eight weeks before starting the ICSI cycle. Endocrine, metabolic and clinical parameters were measured before and after drug therapy; also, the results of ICSI cycle evaluated in the both groups.

Results:

Both drugs improved hirsutism score significantly, but simvastatin better than metformin (Group A, 24.5 ± 3.6 P: 0.0001 VS Group B, 22.9 ± 5.9 P: 0.003). The reduction in body mass index (BMI) was not significant in the groups. Simvastatin reduced some biochemical parameters such as FSH, LH, testosterone, total cholesterol, LDL and increased HDL level significantly, whereas metformin decreased FSH, TG, testosterone and total cholesterol significantly. Overall, respectively 35% and 30% of patients treated with metformin and Simvastatin became pregnant. There was no significant difference between the effects of these two drugs on ICSI cycle results like oocyte in meiosis2 (M2) phase (1.35 ± 1.6 vs. 2 ± 3.87, P value: 0.4) and the number of Grade A, embryo (1.2 ± 1.3 vs. 1.1 ± 1.4, P value: 0.7).

Conclusions:

Simvastatin effectively improved hyperandrogenism signs and symptoms in patients with PCO, but this effect as a pretreatment regiment was not more expressive than metformin in ICSI cycle outcome.

The outcomes of intracytoplasmic sperm injection and laser assisted hatching in women undergoing in vitro fertilization are affected by the cause of infertility

Background

We sought to determine the association between factors that affected clini- cal pregnancy and live birth rates in patients who underwent in vitro fertilization (IVF) and received intracytoplasmic sperm injection (ICSI) and/or laser assisted hatching (LAH), or neither.

Materials and Methods

In this retrospective cohort study, the records of women who underwent IVF with or without ICSI and/or LAH at the Far Eastern Memorial Hospital, Taipei, Taiwan between January 2007 and December 2010 were reviewed. We divided patients into four groups: 1. those that did not receive ICSI or LAH, 2. those that received ICSI only, 3. those that received LAH only and 4. those that received both ICSI and LAH. Univariate and multivariate analyses were performed to determine factors associated with clinical pregnancy rate and live birth rate in each group.

Results

A total of 375 women were included in the analysis. Oocyte number (OR=1.07) affected the live birth rate in patients that did not receive either ICSI or LAH. Mater- nal age (OR=0.89) and embryo transfer (ET) number (OR=1.59) affected the rate in those that received ICSI only. Female infertility factors other than tubal affected the rate (OR=5.92) in patients that received both ICSI and LAH. No factors were found to affect the live birth rate in patients that received LAH only.

Conclusion

Oocyte number, maternal age and ET number and female infertility fac- tors other than tubal affected the live birth rate in patients that did not receive ICSI or LAH, those that received ICSI only, and those that received both ICSI and LAH, respectively. No factors affected the live birth rate in patients that received LAH only. These data might assist in advising patients on the appropriateness of ICSI and LAH after failed IVF.

The Impact of Pituitary Blockage with GnRH Antagonist and Gonadotrophin Stimulation Length on The Outcome of ICSI Cycles in Women Older than 36 Years

BACKGROUND

The objective of this retrospective cohort study was to evaluate whether the length of pituitary blockage with gonadotrophin-releasing hormone (GnRH) antagonists or the stimulation period influence intracytoplasmic sperm injection (ICSI) outcomes in patients older than 36 years of age.

MATERIALS AND METHODS

In this retrospective study, a total of 138 couples with maternal age >36 years undergoing ICSI with an antagonist protocol were included. The influences of stimulation and suppression length on the response to ovarian stimulation and ICSI outcomes were investigated. Receiver operating characteristic curve (ROC) analysis was performed to assess the predictive value of the stimulation period for achievement of implantation and pregnancy.

RESULTS

THE GONADOTROPHIN STIMULATION LENGTH NEGATIVELY INFLUENCED THE IMPLANTATION RATE (RC: -4.200; p=0.023). The area under ROC curve (AUC) could distinguish between women with positive and negative implantation (AUC: 0.611; CI: 0.546-0.673) and pregnancy (AUC: 0.593; CI: 0.528-0.656). The threshold value demonstrated a high negative predictive value on likelihood of implantation (p=0.0032, 90% sensitivity) and pregnancy (p=0.0147, 87.1% sensitivity) when patients underwent more than 10 days of stimulation.

CONCLUSION

The stimulation period negatively influences the implantation rate in women older than 36 years. A stimulation interval greater than 10 days is associated with a negative predictive value for the chance of implantation and pregnancy.

Y choromosomal microdeletion screening in the workup of male infertility and its current status in India

Spermatogenesis is an essential stage in human male gamete development, which is regulated by many Y chromosome specific genes. Most of these genes are centred in a specific region located on the long arm of the human Y chromosome known as the azoospermia factor region (AZF). Deletion events are common in Y chromosome because of its peculiar structural organization. Astonishingly, among the several known genetic causes of male infertility, Y chromosomal microdeletions emerged as the most frequent structural chromosome anomaly associated with the quantitative reduction of sperm. The development of assisted reproductive techniques (ART) like intra-cytoplasmic sperm injection (ICSI) and testicular sperm extraction (TESE) helps to bypass the natural barriers of fertilization, but it increases the concern about the transmission of genetic defects. Experimental evidence suggested that the men with Y chromosomal microdeletions vertically transmitted their deletion as well as related fertility disorders to their offspring via these ART techniques. In India, infertility is on alarming rise. ART centres have opened up in virtually every state but still most of the infertility centres in India do not choose to perform Y chromosomal microdeletion diagnosis because of some advanced theoretical reasons. Moreover, there is no consensus among the clinicians about the diagnosis and management of Y chromosomal microdeletion defects. The current review discusses thoroughly the role of Y chromosome microdeletion screening in the workup of male infertility, its significance as a diagnostic test, novel approaches for screening Y deletions and finally a systematic review on the current status of Y chromosome microdeletion deletion screening in India.

The developmental competence of oocytes retrieved from the leading follicle in controlled ovarian stimulated cycles

BACKGROUND

This study compares the developmental capacity of gametes retrieved from the largest follicle with small follicles of a cohort in controlled ovarian stimulated cycles.

MATERIALS AND METHODS

This prospective study performed in a private assisted fertilization center included 1016 follicles collected from 96 patients who underwent intra cytoplasmic sperm injection (ICSI). After follicular aspiration, oocytes were assigned to two groups according to the diameter of the derived follicle. The large follicle group (n=96) comprised oocytes derived from the leading follicle of the cohort and the small follicle group (n=920) consisted oocytes derived from the smaller follicles of the cohort. The fertilization and percentage of topquality embryos were compared between groups by Chi-square or Fisher's exact test, where appropriate. The effect of the follicular diameter on oocyte dimorphism was assessed by binary logistic regression.

RESULTS

A significantly higher percentage of oocytes derived from the leading follicle were in the metaphase II (MII) stage (100 vs. 70.0%, p<0.001). However we observed no significant differences regarding the percentage of degenerated oocytes between the large (6.25%) and small follicle (5.0%) groups (p=0.550). Regression analysis demonstrated a nearly two-fold increase in the incidence of vacuoles in oocytes derived from the largest follicle of the cohort (OR: 1.81, p=0.046). The fertilization rate (50.0 vs. 38.8%, p=0.038) and the percentage of top quality embryos (84.7 vs. 76.4%, p=0.040) were significantly higher for oocytes derived from the largest follicle. However, the percentage of abnormal fertilized oocytes was equally distributed between the large follicle (15.0%) and small follicle (12. 8%) groups (p=0.550).

CONCLUSION

Our data suggest that intrafollicular mechanisms within the larger follicle of the cohort may allow for these follicles to amplify the responsiveness to exogenous gonadotropin, which leads to the formation of more competent oocytes with higher fertilization and developmental capacities.

Super infection of an ovarian dermoid cyst with actinomyces in an infertile woman

We present super infection of an ovarian dermoid cyst with actinomyces in an infertile patient. This is a case-report study for evaluation a couple with male factor infertility, who was a good candidate for intracytoplasmic sperm injection (ICSI), while a 10 cm dermoid cyst was found in the woman's right ovary. Patient complained of pelvic pain, intermittent fever, dysmenorrhea, and dyspareunia. The cyst was extracted using laparoscopy, whilst in histopathological examination, an actinomycosis super infection was reported. Actinomyc super infection of an ovarian dermoid cyst is a very rare incident which can also occur in women with no history of intrauterine device (IUD) usage or previous fertility.

Application of sperm selection using hyaluronic acid binding in intracytoplasmic sperm injection cycles: a sibling oocyte study

The purpose of this study was to investigate whether sperm selection by hyaluronic acid (HA) binding could improve fertilization rate and embryo quality in intracytoplasmic sperm injection (ICSI) cycles. Two hundred nineteen oocytes obtained from eighteen women were injected with either HA-bound (n = 107) or conventionally selected spermatozoa (n = 112) in a randomized way. All of the participants were infertile couples who had normal sperm parameters but low fertilization rate in previous in vitro fertilization (IVF) cycle (n = 5) or experienced multiple IVF failures (n = 13). Lower fertilization (75.7% vs 83.0%) and cleavage rate on day 2 (72.9% vs 83.0%) was observed in oocytes injected with HA-bound spermatozoa than the conventional group, but the difference was not significant. Significantly lower cleavage rate was observed on day 3 in HA group (56.0% vs 69.6%, P = 0.038). Blastocyst formation rate and the number of transferred embryos were similar in both groups. In multiple IVF failure patients, significantly reduced fertilization rate (71.8% vs 85.3%, P = 0.046) and cleavage rate on day 2 (70.4% vs 85.3%, P = 0.029) and day 3 (53.5% vs 77.3%, P = 0.002) were noticed in HA group. Five women achieved pregnancy continuing more than 12 weeks after transfer (27.8%). Success of ICSI was not related with the number of embryos fertilized by HA-bound spermatozoa. Application of ICSI by sperm selection using HA binding is not helpful in couples with repeated poor fertilization or implantation despite normal sperm parameters.

Efficiency of laser-assisted intracytoplasmic sperm injection in a human assisted reproductive techniques program

OBJECTIVE

Laser-assisted intracytoplasmic sperm injection (LA-ICSI), also known as micro-opening or thinning of the zona pellucida (ZP) prior to ICSI, may help to reduce mechanical damage to the oocyte during the procedure. The aim of the present study was to evaluate and analyze the efficacy of our institutional LA-ICSI program, which features laser-assisted ZP thinning prior to ICSI, in comparison with conventional ICSI (C-ICSI), performed on patients with different clinical characteristics.

METHODS

Patients undergoing a total of 212 ICSI cycles were randomly divided into an LA-ICSI group (106 cycles) and a conventional ICSI group (106 cycles). To reduce tissue damage, we thinned the ZP by approximately 70%, using a laser, before ICSI. Patients thus treated formed the LA-ICSI group. Comparisons included the morphological quality of transferred embryos, blastocyst development of the remaining embryos, and clinical pregnancy, in terms of ICSI method and patient characteristics.

RESULTS

Fertilization, development of remaining embryos, and pregnancy rate were significantly higher in the LA-ICSI group compared with the C-ICSI group. Fertilization, embryonic development, and the pregnancy rate were all improved in younger patients (<38 years of age) and in those who underwent a low number of IVF-ET attempts (<3 trials). In addition, the pregnancy rate was increased in older patients.

CONCLUSION

LA-ICSI may be useful in improving the chance of pregnancy in all ICSI patients.