P–527 Embryonic cell-free DNA (cfDNA) in spent culture medium for aneuploidy screening and its concordance with trophoectoderm biopsy in PGT-A cycles

Study question

Is embryonic cfDNA detectable in blastocyst spent culture medium; can its analysis via Next Generation Sequencing compare with trophoctoderm biopsy results of the respective embryos?

Summary answer

Embryonic cfDNA is detected in blastocyst spent culture medium (BCM) and gives comparable aneuploidy rates with trophoectoderm biopsy in PGT-A cycles.

What is known already

Currently, PGT- A involves the use of invasive techniques to obtain embryonic DNA, with significant technical and ethical limitations. Recently, spent culture medium (SCM) has been proposed as an alternative source of embryonic DNA. Studies have reported the detection of cfDNA in SCM and highlighted the diagnostic potential of non invasive PGT (niPGT) for assessing the genetic status of preimplantation embryos. Moreover, invasive PGT-A can lead to genetic misdiagnosis in case of mosaic embryos, while niPGT-A may be more represantative of the whole embryonic chromosome status. However, the reliability of this approach for clinical applications needs to be further determined.

Study design, size, duration

These are preliminary data from an observational study conducted in the period 2019–2020. 40 embryos from 13 patients, undergoing PGT-A, were analyzed. Trophoectoderm biopsies (TEB) and respective SCMs from individually cultured embryos were analyzed by Next Generation Sequencing NGS. The results from trophoectoderm biopsies and SCMs of the respective embryos were compared.

Participants/materials, setting, methods

The embryos were cultured individually in 10μl drops, from day 3 to the blastocyst stage (day5/6). On day 5/6, TEB was performed and the corresponding BCM was collected and stored at –80 °C, until analysed with NGS. Data were analysed with McNemar’s test and ROC analysis. The results were considered significant when P < 0.05. 95% Confidence intervals (95%CI) were calculated.

Main results and the role of chance

The amplification rate, for embryonic cfDNA from BCM samples collected from embryos cultured for 48–72 hours after day 3, was 100%. DNA concentration in each sample after whole genome amplification (WGA) ranged between 2500–30000 ng/ml for TEB and 2000–20400 ng/ml for BCM. Respective blank medium negative controls associated with each sample that underwent WGA showed no amplification in all cases. The trophoectoderm biopsy showed aneuploidy at a percentage of 61% (95% CI: 43–78%), vs. BCM aneuploidy at a percentage of 55% (95% CI: 37–72%). The overall agreement BCM vs. TE biopsy, from samples taken from the same embryo, was 27/33, 81.8% (95% CI: 68–96%). McNemar test: p = 0.687, non-significant. The aneuploidy agreement was 88.9% (sensitivity) and the euploidy agreement was 73.3% (specificity). In ROC analysis, AUC was 82.3% (95% CI 66.9–97.8). In 4 BCM samples detected euploidy, while TE biopsy showed embryo monosomes, possibly due to mosaicism. 7 samples were excluded due to low quality cfDNA. Of the 33 samples, 7 were male (XY), according to both TE biopsy and BCM analysis, a fact that confirms the safety of the method, as it shows no contamination by maternal DNA.

Limitations, reasons for caution

The study is limited by the small sample size. To become the niPGT reliable, several steps must be optimized: DNA collection methods, DNA amplification and downstream techniques for analysis. Also, the analysis of discarded whole blastocysts as a gold standard control may determine the method’s reliability.

Wider implications of the findings: Non-invasive Preimplantation Genetic Testing (niPGT), is a promishing alternative that may give an accurate and reliable option of detecting euploid human embryos, also dealing with the problem of mosaicism in trophodectoderm biopsies. Further technical refinement is needed to perfect niPGT, so that it can be used in routine clinical practice.

Trial registration number

N/A

The use of serum anti-Mullerian hormone (AMH) levels and antral follicle count (AFC) to predict the number of oocytes collected and availability of embryos for cryopreservation in IVF

AIM

To investigate the predictive value of anti-Mullerian hormone (AMH) and antral follicle count (AFC) on the final number of oocytes retrieved and the availability of embryos for cryopreservation in in vitro fertilization (IVF) cycles.

PATIENTS AND METHODS

In this prospective study, one hundred and twenty women in their first IVF treatment were enrolled. The short stimulation agonist protocol was used for controlled ovarian hyperstimulation in all cases. Serum AMH levels were measured during the menstrual cycle preceding treatment. AFC was measured in cycle day 2, just before starting ovarian stimulation.

RESULTS

A strong, positive correlation between AMH, AFC and the number of collected oocytes was found. The patients with available and suitable supplementary embryos for cryopreservation had higher levels of AMH and larger numbers of AFC.

CONCLUSION

AMH and AFC appear to be valuable markers mainly for ovarian reserve and response to IVF treatment. Serum AMH levels and AFC are significantly associated with the number of retrieved oocytes. Also, a positive correlation with the availability of supernumerary embryos suitable for cryopreservation was observed.

Follicular fluid levels of vascular endothelial growth factor and its receptors and pregnancy outcome of women participating in intracytoplasmic sperm injection cycles

PURPOSE

The intracytoplasmic sperm injection (ICSI) outcome is depended mainly on oocyte quality. Cytokines and their receptors play a critical role in oocyte maturation, fertilization, and embryo implantation. The purpose of the study was to study the levels of vascular endothelial growth factors (VEGFA, VEGFR1, VEGFA) in follicular fluids (FF) women participating in ICSI-in vitro fertilization (IVF) cycles in relation to cycle's outcome.

MATERIAL AND METHODS

One hundred and fifty three samples of 70 women participating in ICSI cycles were classified in three infertility groups: male factor, female factor, and low responders. For controlled ovarian stimulation in male and female factor group, the long agonist protocol with leuprolide and recombinant follicle stimulating hormone (FSH) was employed, while the antagonist cetrorelix was used in low responders. Cytokines levels were evaluated with enzyme-linked immunosorbent assay (ELISA).

RESULTS

In a total of 153 samples, the overall pregnancy rate was 51.6%, the higher one observed in female factor group (59% vs. 37.5% and 28.6% in male a factor and low responders group, p = 0.013. VEGFR2 differed statistically significantly between the two groups, being higher in the pregnancy group [median (IQR): 5,630 (4,870 - 6,651) vs. 4938 (4,068 - 6,020) in the non-pregnancy group, p = 0.003]. There were significant correlations between VEGF receptors, differentiated depending on infertility groups.

CONCLUSIONS

The VEGFA/VEGFR2 system is important in human reproduction and the association pattern between VEGFA receptors may serve as a marker for ICSI outcome. Examination for spermatozoa functional defects may increase pregnancy rate in male factor group.

Binovular complexes after ovarian stimulation. A report of four cases

BACKGROUND

Human ovary is known to contain polyovular follicles at birth but it is considered to be rare in adult ovaries.

CASES

Four cases are presented where binovular complexes were found after ovarian stimulation. The age of women was 22 to 33 years and all of them had a good response to ovarian stimulation. Two different types of binovular complexes were found. The mature oocytes of three binovular complexes were fertilized by ICSI. The generated embryos did not develop beyond the eight-cell stage.

CONCLUSION

The mature oocytes of binovular complexes can be fertilized but their developmental potential is limited.

The effects of benzoylecgonine, oxytocin, ritodrine and atosiban on the contractility of myometrium. An experimental study

PURPOSE

To investigate the response of pregnant and non pregnant rat myometrium to benzoylecgonine, a cocaine metabolite, and oxytocin and to investigate the efficiency of ritodrine and atosiban to overcome the effects of benzoylecgonine and oxytocin.

METHODS

Isolation of rat myometrial tissue and recording of contractile activity with isotonic muscle transducer.

RESULTS

Benzoylecgonine and oxytocin increase myometrial contractility, while atosiban and ritodrine induce myometrial relaxation. Atosiban was able to revoke the action of oxytocin but not the action of benzoylecgonine. Ritodrine was able to induce muscle relaxation in both oxytocin and benzoylecgonine administration.

CONCLUSION

Cocaine metabolites seem to act on the myometrium through different pathways compared with oxytocin. After comparing two widely used tocolytic agents: atosiban and ritodrine, it is indicated that only ritodrine, a beta2 adrenergic receptor agonist, can inhibit the action of cocaine metabolites. This finding indicates that the actions of cocaine on adrenergic mechanisms are responsible to a large part for its effects on myometrium contractility. The use of beta2 adrenergic receptor agonists seems to be preferable for the treatment of myometrial contractions induced by cocaine consumption.

Serum pattern of circulating soluble receptor of leptin throughout the menstrual cycle

AIM

The aim of the study was to investigate the pattern of circulating soluble receptor of leptin (sLeptinR) during the menstrual cycle and the association of sLeptinR to leptin, sex hormones and gonadotropins.

METHODS

Fasting blood samples were collected on alternate days throughout a full cycle from fifteen healthy volunteers. Immunoenzymatic assays were employed to record the relevant levels.

RESULTS

sLeptinR concentrations throughout the cycle were found to vary negligibly. No significant correlations between sLeptinR and leptin, gonadotropins or progesterone, were established. During the follicular phase, subjects presenting with higher estradiol levels tended to have higher sLeptinR concentrations.

CONCLUSION

The little variation of sLeptinR concentrations during the menstrual cycle indicates that the rise of leptin during the luteal phase implies an increase of its bioactivity.

Cytokine profile in cases with premature elevation of progesterone serum concentrations during ovarian stimulation

The aim of this study was to investigate the concentrations of vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), leptin, tumor necrosis factor-alpha, interleukin (IL)-1beta and IL-6, in cycles with a premature rise of serum progesterone. 25 intracytoplasmic sperm injection (ICSI) cycles with (Group 1) and 25 ICSI cycles without a premature progesterone elevation (Group 2) were included. The cut-off value of serum progesterone on the day of human chorionic gonadotropin (hCG) administration was 0.9 ng/ml. The indication for ICSI was male factor infertility exclusively. On the day of hCG injection, serum IL-6, VEGF and bFGF were significantly higher in Group 1 (7.7+/-24.5 pg/ml, 290.2+/-161.4 pg/ml and 15.7+/-8.2 ng/ml respectively) than in Group 2 (1.7+/-0.7 pg/ml, 175.2+/-92.1 pg/ml, and 9+/-1.6 ng/ml respectively). On the day of follicular puncture, serum cytokine concentrations were similar in the two groups. IL-6 intrafollicular concentrations were higher in Group 1 (14.7+/-20.7 pg/ml) than in Group 2 (9+/-9.3 pg/ml, p=0.031). There were no differences regarding the ICSI outcome. Patients with serum progesterone above 0.9 ng/ml, have elevated serum concentrations of IL-6, VEGF, and bFGF, as well as elevated intrafollicular concentrations of IL-6. The outcome of ICSI cycles is not associated with premature elevation of progesterone when the cut-off value is set at 0.9 ng/ml.

IGF-I and epidermal growth factor levels in follicular fluid of women undergoing controlled ovarian hyperstimulation using the multidose GnRH-antagonist protocol or the long GnRH-agonist protocol

The intrafollicular levels of IGF-I and epidermal growth factor (EGF) were studied in women undergoing controlled ovarian hyperstimulation using the multidose GnRH-antagonist protocol or the long agonist protocol, in an attempt to elucidate whether GnRH-antagonists affect the levels of the two growth factors. The follicular fluid concentration of IGF-I, EGF, estradiol and progesterone were detected in 68 women undergoing ovarian hyperstimulation for intracytoplasmic sperm injection (ICSI) cycles. There were no differences in intrafollicular concentrations of EGF and IGF-I in the two studied groups. Additionally, we found no correlation between the intrafollicular levels of IGF-I or EGF and the ICSI outcome. The intrafollicular levels of IGF-I were positively correlated with those of progesterone. In conclusion, the intrafollicular levels of IGF-I and EGF do not seem to be influenced by the stimulation protocol. The intrafollicular levels of both growth factors can not serve as prognostic markers for the ICSI outcome.

The role of basic-fibroblast growth factor (b-FGF) in cyclosporine-induced nephrotoxicity

BACKGROUND

The effect of the b-fibroblast growth factor (b-FGF) on cyclosporine A (CsA)-induced nephrotoxicity in the rat kidney was investigated.

MATERIALS AND METHODS

The rats were divided into six groups: A (control), B (b-FGF-treated), C, D: (CsA-treated and sacrificed on days 14 or 21), E, F (Cs A- and b-FGF- treated and sacrificed on days 14 or 21). The antibody mouse anti-rat CD31 was used to evaluate the kidney vessels present in histological preparations.

RESULTS

The kidney vessels in group B were increased in comparison with the control group (p<0.05). Reduction of kidney vessels in groups C and D (p<0.05) in comparison with the controls was observed, while in groups E and F they were increased when compared to group C (p<0.05) and D (p<0.05), respectively.

CONCLUSION

The angiogenic role of b-FGF was confirmed in normal rats and a possible "protective" role of b-FGF was shown in rat kidney with CsA-induced nephrotoxicity.

Angiogenic effect of intramuscular administration of basic and acidic fibroblast growth factor on skeletal muscles and influence of exercise on muscle angiogenesis

BACKGROUND

Angiogenic factors which control the angiogenic process represent a promising strategy for restoration of blood flow, but require further evaluation before clinical use. Exercise has also been reported to induce neovascularisation in muscles.

OBJECTIVES

To evaluate the angiogenic effects of basic fibroblast growth factor (b-FGF) and acidic fibroblast growth factor (a-FGF) on rat gastrocnemius muscle, when administered intramuscularly, and to compare them with those obtained by daily exercise.

METHODS

Forty nine rats were allotted to the following groups: A, controls; B, exercise by swimming; C1 and C2, intramuscular injection of b-FGF and a-FGF respectively; D1 and D2, b-FGF and a-FGF injection in combination with exercise. The antibody mouse anti-rat CD31 was used to evaluate the numbers of blood vessels present in histological preparations of gastrocnemius muscle.

RESULTS

Significant increases in the numbers of blood vessels of the right gastrocnemius muscles in groups C1 and D1 were observed compared with controls (p<0.05). There was only a slight increase in angiogenesis in the left gastrocnemius muscle of groups C1 and D1 compared with controls (p>0.05), and there was a decrease in angiogenesis in the gastrocnemius muscle of the swimming group compared with controls.

CONCLUSION

The intramuscular administration of b-FGF, but not a-FGF, induced significant local angiogenesis in gastrocnemius muscle at the site of injection.

Clinicopathologic and prognostic significance of cyclooxygenase-2 expression in endometrial carcinoma

BACKGROUND

Endometrial carcinoma is the most common malignancy of the female genital tract in the Western world. COX-2 is highly expressed in endometrial carcinoma, but there is controversy regarding its clinical role and its possible prognostic role. COX-2 expression was determined by immuno-histochemistry and was correlated to standard clinico-pathologic variables in a series of primary untreated endometrial carcinoma patients. COX-2 as an accurate predictor of the disease was also analyzed.

METHODS

One-hundred and ten cases of primary untreated endometrial carcinoma hosts who were admitted to the Department of Obstetrics and Gynecology, University General Hospital of Alexandroupolis, were investigated. Immunohistochemistry was performed using rabbit polyclonal antiserum against human COX-2.

RESULTS

Twenty-eight patients (25.5%) were scored as COX-2 positive. A statistically significant association was found between COX-2 overexpression and FIGO stage (p=0.010). A positive correlation was also found with histological grade (p=0.019) and myometrial invasion (p=0.026). No significant association was found with histologic type of the tumor (p=0.164). COX-2 positive patients had a significant association with sort survival (p=0.028).

CONCLUSIONS

COX-2 expression is an independent clinicopathologic factor and an independent prognostic factor in endometrial carcinoma. It could be used to plan treatment modalities for hosts.

Follicular fluid levels of vascular endothelial growth factor and leptin are associated with pregnancy outcome of normal women participating in intracytoplasmic sperm injection cycles

Cytokines play a critical and multifarious role in follicular maturation. Consequently, they may influence the pregnancy outcome in cycles of assisted reproduction. The aim of this study was to measure the levels of tumor necrosis factor-alpha (TNFalpha), vascular endothelial growth factor (VEGF) and leptin in serum and follicular fluids (FFs) from women undergoing controlled ovarian hyperstimulation (COH) for intracytoplasmic sperm injection cycles (ICSI). We tried to investigate their interrelationships and to evaluate them as predictive markers for the cycle's outcome. Seventeen women participated in this study. Male factor infertility was the only indication for ICSI cycles. For COH, the long agonist protocol with triptorelin and recombinant FSH was employed. Cytokines levels were evaluated by ELISA. Serum cytokine levels did not differ between pregnant and non-pregnant women. FF-VEGF levels were significantly elevated in non-pregnant women (722.2+/-1093.2 pg/ml) as compared to pregnant women (290.3+/-259.8 pg/ml). Leptin concentrations were also significantly higher in FFs of non-pregnant women (682.6+/-625.1 ng/ml) than those of pregnant women (231.6+/-286.5 ng/ml). There were significant positive correlations between FF-leptin and age, as well as between FF-leptin and FF-VEGF concentrations. It was concluded that elevated FF-leptin and VEGF levels are associated with failure of conception in IVF cycles and may serve as markers in clinical practice.

Follicular fluid levels of vascular endothelial growth factor and leptin are associated with pregnancy outcome of normal women participating in intracytoplasmic sperm injection cycles

Cytokines play a critical and multifarious role in follicular maturation. Consequently, they may influence the pregnancy outcome in cycles of assisted reproduction. The aim of this study was to measure the levels of tumor necrosis factor-alpha (TNFalpha), vascular endothelial growth factor (VEGF) and leptin in serum and follicular fluids (FFs) from women undergoing controlled ovarian hyperstimulation (COH) for intracytoplasmic sperm injection cycles (ICSI). We tried to investigate their interrelationships and to evaluate them as predictive markers for the cycle's outcome. Seventeen women participated in this study. Male factor infertility was the only indication for ICSI cycles. For COH, the long agonist protocol with triptorelin and recombinant FSH was employed. Cytokines levels were evaluated by ELISA. Serum cytokine levels did not differ between pregnant and non-pregnant women. FF-VEGF levels were significantly elevated in non-pregnant women (722.2+/-1093.2 pg/ml) as compared to pregnant women (290.3+/-259.8 pg/ml). Leptin concentrations were also significantly higher in FFs of non-pregnant women (682.6+/-625.1 ng/ml) than those of pregnant women (231.6+/-286.5 ng/ml). There were significant positive correlations between FF-leptin and age, as well as between FF-leptin and FF-VEGF concentrations. It was concluded that elevated FF-leptin and VEGF levels are associated with failure of conception in IVF cycles and may serve as markers in clinical practice.

Triptorelin versus cetrorelix in intracytoplasmic sperm injection cycles in women with a single ovary

OBJECTIVE

To compare the response to ovarian stimulation with either the long protocol of a GnRH-agonist or the multiple protocol of a GnRH-antagonist, in women with a single ovary who underwent intracytoplasmic sperm injection (ICSI) cycles.

STUDY DESIGN

Retrospective study including 75 ICSI cycles from 26 women. Sixty-three cycles were stimulated with triptorelin/hMG or rFSH, whereas 12 cycles were stimulated with cetrorelix/hMG or rFSH.

RESULTS

There was not found any statistical significant difference between the two groups regarding the days of stimulation, the number of gonadotropins' ampoules, the peak estradiol levels, the number of aspirated follicles and the number of retrieved oocytes. The fertilization rate, the number of transferred embryos as well as the cumulative embryo score were also similar in both groups.

CONCLUSION

The multiple stimulation protocol of cetrorelix is equally effective with the long protocol of triptorelin in the ovarian stimulation of women with a single ovary.

Gonadotropin releasing hormone antagonists and cryopreservation outcome: a review

REVIEW

The outcome of freeze-thaw cycles with pronuclear stage oocytes or embryos, derived from collecting cycles stimulated with gonadotropin-releasing hormone (GnRH)-antagonists' protocols, was reviewed.

CONCLUSION

The viability of cryopreserved pronuclear stage oocytes and embryos, the quality of transferred embryos and the pregnancy rates of the freeze-thaw cycles seem to be satisfactory regardless of the type and dose of GnRH-antagonist.

A borderline form of empty follicle syndrome. Case report

BACKGROUND

Empty follicle syndrome is known as the failure of oocyte retrieval despite the adequate response to ovarian stimulation. It is a rare phenomenon in in-vitro fertilization and borderline forms of this syndrome have also been described.

MATERIALS AND METHODS

Two cycles in the same patient were stimulated with GnRH agonist/hMG and recFSH; the first followed the long and the second followed the short protocol.

RESULTS

There was a sudden drop in estradiol levels while the ovaries contained a large number of small and medium sized follicles. hCG was administered and oocyte retrieval was performed 36 hours later. There was no indication of low hCG levels. For the first cycle two oocytes were collected: one degenerated and one of poor quality. The second cycle resulted in total failure of oocyte retrieval.

CONCLUSION

The two cycles were classified as borderline forms of empty follicle syndrome. The possible aetiology is discussed.

A comparison of the ovarian response to external stimulation between women with right or left ovary participating in programs of ICSI/ET

INTRODUCTION

Single ovary women compose a group of special interest in assisted reproduction technologies. The aim of the present study was to investigate whether the response to external stimulation and the outcome in women with a single ovary was affected by the location of the ovary.

METHODS

Sixty cycles from 24 women, which stimulated with either hMG or rFSH and a GnRH agonist, were retrospectively studied. Twelve women had right and 12 had left ovary. In all cases, the fertilization was performed by intracytoplasmic sperm injection.

RESULTS

There was not found any statistical significant difference between the two groups regarding the days of stimulation, the peak estradiol levels, the number of aspirated follicles, the number of retrieved oocytes, the fertilization rate and the number of transferred embryos. The cumulative embryo score (CES) was also similar in both groups. Six pregnancies in the group of the right ovary and seven in the group of left ovary were achieved.

CONCLUSION

According to these results, right and left ovary, in single ovary women under external stimulation, are equally active and potent for reproduction.

Endometrial fluid accumulation during controlled ovarian stimulation for ICSI treatment. A report of three cases

The occurrence of endometrial fluid accumulation was examined in patients undergoing ovarian stimulation in a program of intracytoplasmic sperm injection (ICSI), by vaginal ultrasound. Endometrial fluid accumulation was recorded in three cycles out of 124. In one case, the fluid was absorbed before embryo transfer (ET), but in the other cases it was present in ET. In these three cases, the endometrium had been evaluated as normal before ovarian stimulation. Fluid accumulation in the endometrial cavity possibly affects the implantation process negatively. Therefore, alternative options should be considered as cancellation of the embryo transfer and cryopreservation of embryos to be available in a subsequent mild stimulated cycle.

Comparison of poor responders with good responders using intentionally frozen-thawed epididymal spermatozoa in subsequent ICSI cycles

PURPOSE

To compare the outcome of intracytoplasmic sperm injection (ICSI) cycles performed with frozen-thawed epididymal spermatozoa between patients who respond poorly and patients who respond well to ovarian stimulation.

METHODS

17 patients suffering from obstructive azoospermia underwent microsurgical retrieval of epididymal spermatozoa (MESA) and the spermatozoa were frozen. The frozen-thawed spermatozoa were used in subsequent ICSI cycles. In six patients, the female partners responded poorly to ovarian stimulation. They accomplished nine ICSI cycles. In 11 patients, the female partners responded well to ovarian stimulation and they accomplished 16 cycles.

RESULTS

Poor responders were older than those who reponded well. The mean number of metaphase II oocytes collected was lower in the poor responder group. In the poor responders, two couples failed to fertilise the oocytes in two ICSI cycles. In the good responders, one couple failed to fertilise the oocytes in an ICSI cycle. There were no significant differences in fertilization rates between the two groups. The estradiol concentrations on the day of hCG administration were significantly higher in the good responders. There was no pregnancy in the poor responder group, while three patients who responded well conceived. Eight good responders had 34 supernumerary 2PN oocytes which were cryopreserved.

CONCLUSION

Frozen-thawed epididymal spermatozoa from men with obstructive azoospermia are potent to achieve satisfactory fertilization rates. Poor ovarian response to stimulation induction appears to be the main limiting factor in reaching the stage of embryo transfer. It is preferable in older women to cancel cycles with poor response in the hope that a better response might be obtained in a subsequent cycle. Thus, the frozen-thawed epididymal sperm can be preserved and the most stressful and expensive phase of IVF-ICSI treatment can be avoided.

Outcome of anticipated ICSI cycles using intentionally frozen-thawed testicular spermatozoa according to the spouse's response to ovarian stimulation

PURPOSE

To investigate the outcome of ICSI cycles, using frozen-thawed testicular spermatozoa from patients suffering from non-obstructive azoospermia, in relation to the spouse's response to ovarian stimulation.

METHODS

A retrospective study with two groups of couples where males suffered from non-obstructive azoospermia. In group 1 (n = 14), the female partners responded poorly to ovarian stimulation (< or = 4 oocytes retrieved). In group 2 (n=14), the female partners responded well (> or = 10 oocytes retrieved). Both groups underwent 14 cycles of ICSI using frozen-thawed spermatozoa obtained by TESE.

RESULTS

The total amount of gonadotropin, the duration of stimulation, the peak estradiol concentrations and the number of oocytes were significantly different between the two groups. Despite the satisfactory fertilisation rates, the outcome in poor responders was disappointing due to a low number of oocytes. There was only one pregnancy in the poor responder group whereas there were four in the group that responded well. The pregnancy rates per oocyte collection were 7.14% in group 1 versus 28.57% in group 2. The implantation rates were 60.60% versus 55.33%, respectively.

CONCLUSION

It is possible to achieve satisfactory fertilisation rates using frozen-thawed, surgically-retrieved testicular spermatozoa, but the poor ovarian response to stimulation induction is the limiting factor in reaching implantation and pregnancy. It is preferable that poorly stimulated cycles be canceled, in the hope of a better subsequent response.

Father-to-son sperm donation. A report of three cases

Sperm donation is a common practice in assisted reproduction. In cases of azoospermia and negative results of testicular sperm extraction, it appears as the only solution. Sperm donation entails a complete genetic dissociation between husband and offspring, which brings psychological stress for the couple arising from ethical and existential dilemmas. Faced with such dilemmas, some couples prefer father-to-son donation as an alternative solution. Here, three cases of non-obstructive azoospermia are presented where intracytoplasmic sperm injection was performed with father-to-son sperm donation.

Gonadotropin-releasing hormone antagonist protocol: a novel method of ovarian stimulation in poor responders

OBJECTIVE

To estimate the efficacy of gonadotropin-releasing hormone (GnRH) antagonist 'Cetrorelix' in poor responders comparing with the standard long protocol.

DESIGN

The study population consisted of 21 poor responders who underwent ICSI and treated with Cetrorelix according to the multiple-dose protocol and who were compared with 21 poor responders treated according to the long protocol and who also underwent ICSI. Patients in both groups were matched for chronological age, the number of follicles found by ultrasound at the retrieval day and cause of infertility. Fifteen patients of GnRH antagonist group were treated with the combination of GnRH antagonist with clomiphene citrate (CC) plus gonadotropins, while six patients were treated with the combination of GnRH antagonist plus gonadotropins, but without CC.

RESULTS

The use of GnRH antagonist in a multiple dose protocol gave a pregnancy rate of 14.28% which was in the range expected for patient with poor response, but with shorter treatment duration and with fewer ampoules of gonadotropins as compared with the use of a GnRH agonist protocol in a depot formulation. Within Cetrorelix group patients who received CC had a significant shorter duration of stimulation and needed fewer ampoules as compared with patients in the same group who did not receive CC.

CONCLUSIONS

A GnRH antagonist multiple dose protocol may be the protocol of choice for the treatment of poor responders. The use of GnRH antagonist Cetrorelix ended with significantly less ampoules of gonadotropins and a shorter duration of stimulation.

Frozen pronuclear oocytes: advantages for the patient

Since the first reported pregnancy in a human being after a frozen/thawed eight cell stage preembryo, cryopreservation of preembryos has been integrated as an important element of assisted reproductive technologies (ART). The cryopreservation technique has brought several advantages to ART. It allows the transfer of a limited number of embryos in the collection cycle, thereby reducing the risk of multiple pregnancies, and the patients have a reservoir of excess embryos for additional transfers. This maximises the number of embryo transfers per oocyte retrieval, while at the same time increasing the cumulative pregnancy rate from a given treatment cycle. Also, the ability to freeze all the embryos obtained and transfer at a subsequent cycle is useful in the avoidance of hyperstimulation syndrome, or when factors that may jeopardize implantation are apparent. Freezing of oocytes in a pronuclear stage has a valuable role in the management of infertility. Supernumerary zygotes can be cryopreserved safely for future transfer, avoiding additional inconvenience for the patients. The freezing thawing technique does not have any adverse effects on oocytes fertilized microsurgically. Pronuclear stage oocytes eventually survive the cryopreservation procedure better, yielding after culture cleaved embryos appropriate for transfer, which could increase the implantation rate. We believe that the cryopreservation of cleaved embryos, which is problematic, can be safely replaced by this procedure. This is not only an advantage for society as a whole, but also for the people involved in the process, as there should be no ethical or moral conflict for the patients or for the laboratory staff about discarding this material.

Comparison of cryopreservation outcome with human pronuclear stage oocytes obtained by the GnRH antagonist, cetrorelix, and GnRH agonists

This retrospective study was performed to examine the implantation and pregnancy rates of frozen-thawed pronuclear stage oocytes obtained with the use of a GnRH antagonist, Cetrorelix (Cetrotide((R)) ASTA-Medica, Frankfurt/M, Germany) used in a multidose protocol with hMG, and to compare these results with those obtained after a conventional long GnRH analogue protocol (Decapeptyl-Depot, Ferring, Kiel, Germany). The study population consisted of 31 infertile couples with frozen-thawed pronuclear stage oocytes after ICSI treatment using the GnRH antagonist Cetrorelix (Cetrorelix((R))) and 31 infertile couples with frozen-thawed pronuclear stage oocytes after ICSI treatment using the long GnRH analogue protocol. Patients underwent ICSI after down regulation with a GnRH agonist (Decapeptyl) and stimulation with hMG, or a GnRH antagonist (Cetrorelix) and hMG. The supernumerary pronuclear stage oocytes were cryopreserved and transferred in a later mildly stimulated cycle. The implantation and pregnancy rates for frozen-thawed pronuclear stage oocytes derived from the GnRH antagonist compared with the GnRH agonist were 3.26% versus 3.73% (P=1.0000) and 8.33% versus 10.25% (P=1.0000), respectively. To our knowledge we report here the first pregnancies obtained by the transfer of cryopreserved pronuclear stage embryos generated from ICSI using a GnRH antagonist in the collecting cycle. The use of Cetrorelix in a multiple dose protocol in combination with hMG does not demonstrate a negative effect on viability, implantation potential or pregnancy outcome as compared to 2PN conceptuses obtained from a long GnRH agonist-hMG protocol.

Outcome of ICSI cycles using frozen-thawed surgically obtained spermatozoa in poor responders to ovarian stimulation: cancellation or proceeding to ICSI?

OBJECTIVE

To investigate the ICSI outcome of the patients who produced four follicles or less after ovarian stimulation using frozen-thawed surgically obtained spermatozoa.

STUDY DESIGN

The patient cohort of this study was composed of a carefully selected group of 20 men suffering from obstructive and non-obstructive azoospermia and in whom spermatozoa had been seen in their harvested epididymal aspirates and testicular tissues and the cryopreserved specimens had been used for subsequent ICSI cycles. This group of men represent those in whom the female partners produced only four follicles or less after ovarian stimulation.

RESULTS

For the cases of obstructive azoospermia with MESA (n=6) a total of nine cycles was carried out. Four couples went through one cycle, one couple underwent two cycles, one couple accomplished three cycles. Out of the nine cycles, seven went to embryo transfer. No pregnancy occurred in the MESA-ICSI group of patients. The mean+/-S.D. number of oocytes per cycle was 2.556+/-1.236, the mean+/-S.D. number of embryos per transfer was 1.444+/-1.014. Two couples did not have an embryo replacement because of absence of fertilisation. The mean+/-S. D. number of gonadotropin ampoules was 53.88+/-37.30 and the mean+/-S.D. duration of ovarian stimulation was 13.38+/-4.534 days. For the cases of non-obstructive azoospermia with TESE (n=14) a total of 16 cycles was carried out. Thirteen couples went through one cycle, one couple accomplished three cycles. Out of the 16 cycles, 11 cycles went to embryo transfer. One pregnancy occurred in the TESE-ICSI group of patients, which produced live offspring. The mean+/-S.D. number of oocytes per cycle was 3.00+/-1.211, the mean+/-S.D. number of embryos per transfer was 1.313+/-1.195. Five couples did not have an embryo replacement, four of them because of absence of fertilisation and one because of abnormal fertilisation (3 PN). The mean+/-S.D. number of gonadotropin ampoules was 81. 77+/-53.40 and the mean+/-S.D. duration of ovarian stimulation was 16.71+/-3.667 days.

CONCLUSION

In our opinion, these data show that it is possible to achieve satisfactory fertilisation rates using frozen-thawed epididymal and testicular spermatozoa obtained from men with obstructive or non-obstructive azoospermia, but the limiting factor in reaching the stage of embryo transfer is the poor ovarian response to stimulation induction. It therefore seems preferable to cancel these cycles, in the hope that a better response might be obtained in a subsequent cycle, avoiding in this way financial and emotional implications.

ICSI outcome in patients of 40 years age and over: a retrospective analysis

OBJECTIVE

To report and analyse our experience with ICSI treatment in infertile women >/=40 years of age, with the intention of contributing to current debates on the effect of aging on the reproductive potential.

STUDY DESIGN

107 infertile couples in which the female partner was aged >/=40 years and who received ICSI treatment between January 1996 and December 1998.

RESULTS

A total of 107 women underwent 171 treatment cycles during this period. Of 171 cycles initiated 33 were cancelled (cancellation rate=19.3%). In this way, 17 women did not have embryo transfer at all, while 90 patients had 138 cycles with oocyte retrieval and successful embryo transfer, with a mean number of embryos per transfer 2.36. Sixteen pregnancies occurred and eight of them ended in spontaneous abortion. The implantation rate was 4.9%, the pregnancy rate per initiated cycle was 9.35% and per transfer cycle 11.59%. The miscarriage rate was 50%. Moreover, 12 patients had supernumerary embryos, that were cryopreserved and transferred in 17 thawing cycles and resulted in two pregnancies ending in abortion. All pregnancies occurred when three embryos were available, except in two cases with two available embryos. The great majority of the total pregnancies (16 of 18) resulting in women aged between 40 and 42 years.

CONCLUSION

Our data show that women 40 and older with existing ovarian function may benefit from ICSI treatment, even when the indication for treatment is male factor infertility. Supernumerary embryos, that are cryopreserved and transferred in subsequent cycles can improve the overall pregnancy rates per oocyte retrieval, although these women should be aware of the very high risk of miscarriage.

[Limitations of reproduction medicine in male subfertility. Treatment of severe spermatogenesis disorders]

Treatment of severe male subfertility has become available since the intracytoplasmic injection of a single sperm into an oocyte was successfully applied for the first time in 1992. Moreover, also with the use of testicular spermatozoa for this procedure fertilization and pregnancies could be accomplished. This review addresses the development of these techniques and discusses achievements and problems as well as future aspects of the feasibility of early spermatid injection are stressed. Furthermore it includes the basic elements of spermatogenesis and the major concerns regarding the underlying genetic reasons for spermatogenic failure.

Genetics of male subfertility: consequences for the clinical work-up

Major principles of genetic failures, chromosomal alterations and the most common syndromes associated with male subfertility should be taken into account before medical therapy and sophisticated techniques of assisted fertilization are applied to help a couple conceive. This review addresses the most common genetic reasons for male subfertility or infertility with special regard to the importance for the clinical work-up in daily routine and the potential risks for the conceptus.

Fertilization potential of spermatozoa with abnormal morphology

One of the best discriminators for the fertilization potential of human spermatozoa is sperm morphology. The problem in the assessment of the sperm morphological characteristics is their pleiomorphism. Examination of spermatozoa with the light microscope can provide only limited information on their internal structure. More detailed examination of sperm structure using electron microscopy can reveal major, often unsuspected ultrastructural abnormalities. Results and cut-off values for sperm analysis depend on the criteria for normal morphology. World Health Organization recommendations provide a classification suitable for clinical practice. Clinically reliable cut-off limits for normal sperm morphology according to strict Tygerberg criteria were suggested to be 4% in in-vitro fertilization procedures. Patients with severe sperm head abnormalities have a lower chance of establishing successful pregnancies, even though fertilization may be achieved. The outcome of intracytoplasmic sperm injection is not related to any of the standard semen parameters or to sperm morphology. Sperm decondensation defects and DNA anomalies may be underlying factors for the unrecognized derangements of the fertilizing capacity of spermatozoa, regardless of sperm morphology. Centrosome dysfunction may also represent a class of sperm defects that cannot be overcome simply by the insertion of a spermatozoon into the ooplasm. In this article an overview on the composition and ultrastructure of spermatozoa is presented, while emphasizing sperm ultrastructural and sperm DNA anomalies and their effects on fertilization.

The outcome of intracytoplasmic sperm injection in patients with retrograde ejaculation

The objective of this retrospective clinical study was to assess the benefit of assisted fertilization in cases of anejaculatory infertility due to retrograde ejaculation. We report the outcome of intracytoplasmic sperm injection (ICSI) treatment. In 16 couples in which the men suffered from retrograde ejaculation. We performed 35 cycles of ICSI with spermatozoa retrieved from post-ejaculatory urine. The patients had been instructed to alkalinize the urine by ingesting sodium bicarbonate before the procedure. The fertilization rate averaged 51.2%. Seven clinical pregnancies were achieved. Three spontaneous first trimester abortions occurred, but three live offspring were delivered and one pregnancy is ongoing. In conclusion, the use of ICSI may be feasible for patients with retrograde ejaculation who are resistant to medical treatment and whose sperm quality is so low or unpredictable that intrauterine insemination or conventional methods of in-vitro fertilization are not possible.

Pregnancies achieved after frozen-thawed pronuclear oocytes obtained by intracytoplasmic sperm injection with spermatozoa extracted from frozen-thawed testicular tissues from non-obstructive azoospermic men

The use of frozen-thawed testicular tissue as a source of spermatozoa for intracytoplasmic sperm injection (ICSI) in non-obstructive azoospermia yields favourable fertilization and pregnancy rates while avoiding both repetitive biopsies and unexpected cycle cancellations. Spermatozoa were obtained from frozen-thawed testicular biopsy specimens from 67 non-obstructive azoospermic men. Following fertilization, supernumerary two pronuclear (2PN) oocytes were frozen. After thawing, 17 cycles of embryo transfer were carried out with a mean number of 2.7 embryos and a mean cumulative embryo score (CES) of 18.3 per transfer. The clinical pregnancy and implantation rates per transfer in these cycles (23.5 and 8.3% respectively) were comparable to those of fresh embryo transfers (35.7 and 12.7% respectively) with a mean number of 2.7 embryos and a mean CES of 28.7 per transfer. Abortion rates, although higher with cryopreserved 2PN oocytes were not significantly different. With this approach, cryopreservation of supernumerary 2PN oocytes can be used to improve the cumulative pregnancy rates in a severely defective spermatogenetic population. To our knowledge, these are the first pregnancies reported which have been obtained by the transfer of cryopreserved pronuclear oocytes obtained from ICSI using cryopreserved testicular spermatozoa.