Failure to increase the thickness of thin endometria with intrauterine infusion of granulocyte colony stimulating factor (G-CSF).

PURPOSE: To corroborate or refute a previous study suggesting that intrauterine infusion of granulocyte colony stimulating factor (G-CSF) could significantly improve endometrial thickness into more fertile levels when the endometrial thickness was ≤ five mm. MATERIALS AND METHODS: Three women whose endometrial thickness never exceeded five mm on the in vitro fertilization-embryo transfer (IVF-ET) cycle or subsequent attempted frozen ETs using graduated estradiol had intrauterine infusion of G-CSF to the estradiol regimen. RESULTS: Not one of the three women improved the endometrial thickness beyond five mm and none conceived on the G-CSF cycle. One woman had a subsequent pregnancy following a frozen ET with only a four-mm thickness with no infusion of G-CSF. CONCLUSIONS: These data do not confirm the efficacy of intrauterine infusion of G-CSF for poor endometrial thickness. Perhaps only certain cases will respond. A larger series could take time to accumulate since other studies have shown that only 0.3% of women with ≤ five mm endometrial thickness in the late proliferative phase during an IVF-ET cycle will not improve the endometrial thickness > five mm using graduated estradiol protocols.

Effect of taking a one time injection of one mg leuprolide acetate three days after embryo transfer on pregnancy outcome and level of first beta human chorionic gonadotropin (beta-hCG) level.

PURPOSE: To determine if the injection of a gonadotropin releasing hormone agonist (GnRHa) three days after embryo transfer will improve pregnancy and implantation rates. MATERIALS AND METHODS: One mg s.c. of leuprolide acetate was randomly given based on patient decision three days after embryo transfer to some patients undergoing in vitro fertilization-embryo transfer (IVF-ET). RESULTS: For women aged ≤ 43 the clinical pregnancy rate for those not taking the GnRHa was 39.5% (68/122) vs. 54.5% (42/77) for those taking leuprolide acetate (Chi-square, p = 0.0275). The respective implantation rates were 22.6% vs. 30.2% (p = 0.0495). There was no difference in first serum beta human chorionic gonadotropin (beta-hCG) levels according to whether leuprolide was used or not. CONCLUSIONS: Leuprolide acetate similar to other GnRH agonists can improve implantation rates following IVF-ET when injected once in mid-luteal phase. The beneficial effect may be on GnRH receptors in the endometrium rather than the embryo (which had been hypothesized to direct increased placental production of hCG).

Isolating sperm by selecting those with normal nuclear morphology prior to intracytoplasmic sperm injection (ICSI) does not provide better pregnancy rates compared to conventional ICSI in women with repeated conception failure with in vitro fertilization.

PURPOSE: To determine if isolation of sperm by nuclear characteristics using high magnification offers any advantage over the normal morphologic methods when performing intracytoplasmic sperm injection (ICSI) in refractory cases in which the male partner had an abnormal DNA fragmentation index. MATERIALS AND METHODS: Women aged < or = 39 with failure to have a successful conception after three consecutive embryo transfers whose male partner had a DNA fragmentation index > 30% were randomly assigned to isolation of sperm for ICSI by a new high magnification procedure to evaluate nuclear morphology and the usual method with normal magnification where nuclear characteristics were not seen. Women 40-43 were not randomized and were given the option after hearing pros and cons. RESULTS: Overall the live delivered pregnancy rates were similar in the high vs normal magnification groups (33.3% vs 36.3%). CONCLUSIONS: Isolation of sperm with normal nuclei with high magnification does not offer any advantage over conventional IVF for refractory cases where the male partner has a high DNA fragmentation index.

Pregnancy rates following the exclusive transfer of twice frozen twice thawed embryos using a modified slow cool cryopreservation technique.

PURPOSE: To determine the pregnancy rate following the exclusive transfer of twice frozen twice thawed embryos. MATERIALS AND METHODS: All day 3 transfers of exclusive twice frozen-twice thawed embryos were retrospectively identified over a 13-year time-period. The cryopreservation technique used a simplified slow cool freezing protocol. Embryos could have been originally cryopreserved at the 2 pronuclear or multi-cell stage. RESULTS: Survival rates were 83.3%. The live delivered pregnancy rate was 18.1% (15/83). The implantation rate was 13.1% (22/168). CONCLUSIONS: These data suggest that twice frozen twice thawed embryos should not be discarded but either transferred alone if they are the only embryos left, or mixed with frozen embryos that have never been thawed. Though the live delivered pregnancy rates are inferior to fresh embryo transfer the marked reduction in cost and avoidance of the risk of ovarian hyperstimulation justifies their transfer.

Pregnancy rates following frozen embryo transfer (ET) in women failing to conceive despite fresh ET in women using low dosage follicle stimulating hormone (FSH) protocol for follicular maturation of several eggs.

PURPOSE: To determine the pregnancy rate following frozen embryo transfer using embryos derived from low dosage follicle stimulating hormone (FSH) stimulation protocols in women aged < 42 who did not have diminished egg reserve as evidenced by a day 3 serum FSH < or =12 mIU/ml. METHODS: A retrospective review was performed evaluating pregnancy rates on frozen embryo transfers from women who usually had diminished egg reserve and thus used no more than 150 IU of FSH. The pregnancy rates were calculated on the first frozen embryo transfer of women failing to successfully conceive on the fresh embryo transfer. RESULTS: The clinical and live delivered pregnancy rates per transfer were 33.3% (14/42) and 23.8%. The implantation rate was 20.0%. Thirty-one percent of the transfers were in women aged 40-42. CONCLUSIONS: These data show that despite the fact that with minimal stimulation protocols, the remaining frozen embryos are of lesser quality because of de-selection, nevertheless, it is worth transferring these embryos.

Pregnancy outcome following in vitro fertilization-embryo transfer according to the percentage of metaphase II oocytes retrieved.

PURPOSE: To determine if the presence of a lower percentage of metaphase II eggs during oocyte retrieval leads to a lower fertilization rate of these metaphase II eggs since they may be more likely to be not quite fully mature, and to determine if transfer of embryos made from these eggs leads to lower pregnancy and implantation rates. METHODS: Fertilization and pregnancy rates determined according to deciles of percent of metaphase II eggs beginning with <30%. RESULTS: Though there was no difference in fertilization rates when comparing those with <60% metaphase II eggs vs a 60%, there were significantly higher clinical and live delivered pregnancy rates and implantation rates when there were a 60% of the eggs retrieved that were metaphase II. CONCLUSIONS: An inferior pregnancy outcome with a lower percentage of metaphase II eggs despite similar fertilization rates is consistent with the hypothesis that subtle full maturation defects may result in pregnancy failure despite embryo transfer.

"Embryo glue" does not seem to improve chances of subsequent pregnancy in refractory in vitro fertilization cases.

PURPOSE: To determine if the use of Embryo glue improves implantation and pregnancy rates following embryo transfer (ET) in women who failed to conceive in three previous attempts. METHODS: A matched controlled study was performed in women undergoing IVF-ET, donor oocyte recipients and women using their own oocytes having fresh or frozen ETs. A woman having Embryo glue was matched with the very next woman not using glue within six months of age and having the same number of previous failed ETs. RESULTS: Embryo glue did not seem to improve pregnancy or implantation rates. In fact, in evaluating fresh embryo transfers there was a significantly higher live delivered pregnancy rate in the women not using Embryo glue (39.3%) vs those using the glue (14.3%). CONCLUSIONS: Embryo glue does not improve pregnancy outcome in women failing in previous IVF cycles.

Intracytoplasmic sperm injection completely negates the implantation problem associated with conventional fertilization with sperm with low hypo-osmotic swelling test scores as evidenced by evaluating donor-recipient pairs.

PURPOSE: To corroborate or refute the claim that intracytoplasmic sperm injection (ICSI) can overcome the problem found after conventional insemination of oocytes with sperm with low hypoosmotic swelling (HOS) tests of forming embryos with low implantation potential. METHODS: Matched couple pairs sharing one pool of oocytes were identified where one of the male partners had a low HOS test score and the other one with a normal one. Intracytoplasmic sperm injection was always used in those with low HOS test scores (i.e., < 50%) vs ICSI only used for semen abnormalities in the normal HOS group. RESULTS: There were no differences found in either fertilization rates or clinical or live delivered pregnancy rates or implantation rates between these groups. CONCLUSIONS: Intracytoplasmic sperm injection can completely negate the adverse effect that fertilization with sperm with subnormal HOS scores has on embryo implantation potential.

Comparison of pregnancy outcome following frozen embryo transfer (ET) in a gestational carrier program according to source of the oocytes.

PURPOSE: To determine any differences in pregnancy rates if frozen-thawed embryos are transferred to a gestational carrier if the source of oocytes came from infertile women trying to conceive vs a paid egg donor. METHODS: Gestational carriers were used because of uterine problems or health issues. If there was adequate ovarian egg reserve, controlled ovarian hyperstimulation followed by oocyte retrieval was performed on the infertile woman. Otherwise an egg donor was used. RESULTS: No differences in clinical and ongoing delivered pregnancy rates were found but a trend for higher implantation rates in the paid donors was evident. CONCLUSIONS: The trend for higher implantation rates when a paid donor was the source of oocytes may be age-related (35.9 for infertile women vs 29.5 for paid donors). The pregnancy results with frozen embryos were sufficient to allow women to proceed with oocyte retrieval if time is of the essence even if a gestational carrier has not as yet been found.

Cryopreservation of blastocysts using a modification of a simplified freezing protocol with a one step removal of cryoprotectant successfully used previously to freeze 2 pronuclear or multi-cell embryos.

PURPOSE: To describe a modification of a simplified freezing protocol for the cryopreservation of blastocysts. METHODS: 1.5 M glycerol was substituted as a cryoprotectant instead of propanediol. RESULTS: There was a survival rate of 59.1% (13/22) with three live deliveries in seven transfers (42.9% per transfer). The implantation rate was 28.6% (4/14). CONCLUSIONS: This is the first description of a new technique for freezing blastocysts. A larger series is needed to determine if the good pregnancy rates will continue.

Effect of the length of time that donated embryos are frozen on pregnancy outcome.

PURPOSE: To determine if the longer length of time that embryos donated to an anonymous couple have been frozen has a negative effect of subsequent successful pregnancy following thawing and transfer to the recipients. METHODS: Retrospective determination of pregnancy rates according to the length of cryopreservation time has on pregnancy outcome following transfer of embryos designated for donation. RESULTS: Longer time of freezing did not adversely affect subsequent pregnancy rates following frozen embryo transfer. CONCLUSIONS: Donated embryos frozen for over five years (the time when some countries demand that the embryos be discarded) contributed to one-fourth of the donor embryo pool and one-third of the live deliveries.

Length of time of embryo storage does not negatively influence pregnancy rates after thawing and transfer.

PURPOSE: To determine if longer storage of embryos in a cryopreserved state negatively affects the chance of successful implantation following thawing and transfer. METHODS: A retrospective cohort analysis of frozen-thawed embryos that had been donated to recipients. Four time periods were evaluated. RESULTS: No significant decrease in pregnancy or implantation rates was found in the longest freezing group (> or =6 years). In fact, if there was a trend, it was for improved pregnancy rates with longer storage. One of the successes was from embryos stored about 12 years. CONCLUSIONS: Hopefully these data and results from other IVF centers will influence those countries having a mandatory discarding policy to reconsider and lift these restrictions, especially to increase the pool of embryos available for donation.

Artificial oocyte activation with calcium ionophore allowed fertilization and pregnancy in a couple with long-term unexplained infertility where the female partner had diminished EGG reserve and failure to fertilize oocytes despite intracytoplasmic sperm injection.

PURPOSE: To determine if fertilization and embryo development and pregnancy was possible following in vitro fertilization (IVF) in a couple with long-term unexplained infertility where the female partner had diminished egg reserve and where fertilization failure occurred despite conventional oocyte insemination and intracyoplasmic sperm injection (ICSI). METHODS: In vitro fertilization was performed using a low-dose follicle stimulating hormone (FSH) stimulation protocol. Prior to ICSI, artificial oocyte activation with calcium ionophore was used. RESULTS: Only one mature oocyte was retrieved but it fertilized and cleaved to a good quality 8-cell embryo on day 3. A pregnancy with fetal viability was achieved but she subsequently miscarried. A second attempt successful. CONCLUSIONS: Fertilization and pregnancy is possible even in women with diminished egg reserve with previous failed fertilization with ICSI by performing artificial oocyte activation with calcium ionophore. It is not clear if the sperm lacked oscillin or if the eggs were not responsive to oscillin.

Conventional oocyte insemination may result in a better pregnancy outcome than intracytoplasmic sperm injection (ICSI) for unexplained infertility.

PURPOSE: To determine in cases of unexplained infertility whether conventional oocyte insemination vs. intracytoplasmic sperm injection results in differences in fertilization rates, frequency of failed fertilization, clinical and live delivered pregnancy rates, and implantation rates. METHODS: Retrospective evaluation of these parameters in couples undergoing in vitro fertilization embryo transfer (IVF-ET) (minimum 2 embryos) in women with unexplained infertility over a 7-year period. RESULTS: There was a significantly higher fertilization rate (p < .001) with ICSI vs. conventional insemination (73.7% vs. 63.7%). However of greater clinical importance, the clinical and live delivered pregnancy rates were significantly higher with conventional insemination (52.7% and 46.2%) than with ICSI 33.6% and 29.0%. The implantation rates were also significantly higher with conventional oocyte insemination (24.9% vs. 17.8%). Failed fertilization was low in both groups. CONCLUSION: The process of ICSI, whether it involves possible subtle oocyte damage by the procedure or the andrologist not choosing the ideal sperm, may lead to embryos that are less hearty despite their normal appearance.

Comparison of the efficacy of selecting sperm with normal nuclei by high magnification for intracytoplasmic sperm injection (ICSI) according to age in refractory in vitro fertilization (IVF) cases.

PURPOSE: To determine the pregnancy rates according to age in women failing to conceive after three previous embryo transfers or having a husband whose sperm shows a DNA fragmentation index (DFI) > 30% when performing the sperm chromatin structure assay. METHODS: Women up to age 45 were included and there was no restriction for low egg reserve. Live delivered pregnancy rates were determined according to three age groups: < or =34, 35-38, 39-45. The data were also analyzed in a group comparable to previous publications using high magnification ICSI, i.e., younger women with normal egg reserve. Pregnancy rates following frozen embryo transfer were also evaluated. RESULTS: Using all 86 in vitro fertilization-embryo transfer (IVF-ET) cycles the live delivered pregnancy rates were 40% (10/25) for women < or = age 34, 24% (6/25) in women age 35-38, and 13.8% in women aged 39-45. Evaluating the younger group with normal egg reserve with > or =3 previous failed IVF-ET cycles the live delivered pregnancy rate per transfer was 38% (16/42). If one adds the additional six live deliveries from subsequent frozen embryo transfer (6 of 17, 35.3%) this group of women had a 52.3% (22/42) live delivered pregnancy rate from one egg retrieval. CONCLUSIONS: These data were uncontrolled and thus conclusions should be viewed with caution. The results are sufficiently encouraging to warrant a prospective controlled trial and possibly encourage a company to consider commercially manufacturing high magnification microscopes.

A case report supporting the concept that some women have a predisposition for maternal meiosis errors resulting in digyny.

PURPOSE: To determine if a primary aborter with recurrent miscarriage times three with her only two fetal products that were evaluated with chromosome analysis demonstrating triploidy in both fetuses could have a predisposition for maternal meiosis errors. METHODS: In vitro fertilization with intracytoplasmic sperm injection was performed. Embryo biopsy was performed on 3-day old embryos and a single blastomere was evaluated by fluorescent in situ hybridization (FISH). Embryo transfer would be performed on day 5 at the blastocyst stage. RESULTS: There were six normal and seven abnormal embryos. One of the seven was a tetraploid embryo (92XXXX). CONCLUSIONS: The majority of triploidies are related to polyspermy but this factor was excluded by performing ICSI. Thus this woman showed a marked predisposition to digyny. Though the tetraploidy could be explained by fertilization of a digynic egg by a diploid sperm the probability was that in this instance the meiosis error extended back to failure to extrude the first polar body.

The effect of blastomere number on embryo survival upon freezing/thawing.

PURPOSE: To determine if the blastomere number of embryos at the time of freezing is related to its quality post-thaw. METHODS: A retrospective cohort analysis of frozen/thawed embryos. Only multi-cell embryos were used for this study. If an embryo was of good quality it would either be transferred or re-frozen. RESULTS: There did not appear to be any trend for a lower percentage of good quality embryos with fewer numbers of blastomeres. CONCLUSIONS: Though 4-cell embryos have a markedly lower implantation potential upon fresh embryo transfer compared to 6-8-cell embryos, this is not reflected in their ability to survive freeze-thawing.

A comparison of efficacy of freezing embryos at the 2 pronuclear (2PN) stage vs multi-cell when using a simplified freezing protocol with one-step removal of cryoprotectant.

PURPOSE: To compare the efficacy of freezing embryos at the 2 pronuclear stage vs multi-cell stage using a simplified freezing protocol with a one-step removal of the cryoprotectant. METHODS: A retrospective analysis was performed. Survival, delivered pregnancy and implantation rates were compared in transfers of all embryos frozen at 2 pronuclear stage (2PN) or all embryos frozen at multi-cell stage. The results were further stratified and compared according to the number of high quality embryos transferred. RESULTS: In all categories despite comparing similar numbers and quality of embryos transferred there was a significantly higher survival rate of 2PN embryos. Significantly higher delivered pregnancy and implantation rates were seen with 2PN vs multi-cell embryos when there was only one or two embryos with > or = 6 blastomeres and < 25% fragmentation, and a trend for higher delivered pregnancy rates when there were three top quality embryos transferred. CONCLUSIONS: When given the option it is preferable when using this simplified freezing and thawing protocol to freeze at the 2PN stage.

Pregnancy rates per embryo transfer (ET) may be improved by conventional oocyte insemination for male factor rather than intracytoplasmic sperm injection (ICSI).

PURPOSE: To determine if intracytoplasmic sperm injection (ICSI) for mild male factor may create embryos less likely to implant. METHOD: A retrospective analysis of pregnancy outcome following oocyte fertilization with ICSI vs conventional egg insemination was performed. RESULTS: Though there were many less cases using conventional oocyte insemination compared to ICSI so that a meaningful comparison of outcome could not be made, the data could suggest the fertilization by ICSI might result in embryos less likely to implant. CONCLUSIONS: This pilot study should encourage IVF centers to consider conventional oocyte insemination for mild male factor instead of ICSI. Only by evaluating a larger series can it be determined with certainty that fertilization by ICSI may lower the implantation potential of the embryo that is formed.

A comparison of the efficacy of intracytoplasmic sperm injection (ICSI) using ejaculated sperm selected by high magnification versus ICSI with testicular sperm both followed by oocyte activation with calcium ionophore.

PURPOSE: To determine in a couple where the male had globozoospermia with failed fertilization despite intracytoplasmic sperm injection (ICSI) if fertilization could be achieved by using high magnification ICSI or by oocyte activation by calcium ionophore. METHODS: Twenty eggs were retrieved and divided according to source of sperm, i.e., ejaculated by testicular aspiration or with donor sperm. Following ICSI the eggs were exposed to calcium inophore within one hour. The sperm were magnified 6300x in an attempt to find some sperm with evidence of at least some acrosome. RESULTS: None of the seven eggs inseminated by ICSI with ejaculated sperm or the seven inseminated with ICSI with testicular sperm fertilized even with attempted oocyte activation with calcium ionophore. However, four of the six oocytes that were inseminated with donor sperm did fertilize. None of the round-headed sperm showed any partial acrosome even using high magnification ICSI. CONCLUSIONS: It is possible that for successful fertilization with round-headed sperm there has to be at least enough acrosomal material to make some sperm-associated oocyte activating factor.