Importance of cytoplasmic granularity of human oocytes in in vitro fertilization treatments.

The aim of this study was to examine the effect of different stimulation protocols on oocyte granularity and to determine the influence of cytoplasmic granularity on further embryo development. A total of 2448 oocytes from 393 intracytoplasmic sperm injection (ICSI) cycles were analysed retrospectively. Oocytes were classified into 5 groups according to cytoplasmic granularity. (A) no granule or 1-2 small (<5 µm) granules; (B) more than 3 small granules; (C) large granules (>5 µm); (D) refractile body; (E) dense centrally located granular area. Correlation between characteristics of hormonal stimulation, oocyte granularity and embryo development was analysed. The occurrence of cytoplasmic granularity was influenced by the patient's age and characteristics of stimulation. The type of granulation had no effect on fertilization rate and zygote morphology. However, some type of granulation resulted in a lower cleavage rate and more fragmented embryos. Our results provided additional information on how hormonal stimulation affects oocyte quality. While cytoplasmic granularity seems not to have an effect on fertilization and embryo development, the presence of refractile body in the oocyte is associated with reduced cleavage rates and impaired embryo development.

Impact of highly purified versus recombinant follicle stimulating hormone on oocyte quality and embryo development in intracytoplasmic sperm injection cycles.

The quality of oocytes and developing embryos are the most relevant factors determining the success of an in vitro fertilization (IVF) treatment. However, there are very few studies analyzing the effects of different gonadotrophin preparations on oocyte and embryo quality. A retrospective secondary analysis of data collected from a prospective randomized study was performed to compare highly purified versus recombinant follicle stimulating hormone (HP-FSH vs. rFSH). The main outcome measures were quantity and quality of oocytes and embryos, dynamics of embryo development, cryopreservation, clinical pregnancy and live birth rate. The number of retrieved and of mature (MII) oocytes showed no significant differences. Fertilization rate was significantly higher in the HP-FSH group (68.9% vs. 59.9%, p = 0.01). We also found significantly higher rate of cryopreserved embryos per all retrieved oocytes (23.4% vs. 14.5%, p = 0.002) in the HP-FSH group. There were no significant differences in clinical pregnancy and in live birth rates. Oocytes obtained with HP-FSH stimulation showed higher fertilisability, whereas pregnancy and live birth rates did not differ between the groups. However, patients treated with HP-FSH may benefit from the higher rate of embryos capable for cryopreservation, suggesting that cumulative pregnancy rates might be higher in this group.

Spinal anesthesia for cesarean section in a woman with Kartagener's syndrome and a twin pregnancy.

Kartagener's syndrome is an inherited disease characterized by a triad of symptoms: bronchiectasis, situs inversus and sinusitis resulting from defective cilial motility. There are few reports in the literature regarding the optimum anesthetic technique in patients with Kartagener's syndrome. The main anesthetic considerations are related to the respiratory system and increased risk of infection. We report the case of a woman with Kartagener's syndrome and a twin pregnancy conceived by in-vitro fertilization-embryo transfer, who underwent cesarean section under spinal anesthesia. Despite recurrent pulmonary problems, the twin pregnancy resulted in a successful outcome. This was facilitated by a close working relationship between the obstetrician, anesthesiologist and patient.

Correlation between first polar body morphology and further embryo development.

First polar body (PB) morphology of human oocytes can indicate further embryo development and viability. However, controversial data have been published in this topic. Our retrospective study analyses the fertilization and further development of oocytes in relation to different morphological features of the first PB. The morphology of 3387 MII oocytes from 522 in vitro fertilization (IVF) treatments were assessed before intracytoplasmic sperm injection (ICSI). Oocytes were classified according to their first PB morphology. Assessment of fertilization and embryonic development (cell number, embryo grade, amount of anuclear fragmentation and presence of multinucleated blastomeres) was performed 16-20 and 42-48 hours after ICSI. Our results show that fertilization rate and embryo quality is influenced by PB morphology, while speed of development is not affected by the morphology of the first PB. Contrary to previous findings, our results suggest that oocytes with a fragmented PB had a higher developmental ability than those with an intact PB. However, we observed a lower viability of oocytes with a large PB. Since there are contradictions in this and previous observations, an extensive study is needed with standard hormonal stimulation protocol and oocyte evaluation criteria.

Impact of obesity and leptin levels on the secretion of estradiol, inhibin A and inhibin B during ovarian stimulation with gonadotropins.

We examined the impact of high leptin levels on the secretion of estradiol, inhibin A and inhibin B in obese and lean women during ovarian stimulation. Patients undergoing long-term pituitary suppression, ovarian stimulation and in vitro fertilization for non-endocrine reasons were included in this case-control study. Obese women (body mass index (BMI) > 28 kg/m(2); n = 17) were individually matched with lean women (BMI 20-25 kg/m(2); n = 17) for age and baseline follicle stimulating hormone and luteinizing hormone concentrations. Blood samples were collected in a previous menstrual cycle and 1-3 days apart throughout ovarian stimulation. Serum levels of estradiol, leptin, inhibin A and inhibin B were measured. Obese and lean women had similar serum concentrations of estradiol, inhibin A and inhibin B in the follicular and luteal phases of the spontaneous menstrual cycle, and throughout ovarian stimulation. Serum levels of leptin were higher in obese than in lean women, and increased during stimulation in both groups. In the obese group, area-under-the-curve (AUC) leptin levels correlated with AUC inhibin A levels. In the lean group, there was no correlation between AUC leptin levels and AUC levels of ovarian hormones. The results suggest that high leptin concentrations in vivo are not associated with impaired secretion of estradiol and dimeric inhibins during ovarian stimulation.

[First attempts in preimplantation genetic diagnosis: blastomere biopsy]. / Elsó lépéseink a praeimplantatiós genetikai diagnosztikában: blastomerabiopsia.

There is an increasing expectation from couples that serious inherited diseases should be recognized at the earliest stages of embryonic development. A valuable tool for early prenatal diagnosis, preimplantation genetic diagnosis (PGD), involves the removal of 1 or 2 blastomeres from an in vitro fertilized embryo with micromanipulator (blastomere biopsy) without affecting the viability of the embryo. Genetic analysis of the removed blastomeres is performed to determine whether the embryo carries the genes responsible for the examined disease. Based on the results of the genetic analysis it is possible to transfer only unaffected embryos to the uterus. In this study, the authors performed blastomere biopsy on 35 embryos at the 6-10 cells stage. A total of 104 blastomeres were analyzed. On follow-up, 64% of biopsied embryos were cleaved and 43% developed to the morula or blastocyst stage. The introduction of this new procedure into the field of assisted reproduction can provide an alternative for couples who do not want to give birth to children affected by a genetic disease but would reject induced abortion after a positive prenatal diagnosis.

[First attempts in preimplantation genetic diagnosis: genetic analysis]. / Elsó lépéseink a praeimplantatiós genetikai diagnosztikában: genetikai vizsgálatok.

Preimplantation genetic diagnosis is a new approach for the prevention of genetic disorders, which provides a healthy pregnancy avoiding the need for its possible termination. The combination of in vitro fertilization techniques and single cell molecular genetic diagnosis allows only unaffected embryos to be selected for transfer to the uterus. It is an acceptable alternative of prenatal diagnosis for certain couples. Here we report our first attempts in the application of fluorescent PCR for sex determination and the detection of the delta-F508 mutation in human blastomeres. We modelled clinical PGD situations as we performed sex determination on 23 preembryos. Sex determination was successful is 20 preembryos (83%). We performed the detection of the delta-F508 mutation on 23 preembryos, which was successful in 20 preembryos (87%). Our experience suggests, that the established fluorescent PCR analysis is a reliable method for PGD, which enables us to apply it for clinical preimplantation genetic diagnosis.

[Professional and ethical challenges in reproductive biology and genetics at the beginning of the ne millennium]. / A reproduktív biológia és genetika szakmai és etikai kihívásai az új évezred küszöbén.

About 15 to 20 percent of couples are infertile. Developments in reproductive biology have enabled treatment of these couples by means of assisted reproduction. In a broader sense, assisted reproductive technologies involve all methods aiming to restore impaired reproductive function. Preimplantation genetic testing, a new form of prenatal diagnosis, is a result of convergency in the development of assisted reproduction and genetics, and allows couples at risk of transferring hereditary diseases to their offspring to diagnose such abnormalities as early as immediately before or after conception. This article describes technologies of assisted reproduction and preimplantation genetic diagnosis, and discusses ethical as well as legal issues in reproductive medicine.

Leptin and leptin binding activity in the preovulatory follicle of polycystic ovary syndrome patients.

To investigate the clinical importance of leptin's intraovarian effects, we studied the concentration of leptin and leptin binding activity in the plasma and in the follicular fluid of PCOS patients (n=20; median BMI: 27.1 kg/m2, range 19.7-36.3) undergoing controlled ovarian stimulation with long-term GnRH agonist, recombinant FSH, and in vitro fertilization. Follicular fluid and blood samples were collected during follicle aspiration for IVF. Total leptin concentration was measured by radioimmunoassay, and specific leptin binding activity was accessed by a gel filtration column assay. Follicular fluid and plasma leptin levels were similar (median 1135 pmol/l vs. 1409 pmol/l; p=0.81). Follicular fluid to plasma leptin ratio was independently associated with cumulative FSH dose (r=0.63; p=0.006) and insulin resistance index (r=-0.45; p=0.04). Specific leptin binding activity was higher in the plasma than in the follicular fluid [median 7.94% vs. 3.49%; p<0.001]. When multivariate analysis was used to predict FSH consumption, only follicular fluid leptin levels were significantly associated with cumulative FSH dose (r=0.46; p=0.04). We infer that at least in part by increased intrafollicular leptin levels, obesity directly affects ovarian function in PCOS, and may induce a relative resistance to gonadotropin stimulation. This intraovarian effect of leptin can be even more profound because of low leptin binding activity in the preovulatory follicle of obese patients.

Spontaneous bilateral cornual uterine dehiscence early in the second trimester after bilateral laparoscopic salpingectomy and in-vitro fertilization: case report.

A bilateral cornual uterine dehiscence is reported, which occurred 14 weeks after in-vitro fertilization (IVF) in a patient having a medical history of previous bilateral salpingectomy via laparoscopy. Uterine rupture is a rare obstetric complication usually occurring during the third trimester of pregnancy within a uterus which has previously undergone an operation. Ectopic pregnancy is a well known complication of IVF. Post-salpingectomy cornual localization with rupture has also been published. Possible causes are discussed and the attention of the counselling physician is directed to the necessary awareness of such a complication in this high risk population. The reported case is an extreme rarity: a similar case has not been previously published in the literature.

Twin delivery after myomectomy, in vitro fertilization, and embryo reduction in an infertile woman.

A 28-year-old patient had metroplasty performed because of necrosis of a uterine fibroid. During follow-up, the left adnexa were removed because of a recurrent left ovarian cyst. The triplet gestation achieved by in vitro fertilization was reduced to twins. The living premature newborns were delivered abdominally.

A multicentre efficacy and safety study of the single contraceptive implant Implanon. Implanon Study Group.

An open, multicentre study was performed to assess efficacy, safety and acceptability of the single-rod contraceptive implant Implanon. The study involved 635 young healthy women, who were sexually active and of childbearing potential. The women were followed up every 3 months over the entire study period. Originally the study was designed for 2 years, but was extended to 3 years in a group of 147 women from two centres. Altogether, 21 centres in nine different countries participated. The average age of the women was 29 years (range 18-42 years), of whom 83.5% had been pregnant in the past. No pregnancy occurred during treatment with Implanon, resulting in a Pearl Index of 0 (95% confidence interval: 0.0-0.2). In the first 2 years, 31% had discontinued the treatment. Of the 147 women in the study extension, nine discontinued (6%) treatment. Bleeding irregularities was the main reason for discontinuation during the first 2 years of use (17.2%) and adverse experiences in the third year (3.4%). Implant insertion and removal were fast and uncomplicated in the vast majority (97%) of cases. Return of fertility was prompt. In conclusion, Implanon has excellent contraceptive action during its lifetime of 3 years. The safety profile is acceptable and not essentially different from progestogens in general.

An integrated analysis of nonmenstrual adverse events with Implanon.

This integrated analysis evaluates nonmenstrual adverse events, blood pressure, and body weight changes during the use of the single-rod etonogestrel-containing contraceptive implant, Implanon; these aspects are compared for Implanon and Norplant, the six-capsule implant containing levonorgestrel. Overall, 47% of Implanon users had drug-related adverse events, whereas in the comparative studies the figure for those using Implanon (61%) was slightly lower than that for Norplant users (69%). In all Implanon studies, 12 of 1716 women (0.7%) were affected by serious adverse events that were considered drug related. In comparative studies three of the 689 Implanon users (0.4%) and one of 689 Norplant users (0.1%) had such experiences. The most frequently reported drug-related adverse events were acne, breast pain, headache and weight gain. The adverse events that most often caused discontinuation of Implanon were weight gain and acne. The development or aggravation of acne was a frequent adverse event (in 18.5% of Implanon and 22.3% of Norplant users in the comparative studies) but individual studies indicated that there were also many subjects whose acne improved during implant use. There were gradual increases in body weight over time but these may be only partly attributable to implant use and partly attributable to normal increases over time.

Midluteal buserelin is superior to early follicular phase buserelin in combined gonadotropin-releasing hormone analog and gonadotropin stimulation in in vitro fertilization.

OBJECTIVE: To establish whether time to down-regulation and pregnancy and live birth rates were different when buserelin acetate was started in the midluteal phase or early follicular phase in IVF-ET patients. DESIGN: Prospective, controlled, randomized, parallel-group multicenter clinical study. SETTING: Women attending seven infertility clinics. PATIENTS: One hundred twenty-four women with tubal or unexplained infertility with normal menstruation and fertile partners. INTERVENTIONS: Intranasal buserelin acetate started in the midluteal or early follicular phase combined with standard hMG and hCG stimulation after achievement of down-regulation. Established IVF-ET methods. MAIN OUTCOME MEASURES: Duration of down-regulation; clinical pregnancy and live birth rates. RESULTS: Kaplan-Meier estimations of the duration of down-regulation were 15.5 days when buserelin acetate was started in the early follicular phase (127 cycles) and 14.6 days when it was started in the midluteal phase (96 cycles). This difference was statistically significant. The pregnancy rates per first treatment cycle, treatment cycle, oocyte retrieval, and ET were significantly higher when buserelin acetate was started in the midluteal phase. The live birth rates were also higher, but only significantly so for the rate per first treatment cycle. CONCLUSIONS: Clinical pregnancy and live birth rates are better when buserelin acetate is started in the midluteal phase rather than the early follicle phase before hMG and hCG stimulation in preparation for IVF-ET.

Elevated serum inhibin levels and suppressed luteinizing hormone surge in young patients stimulated with gonadotropins.

The physiological role of inhibin and its relation to other sex hormones (estradiol, progesterone, follicle stimulating hormone (FSH) and luteinizing hormone (LH)) has been investigated during gonadotropin-stimulated cycles of 38 in vitro fertilization-embryo transfer/gamete intrafallopian transfer (IVF-ET/GIFT) patients. Human menopausal gonadotropin (hMG) was given from day 3 of the cycle until 1 day before ovulation induction with human chorionic gonadotropin (hCG). Blood samples were taken twice daily and hormone measurements performed by radioimmunoassay or enzyme immunoassay. Patients were divided into two groups: Group A comprised patients < 35 years of age (n = 20) and Group B included patients > or = 35 years of age (n = 18). The pregnancy rate was significantly higher in Group A. During the follicular phase, serum inhibin level rose gradually in both groups but the values were higher in Group A (significantly between days -2 and 0). During the early luteal phase serum inhibin concentrations were similar in both groups. Estradiol pattern did not differ in the two groups. Estradiol pattern did not differ in the two groups. Whilst serum estradiol level did not increase significantly after day 0, serum inhibin concentration reached its peak value 1 day later, on day +1. Serum progesterone was higher in Group A between days +1 and +4 (significantly on days +1, +3 and +4). Serum FSH increased slowly in both groups and did not correlate with serum inhibin concentration. Basal LH concentrations were similar between days -6 and -2 in both groups. Around the time of ovulation induction (day -1, 0 and +1) serum LH was lower in Group A (significantly on day 0).(ABSTRACT TRUNCATED AT 250 WORDS)

Serum inhibin levels in gonadotrophin stimulated in-vitro fertilization/gamete intra-fallopian transfer cycles.

Serum inhibin concentrations of 64 cycles of in-vitro fertilization--embryo transfer (IVF-ET) or gamete intra-Fallopian transfer (GIFT) have been analysed retrospectively. No significant difference was observed in serum inhibin levels of cycles stimulated with buserelin and human menopausal gonadotrophin (HMG) or HMG alone. During the late follicular phase, serum inhibin was higher in cycles resulting in pregnancy than in cycles without a pregnancy (peak values on day +1: 8.3 versus 6.4 IU/ml, respectively). The same difference was found between stimulation cycles resulting in a viable or a non-viable pregnancy (peak values on day +1: 8.3 versus 7.5 IU/ml). However, these differences were not significant. During the early luteal phase, serum inhibin values were similar in these groups of patients. Our results indicate that the use of the gonadotrophin-releasing hormone (GnRH) analogue buserelin, in combination with HMG, for ovarian stimulation does not affect inhibin production by granulosa cells in vivo. The late follicular and early luteal concentrations of serum inhibin have to be considered unsuitable as predictors in IVF/GIFT cycles with respect to pregnancy and pregnancy outcome.

High preovulatory serum luteinizing hormone level is unfavorable to conception.

Serum estradiol, progesterone and luteinizing hormone (LH) levels of 16 pregnant and 58 non-pregnant stimulated in vitro fertilization-embryo transfer (IVF-ET) or gamete intrafallopian transfer (GIFT) cycles have been compared with regard to their predictive value for achievement of pregnancy. Serum estradiol and progesterone pattern of the pregnant and non-pregnant group did not show any significant difference. Around the time of ovulation induction by human chorionic gonadotropin (hCG) the serum LH values proved to be higher in the non-pregnant group than in the pregnant one. In spite of having a permissive function, preovulatory serum estradiol and progesterone seem not to have a predictive value with regard to pregnancy. Elevated preovulatory serum LH is detrimental for pregnancy, therefore the measurement of serum LH beyond hCG administration also, and the cancellation of cycles with high serum LH levels shortly before oocyte retrieval is recommended.

[Effect of the GnRH analog buserelin on sex hormone serum level in relation to treatment onset and duration]. / Wirkung des GnRH-Analogons Buserelin auf die Serum-Spiegel von Sexualhormonen in Abhängigkeit von Behandlungsbeginn und Behandlungsdauer.

Changes of serum estradiol, progesterone, LH, FSH, prolactin, testosterone, androstendione, DHEA and DHEAS levels during a GnRH-analogue (buserelin) treatment have been analysed retrospectively taking account of effectiveness of treatment and its relation to the beginning and duration of treatment. 1200 micrograms/day buserelin were administered intranasally from the first day of the menstrual cycle (n = 30) or the 7th hyperthermic day of the cycle (n = 22). The results proved, that the administration of buserelin to sterile women inhibits the ovarian (estradiol, progesterone) and pituitary (LH, FSH) hormone secretion during the first 10-14 days of treatment. The adrenal hormone secretion (DHEA, DHEAS) remained unaffected, whereas the androgens of ovarian origin (testosterone, androstendione) were suppressed during the GnRH analogue treatment. The serum prolactin level increased during the first two weeks of treatment and returned to pretreatment values within the following two weeks. On the basis of the faster suppression of estradiol secretion with buserelin treatment, beginning in the middle of the luteal phase, this therapy is recommended for ovarian suppression.

[Combined treatment with a GnRH-analog and gonadotropins in IVF-ET/GIFT patients after previously unsuccessful pure HMG stimulation]. / Kombinierte Behandlung mit einem GnRH-Anologon und Gonadotropinen bei IVF-ET/GIFT-Patientinnen nach vorangegangenen erfolglosen reinen HMG-Stimulationen.

Clinical results of a combined GnRH-analogue (buserelin, long protocol) + HMG stimulation of 44 IVF-ET or GIFT patients with previously failed pure HMG stimulation have been analysed. The cancellation rate and the incidence of premature LH surge was found to be lower in the buserelin + HMG group than in the control HMG group (30% vs. 40% and 16% vs. 51%). There was no significant difference between the buserelin + HMG and the control HMG group, neither in the number of retrieved and fertilized oocytes and transferred embryos nor in the fertilization and pregnancy rate. The combined GnRH-analogue and gonadotropin therapy led to a decrease of the cancellation rate and of premature LH surge in patients with previously failed pure HMG stimulation. In this group of patients the use of buserelin leads to treatment results comparable to results of pure HMG stimulated patients without previously failed stimulation cycles. Thus the GnRH-analogue + HMG stimulation is recommended for patients with previously unsuccessful pure HMG stimulation.