The outcome of intracytoplasmic injection of fresh and cryopreserved ejaculated spermatozoa--a prospective randomized study.

BACKGROUND: The overall aim of this prospective, randomized study was to compare the reproductive potential of fresh and frozen-thawed ejaculated spermatozoa from oligoasthenoteratozoospermic patients in an intracytoplasmic sperm injection (ICSI) procedure. METHODS: All patients consenting to participate in this study had a sperm sample frozen prior to the start of a cycle. Patients were randomized using a random number table to undergo ICSI with either fresh (group A, n = 118) or frozen-thawed (group B, n = 122) spermatozoa. All prognostic variables were equally distributed among the two groups. RESULTS: The pregnancy rate per started cycle was 29.7% in group A and 38.5% in group B, P > 0.05. A significant difference was observed in the rate of ongoing pregnancies between group A (23.7%) and group B (35.2%), P < 0.05. CONCLUSION: From our data we can conclude that cryopreservation of spermatozoa from men with poor sperm quality does not negatively affect fertilization and pregnancy rates after ICSI. A larger study will be needed to investigate whether the use of cryopreserved spermatozoa can be helpful in selecting the most vital spermatozoa for ICSI.

Correctly timed coasting reduces the risk of ovarian hyperstimulation syndrome and gives good cycle outcome in an in vitro fertilization program.

One hundred and twelve severely overstimulated in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) patients were treated with coasting when estradiol concentration was > 3000 pg/ml and the leading follicles had attained > or = 18 mm in diameter. Gonadotropin withholding was offered to them as a promising method for the prevention of both cycle cancellation and complications associated with severe ovarian hyperstimulation syndrome (OHSS). The duration of prolonged coasting prior to human chorionic gonadotropin (hCG) administration ranged from 2 to 9 days (mean 3.5). hCG was administered when the serum estradiol dropped to < 3000 pg/ml and at least three growing follicles > or = 20 mm in diameter were present. Fertilization failure was noted in six couples and in another 10 cases freezing of all embryos was decided, therefore embryo transfer was performed on 96 patients. There were 31 clinical pregnancies (five twins) giving a pregnancy rate per patient and per embryo transfer of 30.4% and 32.3%, respectively, with an implantation rate of 18.1%. With regard to all 112 coasted patients, six developed moderate and two severe OHSS. This study shows that withholding gonadotropin administration in high-risk IVF patients results in a good cycle outcome and a very low risk of severe OHSS, and also demonstrates the importance of both the timing of coasting initiation and the timing of hCG administration.

[Assisted reproductive medicine in the next age]. / Wyzwania medycyny rozrodu wspomaganego w nadchodzacym wieku.

Medicine is going from success to success, but with the ever-increasing expectations of the society, the more it achieves, the less it satisfies. This is also true for reproductive medicine. Indeed, advances in basic research and the practical applications of the research that have been performed since the first successful in vitro fertilisation (IVF) in 1978, have given rise to hitherto unimaginable strategies for achieving human reproduction. Couples, that were considered sterile only a few years ago, can now acquire assistance conceiving. Twenty two years after Louise Brown was born, the reproductive medicine methods have spread all over the world and thousands of children have been born as a result of these techniques. ICSI applied to epididymal or testicular sperm in cases of azoospermia permits infertile men to become fathers. Even if the results of reproductive medicine have improved in terms of numbers of pregnancies, it is still striking that it is necessary to use stimulation which sometimes leads to hyperstimulation and multiple pregnancies, that embryo development in vitro is still limited, that implantation only occurs for 15-20% of embryos and this ratio have not changed in the last 20 years. The pregnancy rates currently obtained with IVF are at the most similar to those occurring in vivo. We still need to improve techniques to gain pregnancy rates approaching 50% per embryo. In order to fullfil this task, we need to introduce less aggressive and much simpler ovarian stimulation, routine culture of embryos to the blastocyst stage, pre-implantation genetic diagnosis, cryopreservation and in vitro maturation of oocytes and finally to improve the implantation rates by our ability to understand and control the dialog between blastocyst and receptive endometrium.

[Intracytoplasmic sperm injection (ICSI): the Bialystok experience]. / Wyniki leczenia nieplodnosci metoda icsi w osrodku bialostockim.

OBJECTIVE: To present a complete results of Intracytoplasmic Sperm Injection Program (ICSI) performed at IVF Unit in Bialystok, Poland. DESIGN: Retrospective data analysis. MATERIALS AND METHODS: A total of 2593 cycles of ICSI treatment were analyzed. The results of controlled ovarian hyperstimulation (COH), parameters of fertilization, early embryo development and clinical pregnancy rates were compared depending on the type of COH used. RESULTS: Overall, for 16708 MII oocytes microinjected, the 2 pronuclear fertilization rate was 54%. Embryo transfer was performed in 94% of started cycles and 629 clinical pregnancies were recorded, giving a clinical pregnancy rate of 24% per cycle and 26% per transfer. No influence of COH on embryological and clinical results was noted. CONCLUSION: Intracytoplasmic sperm injection can be used successfully to treat couples with male factor infertility and those who have failed standard IVF. Precisely adapted protocol of ovarian hyperstimulation for every patient could diminish the costs of treatment without negative influence on ICSI results.

[Enzymatic assisted hatching in the infertile couple after failed attempts of IVF ET]. / Enzymatyczne usuniecie oslonki przejrzystej blastocysty pronaza u pacjentek po kilkukrotnych niepowodzeniach w programie IVF ET.

The study was conducted on the patients who had attempted and failed previous IVF procedures. The aim of this study was to determinate effectiveness sequential culture of embryos to blastocyst and assisted hatching by zona pellucida digestation by pronase. In this group the pregnancy rate was 24.1% compared to control 17.8%. The implantation rate was higher in study group than control one. It suggests that the culture embryos to balstocyste stage and assisted hatching by digestation by pronase is safe and effective mode of treatment of infertile couple after failed attempts IVF ET.

[Reinsemination of oocytes by intracytoplasmic sperm injection after the failure of conventional fertilization. Early embryonal development]. / Mikroiniekcja plemnika do cytoplazmy (ICSI) oocytów nie zaplodnionych w warunkach IVF. Wczesny rozwój embrionalny zarodkow.

OBJECTIVE: To analyze the influence of intracytoplasmic sperm injection (ICSI) on early embryo development used for reinsemination of unfertilized 1-day-old oocytes. DESIGN: Prospective observational study. MATERIALS AND METHODS: A total of 126 embryos resulted from reinsemination by ICSI were analyzed with regard for the time course of cleavage and the quality of embryos at 48 hours after injection. Results were compared with those obtained in 698 embryos obtained after routine ICSI program. RESULTS: It has been shown that embryos derived from reinsemination developed slower in comparison with those obtained after regular ICSI program. At 48 hours after microinjection 50% of embryos achieved 4 blastomeres stage and 37% remained on 2 cells stage. 71% of regular ICSI embryos at this same time showed 4 blastomere or more, only 16% remained on 2 blastomeres stage. The quality of embryos was similar in two compared groups, however those obtained following reinsemination at 4 blastomere stage were significantly poorer quality. CONCLUSION: Embryos derived from reinsemination of 1-day old oocytes unfertilized after conventional IVF developed slower and the quality of embryos at 4 blastomere stage was poorer comparing to regular ICSI embryos.

[Prolonged desensitization pretreatment for in vitro fertilization in women with polycystic ovary]. / Przedluzona desensybilizacja u pacjentek z zespolem pecherzykowego zwyrodnienia jajników w programie pozaustrojowego zaplodnienia.

OBJECTIVE: To analyse the outcome of intracytoplasmic sperm injection (ICSI) in women with severe polycystic ovary disease (PCD), stimulated after prolonged pituitary desensitization in comparison with regular long protocol therapy. MATERIALS AND METHODS: The results of controlled ovarian hyperstimulation (COH), fertilization rate, early embryo development parameters and clinical pregnancy rates were compared depending on the duration of pituitary desensitization before gonadotropin administration. A total of 60 patients with severe PCOD were desensitized with GnRH agonist up to 30 days before COH. The results were compared with the group of 213 patients with mild PCOD treated with regular long protocol (control). RESULTS: We observed a slightly higher rate of mature oocytes MII as well as the number of embryos obtained in the control group, however the pregnancy rate in the group with prolonged desensitization was significantly higher (50%) in comparison to the control group (33.8%). CONCLUSION: The prolonged pituitary desensitization before controlled ovarian hyperstimulation gives better chance for obtaining pregnancy in patients with severe PCOD. It could be recommended facing previous treatment failure.

Good results of milder form of ovarian stimulation in an in vitro fertilization/intracytoplasmic sperm injection program.

In a prospective study, we compared two protocols of ovulation stimulation, the clomiphene citrate and human menopausal gonadotropin (hMG) versus D-triptorelin, a long-acting gonadotropin-releasing hormone (GnRH) agonist and hMG in 324 couples having their first in vitro fertilization or intracytoplasmic sperm injection (IVF/ICSI) program, in terms of pregnancy rates and cost-effectiveness of drugs used. The GnRH agonist/hMG group was characterized by a greater mean number of ampoules of hMG used (31.7 versus 10.2), a larger number of oocytes collected (10.4 versus 4.2), and a larger number of embryos obtained (5.8 versus 2.9). With the policy of transferring only two of the best quality embryos, the mean number of embryos replaced were comparable (1.8 in clomiphene citrate/hMG and 1.9 in GnRH agonist/hMG group). The percentage of patients reaching embryo transfer was lower in the clomiphene citrate/hMG than in the GnRH agonist/hMG group (84.1% versus 93.1%, respectively). However, the combined results of the IVF and ICSI procedure in terms of pregnancy rate, both per patient and per embryo transfer were better, though not significantly in the clomiphene citrate/hMG than in GnRH agonist/hMG group (25.0% and 29.7% versus 23.7% and 25.5%, respectively). Similarly, the implantation rate was better (19.0% versus 13.5%, respectively). With the use of clomiphene citrate/hMG, a fivefold less costly drug regimen, we obtained pregnancy rates equivalent to those gained using GnRH agonist/hMG in our IVF/ICSI program.

[The comparison of efficiency of supplement of the second phase in the program IVF-ET by dydrogesterone and progesterone]. / Porównanie skutecznosci suplementacji drugiej fazy w programie IVF-ET dydrogesteronem i progesteronem.

The retrospective study was carried out to compare effectiveness of progesteron and dydrogesteron luetal phase support following in vitro fertilisation and embryo transfer. Two hundred and fifty eight patients undergoing IVF ET received progesteron in itramuscular injections. Two hundred sixty patients received dydrogesteron three times daily p.o. There were no differences in stimulation protocols, indications for IVF and IVF procedures. Pregnancy rate, implantation rate and spontaneous abortion rate were similar in both groups. The effectiveness of luteal phase support in patients undergoing IVF ET program by dydrogesteron and progesteron is similar with significantly lower costs for the last one.

[Monozygotic pregnancy after the treatment for infertility by transfer of frozen-thawed embryos]. / Ciaza mnoga monozygotyczna po leczeniu nieplodnosci metoda pozustrojowego zaplodnienia.

OBJECTIVES: It has been suggested that monozygotic pregnancies occur more frequently after in vitro fertilisation. This phenomenon is attributed to a number of factors including in vitro culture conditions, malformation of the zona pellucida due to manipulation on the oocytes and artificial opening of the zona pellucida. DESIGN: Retrospective analysis of monozygotic pregnancies in an IVF-ET procedures and obstetrical these pregnancies outcome. MATERIALS AND METHODS: A total of 2254 IVF-ET procedures were analysed. Three protocols were used for ovarian stimulation: short or long protocols with gonadotropins releasing hormone analogue or clomiphene citrate with hMG. In 811 cases male factor was diagnosed and intracitoplasmatic sperm injections were performed. RESULTS: 549 clinical pregnancies were achieved in analysed group. In six cases ultrasound examination 5 weeks after embryo transfer showed a greater number of foetus than the number of embryo transferred. In three of those cases the embryos were obtained after ICSI. Age and average thickness of zona pellucida were similar in group of patients with monozygotic pregnancies when compared with all pregnant patients after IVF treatment. CONCLUSIONS: The incidence of monozygotic pregnancy is increased in group pregnancies resulting from IVF ET. No single risk factor can explain this phenomena. This type of pregnancy needs special obstetrical attention.

[Deontological aspects of ovarian stimulation]. / Deontologiczne aspekty stymulacji jajeczkowania.

The physician and the infertile couple should be partners in the development of a treatment plan that optimally meets the couple's needs. The information about the benefits, side effects and costs of treatment is to be presented to the couple. Stimulation of the ovary has become the central component of rapidly developing assisted reproduction. The fundamental rule in ovulation induction is individual approach to each patient and close monitoring of the stimulation, because the dangers of ovarian hyperstimulation syndrome, multiple pregnancy and putative longer term risks. There is general agreement that multiple pregnancies, including twins, are still too common and must be avoided as they are the major causes of maternal and fetal morbidity. Since the advent of ICSI tens of oocytes are not necessary to achieve fertilization, and milder forms of ovarian stimulation should suffice in most IVF/ICSI cycles. Our target in infertility treatment should be the birth of healthy, singleton babies, with no health risks to their mothers.

[Pregnancy and delivery after the transfer of one blastocyst with enzymatically removed zona pellucida]. / Ciaza i poród po transferze blastocysty pozbawionej enzymatycznie oslonki przejrzystej.

OBJECTIVES: The embryonic development up to the blastocyst stage and hatching from zona pellucida are prerequisites for implantation and successful pregnancy. It is suggested that one of the possibilities limiting the implantation rate is impaired hatching. To overcome this problem an artificial alteration of the zona pellucida have been carried out in many laboratories. DESIGN: The report of the first pregnancy in Poland obtained after the transfer of enzymatically zona removed blastocyst. MATERIALS AND RESULTS: The patient was previously treated three times in in vitro fertilisation program without success. In the fourth program the embryos were cultured in co-culture of Vero cells to the blastocyst stadium. On the day 5 after insemination the zona of cavitating and expanding blastocyst was removed by pronase. The zona free blastocyst was transferred to the uterus. As a result of implanted blastocyst the ongoing pregnancy developed normally and the patient delivered healthy baby. CONCLUSION: Enzymatic zona pellucida hatching probably increases the rate of implantation. It is simple, safe and economic techniques.

Fertility and infertility in aging women.

Age is often a dominant factor for women wanting to conceive. The objective of this study was to examine the outcome of an in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) program in relation to a woman's age. Between January 1995 and June 1997 we stimulated 2511 cycles. The mean age of the women was 34 years, with 21.9% under 30, 45.9% between 30 and 35, 24.5% between 36 and 39, and 7.7% over 39 years. All patients aged > or = 40 years had day 3 serum follicle-stimulating hormone (FSH) concentrations < 20 IU/l. The stimulation regimen consisted of 150-450 IU of human menopausal gonadotropin (hMG) or FSH combined with either clomiphene citrate (CC) or gonadotropin-releasing hormone agonist (GnRHa) in a short or long protocol. Age had a significantly negative effect on the stimulation and fertilization failure rates. The clinical pregnancy rate per transfer and the embryo implantation rate declined significantly from 29.4% and 18.9% in women < 30 years to 19.8% and 14.3% in patients between 30 and 35 years, 17.1% and 9.0% between 36 and 39 years and to 12.8% and 7.4% in those aged > or = 40 years. The spontaneous abortion rate was 14.9%, 16.5%, 22.4% and 33.2%, respectively. The clinical pregnancy rate per transfer reflected only imperfectly the performance of the older women because the discharge rate during stimulation and spontaneous abortions reduced the 'take home baby' rate to about 7% per cycle in patients aged > or = 40 years. It is very important in fertility practice to recognize the major impact of advancing maternal age.

Prevention of high-order multiple gestations in an in vitro fertilization program.

The aim of this study was to assess the benefits of the transfer of only two of the best quality embryos, three if a woman was over 35 years of age, in terms of pregnancy rate and the incidence of multiple gestations. In 1993-94, when we were replacing three embryos when available and up to five when the woman was over 35 years of age, 217 clinical pregnancies were obtained (25% per embryo transfer). Among them there were 34 (15.6%) twins and 8 (3.7%) triplet pregnancies. Eighty-one patients had surplus embryos cryopreserved. In 1995, with the new policy of transferring only two embryos and three when the woman was over 35 years of age, 170 patients became pregnant (23.9% per embryo transfer). There were 31 (18.2%) twins and no triplet pregnancies. One hundred and forty-four patients had surplus embryos cryopreserved. Although limiting the number of transferred embryos slightly decreases the pregnancy rate, this small reduction can be considered acceptable if the social, health and financial problems associated with high-order multiple gestations are taken into account.

The outcome of an in vitro fertilization program in women with polycystic ovary syndrome.

The objective of this study was to examine the efficacy of D-triptorelin in the long protocol and follicle-stimulating hormone (FSH) in an IVF-embryo transfer program in a group of patients with polycystic ovary syndrome (PCOS) who had earlier failed to respond or did not conceive after clomiphene citrate (CC)/human menopausal gonadotropin (hMG) or 'flare up' gonadotropin-releasing hormone agonist (GnRHa)/hMG stimulation. Eighty-nine women with PCOS (based on typical ultrasound criteria) had 1-3 treatment cycles without success. The stimulation protocol was changed to D-triptorelin given in midluteal phase and when pituitary desensitization was achieved, FSH administration was started. The clinical pregnancy rate per transfer in this 'negatively selected' group of PCOS patients was 29%. This was the same as the rate for a group of women with tubal factor, as was the spontaneous miscarriage rate. Although the use of GnRH agonists in the long protocol increases the costs of treatment, the number of cancelled cycles is reduced. The pregnancy rate increased in this group of women with PCOS.

[Cryopreservation of embryos in an in vitro fertilization program(IVN-ET)--preliminary results]. / Mrozenie zarodków w programie pozaustrojowego zaplodnienia (IVF-ET)--wyniki wstepne.

The authors present preliminary results of cryopreservation of embryos in IVF-ET programme in the Institute of Obstetrics and Gynecology in Bialystok. The method of slow cooling embryos with 1, 2 propanediol and saccharose were used. In the group of 136 patients with excess embryos after the transfer of two fresh embryos 29 pregnancies (21.3%) were obtained. After the transfer of frozen/thawed embryos up till now 5 pregnancies have been obtained (one child born, 3 pregnancies ongoing, 1 abortion).

["Long protocol" for ovarian stimulation using D-Trp6 LHRH (Triptorelin Depot) and menopausal gonadotropin in the IVF-ET program]. / "Dlugi protokól"stymulacji jajeczkowania z uzyciem D-Trp6 LHRH (Triptorelina Depot) i gonadotropiny menopauzalnej w programie IVF-ET.

39 patients (age 35-40, anovulation, previous failures in the IVF-ET programme) were superovulated using GnRH analogue (Decapeptyl-Depot) in the long protocol and hMG 97 embryos were transferred and 109 were cryopreserved. The clinical pregnancy and implantation rates were 31.6% and 13.4%. The long protocol gives better results in the IVF-ET programme but increases the costs of treatment.

Use of GnRH analog for induction of the ovulatory surge of gonadotropins in patients at risk of the ovarian hyperstimulation syndrome.

A total of 32 patients undergoing in vitro fertilization (IVF) and 16 treated for ovulatory disturbances were stimulated with clomiphene citrate and human menopausal gonadotropin. Gonadotropin releasing hormone (GnRH) analog was used for induction of the ovulatory surge of gonadotropins, because of the risk of ovarian hyperstimulation syndrome. In four patients after IVF-embryo transfer and four patients after ovulation induction, single pregnancies were obtained. None suffered from ovarian hyperstimulation syndrome. The authors suggest that the use of GnRH analog for induction of the gonadotropin ovulatory surge prevents the development of ovarian hyperstimulation syndrome.