Ovarian hyperstimulation syndrome prevention strategies: in vitro maturation.

The only reliable way to eliminate the risk of ovarian hyperstimulation syndrome (OHSS) is complete avoidance of gonadotropin ovarian stimulation. It could be argued that in vitro maturation (IVM) of oocytes represents the most effective strategy to prevent OHSS. IVM has been an established treatment option in many centers worldwide for over a decade. The use of IVM and natural cycle in vitro fertilization (IVF) combined with IVM can result in clinical pregnancy rates that compare to those obtained with conventional IVF. The obstetric and perinatal outcomes of IVM pregnancies are similar to those conceived from stimulated IVF or spontaneous conceptions. To date, more than a thousand healthy infants have been born without an increase in fetal abnormalities. Although IVM may not replace standard IVF, it plays an increasingly important role in assisted reproductive technology, especially in the settings of high responders and those patients at risk of OHSS.

Fertility preservation for young women with rectal cancer--a combined approach from one referral center.

BACKGROUND: Up to 6% of women with colorectal cancer are diagnosed in the reproductive age and are at risk for premature ovarian failure and infertility due to pelvic irradiation and chemotherapy. STUDY DESIGN: Between 1997 and 2007, six women with rectal carcinoma were referred to the McGill Reproductive Center (Montreal, Canada) for fertility preservation. Following resection of their primary tumor, they were scheduled to undergo pelvic irradiation. RESULTS: Five patients underwent laparoscopic ovarian lateral transposition before radiotherapy in order to relocate their ovaries outside the radiation field. A concomitant ovarian wedge resection was performed for ovarian cryopreservation. In two of these women, before dissecting the ovarian cortical tissue for cryopreservation, all visible follicles were aspirated. The sixth patient who had had low anterior resection underwent hormonal ovarian stimulation followed by oocyte retrieval and embryo vitrification. CONCLUSIONS: Fertility preservation in women with rectal cancer is feasible. This includes laparoscopic ovarian transposition and cryopreservation of ovarian tissue, embryo, or oocyte.

Obstetric outcomes following vitrification of in vitro and in vivo matured oocytes.

OBJECTIVE: To evaluate obstetric outcomes with oocyte vitrification after ovarian stimulation (OS) and in vitro maturation (IVM) of immature oocytes. DESIGN: A prospective trial from October 2003 to April 2007. SETTING: University-based medical center. PATIENT(S): OS group: 38 patients undergoing intrauterine insemination who overresponded to OS. IVM group: 20 patients who had previous unsuccessful intrauterine insemination. INTERVENTION(S): Mature oocyte retrieval following OS. Immature oocyte retrieval and IVM. Oocyte vitrification, thawing, insemination, and transfer of the resulting embryos. MAIN OUTCOME MEASURE(S): Live-birth rates and obstetric outcomes. RESULT(S): The OS group was superior to the IVM group in terms of oocyte survival (81.4 +/- 22.6% vs. 67.5 +/- 26.1%), fertilization rate (75.6 +/- 22.5% vs. 64.2 +/- 19.9%), and cumulative embryo score (38.4 +/- 22.3 vs. 20.0 +/- 13.8). However, the differences in the implantation rate per embryo (19.1 +/- 25.8% vs. 9.6 +/- 24.1%), clinical pregnancy rate per cycle started (44.7%, vs. 20.0%), and live-birth rate per cycle started (39.5% vs. 20.0%) were not statistically significant. Twenty healthy babies were born in the OS group and four in the IVM group. CONCLUSION(S): Pregnancies achieved with vitrification of oocytes after OS and IVM treatments do not appear to be associated with adverse pregnancy outcomes. Vitrification of IVM oocytes represents a novel option for fertility preservation.

Live birth after vitrification of in vitro matured human oocytes.

OBJECTIVE: To report the first healthy live birth from immature oocytes retrieved in a natural menstrual cycle, followed by in vitro maturation (IVM) and cryopreservation of the oocytes by vitrification. DESIGN: Case report. SETTING: University-based tertiary medical center. PATIENT(S): A 27-year-old woman with tubal disease and polycystic ovaries. INTERVENTION(S): Immature oocytes were retrieved by transvaginal ultrasound guided follicle aspiration on day 13 of her natural menstrual cycle, matured in vitro and vitrified. The oocytes were thawed in a subsequent menstrual cycle, inseminated by intracytoplasmic sperm injection, and the resulting embryos transferred. MAIN OUTCOME MEASURE(S): Oocyte maturation and survival rates, pregnancy, and live birth. RESULT(S): One metaphase II and 18 germinal vesicle stage oocytes were collected; 16 out of 18 germinal vesicle oocytes matured, and a total of 17 oocytes were vitrified. After thawing, four IVM oocytes survived; three embryos were transferred. The woman went on to deliver a single healthy live baby at term. CONCLUSION(S): We provide proof-of-principle evidence that the novel fertility preservation strategy of immature oocyte retrieval, IVM, and vitrification of oocytes can lead to successful pregnancy and healthy live birth.

Preservation of female fertility: an essential progress.

Chemotherapy and radiation treatment for malignancies or other conditions such as hematologic and autoimmune disorders, have resulted in improved survival rates but may lead to sterility. Women who postpone conception until late reproductive years are also at increased risk to become infertile. The purpose of our review is to evaluate advances and techniques for fertility preservation. We performed a literature search using the keywords fertility preservation, vitrification, oocytes, embryo, ovarian cryopreservation, and ovarian suspension and conducted the search in MEDLINE, EMBASE, and the Cochrane Database of systematic reviews. The results show that today, it is possible to cryopreserve oocytes, embryos, or ovarian tissue. The most commonly used technique remains embryo cryopreservation. Another improvement is the development of vitrification or rapid freezing technique. For women undergoing local pelvic radiation, one should consider ovarian suspension. Medical professionals, patients, and their families should be aware that in some conditions, the reproductive function can be preserved. Although one cannot guarantee future fertility, a realistic hope for women at risk of having premature ovarian failure can now be offered.

Obstetric and perinatal outcome in 200 infants conceived from vitrified oocytes.

Cryopreservation of oocytes by vitrification is a promising new technique for assisted human reproduction. Any new technical development must be accompanied with data concerning obstetric and perinatal outcome. This study analysed the obstetric and perinatal outcomes in 165 pregnancies and 200 infants conceived following oocyte vitrification cycles in three assisted reproduction centres. The results indicate that the mean birth weight and the incidence of congenital anomalies are comparable to that of spontaneous conceptions in fertile women or infertile women undergoing in-vitro fertilization treatment. These preliminary findings may provide reassuring evidence that pregnancies and infants conceived following oocyte vitrification are not associated with increased risk of adverse obstetric and perinatal outcomes.

Comparison of spindle and chromosome configuration in in vitro- and in vivo-matured mouse oocytes after vitrification.

OBJECTIVE: To compare the cytogenetic changes in in vitro- and in vivo-matured oocytes after vitrification. DESIGN: In vitro experiments using murine model. SETTING: Animal model study in university laboratory. ANIMAL(S): CD-1 mice. INTERVENTION(S): In vitro maturation and vitrification of oocytes. MAIN OUTCOME MEASURE(S): Post-warming survival, analysis of spindle and chromosome configurations, aneuploidy screening of parthenogenetically activated oocytes, extent of DNA fragmentation, and early embryonic development after IVF. RESULT(S): Eighty percent of germinal vesicle-stage oocytes matured after in vitro maturation and were cryopreserved by vitrification (n = 354). There was no significant difference in the post-warming survival of in vitro- and in vivo-matured oocytes (94.1% vs. 91.8%, respectively). The majority of in vitro- and in vivo-matured oocytes maintained normal meiotic spindle morphology and chromosome alignment (88.2% vs. 86.9%, respectively) after vitrification and the incidence of aneuploidy was not increased (11.5% vs. 9.3%). However, in vitro-matured oocytes showed a higher rate of DNA fragmentation after vitrification compared to in vivo-matured oocytes. After vitrification, the cleavage and blastocyst formation rates of in vitro-matured oocytes were significantly lower than those of in vivo-matured oocytes (37.0% vs. 60.0% and 5.4% vs. 18.9%, respectively). CONCLUSION(S): Vitrification of in vitro-matured mouse oocytes results in high survival rates, normal meiotic spindle and chromosome alignment, and no increased incidence of aneuploidy. A possible cause of the reduced developmental competence of in vitro-matured and vitrified oocytes may be due to DNA fragmentation.

Combining ovarian tissue cryobanking with retrieval of immature oocytes followed by in vitro maturation and vitrification: an additional strategy of fertility preservation.

OBJECTIVE: To report an additional strategy of fertility preservation, which combines ovarian tissue cryobanking with retrieval of immature oocytes from excised ovarian tissue, followed by in vitro maturation (IVM) and vitrification. DESIGN: Retrospective analysis of case series. SETTING: University teaching hospital. PATIENT(S): Women who underwent oophorectomy or ovarian wedge resection before receiving chemotherapy and/or radiotherapy. INTERVENTION(S): Immature oocyte retrieval, IVM, oocyte vitrification, ovarian tissue cryobanking. MAIN OUTCOME MEASURE(S): Oocytes retrieved from the excised ovarian tissue, oocyte maturation rate, and number of oocytes cryopreserved by vitrification. RESULT(S): Four consecutive patients underwent retrieval of immature oocytes from the antral follicles of the excised ovarian tissue. The mean number of immature oocytes recovered was three (1, 3, 4, and 3, respectively). The mean maturation rate following IVM was 79% (100%, 100%, 50%, and 67%, respectively). In total, eight mature oocytes were vitrified. CONCLUSION(S): Oocytes can be retrieved from excised ovarian tissue, matured in vitro, and cryopreserved by vitrification. This fertility preservation technique could be combined with ovarian tissue cryobanking.

Effect of choline-supplemented sodium-depleted slow freezing versus vitrification on mouse oocyte meiotic spindles and chromosome abnormalities.

OBJECTIVE: To evaluate and compare vitrification and choline-supplemented sodium-depleted slow freezing of mouse oocytes. DESIGN: Animal study. SETTING: University-affiliated hospital. ANIMAL(S): CD-1 mice. INTERVENTION(S): Oocyte cryopreservation by vitrification or choline-supplemented sodium-depleted slow freezing. MAIN OUTCOME MEASURE(S): Survival rate, fertilization and embryonic development in vitro, meiotic spindle and chromosome configuration, and aneuploidy screening after parthenogenetic activation. RESULT(S): A total of 564 oocytes were vitrified, and 791 oocytes were cryopreserved using the slow freezing. The survival rates were 91.8% (518/564) and 73.3% (579/791), respectively. After IVF, the cleavage and blastocyst formation rates of vitrified oocytes were significantly higher than those of slow-frozen oocytes (63.6% vs. 39.9% and 30.50% vs. 20.2%, respectively). Vitrified oocytes were more likely than slow-frozen oocytes to maintain normal meiotic spindles and chromosome alignment (86.9% vs. 70.1%). However, the incidence of aneuploidy was similar in vitrified oocytes and slow-frozen oocytes (9.30% vs. 8.7%). CONCLUSION(S): Vitrification is superior to choline-supplemented sodium-depleted slow freezing, leading to improved survival, fertilization, and embryonic development in vitro. Analysis of meiotic spindle integrity and chromosome alignment indicates that less damage was detected in vitrified oocytes. However, the incidence of aneuploidy is similar in both vitrified and slow-frozen oocytes.

High survival and hatching rates following vitrification of embryos at blastocyst stage: a bovine model study.

Cryopreservation of embryos at the blastocyst stage may provide an effective method to increase the cumulative pregnancy rate for each treatment cycle of ovarian-stimulated IVF. The objective of this study was to evaluate the survival rate and hatching rate of bovine blastocysts following vitrification using a method designed for oocytes, with a view to introducing this methodology into human assisted reproduction technology and reproductive medicine. Bovine blastocysts were produced from abattoir materials subjected to in-vitro maturation and in-vitro fertilization. Survival rate of the bovine blastocysts was 100% (94/94) following vitrification using a method designed for oocyte cryopreservation. There was no difference in the hatching rate of the bovine blastocysts between control (62.5%: 60/96) and vitrified (61.7%: 58/94) groups. The number of dead cells in the blastocysts was not significantly different between control (5.0 +/- 2.9) and vitrified (9.5 +/- 4.0) groups. In conclusion, the results of this study indicate that bovine blastocysts can be vitrified successfully using a procedure designed for oocyte cryopreservation. It is possible that this method may also be successful for the cryopreservation of human embryos. A further study into this is currently being organized.

Retrieval of immature oocytes followed by in vitro maturation and vitrification: a case report on a new strategy of fertility preservation in women with borderline ovarian malignancy.

BACKGROUND: We report a novel fertility preservation strategy in a woman with borderline ovarian tumors involving retrieval of immature oocytes, in vitro maturation (IVM) and subsequent cryopreservation. CASE: A 43-year-old woman underwent laparotomy for cystic ovarian masses on day 18 of her menstrual cycle. A diagnosis of bilateral borderline ovarian tumors was made following histological frozen section analysis. Left salpingo-oophorectomy, right ovarian cystectomy, omentectomy and lymph node sampling were performed. All visible follicles on the surface of the removed ovary were aspirated. Four immature oocytes were retrieved and underwent IVM. Three oocytes matured after 48 h and were cryopreserved. CONCLUSION: Immature oocytes can be successfully isolated from the oophorectomy specimen regardless of the day of menstrual cycle, matured in vitro and cryopreserved, providing a possible strategy for fertility preservation in this group of women.

Failure of uterine fibroid embolization.

OBJECTIVE: To assess the outcomes of patients who underwent uterine fibroid embolization (UFE) and to evaluate factors associated with failure of UFE. DESIGN: Retrospective study. SETTING: University teaching hospital. PATIENT(S): Two hundred thirty-three consecutive patients who underwent UFE from November 1997 to February 2004. INTERVENTION(S): Uterine fibroid embolizations were performed by three interventional radiologists using 355-500-mu polyvinyl alcohol particles. MAIN OUTCOME MEASURE(S): Hysterectomy rate, myomectomy rate, and repeat UFE rate. RESULT(S): With a mean follow-up of 13 months, a total of 22 patients underwent surgery after UFE (9.4%); 16 had hysterectomies (6.9%), and 6 had myomectomies (2.6%). This included 3 patients who underwent repeat UFE and subsequently required surgical intervention. The mean (+/- SEM) time interval between UFE and subsequent treatment was 12.5 +/- 2.0 months. Among patients who required surgery, 13 (59.1%) presented with recurrent menorrhagia, and 5 (22.7%) complained of persistent abdominal pain. Histopathologic examination revealed concomitant findings of adenomyosis in 25% of hysterectomy specimens. Patients who failed UFE were more likely to have had a previous myomectomy (13% vs. 2.4%) and significant reduction in the uterine size 6 months after UFE (57.1% vs. 25.2%). CONCLUSION(S): The overall failure rate of UFE is 9.4%. Failure is mainly due to persistent menorrhagia and abdominal pain. Shrinkage of the uterus after UFE does not necessarily correlate with long-term success of UFE.

Audit of morbidity and mortality rates of 1792 hysterectomies.

STUDY OBJECTIVE: To audit morbidity and mortality rates of laparoscopic, abdominal, and vaginal hysterectomy. DESIGN: Retrospective review of monthly morbidity and mortality rates (Canadian Task Force classification II-2). SETTING: University teaching hospital. PATIENTS: One thousand seven hundred ninety-two women who underwent hysterectomy for benign, nonobstetric indications at the Sir Mortimer B. Davis-Jewish General Hospital. INTERVENTIONS: Laparoscopic supracervical (LASH), vaginal (VH), and abdominal (AH) hysterectomies. MAIN OUTCOME MEASURES: Morbidity outcomes of different types of hysterectomy. Reoperation, admission to the intensive care unit, discordant diagnosis, and prolonged hospitalization also were evaluated. RESULTS: We studied 223 cases of LASH, 1349 AH, and 220 VH. The overall hysterectomy-related morbidity rate was 6.1%. The rate of morbidity was higher in the LASH group (9.4%) than in the AH group (5.2%, p <.01), but no significant difference was noted between AH and VH (8.6%). The incidence of intraoperative bowel injury was 0.4% in the LASH group (a trocar injury in a patient) and 0.3% in the AH group. Bladder injury was encountered in two patients in the LASH group (0.9%) and in another two in the AH group (0.1%). Ureteral injury occurred in a patient in the AH group (0.07%). There were no cases of intraoperative vascular injury. Vaginal hysterectomy was associated with more urinary retention and hematoma formation than the other two groups. Discordant diagnosis was noted in four cases (two missed endometrial cancer, atonic and distended bladder mistaken for an ovarian cyst, and pelvic tuberculosis). The conversion rate to laparotomy was 1.7% in the LASH group and 0.4% in the VH group, and the incidence of reoperation was 0.4% in the AH group. CONCLUSIONS: The overall hysterectomy-related morbidity rate in our series is 6.1%. Compared with other types of hysterectomy, more urinary retention and hematoma formation occur after VH. Laparoscopic supracervical hysterectomy is associated with a higher morbidity rate than AH; mainly because of conversion to laparotomy and blood transfusion.

Cervical stump necrosis and septic shock after laparoscopic supracervical hysterectomy.

The decision to retain or remove the cervix when performing laparoscopic hysterectomy remains a topic of debate. A 38-year-old woman with multiple sclerosis underwent laparoscopic supracervical hysterectomy (LASH) for menometrorrhagia. Two weeks later, she was seen at our institution with septic shock. She underwent an exploratory laparotomy and was found to have cervical stump necrosis and peritonitis. Trachelectomy was performed. The postoperative course was prolonged by persistent fever, pleural effusion, and abscess collections. Although rare, cervical stump necrosis is a possible complication of LASH.

Quality of fertility clinic websites.

OBJECTIVE: To evaluate the overall quality of the Society for Assisted Reproductive Technology (SART)-affiliated fertility clinic websites, according to American Medical Association (AMA) Internet health information guidelines. DESIGN: Cross-sectional evaluation. SETTING: Two hundred sixty-six websites drawn from the SART directory and the World Wide Web. INTERVENTION(S): Three objective scoring scales (ownership, content, and navigation) adapted from AMA guidelines. MAIN OUTCOME MEASURES: Seven objective criteria for ownership, 8 for content, and 11 for website navigation. RESULT(S): Two thirds of SART-affiliated fertility clinics have functional websites. Of the 236 sites evaluated, 58 belong to hospital centers. Overall, the scores for the three scoring scales were low. Compared with the websites of non-hospital clinics, those of hospital centers were more likely to include information about site ownership and affiliations (89.7% vs. 60.7%) and patient privacy (34.5% vs. 20.8%). Also, contents of hospital center websites were significantly easier to distinguish from advertisements (70.7% vs. 47.7%), and reference sources for specific contents were easier to identify (27.6% vs. 8.4%). Hospital center websites were more likely to indicate affiliations and financial disclosures of authors (25.9% vs. 10.7%), to feature a site map (25.9% vs. 12.3%), and to have a search function (31.0% vs. 5.6%). CONCLUSION(S): Websites of SART-affiliated clinics fail to meet most of the AMA health information guidelines. The quality of the hospital centers' websites is better than that of private clinics.

A call for standardization of fertility clinic websites.

Websites for Society for Assisted Reproductive Technology-affiliated clinics fail to meet most American Medical Association health information guidelines. Professional organizations in reproductive medicine need to standardize the accuracy and appropriateness of online reproductive health information.