Increased pregnancy rate using standardized coculture on autologous endometrial cells and single blastocyst transfer : a multicentre randomized controlled trial.

Despite excellent published results, the lack of well-designed, multicentre, randomized clinical trials results in an absence of general consensus on the efficacy of autologous endometrial cells coculture (AECC) in Assisted Reproductive Technology (ART). An open, multicentre, prospective, randomized controlled trial was designed to compare the pregnancy rate (PR) after the transfer of one blastocyst on day 5 after AECC to the transfer of one embryo on day 3 (control group). Patients were women aged 18 to 36, undergoing an ART cycle with no more than 1 embryo transfer failure. Sample size was calculated at 720 for a superiority trial involving an intermediate analysis at 300 patients. We present the results of the intermediate analysis that resulted in the study ending considering the observed difference. Three hundred thirty nine patients were randomized: 170 in the AECC group and 169 in the control group. The clinical PR per transfer was 53.4% with AECC and 37.3% in the control group (p=0.025). The quality of embryos was improved with AECC. These results suggest that implementation of the AECC technique to a large number of In-Vitro Fertilization (IVF) centres could lead to a substantial improvement in the proportion of successful assisted reproduction. The study was supported by the Laboratoires Genévrier, France.

[Informations for the infertile couple]. / Informations à donner au couple infécond.

The aim of the first consultation related to infertility is supposed to be the optimization of all factors that can increase the chances of pregnancy: more frequent sexual intercourse during the fertility windows; lifestyle modifications (better diet, decreased exposure to tobacco or other toxics); older couples can enjoy the same advice but should be proposed a quicker medical support. Maternal preconceptional advice must be transmitted. A testicular cancer must always be excluded in infertile men, while the risk of hormone-dependent cancers in infertile women remains undetermined. With the results of this first consultation, couples will generally be proposed the best solution to achieve their parental project: ovarian stimulation assisted reproductive technology (IUI, IVF or ICSI) or adoption.

[Fort Lauderdale congress report: advances in infertility treatment - Florida, 24-26 January 2002]. / Compte rendu du congrès de Fort Lauderdale : progrès dans le domaine du traitement de l'infertilité - Floride, 24-26 janvier 2002.

The goal of the treatment of infertility is to apply therapeutic techniques to patients in a safe manner and at the same time increase the chances for conceiving and delivering healthy babies: basic and clinical research is more and more finalized directed to these goals. The conference "Advances in Infertility Treatment" held in Fort Lauderdale, Florida on January 24-26, 2002 covered many clinical and research aspects of this important therapeutic area. Important discussed issues included the impact of age, lifestyle, and the genetic set-up of patients in the pathogenesis and development of infertility-causing disorders such as male reproductive dysfunction, polycystic ovary syndrome, and ovarian failure. New ovulation induction regimens that may optimize, reduce complications, and lower costs of ovarian stimulation procedures and of assisted reproduction in general were presented. This was the 5th Ferring Pharmaceuticals Conference in the area of reproductive medicine held in Florida.

Prospective, randomized, controlled study of in vitro fertilization-embryo transfer with a single dose of a luteinizing hormone-releasing hormone (LH-RH) antagonist (cetrorelix) or a depot formula of an LH-RH agonist (triptorelin).

OBJECTIVE: To confirm the value of a single dose of 3 mg of cetrorelix in preventing the occurrence of premature LH surges. DESIGN: Multicenter randomized, prospective study. SETTING: Reproductive medicine units. PATIENT(S): Infertile patients undergoing ovarian stimulation for IVF-ET. INTERVENTION(S): A single dose of 3 mg of cetrorelix (Cetrotide; ASTA Medica, Frankfurt, Germany) (115 patients) was administered in the late follicular phase. A depot preparation of triptorelin (Decapeptyl; Ipsen-Biotech, Paris, France) was chosen as a control agent (39 patients). Ovarian stimulation was conducted with hMG (Menogon; Ferring, Kiel, Germany). MAIN OUTCOME MEASURE(S): Premature LH surges (LH level >10 IU/L), progesterone level greater than 1 ng/L, and IVF results. RESULT(S): No LH surge occurred after cetrorelix administration. The patients in the cetrorelix group had a lower number of oocytes and embryos. The percentage of mature oocytes and fertilization rates were similar in both groups, and the pregnancy rates were not statistically different. The length of stimulation, number of hMG ampules administered, and occurrence of the ovarian hyperstimulation syndrome were lower in the cetrorelix group. Tolerance of cetrorelix was excellent. CONCLUSION(S): A cetrorelix single-dose protocol prevented LH surges in all patients studied. It compares favorably to the "long protocol" and could be a protocol of choice in IVF-ET.

[Luteal phase support after vaginal progesterone: comparative study with micronized oral progesterone]. / Support de la phase lutéale par la progestérone vaginale: étude comparative avec la progestérone micronisée per os.

Two progesterone presentations, a vaginal application of 90 mg progesterone per day (Crinone) or 300 mg progesterone orally administered (Utrogestan) were compared for luteal phase support of patients undergoing an in vitro fertilisation (IVF) procedure. 283 patients were randomly allocated to either treatment. The treatment started within 24 hours after the embryo transfer procedure and continued until day 30 in cases of implantation. Efficacy was assessed using the pregnancy and delivery rates. Safety was assessed through specific symptoms and usual safety monitoring. The pregnancy rate per transfer was not significantly different in the Crinone and Utrogestan groups at day 12 (Crinone: 35.3%, Utrogestan: 29.9%, p = 0.55), at day 30 (Crinone: 28.8%, Utrogestan: 25%, p = 0.61), at day 90 (Crinone: 25.9%, Utrogestan: 22.9%, p = 0.69). No difference in spontaneous abortion rates were seen thereafter. The delivery rate was not significantly different (proportion delivery per patients included, Crinone: 23.0%, Utrogestan: 22.2%, p = 1), as well as the ratio new-born per transferred embryo (Crinone: 11.7%; Utrogestan: 11.1%, p = 0.91). Safety parameters were similar in both groups except for drowsiness, which was more significantly frequent in the oral P group than in the Crinone group at all time points. No serious adverse events were recorded in this study. The fact that Crinone matches the efficacy of the larger doses of progesterone used orally reflects an advantage of the transvaginal route of administration which avoids metabolic inactivation of progesterone during its first liver pass.

Interest of co-cultures for embryos obtained by in-vitro fertilization: a French collaborative study.

Co-cultures of human embryos, particularly with Vero cells, are used by several French groups, mainly in cases of successive failures of implantation. In most cases co-culture is continued until the blastocyst stage, expanded if possible. A total of 1603 co-cultures have been performed by 11 groups over a 2-year period. Of these, 41.8% of cleaved eggs (day 2) reached the blastocyst stage at day 5 or day 6. The mean pregnancy rate and implantation rate per transfer were 32.9 and 24.8% respectively, which represented a significant improvement compared to the transfer of 2 day old embryos. The rate of multiple pregnancies remained high (29.1%), which implies that there should be transfer of not more than two blastocysts. The rate of anomalies perceived at birth or in utero was not different from the rate observed in the general population, taking account of the maternal age.

Luteal support after in-vitro fertilization: Crinone 8%, a sustained release vaginal progesterone gel, versus Utrogestan, an oral micronized progesterone.

Two progesterone presentations, a vaginal application of 90 mg progesterone per day (Crinone) or 300 mg progesterone administered orally (Utrogestan), were compared for luteal phase support of patients undergoing an in-vitro fertilization (IVF) procedure. A total of 283 patients were randomly allocated to either treatment. The treatment started within 24 h after the embryo transfer procedure and continued until day 30 in cases of implantation. Efficacy was assessed using the pregnancy and delivery rates. Safety was assessed through specific symptoms and usual safety monitoring. The pregnancy rates per transfer were not significantly different in the Crinone and Utrogestan groups at days 12 (Crinone 35.3%, Utrogestan 29.9%, P = 0.55), 30 (Crinone 28.5%, Utrogestan 25.0%, P = 0.61) and 90 (Crinone 25.9%, Utrogestan 22.9%, P = 0.69). No differences in the spontaneous abortion rates were seen thereafter. The delivery rates (number of deliveries per patient; Crinone 23.0%, Utrogestan 22.2%, P = 1.00), as well as the ratio of newborn babies per embryo transferred (Crinone 11.7%, Utrogestan 11.1%, P = 0.91), were not significantly different. Safety parameters were similar in both groups, except for drowsiness, which was more significantly frequent in the oral progesterone group than in the Crinone group at all time points. No serious adverse events were recorded in this study. The fact that Crinone matches the efficacy of the larger doses of progesterone used orally reflects an advantage of the transvaginal route of administration which avoids the metabolic inactivation of progesterone during its first liver pass.

[Quality of the conceptus: embryo transfer strategy]. / Qualité du conceptus: stratégie du transfert embryonnaire.

Embryo transfer is one of the key points of human IVF. Success or failure, as well as further incidence of multiple pregnancies are the immediate consequence of this technical point. The IVF transferus has also to manage with the patient anxiety. The technical points of embryo transfer are reviewed. Results of the national french registry concerning transfers of 2 or 3 embryons are also analysed. Then, an experience concerning delayed embryo transfer at the blastocyst stage is reported, taking in to account the high PR obtained after transfer of frozen thawed blastocysts.

[Acute pleurisy secondary to ovarian hyperstimulation after in vitro fertilization]. / Pleurésie aiguë secondaire à une hyperstimulation ovarienne après fécondation in vitro.

Pleurisies due to the syndrome of ovarian hyperstimulation typically accompany ascites and in their most severe form are associated with haemoconcentration, hypovolaemia and thromboembolic phenomena. It is not unusual in this context for pleural effusions to be isolated. They may occur during treatment for sterility by inducing ovulation, they are exudates and predominantly right sided. The pathophysiology is not clear and results in vascular hyperpermeability. Currently, no treatment aimed at the aetiology has proven its own efficacy. Spontaneous regression of the effusion is the rule but in severe forms, where the prognosis is uncertain, correction of hypovolaemia is a priority.

Cocultured blastocyst cryopreservation: experience of more than 500 transfer cycles.

OBJECTIVE: To present our experience using cocultured cryopreserved and transferred blastocysts. DESIGN: Retrospective study of patients undergoing transfer of cryopreserved blastocysts. SETTING: Three different IVF centers. PATIENTS: Four hundred sixty-seven thawed cycles from January 1991 to June 1994. MAIN OUTCOME MEASURE: Pregnancy rate per cycle after transfer of pre-embryos developed from thawed blastocysts. RESULTS: One thousand two hundred thirty-nine blastocysts were thawed. Of these, 1,033 (83%) survived thawing and were transferred. Five hundred sixty-three thawed cycles resulted in 516 (92%) receiving intrauterine transfer. One hundred twelve clinical pregnancies were established, resulting in a 21.7% pregnancy per transfer with a 19% ongoing rate. The implantation rate of 13.4% results from 138 implanted pre-embryos. There was a higher PR in the programmed cycle (79/302; 26.2%) compared with the natural cycle (6/47;13%). CONCLUSIONS: Freezing at the blastocyst stage is a proven and reliable method in IVF technology. Although there may be fewer pre-embryos, their ability to implant appears to approach the potential of a fresh transfer.

Factors affecting human blastocyst formation in vitro and freezing at the blastocyst stage.

Whatever the culture medium, embryo culture generally leads to a major loss of viability in mouse, rabbits even if the morphological development of the embryo is preserved. Moreover, Embryo metabolism is commonly depressed in culture media. The protein turnover is accelerated and the quality of the metabolites transport systems is impaired. Various coculture systems have been designed to avoid this loss of viability and in some animal species, to overcome the so called "embryo developmental arrest" usually observed at the approximate time of genomic activation. Moreover, it is clear now that cocultured embryos have usually higher cells numbers than those observed for embryos cultured in classical culture media. In the human, the problems seem less complicated because embryos can be transferred into the uterus on the second day post fertilization, at a time when they would normally be in the Fallopian tube: this is not possible in animal species. Also, blastocysts can be obtained, even at low rates, in conventional culture media and there is no apparent block of development. In this paper, we will present an overview of Cocultures in different species. Then, we will focus on the Human including the blastocyst formation rate and freezing at the Blastocyst stage. At the beginning of the Story, For coculturing, 2 ideas were put forward: The use of embryonic tissue (trophoblast) to help the embryo through an autocrine effect. The use of female genital tract cells, to assist the embryo through a paracrine effect.

[Multiple pregnancy risk factors in medically assisted reproduction]. / Facteurs de risque de grossesses multiples en procréation médicalement assistée.

FIVNAT registry collected 4,323 clinical pregnancies from 1987 to 1991, and allowed us to analyse the risk factors for multiple pregnancies. The multiple pregnancy rate is around 28%, 23% for twin pregnancies and 5% for triplet pregnancies. The number of transferred embryos is not the only factor to be significantly related with the risk of multiple pregnancy: male infertilities, cleavage rate over 50%, and women's age (at young ages multiple pregnancy rate are higher) are also significant. A multivariate logistic model was applied to analyse the relative part of these different factors. We also estimated the success rate and the multiple pregnancy rate which should have been obtained if the number of transferred embryos has been limited, in order to reduce the multiple pregnancy rate to 3%.

[Cocultures: diagnostic and therapeutic value]. / Cocultures: apports diagnostiques et thérapeutiques.

Results of french multiple collaborative studies are reported to evaluate the possible benefits of coculture in human IVF program. Prospective randomized study of IVF with transfer on day two versus IVF with transfer on day 6 shows that coculture does not improve overall results but leads to a reduction of triple or quadruple pregnancies. When applied to patients with more than 4 failures of embryo transfers on day 2, delayed transfer of blastocyst results in a high rate of clinical pregnancy (39%). Transfers of frozen-thawed blastocysts result in 17.8% ongoing pregnancies. Coculture is also a powerful tool for understanding early embryo development: when fertilization arises from sperm with poor characteristics or from frozen sperm of donor, embryo development appears to be altered: in these situations, rate of normally developing embryo is reduced and early embryo development becomes independent of fertilization rate.

Freezing cocultured human blastocysts.

OBJECTIVE: To determine the possibility of obtaining good pregnancy rates (PRs) after freezing and thawing cocultured blastocysts. DESIGN: Human blastocysts were frozen first according to a protocol available from literature. Two other protocols including the addition of glycerol were designed to improve the results. SETTING: All the patients were under clinical management at the Institut Rhonalpin pour l'Etude de la Reproduction Humaine in Lyons, France. PATIENTS: Patients involved in the in vitro fertilization program have had their supernumerary embryos frozen according to the three protocols presented here. MAIN OUTCOME MEASURES: Embryo recovery after freezing and thawing. Clinical and ongoing pregnancies after embryo transfer (ET). RESULTS: A protocol including sucrose addition and reduction of steps in the preparation of the blastocysts for freezing gave us a 21% PR per transfer (15 ongoing) of 101 transfers (106 thawings). CONCLUSIONS: Freezing of cocultured human blastocysts allow good PRs. This can represent an alternative for repeated failures of ETs at early stages.

Coculture of embryos on Vero cells and transfer of blastocysts in humans.

Preliminary results are presented concerning the first clinical application of cocultures of human embryos. In the experimental group, the embryos were cultured and transferred on day 5 post-insemination. Blastocyst formation was not dependent upon the stimulation regimen. Long term or ultrashort stimulation of the ovaries after gonadotrophin releasing hormone analogue gave 55-60% blastocyst formation. Serum was not necessary to obtain blastocysts. When the embryos were cocultured, we observed an increase in the implantation rates per embryo in the pregnant patients. However, a real increase in the pregnancy rate per transfer was observed in a population of patients who had had repeated failures of embryo transfer. This observation is discussed as possibly bypassing an effect of uterine motility, but the overall beneficial effect has to be assessed in a double blind randomized study. It is probable that improvements will not be observed for all the indications for in vitro fertilization.

Culture of epithelial cells derived from the oviduct of different species.

This study proposes a procedure for the isolation and culture of oviduct epithelial cells of several species. In-vitro culture on such a feeder seems to allow full embryonic development and viability. The inner linings of Fallopian tubes from mouse, rabbit, cow and human were trypsinized and the epithelial cells were enriched with Percoll gradient. Isolated cells, obtained in high yield with good viability, were maintained in monolayer culture in B2-Menezo medium supplemented with serum, which also supports early embryonic development in vitro. The plated primary cultures reached confluence within 8 days, producing a monolayer of cohesive polygonal cells. Associated with this large epithelial cell population, ciliated cells as well as polykaryotic cells and few fibroblastic nests were observed. After the first sub-culture, the ciliated cells disappeared and the epithelial cell monolayer grew rapidly to confluence within 3 days and displayed contact inhibition. No epithelial cell growth could be obtained in culture in the absence of serum. The addition of oestrogens had no effect on any of the cultured oviductal epithelial cells. A spontaneous alteration was observed in morphology and growth after several passages, the number of which depends mainly upon the species.

[Sterility of tubal origin: microsurgery and fertilization in vitro]. / Stérilité d'origine tubaire: microchirurgie ou FIV.

Thanks to recent advances, in-vitro fertilization should alter the clinical indications in cases of sterility due to tubar obstruction. In this article, the authors compare two groups of patients: one group of 109 women treated by means of in-vitro fertilization and another group of 117, treated by microsurgery. In tubar sterility, IVF achieved a 16% pregnancy rate per attempt. In the case of microsurgery, the actuarial rates were calculated (Kaplan Meier method) from a prognostic score. It was found that in the group of women with a "good score", tubar surgery gave results which could be achieved only after 3 or 4 attempts at IVF. On the other hand, in the "poor prognosis" group, IVF was better than microsurgery after a single attempt. Clinical teams should, therefore, reconsider the indications for tubar surgery in the light of the indications for in-vitro fertilization.

[In vitro fertilization or surgery in the treatment of tubal sterility]. / Fécondation in vitro ou chirurgie dans le traitement des stérilités tubaires.

Although it is very difficult to compare the results of the two methods, it would seem that those of tubal surgery remain more or less stationary whilst those of fertilisation in vitro improve and the technique becomes more simple.