Pre-implantation genetic diagnosis-should we use ICSI for all?

OBJECTIVE: Intracytoplasmic sperm injection (ICSI) is commonly used during pre-implantation genetic diagnosis (PGD) in vitro fertilization (IVF), aiming to eliminate the risk of contamination from extraneous sperm DNA. Recently, ICSI "overuse" in non-male infertility has been doubted, since it does not offer an advantage over IVF. Prompted by the aforementioned observations, we sought to assess the accuracy of IVF vs ICSI in PGD cases, as might be reflected by a difference in the prevalence of discarded embryos as a consequent of parental contamination. METHODS: Cohort-historical study of all consecutive patients admitted to the IVF-PGD program in a large tertiary center. The percentages of complete, incomplete diagnosis, PCR failure, abnormal embryos, and the contamination rate with paternal DNA in the IVF-only and the ICSI-only groups. We reviewed the computerized files of all consecutive women admitted to our IVF for a PGD-PCR cycle. Patients were divided accordingly into three groups: an IVF group-where all the oocytes underwent IVF only, an ICSI group-where all oocytes underwent ICSI, and a mixed group-where sibling oocytes underwent both IVF and ICSI. The laboratory data and the genetic diagnostic results were collected and compared between the different insemination groups. RESULTS: Nine-hundred and twenty-seven patients underwent IVF-PGD cycles in our program, 315 in the IVF group, 565 in the ICSI group, and 47 in the mixed group. No differences were observed in fertilization rates, the percentage of embryos available for biopsy, and the percentages of complete, incomplete diagnosis, PCR failure, or abnormal embryos, between the IVF-only and the ICSI-only groups and between the IVF and the ICSI of sibling oocytes in the mixed group. Moreover, contamination with paternal DNA, through contamination with sperm cells, was negligible. Not one single case of misdiagnosis was encountered during the study period. CONCLUSION: It might be therefore concluded that IVF should be the preferred insemination methods in PGD cycles, and ICSI should be indicated only in cases of male-factor infertility.

Pregnancy outcomes in oocyte recipients with fibroids not impinging uterine cavity.

OBJECTIVE: To examine the effects of fibroid uterus on pregnancy outcomes and endometrial features in ovum donation recipients. METHODS: Retrospective analysis of 744 ovum donation cycles was conducted in two private IVF centers between 2005 and 2012. All the recipients underwent transvaginal ultrasound examination, including endometrial thickness and grade measurements. Clinical pregnancy, spontaneous miscarriage, and live birth rates were regarded as the primary outcomes. RESULTS: Leimyomas not distorting the uterine cavity were diagnosed in 264 (35.5%) of the cycles. This group exhibited lower endometrial thickness (8.33 ± 1.8 vs. 8.73 ± 2.03 mm, p = 0.009), lower rates of Grade A (16.1 vs. 30.1%, p < 0.0001), and higher rates of grade C endometrium (10.2 vs. 5.5%, p < 0.0001), compared to the group with sonographically normal uterine cavity. In addition, significantly higher spontaneous miscarriage rates were found in fibroid uteri group (25 vs. 14.5%, p = 0.036). CONCLUSION: Our study results suggest that uterine fibroids not distorting the uterine cavity could constitute a risk factor for spontaneous miscarriage in oocyte donation cycles, possibly via their adverse effect on endometrial receptivity. Further well-designed trials should widely explore this subject, particularly focusing on impact of myomectomy on fertility rates in these patients.

The use of portable CO2 incubator for cross-border shipping of embryos in an international egg donation program.

Two groups of egg recipients were treated, one in situ (165 patients; 195 cycles) and one after cross-border embryo transportation (340 cycles; 340 cycles) using mobile CO(2) incubator. The positive pregnancy rate per cycle was 199/340 (58.6%) and 99/195 (50.7%) in the transportation and the traveling group, respectively (NS). The clinical pregnancy rate (fetal heart beat) was 48.1 and 43.1% per embryo transfer cycle, respectively (NS) and the delivery rate was 44.1 and 35.9% per embryo transfer cycle, respectively (p = 0.01). Long distance transportation of human pre-implantation embryos using portable CO(2) incubator is safe and do not jeopardize their developmental potential.

Comparison between two protocols for thawed embryo transfer: natural cycle versus exogenous hormone replacement.

INTRODUCTION: There are two most popular protocols for Frozen Embryo Transfer: the natural and the E2&P4 replacement cycles. There is still a controversy whether one is superior over the other. PURPOSE: To compare the outcome in patient groups undergoing FET following these protocols. METHODS: About 1235 FET cycles were retrospectively analyzed during a period of 12 years. In 798 cycles (group A), the natural cycle protocol was used, and in 437 cycles (group B), the exogenous E2&P4 administration protocol was used. RESULTS: The average patient age was 32.11 ± 0.27 years in group A and 32.94 ± 0.19 years in group B (p<0.05). The endometrial thickness was 9.54 ± 0.11 mm and 8.95 ± 0.13 mm in groups A and B, respectively (p<0.001). The peak serum E2 level was 162.51 ± 8.97 pg/mL and 250.78 ± 33.67 pg/mL in groups A and B, respectively (p<0.001). The implantation, clinical pregnancy, and ongoing pregnancy rates in groups A and B were 6.47%, 12.91%, and 10.4% versus 4.26%, 8.47%, and 5.95%, respectively (p<0.05). CONCLUSIONS: Natural endometrial preparation yields better outcome in compare with exogenous E2&P4 in FET cycles with higher endometrial thickness, implantation, and clinical pregnancy rates.

Cryopreservation of day 2-3 embryos by vitrification yields better outcome than slow freezing.

OBJECTIVE: To compare the outcome of vitrification versus slow freezing cryopreservation for cleavage stage day 2-3 embryos. DESIGN: A retrospective observational study. SETTING: All thawed embryos assisted reproduction cycles between January 2010 and December 2012 at a single IVF laboratory of a Tertiary Medical Center. PATIENTS: Five hundred and thirty-nine cycles of day 2-3 thawed embryos. INTERVENTIONS: In 327 of the thawed cycles, the embryos were vitrified and in 212 of the cycles the embryos were derived from slow freezing embryos. MAIN OUTCOMES MEASURE: Embryo survival rate, blastomere surviving rate and pregnancy rate. RESULTS: Embryo survival rate was significantly higher after vitrification compared with slow freezing (81.6%, 647/793 versus 70.0%, 393/562 embryos, p < 0.0001). The clinical pregnancy rate per ET was significantly higher following vitrification compared to slow freezing, 20.0%, 63/314 versus 11.9%, 23/193, respectively (p = 0.02). CONCLUSIONS: Vitrification of day 2-3 cleavage stage embryos yields better cycle outcome in all the parameters compared to slow freezing.

Aneuploidy rates for chromosomes X/Y and 18 among preselected spermatozoa in men with severe teratospermia.

Eight infertile men with various degrees of oligoasthenoteratozoospermia and repeated implantation failure were selected for this study due to exceptionally high rates of sperm aneupoidy in their ejaculates. All subjects had normal physical examination, karyotype and serum FSH concentration. Prior to IVF treatment, spermatozoa was collected, processed, micromanipulated and tested for chromosomes X, Y and 18 using fluorescence in-situ hybridization. Aneupoidy rates for chromosomes X, Y and 18 were determined among sperm population selected for normal morphology using high-order magnification light microscopy. A second group of fast motile spermatozoa were collected using an intracytoplasmic sperm injection pipette from the medium-oil interface from microdroplets. The average aneuploidy rates for the three chromosomes were 7.6% (395/5182) in the sperm specimen before selection, 8.7% (116/1326) in the normal morphology selected group and 4.3% (59/1388; P<0.001) in the fast motile selected group. In conclusion, high-magnification light microscopy aimed at selection of spermatozoa with normal morphology did not affect the aneuploidy rate. On the other hand, fast motile spermatozoa harboured significantly less chromosomal abnormalities (P<0.001). Preselection of the most rapid sperm subpopulation for intracytoplasmic sperm injection may improve the qualities of the fertilizing spermatozoon.

Preimplantation genetic haplotyping a new application for diagnosis of translocation carrier's embryos- preliminary observations of two robertsonian translocation carrier families.

PURPOSE: Preimplantation genetic diagnosis using fluorescence in-situ hybridization (PGD-FISH) is currently the most common reproductive solution for translocation carriers. However, this technique usually does not differentiate between embryos carrying the balanced form of the translocation and those carrying the homologous normal chromosomes. We developed a new application of preimplantation genetic haplotyping (PGH) that can identify and distinguish between all forms of the translocation status in cleavage stage embryos prior to implantation. METHODS: Polymorphic markers were used to identify and differentiate between the alleles that carry the translocation and those that are the normal homologous chromosomes. RESULTS: Embryos from two families of robertsonian translocation carriers were successfully analyzed using polymorphic markers haplotyping. CONCLUSIONS: Our preliminary results indicate that the PGH is capable of distinguishing between normal, balanced and unbalanced translocation carrier embryos. This method will improve PGD and will enable translocation carriers to avoid transmission of the translocation and the associated medical complications to offspring.

Assisted reproduction in women over 40 years of age: how old is too old?

Women's fertility progressively declines with advanced age due to depletion of the ovarian follicular reserve and poorer oocyte quality. However, many women of advanced age are eager to conceive from their own ova. The aim of the present study was to evaluate the outcome of IVF cycles among older patients. All IVF retrievals performed in the unit in patients >or=42 years old between 1998 and 2006 were retrospectively analysed. Data were compared with patients <35 years old treated in the unit during the same time period. A total of 843 IVF retrievals in 459 patients >or=42 years old were assessed. Clinical pregnancy rates per cycle were 7.7%, 5.4% and 1.9% for 42, 43 and 44 years old, respectively. Only one IVF cycle in patients aged 44 years resulted in delivery. None of the 54 cycles performed in women of 45 years or older resulted in a pregnancy. A marked decline in clinical pregnancy and delivery rates, accompanied by an increase in spontaneous abortion rates, was found in patients >or=42 years old. In view of these results and as the option of egg donation is a promising alternative with delivery rates close to 50%, it appears that IVF treatment should be limited to patients not older than 43 years old with adequate ovarian response.

Fish based preimplantation genetic diagnosis to prevent DiGeorge syndrome.

PURPOSE: To report the performance of fluorescence in-situ hybridization in the setting of preimplantation genetic diagnosis in order to diagnose embryos affected by DiGeorge syndrome. DESIGN: Case report. SETTING: Academic referral center. PATIENT: A 32 year-old female affected by DiGeorge syndrome. INTERVENTION(S): History and physical examination, karyotyping, amniocentesis, preimplantation genetic diagnosis, fluorescence in-situ hybridization. MAIN OUTCOME MEASURE(S): Avoidance of pregnancy with embryo affected by DiGeorge syndrome. RESULT(S): Termination of pregnancy with an affected embryo followed by fluorescence in-situ hybridization based preimplantation genetic diagnosis and delivery of healthy offspring. CONCLUSION(S): The combination of preimplantation genetic diagnosis with fluorescence in-situ hybridization is recommended to prevent pregnancies with DiGeorge syndrome affected embryos in properly selected patients.

Male infertility associated with adult dominant polycystic kidney disease: a case series.

INTRODUCTION: Although described earlier, the association of male infertility with adult dominant polycystic kidney disease (ADPKD) is quite rare and unfamiliar to some of the multidisciplinary team members caring for affected men. MATERIALS AND METHODS: Infertile men diagnosed to have ADPKD were evaluated by clinical characteristics including testis volume, as well as serum hormone levels, semen analysis, and transrectal ultrasonography (TRUS) because of low volume ejaculate. RESULTS: Semen analysis revealed low-normal volume, normal pH, and azoospermia/virtual azoospermia. Serum hormones were within the normal range. Transrectal ultrasonography demonstrated cystic dilatation of the seminal vesicles in all three men. CONCLUSION: Patients should be referred for andrological evaluation of a presentation similar to obstructive azoospermia. Their potential to achieve paternity by surgical sperm retrieval combined with assisted reproductive technology is another example of cooperation between andrologists and gynecologists.

Ovarian tissue cryopreservation in hematologic malignancy: ten years' experience.

Cryopreservation of ovarian tissue is currently practiced in an attempt to preserve fertility before commencing potentially sterilizing chemotherapy. Clinical and laboratory guidelines are needed to standardize the procedure. Over the last 10 years ovarian tissue was stored in female patients with hematologic malignancies. Patients' records and consultation charts were evaluated, surgical and laboratory reports were revised and ovarian histology was investigated. Fifty-six patients with hematologic malignancies (age 24 +/- 5.5) had cryopreserved ovarian tissue. Thirty-three patients had Hodgkin's disease, 14 non-Hodgkin's lymphoma, 6 acute leukemia, and 3 chronic myelocytic leukemia. Harvesting of ovarian tissue was also performed following previous exposure to chemotherapy (33 patients), 13 of them shortly after the chemotherapy. Partial oophorectomy was the preferred surgical procedure. Fertility was restored with ovarian tissue transplantation in a sterilized patient and following fertility treatment in a patient with very low ovarian reserve. We recommend that indications and timing of ovarian tissue banking should be individualized. Patients previously exposed to chemotherapy can consider ovarian tissue freezing. The extent of tissue removed should take into account the large number of follicles lost and the risk of future sterilization. Tissue handling should enable further investigation of primordial follicles and identification of cancer cells.

Comparison of zygote intrafallopian tube transfer and transcervical uterine embryo transfer in patients with repeated implantation failure.

OBJECTIVE: This study was designed to evaluate the role of zygote intrafallopian transfer (ZIFT) procedure in patients with repeated failure of implantation. STUDY DESIGN: A total of 141 ZIFT cycles of 132 women and 145 embryo transfer (ET) cycles of 97 women in whom five or more embryos were transferred were included in this study. Transcervical uterine embryo transfer and ZIFT cycle outcome in patients with five or more previous implantation failure were compared. Embryos were transferred by laparoscopy into the fallopian tube 24-27 h following oocytes retrieval in the ZIFT group. In the ET group, embryos were transferred transcervically on the third day following oocytes retrieval. RESULTS: The mean age was 34+/-4.9 and 34.9+/-5.0 years in ZIFT and ET group, respectively. No difference was determined between the two groups regarding the basal FSH, E2 value on the day of HCG injection and the number of oocytes retrieved or fertilized. The implantation rate was 6.5% versus 7.2%, clinical pregnancy rate was 22.7% versus 24.8% and live birth rate was 21.2% versus 16.5% in ZIFT and ET groups, respectively. CONCLUSIONS: Implementation of ZIFT procedure in patients with repeated implantation failure is not superior to transcervical uterine embryo transfer.

Conventional in vitro fertilization versus intracytoplasmic sperm injection for sibling oocytes in couples with mild oligoteratoasthenozoospermia and couples with normal sperm.

Use of intracytoplasmic sperm injection (ICSI) in couples with mild oligoteratoasthenozoospermia decreases the complete fertilization failure rate and may also reduce the embryo cleavage rate. ICSI does not benefit couples with normal sperm.

Sonographic evidence of minimal and short-term testicular damage after testicular sperm aspiration procedures.

OBJECTIVE: To evaluate ultrasonically the incidence and duration of tissue damage after testicular sperm aspiration (TESA) procedures. DESIGN: Prospective, nonrandomized study. SETTING: Assisted reproductive technology program. PATIENT(S): Thirty-two men with obstructive azoospermia. INTERVENTION(S): Physical and serial testicular ultrasound examinations 1.5, 3, and 6 months after the surgical procedure. MAIN OUTCOME MEASURE(S): Systematic evaluation of the testicular parenchyma and blood flow. RESULT(S): In 93.7% of the patients (30 of 32), no evidence of parenchymal or vascular injuries was found 6 weeks after the procedure. In the remaining 2 patients, transient evidence of tissue damage disappeared after 3 months. CONCLUSION(S): Testicular sperm aspiration is a safe surgical method for sperm retrieval for IVF. Repeated surgical attempts might be considered within 2 months, provided there is no evidence for tissue damage on sonography.

Monozygotic twinning is not associated with zona pellucida micromanipulation procedures but increases with high-order multiple pregnancies.

Between January 1, 1995 and December 31, 2001, 5,310 cycles were performed in the IVF Unit, Sheba Medical Center, Israel, resulting in 1,066 clinical pregnancies. There was no difference in the rate of pregnancies containing monozygotic twins after zona pellucida micromanipulation procedures (0.9%) compared to conventional insemination (1.0%) (6/677 vs. 4/389).

Prognostic value of the clinical and laboratory evaluation in patients with nonmosaic Klinefelter syndrome who are receiving assisted reproductive therapy.

OBJECTIVE: To characterize clinical and laboratory findings in nonmosaic 47,XXY patients that may help to predict spermatogenetic activity in their testicles. DESIGN: Prospective study. SETTING: Assisted reproductive technology program. PATIENT(S): Twenty patients with nonmosaic Klinefelter syndrome who underwent testicular sperm retrieval for IVF. MAIN OUTCOME MEASURE(S): The correlation between basal FSH, LH and testosterone levels, mean testicular volume, and results of the hCG test and presence or absence of sperm after testicular sperm extraction (TESE). RESULT(S): Sperm was found in nine patients (45%). The mean testicular volume was 7.8 +/- 2.5 mL in men with sperm after TESE and 5.6 +/- 1.2 mL in those without sperm after TESE; corresponding testosterone levels were 3.5 +/- 1.2 ng/mL and 1.7 +/- 0.8 ng/mL. Serum levels of FSH and LH did not significantly differ between groups. After the hCG test, the mean serum testosterone level was 16.0 +/- 6.3 ng/mL in men with sperm after TESE and 6.7 +/- 5.6 ng/mL in those without sperm. CONCLUSION(S): Testicular volume, testosterone levels, and results of the hCG test are important predictive factors of spermatogenesis in patients with nonmosaic Klinefelter syndrome.

Should zygote intrafallopian transfer be offered to all patients with unexplained repeated in-vitro fertilization cycle failures?

BACKGROUND: One of the suggest strategy for patients with repeated implantation failure (RIF) is zygote intrafallopian transfer (ZIFT). However, no data exist regarding to the issue of when and under which circumstances should ZIFT be offered to patients with RIF? We therefore aimed to examine whether repeated implantation failure (RIF) patients characteristics or their previous controlled ovarian hyperstimulation (COH) variables may differentiate between those who will conceive following a ZIFT cycle and those who will not. METHODS: Forty seven consecutive women admitted to our IVF unit during a 7 year period, who underwent ZIFT for RIF, were included. Ovarian stimulation characteristics, number of oocytes retrieved and number and quality of zygotes/embryos transferred were assessed and compared between the ZIFT cycle and the previous IVF/ICSI cycle and between those who conceived following the ZIFT cycle and those who did not. RESULTS: Twelve clinical pregnancies (clinical pregnancy rate- 25.5%) were recorded following the ZIFT cycle. Those who benefit from ZIFT were young patients (≤31 yrs), who underwent ≤6 cycle attempts, yielding over eight 2PN embryos with low (≤0.4) ratio of number of top-quality embryos to total 2PN embryos. Moreover, in those destined for a ZIFT cycle, only those with >7 2PN embryo should undergo a transfer of at least five 2PN embryos. CONCLUSIONS: Further large prospective studies are needed to identify the specific characteristics of RIF women who may benefit from ZIFT.

Effect of local endometrial injury on pregnancy outcomes in ovum donation cycles.

OBJECTIVE: To evaluate the effect of local endometrial injury (LEI) on clinical outcomes in ovum donation recipients. DESIGN: Retrospective cohort analysis of ovum donation cycles conducted from 2005 to 2012. SETTING: Two private IVF centers. PATIENT(S): Total 737 ovum donation cycles. INTERVENTION(S): LEI by endometrial "scratch" with the use of a Pipelle catheter. MAIN OUTCOME MEASURE(S): Clinical pregnancy and live birth rates. RESULT(S): No statistically significant differences were found in clinical pregnancy rates and live birth rates in cycles subjected to LEI compared with those without. Combination of LEI with fibroid uterus resulted with significantly higher clinical pregnancy rates compared with LEI in normal uterine anatomy. CONCLUSION(S): This is the first study done in ovum recipients who underwent LEI by a "scratch" procedure after failed implantation. Unlike most previous reports, which found improved pregnancy rates with the use of "scratch effect" or "minor endometrial injury" after repeated implantation failures in standard IVF with own eggs, we did not find any changes in implantation rates in a population of egg recipients following this procedure. In view of a possible positive effect of LEI in cycles with a previous four or more failures, prospective randomized controlled studies are warranted to better define the target population who may benefit from this intervention.

Tamoxifen co-administration during controlled ovarian hyperstimulation for in vitro fertilization in breast cancer patients increases the safety of fertility-preservation treatment strategies.

OBJECTIVE: To evaluate the safety and efficacy of tamoxifen co-administration during conventional controlled ovarian hyperstimulation (COH) protocols for a fertility-preservation IVF cycle in breast cancer patients. DESIGN: Two groups: retrospective descriptive cohort study and prospective study. SETTING: Breast cancer oncology and fertility-preservation centers in a tertiary hospital. PATIENT(S): Two groups of breast cancer patients: premenopausal patients treated with adjuvant tamoxifen; and patients undergoing in vitro fertilization (IVF) for fertility preservation. INTERVENTION(S): Fertility-preservation cycles, tamoxifen co-administration during conventional IVF. MAIN OUTCOME MEASURE(S): Endocrine records, and IVF results. RESULT(S): Estradiol (E2) levels were chronically high (mean 2663 pmol/L, maximum: 10,000 pmol/L) in 38 of 46 breast cancer patients treated with adjuvant tamoxifen. Co-administration of tamoxifen (48 cycles) during conventional IVF or without tamoxifen (26 cycles), using either the long gonadotropin-releasing hormone-agonist or-antagonist protocols, resulted, respectively, in a mean of 12.65 and 10.2 oocytes retrieved, and 8.5 and 6.4 embryos cryopreserved. Average peak E2 levels were 6,924 pmol/L and 5,093 pmol/L, respectively, but long-term recurrence risk (up to 10 years) was not increased. CONCLUSION(S): In breast cancer patients, co-administration of tamoxifen during conventional COH for fertility preservation does not interfere with IVF results. The high serum E2 levels during COH should be considered safe, as it simulates the high prevalence of persistently high serum E2 levels in premenopausal breast cancer patients safely treated with adjuvant tamoxifen.