Dual trigger protocol is an effective in vitro fertilization strategy in both normal and high responders without compromising pregnancy outcomes in fresh cycles.

OBJECTIVE: To study the birth rates of normal vs. high responders after dual trigger of final oocyte maturation with gonadotropin-releasing hormone (GnRH) agonist and human chorionic gonadotropin in fresh in vitro fertilization (IVF) cycles in which ovarian stimulation was achieved by a flexible GnRH antagonist protocol. DESIGN: Retrospective cohort study. SETTING: University hospital. PATIENTS: In women <35 years of age, 290 fresh IVF cycles using the dual trigger protocol with day 5 embryo transfers from January 2013 to July 2018 were included. Cycles excluded were those with preimplantation genetic testing, gestational carriers, donor oocytes, and fertility preservation. INTERVENTIONS: IVF with dual trigger. MAIN OUTCOME MEASURES: Clinical pregnancy rate, live birth rate. RESULTS: Comparing normal responders, defined as <30 oocytes retrieved, and high responders, defined as ≥30 oocytes retrieved, the clinical pregnancy rates (67.0% vs. 69.3%, respectively) and live birth rates (60.5% vs. 60.0%, respectively) were not significantly different. No cases of ovarian hyperstimulation syndrome were reported in either group. CONCLUSIONS: Ovarian stimulation by a flexible GnRH antagonist protocol followed by dual trigger yields comparable outcomes between normal and high responders in fresh IVF cycles.

Lack of carbon air filtration impacts early embryo development.

PURPOSE: To assess human fertilization and preimplantation embryo development in the presence and in the absence of carbon filtration METHODS: This is a retrospective cohort analysis of fresh, controlled ovarian hyperstimulation cycles as well as previously cryopreserved pronuclear stage embryo transfer cycles in a single IVF center. Embryo development and cycle-based outcomes were compared among three groups: 1) when carbon filtration was present, 2) when carbon filtration was absent, and 3) when carbon filtration had been restored. RESULTS: A total of 524 fresh cycles and 156 cryopreserved embryo cycles were analyzed. Fertilization, cleavage, and blastocyst conversion rates for fresh cycles all declined during the period of absent carbon filtration and recovered after the restoration of carbon filtration. Cryopreserved embryos that were thawed and cultured during the period of absent filtration did not have changes in cleavage or blastocyst conversion rates compared to periods where carbon filtration was present. Clinical pregnancy and live birth rates were unchanged among the three time periods. CONCLUSIONS: The absence of carbon filtration in an IVF laboratory air handler is associated with poor fertilization and early embryo development for fresh cycles. Because development of previously frozen pronuclear stage embryos was unaffected, the lack of carbon filtration may preferentially affect embryos in the peri-fertilization period. Carbon filtration is an integral part to a successful human in-vitro fertilization laboratory.

The association of reproductive senescence with mitochondrial quantity, function, and DNA integrity in human oocytes at different stages of maturation.

OBJECTIVE: To determine the impact of reproductive aging on oocyte mitochondrial quantity, function, and DNA (mtDNA) integrity. DESIGN: Prospective observational study. SETTING: IVF clinic in a tertiary academic care center. PATIENT(S): One hundred two oocytes from 32 women undergoing IVF. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Adenosine triphosphate (ATP) levels, mtDNA number, and mtDNA deletion occurrence in individual oocytes. RESULT(S): Oocyte ATP content increases with maturation (786 ± 87 fmol, 1,037 ± 57 fmol, and 1,201 ± 59 fmol for prophase 1 [P1], metaphase 1 [M1], and metaphase 2 [M2] oocytes, respectively), whereas mtDNA copy numbers do not change (64,500 ± 20,440, 180,000 ± 44,040, and 143,000 ± 31,210 for P1, M1, and M2 oocytes, respectively). Stepwise multiple regression analysis identified developmental stage as a determinant of oocyte ATP, whereas number of oocytes retrieved and cycle day 3 FSH level were determinants of mtDNA copy number. Of the 15 oocytes found to possess the 5-kb mtDNA deletion, 10 were arrested or degenerated oocytes. CONCLUSION(S): Although no direct association was found between female age and oocyte mitochondrial quantity and function, the number of mitochondria was predicted by ovarian reserve indicators. As the oocyte matures, ATP content increases.

Cumulative exposure to high estradiol levels during the follicular phase of IVF cycles negatively affects implantation.

PURPOSE: To investigate the effect of the cumulative exposure to estradiol (E(2)) during the follicular phase on IVF outcome. METHODS: Patients were stimulated with recombinant FSH after GnRH agonist suppression and had a day 3-embryo transfer. Estrogen exposure was determined as the area under the curve (AUC) for serum E(2) levels measured from the first day of stimulation through the day after hCG administration. RESULTS: E(2) AUC thresholds for 10th and 90th percentiles were 4704 pg/ml and 16338 pg/ml, respectively. The pregnancy and implantation rates were highest in the 10th-90th percentile group, and were statistically higher in this group than in the >90th percentile group (54.6% vs. 33.3% and 24.8% and 12.9%, respectively, for pregnancy and implantation rates, P < 0.05). Recovered mature oocytes, fertilization, and number and mean score of transferred embryos were similar. CONCLUSIONS: High cumulative E(2) exposure during the follicular phase of IVF cycles has detrimental effects on implantation.

Predictive value of the hemizona assay for pregnancy outcome in patients undergoing controlled ovarian hyperstimulation with intrauterine insemination.

OBJECTIVE: The hemizona assay (HZA) is an established functional test that examines in vitro sperm-zona pellucida binding capacity with high predictive power for fertilization outcome in IVF. The objective of this study was to evaluate the value of the HZA as a predictor of pregnancy in patients undergoing controlled ovarian hyperstimulation (COH) and intrauterine insemination (IUI). DESIGN: Prospective clinical study. SETTING: Academic center. PATIENT(S): Eighty-two couples with unexplained or male factor infertility that underwent 313 IUI cycles. INTERVENTION(S): Basic semen analysis and HZA were performed within three months of starting COH/IUI therapy. MAIN OUTCOME MEASURE(S): Hemizona index (HZI) and clinical pregnancy. RESULT(S): Overall, patients with an HZI of <30 had a significantly lower pregnancy rate compared to patients with an HZI of > or =30 (11.1% vs. 40.6%, respectively; P<.05; relative risk for failure to conceive: 1.5 (confidence interval 1.2-1.9)). In all patients combined, and in the range of HZI 0-60, the duration of infertility (P=.000) and the HZI (P=.004) were significant determinants of conception (receiver operating characteristics (ROC) analysis). In couples with male infertility, the average path velocity and HZI were significant predictors of conception (P=.001 and P=.005, respectively, ROC analysis). The negative and positive predictive values of the HZA for pregnancy were 93% and 69%, respectively. Logistic regression analysis provided models of HZI (P=.021) and duration of infertility (P=.037) with highest predictability of conception in male factor and unexplained infertility groups, respectively. CONCLUSION(S): The HZA predicted pregnancy in the IUI setting with high sensitivity and negative predictive value in couples with male infertility. Results of this sperm function test are useful in counseling couples before allocating them into COH/IUI therapy.

Efficacy and pregnancy outcome of two methods of semen preparation for intrauterine insemination: a prospective randomized study.

OBJECTIVE: To examine pregnancy outcome with two methods of semen preparation for intrauterine insemination (IUI). DESIGN: Prospective and randomized study. SETTINGS: Academic tertiary center. PATIENT(S): Three hundred eleven couples undergoing 676 consecutive cycles of assisted conception using IUI. INTERVENTION(S): Semen samples collected for IUI were randomized to wash only or density gradient centrifugation (DGC) processing. MAIN OUTCOME MEASURE(S): Various prepreparation and postpreparation semen parameters were used for IUI. The influence of the method of semen processing, and impact of various semen parameters and female factors on pregnancy were examined by receiver operating characteristics (ROC) curves, logistic regression, and life table analysis. RESULT(S): Of the 676 cycles, 88 resulted in conception leading to an overall clinical pregnancy rate of 13.0% per cycle and 28.3% per patient with a miscarriage rate of 34.0%. Eighty-eight percent of pregnancies occurred in the first three cycles of IUI and 95.5% within the first four cycles. The pregnancy rate for wash only was 11.6% (37 of 319) and the rate for DGC was 14.3% (51 of 356). However, in samples with <22 million motile sperm in the inseminate, pregnancy rates were 4% for wash and 18% for DGC. The woman's age for both methods and the percentage of sperm in the original semen with a velocity of > or =80 micro m/s for the wash method influenced pregnancy outcome. CONCLUSION(S): Although samples with an acceptable number of motile sperm can be processed efficiently by wash only, poor quality semen samples should be processed using DGC.

Intrauterine insemination: a systematic review on determinants of success.

Intrauterine insemination (IUI) is a frequently indicated therapeutic modality in infertility. Here, a systematic review of the literature was performed to examine the current status of clinical and laboratory methodologies used in IUI and the impact of female and male factors on pregnancy success. Emphasis was centred in questioning the following: (i) the value of IUI against timed intercourse; (ii) IUI application with or without controlled ovarian hyperstimulation; (iii) timing and frequency of IUI; and (iv) impact of various parameters (male/female) on the prediction of pregnancy outcome. The odds of multiple pregnancy occurrence and its risk factors, as well as the cost-effectiveness of IUI treatment compared with more complex assisted reproductive technologies are discussed. A computerized literature search was performed including Medline and the Cochrane library, as well as a crossover search from retrieved papers. It is concluded that although IUI is a successful contemporary treatment for appropriately selected cases of female and/or male infertility, further research is needed through well-designed studies to improve the methodologies currently utilized. Importantly, the clinical management of the infertile couple should be performed in an expedited manner taking into consideration the age of the woman, the presence of multifactorial infertility and cost-effectiveness of the available treatment alternatives.

Zona pellucida-induced acrosome reaction in human sperm: dependency on activation of pertussis toxin-sensitive G(i) protein and extracellular calcium, and priming effect of progesterone and follicular fluid.

In these studies, we aimed to characterize the effects of the physiological, homologous agonists of the acrosome reaction, i.e. the zona pellucida (ZP) and progesterone/follicular fluid, on human sperm. The specific aims of our studies were: (i) to examine the dependency of the solubilized ZP-induced acrosome reaction on G(i) protein activation and presence of extracellular calcium; and (ii) to determine whether progesterone/follicular fluid exert a priming or synergist effect on the solubilized ZP-induced acrosome reaction. Highly motile sperm from fertile donors were exposed to the agonists in a microassay and the acrosomal status of live sperm was determined by indirect immunofluorescence using PSA-FITC/Hoechst double-staining. Pretreatment with pertussis-toxin (100 ng/ml) and EGTA (2.5 mmol/l) significantly inhibited the ZP-induced acrosome reaction without affecting the spontaneous rate of exocytosis. Progesterone (1.25 microg/ml) and human follicular fluid (10%) exerted a priming, time-dependent effect on the ZP-induced acrosome reaction. These studies demonstrated that: (i) acrosomal exocytosis of capacitated human sperm triggered by the homologous ZP is dependent on the activation of G(i) proteins (pertussis toxin-sensitive) and the presence of extracellular calcium; and (ii) progesterone and follicular fluid exert a priming effect on the ZP-induced acrosome reaction.

Lipiodol versus methylene blue for prevention of postsurgical adhesion formation in a rat model.

OBJECTIVE: To determine the effects of intraperitoneal Lipiodol and methylene blue in prevention of postsurgical adhesion formation. STUDY DESIGN: Thirty female rats were divided into three equal groups and a standard damage to provoke adhesion formation was made by laparotomy to each of them. Methylene blue and Lipiodol was administered intraperitoneally to the first and second groups, respectively; while the third group was taken as control and no additional intervention was made. Adhesions were scored by a second look laparotomy which was made 21 days after the first operation. RESULTS: Adhesion scores of the second group (i.e. Lipiodol group) were significantly lower than that of controls. No significant differences were present between any other groups (i.e. methylene blue versus control and methylene blue versus Lipiodol). CONCLUSION: Intraperitoneal administration of Lipiodol inhibits postsurgical adhesion formation in rats.

The effect of surgical sterilization on ovarian function: a rat model.

OBJECTIVE: To evaluate the effects of various methods of sterilization on ovarian function, in a rat model. STUDY DESIGN: Forty-eight female Whistar albino rats weighing 200-250g are divided equally into four groups. All rats underwent laparotomy, while no specific intervention was made to the first group. Bilateral tubal ligation by Pomeroy's technique, unipolar and bipolar cautery was done to the second, third and fourth groups, respectively. All rats were then individually caged and fed on demand for 6 months. Afterwards, the rats were sacrificed and underwent bilateral oophorectomy. A pathologist blinded to the groups made histological examination by counting number of healthy tertiary follicles and corpora lutea in each ovary. The results of the groups were statistically compared by one-way ANOVA using post-hoc Bonferroni correction. RESULTS: Rats in group 1 had significantly higher number of healthy tertiary follicles than every other group. Rats in group 1 also had significantly more corpora lutea than those in group 3. CONCLUSION: Tubal ligation may affect ovarian function, which in turn may reflect to ovarian histology in rats.