Endometrial Injury Upregulates Expression of Receptivity Genes in Women with Implantation Failure.

BACKGROUND: Homeobox genes A10 (HOXA10) and A11 (HOXA11), members of the abdominal B gene family, are responsible for embryonic survival and implantation. This study was planned to investigate whether endometrial injury alters the expression of both transcripts in women with implantation failure. METHODS: A total of 54 women with implantation failure were divided into two equal groups as experimental (scratching) and sham (no scratching). Participants in the scratching group were exposed to endometrial injury in the mid-luteal phase, and those in the sham group were exposed to endometrial flushing. The scratching group, but not the sham group, underwent prior endometrial sampling. A second endometrial sampling was performed on the scratching group in the mid-luteal phase of the following cycle. The mRNA and protein levels of the HOXA10 and 11 transcripts were determined in endometrial samples collected before and after injury/flushing. Participants in each group underwent IVF/ET in the cycle after the second endometrial sampling. RESULTS: Endometrial injury caused a 60.1-fold (p < 0.01) increase in HOXA10 mRNA and a 9.0-fold increase in HOXA11 mRNA (p < 0.02). Injury resulted in a significant increase in both HOXA10 (p < 0.001) and HOXA11 protein expression (p < 0.003). There was no significant change in HOXA10 and 11 mRNA expressions after flushing. Clinical pregnancy, live birth, and miscarriage rates of the both groups were similar. CONCLUSIONS: Endometrial injury increases homeobox transcript expression at both mRNA and protein levels.

Comparison of gender-specific human embryo development characteristics by time-lapse technology.

Numerous studies indicate that there might be differences in embryo growth dynamics between male and female embryos. However, current data in humans are scarce and the results are inconclusive or conflicting. This study asks whether there exist gender-specific embryo development kinetics or parameters between human male and female embryos that can be observed by time-lapse technology. Study included data from 139 consecutive cycles (177 embryos transferred, 179 sacs analysed) with positive pregnancy that resulted in 100% implantation. Single- or double-embryo transfers were performed. Cases were analysed for parameters including cleavage time points and duration in each cleavage from two cells to hatching blastocyst stages and time interval between cleavages. Morphokinetic parameters of 78 female and 60 male embryos from a total of 119 cycles (139 sacs were examined after transfer of 138 embryos) were processed for data analysis according to the gender group. A detailed analysis of the data regarding each time point or interval between consecutive events according to these groups showed them to be similar in cell division kinetics, from the early cleavage through their development to blastocyst stage. However, female embryos showed earlier cavitation than male embryos, but the results did not reach statistical significance.

Klinefelter syndrome: does it confer a bad prognosis in treatment of nonobstructive azoospermia?

OBJECTIVE: To determine the effectiveness of microsurgical testicular sperm extraction (micro-TESE) and intracytoplasmic sperm injection (ICSI) for men with Klinefelter syndrome (KS). DESIGN: Retrospective clinical study. SETTING: Private IVF center. PATIENT(S): Men with nonmosaic KS (n = 106), and men with nonobstructive azoospermia (NOA) and normal karyotypes (n = 379). INTERVENTION(S): Micro-TESE on the day of oocyte retrieval. MAIN OUTCOME MEASURE(S): Sperm recovery, fertilization, pregnancy, and spontaneous abortion rates. RESULT(S): Sperm was successfully recovered in 50 of 106 (47%) men in the KS group and 188 of 379 (50%) in the NOA group. The fertilization rate was higher in the NOA group than the KS group (65% vs. 57%, respectively); however, pregnancy (55% vs. 53%) and abortion rates (12% vs. 11.5%) did not differ statistically significantly between groups. In the KS group, 23 pregnancies resulted in 29 live births; the 21 children who underwent genetic evaluation had normal karyotypes. CONCLUSION(S): Sperm recovery rates in men with KS were similar to those of men with NOA and normal karyotypes. The fertilization rate was statistically significantly lower for men with KS than men with NOA, but pregnancy and abortion rates were similar. We observed good sperm recovery and ICSI outcomes for patients with KS.

Birth after 12 hours of oocyte refrigeration.

OBJECTIVE: To assess cycle outcome after oocyte refrigeration. DESIGN: Case report. SETTING: Private IVF center. PATIENT(S): One couple in a donor oocyte program. INTERVENTION(S): Intracytoplasmic sperm injection and blastocyst culture after refrigeration of oocytes for 12 hours. MAIN OUTCOME MEASURE(S): Birth. RESULT(S): Fourteen two-pronuclei zygotes from 17 metaphase II refrigerated oocytes resulted in transfer of two blastocysts at day 5 and cryopreservation of six excess embryos at day 6. The patient delivered one healthy male baby after 38 weeks' gestation. CONCLUSION(S): The successful outcome of oocyte refrigeration indicates that this protocol could be useful in circumstances in which a delay in obtaining spermatozoa arises.

Comparison of cabergoline and bromocriptine in patients with asymptomatic incidental hyperprolactinemia undergoing ICSI-ET.

We retrospectively assessed outcomes of in vitro fertilisation in groups of women with asymptomatic incidentally discovered hyperprolactinaemia (AIH) undergoing ovarian stimulation and ICSI-ET relative to the types of dopamine agonist and gonadotropin releasing hormone analogue used. Of 5840 women who underwent COH and ICSI-ET, 239 were included in the study; 122 had been treated with cabergoline, and 117 with bromocriptine, during the COH. The mean age, duration of stimulation, and total number of gonadotropin ampules employed were comparable in the two groups using the agonist and antagonist protocols, as were the number of oocytes retrieved and the proportion of mature MII and fertilised (2pn) oocytes. There were no significant differences in implantation, pregnancy, and miscarriage rates between the agonist and antagonist arms of the study. The cost of treatment was significantly higher with cabergoline than with bromocriptine (p = 0.0001). However, side effect rate was significantly higher with bromocriptine than with cabergoline (15.3% vs. 2.5%; p = 0.0004). In conclusion, we found that cabergoline and bromocriptine showed no differences in IVF outcomes and pregnancy results in patients with AIH.

Early pregnancy loss rates were different among singleton gestations conceived by ICSI using GnRH agonist and antagonist.

This study compared early pregnancy losses (termination of pregnancy before 12 weeks of gestation, EPL) among conceptions achieved by ICSI according to the type of GnRH analogue for ovarian stimulation. Only singleton gestations (2,184) and fresh embryo transfers were included. GnRH agonist was used in 848 gestations out of 2,184 and GnRH antagonist was used in the remaining 1,336 gestations. EPL was found to be significantly higher in GnRH antagonist gestations compared to GnRH agonist (27.2% vs 18.9%). This significant difference persisted when gestations were segregated according to maternal age, especially among women younger than 35 years old. Therefore our results suggest that gestations conceived by ovarian stimulation including GnRH antagonists may have higher probability of having EPL.

Frozen-thawed cleavage-stage embryo transfer cycles after previous GnRH agonist or antagonist stimulation.

This study presents the results of fresh and frozen-thawed embryo transfers in women undergoing IVF with gonadotrophin-releasing hormone (GnRH) agonists and GnRH antagonists. By evaluating cycle outcomes, the impact of two different protocols on the endometrium was indirectly evaluated. For 714 women, embryos were frozen following day-3 fresh embryo transfer and the outcome of those fresh cycles (329 agonist cycles and 290 antagonist cycles) and subsequent frozen-thawed embryo transfer (91 agonist cycles and 104 antagonist cycles) were evaluated. Peak oestradiol concentrations of both groups were similar; however, significantly more oocytes were retrieved and more embryos frozen in the agonist versus antagonist group (both P = 0.0001). In fresh embryo transfer cycles, implantation and pregnancy rates in the agonist versus antagonist group were 42.3% versus 32.0% (P = 0.0001) and 68.6% versus 58.2% (P = 0.009) respectively. However, neither implantation or pregnancy rate significantly differed among frozen-thawed embryo transfer cycles between the two groups (21.4% versus 23.5% and 52.2% versus 52.4% respectively). These results suggest that ovarian stimulation parameter outcomes of GnRH antagonist cycles were not inferior to GnRH agonist cycles, therefore reduced embryo implantation and pregnancy rates in GnRH antagonist cycles can be attributable to possible deleterious effects on the endometrium.

Early clinical pregnancy loss rate in poor responder patients does not change compared to age-matched normoresponders.

OBJECTIVE: To investigate the early clinical pregnancy loss rate (ECPLR) of singleton gestations in poor responder (PR) patients. DESIGN: A retrospective study. SETTING: Private assisted reproductive technology center. PATIENT(S): A total of 2,157 singleton clinical pregnancies were identified, 195 from PR and 1,962 from normoresponder (NR) patients. Poor response was accepted as retrieval of four or fewer oocytes. Patients who yielded more than five oocytes were accepted as NR control group. INTERVENTION(S): Patients were age stratified as or=40 years. MAIN OUTCOME MEASURE(S): Comparative evaluation of ECPLR in PR and NR patients according to age. RESULTS: Out of 195 singleton clinical pregnancies achieved in poor responders, 31% resulted in early clinical pregnancy loss; ECPLR were 22%, 32%, and 59% in the or=40 year age groups, respectively. When ECPLR in singleton gestations of PR patients was compared with that of NR patients according to age, no significant differences were found for all age groups. CONCLUSION(S): Early clinical pregnancy loss rate was not found to differ significantly between PR and NR patients at all age groups. Therefore, PR patients should be counseled about their lower probability of clinical pregnancy but similar ECPLR compared with their age-matched NR counterparts.

Route of progesterone administration for luteal phase support may affect outcome of controlled ovarian hyperstimulation for IVF with ICSI using GnRH antagonist.

PURPOSE: This study evaluated the impact of route of progesterone administration as luteal phase support on the outcome of assisted conception cycles. METHODS: Intramuscular progesterone in oil (IMP) at 100 mg daily was administered to 903 women following oocyte retrieval whereas vaginal progesterone gel (VMP) at 90 mg was administered twice daily to 1,110 women. Retrospective analysis was performed according to the type of GnRH analogue used. Implantation (IR), clinical pregnancy (CPR) and biochemical pregnancy rates (BPR) were main outcomes. RESULTS: In GnRH agonist cycles, neither IR, CPR or BPR differed according to the route of progesterone. However, in GnRH antagonist cycles, IR and CPR were significantly lower in VMP group compared to IMP group. BPR also was significantly higher in VMP group compared to IMP group. CONCLUSION: Our results suggest that route of progesterone administration for luteal phase support can be an important prognostic factor according to the type of GnRH analogue used for controlled ovarian hyperstimulation.

Comparison of preovulatory follicular concentrations of epidermal growth factor, insulin-like growth factor-I, and inhibins A and B in women undergoing assisted conception treatment with gonadotropin-releasing hormone (GnRH) agonists and GnRH antagonists.

Follicular fluid contents of 69 age-matched women undergoing ovarian stimulation with a GnRH agonist and a GnRH antagonist were collected during oocyte retrieval. The groups did not differ in baseline characteristics and in terms of assisted conception treatment outcome. Similarly, follicular fluid levels of epidermal growth factor, insulin-like growth factor, and inhibins A and B were found not to be different. Our results suggest that follicular development in regard to ovarian growth factor dynamics is not different in women undergoing ovarian stimulation with GnRH antagonists than in women using GnRH agonists.

Comparisons of follicular levels of sex steroids, gonadotropins and insulin like growth factor-1 (IGF-1) and epidermal growth factor (EGF) in poor responder and normoresponder patients undergoing ovarian stimulation with GnRH antagonist.

OBJECTIVE: To determine the serum and intrafollicular concentrations of sex steroids, epidermal growth factor (EGF) and insulin like growth factor-1 (IGF-1) in women demonstrating poor response to ovarian stimulation with gonadotropins and GnRH antagonists, and to compare the results with age-matched women displaying normal ovarian response. STUDY DESIGN: This is a prospective cross-sectional study conducted in a private IVF center. Forty-eight age-matched women producing 5 or fewer oocytes (poor responders) or 10 or more oocytes (normoresponders) at the end of controlled ovarian stimulation for assisted conception participated in the experiment. Gonadotropins and GnRH antagonists were used for ovarian stimulation, while ICSI was employed for assisted fertilization. Serum and follicular concentrations of FSH, LH and sex steroids (estradiol, progesterone and testosterone), and follicular concentrations of EGF and IGF-1 were assayed in both groups. RESULTS: Serum and follicular levels of E(2) and progesterone were significantly lower in the poor responder group compared to the normoresponder group. Follicular level of testosterone was also lower in poor responders, but not to a level of statistical significance. The serum FSH level was higher in the poor responder group, but follicular levels of gonadotropins did not differ between the two groups. The follicular level of IGF-1 was significantly lower in poor responders. In contrast, the EGF concentration did not differ between the two groups. CONCLUSIONS: Decreased levels of sex steroids in poor responder patients undergoing COH with GnRH antagonist, suggests that reduced IGF-1 expression acts as a modulator of impaired ovarian steroidogenesis.

Outcome of 1114 ICSI and embryo transfer cycles of women 40 years of age and over.

The purpose of this study was to contribute to the development of strategies to obtain acceptable outcomes in assisted reproduction treatments in women over 40 years of age. A retrospective study was carried out on the database of the German Hospital in Istanbul using data from the years 1997 to 2004. A total of 1114 embryo transfer cycles were assessed. The pregnancy, implantation and delivery rates of the assessed population were 18.2, 8.3 and 10.9% respectively. The results showed that the demographics and outcome of cycles of women at 40 years differed significantly from those over 40. Cycles in which six or more oocytes were retrieved displayed better characteristics and outcome than those with five or fewer. The clinical pregnancy and delivery rates after transfer of three embryos were similar to four or more. Therefore, women over 40 years with a good ovarian response and at least three embryos available for transfer have an acceptable pregnancy and delivery rate with a low multiple pregnancy risk.

Subclinical pregnancy losses among women undergoing in-vitro fertilization with ICSI.

BACKGROUND: The purpose of this study is to asses the frequency of subclinical pregnancy loss (SPL) among women undergoing controlled ovarian hyperstimulation (COH) and in-vitro fertilization with ICSI. METHODS: The study was retrospectively conducted in a private IVF center. SPL was defined by a temporary rise in serum beta hCG, along with the absence of signs of intra- and extra-uterine pregnancy by transvaginal ultrasonography. Overall 5273 COH and ICSI cycles with embryo transfer (ET) were segregated according to serum E(2) levels percentiles (-24th, 25th, 74th, and 75th), women age and the type of spermatozoa for assisted fertilization (ejaculated and surgically retrieved). Those groups were assessed for SPL rates. RESULTS: Among the 3125 (59.25) conception cycles, 305 (9.7%) were diagnosed as SPL. There was no difference in SPL rate among E(2) percentile groups. Women older than 35 years of age had significantly higher rate of SPL compared to younger women. There was also no difference in SPL rate among pregnancies in whom surgically retrieved spermatozoa used or ejaculated spermatozoa used for assisted fertilization. CONCLUSION: Our results demonstrated that SPL rate was not influenced by the levels of E(2) during COH or the origin of spermatozoa used for assisted fertilization. However, maternal age was found to be detrimental for SPL.

Efficiency of changing the embryo transfer time from day 3 to day 2 among women with poor ovarian response: a prospective randomized trial.

OBJECTIVE: To compare the outcome of day 2 and day 3 embryo transfers in women demonstrating poor ovarian response. DESIGN: Prospective randomized clinical trial. SETTING: Private assisted reproductive technology center. PATIENT(S): Two hundred eighty-one women demonstrating poor ovarian response to controlled ovarian hyperstimulation. INTERVENTION(S): Women who were poor responders were randomly allocated to day 2 or day 3 embryo transfer following oocyte retrieval. MAIN OUTCOME MEASURE(S): Implantation rates and pregnancy rates per oocyte retrieval and embryo transfer. RESULT(S): The clinical pregnancy rates per oocyte retrieval (37.2% vs. 21.4%, respectively; P<.05) and per embryo transfer (38.9% vs. 24.1%, respectively; P<.05) were significantly higher in the day 2 embryo transfer group compared with day 3. On the other hand, implantation rates were not different between groups (23.9% vs. 17.2%, respectively; P=.08). CONCLUSION(S): Our results demonstrated that transfering embryos on day 2 could provide an alternative to the management of poor responder patients.

Early cleavage morphology affects the quality and implantation potential of day 3 embryos.

OBJECTIVE: To assess the development and implantation potential of early-cleaved embryos displaying various morphological patterns. DESIGN: Retrospective analysis. SETTING: Private IVF center. PATIENT(S): Embryos obtained from 1,556 transfer cycles were assessed. Early-cleaved embryos were grouped according to their cleavage patterns as: even (1,490); uneven (3,238); and fragmented (768), or according to nuclear morphologies as: mononucleation (2,008) and other nuclear morphologies; nonmononucleation (3,488). Seven thousand four hundred forty-five embryos were late cleaved. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Embryo quality, pregnancy (PR), and implantation rates. RESULT(S): Day 3 embryo quality was highest in evenly early-cleaved embryos and in those displaying mononucleation. Early-cleaved embryos displaying fragmentation and late-cleaved embryos yielded the poorest day 3 quality. Early cleavage cycles displayed higher PR and implantation rate than late cleavage with the exception of other nuclear morphologies, in which similar outcome was obtained. Mononucleated early-cleaved embryos implanted at a higher frequency than early-cleaved embryos displaying other nuclear morphologies. CONCLUSION(S): The morphology of early cleavage correlates to day 3 embryo quality and implantation rate.

Impact of coasting in patients undergoing controlled ovarian stimulation with the gonadotropin-releasing hormone antagonist cetrorelix.

Coasting is the most popular modality for the prevention of ovarian hyperstimulation syndrome, but this procedure has not been evaluated in patients undergoing controlled ovarian hyperstimulation (COH) with GnRH antagonists. The impact of coasting in a cycle in which GnRH antagonist is used was evaluated in 29 women, and it was found that coasting did not deleteriously affect the outcome in high-responder patients undergoing COH with GnRH antagonists.