Association between embryo morphokinetic development and intracytoplasmic sperm injection with epididymal sperm via time-lapse imaging.

The objective of this study was to investigate the impact of sperm source on embryo morphokinetics and the clinical outcomes of intracytoplasmic sperm injection (ICSI) cycles by considering the clustering of data (multiple embryos per patient that share a comparable developmental timing). This matched cohort study was performed at a private university-affiliated in vitro fertilization center. Women who underwent ICSI with epididymal sperm between January 2019 and December 2020 (the percutaneous epididymal sperm aspiration group, n = 32 cycles) were matched with women who underwent ICSI with ejaculated sperm because of idiopathic male factor infertility (the male factor infertility [MFI] group, n = 32 cycles) or female infertility (the control group, n = 32 cycles). Embryos were cultured in a time-lapse imaging incubator, and morphokinetic development was recorded and compared among the groups. Significantly slower divisions were observed in embryos derived from epididymal sperm than in those derived from the MFI and control groups. Embryos derived from epididymal sperm had a significantly lower KIDScore (3.1 ± 0.2) than did those derived from ejaculated spermatozoa from the MFI (5.4 ± 0.1) and control (5.6 ± 0.2, p < 0.001) groups. Epididymal sperm-derived embryos showed a significantly greater occurrence of multinucleation (23.2%) than did those derived from ejaculated sperm from the MFI and control groups (2.8% and 3.7%, p < 0.001, respectively). Epididymal sperm-derived embryos were significantly more likely to undergo direct or reverse cleavage (11.1%) than ejaculated sperm-derived embryos in the control group (4.3%, p = 0.001). In conclusion, delayed cell cleavage and increased incidences of blastomere multinucleation and abnormal cleavage patterns are observed when epididymal-derived sperm are used for ICSI.

Progesterone-primed cycles result in slower embryos without compromising implantation potential and with the advantages of oral administration and potential cost reduction.

OBJECTIVE: To study the impact of the use of progesterone on embryo morphokinetics and on the outcomes of intracytoplasmic sperm injection cycles. DESIGN: Cohort study. SETTING: Private university-affiliated in vitro fertilization center. PATIENT(S): This study included 236 freeze-all intracytoplasmic sperm injection cycles and the resultant 2,768 injected oocytes cultured in a time-lapse imaging incubation system. Patients were matched by age and divided into groups depending on the protocol used to prevent the luteinizing hormone surge: progestin-primed (144 cycles and 1,360 embryos) and gonadotropin hormone-releasing hormone (GnRH) antagonist (144 cycles and 1,408 embryos) groups. INTERVENTION(S): The kinetic recorded markers were time to pronuclear appearance and fading, time to 2-8 cells, time to morulation, time to start of blastulation, and time to blastulation. The durations of cell cycles and time to complete synchronous divisions were calculated. The Known Implantation Data Score ranking was recorded. Morphokinetics and clinical outcomes were compared between the groups. MAIN OUTCOME MEASURE(S): Embryo morphokinetics and clinical outcomes. RESULTS: Slower time to pronuclear appearance, time to 2 cells, time to 7 cells, time to start of blastulation, and time to blastulation were observed in embryos derived from progestin-primed cycles than in those from the GnRH antagonist group. No significant differences were noted in any other morphokinetic milestone. Significantly higher cancellation and implantation rates were observed in the progestin-primed group. However, no significant differences were noted in the pregnancy and miscarriage rates. The expenses for treatment using premature GnRH antagonist and progestins were US$318.18 and US$11.05, respectively. CONCLUSIONS: Exogenous progesterone replaces the GnRH antagonist for the prevention of premature luteinizing hormone surge, in freeze-all cycles, with the advantage of oral administration and potential cost reduction.

Delphi consensus on add-ons and social midia in Assisted Reproductive Technology.

This article reports the annals of a national consensus meeting on add-ons and social networks in Assisted Reproduction Techniques (ART). The panel of experts has developed a set of consensus points and this document is intended to be referenced as a national consensus to allow social networks and add-ons to be used in ART, following the standards of the Code of Medical Ethics and the Federal Council of Medicine, in a safe ethical and responsible way.

The Child's Right to Know Versus the Parents' Right Not to Tell: The Attitudes of Couples Undergoing Fertility Treatments Towards Identity-Release Gamete Donation.

Background: In Brazil, donor anonymity is mandatory; however, the tendency of Brazilians towards the practice is unknown. In this study, an attempt was made to investigate whether couples undergoing assisted reproductive technology (ART) have a different perception of anonymous versus identity-release gamete donation than a target population in Brazil. Methods: This cross-sectional study was performed from September 1, 2020 to December 15, 2020. For that purpose, surveys through online platforms were conducted, including either patients undergoing ART (ART-group, n=400) or subjects interested in the theme (interested-group, n=100) randomized by age at a 1:4 ratio. The survey collected information on the participants' attitudes towards anonymity of gamete donors, and answers were compared between the groups. Results: Most participants stated that the relationship between children and their parents would be affected by the child's knowledge of the origin of its conception. Most participants in the ART-group believed that the gamete donor's identity should not be revealed to the child, while only half of the interested-group stated the same. Most of the participants stated that "the donor's identity should be revealed if the child questions its biological origin". "From birth" was the second most common response, while "when the child turns 18 years old" and "sometime during teenage years" were less common answers. Conclusion: The attitudes of ART patients about anonymity are conservative, with most participants believing that family relationships may be affected if the child is aware of the origin of his/her conception. These patients also believe that the identity of the gamete donor should not be revealed to the child.

Serum anti-Müllerian hormone concentrations are related to embryo development: lessons from time-lapse imaging.

Our objective was to study whether serum anti-Müllerian hormone (AMH) concentrations were associated with embryo morphokinetic events. This retrospective cohort study was performed in a private university-affiliated in vitro fertilization centre between March 2019 and December 2020 and included 902 oocytes cultured in a time-lapse imaging incubator, obtained from 114 intracytoplasmic sperm injection cycles performed. The relationship between AMH concentrations and morphokinetic events was investigated by considering the clustering of data (multiple embryos/patient). Evaluated kinetic markers were time to pronuclei appearance (tPNa) and fading (tPNf), time to two (t2), three (t3), four (t4), five (t5), six (t6), seven (t7), and eight cells (t8), (tSB) and time to the start of blastulation (tSB) and to blastulation (tB). Significant inverse relationships were observed between serum AMH concentrations and tPNf, t3, t4, t5, t6, t7, t8, and tB. The AMH was positively correlated with the KIDScore and implantation rate. Increased serum AMH concentrations correlated with faster embryo development. The clinical implications of this effect on embryo development warrant further investigation.

Beetroot, watermelon and ginger juice supplementation may increase the clinical outcomes of Intracytoplasmic Sperm Injection cycles.

OBJECTIVE: To prove the hypothesis that beetroot, watermelon and ginger juice supplementation improves the endometrial receptivity and clinical outcomes of intracytoplasmic sperm injection (ICSI) cycles. METHODS: This prospective randomized study enrolled 436 female patients undergoing ICSI cycles from January/2018 to June/2021, in a private university-affiliated IVF center. Female patients were randomized in a 1:3 ratio to either Control (n=109) or Supplementation Group (n=327). All patients received nutritional orientation before the beginning of the treatment. Participants in the Supplementation Group were instructed to intake a daily dose of homemade juice, prepared with fresh beetroot, watermelon and ginger, from the day of embryo transfer until the day of pregnancy test, while patients in Control Group did not follow the juice protocol. Generalized Linear Models, adjusted for potential confounders (female age, body mass index - BMI, endometrial thickness upon embryo transfer, and number of transferred embryos), followed by Bonferroni post hoc test for the comparison of means between groups, were used to investigate the impact of juice supplementation on the clinical outcomes of ICSI. RESULTS: Patients and cycles characteristics were equally distributed among Supplementation and Control groups. Implantation rate (25.2% vs. 20.5%, p<0.001) and clinical pregnancy rate (41.0% vs. 22.0%, p=0.039) were significantly higher in the Supplementation compared to the Control group. CONCLUSIONS: The use of beetroot, watermelon and ginger juice may be considered a promising strategy for improving clinical outcomes in assisted reproductive technology (ART), without any side effects.

Time-lapse monitoring: An adjunct tool to select embryos for preimplantation genetic testing.

The goal for the present study was to investigate the effect of aneuploidy on embryo morphokinetics events in a time-lapse imaging (TLI) system incubator. This retrospective cohort study was performed in a private university-affiliated in vitro fertilization center, between 2019 March and December 2020. Kinetic data were analyzed in 935 embryos, derived from 316 patients undergoing intracytoplasmic sperm injection cycle with preimplantation genetic testing (PGT) for aneuploidy, individually cultured in a TLI incubator until Day 5 of development. Timing of morphokinetic variables, the incidences of multinucleation, and Known Implantation Data Score (KIDScore)-Day 5 were compared between euploid (n = 352) and aneuploid embryos (n = 583). Aneuploid embryos showed significantly longer timing to complete specific morphokinetic parameters compared to euploidy embryos. Euploidy embryos also showed a significantly higher KIDScore when compared with the aneuploidy ones. Our evidence suggests that TLI monitoring may be an adjunct approach to select embryos for PGT; however, cautious investigation is still needed.

The effect of sperm DNA fragmentation on ICSI outcomes depending on oocyte quality.

BACKGROUND: Sperm deoxyribonucleic acid (DNA) fragmentation is commonly encountered in spermatozoa, and the oocyte assumes responsibility for repairing sperm DNA fragmentation during the oocyte-embryo transition. OBJECTIVES: This study aimed to investigate whether the effect of sperm DNA fragmentation on intracytoplasmic sperm injection outcomes depends on the incidence of oocyte dimorphisms. MATERIALS AND METHODS: For the present cohort, 2942 fertilized oocytes from 525 patients submitted to intracytoplasmic sperm injection cycles were assessed. The present study was conducted in a private in vitro fertilization center affiliated to a university from June 2016 to July 2019. Semen samples were divided into the following two groups depending on the sperm DNA fragmentation index: a low fragmentation index group (<30% sperm DNA fragmentation, n = 1468) and a high fragmentation index group (≥30% sperm DNA fragmentation, n = 486). In addition, mature oocytes were examined before sperm injection, and intracytoplasmic and extracytoplasmic defects were recorded. The effect of the sperm DNA fragmentation index on laboratory and clinical intracytoplasmic sperm injection outcomes (depending on the presence of oocyte defects) was evaluated. RESULTS: Significant increases in the rates of fertilization, high-quality embryo, implantation, and pregnancy were noted for cycles with <30% sperm DNA fragmentation than cycles with ≥30% sperm DNA fragmentation (regardless of the presence of oocyte dimorphisms). The presence of dimorphisms significantly impacted laboratory and clinical outcomes. The lowest fertilization and high-quality embryo rates were observed when a high sperm DNA fragmentation index was associated with the presence of dark cytoplasm, vacuoles, resistant membrane, and non-resistant membrane. The lowest implantation and pregnancy rates were observed when a high sperm DNA fragmentation index was associated with the presence of vacuoles, defective perivitelline space, and fragmented polar body. The effect of sperm DNA fragmentation on miscarriage rates was significantly influenced by the presence of centrally located cytoplasmic granulation, a defective perivitelline space and non-resistant membrane. CONCLUSION: A high sperm DNA fragmentation index increases the likelihood of miscarriage in intracytoplasmic sperm injection cycles, an effect that may potentially be magnified by the presence of oocyte dysmorphisms.

Serum miR-181d-5p levels in response to controlled ovarian stimulation: predictive value and biological function.

The response to controlled ovarian stimulation (COS) for in vitro fertilization (IVF) varies dramatically from one patient to another, affecting success rates. A previous large-scale study identified increased serum miR-181d-5p levels in patients with high response to COS prior to stimulation. We aim to evaluate whether the expression of miR-181d-5p differs according to the ovarian response to COS in women undergoing intracytoplasmic sperm injection (ICSI) cycles. Samples collected prior to COS for ICSI were split into three groups depending on the ovarian response to COS: poor response (PR), <4 oocytes retrieved (n=25); normal response (NR), ≥8 and ≤12 oocytes retrieved (n=21); and high response (HR), >25 oocytes retrieved (n=20). miR-181d-5p serum levels were compared among experimental groups. miR-181d-5p levels were increased in the HR group when compared to the PR (p=0.0001) and NR groups (p=0.0079). miR-181d-5p levels correlated with the number of aspirated follicles (p<0.0001), retrieved oocytes (p<0.0001), and mature oocytes (p=0.0002). Increased miR-181d-5p levels independently predict a high response (p=0.006), with Positive and Negative Predictive Values of 66.7% and 69.4%, respectively. miR-181d-5p was also detected in the ovarian tissue in a mouse model. Moreover, computational analysis of miR-181d-5p predicted targets and promoter region suggested that this miRNA might be involved in the regulation of key signaling pathways and biological processes for female reproductive biology. In conclusion, miR-181d-5p is a promising circulating predictor of high stimulation and potential mediator of the hypothalamus-pituitary-gonad axis, providing opportunities for the individualization of COS protocols.

Previous infection with SARS-CoV-2 impacts embryo morphokinetics but not clinical outcomes in a time-lapse imaging system.

The goal for the present study was to investigate whether previous infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may compromise embryo morphokinetics and implantation. For that, a historical cohort study was performed in a private university-affiliated in vitro fertilization center. The study included 1628 embryos from 88 patients undergoing intracytoplasmic sperm injection (ICSI) cycles. Patients were age-matched in a 1:3 ratio to either a coronavirus disease (COVID) group, including patients with a positive SARS-CoV-2 immunoglobulin test (n = 22 patients, 386 embryos), or a control group, including patients with a negative SARS-CoV-2 immunoglobulin test (n = 66, 1242 embryos). The effect of previous infection with SARS-CoV-2 on morphokinetic events and ICSI outcomes was evaluated. Embryos derived from patients in the COVID group presented longer time to pronuclei appearance and fading, time to form two, three, four and five cells, and time to blastulation. The durations of the third cell cycle and to time to complete synchronous divisions were also significantly increased in the COVID group compared with the control group, whereas known implantation diagnosis score Day 5 ranked significantly lower in the COVID group. No differences were observed between the COVID and control groups on clinical outcomes. In conclusion, patients planning parenthood, who have recovered from COVID-19 infection, must be aware of a possible effect of the infection on embryo development potential.

Consensus and Diversity in the Management of Varicocele for Male Infertility: Results of a Global Practice Survey and Comparison with Guidelines and Recommendations.

PURPOSE: Varicocele is a common problem among infertile men. Varicocele repair (VR) is frequently performed to improve semen parameters and the chances of pregnancy. However, there is a lack of consensus about the diagnosis, indications for VR and its outcomes. The aim of this study was to explore global practice patterns on the management of varicocele in the context of male infertility. MATERIALS AND METHODS: Sixty practicing urologists/andrologists from 23 countries contributed 382 multiple-choice-questions pertaining to varicocele management. These were condensed into an online questionnaire that was forwarded to clinicians involved in male infertility management through direct invitation. The results were analyzed for disagreement and agreement in practice patterns and, compared with the latest guidelines of international professional societies (American Urological Association [AUA], American Society for Reproductive Medicine [ASRM], and European Association of Urology [EAU]), and with evidence emerging from recent systematic reviews and meta-analyses. Additionally, an expert opinion on each topic was provided based on the consensus of 16 experts in the field. RESULTS: The questionnaire was answered by 574 clinicians from 59 countries. The majority of respondents were urologists/uro-andrologists. A wide diversity of opinion was seen in every aspect of varicocele diagnosis, indications for repair, choice of technique, management of sub-clinical varicocele and the role of VR in azoospermia. A significant proportion of the responses were at odds with the recommendations of AUA, ASRM, and EAU. A large number of clinical situations were identified where no guidelines are available. CONCLUSIONS: This study is the largest global survey performed to date on the clinical management of varicocele for male infertility. It demonstrates: 1) a wide disagreement in the approach to varicocele management, 2) large gaps in the clinical practice guidelines from professional societies, and 3) the need for further studies on several aspects of varicocele management in infertile men.

Ovarian stimulation with luteinizing hormone supplementation: the impact of timing on ovarian response and ICSI outcomes.

OBJECTIVE: To investigate whether the timing of rLH addition to rFSH during controlled ovarian stimulation (COS) impacts ovarian response and the outcomes of intracytoplasmic sperm injection (ICSI) cycles. METHODS: Data of 1278 patients undergoing ICSI between 2015 and 2018, in a private university-affiliated IVF center were analyzed. Patients were divided into groups according to the timing of LH addition to the COS protocol: Group LH-start (n=323), in which LH was administered since day 1 of ovarian stimulation; and Group LH-mid (n=955), in which LH was administered concomitantly with gonadotropin releasing hormone (GnRH) antagonist. Data were also stratified according to female age and response to COS. The outcomes of COS and ICSI were compared between the groups. RESULTS: For the general group and in patients aged ≥ 35 years, higher blastocyst development rates were in Group LH-mid compared to Group LH-start. In patients with poor response to COS (POR), higher fertilization rate, blastocyst development rate and implantation rate were observed in Group LH-mid. CONCLUSIONS: rLH supplementation in POR patients may improve laboratorial and clinical outcomes when started in the mid-follicular phase, in GnRH antagonist ICSI cycles.

High oocyte immaturity rates affect embryo morphokinetics: lessons of time-lapse imaging system.

RESEARCH QUESTION: Does oocyte immaturity rate affect morphokinetic events in a time-lapse imaging (TLI) system? DESIGN: Historical cohort study carried out in a private university-affiliated IVF centre. Injected oocytes (n = 3368) cultured in a TLI incubator, from intracytoplasmic sperm injection (ICSI) cycles (n = 474) carried out between March 2019 and December 2020, were analysed. The effects of immature oocyte rates (the number of germinal-vesicle and metaphase I oocytes by the number of retrieved oocytes in each cycle, on morphokinetic events) were investigated considering clustering of data using mixed models. Evaluated kinetic markers were pronuclei appearance (tPNa), timing to pronuclei fading (tPNf), timing to two (t2), three (t3), four (t4), five (t5), six (t6), seven (t7), and eight cells (t8), timing to morulae (tM) and timing to start of blastulation (tSB) and to blastulation (tB). Durations of the second (t3-t2) and third (t5-t3) cell cycles (cc2 and cc3, respectively) and timing to complete synchronous divisions s1 (t2-tPNf), s2 (t4-t3) and s3 (t8-t5) were also evaluated. RESULTS: Positive relationships were observed between oocyte immaturity rates and slower tPNa, tPNf, t2, t3, t4, t5, t6, t7, t8, tSB, tB and cc3. Multinucleation at two- and four-cell stages were positively correlated with oocyte immaturity rate. The KIDScore ranking was negatively correlated with oocyte immaturity rate. No associations were found between oocyte immaturity rate and clinical outcomes. CONCLUSIONS: Increasing oocyte immaturity rate correlates with delayed cell cleavage and blastulation. These findings highlight the importance of TLI for the identification and de-selection of slow-growing embryos for transfer, in cycles with high oocyte immaturity rate.

Ethics and IVF add-ons: We need to talk about it.

In vitro fertilization (IVF) 'add-ons' are adjunct treatments used in addition to standard IVF protocols, in an attempt to improve success rates. However, the benefits for add-ons are often not supported by high-quality evidence. Nevertheless, many infertile patients are willing to try anything that might help them to improve their chances of having a baby. Therefore, the use of add-ons has been widespread and has led to extensive debate and discussion. The goal of this manuscript was to discuss the ethics underling the use of adjunct therapies in clinical practice before their safety has been thoroughly ascertained. IVF patients are routinely offered and charged for a wide range of adjunct treatments that they are told may improve their chance of a live birth, despite there being no clinical evidence supporting such efficacy. Add-on treatments are well accepted by most infertile patients, especially those who have already started their IVF treatments. A particular concern is that many clinics around the world are advertising and offering clinical adjuncts to infertile couples undergoing IVF, however, information on add-ons is often inaccurate. Data concerning the lack of scientific evidence supporting add-on efficacy and whether an add-on may cause unanticipated harm or worsen treatment outcomes is not available on most websites. IVF patients are a vulnerable population, thus there is a need for transparency about interventions for IVF, including uncertainties and risks, to support patient decision-making regarding the use of certain adjunctive therapies. Such information can be provided by clear guidelines and effective regulation.

Paternal ageing impacts blastulation and the outcomes of pregnancy at different levels of maternal age: A clustering analysis of 21,960 oocytes and 3837 ICSI cycles.

The objective of this cross-sectional study was to investigate the impact of paternal age on the outcomes of intracytoplasmic sperm injection (ICSI) cycles at different values of maternal age. A total of 21,960 injected oocytes deriving from 3837 ICSI cycles performed between January 2014 and October 2020, performed in a private university-affiliated in vitro fertilization centre was included. The main effects of maternal and paternal age, as well as the effect of their product (interaction term) on embryo development and pregnancy outcomes were investigated considering the clustering of data. The coefficients for the interaction term were statistically significant for blastocyst development, top-quality blastocyst, implantation, pregnancy, miscarriage, and live-birth rates. For every 1-year increase in paternal age, the odds ratio of live-birth reduces by 1% in females aged 37 years, 1.6% in those aged 38 years, 2.4% in 39-year-old females, 5% in 42-year-old females and so on. An increase in the interaction term by 1 year decreases the pregnancy rate by 0.4% and live-birth rate by 0.8 and increases the miscarriage rate by 1.2%. The slopes of maternal age on blastulation, blastocyst quality, and implantation, pregnancy, miscarriage, and live-birth rate significantly changed (worsened) for every year increase in paternal age.

Improved embryonic development and utilization rates with EmbryoScope: a within-subject comparison versus a benchtop incubator.

The objective of this study was to investigate whether, in consecutive intracytoplasmic sperm injection (ICSI) cycles, embryonic development in an incubator with a time-lapse imaging (TLI) system is better than the previous one obtained in a benchtop incubator (G-185) with similar cultivation characteristics. The study was of a retrospective within-subject design, in which each cycle served as its own control. Data were obtained via the chart review of patients undergoing ICSI in a private university-affiliated in vitro fertilization (IVF) centre who fulfilled the following criteria: second ICSI attempt in which embryos were cultured in a TLI incubator system (TLI group, n = 71), preceded by a first ICSI attempt in which embryos were cultured in a benchtop incubator (Control group, n = 71). Embryonic development up to the fifth day of development, oocyte utilization rate (OUR; transferred embryos plus frozen embryos per total number of retrieved oocytes) and embryo utilization rate (EUR; transferred embryos plus frozen embryos per normally fertilized oocyte) were compared between the groups. There were significant differences in the day 2 non-cleavage rate, day 5 embryo rate, blastocyst development rate, frozen blastocyst rate, OUR, and EUR, in favour of the TLI group. Embryonic development, frozen blastocyst rate, OUR and EUR in the second ICSI cycle were significantly improved when the culture was performed in the EmbryoScope, compared with those rates obtained with culture in a G-185 in the first ICSI cycle of the same patients. The results may also lead to higher cumulative pregnancy outcomes following embryo thawing and transfer.

Post-Vasectomy Semen Analysis: Optimizing Laboratory Procedures and Test Interpretation through a Clinical Audit and Global Survey of Practices.

PURPOSE: The success of vasectomy is determined by the outcome of a post-vasectomy semen analysis (PVSA). This article describes a step-by-step procedure to perform PVSA accurately, report data from patients who underwent post vasectomy semen analysis between 2015 and 2021 experience, along with results from an international online survey on clinical practice. MATERIALS AND METHODS: We present a detailed step-by-step protocol for performing and interpretating PVSA testing, along with recommendations for proficiency testing, competency assessment for performing PVSA, and clinical and laboratory scenarios. Moreover, we conducted an analysis of 1,114 PVSA performed at the Cleveland Clinic's Andrology Laboratory and an online survey to understand clinician responses to the PVSA results in various countries. RESULTS: Results from our clinical experience showed that 92.1% of patients passed PVSA, with 7.9% being further tested. A total of 78 experts from 19 countries participated in the survey, and the majority reported to use time from vasectomy rather than the number of ejaculations as criterion to request PVSA. A high percentage of responders reported permitting unprotected intercourse only if PVSA samples show azoospermia while, in the presence of few non-motile sperm, the majority of responders suggested using alternative contraception, followed by another PVSA. In the presence of motile sperm, the majority of participants asked for further PVSA testing. Repeat vasectomy was mainly recommended if motile sperm were observed after multiple PVSA's. A large percentage reported to recommend a second PVSA due to the possibility of legal actions. CONCLUSIONS: Our results highlighted varying clinical practices around the globe, with controversy over the significance of non-motile sperm in the PVSA sample. Our data suggest that less stringent AUA guidelines would help improve test compliance. A large longitudinal multi-center study would clarify various doubts related to timing and interpretation of PVSA and would also help us to understand, and perhaps predict, recanalization and the potential for future failure of a vasectomy.

Dual trigger improves response to ovarian stimulation and ICSI outcomes in patients with a previous r-hCG triggered ICSI cycle.

OBJECTIVE: To evaluate if ovarian response to controlled ovarian stimulation (COS) and intracytoplasmic sperm injection (ICSI) outcomes are improved by the use of dual trigger (gonadotropin-releasing hormone (GnRH) agonists plus recombinant human chorionic gonadotropin (r-hCG)) in patients with previous cycles triggered with r-hCG. METHODS: This case-control study included 88 matched cycles performed in 88 patients, which had the first ICSI cycle triggered with r-hCG (n=44), and the following ICSI cycle with dual trigger (n=44). We compared the cycle outcomes between the groups. In a second case-control within-subject analyses, we compared the ICSI outcomes between patients which had the first ICSI cycle triggered with r-hCG only (n=18), and the following ICSI cycle with dual trigger (n=18) or r-hCG only (n=18). RESULTS: Upon investigating repeated cycles (r-hCG only vs. dual trigger), we found higher oocyte yield and mature oocyte rates, lower immature oocyte rates, higher fertilization rates, and higher blastocyst development rates; and higher rates of cycles with embryos transferred and implantation in the dual trigger cycle. CONCLUSIONS: The dual trigger regimen is a more effective approach than r-hCG trigger in patients with a previous r-hCG triggered ICSI cycle, yielding improved response to COS, and better laboratorial and clinical outcomes.

Maternal lifestyle and nutritional habits are associated with oocyte quality and ICSI clinical outcomes.

RESEARCH QUESTION: Do maternal lifestyle factors influence the incidence of oocyte dimorphisms and outcomes of intracytoplasmic sperm injection (ICSI) cycles? DESIGN: A total of 752 female patients undergoing an ICSI cycle at a private university-affiliated IVF centre from January 2015 to December 2019 were included in this historical cohort study. Before starting ovarian stimulation, participants completed a questionnaire on cigarette smoking habits, consumption of alcoholic beverages, refined sugar, artificial sweeteners, soft drinks, fruits, legumes and vegetables, milk and dairy, and meat, as well as exercise frequency over the past 6 months. Oocyte morphology was evaluated before ICSI. The influence of maternal lifestyle factors on the incidence of oocyte dimorphisms and ICSI outcomes was evaluated by multivariate general linear models and generalized linear models, adjusted for potential confounders. The main outcome measures were the incidence of oocyte dimorphisms per cycle and clinical outcomes. RESULTS: Lifestyle factors and nutritional habits such as cigarette smoking, and the consumption of alcohol, refined sugar and artificial sweeteners, were positively associated with incidence of several oocyte dimorphisms and negatively associated with the response to ovarian stimulation and embryo development. Negative relationships were also observed between these habits and clinical outcomes, apart from miscarriage rate, in which positive relationships were observed. Significant negative dose-dependent relationships between these habits and implantation rates were noted (P < 0.001). Alcoholic beverage consumption also showed inverse dose-dependent relationships with clinical pregnancy and live birth rates. Live birth rate was also negatively associated with cigarette smoking, in a dose-dependent manner. CONCLUSIONS: Poor maternal habits were associated with reduced oocyte quality and ICSI outcomes in this study. Many of these associations were shown to be dose-dependent.

Improving Implantation Rate in 2nd ICSI Cycle through Ovarian Stimulation with FSH and LH in GNRH Antagonist Regimen.

OBJECTIVE: To investigate whether patients with a previous recombinant follicle stimulating hormone (rFSH)-stimulated cycle would have improved outcomes with rFSH + recombinant luteinizing hormone (rLH) stimulation in the following cycle. METHODS: For the present retrospective case-control study, 228 cycles performed in 114 patients undergoing intracytoplasmic sperm injection (ICSI) between 2015 and 2018 in an in vitro fertilization (IVF) center were evaluated. Controlled ovarian stimulation (COS) was achieved with rFSH (Gonal-f, Serono, Geneva, Switzerland) in the first ICSI cycle (rFSH group), and with rFSH and rLH (Pergoveris, Merck Serono S.p.A, Bari, Italy) in the second cycle (rFSH + rLH group). The ICSI outcomes were compared among the groups. RESULTS: Higher estradiol levels, oocyte yield, day-3 high-quality embryos rate and implantation rate, and a lower miscarriage rate were observed in the rFSH + rLH group compared with the rFSH group. In patients < 35 years old, the implantation rate was higher in the rFSH + rLH group compared with the rFSH group. In patients ≥ 35 years old, higher estradiol levels, oocyte yield, day-3 high-quality embryos rate, and implantation rate were observed in the rFSH + rLH group. In patients with ≤ 4 retrieved oocytes, oocyte yield, mature oocytes rate, normal cleavage speed, implantation rate, and miscarriage rate were improved in the rFSH + rLH group. In patients with ≥ 5 retrieved oocytes, higher estradiol levels, oocyte yield, and implantation rate were observed in the rFSH + rLH group. CONCLUSION: Ovarian stimulation with luteinizing hormone (LH) supplementation results in higher implantation rates, independent of maternal age and response to COS when compared with previous cycles stimulated with rFSH only. Improvements were also observed for ICSI outcomes and miscarriage after stratification by age and retrieved oocytes.

OBJETIVO: Investigar se há algum efeito da suplementação com hormônio luteinizante (LH, na sigla em inglês) no regime com antagonista do hormônio liberador de gonadotropina (GnRH, na sigla em inglês) sobre os resultados dos ciclos consecutivos de injeção intracitoplasmática de espermatozoides (ICSI, na sigla em inglês). MéTODOS: Para o presente estudo retrospectivo de caso-controle, foram avaliados 228 ciclos de microinjeção intracitoplasmática de espermatozoides (ICSI, na sigla em inglês) realizados em 114 pacientes entre 2015 e 2018 em um centro privado de fertilização in vitro (FIV) afiliado a uma universidade. O estímulo ovariano controlado (EOC) foi feito com hormônio folículo- estimulante recombinante (rFSH, na sigla em inglês) (Gonal-f, Serono, Genebra, Suíça) no primeiro ciclo de ICSI (grupo rFSH), e com rFSH e rLH (Pergoveris, Merck Serono S.p.A, Bari, Itália) no segundo ciclo (grupo rFSH + rLH). Os desfechos dos ciclos de ICSI foram comparados entre os grupos. RESULTADOS: Níveis mais elevados de estradiol, de recuperação oocitária, taxa de embriões de alta qualidade no 3° dia e taxa de implantação, e menor taxa de aborto foram observados no grupo rFSH + rLH. Em pacientes < 35 anos, a taxa de implantação foi maior no grupo rFSH + rLH em comparação com o grupo rFSH. Em pacientes com ≥ 35 anos, maiores níveis de estradiol, recuperação oocitária, a taxa de embriões de alta qualidade no 3° dia e a taxa de implantação foram observados no grupo rFSH + rLH. Em pacientes com baixa resposta ao EOC (≤ 4 oócitos recuperados), a recuperação oocitária, a taxa de oócitos maduros, a taxa de velocidade normal de clivagem, a taxa de implantação e a taxa de aborto foram melhoradas no grupo rFSH + rLH. Em pacientes com resposta normal ao EOC (≥ 5 oócitos recuperados), níveis mais elevados de estradiol, recuperação oocitária e taxa de implantação foram observados no grupo rFSH + rLH. CONCLUSãO: A estimulação ovariana com suplementação de LH resultou em taxas de implantação mais altas, independentemente da idade materna e da resposta ao EOC, em comparação com os ciclos anteriores estimulados apenas com rFSH. Melhorias também foram observadas nos resultados da ICSI e na taxa de aborto quando as pacientes foram estratificadas por idade e número de oócitos recuperados.