Comparison of in vitro fertilization outcomes in ICSI cycles after human sperm preparation by density gradient centrifugation and direct micro swim-up without centrifugation.

OBJECTIVE: The aim of this study was to evaluate the efficacy of a non-expensive, easy and fast technique (direct micro swim-up) for sperm preparation in intracytoplasmic sperm injection (ICSI) treatments without the use of centrifuge. METHODS: We carried out a multicentric study in which a total of 140 ICSI-cycles were included. Sibling oocytes were divided into two groups according to semen preparation procedures: group A, discontinuous gradients (DG) (oocytes n=668), and group B, direct micro swim-up (MSU) (oocytes n=660). We analyzed differences in some key performance indicators. RESULTS: Fertilization rates were not statistically different between the DG and MSU groups (76.0% vs. 81.8%, respectively, p=0.248); while significant differences were found in blastulation rates per fertilized oocytes (41.7% vs. 58.5%, p=0.009), blastulation rates per D3 embryos (46.1% vs. 63.7%, p=0.045), and pregnancy rates (25.8% vs. 41.9%, p=0.045). The abortion rate was reduced in the MSU group as compared to DG, but not in a significant manner (12.9% vs. 29.4%, p=0.161). CONCLUSION: The MSU procedure has the advantage of reducing costs, time and mismatches, while ensuring comparable, and in some cases, better results than DG treatments. This technique can therefore be used as an alternative method to other conventional semen treatments.

Non-invasive preimplantation genetic screening using array comparative genomic hybridization on spent culture media: a proof-of-concept pilot study.

The aim of this pilot study was to assess if array comparative genomic hybridization (aCGH), non-invasive preimplantation genetic screening (PGS) on blastocyst culture media is feasible. Therefore, aCGH analysis was carried out on 22 spent blastocyst culture media samples after polar body PGS because of advanced maternal age. All oocytes were fertilized by intracytoplasmic sperm injection and all embryos underwent assisted hatching. Concordance of polar body analysis and culture media genetic results was assessed. Thirteen out of 18 samples (72.2%) revealed general concordance of ploidy status (euploid or aneuploid). At least one chromosomal aberration was found concordant in 10 out of 15 embryos found to be aneuploid by both polar body and culture media analysis. Overall, 17 out of 35 (48.6%) single chromosomal aneuploidies were concordant between the culture media and polar body analysis. By analysing negative controls (oocytes with fertilization failure), notable maternal contamination was observed. Therefore, non-invasive PGS could serve as a second matrix after polar body or cleavage stage PGS; however, in euploid results, maternal contamination needs to be considered and results interpreted with caution.

Reproductive outcome in European and Middle Eastern/North African patients.

The aim of this retrospective cohort study was to assess differences in infertility-related baseline characteristics and IVF outcome between European and Middle Eastern/North African (MENA) patients. Of 2703 patients undergoing their first IVF cycle, 2485 were Caucasian of European descent and 218 originated from the MENA region. MENA patients were significantly younger (30.6 versus 34.0 years, P < 0.001), less likely smokers, with higher body mass indexes. Infertility duration was longer in MENA patients (P < 0.001), their male partners were younger (P < 0.001) and smoked more often than European male patients (P = 0.005). Male factor infertility (P = 0.017) and polycystic ovary syndrome (PCOS; P = 0.032) was more prevalent in MENA patients, showed significantly higher basal FSH concentrations (P = 0.012) and significantly fewer oocytes retrieved (RR 0.83, 95% CI 0.74-0.93, P = 0.001). Clinical pregnancy rates were comparable (22.4% [European] versus 22.9% [MENA]). Fewer MENA patients had surplus embryos cryopreserved (OR 0.41, 95% CI 0.22-0.76, P = 0.004). Despite younger age and higher prevalence of PCOS, MENA patients had significantly lower oocyte yields than their European counterparts (P = 0.001). These findings suggest a more rapid decline in ovarian function in women of MENA descent.

Correction: Increasing Live Birth Rate by Preimplantation Genetic Screening of Pooled Polar Bodies Using Array Comparative Genomic Hybridization.

[This corrects the article DOI: 10.1371/journal.pone.0128317.].

Increasing live birth rate by preimplantation genetic screening of pooled polar bodies using array comparative genomic hybridization.

Meiotic errors during oocyte maturation are considered the major contributors to embryonic aneuploidy and failures in human IVF treatment. Various technologies have been developed to screen polar bodies, blastomeres and trophectoderm cells for chromosomal aberrations. Array-CGH analysis using bacterial artificial chromosome (BAC) arrays is widely applied for preimplantation genetic diagnosis (PGD) using single cells. Recently, an increase in the pregnancy rate has been demonstrated using array-CGH to evaluate trophectoderm cells. However, in some countries, the analysis of embryonic cells is restricted by law. Therefore, we used BAC array-CGH to assess the impact of polar body analysis on the live birth rate. A disadvantage of polar body aneuploidy screening is the necessity of the analysis of both the first and second polar bodies, resulting in increases in costs for the patient and complex data interpretation. Aneuploidy screening results may sometimes be ambiguous if the first and second polar bodies show reciprocal chromosomal aberrations. To overcome this disadvantage, we tested a strategy involving the pooling of DNA from both polar bodies before DNA amplification. We retrospectively studied 351 patients, of whom 111 underwent polar body array-CGH before embryo transfer. In the group receiving pooled polar body array-CGH (aCGH) analysis, 110 embryos were transferred, and 29 babies were born, corresponding to live birth rates of 26.4% per embryo and 35.7% per patient. In contrast, in the control group, the IVF treatment was performed without preimplantation genetic screening (PGS). For this group, 403 embryos were transferred, and 60 babies were born, resulting in live birth rates of 14.9% per embryo and 22.7% per patient. In conclusion, our data show that in the aCGH group, the use of aneuploidy screening resulted in a significantly higher live birth rate compared with the control group, supporting the benefit of PGS for IVF couples in addition to the suitability and effectiveness of our polar body pooling strategy.

Suppression of ovarian function by a combined oral contraceptive containing 0.02 mg ethinyl estradiol and 2 mg chlormadinone acetate given in a 24/4-day intake regimen over three cycles.

OBJECTIVE: To describe the suppression of ovarian function with 0.02 mg ethinyl E(2)-2 mg chlormadinone acetate administered in a 24/4-day intake regimen in healthy women. DESIGN: Open, uncontrolled, multiple dosing, phase II trial. SETTING: Single clinic. PATIENT(S): Forty women treated. INTERVENTION(S): Treatment for up to three cycles with 0.02 mg ethinyl E(2)-2 mg chlormadinone acetate given in a 24/4-day regimen. MAIN OUTCOME MEASURE(S): Assessments of ovarian function classified by the Hoogland and Skouby score, thickness of endometrium, cervical reaction, and sex hormone levels, as well as overall tolerability. RESULT(S): No ovulation was observed in the per protocol set (N=36), and one in the full analysis set (N=38) after vomiting and diarrhea. Absence of ovarian activity, residual ovarian activity, and formation of a luteinized unruptured follicle were observed in 75.0%, 15.9%, and 1.1% of medication cycles, respectively. Endometrial thickness was suppressed to 4 to 5 mm compared with 10 to 12 mm without medication. Cervical reaction was negative. Hormone levels were lower with medication than without, and the medication was well tolerated. Treatment-related adverse events were typical of those associated with hormonal contraceptive use. CONCLUSION(S): Follicular development, cervical reaction, and endometrial thickness were suppressed profoundly after 0.02 mg ethinyl E(2)-2 mg chlormadinone acetate administration in a 24/4-day regimen, resulting in inhibition of ovulation and unfavorable conditions for fertilization, implantation, and thus pregnancy.

Previous tubal ectopic pregnancy raises the incidence of repeated ectopic pregnancies in in vitro fertilization-embryo transfer patients.

PURPOSE: To investigate the incidence of Tubal Ectopic Pregnancies (TEP) in IVF-ET patients with respect to the status of the fallopian tubes after a previous TEP. MATERIAL AND METHODS: This retrospective study compares patients undergoing 481 IVF-ET cycles after conservatively or surgically treated TEP(s) with a Control Group (idiopathic or male factor for IVF-ET indication). Medical reports of surgery and/or hysterosalpingograms prior to the IVF cycles classified the status of the fallopian tubes. RESULTS: 12 TEPs (8.95%/Pregnancies (PR)) occurred in the Study Group. In the Control Group one TEP (0.75%/PR; p < 0.001) was found. Smoking increased the probability of TEPs (p = 0.0028) and of pathological pregnancies (abortion, biochemical and ectopic PR; (p = 0.0411)). For statistic evolution logistic regression (PROC GENMOD) and a repeated measure model were applied. CONCLUSION: Women with a previous TEP should be informed about the significantly increased risk for a further TEP in IVF-ET treatment, especially if they are smoking.

The forgotten variable: impact of luteinizing hormone on the prediction of ovarian reserve.

The impact of basal LH levels in the prediction of ovarian function in women initiating fertility treatment remains controversial. The present study demonstrates high-normal basal LH levels as a good, and low-normal basal LH levels as a negative prognostic sign for oocyte yield in regular-cycling women with borderline basal FSH levels (10.1-15 mU/mL).

Age-specific FSH levels as a tool for appropriate patient counselling in assisted reproduction.

BACKGROUND: The purpose of this study was to assess whether, even within a normal FSH range (< or =10 mU/ml), age-specific FSH levels are predictive of ovarian reserve. METHODS: Between January 1998 and December 2001, 535 women, undergoing controlled ovarian stimulation with 225 IU of recombinant (rec) FSH and 75 IU of recLH, were included in this retrospective cohort study. Criteria for enrolment were: age 25-40 years, basal FSH (b-FSH) < or =10 mU/ml and basal LH < or =12 mU/ml. Patients were assigned to three age groups (group I: 25-29 years; group II: 30-35 years; and group III: 36-40 years). Each age group was divided into quartiles according to b-FSH levels, comparing the lowest and highest b-FSH quartiles for basal hormonal patterns and outcome-related parameters. RESULTS: At ages 25-35 years, women in the lowest FSH quartiles demonstrated significantly increased numbers of oocytes at retrieval (group I: low b-FSH quartile 8.4 +/- 3.7 versus high b-FSH quartile 6.4 +/- 2.7, P < 0.02; group II: 7.5 +/- 4.0 versus 6.3 +/- 3.0, P < 0.047), whereas no difference with regard to oocyte yield was observed in patients above age 35 (group III: low b-FSH quartile 5.5 +/- 3.1 versus high b-FSH quartile 5.6 +/- 3.5). No statistical correlation was found between FSH quartiles and clinical pregnancy rates or miscarriage. CONCLUSIONS: In young women, age-specific high b-FSH levels, even within normal ranges, are associated with significantly reduced numbers of oocytes retrieved. B-FSH concentrations should, therefore, be interpreted in an age-specific manner to allow for appropriate patient counselling in IVF.

Abnormal embryonic development diagnosed embryoscopically in early intrauterine deaths after in vitro fertilization: a preliminary report of 23 cases.

OBJECTIVE: To provide data about the phenotypic appearance of the embryo of early failed pregnancies after IVF. DESIGN: Clinical prospective descriptive study. SETTING: Tertiary care center. PATIENT(S): Twenty-three women who had conceived by IVF and had a missed abortion before 12 weeks of gestation. INTERVENTION(S): Embryoscopic examination of the embryo before curettage. Cytogenetic analysis of the chorionic villi by standard G-banding cytogenetic techniques or by comparative genomic hybridization in combination with flow cytometry analysis. MAIN OUTCOME MEASURE(S): Embryonic phenotype and karyotype were determined. RESULT(S): Twenty-one of 23 IVF embryos showed structural defects on embryoscopic examination. Seventeen of 23 specimens had a chromosomal abnormality. The majority were numerical aberrations such as monosomy X (2 cases). Trisomies for chromosomes 18 (one case), 16 (three cases), 15 (one case), 14 (two cases), 13 (one case), 12 (one case), 11 (one case), 10 (one case), 9 (one case), 8 (one case), and 3 (one case) were observed. A structural chromosome anomaly leading to a chromosomal trisomy was observed in one case. Aneuploidy explained the grossly abnormal embryonic development documented by embryoscopy in 15 of 21 cases. CONCLUSION(S): Aneuploidy is the major factor affecting normal embryonic development in missed abortions after IVF. Further investigation is needed to elucidate mechanisms that might prevent normal embryogenesis but evade detection by the cytogenetic techniques used in the present study.

Preimplantation diagnosis (PGD)--a European clinician's point of view.

This paper describes the current status of preimplantation diagnosis from the viewpoint of an experienced clinician specialized in reproductive medicine. Current progress and international experiences with different applications and techniques are being reviewed on the basis of the literature. Particular interest is focused on possible advantages of routinely diagnosing major chromosome aneuploidies in preimplantation-embryos of patients undergoing in vitro fertilization and embryo transfer. Last but not least, a short survey of the international guidelines and legislation is compared to the situation in the author's country, Austria, where it is currently unclear whether preimplantation diagnosis is allowed or not.

Minimal stimulation using recombinant follicle-stimulating hormone and a gonadotropin-releasing hormone antagonist in women of advanced age.

OBJECTIVE: To determine whether minimal stimulation with short-term application of low-dose recombinant follicle-stimulating hormone (FSH) together with a gonadotropin-releasing hormone (GnRH) antagonist represents a cost-effective treatment regimen for patients with elevated FSH levels, aged 40 and above. DESIGN: Retrospective cohort study. SETTING: Academically affiliated private in vitro fertilization (IVF) program. PATIENT(S): Eighty-five IVF cycles using minimal ovarian stimulation and 85 cycles with a standard long-stimulation protocol, conducted between January 2000 and January 2002, in women aged 40 and above who had slightly increased FSH levels. INTERVENTION(S): Patients on the long protocol underwent standard cycle monitoring and stimulation. In contrast, women with minimal stimulation had transvaginal sonography initiated on day 8 of the menstrual cycle and at a follicle size of 13 mm. We administered 0.25 mg of GnRH antagonist and 75 IU recombinant FSH daily until ovulation induction. MAIN OUTCOME MEASURE(S): Numbers of oocytes, and rates of cancellation and pregnancy. RESULT(S): Minimal stimulation cycles resulted in a clinical pregnancy rate of 8.2% per started cycle and 10% per embryo transfer (ET), whereas the control group yielded a clinical pregnancy rate of 10.6% per started cycle and of 10.7% per ET (not statistically significant). CONCLUSION(S): In women aged 40 and above with abnormal FSH levels, minimal stimulation protocol achieves similar pregnancy rates to a standard protocol, and thus represents a cost-effective alternative.

[Preimplantation diagnosis (PID) in humans from the clinical viewpoint]. / Uber die Präimplantationsdiagnostik (PID) beim Menschen aus klinischer Sicht.

This paper describes the current status of preimplantation diagnosis from the viewpoint of an experienced clinician specialized in reproductive medicine. Current progress and international experience with different applications and techniques are reviewed on the basis of the literature. Particular interest is focused on possible advantages of routinely diagnosing major chromosome aneuploidies in preimplantation-embryos of patients undergoing in vitro fertilization and embryo transfer. Last but not least, a short survey of the international guidelines and legislation is compared to the situation in Austria where it is currently unclear whether preimplantation diagnosis is allowed or not.

A prospective randomized multicenter study to evaluate the best day for embryo transfer: does the outcome justify prolonged embryo culture?

PURPOSE: This study aimed to evaluate the best day for embryo transfer in a prospective unrestricted randomized multicenter trial. METHODS: Data were collected on a preformed Excel-sheet which contained random numbers from 1 to 5 for each subsequent patient as a preprogrammed day for embryo transfer. Information was requested on patient's age, indication for sterility treatment, stimulation protocol used, numbers of oocytes retrieved, fertilized oocytes, cryopreserved embryos, and cell stage of embryos transferred. RESULTS: A total of 329 embryo transfers were performed, resulting in 106 clinical pregnancies (32.2%). Pregnancy rates achieved were 20.0% on day 1, 30.4% on days 2 and 3, and 50.0% on days 4 and 5 (p = 0.03). CONCLUSIONS: Within the scope of the present randomized multicenter trial, embryo transfers performed on days 4 and 5 enhanced the pregnancy rate significantly, compared to those of days 1, 2, and 3.

Do lunar cycles influence in vitro fertilization results?

PURPOSE: Our objective was to investigate the lunar influence on IVF-ET outcomes. METHODS: Between 1992 and 1999 we have completed 7572 preprogrammed IVF-ET treatment cycles with the same stimulation protocol in two outpatient units. (Vienna, Austria and Budapest, Hungary) Multiple regression (SAS; proc Logistic) and two separate analyses were performed on pregnancy rates using a harmonic sinoidal trend based on the synodic and anomalistic lunar cycles respectively. RESULTS: The overall pregnancy rate was 30.9%. The amplitude of harmonic sinoidal, trend for the synodic lunar cycles was chi2 = 1.63,2d.f., p = 0.44 and chi2 = 6.27,2d.f., p = 0.044 for the anomalistic moon periods. For the anomalistic lunar months the amplitude of harmonic sinoidal trend was borderline in terms of higher pregnancy rates with the moon in Perigee. CONCLUSION: The cause of seasonal changes in IVF-ET outcomes is probably very complex. Our results indicate that lunar influence may only be one of the contributing factors. Further studies are needed to clarify unexplained fluctuations of pregnancy outcomes.

Comparison of stimulation with clomiphene citrate in combination with recombinant follicle-stimulating hormone and recombinant luteinizing hormone to stimulation with a gonadotropin-releasing hormone agonist protocol: a prospective, randomized study.

OBJECTIVE: To compare IVF-ET outcome with a new stimulation protocol using clomiphene citrate (CC) with recombinant FSH and LH to stimulation with the standard long GnRH-a protocol. DESIGN: Prospective randomized study. SETTING: Outpatient infertility clinic in Vienna, Austria. PATIENT(S): Two hundred ninety-four infertile women undergoing IVF-ET; 154 IVF cycles stimulated with CC + recombinant FSH + recombinant LH (group A) and 140 cycles with long GnRH-a suppression + recombinant FSH (group B). INTERVENTION(S): Controlled ovarian hyperstimulation, egg retrieval, and ET. MAIN OUTCOME MEASURE(S): Cycle parameters (number of oocytes, fertilization, number of embryos) and outcome (pregnancy rate, cancellation rate, ovarian hyperstimulation syndrome [OHSS]). RESULT(S): Pregnancy rate per ET was 42.9% (implantation rate, 21.3%) in group A and 36.6% (17.4%) in group B. Cancellation rates were similar. The OHSS occurred in four cases (3%) in group A and 12 cases (10%) in group B. CONCLUSION(S): Stimulation with CC + recombinant FSH + recombinant LH leads to comparable pregnancy rates vs. the long protocol. With this new stimulation, less gonadotropins are used and there is less need for monitoring (lower cost for patient and clinic). The risk of OHSS is reduced as well. Therefore, this protocol should be regarded as the first-line treatment.

Ascorbic acid supplement during luteal phase in IVF.

PURPOSE: To evaluate the impact of ascorbic acid of different doses as additional support during luteal phase in infertility treatment by means of a prospective, randomized, placebo-controlled, group comparative, double-blind study. METHODS: Voluntary daily oral intake of either ascorbic acid (1, 5, or 10 g/day) or Placebo for 14 days after follicle aspiration for IVF-ET procedure. Data was obtained on 620 cases of women, age <40 years, undergoing first IVF-embryo transfer cycles in two private outpatient infertility clinics. All women were stimulated by the same protocol. The mean age was 31.73 (+/- 4.4 SD) years. RESULTS: No differences in clinical pregnancy rate and implantation rate were noted in statistical logistic regression analysis between the four intake groups. CONCLUSIONS: There was no clinical evidence of any beneficial effect, as defined by main outcome measures, of ascorbic acid on IVF-ET. Our data suggest there is no obvious value of high dosed intake of vitamin C during luteal phase in infertility treatment.