Healthy live birth using theophylline in a case of retrograde ejaculation and absolute asthenozoospermia.

OBJECTIVE: To analyze whether the use of ready-to-use theophylline is a feasible option in a case of retrograde ejaculation and absolute asthenozoospermia. DESIGN: Case report. SETTING: In vitro fertilization unit of a public hospital. PATIENT(S): Thirty-one-year-old nulliparous woman, and 39-year-old male with retrograde ejaculation and absolute asthenozoospermia. INTERVENTION(S): Retrieval of postejaculatory urine, restoration of motility using a methylxanthine, intracytoplasmic sperm injection, single-embryo transfer. MAIN OUTCOME MEASURE(S): Sperm motility, fertilization, embryo quality, live birth. RESULT(S): Successful fertilization and a single-embryo transfer resulted in a healthy live birth. CONCLUSION(S): Theophylline turned out to be a safe, efficient agent for stimulating immotile spermatozoa in patients with retrograde ejaculation.

Application of a ready-to-use calcium ionophore increases rates of fertilization and pregnancy in severe male factor infertility.

OBJECTIVE: To analyze whether a ready-to-use calcium ionophore improves outcomes, from fertilization to live birth, in patients with severe male factor infertility. DESIGN: Artificial oocyte activation offered to applicable patients over a 20-month period. SETTING: Specialized in vitro fertilization (IVF) centers in Austria and Germany. PATIENT(S): Twenty-nine azoospermic and 37 cryptozoospermic men. INTERVENTION(S): Mature oocytes treated with a ready-to-use Ca(2+)-ionophore (GM508 Cult-Active) immediately after intracytoplasmic sperm injection (ICSI). MAIN OUTCOME MEASURE(S): Rates of fertilization, implantation, clinical pregnancy, and live birth. RESULT(S): Patients had had 88 previous cycles without artificial activation that resulted in a fertilization rate of 34.7%, 79 transfers (89.8%), and 5 pregnancies, which all spontaneously aborted except one. After artificial oocyte activation, the fertilization rate was 56.9%. In terms of fertilization rate, both azoospermic (64.4%) and cryptozoospermic (48.4%) men statistically significantly benefited from use of the ionophore. In 73 transfer cycles, positive ß-human chorionic gonadotropin levels were observed in 34 cases (46.6%) and 29 cycles (39.7%) that ended with a clinical pregnancy. The corresponding implantation rate was 33.3%. Four spontaneous abortions occurred (11.8%), and 32 healthy children were born. CONCLUSION(S): This is the first prospective multicenter study on artificial oocyte activation in severe male factor infertility. Present data indicate that a ready-to-use calcium ionophore can yield high fertilization and pregnancy rates for this particular subgroup. In addition to fertilization failure after ICSI, severe male factor infertility is an additional area for application of artificial oocyte activation.

Successful pregnancy in vitrified/warmed blastocyst intrafallopian transfer.

OBJECTIVE: To analyze whether the use of blastocyst intrafallopian transfer is a feasible option in a case of repeated difficult ET. DESIGN: Case report. SETTING: Public hospital. PATIENT(S): Forty-year old nulliparous patient. INTERVENTION(S): Transfer of two vitrified/warmed blastocysts into the right tube by means of laparoscopy. MAIN OUTCOME MEASURE(S): Successful ET, clinical pregnancy. RESULT(S): Successful ET procedure resulting in positive ß-hCG and clinical pregnancy. CONCLUSION(S): In cases of repeated difficult ETs (regardless of whether the patient shows cervical adhesions or any type of genital malformations), blastocyst intrafallopian transfer can be a successful alternative approach.

Assisting in vitro fertilization by manipulating cumulus-oocyte-complexes either mechanically or enzymatically does not prevent IVF failure.

OBJECTIVE: This prospective study was set up in order to analyze whether additional treatment (cutting off supernumerous cumulus cells; adding hyaluronidase) of the cumulus-oocyte-complex (COC) would help to improve treatment outcome. MATERIAL AND METHODS: COCs from 50 patients were prospectively subdivided into a control group A (no manipulation of COC) and two study groups. In group B, surplus cumulus cells were cut off using syringes, and in the second study group COCs were incubated with a 1:11 dilution of hyaluronidase (final concentration 7 IU/l). Main outcome measures were fertilization rate, embryo development, as well as rates of implantation, pregnancy, and live birth. RESULTS: Fertilization was higher in group C as compared to the untreated control group A (p<0.05). However, complete fertilization failure could not be avoided by any of the modified IVF approaches. Compaction on day 4 and blastocyst quality on day 5 were significantly improved in group C as compared to group B (but not to group A). Rates of implantation, pregnancy, and live birth were not affected by any of the methods. CONCLUSION: ICSI seems to be the only choice for avoiding the vast majority of fertilization failures after IVF.

Automatic user-independent zona pellucida imaging at the oocyte stage allows for the prediction of preimplantation development.

OBJECTIVE: To analyze whether a change in three-dimensional structure of the zona pellucida could indicate suboptimal gamete quality. DESIGN: Prospective study. SETTING: Women's general hospital. PATIENT(S): A total of 72 patients who gave informed consent. INTERVENTION(S): The birefringence of all oocytes was prospectively analyzed with an automatic user-independent polarization microscopy imaging system. MAIN OUTCOME MEASURE(S): Birefringence of the inner zona layer, preimplantation development, implantation, and pregnancy. RESULT(S): In approximately one third of all gametes (244/712), the system's automatic detection of the inner zona layer did not succeed. This phenomenon was a negative predictor of compaction (P<0.01), blastulation (P<0.001), and pregnancy (P<0.001). In cases of successful zona imaging, the score based on the birefringence of the inner zona layer was a strong predictor of blastocyst formation but not of embryo quality or pregnancy (P>0.05). Interestingly, antagonist protocol resulted in lower zona scores as compared with the long protocol (P<0.05). CONCLUSION(S): Combining the information from both undetected and detected oocytes, zona imaging was a helpful tool in oocyte selection. This knowledge might further help to reduce both the time in culture and the number of concepti considered for transfer.

Prognosis of oocytes showing aggregation of smooth endoplasmic reticulum.

Few cytoplasmic dysmorphisms of oocytes have been reported to negatively influence the further fate of the ova. One such anomaly, namely the central aggregation of the smooth endoplasmic reticulum (SER), has recently been associated with suboptimal outcome in a limited number of patients. In order to increase prognostic value, it was decided to prospectively screen all intracytoplasmic sperm injection patients within 1 year for eggs showing aggregations of SER. In addition, all deliveries (obstetric and neonatal data) were analysed. Occurrence of SER cluster was related to duration (P < 0.001) and dosage (P < 0.01) of the stimulation. Fertilization (58.9%) and blastulation rate (44.0%) were lower (P < 0.01) in affected ova compared with unaffected counterparts (77.4 and 87.8%, respectively). Pregnancies in women with affected gametes were accompanied by a higher incidence of obstetric problems (P < 0.01) leading to a non-significant trend towards earlier delivery and significantly reduced birthweight (P < 0.05). It is strongly recommended to avoid transfer of embryos/blastocysts derived from SER cluster-positive gametes. Patients have to be informed that even transfer of sibling oocytes without this anomaly involves a higher risk of detrimental outcome.

Is oocyte morphology prognostic of embryo developmental potential after ICSI?

Metaphase II-stage oocytes collected from patients following ovarian stimulation show varying qualities. Both nuclear and cytoplasmic maturation have to be completed in a co-ordinated mode to ensure optimal conditions for subsequent fertilization. Disturbances or asynchrony of these processes may result in different morphological abnormalities, depending on whether nuclear or cytoplasmic maturation has been affected. In this respect it has been suggested that dysmorphic features occurring early in meiotic maturation may be associated with a higher frequency of aneuploidy and fertilization failure, while those occurring late in maturation may cause a higher incidence of developmental failure. In fact, more than half of the gametes collected show morphological abnormalities, some of which seem to be correlated with an impaired outcome (e.g. aggregation of endoplasmic reticulum, vacuolization, increased ooplasmic viscosity, giant eggs). Therefore, it is strongly recommended to include oocyte quality in all scoring systems applied in IVF laboratories.

Predictive value of cumulus cell apoptosis with regard to blastocyst development of corresponding gametes.

OBJECTIVE: To test if a high degree of apoptosis in cumulus cells could indicate diminished oocyte quality and developmental competence. DESIGN: Prospective analysis. SETTING: Public hospital and university. PATIENT(S): Thirty seven women who gave written consent to participate in this study. INTERVENTION(S): Cumulus-oocyte complexes were denuded separately and the resulting cumulus cell suspensions were analyzed for presence of apoptosis using a terminal deoxynucleotidyl transferase-mediated digoxigenin-dUTP nick-end labeling (TUNEL) assay detection kit. MAIN OUTCOME MEASURE(S): Percentage of apoptotic cumulus cells and blastocyst formation rate. RESULT(S): Younger patients (< or = 35 years) showed significantly fewer apoptotic cumulus cells than older ones. In all patients gamete maturity was shown to be highly correlated to the rate of apoptosis in cumulus cells. At zygote and cleavage stages (days 1 to 4) no morphologic features were related to the degree of programmed cell death. However, blastocyst development was predictable taking into account the percentage of apoptosis in associated somatic cells. In addition, there was a trend toward better quality blastocysts from follicles with a lower rate of apoptotic cells. No influence on pregnancy and implantation rate was observed. CONCLUSION(S): Apoptotic processes within follicles seem to impair oocyte maturation. Though not manifested in the morphologic appearance, gametes and embryos derived from cumulus complexes with no or minor apoptosis have an increased chance of giving rise to optimal blastocysts.

Cytoplasmic pitting has a negative influence on implantation outcome.

PURPOSE: Since cytoplasmic pitting is a morphological phenomenon discussed controversially, this study was set up in order to assess the actual influence of cytoplasmic pitting on treatment outcome. METHODS: Four hundred and one patients undergoing 484 consecutive treatment cycles were evaluated retrospectively in order to assess the actual influence of pitting on treatment outcome. RESULTS: Pitting was found to be reduced in single culture as compared to group culture (p < 0.01). No correlation of cytoplasmic texture with rates of implantation and pregnancy could be observed, but a significantly higher proportion (p < 0.05) of gestational sacs vanished in the group with exclusive transfer of pitted embryos compared to the unaffected group. Obstetric and perinatal outcome was not affected. CONCLUSIONS: It is possible that culture conditions favor cytoplasmic pitting, a morphological phenomenon which, in the extreme case, may result in early loss of gestation sacs.

Occurrence and developmental consequences of vacuoles throughout preimplantation development.

OBJECTIVE: Since little is known about the actual incidence and fate of vacuoles at different stages of development this preliminary study was set up to accurately measure vacuoles and track them to day 5. DESIGN: Prospective study. SETTING: Women's General Hospital in Austria. PATIENT(S): A total of 223 consecutive IVF and intracytoplasmic sperm injection (ICSI) cycles (206 patients). INTERVENTION(S): Accurate measurement of vacuoles. Affected gametes and embryos were cultured individually and tracked until day 5. MAIN OUTCOME MEASURE(S): Size and number of vacuoles, fertilization rate, blastocyst formation rate, blastocyst quality. RESULT(S): There was a significant relationship between size of the vacuole (cut-off value 14 microm) and fertilization (P<.05). At zygote stage the incidence of vacuoles was higher (P<.01) in ICSI (11.6%) than in IVF (5.3%). Only 32.2% of affected ICSI-embryos reached blastocyst stage on day 5 compared with 53.0% of the normal ones (P<.001). In terms of blastocyst formation vacuolization on day 4 (P<.001) turned out to be the most severe one. At blastocyst stage inner cell mass was affected less frequently than the trophectoderm (P<.05). CONCLUSION(S): Three types of vacuoles could be identified: (1) those already present at oocyte collection, which develop during maturation (day 0); (2) those artificially created by ICSI (day 1); and (3) those accompanied with developmental arrest (day 4). The later that vacuoles arose, the more detrimental their effect on blastocyst formation.

Successful birth after laser assisted immobilization of spermatozoa before intracytoplasmic injection.

OBJECTIVE: To describe the first ICSI pregnancy achieved with sperm that were immobilized by using a noncontact diode laser. DESIGN: Case report. SETTING: Fertility center. PATIENT(S): A 36-year-old woman who had had primary infertility for 9 years. INTERVENTION(S): Sperm immobilization by using a 1.48-microm wavelength diode laser and subsequent ICSI. MAIN OUTCOME MEASURE(S): Fertilization and cleavage rates and pregnancy. RESULT(S): Transfer of two embryos with minor fragmentation led to a single pregnancy. The patient delivered a healthy baby in week 38 of gestation. CONCLUSION(S): Use of a noncontact diode laser for sperm immobilization may be a useful alternative to the conventional mechanical approach.