Insights from clinical experience in treating IVF poor responders.

'Poor responders' is a term used to describe a subpopulation of IVF patients who do not respond well to ovarian stimulation with gonadotrophins. While there is no standard definition of a poor responder, these patients tend to be of advanced maternal age (≥40 years), have a history of poor ovarian response with conventional stimulation protocols, and/or have low ovarian reserve. Despite the heterogeneity of this patient group, there are characteristics and needs common to many poor responders that can be addressed through a holistic approach. Stimulation during the earlier stages of follicle maturation may help synchronize follicle development for improved response to later gonadotrophin stimulation, and supplementation with dehydroepiandrosterone or human growth hormone may promote early follicle development in poor responders. IVF protocols should be specifically tailored to poor responders to complement the patient's natural cycle. Because poor responders tend to have high levels of stress and anxiety, patients should receive psychological counselling and support, both prior to and during IVF cycles, to ensure optimal outcomes and improve patients' experience. It is important to set realistic expectations with poor responders and their partners to help patients make informed decisions and better manage their distress and anxiety.

Casting for determinants of blastocyst yield and of rates of implantation and of pregnancy after blastocyst transfers.

OBJECTIVE: To identify determinants of blastocyst yield, implantation rate, and pregnancy outcome. DESIGN: Retrospective analysis of outcomes of 1,653 cycles of IVF. SETTING: Private infertility clinic. PATIENT(S): Couples presenting to an infertility clinic for IVF. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Blastocyst yield, implantation rate, and pregnancy. RESULT(S): Of a broad array of potential determinants, only the total numbers of oocytes retrieved and properties of day 3 embryos were consistently predictive of blastocyst formation. Relative to numbers of oocytes fertilized by intracytoplasmic sperm injection (ICSI), yields of quality blastocysts were highest in cycles in which <10 oocytes were retrieved. Blastocyst yield was closely linearly correlated with average numbers of blastomeres in embryos on day 3. As oocyte yields rose, average grades and the implantation potential of the blastocysts selected for transfer increased by approximately 0.015 and 0.15%, respectively, for each additional oocyte. Independently, the implantation potential of blastocysts decreased 1.1% for each advancing year in age of the oocyte provider, and, for autologous transfers, uterine receptivity declined an additional 0.6% per year. Higher yields of blastocysts from cycles with high oocyte numbers afforded better selection of blastocysts for transfer, supporting higher overall implantation and pregnancy rates. CONCLUSION(S): While the proportion of fertilized oocytes that progressed to quality blastocysts diminished as numbers of recovered oocytes rose, rates of implantation and pregnancy after transfer of the selected best blastocysts increased. The age of the oocyte provider and oocyte yields independently impacted blastocyst implantation potential and uterine receptivity after controlled ovarian hyperstimulation, ICSI, and blastocyst transfer.

Age thresholds for changes in semen parameters in men.

OBJECTIVE: To determine whether age thresholds for elements of semen quality exist. DESIGN: Retrospective analysis (covariance and point-change analysis) of results of 4,822 semen analyses and 259 fluorescence in situ hybridization (FISH) analyses. SETTING: Reference laboratory within an infertility clinic. PATIENT(S): A total of 5,081 men aged 16.5-72.3 years. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Ejaculate volume, sperm concentration, sperm motility, sperm motion parameters, strict morphology, and results of FISH analysis. RESULT(S): Measured parameters of ejaculates did not change before 34 years of age. Immediately thereafter, total sperm numbers (and total motile) declined. Sperm concentration and the proportion of sperm of normal morphology declined after 40 years. Sperm motility and progressive parameters of motile sperm fell after 43 years and ejaculate volume after 45 years. The ratio of Y:X-bearing sperm in ejaculates decreased only after 55 years. CONCLUSION(S): Our findings project a declining likelihood of pregnancy following intercourse with men >34 years old, independent from the woman's age and increasing with advancing age. Age-related mechanisms associated with this oligoasthenoteratozoospermic progression are discussed.

The rate at which serum total beta-subunit human chorionic gonadotropin increases after embryo transfer is a predictor of the viability of pregnancy and an identifier of determinants of pregnancy.

OBJECTIVE: To determine whether elements of treatment associated with faster doubling times of total beta-hCG in serum (beta-t2) in pregnant patients are also associated with a higher likelihood of pregnancy in all patients. DESIGN: Retrospective analysis of beta-t2 values, elements of ovarian stimulation (COH), and outcomes. SETTING: Private assisted reproductive technology (ART) center. PATIENT(S): Initial analysis of data from 432 cycles in which conception occurred after COH and embryo transfer, followed by analysis of pregnancy outcomes after 1,287 cycles of COH/ embryo transfer. INTERVENTION(S): No interventions. MAIN OUTCOME MEASURES: The beta-t2 values initially computed from consecutive serum beta-hCG levels in ongoing pregnancies were correlated with multiple properties of the patients and their treatment cycles. RESULT(S): The beta-t2 values during early pregnancy increased exponentially from about 1.6 days at 12 days to about 3.0 days at 24 days after embryo transfer. In those pregnancies which spontaneously aborted, early average beta-t2 values were higher than those for ongoing pregnancies; absolute beta-hCG levels did not differ. Positive correlations were established between beta-t2 values, the number of days of stimulation, and the number of ampules of drug administered per oocyte retrieved. The beta-t2 values were inversely related to average numbers of blastomeres in transferred embryos. Ongoing pregnancy rates (PR) were higher for cycles with lower gonadotropin dosages per oocyte retrieved, and when the average number of blastomeres in transferred embryos was higher. CONCLUSION(S): Steeper beta-hCG doubling times in early pregnancy were associated with lower gonadotropin dosages during ovarian stimulation and with higher numbers of blastomeres in transferred embryos. The latter variables were, in turn, associated with a higher likelihood of pregnancy after embryo transfer.

Embryo fragmentation as a determinant of blastocyst development in vitro and pregnancy outcomes following embryo transfer.

OBJECTIVE(S): To determine how the type of embryo fragmentation on day 3 affects progression of human embryos to blastocyst and pregnancy rates following embryo transfer. STUDY DESIGN: Retrospective analysis of all in vitro fertilization cycles in patients < or =40 years of age or younger from January 2002 through December 2003, during which time surplus day 3 embryos were transferred to blastocyst medium for extended culture. All embryos (4 cells or more) not suitable for transfer or freezing 72 hours following in vitro fertilization were placed into microdroplets (60 microL) of blastocyst medium and cultured for an additional 48 hours to assess blastocyst formation. Normal blastocyst development required blastulation, a visible inner-cell mass, trophectoderm cells covering 60% of the inner zona surface and thinning of the zona. The rate of blastocyst formation was then analyzed (chi 2 and analysis of variance) against the type of fragmentation 72 hours after insemination. Pregnancy outcomes were analyzed with respect to the pattern of fragmentation in cleaving embryos transferred after 3 days of culture. RESULTS: A total of 1566 embryos were cultured beyond day 3 of development of which 229 (14.6%) reached the blastocyst stage and were frozen. Embryos exhibiting no fragmentation or type I fragmentation had significantly higher blastocyst development rates (27.9% and 19.9%) than embryos with type 2 or 3 fragmentation (13.9 and 8.8, respectively; P < .001). No embryos with type 4 or 5 fragmentation progressed to blastocyst. The average type of fragmentation in transferred embryos correlated with pregnancy outcome and embryo age. CONCLUSION(S): More pervasive embryo fragmentation was associated with a decreasing rate of blastocyst development with day 3 embryos. To the extent that blastocyst development rates of day 3 embryos is an index of embryo viability, our findings establish that careful classification of the type of embryo fragmentation is important in selection of day 3 embryos for transfer. Recent reports of associations among embryo fragmentation, aneuploidy, apoptosis, and patient age support these conclusions.

A Markov model of the cost-effectiveness of human-derived follicle-stimulating hormone (FSH) versus recombinant FSH using comparative clinical trial data.

This study compared the cost and effectiveness of highly purified, human-derived follicle-stimulating hormone (FSH) (Bravelle) to recombinant FSH (Follistim) using Markov modeling and Monte Carlo simulation. One IVF treatment cycle resulted in costs of 11,584 dollars +/- 211 dollars for human-derived FSH and 12,762 dollars +/- 170 dollars for recombinant FSH, while three treatment cycles, holding the transition probabilities of the first cycle constant for the next two cycles, resulted in costs of 22,712 dollars +/- 1,107 dollars for human-derived FSH and 24,935 dollars +/- 1,205 dollars for recombinant FSH.

Evaluation of mixed protocols with Bravelle (human-derived FSH) and Repronex (hMG) to assess clinical efficacy (EMBRACE) in women undergoing in vitro fertilization.

OBJECTIVE: To compare the efficacy and safety of three different ratios of human-derived follicle-stimulating hormone/human menopausal gonadotropin (human-derived FSH:hMG, Bravelle and Repronex) mixed together in the same syringe and administered subcutaneously once daily, to in vitro fertilization (IVF) patients <34 years or 34 to 40 years of age. DESIGN: Two randomized, prospective, age stratified, IVF studies. SETTING: Twenty-one academic and private clinics with experience in IVF/embryo transfer (ET). PATIENT(S): Infertile premenopausal women undergoing IVF-ET. INTERVENTION(S): Pituitary suppression with leuprolide acetate, randomization to one of three treatment groups, followed by gonadotropin stimulation (GS) for up to 15 days. The human-derived FSH:hMG ratios were the following: Group 1, a 1:1 ratio throughout; Group 2, a 3:0 ratio that was changed to 1:1 after GS day 5; Group 3, a 2:1 ratio that was increased to 3:1, 4:1, or 5:1 after GS day 5, as needed. MAIN OUTCOME MEASURE(S): Mean number of oocytes retrieved; peak estradiol levels; dose and duration of stimulation; implantation rates; adverse events; injection site pain; and pregnancy and live birth rates. RESULT(S): Overall, women <34 years had higher E(2) levels, more oocytes retrieved, and improved implantation and live birth rates compared with women 34 to 40 years old. Nonetheless, each ratio of human-derived FSH:hMG produced comparable implantation rates, and continuing pregnancy and take-home baby rates. CONCLUSION(S): All three ratios of human-derived FSH:hMG in both age groups produced comparable pregnancy and live birth rates with similar safety results.

Potential factors affecting embryo survival and clinical outcome with cryopreserved pronuclear human embryos.

OBJECTIVE: This study was undertaken to determine whether the method of fertilization has a significant impact on survival and/or clinical pregnancy rates of cryopreserved human pronuclear (2PN) stage embryos. DESIGN: A retrospective analysis of cryosurvival and clinical pregnancy rates after thawing of 2PN stage embryos from January 2000 through December 2002 in a private Assisted Reproductive Technology (ART) center. MATERIAL AND METHODS: A total of 1408 human 2PN embryos were cryopreserved using a Planer Kryo 10 Series III freezing unit (TS Scientific, Perkasie, Pa) after dehydration/equilibration through Propanediol (Sigma Chemical, St. Louis, Mo) and sucrose. On thawing, embryos were cultured in vitro with P-1 medium with 10% Serum Substitute Supplement (Irvine Scientific, Santa Ana, Calif). Embryo transfer was performed at 40 to 48 hours from time of thaw into a recipient uterus after standard estradiol/progesterone preparation. RESULTS: In 2000, 78% of all frozen 2PN embryos survived and were transferred in 181 cycles producing a delivery rate of 26% per transfer. However, 59% of these cycles were intracytoplasmic sperm injection (ICSI), and the survival of frozen 2PN from these cycles (72%) was lower than the respective survival of frozen 2PN embryos from in vitro fertilization (IVF) (81%; P<.025). Changes to protocols for thawing frozen 2PN embryos were therefore explored and implemented during 2001, resulting in equivalent survival rates of frozen 2PN embryos from IVF and ICSI during 2001 (78% and 80%, respectively) and 2002 (73% and 74%, respectively). Coincidentally, the proportion of all cycles that were performed with ICSI increased (73% in 2001 to 78% in 2002; P<.01) and pregnancy rates after transfer of frozen/thawed 2PN embryos from ICSI increased from 15% in 2000 to 30% in 2002. CONCLUSION: 2PN stage embryo cryosurvival may be negatively affected by ICSI, possibly caused by disruption of the zona pellucida and vitelline membrane before cryopreservation, and/or because ICSI promotes fertilization of some compromised eggs (producing compromised 2PN embryos) that would not have fertilized by conventional IVF. Without close attention to embryo freezing and thawing protocols relative to outcome, lower cryosurvival of unselected ICSI-produced embryos can negatively impact pregnancy outcomes.

Impacto del ácido ascórbico y su correlación con la reacción acrosomal, movilidad espermática, acridina naranja y prueba de penetrancia en huevo de hámster / Relation betwen acrosomal reaction, sperm motility, acridine orange and sperm penetration essay with ascorbic acid

Objetivo: Determinar si el uso del ácido ascórbico (AA) actúa como tratamiento protector antioxidante de la integridad del ADN del espermatozoide. Se valoró la movilidad espermática, la reacción acrosomal, la prueba de penetrancia en huevo de hámster y la integridad del ADN con la tinción de acridina naranja. Material y método: La muestra de esperma de 10 pacientes bajo estudio de infertilidad fue suplementada con AA a diferentes concentraciones con la finalidad de encontrar la dosis terapéutica y tóxica en el espermatozoide. Durante 48 horas de incubación se analizaron la muestra de esperma de 52 pacientes estudiados por infertilidad. Se realizó una dilución de 40 millones de espermas móviles/mL y se dividió en cuatro grupos: control (grupo 1), 300 µM AA (grupo 2), 50 por ciento líquido folicular de paciente donadora de óvulos (grupo 3), 50 por ciento líquido folicular de paciente con IVF sin éxito (grupo 4). Resultados: La supervivencia y movilidad espermática, 67 + 3 por ciento, lograda con la suplementación de 300 µM de AA mostraron una significativa relación positiva en la movilidad después de 24 horas (p < 0.005) con el suplemento de AA. El porcentaje de reacción acrosomal después de 24 horas de incubación fue de 35.35 + 2.2 y de 50.1 + 3.1 después de 48 horas (p < 0.001) sin diferencia estadísticamente significativa entre los tratamientos. A las 24 horas de tratamiento, el porcentaje de integridad del ADN fue de 82.72 + 1.78 y después de 48 horas de 92.66 + 1.76 (p < 0.001), no siendo estadísticamente significativo con el tratamiento. Después de 24 horas, en el 60 por ciento de los casos el número de huevos penetrados y el número de penetraciones fue mayor en el grupo de AA que en el control; sin embargo, no existió diferencia estadísticamente significativa con el tratamiento. Conclusiones: Después de 24 horas de incubación en el medio con AA, se incrementa la movilidad espermática y la reacción acrosomal. Es posible el uso de AA como inductor de reacción acrosomal y como protector de la integridad del ADN. La diferencia en la prueba de penetrancia en huevo de hámster no fue estadísticamente significativa en el grupo de AA; sin embargo, el efecto en el número de huevos penetrados y el número de penetraciones está presente. Nosotros consideramos que al incrementar el número de pacientes la diferencia será significativa.