Sperm retrieval and concomitant tumor resection in azoospermic men with congenital adrenal hyperplasia and bilateral testicular adrenal rest tumors: a case report.

PURPOSE: The objective of this study was to offer a new treatment approach for sperm retrieval simultaneously with tumor resection in azoospermic men with congenital adrenal hyperplasia (CAH), orchialgia, and bilateral testicular adrenal rest tumors (TARTs) who fail to respond to medical treatment. METHODS: This is a retrospective chart review from a couple's fertility center. RESULTS: Between May 2013 and May 2015, two azoospermic men with CAH and bilateral TARTs, with orchialgia, and desire to conceive underwent bilateral TART resection in the same surgical setting as sperm retrieval after remaining azoospermic with normalization of gonadotropins with treatment with human chorionic gonadotropin (hCG). Both men had adequate sperm retrieved for in vitro fertilization/intracytoplasmic sperm retrieval (IVF/ICSI) at the time of bilateral TART resections. They had complete TART resections with resolution of orchialgia. The wife of one patient had a successful pregnancy with use of retrieved sperm resulting in a live birth, and the sperm from the other man is cryopreserved for future use. CONCLUSIONS: It is feasible to perform successful sperm retrieval simultaneously with TART resection in azoospermic men with CAH after medical treatments with persistent azoospermia, rather than subjecting these men to multiple invasive procedures.

Live birth following IVF/ICSI using oocytes from donor who was conceived via IVF: a case report.

PURPOSE: The purpose of the study was to report a case of live birth following donor oocyte in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) in which the oocyte donor herself was conceived via IVF. To our knowledge, such a case has not been previously reported. METHODS: Retrospective chart review; this case is reported after chart review of a successful outcome. RESULTS: A 42 year-old woman, with diminished ovarian reserve, and her husband desired to conceive. She underwent a fresh IVF/ICSI cycle with her own oocytes, which unfortunately was not fruitful in terms of pregnancy or cryopreserved embryos. The couple was counseled regarding the option of donor oocytes, and they elected to proceed with a fresh cycle of donor oocyte IVF/ICSI. The couple selected an anonymous oocyte donor from a donor agency who was a first-time oocyte donor and, interestingly, was conceived via IVF herself. The fresh donor oocyte/IVF/ICSI cycle did not result in pregnancy; however, two supernumerary blastocysts were cryopreserved for future cycles. The recipient's subsequent frozen-thawed embryo transfer (FET) resulted in a singleton gestation and live birth. CONCLUSIONS: An oocyte donor who was conceived via IVF had good ovarian response to stimulation, a good number of oocytes retrieved, and the formation and cryopreservation of blastocysts which, in a subsequent FET cycle, resulted in pregnancy and live birth for a recipient couple. To our knowledge, this is the first case reported of live birth with the use of donor oocytes from an oocyte donor who herself was conceived via IVF.

New pH-buffering system for media utilized during gamete and embryo manipulations for assisted reproduction.

Maintenance of stable pH is important for optimizing gamete and embryo culture. One method to stabilize pH entails using zwitterionic buffers in IVF handling media used outside the laboratory incubator. Current handling media utilize single buffers, such as MOPS or HEPES. However, the use of a single buffer limits the ability to adjust the range of buffering capacity. Furthermore, changes in temperature alter buffering of these compounds. Therefore, traditional IVF handling media utilizing a single buffer may not provide ideal pH buffering. This study reports that combining multiple buffers, such as HEPES, MOPS and DIPSO, into a single medium in various ratios gives the ability to shift the effective buffering range to cover a specific pH. Additionally, by combining various buffers, it is possible to expand pH buffering over a range of temperatures, while simultaneously reducing the absolute concentration of individual buffers, thereby reducing or alleviating toxicity concerns. This report verifies that DIPSO, MOPS and HEPES, and their combinations, support embryo development. Therefore, utilization of bi- and tri-buffered media, containing a mixture of HEPES, MOPS or DIPSO, offers advantages compared with media containing HEPES or MOPS alone, and may be used for procedures such as oocyte retrieval, intracytoplasmic sperm injection, embryo transfer and cryopreservation.

An update on embryo culture for human assisted reproductive technology: media, performance, and safety.

Several culture medium formulations are now available for the successful production and propagation of viable human embryos. In the most popular format, nutrients are provided in a temporal sequence that matches metabolic and amino acid composition with the requirements of specific developmental stage. An alternative philosophy, that all nutritional requirements for preimplantation embryogenesis can be met with a single medium formulation, is represented in commercially available formulations as well. Regardless of format employed, it is not widely appreciated in assisted reproductive technology laboratories that medium performance is strongly influenced by other components of the culture system, such as transitional conditions employed during the retrieval, pH, gas phase, and patient-specific characteristics. There is now further concern that in vitro culture, in general, modifies normal embryonic epigenetic processes and gene expression, genetic changes that may relate to specific ingredients of culture media.

Antimüllerian hormone as a predictor of good-quality supernumerary blastocyst cryopreservation among women with levels <1 ng/mL versus 1-4 ng/mL.

OBJECTIVE: To determine whether antimüllerian hormone (AMH) levels predict the availability of good-quality supernumerary blastocysts for cryopreservation. DESIGN: Retrospective study. SETTING: Two fertility centers. PATIENT(S): First fresh IVF cycles (n = 247) grouped as follows: 40 women <35 year old with AMH <1 ng/mL and 77 women with AMH 1-4 ng/mL; 62 women ≥35 year old with AMH <1 ng/mL, and 68 women with AMH 1-4 ng/mL. INTERVENTION(S): AMH level measured before IVF with ovarian stimulation protocols based on patient age and AMH level, including short gonadotropin-releasing hormone (GnRH) agonist, GnRH antagonist, or GnRH agonist microdose flare; supernumerary good-quality blastocysts cryopreserved on days 5 or 6 after retrieval. MAIN OUTCOME MEASURES(S): Supernumerary good-quality blastocysts for cryopreservation in relation to AMH levels. RESULT(S): Among women <35 years of age, there was a statistically significant difference in the number of patients with supernumerary good-quality blastocysts for cryopreservation between the groups with AMH <1 ng/mL and AMH 1-4 ng/mL (30.0% vs. 58.4%) when adjusted for age. Among women ≥35 years of age, there was a statistically significant difference in the number of patients with supernumerary good-quality blastocyst cryopreservation between groups with AMH <1 ng/mL and AMH 1-4 ng/mL (16.1% vs. 42.6%), when adjusted for age. CONCLUSION(S): Low AMH levels are associated with a statistically significantly lower likelihood of blastocysts for cryopreservation as compared with higher AMH levels. This effect was seen among women both <35 and ≥35 years of age. Patient counseling should include realistic expectations for the probability of good-quality supernumerary blastocysts available for cryopreservation.

Development of culture media for human assisted reproductive technology.

Contemporary culture systems in human assisted reproductive technologies meet the metabolic needs of preimplantation embryos by addressing energetic and amino acid requirements in a stage-specific manner. This approach significantly enhances viability compared with the historical use of simple salt solutions or complex somatic cell media.

Human embryo culture media comparisons.

Every program of assisted reproduction strives to maximize pregnancy outcomes from in vitro fertilization and selecting an embryo culture medium, or medium pair, consistent with high success rates is key to this process. The common approach is to replace an existing medium with a new one of interest in the overall culture system and then perform enough cycles of IVF to see if a difference is noted both in laboratory measures of embryo quality and in pregnancy. This approach may allow a laboratory to select one medium over another but the outcomes are only relevant to that program, given that there are well over 200 other variables that may influence the results in an IVF cycle. A study design that will allow for a more global application of IVF results, ones due to culture medium composition as the single variable, is suggested. To perform a study of this design, the center must have a patient caseload appropriate to meet study entrance criteria, success rates high enough to reveal a difference if one exists and a strong program of quality assurance and control in both the laboratory and clinic. Sibling oocytes are randomized to two study arms and embryos are evaluated on day 3 for quality grades. Inter and intra-observer variability are evaluated by kappa statistics and statistical power and study size estimates are performed to bring discriminatory capability to the study. Finally, the complications associated with extending such a study to include blastocyst production on day 5 or 6 are enumerated.

The principal variables of cryopreservation: solutions, temperatures, and rate changes.

OBJECTIVE: To describe several fundamental variables that influence ultimate survival of oocytes and embryos when they are cryopreserved. DESIGN: The literature describing fundamental and applied aspects of cryobiological variables that determine the responses of oocytes and embryos has been reviewed. CONCLUSION(S): When oocytes and embryos are to be cryopreserved, they are suspended in a solution of one of several low-molecular-weight solutes. The permeability of oocytes and embryos to these various low-molecular-weight compounds differs. These differences determine how these compounds are taken up by cells. That, in turn, influences how these compounds act to protect cells against damage when the cells are subjected to cryopreservation. Because of those protective effects, the compounds are referred to as cryoprotective additives. Another principal variable that influences oocyte and embryo survival is the rate at which the cells are cooled to subzero temperatures. After being stored for some time at -196°C in liquid nitrogen, the cryopreserved oocytes and embryos are warmed to liquefy the medium. The rate at which the specimens are warmed is at least as important, if not more important, in determining the ultimate survival of the oocytes and embryos. The effects of these physical variables on cell survival also are described.

ART failure: oocyte contributions to unsuccessful fertilization.

BACKGROUND: The complexity of fertilization failure during assisted reproductive technologies (ART) is often under-appreciated, as this failure can occur at any number of essential mechanistic and cellular events. Importantly, successful fertilization is heavily dependent upon inherent qualities of the oocytes, and thus reliant upon fidelity of oocyte maturation. METHODS: Pubmed and medline were searched up to April 2008 for papers on oocyte fertilization and its mechanistic components. References to clinical/human studies were selected wherever possible. RESULTS: Successful oocyte maturation cannot simply be determined via visual assessment of polar body extrusion, but rather entails coordination of numerous cytoplasmic processes not readily observed. Proper regulation of intra-oocyte signaling cascades is crucial for sufficient production and storage of carbohydrates and proteins, successful relocation of organelles and regulation of metabolic pathways required for an apparently mature metaphase II oocyte to complete subsequent fertilization events; such as cumulus penetration, sperm/oocyte binding, fusion, oocyte activation, sperm processing and pronuclear (PN) formation. Regulation of oocyte maturation begins during oocyte growth and is intimately connected with events influencing folliculogenesis. Therefore, the oocyte is subject to a multitude of potential effector impacting fertilization potential and developmental competence long before encountering the artificial environment of the IVF laboratory. CONCLUSIONS: Although meticulous care and continued research is essential for future improvement, failure to fertilize and properly form PN following clinical ART is likely to be dependent on historical events in oocyte maturation, not easily explained or prevented through simple modification of contemporary laboratory protocols.

Recent advances in the production of viable human embryos in vitro.

The introduction of stress to embryonic blastomeres through inappropriate culture conditions results ultimately in the loss of viability. Retention of normal metabolic function in human preimplantation embryos, as well as those of other mammalian species, has been improved by the use of stage-appropriate culture media wherein energy substrates and amino acids are provided in a temporally evolving sequence. While the time dependence of nutrient exposure to embryos has received wide attention, spatial considerations in the embryonic microenvironment have received none. The manner in which media are presented to embryos, the rate at which media are changed, the rate at which cell products are removed and the macromolecular influences upon embryonic microenvironments have received far less attention in the experimental literature. Recent advances in micro-scale engineering allows for the rapid production of matrices containing culture channels slightly larger than the dimensions of preimplantation embryos. Microfluidic systems hold great promise for providing physical configurations yielding significantly reduced volumes but simultaneously providing control over the dynamics of media change and waste removal via fluid flow with time. Additionally, macromolecules may be presented from fixed sites in a minimum volume of solvent thus allowing us to test the importance of space and geometry in facilitating the physical and chemical effectiveness of the embryonic milieu.