Antiphospholipid antibodies and idiopathic infertility.

OBJECTIVE: The aim of our study was to evaluate obstetric outcome of women affected by idiopathic infertility showing persistently positive antiphospholipid antibodies (aPL). METHODS: : From 2000 consecutive patients undergoing ART, we selected 151 (7.55%) clinical records of patients affected by idiopathic infertility undergoing ICSI and showing positive aPL. RESULTS: Persistently positive aPL were found in 64/151 (42.38%) of the patients: in 34/64 (53.12%) at medium/high titers (group A) and in 30/64 (46.87%) at low titers (group B). Primary or secondary antiphospholipid syndrome (APS) was diagnosed in 25% of the patients, whereas 37.5% women showed clinical and/or laboratory features suggestive of APS, but not fulfilling clinical or laboratory classification criteria. Idiopathic infertility was the sole symptom in 31.25%. In 55% of these infertile patients, a history of recurrent failures of assisted reproductive techniques (ART) was also observed. Eighty-eight percent (88.88%) of women became pregnant and 77.77% gave birth. During pregnancy, an increase of aPL values was observed in 29.41% women of group B. CONCLUSIONS: A careful selection of patients allowed us to confirm that women affected by idiopathic infertility show a high prevalence of aPL, suggesting that these autoantibodies can also affect conception. Considering pregnancy complications and thrombotic risk related to ovarian stimulation, measuring aPL can represent a valid tool to identify among infertile women undergoing ART those at higher risk of pregnancy complications potentially life-threatening for mother and the fetus. In such patients, an accurate diagnosis and an adequate therapy are related to a better ART outcome.

Oocyte competence is independent of the ovulation trigger adopted: a large observational study in a setting that entails vitrified-warmed single euploid blastocyst transfer.

PURPOSE: To assess whether the GnRH-agonist or urinary-hCG ovulation triggers affect oocyte competence in a setting entailing vitrified-warmed euploid blastocyst transfer. METHODS: Observational study (April 2013-July 2018) including 2104 patients (1015 and 1089 in the GnRH-a and u-hCG group, respectively) collecting ≥1 cumulus-oocyte-complex (COC) and undergoing ICSI with ejaculated sperm, blastocyst culture, trophectoderm biopsy, comprehensive-chromosome-testing, and vitrified-warmed transfers at a private clinic. The primary outcome measure was the euploid-blastocyst-rate per inseminated oocytes. The secondary outcome measure was the maturation-rate per COCs. Also, the live-birth-rate (LBR) per transfer and the cumulative-live-birth-delivery-rate (CLBdR) among completed cycles were investigated. All data were adjusted for confounders. RESULTS: The generalized-linear-model adjusted for maternal age highlighted no difference in the mean euploid-blastocyst-rate per inseminated oocytes in either group. The LBR per transfer was similar: 44% (n=403/915) and 46% (n=280/608) in GnRH-a and hCG, respectively. On the other hand, a difference was reported regarding the CLBdR per oocyte retrieval among completed cycles, with 42% (n=374/898) and 25% (n=258/1034) in the GnRh-a and u-hCG groups, respectively. Nevertheless, this variance was due to a lower maternal age and higher number of inseminated oocytes in the GnRH-a group, and not imputable to the ovulation trigger itself (multivariate-OR=1.3, 95%CI: 0.9-1.6, adjusted p-value=0.1). CONCLUSION: GnRH-a trigger is a valid alternative to u-hCG in freeze-all cycles, not only for patients at high risk for OHSS. Such strategy might increase the safety and flexibility of controlled-ovarian-stimulation with no impact on oocyte competence and IVF efficacy.

Reduction of multiple pregnancies in the advanced maternal age population after implementation of an elective single embryo transfer policy coupled with enhanced embryo selection: pre- and post-intervention study.

STUDY QUESTION: Is an elective single-embryo transfer (eSET) policy an efficient approach for women aged >35 years when embryo selection is enhanced via blastocyst culture and preimplantation genetic screening (PGS)? SUMMARY ANSWER: Elective SET coupled with enhanced embryo selection using PGS in women older than 35 years reduced the multiple pregnancy rates while maintaining the cumulative success rate of the IVF programme. WHAT IS KNOWN ALREADY: Multiple pregnancies mean an increased risk of premature birth and perinatal death and occur mainly in older patients when multiple embryos are transferred to increase the chance of pregnancy. A SET policy is usually recommended in cases of good prognosis patients, but no general consensus has been reached for SET application in the advanced maternal age (AMA) population, defined as women older than 35 years. Our objective was to evaluate the results in terms of efficacy, efficiency and safety of an eSET policy coupled with increased application of blastocyst culture and PGS for this population of patients in our IVF programme. STUDY DESIGN, SIZE, DURATION: In January 2013, a multidisciplinary intervention involving optimization of embryo selection procedure and introduction of an eSET policy in an AMA population of women was implemented. This is a retrospective 4-year (January 2010-December 2013) pre- and post-intervention analysis, including 1161 and 499 patients in the pre- and post-intervention period, respectively. The primary outcome measures were the cumulative delivery rate (DR) per oocyte retrieval cycle and multiple DR. PARTICIPANTS/MATERIALS, SETTING, METHODS: Surplus oocytes and/or embryos were vitrified during the entire study period. In the post-intervention period, all couples with good quality embryos and less than two previous implantation failures were offered eSET. Embryo selection was enhanced by blastocyst culture and PGS (blastocyst stage biopsy and 24-chromosomal screening). Elective SET was also applied in cryopreservation cycles. MAIN RESULTS AND THE ROLE OF CHANCE: Patient and cycle characteristics were similar in the pre- and post-intervention groups [mean (SD) female age: 39.6 ± 2.1 and 39.4 ± 2.2 years; range 36-44] as assessed by logistic regression. A total of 1609 versus 574 oocyte retrievals, 937 versus 350 embryo warming and 138 versus 27 oocyte warming cycles were performed in the pre- and post-intervention periods, respectively, resulting in 1854 and 508 embryo transfers, respectively. In the post-intervention period, 289 cycles were blastocyst stage with (n = 182) or without PGS (n = 107). A mean (SD) number of 2.9 ± 1.1 (range 1-4) and 1.4 ± 0.8 (range 1-3) embryos were transferred pre- and post-intervention, respectively (P < 0.01) and similar cumulative clinical pregnancy rates per transfer and per cycle were obtained: 26.8, 30.9% and 29.7, 26.3%, respectively. The total DR per oocyte retrieval cycle (21.0 and 20.4% pre- and post-intervention, respectively) defined as efficacy was not affected by the intervention [odds ratio (OR) = 0.8, 95% confidence interval (CI) = 0.7-1.1; P = 0.23]. However, a significantly increased live birth rate per transferred embryo (defined as efficiency) was observed in the post-intervention group 17.0 versus 10.6% (P < 0.01). Multiple DRs decreased from 21.0 in the preintervention to 6.8% in the post-intervention group (OR = 0.3. 95% CI = 0.1-0.7; P < 0.01). LIMITATIONS, REASONS FOR CAUTION: In this study, the suitability of SET was assessed in individual women on the basis of both clinical and embryological prognostic factors and was not standardized. For the described eSET strategy coupled with an enhanced embryo selection policy, an optimized culture system, cryopreservation and aneuploidy screening programme is necessary. WIDER IMPLICATIONS OF THE FINDINGS: Owing to the increased maternal morbidity and perinatal complications related to multiple pregnancies, it is recommended to extend the eSET policy to the AMA population. As shown in this study, enhanced embryo selection procedures might allow a reduction in the number of embryos transferred and the number of transfers to be performed without affecting the total efficacy of the treatment but increasing efficiency and safety. STUDY FUNDING/COMPETING INTERESTS: None. TRIAL REGISTRATION NUMBER: None.

Severe male factor in in vitro fertilization: definition, prevalence, and treatment. An update.

Infertility affects 10%-15% of couples worldwide. Of all infertility cases, 20%-70% are due to male factors. In the past, men with severe male factor (SMF) were considered sterile. Nevertheless, the development of intracytoplasmic sperm injection (ICSI) drastically modified this scenario. The advances in assisted reproductive technology (ART), specifically regarding surgical sperm retrieval procedures, allowed the efficacious treatment of these conditions. Yet, before undergoing ICSI, male factor infertility requires careful evaluation of clinical and lifestyle behavior together with medical treatment. Epidemiologically speaking, women whose male partner is azoospermic tend to be younger and with a better ovarian reserve. These couples, in fact, are proposed ART earlier in their life, and for this reason, their ovarian response after stimulation is generally good. Furthermore, in younger couples, azoospermia can be partially compensated by the efficient ovarian response, resulting in an acceptable fertility rate following in vitro fertilization (IVF) techniques. Conversely, when azoospermia is associated with a reduced ovarian reserve and/or advanced maternal age, the treatment becomes more challenging, with a consequent reduction in IVF outcomes. Nonetheless, azoospermia seems to impair neither the euploidy rate at the blastocyst stage nor the implantation of euploid blastocysts. Based on the current knowledge, the assessment of male infertility factors should involve: (1) evaluation - to diagnose and quantify seminologic alterations; (2) potentiality - to determine the real possibilities to improve sperm parameters and/or retrieve spermatozoa; (3) time - to consider the available "treatment window", based on maternal age and ovarian reserve. This review represents an update of the definition, prevalence, causes, and treatment of SMF in a modern ART clinic.

DuoStim - a reproducible strategy to obtain more oocytes and competent embryos in a short time-frame aimed at fertility preservation and IVF purposes. A systematic review.

Recent evidence suggests that follicular development occurs in a wave-like model during the ovarian cycle, where up to three cohorts of follicles are recruited to complete folliculogenesis. This understanding overtakes the previous dogma stating that follicles grow only during the follicular phase of the menstrual cycle. Therefore, in in vitro fertilization (IVF), novel protocols regarding ovarian stimulation have been theorized based on the use of gonadotrophins to prompt the growth of antral follicles at any stage of the menstrual cycle. These unconventional protocols for ovarian stimulation aim at a more efficient management of poor-prognosis patients, otherwise exposed to conflicting outcomes after conventional approaches. DuoStim appears among these unconventional stimulation protocols as one of the most promising. It combines two consecutive stimulations in the follicular and luteal phases of the same ovarian cycle, aimed at increasing the number of oocytes retrieved and embryos produced in the short time-frame. This protocol has been suggested for the treatment of all conditions requiring a maximal and urgent exploitation of the ovarian reserve, such as oncological patients and poor responders at an advanced maternal age. At present, data from independent studies have outlined the consistency and reproducibility of this approach, which might also reduce the drop-out between consecutive failed IVF cycles in poor-prognosis patients. However, the protocol must be standardized, and more robust studies and cost-benefit analyses are needed to highlight the true clinical pros and cons deriving from DuoStim implementation in IVF.

Advanced Maternal Age in IVF: Still a Challenge? The Present and the Future of Its Treatment.

Advanced maternal age (AMA; >35 year) is associated with a decline in both ovarian reserve and oocyte competence. At present, no remedies are available to counteract the aging-related fertility decay, however different therapeutic approaches can be offered to women older than 35 year undergoing IVF. This review summarizes the main current strategies proposed for the treatment of AMA: (i) oocyte cryopreservation to conduct fertility preservation for medical reasons or "social freezing" for non-medical reasons, (ii) personalized controlled ovarian stimulation to maximize the exploitation of the ovarian reserve in each patient, (iii) enhancement of embryo selection via blastocyst-stage preimplantation genetic testing for aneuploidies and frozen single embryo transfer, or (iv) oocyte donation in case of minimal/null residual chance of pregnancy. Future strategies and tools are in the pipeline that might minimize the risks of AMA through non-invasive approaches for embryo selection (e.g., molecular analyses of leftover products of IVF, such as spent culture media). These are yet challenging but potentially ground-breaking perspectives promising a lower clinical workload with a higher cost-effectiveness. We also reviewed emerging experimental therapeutic approaches to attempt at restoring maternal reproductive potential, e.g., spindle-chromosomal complex, pronuclear or mitochondrial transfer, and chromosome therapy. In vitro generation of gametes is also an intriguing challenge for the future. Lastly, since infertility is a social issue, social campaigns, and education among future generations are desirable to promote the awareness of the impact of age and lifestyle habits upon fertility. This should be a duty of the clinical operators in this field.

Abnormally fertilized oocytes can result in healthy live births: improved genetic technologies for preimplantation genetic testing can be used to rescue viable embryos in in vitro fertilization cycles.

OBJECTIVE: To test whether abnormally fertilized oocyte (AFO)-derived blastocysts are diploid and can be rescued for clinical use. DESIGN: Longitudinal-cohort study from January 2015 to September 2016 involving IVF cycles with preimplantation genetic testing for aneuploidy (PGT-A). Ploidy assessment was incorporated whenever a blastocyst from a monopronuclear (1PN) or tripronuclear zygote (2PN + 1 smaller PN; 2.1 PN) was obtained. SETTING: Private IVF clinics and genetics laboratories. PATIENT(S): A total of 556 women undergoing 719 PGT-A cycles. INTERVENTION(S): Conventional chromosome analysis was performed on trophectoderm biopsies by quantitative polymerase chain reaction. For AFO-derived blastocysts, ploidy assessment was performed on the same biopsy with the use of allele ratios for hetorozygous SNPs analyzed by means of next-generation sequencing (1:1 = diploid; 2:1 = triploid; loss of heterozygosity = haploid). Balanced-diploid 1PN- and 2.1PN-derived blastocysts were transferred in the absence of normally fertilized transferable embryos. MAIN OUTCOME MEASURE(S): Ploidy constitution and clinical value of AFO-derived blastocysts in IVF PGT-A cycles. RESULT(S): Of the 5,026 metaphase II oocytes injected, 5.2% and 0.7% showed 1PN and 2.1PN, respectively. AFOs showed compromised embryo development (P<.01). Twenty-seven AFO-derived blastocysts were analyzed for ploidy constitution. The 1PN-derived blastocysts were mostly diploid (n = 9/13; 69.2%), a few were haploid (n = 3/13; 23.1%), and one was triploid (n = 1/13; 7.7%). The 2.1PN-derived blastocysts were also mostly diploid (n = 12/14; 85.7%), and the remainder were triploid. Twenty-six PGT-A cycles resulted in one or more AFO-derived blastocysts (n = 26/719; 3.6%). Overall, eight additional balanced-diploid transferable embryos were obtained from AFOs. In three cycles, the only balanced-diploid blastocyst produced was from an AFO (n = 3/719; 0.4%). Three AFO-derived live births were achieved: one from a 1PN zygote and two from 2.1PN zygotes. CONCLUSION(S): Enhanced PGT-A technologies incorporating reliable ploidy assessment provide an effective tool to rescue AFO-derived blastocysts for clinical use.

Preimplantation genetic diagnosis for aneuploidy testing in women older than 44 years: a multicenter experience.

OBJECTIVE: To report laboratory and clinical outcomes in preimplantation genetic diagnosis for aneuploidies (PGD-A) cycles for women 44 to 47 years old. DESIGN: Multicenter, longitudinal, observational study. SETTING: In vitro fertilization (IVF) centers. PATIENT(S): One hundred and thirty-seven women aged 44.7 ± 0.7 years (range: 44.0-46.7) undergoing 150 PGD-A cycles during April 2013 to January 2016. INTERVENTION(S): Quantitative polymerase chain reaction-based PGD-A on trophectoderm biopsies and cryopreserved euploid single-embryo transfer (SET). MAIN OUTCOMES MEASURE(S): Primary outcome measure: delivery rate per cycle; secondary outcome measures: miscarriage rate, and the rate and reasons for cycle cancelation with subanalyses for female age and number of metaphase 2 oocytes retrieved. RESULT(S): In 102 (68.0%) of 150 cycles blastocyst development was obtained, but only 21 (14.0%) were euploid blastocysts. The overall euploidy rate was 11.8% (22 of 187). Twenty-one SET procedures were performed, resulting in 13 clinical pregnancies, of which 1 miscarried and 12 delivered. The delivery rate was 57.1% per transfer, 8.0% per cycle, and 8.8% per patient. The logistic regression analysis found that only female age (odds ratio 0.78) and number of metaphase 2 oocytes retrieved (odds ratio 1.25) statistically significantly correlated with the likelihood of delivery. The delivery rate per cycle was 10.6% (11 of 104) in patients aged 44.0 to 44.9 years and 2.6% in patients aged 45.0 to 45.9 years (n = 1 of 38). No euploid blastocysts were found for patients older than 45.0 years. CONCLUSION(S): Extensive counseling based on biological and clinical data should be provided to women older than 43 years who are requesting IVF because of their very low odds of success and high risk for embryonic aneuploidies. Nevertheless, the low miscarriage and good delivery rates reported in this study in women with good ovarian reserve aged 44 should encourage the use of PGD-A in this population.

Reduction of the incidence of sperm DNA fragmentation by oral antioxidant treatment.

Sperm DNA fragmentation is known to compromise male fertility. Previous findings have suggested the implication of oxidative stress in the etiology of this pathological condition. The present study was conducted to find out if the pathologically increased incidence of DNA fragmentation in ejaculated spermatozoa can be reduced by oral treatment with two antioxidants, vitamins C and E. Sixty-four men with unexplained infertility and an elevated (> or = 15%) percentage of DNA-fragmented spermatozoa in the ejaculate were randomized between an antioxidant treatment (1 g vitamin C and 1 g vitamin E daily for 2 months) group and a placebo group. Sperm DNA fragmentation was evaluated by terminal deoxyribonucleotidyl transferase-mediated dUTP nick-end labeling assay before and after treatment. No differences in basic sperm parameters were found between the antioxidant treatment and the placebo group before or after treatment. However, the percentage of DNA-fragmented spermatozoa was markedly reduced (P < .001) in the antioxidant treatment group after the treatment (9.1 +/- 7.2) as compared with the pretreatment values (22.1 +/- 7.7). No difference in the pretreatment and posttreatment incidence of sperm DNA fragmentation was observed in the placebo group. These data show that sperm DNA damage can be efficiently treated with oral antioxidants administered during a relatively short time period.

Natural in vitro fertilization cycles.

Although the first in vitro fertilization (IVF) baby was born after a natural IVF cycle, very soon this procedure was almost abandoned mainly because of the very high cancellation rates, and controlled pharmacological ovarian hyperstimulation became the standard treatment in IVF cycles of normoresponder patients. However, in poor-responder patients, where only very few follicles can be recruited and very few oocytes, if any, can be retrieved after controlled ovarian hyperstimulation, natural IVF cycles may offer a comparable number of follicles, reduced costs, and less discomfort for the patients. In this group of patients, natural IVF cycle is a cost-effective approach.

Efficiency of slush nitrogen vitrification of human oocytes vitrified with or without cumulus cells in relation to survival rate and meiotic spindle competence.

OBJECTIVE: To evaluate the efficiency of slush nitrogen vitrification of human oocytes with or without cumulus cells in terms of survival rate and maintenance of meiotic spindle. DESIGN: Randomized, comparative study. SETTING: Medical center. PATIENT(S): A total of 274 oocytes obtained from 46 couples undergoing infertility treatment. INTERVENTION(S): Metaphase II oocytes were divided into groups A and B, vitrified with and without cumulus cells, respectively. MAIN OUTCOMES MEASURE(S): Survival rates and maintenance of meiotic spindle observed immediately after warming and 3 hours after incubation. RESULT(S): No statistically significant difference was detected between the two groups in terms of survival rate, but a significantly higher percentage of detectable spindle was observed in group B (completely denuded oocytes), either immediately after warming or 3 hours after incubation. CONCLUSION(S): Complete denudation of oocytes before slush nitrogen vitrification does not influence survival rates but positively affects oocyte meiotic spindle competence. These data support the hypothesis that cumulus cells during vitrification represent an obstacle to cryoprotectant penetration more than having a protective role for the oocyte.

Successful management of a triplet heterotopic caesarean scar pregnancy after in vitro fertilization-embryo transfer.

OBJECTIVE: To report a case of a triplet heterotopic caesarean scar pregnancy (CSP) with two gestational sacs implanted in the caesarean scar after in vitro fertilization-embryo transfer. DESIGN: Case report. SETTINGS: Private reproductive medicine center and obstetric department of a university hospital. PATIENT(S): A 31-year-old woman with previous caesarean section affected by secondary infertility related to male azoospermia. INTERVENTION(S): In vitro fertilization-embryo transfer followed by early ultrasound diagnosis of heterotopic CSP and selective embryo reduction performed by transvaginal ultrasound-guided potassium chloride and methotrexate injection in the ectopic gestational sacs. MAIN OUTCOME MEASURE(S): Successful pregnancy outcome. RESULT(S): An ongoing intrauterine pregnancy with a live birth after successful management of ectopic gestational sacs. CONCLUSION(S): Triplet heterotopic CSP with two ectopic gestational sacs may occur after IVF-ET and, to our knowledge, this is the first time such a complication has been reported. Ultrasound is the main tool allowing early diagnosis of this condition, and the injection of potassium chloride and methotrexate is a safe and efficacious treatment method. The gynecologist managing early pregnancy should be aware of the possibility of CSP, and patients must be appropriately counseled about the different treatment options.

Negligible serum anti-müllerian hormone: pregnancy and birth after a 1-month course of an oral contraceptive, ovarian hyperstimulation, and intracytoplasmic sperm injection.

OBJECTIVE: To describe a patient with isolated negligible (<0.5 ng/mL or <3.6 pmol/L) anti-müllerian hormone (AMH) levels who underwent intracytoplasmic sperm injection (ICSI) for severe oligoasthenoteratozoospermia, displayed ovarian hyperstimulation after a 1-month course of an oral contraceptive (OC), had a singleton pregnancy and delivered a healthy boy. DESIGN: Case report. SETTING: Reproductive center at a private hospital. PATIENT(S): A 34-year-old woman with isolated negligible (<0.5 ng/mL or <3.6 pmol/L) AMH level and poor response to controlled ovarian hyperstimulation (COH) and her 38-year-old partner with severe oligoasthenoteratozoospermia. INTERVENTION(S): A 1-month course of an OC, modified minimal stimulation cycle with recombinant FSH, antagonist (cetrorelix) administration to inhibit LH surge, triggered ovulation using 10,000 U of hCG and ICSI. MAIN OUTCOME MEASURE(S): Level of AMH, pregnancy, and birth. RESULT(S): Three high quality embryos were obtained and transferred 48 hours after ICSI. Transvaginal ultrasound at 8 weeks' gestation showed a vital singleton pregnancy. The pregnancy continued uncomplicated. The patient gave birth to a healthy boy, weighing 3,280 g, by caesarean section at 39 weeks' gestation. CONCLUSION(S): Ovarian hyperstimulation, pregnancy, and birth may occur after a short course of an OC and ICSI in poor responder, normogonadotropic, regularly menstruating young women with isolated negligible AMH.

Significance of metaphase II human oocyte morphology on ICSI outcome.

OBJECTIVE: To evaluate the influence of specific oocyte morphologic features (morphotypes) on intracytoplasmic sperm injection (ICSI) outcome. The identification of oocyte quality markers is particularly important when a low number of oocytes can be used for IVF. DESIGN: Retrospective analysis. SETTING: Medical center. PATIENT(S): Five hundred sixteen consecutive ICSI cycles. Only couples affected by severe male factor infertility were excluded. INTERVENTION(S): A total of 1,191 metaphase II (MII) oocytes (1-3 per patient) were randomly selected from the cohort of oocytes obtained from each patient and evaluated for morphologic appearance. MAIN OUTCOME MEASURE(S): Fertilization, pronuclear morphology, embryo quality, pregnancy rate. RESULT(S): There was a presence of vacuoles, abnormal I polar body, and large perivitelline space related to a lower fertilization rate. Pronuclear morphology was effected by the presence of a large perivitelline space, diffused cytoplasmic granularity, and/or centrally located granular area. The latter characteristic also negatively related to day 2 embryo quality. According to the odds ratios obtained for each oocyte morphotype to reach at least one outcome, an MII oocyte morphologic score (MOMS) was calculated. A significant relationship was found between MOMS and female age, female basal FSH, and clinical outcome. CONCLUSION(S): Morphologic evaluation before ICSI helps to identify MII oocytes with higher developmental potential.

ICSI in cases of sperm DNA damage: beneficial effect of oral antioxidant treatment.

BACKGROUND: Most studies examining the use of ICSI for cases of elevated sperm DNA fragmentation report poor pregnancy and implantation rates. ICSI with testicular sperm samples has recently been suggested for these cases. Here we test a less invasive approach based on oral antioxidant treatment prior to ICSI with ejaculated spermatozoa. METHODS: Thirty-eight men with an elevated (> or =15%) percentage of DNA-fragmented spermatozoa in the ejaculate were treated with antioxidants (1 g vitamin C and 1 g vitamin E daily) for 2 months after one failed ICSI attempt. In 29 (76%) of these cases this treatment led to a decrease in the percentage of DNA-fragmented spermatozoa, and a second ICSI attempt was performed. Outcomes of the two attempts were compared. RESULTS: No differences in fertilization and cleavage rates or in embryo morphology were found between the ICSI attempts performed before and after the antioxidant treatment. However, a marked improvement of clinical pregnancy (48.2% versus 6.9%) and implantation (19.6% versus 2.2%) rates was observed after the antioxidant treatment as compared with the pretreatment ICSI outcomes. CONCLUSIONS: Oral antioxidant treatment appears to improve ICSI outcomes in those patiens with sperm DNA damage, in whom this treatment reduces the percentage of damaged spermatozoa.

Significance of morphological attributes of the early embryo.

There are many morphological transformations during development of human embryos that mainly involve phenomena that can be easily assessed in living embryos by simple non-invasive microscopical observation. A clear correlation between pronuclear morphology and the ability of the resulting embryo to continue developing and to implant has been described. There is also general agreement that a positive relationship exists between early embryo morphology and implantation rate. The parameters classically involved in embryo evaluation are: cleavage rate, blastomere symmetry, cytoplasmic appearance, extent of fragmentation and blastomere nuclear status. In this paper, morphological features that have been related to embryo developmental potential are described. Furthermore, the ability of a cumulative classification scheme developed in the laboratory to predict blastocyst formation and implantation is analysed.

Developmental potential of fully intact and partially damaged cryopreserved embryos after laser-assisted removal of necrotic blastomeres and post-thaw culture selection.

OBJECTIVE: Partially damaged frozen and thawed embryos are currently considered to have a lower viability than intact ones. This study was undertaken to compare the performance of intact frozen and thawed embryos with that of partially damaged embryos after removal of the necrotic blastomeres. DESIGN: Observational clinical series. SETTING: Private hospital. PATIENT(S): Three hundred twenty-six infertile couples undergoing frozen embryo transfer. INTERVENTION(S): Removal of necrotic blastomeres from frozen-thawed human embryos. MAIN OUTCOME MEASURE(S): Pregnancy and implantations rates. RESULT(S): Outcomes of frozen embryo transfer cycles in which all embryos were fully intact (group 1) were compared with those in which all embryos have lost 1-2 blastomeres (group 2) or 3-4 blastomeres (group 3). Laser-assisted hatching was performed in all embryos, and necrotic blastomeres were removed from partially damaged embryos on this occasion. Only embryos that resumed mitotic activity after thawing were transferred. Comparable clinical pregnancy rates (PR) (38.7%, 39.6%, and 29.4%), delivery rates (34.4%, 34.0%, and 29.4%), and implantation rates (21.6%, 21.4%, and 17.2%) were obtained in groups 1, 2, and 3, respectively. CONCLUSION(S): The developmental potential of partially damaged frozen and thawed embryos can be equivalent to fully survived embryos if the necrotic blastomeres are removed from the partially damaged embryos and only those of them that show post-thaw cleavage are selected for transfer.

Efficient treatment of infertility due to sperm DNA damage by ICSI with testicular spermatozoa.

BACKGROUND: Sperm DNA damage (fragmentation) is a recently discovered cause of male infertility for which no efficient treatment has yet been found. Previous findings have suggested that clinically relevant sperm DNA damage may occur at the post-testicular level. This study was undertaken to assess the clinical usefulness of ICSI with testicular spermatozoa in this indication. METHODS: The percentage of spermatozoa with fragmented DNA, assessed by terminal deoxyribonucleotidyl transferase-mediated dUTP nick-end labelling assay, and ICSI outcomes were compared in two sequential attempts performed, respectively, with ejaculated and testicular spermatozoa in 18 men with increased sperm DNA fragmentation. RESULTS: The incidence of DNA fragmentation was markedly lower in testicular spermatozoa as compared with ejaculated spermatozoa. No differences in fertilization and cleavage rates and in embryo morphological grade were found between the ICSI attempts performed with ejaculated and with testicular spermatozoa. However, eight ongoing clinical pregnancies (four singleton and four twin) were achieved by ICSI with testicular spermatozoa (44.4% pregnancy rate; 20.7% implantation rate), whereas ICSI with ejaculated spermatozoa led to only one pregnancy which was spontaneously aborted. CONCLUSIONS: These data show that ICSI with testicular spermatozoa provides the first efficient assisted reproduction treatment option for men with high levels of sperm DNA damage.

Day 3 embryo transfer with combined evaluation at the pronuclear and cleavage stages compares favourably with day 5 blastocyst transfer.

BACKGROUND: The respective advantages of day 3 and day 5 embryo transfer are a matter of debate. Previous comparisons did not include pronuclear stage zygote scoring and cumulative success rates (fresh and cryopreserved embryos). METHODS: Patients were randomized prospectively for day 3 or day 5 embryo transfer. Day 3 embryos were selected for transfer and cryopreservation by using combined evaluation at the pronuclear and cleavage stages. RESULTS: There was no difference between day 3 and day 5 fresh embryo transfers as to the rates of pregnancy (58 versus 62%), clinical pregnancy (56 versus 58%), delivery (50 versus 48%), implantation (35 versus 38%) and birth (33 versus 36%) rates. The corresponding values for cryopreserved embryo transfers were also similar. However, day 3 embryo transfer compared favourably with day 5 transfer when the pregnancy (90 versus 66%), clinical pregnancy (85 versus 62%) and delivery (77 versus 52%) rates were calculated per oocyte recovery attempt. CONCLUSIONS: With a selected population of good prognosis patients and our embryo selection criteria, the implantation potential of day 3 and day 5 embryos is equal. Per oocyte recovery attempt, day 3 transfer is more clinically efficient than day 5 transfer, but at least one transfer of cryopreserved embryos is necessary to manifest this superiority.