Ongoing twin pregnancy after ICSI of PESA-retrieved spermatozoa into in-vitro matured oocytes
Abstract
The recovery of immature oocytes from unstimulated ovaries followed by in-vitro maturation (IVM) is an attractive alternative
to conventional IVF in the treatment of female infertility. Similarly, surgical recovery of spermatozoa from the epididymis
by percutaneous sperm aspiration (PESA) has simplified the retrieval of the male gamete in treatment of men with obstructive
azoospermia. We report the first ongoing clinical twin pregnancy resulting from intracytoplasmic sperm injection (ICSI) of
spermatozoa retrieved by PESA into IVM oocytes. In the treatment of a 24-year old woman, 12 immature oocytes were retrieved.
Six oocytes matured (maturation rate 50%) after 24-hour incubation and were inseminated by ICSI. Four oocytes had two pronuclei
(fertilization rate 67%) and 3 good quality embryos were transferred. A viable twin pregnancy was confirmed by ultrasound
scan. This report illustrates the use of a combination of less invasive assisted reproductive techniques in overcoming barriers
to infertility.
... Previous studies have shown that, upon IVM, nearly 50% of immature oocytes reach maturation after 24-28 hours (28). Heterogeneous embryological outcomes have been reported concerning maturation (33%-82%), fertilization (19%-80%), and cleavage rate (7%-96%) after IVM (29)(30)(31)(32)(33)(34)(35). ...
Objective:
To study the effectiveness of a new in vitro maturation (IVM) approach based on heterologous follicular fluid (HFF) and supernatant of cumulus-granulosa cells (CGCs) mimicking the intact follicular microenvironment to rescue immature denuded oocytes (IDOs) of patients with polycystic ovary syndrome (PCOS) whose IVM or IVF outcomes remain poor.
Design:
Randomized controlled trial.
Setting:
University-affiliated private center.
Patient(s):
One hundred fifty-nine IDOs were obtained from 47 patients with PCOS. First, a simple IVM system (S-IVM; 40 IDOs; control group) was compared with different protocols based on the addition of autologous follicular fluid (AFF-IVM; 44 IDOs), HFF (HFF-IVM; 42 IDO), or HFF with CGC isolated from seven women without PCOS and presenting 100% in vivo oocyte maturation (HFF/CGC-IVM; 33 IDOs).
Intervention(s):
None.
Main outcome measure(s):
IVM outcomes were compared among the four groups (S-IVM, AFF-IVM, HFF-IVM, HFF/CGC-IVM); then the vitro and in vivo maturation results (from controlled ovarian stimulation of PCOS patients) were compared for each group.
Result(s):
The HFF/CGC-IVM method gave the best yield of developed blastocysts per IDO compared with S-IVM, AFF-IVM, and HFF-IVM (27% vs. 2%, 2%, and 12%, respectively). The IVM rate with the HFF/CGC-IVM method was even higher than that compared with the in vivo maturation rate (79% vs. 42%), with significant improvement in the cleavage rate (71% vs. 61%).
Conclusion(s):
This adapted IVM system could be used to reach an acceptable result in meiotic competence and competent metaphase II oocytes capable of developing into intact embryos after fertilization and before transfer.
Congenital domestic absence of vas deferens (CBAVD) is a common factor in male infertility, and percutaneous epididymal sperm aspiration (PESA) combined with intracytoplasmic sperm injection (ICSI) is a primary clinical treatment, but the effect of the sperm obtained on pregnancy outcome remains to be explored. This study aimed to investigate the relationship between sperm motility with clinical outcome of PESA–ICSI in infertile males with CBAVD. A cohort of 110 couples was enrolled. In total, 76 infertile males were included in the high motility group, while the remaining 34 males were placed in the low motility group. Clinical pregnancy, embryo implantation rate and live birth rate were included as the primary outcome. After all follow-ups, we found that the high motility group achieved higher normal fertilization rates, cleavage rates, transplantable embryo rates and high-quality embryo rates than those in low motility group (normal fertilization rate, 78.2 ± 11.7% vs. 70.5 ± 10.2%, P = 0.003; cleavage rate, 97.1 ± 2.9% vs. 92.3 ± 3.0%, P = 0.000; transplantable embryo rate, 66.8 ± 14.9% vs. 58.6 ± 12.6%, P = 0.009 and high-quality embryo rate, 49.9 ± 10.5% vs. 40.5 ± 11.2%, P = 0.000). Additionally, compared with the low motility group, the clinical pregnancy rates, embryo implantation rates, and live birth rates in the high motility group were significantly increased (pregnancy rate, 61.8% vs. 26.5%, P = 0.009; embryo implantation rate, 36.5% vs. 18.0%, P = 0.044; live birth rate, 55.3% vs. 17.6%, P = 0.000). We concluded that the motility of sperm obtained by PESA affected the clinical outcome of ICSI in infertile males with CBAVD.
There is a growing interest in natural cycle in vitro fertilization (IVF) and in vitro maturation (IVM) treatment. Recovery of immature oocytes followed by IVM is a potentially useful treatment for women with infertility. The method is particularly effective for infertile women who have numerous antral follicles due to polycystic ovaries or polycystic ovarian syndrome. Today, given the efficiency of IVF and improvements in the culture system, natural cycle IVF and mild stimulation IVF may be more suitable for women undergoing infertility treatment. One very attractive possibility for enhancing the successful outcome of natural cycle or mild stimulation IVF treatment is combining it with immature egg retrieval and IVM. The use of IVM technology can thus be broadened to treat women suffering from all causes of infertility. In the meantime, it opens a possibility for cancer patients for fertility preservation, because some cancer patients cannot be treated with ovarian stimulation. The aim of this chapter is to share our experience and protocols with the assisted reproductive technology (ART) fraternity.
In this report, we present a case of in vitro maturation (IVM) with surgical retrieved testicular sperm in a normo-ovulatory female. Human chorionic gonadotropin-primed IVM, testicular biopsy for sperm retrieval and intracytoplasmic sperm injection with fresh sperm were performed. Fourteen cumulus-oocyte complexes were obtained in germinal vesicle or metaphase I stage, eight oocytes reached metaphase II, seven presumptive zygotes were obtained, and three cleavage stages embryos in day 2 were transferred producing a singleton pregnancy. A single healthy newborn was obtained. Our results suggest that IVM may be an alternative for in vitro fertilization in normo-ovulatory women even if surgical retrieval of sperm is needed. Further research is required to depict contributing factors to the success of IVM in indications different from polycystic ovaries syndrome and the role of male gamete.
Although the initial live birth resulting from human in vitro fertilization (IVF) was achieved by natural-cycle IVF, this procedure was gradually replaced by ovarian stimulation IVF because it was found that the number of oocytes retrieved related to the embryos available for transfer which, in turn, directly affected successful pregnancy. However, repeated ovarian stimulation by gonadotropins has certain drawbacks including a higher risk of ovarian hyperstimulation syndrome and the concerns about a possible increased risk of ovarian, endometrial, and breast cancers. Therefore, there is a growing interest in natural-cycle IVF and in vitro maturation (IVM) treatment. Recovery of immature oocytes followed by IVM is a potentially useful treatment for women with infertility. The method is particularly effective for infertile women who have numerous antral follicles due to polycystic ovaries or polycystic ovarian syndrome. Today, given the efficiency of IVF and improvements in the culture system, natural-cycle IVF is more suitable for women undergoing infertility treatment. One very attractive possibility for enhancing the successful outcome of natural-cycle IVF treatment is combining it with immature egg retrieval and IVM. The use of IVM technology can thus be broadened to treat women suffering from all causes of infertility. The aim of this chapter is to share our experience and protocols with the assisted reproductive technology fraternity.
Background:
Repeated in vitro Fertilization (IVF) failure together with Ovarian Hyperstimulation Syndrome (OHSS) is one of the distressing situations leading couples to search for alternative treatment options. For such patients with Polycystic Ovarian Syndrome (PCOS) who have experienced Ovarian Hyperstimulation Syndrome, mild ovarian stimulation with in vitro oocyte maturation could be a promising alternative. Testicular Sperm Aspiration (TESA) of spermatozoa from a known obstructive azoospermic patient is a limiting factor for IVM (in vitro maturation) but the couple reported here accepted mild IVF -IVM with TESA.
Case presentation:
In the treatment of a 32-year old woman, 9 immature oocytes were retrieved, 5 in vitro matured oocytes (maturation rate 55%) and after fertilization by Intracytoplasmic Sperm Injection (ICSI), 3 oocytes (fertilization rate 60%) which had two pronuclei and two good quality embryos on day 2, were transferred. A live pregnancy was observed by ultrasound scan and healthy infant was delivered.
Conclusion:
Although the number of births from ICSI of immature oocytes injected with surgically derived sperm is quite low, the selection of this mode of therapy as an alternative to conventional IVF will overcome the limitations and provides a new option in IVF practice.
Despite their central role in clinical in vitro fertilization (IVF), the specific factors that establish physiological competence for the human oocytes are largely unknown and as a consequence, the absence of analytical measures to assess competence is a key factor in the unpredictability of outcome in IVF. The inability readily to distinguish between competent and incompetent oocytes has important consequences for the ‘success rates’ of treatment. Not only may incompetent embryos be mistakenly chosen over competent ones for transfer, but more crucially, patients who lack competent oocytes cannot be identified early in the work-up of infertility assessment so as to allow them to be diverted from the distress of cycles of costly and ineffective treatment.
Introduction In vitro fertilization (IVF) treatment not only proved to be the most effective treatment of subfertility but also extended treatment opportunities with its complementary procedures such as intracytoplasmic sperm injection, testicular sperm retrieval, gamete and embryo cryopreservation, and preimplantation genetic diagnosis. IVF has completely changed the field of reproductive medicine. Although the first IVF birth was achieved with “the reimplantation of a human embryo” derived from a single oocyte retrieved in a natural cycle, soon it was realized that pregnancy and birth rates per treatment cycle could be increased with simultaneous transfer of multiple embryos following retrieval of multiple mature oocytes with controlled ovarian stimulation (COS). Simultaneous transfer of multiple embryos substantially increased pregnancy rates and on average they reached 20–40% per started cycle. The results achieved by most treatment centers exceed spontaneous conception rates in healthy fertile couples. Production of multiple embryos requires COS with exogenous gonadotropin administration combined with gonadotropin releasing hormone analogs. Unfortunately, COS is not without limitations. First, the cost of drugs poses a substantial financial burden and at times prevents a couple's access to treatment. The cost of medications can reach as high as 40% of overall treatment cost. Second, COS requires frequent monitoring scans and creates further direct and indirect costs, loss of working time and inconvenience. Furthermore, the most important medical problem associated with COS is the risk of ovarian hyperstimulation syndrome (OHSS).
In vitro fertilization (IVF) treatment has been a major and perhaps the most influential breakthrough in the field of reproductive medicine. The technique itself, together with accompanying procedures such as intracytoplasmic sperm injection, testicular sperm retrieval, gamete and embryo cryopreservation, and preimplantation genetic diagnosis, has changed the way infertility treatments are practiced. Since the birth of the first IVF baby in 1978, millions of babies have been born, bringing joy not only to their parents, some of whom would never have conceived without the use of these technologies, but also to the healthcare professionals helping them through their treatments. In the simplest words, the IVF technique involves fertilization of a human oocyte with sperm under laboratory conditions. However, human oocytes can only be fertilized once they reach the metaphase two stage (MII). Although there are thousands of immature oocytes harbored within the primordial follicles in the ovaries of a reproductive-aged woman, almost always only one completes its development and reaches the MII stage in a given menstrual cycle. Therefore, in a natural cycle, only one MII oocyte is amenable to fertilization, either in vivo or in vitro, for a limited duration. In fact, the first successful IVF treatment was performed with fertilization of a single MII oocyte collected in a natural cycle. However, soon it was realized that pregnancy and birth rates per treatment cycle could be increased in parallel with the number of mature oocytes collected.
The present study examined whether the rates of oocyte maturation, fertilization and development, as well as pregnancy rate could be improved by human chorionic gonadotrophin (HCG) priming 36 h before immature oocyte retrieval in patients with polycystic ovarian syndrome (PCOS). Immature oocyte retrieval was performed on day 10-14 of the cycles and patients were randomly allocated either to be primed with 10 000 IU of HCG before the retrieval, or not primed. Immature oocytes were cultured for 24-48 h in TC-199 medium with 20% (v/v) inactivated fetal bovine serum (FBS) supplemented with 75 mIU/ml follicle stimulating hormone (FSH) and luteinizing hormone (LH). Intracytoplasmic sperm injection (ICSI) was performed in all mature oocytes and the resulting embryos were transferred on day 2 or 3 after ICSI. A total of 17 patients underwent 24 completed treatment cycles. Thirteen cycles were primed with HCG and 11 other cycles were not primed. The mean number of oocytes retrieved was comparable in the two groups (7.8 +/- 3.9 versus 7.4 +/- 5.2). The percentage of oocytes achieving maturation at 48 h was significantly higher (P < 0.05) in the HCG-primed group (84.3%, 86/102) than in the non-HCG-primed group (69.1%, 56/81). Oocyte maturation was hastened in the HCG-primed group. Following 24 h of culture, 78.2 +/- 7.1% of oocytes were matured in the HCG-primed group compared with 4.9 +/- 2.5% of oocytes in the non-HCG-primed group (P < 0.001). There were no significant differences in the rates of oocyte fertilization and cleavage in these two groups. There were five clinical pregnancies (38.5%) in the HCG-primed group, and three pregnancies (27.3%) in the non-HCG-primed group.
By means of pelvic ultrasonography, a multifollicular ovarian appearance was observed in women with weight-loss-related amenorrhoea. Multifollicular ovaries (MFO) are normal in size or slightly enlarged and filled by six or more cysts 4-10 mm in diameter; in contrast to women with polycystic ovaries (PCO), stroma is not increased. Unlike PCO patients, women with MFO were not hirsute and serum concentrations of luteinising hormone and follicle stimulating hormone were normal and decreased, respectively. The uterus was small indicating oestrogen deficiency. In MFO, treatment with gonadotropin releasing hormone (LHRH) induced ovulation in 83% of cycles and there were seven pregnancies in 8 women; in PCO, only 40% of cycles were ovulatory and there were eleven pregnancies (8 women) but six of these aborted. In MFO ovarian morphology reverted to normal in ovulatory cycles, whereas in PCO the polycystic pattern persisted despite the presence of a domainant follicle. MFO may represent a normal ovarian response to weight-related hypothalamic disturbance of gonadotropin control.
Intracytoplasmic sperm injection (ICSI) is a promising assisted-fertilisation technique that may benefit women who have not become pregnant by in-vitro fertilisation (IVF) or subzonal insemination (SUZI) of oocytes. We have used ICSI to treat couples with infertility because of severely impaired sperm characteristics, and in whom IVF and SUZI had failed. Direct injection of a single spermatozoon into the ooplasm was done in 47 metaphase-II oocytes: 38 oocytes remained intact after injection, 31 became fertilised, and 15 embryos were replaced in utero. Four pregnancies occurred after eight treatment cycles--two singleton and one twin pregnancy, and a preclinical abortion. Two healthy boys have been delivered from the singleton pregnancies and a healthy boy and girl from the twin pregnancy.
This study describes the results with immature human follicular oocytes harvested from unstimulated ovaries, matured in vitro, fertilized, and transferred to an agonadal recipient. Two hundred seventy immature oocytes were aspirated from 23 ovaries removed for various gynecological indications from August 1988 to October 1989. The numbers of follicular oocytes collected from ovaries were compared by patients' ages and the stages of menstrual cycle. Immature oocytes in vitro were incubated with either mature follicular fluid (FF) or fetal cord serum (FCS). The maturation rate in the mature FF group was 55.8%, significantly higher than the 35.9% in the FCS group. In addition, mature FF group was shown to provide a significantly higher fertilization rate than the FCS group (81.0% versus 31.6%). More fertilized eggs developed into normal embryos in the nonstimulated cycle group than in stimulated cycles with routine treatment. Finally, five embryos were transferred to a woman with premature ovarian failure on day 18 of a steroid replacement cycle. She subsequently delivered healthy triplet girls. These results suggest that in vitro maturation of immature oocytes from unstimulated ovaries with mature follicular fluid could be used successfully in a donor oocyte program after in vitro fertilization.
Summary This report serves to describe the initial experience in a Canadian in vitro fertilization program. While our unit is still early on the learning curve, we are thus far gratified with a pregnancy rate of 17.3% per treatment cycle and 20% per laparoscopy.
The present report covers the results of a 26-month period in which 1275 consecutive treatment cycles by intracytoplasmic sperm injection (ICSI) were performed in 919 couples. These couples were afflicted with male factor infertility and had had at least one previous failed conventional in vitro fertilization (IVF) treatment cycle. In other couples, the husband had semen parameters incompatible with conventional IVF or suffered from excretory azoospermia which required microsurgical epididymal sperm aspiration or testicular sperm retrieval. Overall, the 2 pronuclear (PN) fertilization rate was 47.7% per retrieved oocyte-cumulus complex and 66.4% per successfully injected metaphase II oocyte. Embryo transfer was performed in 90.8% of started cycles and 362 clinical pregnancies were recorded, giving a clinical pregnancy rate of 28.4% per started cycle or 31.3% per transfer. In addition, updated results on the outcome of pregnancies after microassisted fertilization are presented. As of 30 August 1994, 416 children have been born. Although 16 major congenital malformations have been observed (3.9%), there appears to be no reason for serious concern as regards the occurrence of major congenital anomalies after ICSI.
To determine the maturational and developmental competence of immature oocytes recovered in situ from anovulatory and ovulatory patients with polycystic ovaries (PCO).
A newly designed method for recovery of immature oocytes from 2 to 10 mm follicles by transvaginal ultrasound or laparoscopy was used to compare the recovery and maturation of oocytes from 9 anovulatory polycystic ovarian syndrome (PCOS) patients and 10 ovulatory patients without polycystic ovaries (PCO) (experiment 1). In a second study (experiment 2), we compared the maturation, fertilization, and development of oocytes recovered from another 10 anovulatory PCOS and 13 ovulatory PCO patients. Two types of culture methods and time intervals for maturation were also examined.
In experiment 1, a significantly higher number of immature oocytes were recovered from PCOS patients (15.3) compared with non-PCO patients (2.8). Sixty-five percent of oocytes cultured in medium with gonadotropins, estrogen, and fetal calf serum matured to metaphase II by 43 to 47 hours, and 81% were mature at 48 to 54 hours of culture. Thirty-four percent of the inseminated oocytes fertilized and 56% of the cultured pronuclear oocytes cleaved to eight cells or more. In experiment 2, there was no significant difference between anovulatory PCOS and ovulatory PCO patients in the number of oocytes recovered or their maturation, fertilization, and development. There was no difference between oocytes matured in medium or in coculture with mature granulosa cells, with or without added hCG. However, significantly fewer oocytes were immature and more fertilized when oocytes were inseminated after 34.5 to 35.5 hours of maturation than 29.5 to 32.5 hours of maturation. A pregnancy and the birth of a normal baby occurred in one of the anovulatory PCOS patient receiving an abbreviated steroid replacement protocol after ET.
Immature oocyte recovery could be developed as a new method for the treatment of women with infertility due to PCO because the oocytes of these patients retain their maturational and developmental competence.
To report a normal pregnancy and the delivery of a healthy child after the combination of in vitro maturation of germinal-vesicle stage oocytes and intracytoplasmic sperm injection (ICSI) in a patient.
Procedures were performed in a tertiary IVF center coupled with an institutional research environment.
Maturation rate of immature oocytes after in vitro maturation and intactness, fertilization, and developmental rates of oocytes after microinjection.
Nine of 14 germinal-vesicle stage oocytes matured to the metaphase II stage after 30 hours of in vitro culture (64%). Seven of eight injected and intact oocytes fertilized normally (78%) and five of them cleaved with < 20% fragmentation (71%). Four embryos were transferred and a singleton pregnancy was obtained that ended in the delivery of a healthy child.
In vitro maturation of immature oocytes together with ICSI can result in normal fertilization, embryo development, pregnancy, and the delivery of healthy child.