Faculty Bibliography

We evaluated the maturational competence of mouse oocytes reconstructed by the transfer and electrofusion of germinal vesicles (GV) into anuclear cytoplasts of GV stage oocytes (both auto- and hetero-transfers), metaphase II stage oocytes or zygotes. Following in-vitro culture, the maturation rates of the reconstructed oocytes to metaphase II did not significantly differ between auto- and hetero-transfers (40/70 versus 95/144 respectively); these rates also did not differ from those of control oocytes (57/97) which were matured in vitro without micromanipulation and electrofusion. In contrast, when a GV was transferred into an enucleated metaphase II oocyte or a zygote, only a few reconstructed oocytes underwent germinal vesicle breakdown (5/30 and 2/21 respectively); moreover, none reached metaphase II stage. Cytogenetic and immunofluorescence analyses were conducted on hetero-GV oocytes that extruded a first polar body. Each oocyte showed two groups of chromosomes, one in the cytoplast and one in the polar body, as well as a bipolar spindle with twenty univalent chromosomes. Our findings suggest that oocytes reconstructed by GV transfer into a cytoplast of the same developmental stage mature normally in vitro through metaphase II. Such oocytes may be a useful research model to elucidate the cytoplasmic and nuclear mechanisms regulating meiosis and the relationships between meiotic errors and age-related changes in the oocyte

OBJECTIVE: To assess the impact of ET difficulty on IVF outcome and to optimize the ET procedure. DESIGN: Retrospective analysis of IVF outcome by ET catheter type and ET difficulty. Prospective treatment and follow-up of patients with a history of extremely difficult cervical passage. SETTING: Large university-based IVF program. PATIENT(S): All patients < 40 years of age undergoing IVF-ET from September 1995 to May 1998. INTERVENTION(S): Surgical correction of cervical stenosis. MAIN OUTCOME MEASURE(S): Pregnancy and embryo implantation rates. RESULT(S): Only 0.6% of ETs were 'extremely difficult.' Pregnancy rates were not statistically significantly different among ETs graded easy, moderate, and difficult. In contrast, no pregnancies occurred in the rare 'extremely difficult' ET group. Eight patients with a history of extremely difficult cervical passage underwent surgical correction of their cervical stenosis. Twelve postoperative IVF-ET in these women resulted in eight clinical pregnancies, six of which were multiple gestations. The embryo implantation rate of these cycles was 42.2%. CONCLUSION(S): Patients with a history of extremely difficult ET may benefit from hysteroscopic evaluation and possible modification of their cervical canal before a future IVF attempt

STUDY OBJECTIVE: To analyze fertility outcomes after resection of submucous myomas by operative hysteroscopy in infertile women. DESIGN: Retrospective analysis (Canadian Task Force classification II-2). SETTING: Academic tertiary referral center. PATIENTS: Forty-one women (age 28-42 yrs) old with primary and secondary infertility, and histologically proved submucous myomas. Intervention. Hysteroscopic myomectomy performed with a rigid resectoscope. MEASUREMENTS AND MAIN RESULTS: Of the 41 patients, 25 (60.9%) became pregnant overall and 20 (48.7%) delivered at term. Seventeen patients delivered a single fetus. Five delivered twins, three at term and two at 33 and 35 weeks. One woman delivered triplets at 31 weeks. The total delivery rate was 56.0%. Two women miscarried, at 6 and 8 weeks. One patient developed postoperative Asherman's syndrome. CONCLUSION: Our results indicate that hysteroscopic myomectomy improves fertility in previously infertile women. Resection is a viable alternative to abdominal myomectomy for submucous myomas. (J Am Assoc Gynecol Laparosc 6(2):155-158, 1999)

OBJECTIVE: To describe a micromanipulation-electrofusion procedure for transferring germinal vesicles (GVs) between immature human oocytes. DESIGN: Pilot study to assess oocyte maturation after an invasive micromanipulation procedure. SETTING: Research laboratory at a university medical center. PATIENT(S): Immature oocytes were discarded from intracytoplasmic sperm injection (ICSI)-IVF cycles of patients 23-48 years of age. INTERVENTION(S): Initially, GV removal and transfer were performed on the same oocyte; these 'self-reconstructed' oocytes were then cultured in vitro for up to 50 hours and examined periodically for maturation as judged by the extrusion of the first polar body. In a second study, GVs from oocytes of 'old' patients (>38 years old) were successfully transferred into enucleated immature oocytes of 'young' patients (<31 years old). MAIN OUTCOME MEASURE(S): Extrusion of the first polar body was monitored in 'reconstructed' and control oocytes; karyotypes also were analyzed at meiosis II. RESULT(S): From 48 oocytes from old patients, 12 GVs were successfully removed, transferred, and fused into previously enucleated oocytes from young patients. After in vitro culture, 7 of these 'reconstructed' oocytes matured to meiosis II, a maturation rate not significantly different from that observed in nonmanipulated controls. A normal, second meiotic metaphase chromosome complement was observed in 4 of 5 reconstructed oocytes. CONCLUSION(S): Normal meiosis can occur after the transfer of a GV into an enucleated host oocyte. Germinal vesicle transfer may be a valuable research procedure that generates cell models to characterize the cytoplasmic-nuclear interplay for cell cycle regulation, maturation, and fertilization in the human oocyte; it also may be a potentially attractive alternative to oocyte donation

OBJECTIVE: To determine whether electrically stimulated Ca2+ influx can 'rescue' fertilization and early embryogenesis in human oocytes that fail to fertilize after intracytoplasmic sperm injection (ICSI). DESIGN: Prospective, randomized trial of a laboratory procedure. SETTING: A research laboratory at a university medical center. PATIENT(S): Discarded oocytes from ICSI-IVF cycles. INTERVENTION(S): Oocytes (n = 104) that showed no evidence of fertilization 16-24 hours after ICSI were assigned to three treatment groups: group 1 (one direct current electrical pulse at 1.36-1.50 kV/cm for 40-60 micros), group 2 (three pulses every 15-20 minutes), or group 3 (treated the same as group 2 but with no electrical stimulation). MAIN OUTCOME MEASURE(S): After stimulation, the oocytes were cultured in vitro for 3-5 days. Oocytes that displayed two pronuclei and a second polar body within 16 hours were considered to have fertilized normally. Fertilization and embryo cleavage rates were compared between groups. RESULT(S): Fertilization occurred in 26 (70%) of 37 and 38 (78%) of 49 group 1 and 2 oocytes, respectively, but in only 5 (27%) of 18 group 3 oocytes. Within 3 days, group 2 embryos routinely developed beyond the two-cell to four-cell stage (61% versus 13% in group 1); 11% of these oocytes developed to the morula or early blastocyst stage. Sex chromosome analyses indicated 10 male and 8 female embryos. CONCLUSION(S): Oocytes that fail to fertilize by 24 hours after ICSI can resume apparently normal fertilization and early embryonic development in response to electrical stimulation. Moreover, the degree of cytoplasmic activation as determined by the number of pulses applied affects fertilization efficiency and early embryonic development

OBJECTIVE: To evaluate the efficacy of oral micronized progesterone compared with IM progesterone in oil for luteal support in patients undergoing IVF who are treated with a GnRH agonist. DESIGN: Randomized prospective clinical trial. SETTING: University-based IVF center. PATIENT(S): Women <40 years of age who were undergoing IVF with luteal GnRH pituitary down-regulation. INTERVENTION(S): Patients were randomized to receive either oral micronized progesterone (200 mg three times daily) or IM progesterone (50 mg daily). MAIN OUTCOME MEASURE(S): Progesterone levels at standardized days 21 and 28, and pregnancy and embryo implantation rates. RESULT(S): Day 21 progesterone levels were 77.6+/-13.2 ng/mL in the IM group and 81.5+/-16.2 ng/mL in the oral group. Day 28 progesterone levels were 76.3+/-15.0 ng/mL in the IM group and 53.6+/-10.1 ng/mL in the oral group. The clinical pregnancy rates were 57.9% and 45.8% for the IM and oral groups, respectively. The implantation rate per embryo was significantly higher in the IM group (40.9%) than in the oral group (18.1%). CONCLUSION(S): When used according to our protocols, oral progesterone and IM progesterone result in comparable levels of circulating progesterone. However, oral progesterone results in a reduced implantation rate per embryo

OBJECTIVE: To determine whether baseline serum FSH and/or E2 concentrations can predict the risk for fetal chromosomal abnormalities. DESIGN: Case control study. SETTING: Reproductive technology program at a university hospital. PATIENT(S): Patients who underwent dilation and curettage (D + C), and whose products of conception were karyotyped. INTERVENTION(S): Patients underwent natural conception or controlled ovarian hyperstimulation followed by intrauterine insemination, in vitro fertilization and embryo transfer, gamete intrafallopian transfer, or zygote intrafallopian transfer. MAIN OUTCOME MEASURE(S): Baseline serum FSH and E2 concentrations and fetal karyotype. RESULT(S): Genetic evaluation of 78 D + C specimens revealed 34 normal and 44 abnormal fetal karyotypes. A significantly greater proportion of women with abnormal fetal karyotype had elevated baseline serum FSH (> or =15 mIU/mL [RIA] or 10 mIU/mL [Immulite]) and/or E2 > or = 50 pg/mL [Immulite]) compared with women of normal fetal karyotype. Among karyotypically abnormal abortuses, autosomal trisomy was the most common abnormality noted (79.5%), followed by mosaicism (6.8%), triploidy (6.8%), monosomy XO (4.5%), and balanced translocation (2.3%). CONCLUSION(S): Baseline serum FSH and/or E2 concentrations may be valuable as predictors of fetal aneuploidy

Barriers to assisted reproduction include clinical diagnoses that present the greatest challenge in achieving reproductive success and laboratory limitations that prevent the in vitro production of healthy, viable embryos with the highest likelihood for implantation. Although patients with various conditions are candidates for assisted reproductive technologies, advanced reproductive age, male factor infertility, and unexplained;infertility are the barriers that have most significantly affected assisted reproductive technologies success in the recent years. The success of in vitro fertilization is directly related to gamete quality. The goal of every ovarian stimulation protocol is the harvesting of an adequate number of mature preovulatory follicles. Several different stimulation protocols have been specifically designed to provide optimal ovarian response in patients with a history of unsuccessful attempts of in vitro fertilization. Subzonal sperm injection and partial zona dissection, techniques that were developed to improve fertilization in cases of severe male factor infertility, have for the most part given way to intracytoplasmic sperm injection, the process in which a single spermatozoon is injected into an oocyte. Intracytoplasmic sperm injection results in superior fertilization rates and does not appear to adversely affect embryo viability, a condition often encountered with subzonal sperm injection and partial zona dissection. Embryo morphologic characteristics provide the most accurate index for predicting implantation after in vitro fertilization. Embryo morphologic characteristics are directly related to in vitro culture conditions. Coculture techniques have been developed specifically to overcome the developmental arrests observed with standard in vitro fertilization techniques. Assisted hatching, the microsurgical removal of a small segment of the zona pellucida, has been shown to improve implantation, especially in patients with history of previous poor outcome with in vitro fertilization. Preimplantation genetic diagnosis is the technique of performing genetic testing on cell-stage embryos before initiation of pregnancy. Preimplantation genetic diagnosis involves single-blastomere biopsy of an early cleavage-stage preimplantation embryo, followed by genetic testing with polymerase chain reaction or fluorescent in situ hybridization. In the future, as implantation rates improve, fewer embryos will be transferred without fear of compromising in vitro fertilization success. Such new techniques as cytoplasmic and germinal vesicle transfer may prove beneficial as therapeutic alternatives to oocyte donation.

BACKGROUND: The Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome occurs in 1 of every 4,000-5,000 female births. It is characterized by normal external genitalia, an absent vagina, absent or rudimentary uterus, and normal fallopian tubes and ovaries. When associated with a rudimentary uterine horn, cyclic catamenial pelvic pain may result. The standard procedure for pain relief has been removal of the uterine horn by laparotomy. CASE: A rudimentary uterine horn was diagnosed in a woman with MRKH syndrome who developed monthly severe pelvic pain. Removal of the structure was performed via laparoscopy. The patient had complete resolution of her pain. CONCLUSION: As an alternative to laparotomy, laparoscopic resection of a rudimentary horn in patients with MRKH syndrome is both feasible and beneficial in the treatment of pelvic pain