IVF News

 

Dr.Thomas IVF- The International School of Embryology is conducting ongoing IVF training programme for Embryologist and Gynaecologist. 

 

Embryologist:

Sperm wash methods and Intra uterine insemination (hands on experience.).

IVF Lab. basics, sterile techniques, culture media, preparation of culture dishes for IVF and ICSI (with and without oil overlay), handling of oocyte under stereo zoom microscope and insemination with sperms, sperm preparation  for IVF & ICSI, denuding eggs, pronuclear stage observation, sigle culture and group culture,day 3 embryo transfers, embryo transfer techniques, setting up of inverted  microscope and micro manipulator system for performing ICSI, ICSI dish preparation, doing microinjection (IVF and ICSI hands-on)  , advise regarding settings up of IUI and IVFlab,Laser Assisted Hatching, Sperm Freezing,Embryo freezing( 2PN& cell stage) PESA, MESA andTesticular Biopsy .....duration  1 to 2 months

 

Medical graduates (Gynaecologists) : infertility history taking ,patient examination , pre IVF&ICSI investigation ,tests advised patient selection criteria, various ovarian stimulation protocols (COHS), tailoring protocols as per patient needs, performing trans vaginal ultrasonography, follicular growth monitoring, Dummy Embryo Transfer, semen analysis, semen culture, adjuvant drugs used in ART, management of OHSS and oocyte retrieval (pick-up) Frozen Embryo Transfer,Egg donation and Embryo donation and surrogacy.....duration 1 to 2 months

Interested candidate may contact

Dr.Thomas

Institute Director

Dr.Thomas ivf - International school of Embryology-chennai

Chennai Fertility center and Research Institute - chennai

Dr.Thomas Fertility center & Hospital - Pondycherry

Chennai India.

Email: [email protected]   or [email protected]

+919841165197

[ Full Article ]

Over the weekend, a misleading and inflammatory story appeared in the Sunday Times newspaper concerning the number of selective terminations performed in the UK. Entitled 'IVF mothers abort 'spare' babies', the article told us that 'women who find they are expecting twins or triplets after receiving treatment for infertility are choosing to have one or more babies aborted'. Further, the article told us that babies are destroyed 'usually to spare the mothers the additional burden of raising them'. The article gave the impression that hundreds of women are destroying their unwanted multiple babies on a whim to suit their lifestyles. But the reality of selective terminations is rather different.

Selective terminations are offered to women who are carrying twins, triplets or quads; most, though not all, of which are the result of fertility treatment. Those who decide to reduce the number of fetuses that they are carrying do not do so for their own convenience, but because of the health risks to their prospective children. Babies in multiple pregnancies are more likely to be born early, thereby increasing the chance of low birth weights and increasing the chance of disability. Although the selective termination itself is not without risk to the whole pregnancy, some couples feel that such a risk is worth taking in order to promote the health of the remaining fetuses.

What provoked the publication of this story? Are selective terminations on the rise or more frequently offered to women with multiple pregnancies? It seems that the story was written after new statistics on the number of abortions performed in England and Wales were released by the Office of National Statistics. The statistics show that the total number of abortions performed in 2001 was 187,402. Of these, 40 were selective terminations, 20 of which were carried out because of fetal abnormality. This very small number of selective terminations has hovered around 40 for the past decade and, if anything, is likely to fall from now on, as the number of multiple conceptions starts to come down.

Contrary to the impression given by the Sunday Times article, selective terminations are not common, nor are they on the increase. They are performed in rare circumstances in which, for an individual couple, reducing the number of fetuses in a pregnancy, as undesirable as it might seem, is the best way to protect the health and wellbeing of their future children.
[ Full Article ]

Pope Benedict XVI has told an international Catholic conference on the scientific and bioethical considerations of 'The Human Embryo Before Implantation', that IVF embryos have a right to life, even before implantation. Speaking to the Pontifical Academy for Life, he declared that all human life was 'sacred and inviolable' and that 'moral judgment is valid from the start of the life of an embryo, even before it is implanted in the maternal womb'. The Vatican hosted the conference to review whether current scientific data supports the Vatican's hard-line position on IVF. The Vatican opposes IVF and related procedures because embryos created in a laboratory are often discarded, whereas others are frozen and still others are created for medical research purposes, for example to create stem cells.

Pope Benedict also restated the Catholic Church's opposition to IVF, and added that it should only welcome reproductive assistance if it 'facilitates' sexual activity between a couple. Speaking at the same conference, a senior Vatican official also said that there is no moral justification for discriminating between embryos used in IVF procedures. Monsignor Elio Sgreccia, who heads the Vatican's Pontifical Council for Life, said the theory that laboratory-created embryos were not worthy of the same legal protection and the right to life as an already implanted embryo was morally wrong.

[ Full Article ]

Tetsuaki Hara, MD, PhD received his MD from the Hiroshima University School of Medicine in 1980. Following his residency and completion of his doctorate in 1991, he became a university instructor in 1991, assistant professor in 1996 and associate professor of gynaecology and obstetrics in 1999, at Hiroshima University School of Medicine. Since 2007, he has worked as a director of the division of reproductive medicine, Hiroshima Prefectural Hospital. Currently, his research interests include ovarian reserve, ovarian stimulation, polycystic ovary syndrome, single-embryo transfer, embryo culture and gynaecological endoscopic surgery.

PII: S1472-6483(12)00699-2

doi:10.1016/j.rbmo.2012.11.014

© 2012 Reproductive Healthcare Ltd. Published by Elsevier Inc All rights reserved. 

Abstract 

Human embryos normally experience mechanical stimuli during development in vivo. To apply appropriate stimuli to embryos, this study group developed a tilting embryo culture system (TECS) and investigated whether it could improve the grade of fresh human embryos compared with a control static culture system. A total of 450 retrieved oocytes from 32 IVF or intracytoplasmic sperm injection cycles of 32 women were cultured for 5–6days. Oocytes were divided randomly into TECS and control groups and then were inseminated in vitro. All embryos were evaluated at days 3 and 5 using standard grading criteria for embryo quality. The rates of fertilization per mature oocyte and high-grade cleavage-stage embryo formation in the TECS group were similar to those in the control group. The rates of blastocyst formation and of blastocysts graded 3BB or higher at day 5 were significantly higher in the TECS group than those in the control group: 45.3% (67/148) versus 32.1% (51/159) (P=0.018) and 29.1% (43/148) versus 17.6% (28/159) (P=0.018), respectively. The TECS group produced more high-grade blastocysts than the control group. Embryo movement or mechanical stimulation during embryo culture may be beneficial for human embryonic development.

A culture system that produces high-quality blastocysts capable of implantation is critically important for IVF and embryo transfer. Human embryos normally experience mechanical stimuli during development in vivo. To apply appropriate stimuli to embryos, we developed a tilting embryo culture system (TECS) by placing a culture dish on an automatically tilting plate to move embryos back and forth along the bottom of the dish. We investigated whether the TECS could improve the grade of fresh human embryos to be transferred compared with that of a control static culture system. A total of 450 retrieved oocytes from 32 IVF or intracytoplasmic sperm injection cycles of 32 women were cultured for 5days. The oocytes were divided randomly into TECS and control groups and inseminated in vitro. In the TECS group, the dishes were subjected to a maximum 20° tilt for 10min in each direction at 1° per second. All embryos were evaluated at days 3 and 5 using standard embryo quality grading criteria. The rate of fertilization and high-grade cleavage-stage embryo formation in the TECS group were similar to in the control group. The rate of blastocyst formation and growth of blastocysts graded 3BB or higher were significantly higher in the TECS group than in the control group: 45.3% (67/148) versus 32.1% (51/159) and 29.1% (43/148) versus 17.6% (28/159), respectively. The TECS produced more high-grade blastocysts than the control group, which increased the number of usable blastocysts, by exposing embryos to normal levels of mechanical stimuli in vitro.

Introduction 

The development of a reliable culture system to increase the number of usable embryos with high implantation competence in one oocyte retrieval cycle is critically important for IVF and embryo transfer. Some reports of culture systems to control chemical and mechanical microenvironments for in-vitro mammalian embryo culture have been published, such as a microwell approach (Vajta et al., 2000, Hashimoto et al., 2009, Ebner et al., 2010), pulsative mechanical microvibration (Isachenko et al., 2010, Mizobe et al., 2010) and dynamic culture systems with fluid motion (Suh et al., 2003, Cabrera et al., 2006, Smith and Takayama, 2007, Blockeel et al., 2009, Heo et al., 2010, Smith et al., 2011, Swain and Smith, 2011). For human embryo culture, microwell culture increases the cell number of the inner cell mass in blastocysts (Hashimoto et al., 2009), and pulsative mechanical microvibration improves the pregnancy rate regardless of the day of embryo transfer (Isachenko et al., 2010). These results suggest that human embryonic development in vitro can be significantly improved by optimization of chemical and mechanical microenvironments.

In vivo, human embryos are normally transported to the uterine cavity from the Fallopian tube, where fertilization and early embryogenesis occur. Phasic contraction of the smooth muscle in the wall of the Fallopian tube and the currents produced by its ciliated epithelium enable the Fallopian tube to act as a peristaltic pump to push the embryo towards the uterotubal junction (Lyons et al., 2002, Lyons et al., 2006, Zervomanolakis et al., 2007). This movement likely stimulates the embryo continuously during transport, which may also be affected by direct contact, because the tubal lumen from the ampulla to the isthmus and the diameter of an embryo are similar. Such motion and contact presumably provide mechanical stimuli, such as shear stresses, compression and frictional forces, from the tubal fluid. Mechanical stimuli can induce the proliferation and differentiation of many cell types such as endocytes, muscle cells and osteoblasts (Wang and Thampatty, 2006). Therefore, mechanical factors in the Fallopian tube might play an important role in embryonic development. However, the static culture conditions used in conventional IVF do not mimic these mechanical stimuli for embryos.

In a previous study (Matsuura et al., 2010), to apply appropriate mechanical stimuli for routine clinical use, this study developed a tilting embryo culture system (TECS) by placing a conventional culture dish on an automatically tilting plate to move embryos back and forth along the bottom of the dish using mouse embryos or donated human embryos destined to be discarded. It was found that the TECS was safe for embryos and significantly increased blastocyst cell numbers under mechanical stimuli without inducing apoptosis. The current study investigates whether the TECS increases the numbers of morphologically high-grade human blastocysts for embryo transfer or cryopreservation compared with those obtained by a control static culture system.

Materials and methods 

Patients 

This study was approved by the Institutional Review Boards of Hiroshima Prefectural Hospital (reference no. H19-10, approved 31 August 2007) and Okayama University (reference no. 420, approved 24 April 2007). After written informed consent was obtained from patients, conventional IVF or intracytoplasmic sperm injection (ICSI) cycles were carried out in 32 women at the division of reproductive medicine, Hiroshima Prefectural Hospital from March 2008 to May 2010. Patients were enrolled when 10 or more oocyte–cumulus-complexes were retrieved. The standard infertility work up was carried out for all patients and male partners.

The patient characteristics are summarized in Table 1. The exclusion criteria were women older than 40years, severe male factor disorders such as oligoasthenoteratozoospermia or azoospermia and endocrinological disorders such as a hypothalamic/pituitary disorder (World Health Organization type I; ESHRE Capri Workshop Group, 1995), hyperthyroidism, hypothyroidism or hyperprolactinaemia. Women diagnosed with polycystic ovary syndrome classified according to the Rotterdam criteria (The Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group, 2004) were included.

Ovarian stimulation 

A gonadotrophin-releasing hormone (GnRH) analogue long protocol (n=25) and GnRH antagonist flex and multidose protocol (n=7) were used for ovarian stimulation. The GnRH analogue long protocol has been described elsewhere (Hara et al., 2005). Briefly, pituitary secretion was down-regulated by administration of the GnRH analogue buserelin (Suprecur; Mochida Pharmaceutical, Tokyo, Japan) as a nasal spray. Pituitary down-regulation was confirmed by both transvaginal ultrasonography and serum oestradiol measurement. Then, injections of recombinant FSH (150–225IU/day, Follistim; Schering-Plough, Osaka, Japan) were started. In the GnRH antagonist protocol, injections of recombinant FSH (150–225IU/day) were started following menstrual cycle control with oral contraceptive pills (Planovar combination tablets; Pfizer Japan, Tokyo, Japan) for 12days. When the dominant follicle exceeded 14mm in diameter, a GnRH antagonist (0.25mg cetrorelix, Cetrotide; Shionogi, Osaka, Japan) was administered daily until ovulation was triggered. An intramuscular injection of human chorionic gonadotrophin (HCG, 5000IU; Aska Pharmaceutical, Tokyo, Japan) was administered when at least two follicles exceeded 17mm in diameter. Oocytes were retrieved at 34–36h after the HCG injection.

Randomization of retrieved oocytes 

Retrieved oocytes were randomly divided into TECS and control groups. Randomization was performed using a computer-generated list of random numbers (n=450). Oocytes were allocated to TECS or control groups if the number was even (zero was regarded as even) or odd, respectively. The TECS was applied to the allocated oocytes during preincubation before IVF or ICSI. After the oocyte was allocated and cultured for 4h in human tubal fluid (Irvine Scientific, Santa Ana, CA, USA), at 37°C with 5% CO₂, 5% O₂ and 90% N₂, it was inseminated for 2h with spermatozoa selected previously by density gradient centrifugation and a swim-up procedure. ICSI was used for insemination when repeated analyses showed total sperm counts in the treated semen were below 1×10⁶. ICSI was performed by standard procedures.

Tilting embryo culture system 

The TECS equipment (Strex, Osaka, Japan) was developed to apply appropriate ‘natural’ mechanical stimuli to embryos in vitro (Matsuura et al., 2010). The TECS is an electrical device with a power cord which is designed to be used in a standard humidified incubator. It consists of a control unit and a waterproof motor unit with a tilting plate (Figure 1), one-well culture dishes (IVF One Well Dish, 353653; BD Falcon, Tokyo, Japan) and/or four-well dishes (IVF MultiDish, 144444; Nunc, Roskilde, Denmark) were set on the plate. Motion parameters, such as the uniform radial velocity, maximum tilt angle and holding time at the maximum tilt angle, were set and applied by the control unit outside of the incubator. Dishes were subjected to a maximum 20° tilt in each direction at 1°/sec. This setting allowed embryos to move back and forth along the bottom of the dish at approximately 1mm/min (Matsuura et al., 2010).

Embryo culture, cryopreservation and elective single blastocyst transfer 

Fertilization was determined to have occurred when two pronuclei were identified at approximately 20h after IVF or ICSI. Fertilized oocytes continued to be cultured in sequential medium (BlastAssist system; Jyllinge, Denmark) at 37°C with 5% CO₂, 5% O₂ and 90% N₂ for 5days in group culture without an oil overlay. The embryo density was 150μl/embryo. Three to six oocytes or embryos were cultured in a one-well culture dish with 450–900μl medium. One or two oocytes or embryos were cultured in a four-well culture dish with 150–300μl medium.

Embryos were evaluated at day 3 in terms of the number, symmetry and granularity of the blastomeres, type and percentage of fragmentation, the presence of multinucleated blastomeres and degree of compaction, as described previously (Alikani et al., 2000). High-grade day-3 embryos were characterized by having no multinucleated cells and consisting of 7–9 cells. Furthermore, in such embryos, less than 15% of the volume of the embryo should have contained fragmentation, and the embryo should have appeared symmetrical with only slightly asymmetric blastomeres. Embryos at day 5 were evaluated using Gardner’s criteria (Gardner et al., 2000) for a blastocyst. Blastocysts scoring 3BB or higher were designated as high grade. Blastocysts containing a grade C inner cell mass or trophectoderm were not designated high grade. Morulae and blastocysts scoring less than 3BB at day 5 were cultured to day 6.

The highest-grade blastocyst of each cycle, defined as the most morphologically advanced with a grade of 3BB or higher at day 5, in either group was transferred into patients at day 5 when the blastocyst was eligible for elective single blastocyst transfer according to the hospital’s policy. When the embryo grade was the same in either group, the control-cultured blastocyst was transferred. No embryos underwent assisted hatching before a fresh embryo transfer was performed. Blastocyst transfer was carried out using a Kitazato ET 3.0 Fr Catheter (Kitazato Medical, Tokyo, Japan) under transvaginal ultrasonographic guidance. Cryopreservation of supernumerary blastocysts scoring 3BB or higher at day 5 was carried out by vitrification (Kuwayama et al., 2005). All blastocysts graded 3BB or higher were vitrified if a patient was at risk of ovarian hyperstimulation syndrome or if the ovarian stimulation used the GnRH antagonist protocol, according to the hospital’s IVF/ICSI policy. When only morulae or lower-grade embryos were available, no fresh embryos were transferred. After embryos were cultured up to day 6, blastocysts scoring 3BB or higher were also cryopreserved by the same method. Conventional IVF or ICSI procedures were carried out by the same blinded embryologist. Embryos were evaluated by one embryologist who was blinded to the culture allocation, as were the clinicians, nurses and embryologists who carried out embryo transfers.

Vitrified–warmed blastocyst transfer cycles and outcomes of embryo transfer 

Micronized vaginal progesterone (450mg/day; Nacalai Tesque, Kyoto, Japan) and a transdermal oestradiol patch (Estrana tape, 0.72mg; Hisamitsu Pharmaceutical, Tokyo, Japan) were used for luteal support in women at least until a pregnancy test was carried out for a fresh blastocyst transfer. All vitrified–warmed blastocyst transfers were performed during artificial hormone replacement cycles with transdermal oestradiol patches and micronized vaginal progesterone using identical endometrial preparation protocols. Biochemical pregnancy was determined by elevation of serum βHCG over the detection range of the assay without visualization of a gestational sac by transvaginal ultrasonography. Clinical pregnancy was determined by demonstration of a gestational sac by transvaginal ultrasonography. After delivery, medical records were obtained detailing each patient’s obstetric history as reported by their obstetricians. The outcomes of embryo transfer were followed up until June 2011, when some cryopreserved blastocysts were warmed and discarded because a couple wished to discontinue storage of cryopreserved blastocysts. Serum oestradiol and βHCG were measured using an automated electrochemiluminescence immunoassay with a Cobas E601 Analyser (Roche Diagnostics, Mannheim, Germany).

Power analysis 

To detect an increase of 15% in grade 3BB or higher blastocyst formation rate (on day 5) (i.e. from 20% to 35%) for fertilized oocytes, 137 fertilized oocytes in each group would be needed to achieve a power of 80% with a chi-squared test at a significance level of 5%. This increase in grade 3BB or higher blastocyst formation rate was based on previous results at the division of reproductive medicine, Hiroshima Prefectural Hospital during 2008 (T. Hara, unpublished results).

Statistical analysis 

Continuous data were shown as the mean±SD. Categorical data were analysed using chi-squared tests to compare the rates of fertilization, cleavage, high-grade cleavage-stage embryo formation, blastocyst formation and grade 3BB or higher blastocyst formation in the two culture systems. Variables associated with embryo grade in the univariate analysis (patient’s age at oocyte retrieval (⩽34 or 35years), type of infertility (primary or secondary), cause of infertility (tubal, endometriosis, unknown or male), type of ovarian stimulation (antagonist or agonist methods), type of insemination (conventional or ICSI) and culture system (TECS or control)) were included in a multivariate analysis. A multiple logistic regression analysis with a stepwise method was used to determine the impact of grade 3BB or higher blastocyst formation. Significant differences, odds ratios (OR) and their 95% confidence intervals (95% CI) were calculated from the model’s coefficients and their standard deviations. A value of P<0.05 was considered statistically significant. JMP 7 computer software (SAS Institute) was used for statistical data analysis.

Results 

The demographic characteristics of the couples, the type of ovarian stimulation, the result of the semen analysis and the method of insemination are summarized in Table 1. Thirty-two women were enrolled in this study. The response to ovarian stimulation was good in all patients. The mean number of retrieved oocytes was 17.0±4.9 (range 10–29). Semen analysis of most of the male partners confirmed normozoospermia. However, seven cases underwent ICSI according to the hospital’s criteria for male subfertility. The clinical background and final embryonic development after TECS or control culture for each case are summarized in Supplementary Table S1 (available online only).

The embryonic development rates in the TECS and control groups are summarized in Table 2. Fertilization and cleavage rates were not significantly different between groups. The rate of formation of high-grade cleavage-stage embryos at day 3 was not significantly higher in the TECS group, compared with that in the control group. The rates of blastocyst formation at days 5 and 6 from fertilized oocytes were significantly higher in the TECS group compared with those in the control group: 45.3% (67/148) versus 32.1% (51/159) (P=0.018) and 48.0% (71/148) versus 35.2% (56/159) (P=0.023), respectively. The rates of blastocyst graded higher than 3BB at days 5 and 6 from fertilized oocytes were also significantly higher in the TECS group compared with those in the control group: 29.1% (43/148) versus 17.6% (28/159) (P=0.018) and 31.1% (46/148) versus 19.5% (31/159) (P=0.019), respectively.

Values are n/total (%). Chi-squared tests were used to compare embryonic development rates and the Mann–Whitney nonparametric U-test was used to compare the effectiveness of producing the highest-grade blastocysts between the two systems. P<0.05 was considered to be statistically significant.Control=static embryo culture system; D=day; NS=not statistically significant; TECS=tilting embryo culture system.

Among the variables associated with embryo grade, the culture system was only related to blastocysts graded higher than 3BB at day 5, and the TECS was significantly superior to static culture (P=0.018) in the univariate analysis (Table 3). In multiple logistic regression analysis, patient’s age and culture system were independent factors to predict formation of blastocysts graded higher than 3BB at day 5 (R²=0.034, model P=0.049) (Table 4). The formation of blastocysts graded higher than 3BB from patients aged 35years at day 5 was significantly inferior to that in patients aged ⩽34years (OR 0.495, 95% CI 0.257–0.935, P=0.032). The formation of blastocysts graded higher than 3BB in the TECS group at day 5 was significantly superior to that in the control group (OR 1.936, 95% CI 1.126–3.371, P=0.017).

The outcomes of embryo transfer per person are shown in Supplementary Figure 1. Among 32 patients, at least one grade 3BB or higher blastocyst up to day 6 developed using the TECS or static culture for 25 patients. Among the 25 patients that received a blastocyst from the TECS or the control group, 24 patients showed positive serum βHCG, 21 became clinically pregnant and 20 had a live birth. Twenty-two babies were born because two patients delivered twice. In seven cases, either fresh embryo transfer or cryopreservation was not performed because no grade 3BB or higher blastocysts developed using either the TECS or static culture. In 11 cases, fresh embryo transfers were performed. In 13 cases, all embryos were cryopreserved to prevent ovarian hyperstimulation syndrome or because a GnRH antagonist protocol had been used.

The outcomes of embryo transfer per embryo are shown in Supplementary Figure 2 and summarized in Table 5. Among the seven fresh embryo transfers from the TECS group, all embryos developed to a successful birth. The rest of the embryos in the TECS group (n=39) were cryopreserved for the clinical reasons described in the materials and methods. Among them, 21 vitrified blastocysts were warmed and then transferred. Of the 21 blastocysts transferred, 19 blastocysts resulted in a positive serum βHCG, 16 developed to a clinical pregnancy and 11 to a successful birth. In total, 26 blastocysts resulted in positive serum βHCG, 23 in a clinical pregnancy and 18 in a successful birth. The positive serum βHCG rate of embryos from the TECS group was significantly higher than those from the control group: 92.9% (26/29) versus 66.7% (6/9) (P=0.046).

Discussion 

As far as is known, this is the first report that quantitatively defines appropriate mechanical stimulation of human embryos in vitro to improve the production of high-grade blastocysts for implantation, pregnancy and birth rates. This study confirms that the level of mechanical stimuli applied during embryo culture is not detrimental through all embryonic stages from fertilization to the blastocyst. The retrieved oocyte–cumulus-complexes from each patient were divided randomly into either a TECS or a control group before insemination or ICSI, which decreased the selection bias. The rates of formation of blastocysts graded 3BB or higher from fertilized oocytes by the TECS method were also greater than those obtained with a conventional static culture system. Thus, the TECS approach increases the number of blastocysts and would increase the cumulative number of pregnancies or live births in elective single blastocyst transfer cycles using either fresh or cryopreserved blastocysts. Thus far, the finding that a TECS enhances the grade of embryos has not been reported.

There are two possible reasons for why the formation rate of higher-grade blastocysts was higher. First, in this study, the TECS was applied to oocytes before IVF or ICSI. Similar stimuli have been applied to embryos after fertilization by other institutions (personal communications: Yoshimasa Asada and Tetsunori Mukaida). The effect of mechanical stimuli on the fertilization of human oocytes remains unclear, although mechanical stimuli play fundamental roles in fertilization in other species (Knoll et al., 2003, Horner and Wolfner, 2008). In this study, the fertilization rate in the TECS group was not significantly higher than the control group. This result suggests that mechanical stimuli might enhance cell proliferation, rather than fertilization, via unknown mechanisms. Mizobe et al. (2010) reported that cytoplasmic maturation of in-vitro-matured pig oocytes is enhanced by mechanical vibration, whereas Isachenko et al., 2010, Isachenko et al., 2011 reported that the blastocyst formation rate of 2PN zygote increases by 10% using a mechanical vibration device. These reports suggest that appropriate mechanical stimuli before fertilization by the TECS used in this study might stimulate subsequent oocyte maturation as well as cell proliferation in the embryo. What needs to be clarified is the optimal time to apply the TECS during embryo culture, i.e. just after oocyte retrieval or after recognition of fertilization. Second, the blastocyst conversion rate was somewhat low in the control group of this study. The control conditions used in the study may be suboptimal and would explain the significant increase in blastocyst formation using the TECS over a suboptimal system, which may be another reason why this study has shown a positive improvement following TECS, although other studies using a TECS have not.

One limitation is the ending of the study before transfer of all cryopreserved–warmed blastocysts, when a couple wished to discard their cryopreserved blastocysts. The implantation rate of blastocysts from the TECS group was significantly higher than that of blastocysts from the control group. However, the clinical pregnancy and birth rates from blastocysts obtained from the TECS group were not significantly higher than those from the control group, although the rates were higher for the TECS group than those in the control group. However, considering the difference in rates between the TECS and control groups, more power would clarify the superiority of the TECS over static culture. Such cumulative data need to be calculated after the transfer of fresh blastocysts and the transfer of all cryopreserved blastocysts. For this reason, this study could not clarify that the clinical pregnancy or birth rates from blastocysts from the TECS group were significantly higher than those from the control group. The second limitation of this study was that it enrolled only good responders to ovulation induction regimens. It is still unclear whether the TECS enhances the rate of formation of high-grade blastocysts from women who are poor responders to ovulation induction regimens. To address these important questions, a multicentre prospective randomized case-control trial is currently being prepared, which will include a broader range of patients.

A culture system using microfluidic technology has been reported to enhance mouse embryonic development and pregnancy rates (Cabrera et al., 2006, Heo et al., 2010). Recently, this system has been applied to a clinical situation and reported to increase the production of high-quality human cleavage-stage embryos through a reduction of embryo fragmentation (Alegretti et al., 2011). Although this system is sophisticated and promises to improve embryonic development, the device that controls the continual pulsatile or peristaltic fluid flow is very specific and quite complex to use. In contrast, the TECS can be rapidly implemented in a laboratory, because it can be fitted to a standard incubator and adapted to different types of culture dishes. Using conventional culture dishes in this study, the formation rate of blastocysts graded 3BB or higher was significantly greater using the TECS compared with the conventional static culture system.

Excessive shear stress has been reported to cause physical damage to embryos (Xie et al., 2006, Xie et al., 2007). Thus, shear stresses exceeding 1.2dynes/cm² result in death of the blastocyst within 12h (Xie et al., 2006). However, a previous study showed that the velocity of embryo movement on the TECS plate is approximately 0.1mm/min, equivalent to shear stress of only 0.007dynes/cm² (Matsuura et al., 2010). Moreover, the shear stresses produced by the TECS are not harmful to mouse or human embryos destined to be discarded (Matsuura et al., 2010). The previous study also demonstrated that the cell numbers of mouse and human blastocysts cultured using the TECS are greater than those of blastocysts cultured in a static culture system, suggesting that the TECS enhances the rate of cell division in embryos. According to other reports (Xie et al., 2006, Cui et al., 2008), the number of cells in mouse embryos is negatively correlated with the percentage of apoptotic cells. In bone and endothelial cells, downstream transcription factors in the nucleus are activated by mechanical stimuli such as shear stresses, and mechanotransduction, gene transcription and DNA synthesis are also activated (Wang and Thampatty, 2006). Cell numbers might increase in the absence of apoptosis as a result of the enhancement of cell division induced by these activations.

Another explanation for the enhancement of cell division is facilitated diffusion of waste products from cultured embryos in the TECS. After addition of a microsphere to the centre of a 50μl microdrop, the times for the microsphere to reach the edge of the microdrop were 60 and 5min under a static condition and using the TECS, respectively. Facilitated diffusion reduces the autocrine effect in the TECS, because the concentration of products for embryo growth near the embryo decreases faster compared with that in static culture, which is consistent with microfunnel results (Heo et al., 2010). Under the culture conditions of this study, embryo numbers in the culture medium were between one and six, and the embryo concentration was 150μl/embryo. Decreasing the culture medium volume per embryo may result in a beneficial effect using the TECS. Group culture of human embryos in vitro improves their development, probably due to paracrine and enhanced autocrine factors by the paracrine interaction (O’Neill, 2008, Ebner et al., 2010). Paracrine mediators would not be concentrated by the facilitated diffusion with fluid motion, and paracrine factors would not be dominant for the improvement of human embryonic development using the TECS. At present, it cannot be determined which mechanical stimuli or/and diffusion of waste products in the culture medium is dominant for the improvement of embryonic development. Delineating the molecular responses of human embryos, such as with intracellular calcium ion and 1,4,5-triphosphate concentrations, to mechanical stimuli may help to clarify the enhancement of cell division using dynamic culture systems (Isachenko et al., 2010).

In conclusion, a tilting embryo culture system was developed to apply appropriate mechanical stimuli such as shear stress to embryos in vitro for clinical assisted reproduction, which leads to a higher rate of production of high-grade blastocysts with a higher implantation potential than those obtained from a static culture method. The system is a promising culture method that enhances the numbers of usable blastocysts in a single oocyte retrieval cycle by exposing them to mechanical stimuli similar to those found in the Fallopian tube.

Acknowledgements 

This study was supported by a Grant-in-Aid for Scientific Research on Priority Areas to KN (‘System cell engineering by multi-scale manipulation’, no. 17076006) and Special Coordination Funds for Promoting Sciences and Technology to KM from the Japanese Ministry of Education, Science, Sports and Culture.

References 

1. Alegretti JR, Rocha AM, Barros BC, Serafini P, Motta ELA, Smith GD. Microfluidic dynamic embryo culture increases the production of top quality human embryos through reduction in embryo fragmentation. Fertil. Steril. 2011;96:S58 View In Article | Full Text | Full-Text PDF (45 KB | CrossRef
   
   
2. Alikani M, Calderon G, Tomkin G, Garrisi J, Kokot M, Cohen J. Cleavage anomalies in early human embryos and survival after prolonged culture in-vitro. Hum. Reprod. 2000;15:2634–2643 View In Article | MEDLINE | CrossRef
   
   
3. Blockeel C, Mock P, Verheyen G, Bouche N, Goff PL, Heyman Y, et al. An in vivo culture system for human embryos using an encapsulation technology: a pilot study. Hum. Reprod. 2009;24:790–796 View In Article | CrossRef
   
   
4. Cabrera LM, Heo YS, Ding J, Takayama S, Smith GD. Improved blastocyst development with microfluidics and Braille pin actuator enabled dynamic culture. Fertil. Steril. 2006;86:S43 View In Article | Full Text | Full-Text PDF (97 KB) | CrossRef
   
   
5. Cui XS, Shen XH, Kim NH. High mobility group box 1 (HMGB1) is implicated in preimplantation embryo development in the mouse. Mol. Reprod. Dev. 2008;75:1290–1299 View In Article | CrossRef
   
   
6. Ebner T, Shebi O, Moser M, Mayer RB, Arzt W, Tews G. Group culture of human zygotes is superior to individual culture in terms of blastulation, implantation and live birth. Reprod. Biomed. Online. 2010;21:762–768 View In Article | Abstract | Full Text | Full-Text PDF (345 KB) | CrossRef
   
   
7. The ESHRE Capri Workshop. Anovulatory infertility. The ESHRE Capri Workshop Group. Hum. Reprod. 1995;10:1549–1553 View In Article | MEDLINE | CrossRef
   
   
8. Gardner DK, Lane M, Stevens J, Schlenker T, Schoolcraft WB. Blastocyst score affects implantation and pregnancy outcome.Fertil. Steril. 2000;73:1155–1158 View In Article | Abstract | Full Text | Full-Text PDF (60 KB) | CrossRef
   
   
9. Hara T, Katsuki T, Kusuda T, Ohama K. Pregnancy rate, multiple pregnancy rate, and embryo quality: clues for single blastocyst transfer from double blastocyst transfer in an unselected population. Reprod. Med. Biol. 2005;4:153–159 View In Article
   
   
10. Hashimoto S, Iwamoto D, Taniguchi S, Saeki K, Kato N, Morimoto Y. Successful culture and time-lapse photography of individual human embryos using non-porous poly-(dimethylsiloxane) micro-well plates. Fertil. Steril. 2009;92:S36 View In Article | Full Text | Full-Text PDF (43 KB) | CrossRef
    
    
11. Heo YS, Cabrera LM, Bormann CL, Shah CT, Takayama S, Smith GD. Dynamic microfunnel culture enhances mouse embryo development and pregnancy rates. Hum. Reprod. 2010;25:613–622 View In Article | CrossRef
    
    
12. Horner VL, Wolfner MF. Mechanical stimulation by osmotic and hydrostatic pressure activates Drosophila oocytes in vitro in a calcium-dependent manner. Dev. Biol. 2008;316:100–109 View In Article | CrossRef
    
    
13. Isachenko E, Maettner R, Isachenko V, Roth S, Kreienberg R, Sterzik K. Mechanical agitation during the in vitro culture of human pre-implantation embryos drastically increases the pregnancy rate. Clin. Lab. 2010;56:569–576 View In Article
    
    
14. Isachenko V, Maettner R, Sterzik K, Strehler E, Kreinberg R, Hancke K, et al. In-vitro culture of human embryos with mechanical micro-vibration increases implantation rates. Reprod. Biomed. Online. 2011;22:536–544 View In Article | Abstract | Full Text | Full-Text PDF (230 KB) | CrossRef
    
    
15. Knoll R, Hoshijima M, Chien K. Cardiac mechanotransduction and implications for heart disease. J. Mol. Med. 2003;81:750–756 View In Article | MEDLINE | CrossRef
    
    
16. Kuwayama M, Vajta G, Ieda S, Kato O. Comparison of open and closed methods for vitrification of human embryos and the elimination of potential contamination. Reprod. Biomed. Online. 2005;11:608–614 View In Article | Abstract | Full-Text PDF (249 KB) | CrossRef
    
    
17. Lyons RA, Djahanbakhch O, Mahmood T, Saridogan E, Sattar S, Sheaff MT, et al. Fallopian tube ciliary beat frequency in relation to the stage of menstrual cycle and anatomical site. Hum. Reprod. 2002;17:584–588 View In Article | MEDLINE | CrossRef
    
    
18. Lyons RA, Saridogan E, Djahanbakhch O. The effect of ovarian follicular fluid and peritoneal fluid on Fallopian tube ciliary beat frequency. Hum. Reprod. 2006;21:52–56 View In Article | MEDLINE | CrossRef
    
    
19. Matsuura K, Hayashi N, Kuroda Y, Takiue C, Hirata R, Takenami M, et al. Improved development of mouse and human embryos using a tilting embryo culture system. Reprod. Biomed. Online. 2010;20:358–364 View In Article | Abstract | Full Text | Full-Text PDF (341 KB) | CrossRef
    
    
20. Mizobe Y, Yoshida M, Miyoshi K. Enhancement of cytoplasmic maturation of invitro-matured pig oocytes by mechanical vibration. J. Reprod. Dev. 2010;56:285–290 View In Article | CrossRef
    
    
21. O’Neill C. The potential roles for embryotrophic ligands in preimplantation embryo development. Hum. Reprod. 2008;14:275–288 View In Article | MEDLINE | CrossRef
    
    
22. The Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil. Steril. 2004;81:19–25 View In Article | Full Text | Full-Text PDF (29 KB) | CrossRef
    
    
23. Suh RS, Phadke N, Ohl DA, Takayama S, Smith GD. Rethinking gamete/embryo isolation and culture with microfluidics. Hum. Reprod. Update. 2003;9:451–461 View In Article | MEDLINE | CrossRef
    
    
24. Smith GD, Takayama S. Gamete and embryo isolation and culture with microfluidics. Theriogenology. 2007;68:S190–S195 View In Article | CrossRef
    
    
25. Smith GD, Swain JE, Bormann CL. Microfluidics for gametes, embryos, and embryonic stem cells. Semin. Reprod. Med.2011;29:5–14 View In Article
    
    
26. Swain JE, Smith GD. Advances in embryo culture platforms: novel approaches to improve preimplantation embryo development through modification of the microenvironment. Hum. Reprod. Update. 2011;17:541–557 View In Article | CrossRef
    
    
27. Vajta G, Peura TT, Holm P, Paldi K, Greve T, Trounson AO, et al. New method for culture of zona-included or zona-free embryos: The Well of the Well (WOW) system. Mol. Reprod. Dev. 2000;55:256–264 View In Article | CrossRef
    
    
28. Wang JHC, Thampatty BP. An introductory review of cell mechanobiology. Biomech. Model. Mechanobiol. 2006;5:1–16 View In Article | MEDLINE | CrossRef
    
    
29. Xie Y, Wang F, Zhong W, Puscheck E, Rappolee DA, Shen H. Shear stress induces preimplantation embryo death that is delayed by the zona pellucida and associated with stress-activated protein kinase-mediated apoptosis. Biol. Reprod. 2006;75:45–55 View In Article | MEDLINE | CrossRef
    
30. Xie Y, Wang F, Puscheck EE, Rappolee DA. Pipetting causes shear stress and elevation of phosphorylated stress-activated protein kinase/jun kinase in preimplantation embryos. Mol. Reprod. Dev. 2007;74:1287–1294 View In Article | CrossRef
    
    
31. Zervomanolakis I, Ott HW, Hadziomerovic D, Mattle V, Seeber BE, Virgolini I, et al. Physiology of upward transport in the human female genital tract. Ann. N. Y. Acad. Sci. 2007;1101:1–20 View In Article | MEDLINE | CrossRef

[ Full Article ]

The American Society for Reproductive Medicine, founded in 1944, is an organization of more than 8,000 physicians, researchers, nurses, technicians, and other professionals dedicated to advancing knowledge and expertise in reproductive biology. Affiliated societies include the Society for Assisted Reproductive Technology, The Society for Male Reproduction and Urology, the Society for Reproductive Endocrinology and Infertility, and the Society of Reproductive Surgeons.�

[ Full Article ]

Australian doctors have used preimplantation genetic diagnosis (PGD) to ensure that a baby shared a rhesus negative blood group with its mother. The team, based at the University of Sydney, used the technique to avoid the risk of rhesus disease, caused when the blood of a rhesus-positive baby triggers an immune reaction in its rhesus-negative mother. The doctors, who published the case in the early online edition of Human Reproduction, say it is the first report of using PGD for this purpose.



People described as rhesus-positive -around 85 per cent of the population - have a protein called the rhesus antigen on the surface of their red blood cells, which is missing from rhesus-negative individuals. During most of pregnancy, the blood of a mother and her fetus are kept separate, but during late pregnancy or labour, a few fetal blood cells can escape into the mother's circulation. In a rhesus-negative woman carrying a rhesus-positive baby, this can provoke a response from the mother's immune system, 'priming it' to attack the fetal red blood cells in subsequent rhesus-positive pregnancies.



Left untreated, this process can cause severe anaemia, and sometimes death. In the vast majority of cases, rhesus disease can be prevented by injecting a rhesus-negative woman with anti-rhesus injections throughout her pregnancy. However, of 62,000 rhesus-positive babies born to rhesus-negative mothers in England and Wales each year, around 500 have blood problems, and up to 30 will die.



The Australian team treated a couple whose second child had severe rhesus disease. Following PGD to select a rhesus-negative embryo, the mother gave birth to a healthy baby girl in 2003. 'A couple who have had a significantly affect pregnancy are faced with the dilemma of whether or not to attempt further pregnancies', said team leader Sean Seeho, adding that the tendency for the disease to worsen 'with each subsequent rhesus-incompatible pregnancy plays a major part in the decision'. The technique is only an option for couples in which the father is either rhesus-negative, or has inherited the rhesus-negative trait as well as the rhesus-positive trait.
[ Full Article ]

Dr. T.C Anand Kumar, the pioneer of India’s first scientifically documented test tube baby, passed away on January 26, 2010 at the age of 74. A reproductive biologist of international repute, he will always be remembered for his diverse contributions to the field ranging from the role of the neuro-endocrine system in reproduction; developing the means of administering hormones via the nasal route and spear-heading the team that produced India’s first test tube baby at the ICMR’s Institute for Research in Reproduction and the KEM Hospital, Mumbai in 1986. After his retirement as the Director of the Institute for Research in Reproduction, Mumbai, he founded Hope Infertility Clinic in Bangalore in 1991 where many of the first generation of ART specialists in the country were trained and started their careers in this field.

Having attained his doctorate in India, he went to Birmingham, UK to pursue his studies. Despite several job opportunities provided to him in UK, he was committed by a national spirit and returned to India to participate in the growth of science in the young nation. It was then that he started the electron microscopy laboratory at the All India Institute Medical Sciences in the 1970 which is still functional today.

He continued sharing his wisdom and experience with the younger generation of scientists by serving as an advisor on many committees on the World Health Organization, Department of Science and Technology, Council of Scientific & Industrial Research, Government of India; Department of Biotechnology, Government of India and the Indian Council of Medical Research till September 2009.

His work was recognized by his peers and he received the Shanti Swaroop BHatnagar Award, the highest scientific award in the country; the Sanjay Gandhi National Award, and was fellow of prestigious Indian Academy of Science; the National Academy of Medical Science (India) and fellow of the Gonville and Caius College, Cambridge.

The visionary in Dr Anand Kumar was equally concerned about the welfare of his patients seeking treatment with newer reproductive technologies. When the first scientifically documented test tube baby was born, he was always questioned whether an over populated country needed test-tube babies. With this modality of treatment gaining acceptance and hundreds of clinics operating in India, he took a lead in formulating National Guidelines for Accreditation, Supervision and Regulation of ART Clinics in India.

A man who stood for truth had the greatness to give away his fame and glory of being the pioneer of India’s first test tube baby when he discovered all the hand-written notes of Dr Subhas Mukerjee. Dr Mukerjee from Kolkata had claimed to have created a test tube baby in 1979 (the second in the world) but his claims were neither substantiated nor recognized by scientists or the authorities leading to the man ending his life prematurely. Dr Anand Kumar had the courage to research his predecessors’ findings and scientifically present it to the world giving Dr Mukerjee his due place in medical history (Anand Kumar T C. Curr Sci. 72:526-531; 1997). Such generosity and honesty is a very rare and precious attribute.

Dr Anand Kumar’s love for science and the search for the truth will always be remembered. His students who are now highly placed all over the world would always cherish their mentor. He is survived by his wife, Karpagam son Vijay and a daughter Ambika and three grand children.

[ Full Article ]

Scientists at the Reproductive Genetics Institute in Chicago, US, say that they have developed a technique that could be used to allow two women to have a child together, without the need for sperm.

The technique involves manipulating cells taken from a woman and turning them into 'artificial sperm' which could then be used to fertilise another woman's egg, allowing two women to be the genetic parents of a child. The technique was developed to help men with no sperm have children.

The Chicago scientists say that they are already trialling the technique on human eggs, and it may be available within two years. Many other scientists, however, believe that the technique is dangerous. It involves a process known as 'haploidisation', where chromosomes within a cell are forced to separate in half. It is believed that this might cause illnesses that would not be apparent until the child was older. Professor Bill Ledger, from Sheffield University in the UK, said 'this technology has a high risk of creating damaged people and therefore I don't think it should be allowed to go ahead'.

But Mohammed Taranissi, a UK fertility specialist who has been working with the Chicago team, believes that the technique shows promise. He said 'it's being done in human eggs as we speak and the first results are going to be presented at a conference in April'.
[ Full Article ]

What Is In Vitro Fertilization (IVF)?

In Vitro Fertilization (IVF) was first done successfully in United Kingdom in 1977.  Decades ago, women who suffered an ectopic pregnancy (a condition in which the fetus grows in the fallopian tube or outside of the uterus), were treated by removing the affected fallopian tube. Unfortunately, following one ectopic pregnancy the woman had a much greater chance of repeating the same ill fate most likely losing both fallopian tubes. IVF was initially developed to help women without fallopian tubes become pregnant.

While the first IVF pregnancy in 1977 was ectopic, the first IVF baby was successfully conceived in Oldham, England in 1978, resulting in the birth of Louise Brown. Since then, there have been over one million children born by means of in vitro fertilization.

The introduction of in vitro fertilization completely changed, and greatly improved, the way doctors are able to treat the most difficult cases of infertility- even those that were previously considered untreatable. While it's not a "cure all", IVF has revolutionized the world of infertility and the medical field's approach towards treating and understanding the disease. 

In Vitro fertilization denotes "the fertilization of eggs with sperm in a laboratory". There are many stages to IVF.

Ovarian Stimulation
Each woman contains thousands of sacs, which are filled with fluid, called follicles. Inside each of the follicles is an egg, called an ovum. Normally each follicle, in a typical reproductive cycle, has a single egg attached, which will inevitably reach maturity.  Each woman will be given fertility medicines to develop multiple eggs, and in order to stimulate ovulation.

The typical protocol involves the woman being administered three types of medications: a GnRH agonist or antagonist, in order to suppress the woman's natural hormones, a gonadotropin in order to stimulate follicles and egg development, and HCG to finalize egg development and to trigger ovulation. It will be up to your doctor to discuss and plan with you the protocol, timing and the exact medications, which will be used in your cycle.

In order to monitor the progress of the developing follicles, every few days the women's hormonal blood levels are checked and a pelvic ultra sound is performed. Once there are between 10 and 30 developing follicles (eggs), and they have reached their goal size, the egg retrieval process will be planned.

Oocyte Retrieval
When the follicles have reached full growth, the egg retrieval is performed with the use of a guided ultrasound.   In a doctor's office or in a surgical facility the retrieval is performed, in order to remove the eggs from the woman's ovaries. The procedure will take approximately twenty minutes and the women will most likely be given an anesthetic for her comfort.

The procedure is performed with a long ultrasound probe into the woman's vagina. Next, a special needle in conjunction with the probe passes through the side of the vagina into the woman's ovary, where each developing follicle is easily aspirated.  In general, approximately 70% of the mature eggs will fertilize. Unfortunately, because of some slow destruction along the process, the final total number of healthy embryos is often much less than the original count of eggs and follicles. 

Following the retrieval, the woman is typically asked to rest for approximately one hour, while the embryologist examines the collected eggs for their quantity as well as their quality.
Typically, the woman will be able to return to her normal routine the following day.

Sperm Collection
There is a theory that frequent ejaculation may artificially lower the sperm count. Because of this, the man will be asked to abstain from ejaculation for a minimum of forty-eight hours prior to giving his semen. But in actuality a man with a normal sperm count will not be affected, even if he ejaculates daily.  Most laboratories require the sperm specimen within a few hours after the retrieval of the woman's eggs. In order for the semen to be separated from the liquid portion, the fresh donation is immediately taken to the lab where it's washed and separated into a medium sterile amount and then concentrated into a small quantity. At this point the sperm are tested with an array of techniques to increase their ability to fertilize the egg. In order to increase the enzymes that will be needed for egg penetration and fertilization, the sperm are treated and incubated, which alters the membrane. Next, the sperm is processed in a centrifuge, which enables the laboratory to identify the most optimal quality and concentration of the sperm. 

Fertilization and Embryo Culture
In a Petri dish, the recently collected egg is combined with the most optimal sperm. This process is called fertilization, which in actuality is the entry of the sperm into the egg.  As though it would occur naturally with your own body fluids and reproductive tract, the egg and sperm are bathed in a nourishing liquid and incubated for the next three to five days. At this point the egg and sperm will be closely monitored to see which of the eggs is fertilized. Typically, fertilization takes place within a few hours. Once the egg is fertilized, it will continue to grow in the incubator, until it becomes an embryo. Contributing to to the warmth of the uterus, the embryos will continue to grow and develop in the incubator, which will be set at normal body temperature. The laboratory simply serves as a temporary womb, to insure the optimal growth of the newly formed embryos.

Note: If there is a significant male factor involved, then several hours after egg collection ICSI is performed.
Embryos that are continuing to grow and develop properly will consist of between four to eight cells, within two to three days. The development of cells will be used as a guide, to determine which of the embryos are best for transfer into the uterus. On the following day, the patients will learn their total number of healthy embryos.  Unfortunately, as stated before, the final total number of healthy embryos is often much less than the original count of eggs and follicles. Three days after the egg retrieval process, the embryos chosen for the transfer will be identified.

Note: At this point in the IVF cycle, if the patient is planning a blastocyst transfer, this step will occur on the fifth or sixth day.
 
Typically, the reproductive endocrinologist and the embryologist will review the quality of the embryos and discuss their recommendation regarding the number to be transferred.

Note: Embryos which are not selected for transfer, and are still considered to be good quality, may be excellent candidates for cryopreservation with liquid nitrogen. By thawing the frozen embryos and replacing them into the uterus, the patient can undergo future IVF cycles, without repeating the previous steps.

Embryo Transfer
The embryo transfer is one of the most important aspects of in vitro fertilization. Initially the doctor will require the patient to have a full bladder (48 ounces of water) for the transfer. Because your bladder sits in front of the uterus, it outlines the uterus so the physician can more clearly see the catheter, as it passes through your cervix to your uterus. It's important to note that there is a middle ground when it comes to the fullness of the bladder. Too full and the procedure could cause discomfort and not full enough, and the doctor will have difficulty seeing the catheter.  It may seem simple, but the transfer is the most crucial part of the in vitro fertilization cycle. Here is where the skill, knowledge, experience and ability of the physician is chosen will matter most. During the procedure you will be placed on the examination table, with your feet in stirrups; very much like the position you are required to take during your typical visit for your annual pap test. At this point the embryos that appear to be the most viable are transferred between two to six days after egg retrieval, by the use of ultrasound guidance.

Typically, under the direction of a transabdominal ultrasound, the embryos are replaced into the uterus by a very thin and flexible catheter, which is introduced through the vagina and the cervix and into your uterus. The lab assistant will load the embryos into the catheter, and the doctor will carefully inject the embryos into the uterus. The doctor must transfer the embryos into the optimal part of the uterine lining, with as little disturbance to the uterus and cervix as possible. Once the catheter is withdrawn, the lab assistant returns to the laboratory to examine the catheter, to make certain the embryos have been successfully transferred. Although the embryo transfer is the shortest step in the IVF procedure, the doctor will ask that each patient stay reclined for a minimum of thirty minutes to one hour.

During this time you may experience some normal abdominal pain or pelvic cramping. Once the patient has been transferred, within the next couple of days, the growing embryos should begin to implant into the patient's uterine lining.   

Post Transfer
Once transferred the patient may notice some slight vaginal discharge, which is a result of the supplies and equipment used during the procedure itself. Most physicians will ask their patients to remain on bed rest for approximately forty-eight hours. Depending on your medical history and your doctor's preference, each patient will follow the transfer with a different protocol. Most patients follow the transfer by continuing to take medication and supplements to maintain and stabilize the pregnancy. Two weeks after the transfer, the patient will undergo a blood pregnancy test. If the pregnancy test is positive, most physicians will require the patient to repeat the test every two days until the HCG levels are high enough to visualize the pregnancy sac on a transvaginal ultrasound. Three to four weeks following the embryo transfer, the beta HCG levels should be more than 2000 IU. Finally, in order to confirm the fetal cardiac activity, a follow-up ultrasound is then performed. Next the patient will be released from the reproductive endocrinologist and transferred to their obstetrician/gynecologist for prenatal care.

For More Information visit:  http://www.conceivableworld.com

[ Full Article ]

Washington, DC – Several new research studies presented at the American Society for Reproductive Medicine meeting tackled the question of how best to help older women seeking to have children.�

Using data collected by the Society for Assisted Reproductive Technology (SART) the SART writing group analyzed data from IVF cycles performed between 2000 and 2004. They examined records of more than 5500 cycles performed in women over age 37. They found that for 38 and 39 year olds, compared to a single embryo transfer, the use of up to two embryos increased the number of cycles leading to a live birth; however transferring more embryos did not increase the delivery rate, but did increase the number of multiple births. For women age 40, using 3 embryos did increase the delivery rate, but not the multiple-birth rate. For women aged 41 and 42, transferring more than 2 embryos did not increase the delivery rate, but did increase the number of twins.

Another study by that same research team evaluated more than 38,000 cycles in women over age 37. They found that for 38 and 39 year old women both delivery rates and rates of multiple-birth rates increased as the number of embryos transferred increased to 3. Transferring more than 3 embryos did not increase pregnancy rates for this age group. Forty year old patients did see an increase in pregnancy rates as well as rates of multiple gestations.

A team from the Robert Wood Johnson Medical School found that increasing the number of embryos transferred in patients over age 40 could increase their pregnancy rates.

A team of researchers in Houston and Colorado analyzed nearly 300 cycles done on 41 and 42 year old patients in their programs. They used the outcomes of those cycles to create a mathematical model that projects that cycles using up to 6 embryos for patients over age 40 would result in very few multiple gestations.

In Connecticut, insurance companies are required to offer coverage for infertility patients up to age 40. Researchers found that women beyond age 40 were treated successfully. The live birth rate for 43 year olds was 10% and for 44 year old patients it was 5.4%.

“SART is committed to collecting and using data to ensure we provide our patients the best care possible. We are constantly striving to maximize the chances for each patient to have a safe successful singleton pregnancy,” said David Grainger, MD, MPH, President of the Society for Assisted Reproductive Technology (SART).

O-75, Stern et al, Optimizing the Number of Cleavage Stage Embryos to Transfer on Day 3 in Women 38 and Older: A SART Database Study
O-167, Optimizing the Number of Blastocyst Stage Embryos to Transfer in Women 38 and Older: A SART Database Study

P-110, Hickman et al, Are We Justified in Transferring more Embryos in Older Women?

P-519, Katsoff et al, In Contrast to Younger Women, the Transfer of 2 or 3 Embryos in Women Aged 40-42 with Increases Day Three Serum Follicle Stimulating Hormone (FSH) Markedly Improves Pregnancy Rates (PRs) Jerome Check, MD, PhD presenting.�

P-515, Cetinkaya et al, Reproductive Outcome of Women > 43 Years Old Undergoing ART Treatment with their own Oocytes Pasquale Patrizio, MD contact for discussion.

The American Society for Reproductive Medicine, founded in 1944, is an organization of more than 8,000 physicians, researchers, nurses, technicians, and other professionals dedicated to advancing knowledge and expertise in reproductive biology. Affiliated societies include the Society for Assisted Reproductive Technology, The Society for Male Reproduction and Urology, the Society for Reproductive Endocrinology and Infertility, and the Society of Reproductive Surgeons.�

[ Full Article ]