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Objective: In the present study, we aimed to retrospectively evaluate the cumulative live birth rate (LBR) after up to three consecutive embryo transfer (ET) cycles, either fresh or frozen, in women with expected poor ovarian response (ePOR). Methods: We selected 115 women who entered the first in vitro fertilization (IVF) cycle between August 2013 and July 2016. The women were divided into an ePOR group (37 women) and a non-ePOR group (78 women). All women in the ePOR group were ≥40 years old or had serum anti-Müllerian hormone levels of less than 1.1 ng/mL at the time of the first IVF cycle. Live birth outcomes were monitored until December 2017. The cumulative LBR (with both conservative and optimistic estimates) was calculated according to the serial number of ET cycles. Results: After up to three ET cycles, the overall cumulative LBR was significantly lower in the ePOR group than in the non-ePOR group (conservative estimate, 10.8% vs. 44.9%, respectively; optimistic estimate, 14.7% vs. 56.1%, respectively; log-rank test, p=0.003). Conclusion: Women with ePOR exhibited a lower cumulative LBR than women in the non-ePOR group, and this information should be provided to ePOR women during counseling before starting IVF.

Objective: The purpose of this study was to determine the effect of vaginal progesterone for luteal phase support (LPS) on the clinical pregnancy rate (CPR) in natural frozen embryo transfer (FET) cycles via a meta-analysis.Methods: We performed a meta-analysis of randomized controlled trials (RCTs) and retrospective studies that met our selection criteria. Four online databases (PubMed, Embase, Medline, and the Cochrane Library) were searched between January 2017 and May 2017. Studies were selected according to predefined inclusion criteria and meta-analyzed using R software version 2.14.2. The main outcome measure was CPR.Results: A total of 18 studies were reviewed and assessed for eligibility. One RCT (n=435) and three retrospective studies (n=3,033) met the selection criteria. In a meta-analysis of the selected studies, we found no significant difference in the CPR (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.60–1.55) between the vaginal progesterone and control groups. An analysis of the two retrospective cohort studies that reported the live birth rate (LBR) following FET showed a significantly higher LBR in the vaginal progesterone group (OR, 1.72; 95% CI, 1.21–2.46). A subgroup meta-analysis of FET conducted 5 days after injection of human chorionic gonadotropin showed no significant differences between the two groups with regard to the CPR (OR, 1.18; 95% CI, 0.90–1.55) or miscarriage rate (OR, 0.73; 95% CI, 0.36–1.47).Conclusion: The results of this meta-analysis of the currently available literature suggest that LPS with vaginal progesterone in natural FET cycles does not improve the CPR.

OBJECTIVE This study aimed to investigate whether the injection funnel persistence time and oolemma resistance during the intracytoplasmic sperm injection (ICSI) are associated with subsequent embryo quality. DESIGN A prospective observational study at a university hospital. METHODS One hundred and twenty normal-appearing metaphase II oocytes were collected from 54 ICSI cycles. Injection funnel was observed at 0, 30, 60, and 90 s after ICSI, and the injection funnel persistence time was assigned to "no funnel," "0-30," "30-60," "60-90," and ">90 s." The degree of oolemma resistance during ICSI was recorded as "no," "mild," "moderate," and "severe." Subsequent embryos on day 3 after ICSI were evaluated morphologically, and formation of top-quality embryo and embryo score was assessed. We newly developed "oolemma score," based on the injection funnel persistence time and oolemma resistance, and the predictability of top-quality embryo was assessed. RESULTS Among the five groups by injection funnel persistence time, the proportion of top-quality embryo and embryo score (64.3%, 32) was highest in the "30-60 s," but not significant. Among the four groups by oolemma resistance, the proportion of top-quality embryo and embryo score (53.7%, 32) was highest in "no group." The proportion of top-quality embryo in "no group" was significantly higher than "moderate group" (p = 0.012) and "severe group" (p = 0.043). The median embryo score in "no group" was significantly higher than "severe group" (p = 0.041). Newly developed "oolemma score" could predict well the formation of top-quality embryo with a statistical significance (cutoff >14.5, area under the curve 0.695, p

This study aimed to evaluate the efficacy of random-start controlled ovarian stimulation (COS) in cancer patients for emergency fertility preservation. In this retrospective comparative study, 22 patients diagnosed with cancer and 44 infertile women undergoing conventional in vitro fertilization (IVF) were included. In cancer patients, ovarian stimulation was started on the day of referral, irrespective of their menstrual cycle date. The control group was selected by age matching among women undergoing conventional IVF. COS outcomes were compared between groups. The number of total and mature oocytes retrieved and the oocyte maturity rate were higher in the random-start group than in the conventional-start group. However, duration of ovarian stimulation was longer in the random-start group (11.4 vs. 10.3 days, P = 0.004). The addition of letrozole to lower the estradiol level during COS did not adversely affect total oocytes retrieved. However, oocyte maturity rate was lower in cycles with letrozole than in cycles without letrozole (71.6% vs. 58.2%, P = 0.019). Our study confirms the feasibility and effectiveness of random-start COS in cancer patients. Graphical Abstract

The present study aimed to identify microorganisms in follicular fluids and to investigate their association with in vitro fertilization (IVF) outcomes.This study was conducted as a prospective study of 49 infertile females undergoing IVF/intracytoplasmic sperm injection cycles between 2013 and 2016. Paired follicular fluid and vaginal secretions were collected on the day of ovum pick up and were cultured to detect microorganisms.Fifteen women (30.6%) had no microorganisms in follicular fluid or vaginal swabs, 23 (46.9%) had microorganisms on vaginal swab alone, 3 (6.1%) had microorganisms in follicular fluid alone, and 8 (16.3%) had microorganisms in both follicular fluid and vaginal swabs. The same microorganisms were detected in both the follicular fluid and vaginal swabs of three women, while different microorganisms were detected between follicular fluid and vaginal swabs in five women. Follicular fluid microorganisms were not associated with embryo quality or clinical pregnancy rates during IVF cycles. However, significantly decreased implantation rates (9.1% vs. 29.4%,Follicular fluid contains microorganisms that can differ from those in the vagina of the same women; however, they do not appear to be associated with embryo quality or clinical pregnancy rates in IVF cycles. In contrast, vaginal pathogens were found to be associated with worse implantation rates and clinical pregnancy rates in IVF cycles.

This study aimed to investigate the factors affecting blastocyst formation rate. One hundred and seven fresh in vitro fertilisation (IVF) and elective day 5 blastocyst transfer cycles were selected...

This study aimed to analyze the effects of a new protocol with letrozole on the outcomes of

For patients at risk of premature ovarian failure with cancer treatment, it is an important option to re-implant the ovarian tissue (OT) after cryopreservation to preserve endocrine function and fertility. With this technique, about 30% of pregnancy success rate and about 90 live births have been reported to date. However, there has been no case report of successful in vitro fertilization (IVF) and embryo transfer (ET) with oocytes collected from transplanted cryopreserved OT in Korea. We report a 30-year old woman with rectal cancer who underwent IVF and ET after cryopreserved OT thawing and re-implantation. She has been diagnosed with stage IIIC rectal cancer after surgery, and right ovary was removed and cryopreserved between cycles of chemotherapy. After completion of chemotherapy and radiotherapy, the patient underwent orthotopic transplantation of cryopreserved OTs. Three months after transplantation, the serum follicle-stimulating hormone level decreased from 91.11 mIU/mL to 43.69 mIU/mL. Thereafter, the patient underwent 11 ovarian stimulation cycles, and in 7 cycles, follicle growth was observed at the OT graft site. In one of these cycles, the oocyte was successfully retrieved and one embryo was transplanted after IVF. The patient was not pregnant, but the cryopreservation of OT can save the fertility after anticancer chemotherapy., Graphical Abstract

Necrostatin 1 (Nec1) is widely used in disease models to examine the contribution of receptor-interacting protein kinase 1 in cell death. The biological actions of Nec1 are blocking necrotic cell death. The purpose of this study was to investigate whether adding Nec1 into in vitro maturation (IVM) media, followed by vitrification procedures, could enhance the survival and developmental competency of oocytes. Germinal vesicle oocytes were matured in IVM medium containing 2 different doses of Nec1 (0.5 and 1 μmol/L). After IVM, the oocytes were vitrified using a 2-step exposure to equilibrium and vitrification solutions. After warming, the rates of survival, fertilization, embryonic development up to blastocyst in vitro, morphology of spindle and chromosome, membrane integrity, mitochondria integrity, and several gene expressions were evaluated. The survival and developmental competency of oocytes were higher in the 1 μmol/L Nec1-treated group than control. The proportion with intact spindles/chromosomes and stable membranes was similar in all the groups. The mitochondrial integrity of all Nec1-treated groups showed a higher score with strong staining. The 1 μmol/L Nec1 showed significantly increased expressions of Mad2, Gdf9, and Bcl2. The Cirp level had a tendency to be downregulated in the 0.5 µmol/L Nec1 but upregulated in the 1 μmol/L Nec1, compared with the control. The Mtgenome expressions were significantly decreased in both Nec1 groups. The supplementation of 1 μmol/L Nec1 into the IVM medium could be beneficial for the survival and development of immature oocytes after vitrification.

Purpose This study attempted to derive an objective and sophisticated definition of poor ovarian response (POR). Materials and methods A total of 176 consecutive in vitro fertilization (IVF) cycles (137 patients) with conventional ovarian stimulation during 2009 to 2012 were studied by retrospective analysis. Optimal oocyte number (total or mature) was determined by statistics-based (distribution of oocyte number) and prognosis-based approaches (prediction for IVF outcome). Receiver operating characteristics curve analysis was used to show what number of oocytes could predict IVF pregnancy and whether clinical and laboratory variables could predict newly defined POR. Results The 25th percentile of the distribution corresponded to total oocytes ≤2 and mature oocyte ≤1. The cut-off values for the prediction of IVF outcomes were total oocytes >5 and mature oocyte >1. Considering the incidence of POR (34.1%), a reasonable definition of POR was decided as total oocytes ≤2 or mature oocyte ≤1. For the prediction of this new definition, the extreme cut-off value (by setting a false positive rate of 5%) of serum anti-Mullerian hormone (AMH) was ≤0.76 ng/mL, which was better than serum follicle stimulating hormone or age. A new simple definition of POR was derived as total oocytes ≤2 or mature oocyte ≤1 in a previous cycle or a serum AMH level of ≤0.76 ng/mL. When this simple criterion was re-applied to our data, the predictive performance was similar to the Bologna criteria. Conclusion We here propose a new definition of POR, which is simple and supported by statistical and prognostic analyses.

This prospective study investigated the relationship between anti-Müllerian hormone (AMH) level in the follicular fluid (FF) and the quality of the oocyte and embryo. A total of 65 FF samples from 54 women were included in this study. FF was collected from the largest preovulatory follicle sized≥20 mm of mean diameter from each ovary. Samples were divided into 3 groups according to the FF AMH levels: below the 33th percentile (low group, FF AMH3.6 ng/mL, n=22). The quality of the ensuing oocytes and embryos was evaluated by fertilization rate and embryo score. FF AMH levels correlated positively with the matched embryo score on day 3 after fertilization (r=0.331, P=0.015). The normal fertilization rate was significantly lower in the low group than in the intermediate group (61.9% vs. 95.5% vs. 77.3%, respectively, P=0.028). Our results suggest that the FF AMH level could be a predictor of the ensuing oocyte and embryo quality. Graphical Abstract

To determine whether intracytoplasmic sperm injection (ICSI) could prevent total fertilization failure (TFF) and enhance the embryo quality in patients with non-male factor infertility.A total of 296 in vitro fertilization (IVF) cycles performed in patients with non-male factor infertility between April 2009 and March 2013 were included in this retrospective study. During the period, ICSI and conventional IVF were performed in 142 and 154 cycles, respectively. The usual indications for ICSI were in the cycles of patients with (1) known low fertilization rate, (2) repetitive implantation failure, (3) advanced maternal age, (4) presence of endometrioma, (5) low oocyte yield (number of oocytes ≤3), or (6) poor quality oocytes. The rate of TFF, normal fertilization, abnormal pronuclei (PN) formation, embryo quality, and pregnancy outcomes between the patients treated with ICSI and conventional IVF cycles were compared.The patients treated with ICSI (ICSI group, n=142) presented fewer number of oocytes than patients treated with conventional IVF cycles (n=154). The TFF rate was not different (4.2% vs. 0.6%, P=0.059), but the ICSI group presented a significantly higher rate of normal fertilization (83.4% vs. 79.1%, P=0.04) and lower rate of abnormal PN formation (3.9% vs. 13.3%, P0.01). The cleavage stage embryo quality was better in the ICSI group (grade A: 31.1% vs. 21.3%, P=0.001; grade A+B: 65.1% vs. 47.6%, P0.001).The result of this study does not support the use of ICSI to prevent TFF in patients with non-male factor infertility. However, ICSI improved the fertilization rate and the embryo quality.

Objective To develop a nomogram for prediction of ongoing pregnancy after in vitro fertilization (IVF)-embryo transfer (ET) using age of women and serum biomarkers. Study design Prospective longitudinal study of 103 patients undergoing IVF-ET at a university-based hospital. Serum HCG and progesterone levels were measured at the time of the pregnancy test (14 days after oocyte retrieval) and pregnancy outcomes were followed. The main outcome was ongoing pregnancy prediction. Results For the prediction of ongoing pregnancy, a combination of serum HCG, progesterone and age of the woman shows the best predictive accuracy (AUC 0.912 [95% CI 0.815–1.000], sensitivity 89.3%, specificity 80.0%, positive predictive value 89.3%, negative predictive value 80.0%). On the basis of these variables, we developed a nomogram to predict ongoing pregnancy. Conclusion A nomogram could help to predict ongoing pregnancy after IVF-ET. The nomogram needs further validation to improve individualized prediction of ongoing pregnancy.

Does exposure to lysophosphatidic acid (LPA) during in vitro maturation (IVM) enhance the maturation and developmental competence of mouse oocytes?Supplementation of IVM medium with 30 μM LPA enhanced the developmental competence of in vitro matured oocytes and so made them more comparable to in vivo matured control oocytes.LPA is a small phospholipid that acts as an extracellular signaling molecule by binding to and activating at least five G protein-coupled receptors. LPA has various biological actions, with both developmental and physiological effects.During IVM, LPA at six different doses (0, 1, 10, 30, 50 or 100 μM) was added into the TCM-199 medium. After maturation, the developmental competence and other parameters of the oocytes were assessed.Immature GV stage oocytes from 5- to 6-week-old female BDF-1 mice were incubated for 17-18 h in IVM medium containing 0, 1, 10 or 30 μM LPA and then either fertilized in vitro with epididymal sperm, or assessed for spindle morphology, mitochondrial membrane potential (ΔΨm) or the mRNA expression of a meiotic checkpoint gene (Mad2), a microtubule structure gene (Hook1), two maternally derived genes (Mater and Hsf1) and an apoptosis-related gene (Caspase6). The fertilized embryos were grown in vitro to assess blastocyst-formation rates, differential cell counts and apoptosis.Rates of maturation, fertilization and blastocyst formation and hatching were significantly higher in the 30 μM LPA-supplemented group (94.3, 96.3, 79.1 and 51.3%, respectively) than in the unsupplemented control (0 μM) group (80.5, 87.5, 61.3 and 37.8%, respectively) and more comparable to that of the in vivo matured oocytes (100, 96.5, 95.3 and 92.9%, respectively). LPA did not adversely affect mitochondrial activity, spindle integrity, blastocyst cell number, caspase positivity or Mad2 expression. Oocytes matured in 30 μM LPA had reduced Caspase6 expression, but Hook1, Mater and Hsf1 were up-regulated in all of the LPA-supplemented groups.Chromosomal aneuploidy in the resultant blastocysts and the production of normal pups were not assessed. Only mouse oocytes were assessed.Supplementation of IVM medium with 30 μM LPA may enhance the developmental competence of mouse oocytes without affecting apoptosis, spindle normalcy or mitochondrial integrity.This study was supported by a research grant (02-2012-021) from the Seoul National University Bundang Hospital. The authors declare that they have no competing interests.

Objective: To investigate outcomes of stimulated IVF cycles in which GnRH antagonist was omitted on the ovulation triggering day. Methods: A total of 86 women who underwent controlled ovarian hyperstimulation with recombinant FSH and GnRH antagonist flexible multiple-dose protocols were recruited and prospectively randomized into the conventional group (group A) or cessation group (group B). The GnRH antagonist, 0.25 mg/day of cetrorelix, was started when the leading follicle reached 14 mm in diameter and was continuously administered until the hCG triggering day (group A, 43 cycles) or until the day before hCG administration (group B, 43 cycles). The maturity of oocytes, fertilization rate, embryo quality, and implantation and clinical pregnancy rates were evaluated. Results: The duration of ovarian stimulation, total dose of gonadotropins, serum estradiol levels on hCG administration day, and number of oocytes retrieved were not significantly different between the two groups. The total dose of GnRH antagonist was significantly lower in group B than group A (2.5 ± 0.9 vs. 3.2 ± 0.8 ampoules, p < 0.05). There was no premature luteinization in any of the subjects. The proportion of mature oocytes and fertilization rate were not significantly different in group B than group A (70.7% vs. 66.7%; 71.1% vs. 66.4%, respectively). There were no significant differences in the implantation or clinical pregnancy rates. Conclusion: Our prospective randomized study suggested that cessation of GnRH antagonist on the hCG administration day during a flexible multiple-dose protocol could reduce the total dose of GnRH antagonist without compromising its effects on pregnancy rates.

We performed this study to investigate the effect of ketorolac (a non-steroidal anti-inflammatory drug) administration around ovarian stimulation on in vivo and in vitro fertilization process. Sixty-four female mice (ICR) were injected with ketorolac (0, 7.5, 15 and 30 µg/d) for 3 d starting from the day of eCG treatment. In experiment 1, 41 mice were triggered by hCG and then mated; two-cell embryos were obtained and in vitro development up to blastocyst was observed. In experiment 2, 23 mice were triggered by hCG and mature oocytes were collected; in vitro fertilization rate and subsequent embryo development up to blastocyst was recorded. In experiment 1, the blastocyst-forming rates per in vivo fertilized two-cell embryo showed an inverse relationship with a dosage of ketorolac (97.6%, 64.2%, 35.4% and 25.9%). In experiment 2, degenerated oocytes were frequently observed in a dose-dependent manner (4.3%, 22.9%, 22.4% and 75.0%). Lower fertilization rates were noted in all the three ketorolac-treating groups; blastocyst-forming rate was significantly lower in 30-µg-treating group when compared with the control group. Administration of ketorolac around ovarian stimulation significantly affects the development of in vivo fertilized embryo in a dose-dependent manner. High-dose ketorolac could result in a poor oocyte quality and decreased embryo developmental competence.

Objective To investigate the effect of antifreeze protein (AFP) supplementation during mouse oocyte vitrification on the survival, fertilization and embryonic development. Design Animal study. Setting University laboratory. Animal(s) BDF-1 mice. Intervention(s) In vivo–matured metaphase II oocytes were vitrified with the use of CryoTop by two-step exposure to equilibrium and vitrification solution supplemented or not with 500 ng/mL AFP III. Main Outcome Measure(s) Postwarming survival, fertilization, embryonic development up to blastocyst in vitro, morphology of spindle and chromosome, membrane integrity, adenosine triphosphate (ATP) contents, and several gene expressions. Result(s) In the AFP-treated group, blastocyst formation rate was significantly higher and blastomere count with positive caspase was significantly lower compared with the nontreated group. Rate of intact spindle/chromosome, stable membrane, and ATP contents were significantly higher in AFP group. AFP group showed higher Mad2 and lower Eg5 gene expression. Both vitrification groups showed increased Hsf1 , Zar1, and Zp1 / Zp2 expression and decreased Hook1 and Zp3 expression compared with fresh control samples. Conclusion(s) Supplementation of AFP in vitrification medium has a protective effect on mouse oocytes for chilling injury; it can preserve spindle/membrane integrity and intracellular ATP contents. More stable spindle integrity in the AFP group may be associated with higher Mad2 and lower Eg5 gene expression.

Endometrial biopsies were performed during the luteal phase just before an IVF cycle in 104 infertile women, and immunohistochemical staining was performed to investigate expression patterns of hCG-LH receptor, leukemia-inhibitory factor, macrophage colony-stimulating factor, HOXA-10, vascular endothelial growth factor A, and their relation to subsequent IVF pregnancy. Only glandular expression of vascular endothelial growth factor A in early luteal endometrium was significantly higher in the pregnant group compared with the nonpregnant group (6.0 ± 3.9 vs. 2.9 ± 3.4) and thus could be a predicting marker for subsequent IVF pregnancy.

Purpose To investigate the associations between sperm DNA fragmentation (SDF) and embryo formation rate in normal responder women to in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI). Materials and Methods Fifty-three consecutive, fresh IVF/ICSI cycles performed from 2014 to 2017 were selected. All women were normal responders (4 to 14 mature oocytes were retrieved) and at least one normally fertilized oocyte with two pronuclei was obtained in all cycles. Semen was collected on the day of oocyte retrieval, and SDF levels were measured by sperm chromatin dispersion test (Halosperm assay). At day 3 after insemination, embryo quality was evaluated by morphologic criteria and categorized as A/B/C/D. Top quality embryo were defined as grade A embryos with seven cells or more. Results SDF levels showed a positive linear correlation with the male's age (r=0.307, p=0.025) and a negative linear correlation with sperm motility (r=−0.491, p70%, the cut-off value SDF was

Aim: To investigate the dose-dependent effect of sphingosine-1-phosphate (S1P) supplementation on meiotic maturation, apoptosis and developmental competence of immature mouse oocytes. Methods: Immature oocytes from 5- to 6-week-old BDF1 mice were incubated in maturation medium containing S1P with six different doses (10 nM, 50 nM, 100 nM, 500 nM, 1 µM, and 2 µM) for 18–19 h. Fertilization and blastocyst formation was assessed. All blastocysts were stained by anti-caspase antibody. Results: Treatment with 100 nM, 500 nM and 1 µM S1P showed significantly higher blastulation rate [66.0, 62.1 and 66.2%, respectively, p < 0.05 when compared with control (40.0%)]. Blastomere count was similar across six treatment groups, but the percentage of apoptotic blastomere was significantly lower in the 100 nM, 500 nM, and 2 µM S1P-treated groups [5.4, 6.5, and 3.7%, respectively, p < 0.05 when compared with control (10.6%)]. Conclusion: Considering the blastulation rate together with the apoptotic event in the blastocysts, adding 100 and 500 nM S1P within oocyte maturation medium could be beneficial in the development of immature mouse oocytes.

Aims: In this self-matched observational study, the factors associated with the presence of tripronuclear (3PN) embryos, in conventional in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) cycles using gonadotropin-releasing hormone agonist long protocols, were investigated. Material & Methods: Clinical parameters were analyzed in 202 consecutive IVF-IVF or ICSI-ICSI matched cycles. The differences between the former and latter cycles were evaluated and compared according to the presence of 3PN embryos: group A [3PN (−) followed by 3PN (−)]; group B [3PN (−) followed by 3PN (+)]; group C [3PN (+) followed by 3PN (−)]; group D [3PN (+) followed by 3PN (+)]. Results: For the IVF-IVF cycles, the E2 on human chorionic gonadotropin injection day and the number of retrieved oocytes were increased in the 3PN (+) cycles compared to the 3PN (−) cycles of Groups B (2165.2 ± 1423.3 pg/mL vs 1468.2 ± 796.2 pg/mL, P = 0.016; 10.4 ± 9.1 vs 7.2 ± 5.7, P = 0.010) and C (2382.7 ± 1214.5 pg/mL vs 1553.0 ± 1119.6 pg/mL, P = 0.004; 13.1 ± 9.1 vs 9.1 ± 7.0, P

Objective To clarify whether adding E 2 to standard luteal P supplementation is beneficial both in GnRH agonist and antagonist IVF cycles. Design Meta-analysis of nine randomized controlled trials. Setting University hospital center for reproductive medicine and IVF. Intervention(s) None. Main Outcome Measure(s) Clinical pregnancy rate (PR) per patient, clinical PR per embryo transfer (ET), implantation rate, ongoing PR per patient, clinical abortion rate, and ectopic PR. Result(s) There were no statistically significant differences between E 2 +P versus P-only group regarding overall IVF outcomes. From seven studies including GnRH agonist cycles, no statistical significant differences were found between the two groups in clinical PR per patient (relative risk [RR] 1.32, 95% confidence interval [CI] 0.79–2.19), clinical PR per ET (RR 1.83, 95% CI 0.96–3.49), implantation rate (RR 1.20, 95% CI 0.34–4.21), ongoing PR per patient (RR 1.34, 95% CI 0.37–4.82), clinical abortion rate (RR 1.05, 95% CI 0.48–2.28), and ectopic PR (RR 0.53, 95% CI 0.07–4.10). Clinical PR per patient (RR 0.94, 95% CI 0.62–1.42) and ongoing PR per patient (RR 1.09, 95% CI 0.79–1.50) from three studies including GnRH antagonist cycles only were all similar between the two groups. Conclusion(s) The combined data presented in this meta-analysis suggest that the addition of E 2 to P for luteal phase support does not improve IVF outcomes in GnRH agonist and antagonist cycles. However, the authors feel that there is an obvious need for further large-scale studies regarding GnRH antagonist cycles.

Aims: To evaluate the efficacies of the estrogen receptor-α (ER-α) gene polymorphisms and of the intrafollicular insulin-like growth factor (IGF) system for predicting pregnancy in in vitro fertilization and embryo transfer (IVF-ET) patients. Methods: A total of 96 patients undergoing IVF-ET were included in this study. Genotyping for the ER-α gene PvuII and XbaI polymorphisms was performed using polymerase-chain reaction and single base extension method. Follicular fluid (FF) IGF-I, IGF-II, and IGFBP-3 concentrations were measured by RIA, and IGFBP-4 by ELISA. We compared, between pregnant (n = 28) and non-pregnant groups (n = 68), the allele frequency, genotype distribution and haplotype distribution of PvuII and XbaI polymorphisms, and then FF IGF-I, IGF-II, IGFBP-3, IGFBP-4 concentrations and their ratios. Results: No significant differences were found between the two groups in terms of allele, genotype or haplotype distributions of the ER-α gene PvuII and XbaI polymorphisms between the two groups. The mean FF IGF-I/IGFBP-3 ratio was significantly higher in the pregnant group (5.9 ± 1.5 vs. 4.8 ± 1.5 ×10–2). Conclusions: The intrafollicular IGF-I/IGFBP-3 ratio of the FF of the dominant follicle during oocyte retrieval appears to be related to the establishment of pregnancy in IVF-ET patients, whereas the ER-α gene PvuII and XbaI polymorphisms do not.

Objective To compare follicular fluid (FF) anti-Mullerian hormone (AMH) and inhibin B concentrations for GnRH agonist (GnRH-a) and GnRH antagonist cycles and to determine the correlations between FF AMH or inhibin B concentrations and controlled ovarian hyperstimulation (COH) outcomes. Design Prospective comparative study. Setting University hospital. Patient(s) Eighty-seven women who underwent COH cycles, either in the GnRH-a long-protocol group (n = 43) or the GnRH antagonist multiple-dose flexible-protocol group (n = 44). Intervention(s) Follicular fluid was obtained from dominant follicles during oocyte retrieval, and FF AMH, inhibin B, E 2 , and P concentrations were measured. Serum levels of AMH and inhibin B also were assessed on the day of oocyte retrieval. Main Outcome Measure(s) Follicular fluid AMH and inhibin B concentrations. Result(s) Concentrations of serum AMH and inhibin B and of FF AMH, inhibin B, E 2 , and P were similar in the two groups. Follicular fluid AMH levels were found to be significantly correlated with age, gonadotropin dose, number of follicles on hCG day, and number of oocytes retrieved. Conclusion(s) Our results suggest that there is no significant difference in follicular microenvironment in terms of AMH and inhibin B secretion between GnRH-a and GnRH antagonist protocols and that FF AMH is a marker that reflects ovarian reserve and response to COH.

Objective: Ovarian reserve tests are commonly used to predict ovarian response in infertile patients undergoing ovarian stimulation. Although serum markers such as basal follicle-stimulating hormone (FSH) or random anti-Mullerian hormone (AMH) level and ultrasonographic markers (antral follicle count, AFC) are good predictors, no single test has proven to be the best predictor. In this study, we developed appropriate equations and novel nomograms to predict the number of oocytes that will be retrieved using patients’ age, serum levels of basal FSH and AMH, and AFC. Methods: We analyzed a database containing clinical and laboratory information of 141 stimulated in vitro fertilization (IVF) cycles performed at a university-based hospital between September 2009 and December 2013. We used generalized linear models for prediction of the number of oocytes. Results: Age, basal serum FSH level, serum AMH level, and AFC were significantly related to the number of oocytes retrieved according to the univariate and multivariate analyses. The equations that predicted the number of oocytes retrieved (log scale) were as follows: model (1) 3.21–0.036 × (age)+0.089 × (AMH), model (2) 3.422–0.03 × (age)–0.049 × (FSH)+0.08 × (AMH), model (3) 2.32–0.017 × (age)+0.039 × (AMH)+0. 03 × (AFC), model (4) 2.584–0.015 × (age)–0.035 × (FSH)+0.038 × (AMH)+0.026 × (AFC). model 4 showed the best performance. On the basis of these variables, we developed nomograms to predict the number of oocytes that can be retrieved. Conclusion: Our nomograms helped predict the number of oocytes retrieved in stimulated IVF cycles.

Background: It has not been established whether the clinical outcomes of tubal heterotopic pregnancy resulting from assisted conception are different to those of spontaneous conception. The aim of this study was to compare the clinical course and the outcome of intrauterine gestation following surgical treatment for tubal heterotopic pregnancy according to the method of pregnancy. Methods: Medical records of 13 cases of tubal heterotopic pregnancy experienced in Seoul National University Hospital during 1990–2004 and 30 case reports of tubal heterotopic pregnancy published in the Korean Journal of Obstetrics and Gynecology during 1980–2004 were reviewed retrospectively. The clinical outcomes were compared between the assisted (n = 23) and spontaneous conception groups (n = 20). Results: The assisted conception group had a significantly higher preoperative systolic blood pressure and a previous history of pelvic pathology. The spontaneous group had a higher incidence of tubal rupture and hemoperitoneum. The assisted conception group had a higher live birth rate than the spontaneous group (47.8 vs. 20%, p = 0.056). Conclusions: In tubal heterotopic pregnancy, the assisted conception group had a more favorable clinical course and intrauterine gestation outcome following surgical treatment when compared with the spontaneous conception group.

This study assesses the fertilization and blastocyst-forming rate in mice cumulus-oocyte complexes (COCs) after the exposure of human ovarian endometriotic fluid. Endometriotic fluid was obtained from a single patient by aspiration at the time of a laparoscopic cystectomy and serially diluted. COCs were obtained from 46-week-old female BDF1 mice. After exposure to ovarian endometriotic fluid for five minutes, the COCs were washed three times and the oocytes were then fertilized by mice sperm. The fertilization and blastocyst formation rate and the proportion of hatching/hatched blastocyst in the four treatment groups were not inferior to those in non-exposure group.

Our purpose was to compare the normal fertilization rate, multi-pronuclei (PN) formation rate, and embryonic development of in vitro-matured oocytes between conventional insemination and intracytoplasmic sperm injection (ICSI).A total of 213 stimulated in vitro fertilization (IVF) cycles were selected, in which at least one immature oocyte was obtained (from 2010 to 2014). Immature oocytes were assigned to germinal vesicle (GV)-stage or metaphase I (MI)-stage oocyte groups. Cycles with obligatory ICSI due to male-factor infertility were excluded. Cycles were divided into two groups according to fertilization method: there were 97 cycles with conventional insemination and 116 cycles with ICSI. After in vitro maturation of 324 GV-stage oocytes and 341 MI-stage oocytes, the fertilization rate, multi-PN formation rate, and embryonic development were compared according to the fertilization method.The normal fertilization rate was similar in the conventional insemination and the ICSI both in GV-derived and MI-derived oocytes. Both fertilization methods resulted in a similar multi-PN formation rate in GV-derived oocytes; however, in MI-derived oocytes, the multi-PN formation rate was zero with ICSI and this was significantly lower than that with conventional insemination (9.6%, P = 0.001).In non-male-factor infertility, ICSI should be considered when MI oocytes are matured.

Histone acetylation has been known to be significant in spermatogenesis. Histone acetylation is regulated by the act of histone deacetylases (HDACs) and histone acetyltransferases (HATs). We investigated the link between expression levels of HDACs and HATs in mouse sperm and subsequent blastocyst formation rate. In the univariate analysis, expression levels of HDAC1 and HAT were generally not associated with the blastocyst formation rate. When divided by the mature oocyte number category, a significant positive association was observed between the expression levels of HDAC1 and the blastocyst-forming rate in the highest (> 75th) percentile group (a group with ≥34 mature oocytes). In conclusion, expression of sperm HDAC1 could be considered as a possible predictor of embryo development in mice with high ovarian response.

STUDY QUESTION Are mRNAs for specific aquaporins (AQPs) expressed in human luteinized granulosa cells (GCs) and are their expression levels correlated with in vitro fertilization (IVF) outcomes? SUMMARY ANSWER The mRNAs of AQP1-7, 9, 11, and 12 were expressed in human luteinized GCs; the level of AQP1 mRNA was negatively associated with retrieved oocyte number and the level of AQP7 mRNA was positively associated with fertilization rate. WHAT IS KNOWN ALREADY mRNAs of AQP1-4 and AQP9 have been detected in human GCs. STUDY DESIGN, SIZE, DURATION Prospective observational study involving 111 women undergoing a stimulated IVF cycle. PARTICIPANTS/MATERIALS, SETTING, METHODS In a preliminary experiment on 27 women, the mRNA expression of AQP0-12 in GCs was explored by RT-PCR. In the main experiment, luteinized GCs were obtained from 111 women at the time of oocyte retrieval of whom 102 had an embryo replacement. Real-time quantitative RT-PCR (qRT-PCR) was performed to quantify the mRNA level of AQP1-7, 9, 11, and 12. The mRNA for luteinizing hormone receptor (LHR) and steroidogenic acute regulatory protein (StAR) were also quantified by qRT-PCR. MAIN RESULTS AND THE ROLE OF CHANCE mRNAs for AQP0, 8 and 10 were not detected in the preliminary experiment. In samples from 111 women, retrieved oocyte number was negatively associated with the mRNA levels of AQP1, 4, 6, and 11 and LHR (r = -0.311, r = -0.233, r = -0.203, r = -0.194, and r = -0.202, respectively, P < 0.05 for each), however, after adjustment for woman's age and serum anti-Mullerian hormone (AMH) levels, only correlation with AQP1 was found (r = -0.299, P < 0.05). BMI was negatively associated (after adjustment for age) with the mRNA level of AQP7 (r = -0.259, P < 0.05). Fertilization rate was positively associated with the mRNA level of AQP7 (r = 0.269, P < 0.05). The number or quality of embryos or clinical pregnancy was not associated with the mRNA levels of any of ten AQP subtypes. The mRNA levels for the ten AQP subtypes were correlated positively with LHR expression but negatively with StAR expression. Amongst high responders (oocyte number ≥14), the mRNA levels of AQP11 (1.4 ± 0.7 versus 1.7 ± 0.6) and LHR (1.3 ± 0.7 versus 1.7 ± 0.7) were significantly lower in the group with PCOS than in the non-PCOS group. LIMITATIONS, REASONS FOR CAUTION A relative small number of subjects in PCOS group is the main limitation of our study. P-values were not corrected for multiple comparisons. WIDER IMPLICATION OF THE FINDINGS AQP1 may be one of the factors that modulate individual ovarian response to exogenous gonadotrophin. The mRNA level of AQP7 was positively associated with fertilization rate, which is a surrogate marker of oocyte competence, thus expression of AQP7 could be a marker for adequate folliculogenesis and healthy oocytes. STUDY FUNDING/COMPETING INTERESTS This work was supported by grant no. A120043 from the Korea Health Care Technology R&D Project, Ministry of Health and Welfare, Korea. None of the authors has any conflict of interest to declare.

This study was performed to evaluate the efficiency of simplified EM grid vitrification, skipping the step of removing the cryoprotectant (5.5 M EG + 1.0 M sucrose) droplet on the grid after loading oocytes, compared to conventional cryopreservation protocols for mouse mature oocytes. Firstly, the recovery, survival, fertilization and hatching rates of simplified EM grid vitrification were compared with those of the slow freezing method using 1.5 M DMSO. Then, conventional EM grid vitrification was compared with simplified EM grid vitrification. Simplified EM grid vitrification showed higher survival, fertilization and hatching rates than those of the slow freezing method (85.6% vs. 63.2%; 51.0% vs. 22.3%; 38.7% vs. 12.5%, p < 0.01, respectively). Moreover, simplified EM grid vitrification showed higher recovery, survival and fertilization rates than those of conventional EM grid vitrification (100% vs. 95.0%, p = 0.024; 90.0% vs. 78.9%, p = 0.033; 56.7% vs. 38.7%, p = 0.021, respectively). Hatching rate tended to be higher for simplified EM grid vitrification compared to conventional EM grid vitrification (41.1% vs. 24.1%). In conclusion, simplified EM grid vitrification is a convenient and efficient method for cryopreservation of mouse mature oocytes, compared to conventional EM grid vitrification and slow freezing methods.

Background Insulin-like growth factors (IGF) and their binding proteins (IGFBP) play a major role in the autocrine and paracrine regulation of folliculogenesis. This is the first study that has compared follicular fluid (FF) IGF-I, IGF-II, IGFBP-3, IGFBP-4 and pregnancy-associated plasma protein (PAPP)-A concentrations, and their ratios, to investigate whether there was any difference in the intrafollicular microenvironment between the GnRH agonist (GnRHa) and antagonist (GnRHant) protocols for controlled ovarian stimulation (COS). Methods A total of 68 IVF cycles were included in this study; two groups were studied: GnRHa long protocol group (n = 36) and the flexible GnRHant multiple-dose protocol group (n = 32). FF was obtained from dominant follicles during oocyte retrieval and stored at -70 degrees C until assayed. IGF-I, IGF-II and IGFBP-3 concentrations were measured by radioimmunoassay and IGFBP-4 and PAPP-A by enzyme-linked immunosorbent assay. Results The duration of COS was significantly longer, and total dose of gonadotrophins used, serum estradiol (E(2)) levels on hCG day and the number of oocytes retrieved were significantly higher in the GnRHa long protocol group. The concentrations of FF IGF-II and IGFBP-4 were significantly higher, and the ratio of IGF-I/IGFBP-4 was significantly lower in the GnRHa long protocol group. Serum E(2) levels per mature follicle were not different between the two groups. Conclusions Our data may indicate a difference of intrafollicular microenvironment between cycles using GnRHa long protocols and those using GnRHant protocols. However, the difference in microenvironment does not appear to result in a difference in clinical outcome.

Aim: To assess the clinical efficacy and safety of the gonadotropin-releasing hormone (GnRH) antagonist, ganirelix (Orgalutran), treatment in women undergoing controlled ovarian hyperstimulation (COH) for in vitro fertilization and embryo transfer (IVF-ET) in Korean women. Methods: This was a non-comparative, open-label, single-center trial carried out on 31 infertile Korean women. A daily dose of 0.25 mg of the GnRH antagonist, ganirelix, was given, beginning on the sixth day of recombinant follicle-stimulating hormone (FSH) treatment. If the ovarian response was low, ganirelix treatment was delayed until the leading follicle reached a mean diameter of 14 mm. The ganirelix treatment was continued until the day of human chorionic gonadotropin (hCG) injection. Descriptive statistics were recorded for all parameters. Results: The median duration of ganirelix treatment was 4 days (range: 2–6 days) and the median total recombinant FSH dose was 1350 IU (900–2350 IU). During ganirelix treatment, the incidence of luteinizing hormone (LH) rises (LH = 10 IU/L) was 3.2% (one of 31 cases). On the day ovulation was triggered by hCG, the mean number of follicles ≥11 mm in diameter was 12.4 ± 4.5, and the median of serum estradiol concentration was 4289.9 (1893.7–8268.5) pmol/L. The mean number of oocytes per retrieval was 10.9 ± 6.1. The fertilization rate was 61.5%, and the mean number of replaced embryos was 2.8 ± 0.6. The mean implantation rate was 10.0%, and the clinical pregnancy rate per transfer was 23.3% (seven of 30 cases) and the ongoing pregnancy rate per transfer was 20.0% (six of 30 cases). Conclusion: The results of the present study support ganirelix as a safe, short, convenient and effective treatment for patients undergoing COH for IVF in Korean women.

Objective We studied the association between sperm DNA fragmentation (SDF) and several clinical in vitro fertilization outcomes. Methods We retrospectively analyzed 169 consecutive fresh IVF cycles. Semen was collected on the day of oocyte retrieval, and we assessed standard semen parameters and the SDF level (by terminal deoxynucleotidyl transferase dUTP nick-end labeling). Poor ovarian response (POR) was defined as the collection of three or fewer mature oocytes. Oocytes were inseminated by the conventional method or intracytoplasmic sperm injection. Results SDF did not affect the fertilization or pregnancy rate, but did have a significant effect on the miscarriage rate. In the miscarriage group (n=10), the SDF level was significantly higher (23.9% vs. 14.1%) and number of mature oocytes was significantly lower (4.3 vs. 7.6) than in the live birth group (n=45). Multiple regression analysis showed that SDF was an independent predictor of miscarriage (odds ratio, 1.051; 95% confidence interval, 1.001-1.104). The cutoffs for the SDF level and number of mature oocytes that could predict miscarriage were >13% and ≤3, respectively. In the low-SDF group (≤13%), the miscarriage rate was similar in POR patients and those with a normal ovarian response (NOR; 14.2% vs. 4.3%). In the high-SDF group (>13%), the miscarriage rate was significantly higher in the POR group than in the NOR group (60.0% vs. 13.3%, p=0.045). Conclusion Our study demonstrated that a high SDF level (>13%) was associated with a high miscarriage rate, and that it mainly contributed to miscarriage in the POR group. The results suggest that SDF measurements should be considered in couples with POR in order to predict the prognosis of the pregnancy.

The purpose of this study was to investigate whether sperm selection by hyaluronic acid (HA) binding could improve fertilization rate and embryo quality in intracytoplasmic sperm injection (ICSI) cycles. Two hundred nineteen oocytes obtained from eighteen women were injected with either HA-bound (n = 107) or conventionally selected spermatozoa (n = 112) in a randomized way. All of the participants were infertile couples who had normal sperm parameters but low fertilization rate in previous in vitro fertilization (IVF) cycle (n = 5) or experienced multiple IVF failures (n = 13). Lower fertilization (75.7% vs 83.0%) and cleavage rate on day 2 (72.9% vs 83.0%) was observed in oocytes injected with HA-bound spermatozoa than the conventional group, but the difference was not significant. Significantly lower cleavage rate was observed on day 3 in HA group (56.0% vs 69.6%, P = 0.038). Blastocyst formation rate and the number of transferred embryos were similar in both groups. In multiple IVF failure patients, significantly reduced fertilization rate (71.8% vs 85.3%, P = 0.046) and cleavage rate on day 2 (70.4% vs 85.3%, P = 0.029) and day 3 (53.5% vs 77.3%, P = 0.002) were noticed in HA group. Five women achieved pregnancy continuing more than 12 weeks after transfer (27.8%). Success of ICSI was not related with the number of embryos fertilized by HA-bound spermatozoa. Application of ICSI by sperm selection using HA binding is not helpful in couples with repeated poor fertilization or implantation despite normal sperm parameters.

Purpose During stimulated in vitro fertilization (IVF) cycle, up to 30% of the recovered oocytes are immature ones which have poor fertilization capacity; however, the precise influencing factors are largely unknown. Here, we analyzed the association of oocyte immaturity with woman's age in IVF cycles stimulated by single regimen. Materials and methods A total of one-hundred ninety five IVF cycles stimulated by recombinant FSH and GnRH antagonist protocol between 2003 and 2009 were analyzed retrospectively. The mean age of women was 34.2 ± 4.0 (26-45 years). After triggering by exogenous hCG, an ultrasound-guided retrieval of oocytes was performed 35-36 hours later. All clinical data were stratified by woman's age; group I: ≤ 30 (n=36), II: 31-35 (n=83), III: 36-40 (n=57), and IV: ≥ 41 (n=19). Results The total retrieved oocytes, as well as immature oocytes, were significantly lower in group IV, however, the mean % of immature oocytes was significantly higher in group IV than other age groups. Oocyte immaturity tended to decrease as increasing age in women aged 40 years or less. Conclusion In stimulated IVF cycle, much higher oocyte immaturity was noted in women aged 41 years or more.

To examine the relationship between the ratio of difference in number of retrieved oocytes from the two ovaries to total number of oocytes (difference ratio, |N(RO) - N(LO)|/N(TOTAL)) and in?vitro fertilization (IVF) outcome.Retrospective review of medical record for infertility patients with intact two ovaries who had undertaken controlled ovarian stimulation (COS) and IVF cycles in Seoul National University Hospital was conducted. Characteristics and IVF outcomes were compared according to the difference ratio (|N(RO) - N(LO)|/N(TOTAL)) using student t-test and χ² test. To adjust for the effect of confounding factors, binary logistic regression test was performed.When the study population was divided according to the difference ratio by cut-off value of 0.4, patients with difference ratio less than 0.4 showed significantly higher pregnancy rate (25.7% vs. 17.1%, p = 0.021). A significant correlation was noted between the difference ratio and achievement of pregnancy after adjustment for patient's age and total number of top quality embryos transferred (adjusted OR = 0.40, 95% CI 0.19-0.83, p = 0.014).The difference ratio of retrieved oocytes in patients with intact two ovaries was observed to have prognostic value in IVF cycles.

SummaryWe performed this study to investigate the effect of histone deacetylase inhibition during extended culture of in vitro matured mouse oocytes. In vitro matured mouse (BDF1) oocytes were cultured in vitro for 6, 12, and 24 h, respectively, and then inseminated. During in vitro culture for 6 and 12 h, two doses of trichostatin A (TSA), a histone deacetylase inhibitor, were added (100 nM and 500 nM) to the culture medium and the oocytes were then inseminated. During the 24-h in vitro culture, two doses of TSA were added (100 nM and 500 nM) to the medium and the oocytes were activated with 10 mM SrCl2. After the 6-h culture, the fertilization rate was similar to that of the control group, but the blastocyst formation rate was significantly decreased. After the 12-h culture, both the fertilization and blastocyst formation rates were significantly decreased. After the 24-h culture, total fertilization failure occurred. In the oocytes cultured for 6 and 12 h, the fertilization and blastocyst formation rates did not differ between the TSA-supplemented and control groups. Although extended culture of the mouse oocytes significantly affected their fertilization and embryo development, TSA supplementation did not overcome their decreased developmental potential.

This study was performed to evaluate the association between adding luteinizing hormone (LH) activity and the incidence of tripronuclear (3PN) zygotes occurrence.The incidence of 3PN and cycle outcomes was compared between recombinant follicle stimulating hormone (rFSH)-only and rFSH with exogenous LH activity groups. These comparisons were performed in gonadotropin releasing hormone (GnRHa, n = 196) and gonadotropin releasing hormone antagonist (GnRHant, n = 182) subgroups, and in in vitro fertilisation (IVF) (n = 243) and intracytoplasmic sperm injection (ICSI) (n = 135) cycles, respectively.The percentage of 3PN was significantly lower in LH activity-added group compared to rFSH-only group (3.6% vs. 5.6%, p = 0.029). Both in GnRHa and GnRHant subgroups, this incidence tended to be lower in LH-supplemented group, although these differences did not reach statistical significance. In IVF cycles, LH activity-added group showed a lower 3PN rate versus rFSH-only group (4.0% vs. 6.7%, p = 0.018). No difference of 3PN rate was found in ICSI cycles.Supplementation of exogenous LH activity to ovarian stimulation may be associated with lower prevalence of 3PN zygotes in IVF cycles, but not in ICSI cycles.

This study investigated the effects of total E 2 production during controlled ovarian stimulation (COS) calculated by "modified area under the curve for E 2 (AUC-E 2 )" and of the changes in E 2 level during the initial stimulation period calculated as "slope of initial increase in E 2 (Sl-E 2 )" on the outcomes of IVF cycles using GnRH antagonist protocols. The findings suggest that the rate of initial increase in E 2 rather than total E 2 production during COS might affect the competence of retrieved oocytes in GnRH antagonist cycles.