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BACKGROUND Embryologists currently face a challenge when counselling patients regarding the stage and the number of embryos to transfer when no top-quality embryos (TQE) are available. METHODS The aim of this study was to evaluate the efficacy of single blastocyst transfer (SBT) in comparison with the transfer of two cleavage-stage embryos in women under 36 years old. A total of 450 women under 36 years undergoing their first or second IVF treatment who had no TQE on Day 2 were included in this prospective study. Couples were assigned to either a SBT or a double cleavage-stage embryo transfer (DET). The clinical end-points monitored were rates of implantation, delivery and multiple deliveries. RESULTS The rate of transfer was significantly lower for couples assigned to the SBT group compared with the DET group (88 versus 100%, respectively, P < 0.001) while the delivery rate per oocyte retrieval was similar in both groups (26.7%). By contrast, the rate of multiple deliveries was significantly lower in the SBT group compared with the DET group (3.3 versus 23.3%, respectively, P < 0.01). Blastocyst cryopreservation was twice as high in the SBT group compared with the DET group (39 versus 18%, respectively, P < 0.001). CONCLUSIONS These findings show the value of extended embryo culture for couples without TQE. In such situations, delaying embryo transfer in order to select a single blastocyst with the highest potential for implantation can reduce the number of multiple pregnancies. Furthermore, our results demonstrate that extended culture allows blastocyst cryopreservation from embryos not available for Day 2 cryopreservation.

The 'ESHRE Guidelines for Good Practice in IVF Laboratories' were drawn up by the Special Interest Group (SIG) in Embryology and published in the year 2000, and since then they constitute the minimal requirements for any laboratory offering assisted reproduction techniques (ART). In the understanding that the embryologist has a responsibility for the correct and justified application of ART in the laboratory, the implementation of these guidelines requires a quality management programme to be in place that encompasses and integrates the operative units, the processes and procedures that represent the core of ART clinics. In March 2004, the European Parliament issued the Directive 2004/23/EC 'On setting standards of quality and safety for the donation, procurement, testing, processing, preservation, storage and distribution of human tissues and cells'. The Directive applies to human tissues and cells, including fresh or frozen reproductive cells for application to the human body, and is mainly concerned with increasing quality and safety through the implementation of a quality management system. Therefore, the European Society of Human Reproduction and Embryology (ESHRE) undertook a series of initiatives aiming to promote assurance of good laboratory practice and to define the concept of qualified embryologists. One ESHRE initiative was to revise the guidelines for good practice in IVF laboratories, not only in response to the need of embryologists for support and guidance in their duties, but also as a complement to the requirements issued by the Tissue and Cell Directive. The SIG in Embryology hopes that this document may assist the laboratory staff to operate according to the requirements of harmonization, implementation, inspection and certification that are now common to all European member states.

Clinicians who treat unsuccessful couples despite repeated transfers of good quality embryos face a challenge. Among the various strategies that have been described, embryo transfer at the blastocyst stage has been postulated to improve implantation. A prospective non-randomized analysis was performed in 276 IVF patients who failed to conceive after at least two early embryo transfers of at least two grade 1-2 embryos per cycle. For the next attempt, couples chose between day 2 embryo transfer (D2 group; n = 147) and day 5/6 blastocyst transfer (D5/D6 group; n = 129) before starting the following attempt. Embryo quality was assessed and results were expressed as clinical pregnancy, live birth and implantation rates per cycle. Embryo grade 1 number was similar between both groups, whereas mean embryo score of the whole cohort was slightly higher in the D2 group. The live birth rates per cycle (27.9 versus 19.7%) and implantation rates per cycle (25.4 versus 12.4%) were higher in the D5/D6 group compared with the D2 group. Improved embryo selection and uterine receptivity may explain the additional benefit of embryo transfer at the blastocyst stage for couples with repeated implantation failures.

A cohort follow-up study was designed to compare the efficacy of IVF using frozen donor semen (IVF-D) following previously failed DI cycles (unexplained female infertility) and direct IVF-D treatment because of tubal infertility (control group). The cohort comprised 189 couples initiating IVF-D after previously failed DI cycles (n = 126) or directly (n = 63). Couples were followed until completion (success or drop-out for personal or medical reasons). Live births and drop-out were expressed both as rate per cycle and crude cumulative rate. Characteristics of IVF-D cycles were similar between the two groups. Moreover, overall outcome was also similar in terms of crude cumulative live birth rate (54.0 versus 57.1% for failed DI cycles and tubal infertility groups respectively). This is the first report on crude cumulative live birth rate based on a cohort follow-up study in unexplained previously failed DI cycles and tubal infertility. Previously failed DI cycles did not impair the chances of achieving a successful pregnancy using IVF-D in this series. Slight oocyte dysfunction, which might underlie the failure of DI cycles, might be overcome using IVF-D.

Background: This study was designed to determine the efficacy of a programme using frozen donor semen in a cohort of patients returning for treatment after previously conceiving through donor insemination (DI)., Methods: The cohort included 222 couples with secondary infertility (previous live birth) in one University Hospital Centre. The treatment sequence involved DI cycles until completion. Live births, drop-out for personal or medical reasons and recourse to IVF with donor semen (IVF-D) were recorded for all patients. Live births were expressed as both rate per cycle and crude cumulative rate., Results: At the end of the DI cycles, 65% of couples in the cohort achieved second parenthood. Most of them (77%) succeeded after only four DI cycles. The majority of couples who stopped treatment did so for personal reasons., Conclusions: Patients involved in a second parenthood project belong to a 'selected' population. Management and counselling of such patients need to reconcile the early efficacy of DI cycles, the invasiveness of the IVF-D procedure and the availability of donor semen.

Purpose: Our purpose was to determine the obstructed epididymal epithelium morphometric state and to elucidate the influence of morphometric parameters on the fertilizing ability of aspirated spermatozoa., Methods: During MESA with IVF, epididymal tissue samples were carefully dissected, fixed, and prepared for morphometric analysis. The epithelium of the three regions was studied: head, body, and tail (when present). The total area/luminal area ratio, epithelium thickness, and stereocilium length were measured., Results: We have found significant differences in the total area/luminal area ratio, epithelium thickness, and stereocilium length in obstructed epithelium length > 4 versus 0.5-2 cm (P < or = 0.01). Epithelium thickness and stereocilium length were significantly lower when no fertilization was observed in IVF., Conclusions: These results suggest that morphometric data of obstructed epididymis epithelium can be used as a means of explaining the failure of IVF with epididymal spermatozoa.

This study measured glycosaminoglycans (GAGs) in human follicular fluid (hFF) obtained from patients undergoing hormonal stimulation with combined GnRH agonist followed by gonadotropin hormone (hMG or FSH) for in vitro fertilization (IVF). The GAGs were partially characterized through the use of various mucopolysaccharidases and then their effects tested on human sperm motility. In hFF, the GAG and protein concentrations were 4.4 +/- 1.3 mg/L and 32.6 +/- 3.2 g/L respectively. Chondroitins (CS) and hyaluronic acid (HA) significantly stimulate sperm motion in comparison to the control. The oocytes inseminated with GAGs-pretreated spermatozoa showed a significantly higher rate of cleavage and pregnancy or delivered number. The present results suggest that hFF is a rich source of sulfated glycosaminoglycan (CS), and non-sulfated glycosaminoglycan (HA). The stimulatory effects of hFF on human sperm motility may well depend on CS and HA. GAGs pretreated sperm may enhance the fertilizing ability of spermatozoa and thus the IVF outcome.