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In the past decades, the efficiency of human assisted reproductive technologies (ART) has improved. We have witnessed important new developments such as intracytoplasmic sperm injection, blastocyst culture, vitrification, and methods for genetic analysis of human embryos. Despite these improvements, current ART laboratories are to a large extent composed of general laboratory equipment that is not designed and manufactured especially for human ART. Human reproductive cells have different physiochemical requirements than somatic cells. We encourage the development of laboratory equipment, utensils, and consumables that are designed specifically for human ART. In addition, the quality and consistency of commercially available culture media have improved, but the composition of commercially available ART culture media varies considerably. It is difficult to see the scientific rationale for this variation. Currently it is not known which of these formulations gives the best clinical results. Finally, selection of embryos in routine ART should be done with the use of variables that have been shown to have statistically independent selection power. With the advent of automatic and objective methods for recording morphology and growth kinetics of human embryos, there is a possibility to pool data sets from many different clinics. This may enable the construction of selection algorithms based on objectively recorded embryo parameters. New methods for the genetic analysis of chromosomal status of embryos may prove to be useful, but they should be tested in controlled randomized trials before being introduced for routine use in ART., (Copyright © 2013 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To report a case of conjoined twins conceived through assisted reproduction after intracytoplasmic sperm injection (ICSI) and the transfer of three eight-cell embryos on day 3., Design: Case report., Setting: Assisted reproduction unit of a private hospital., Patient(s): A 32-year-old patient underwent ICSI and received three embryos., Intervention(s): Ovarian stimulation and ICSI., Main Outcome Measure(s): Images of the embryos and ultrasound images of the fetuses., Result(s): One embryo measuring 7 weeks, relatively big in size and bizarre in appearance with one heartbeat, was detected on transvaginal ultrasound at 6 weeks, 4 days of pregnancy. Two weeks later, another ultrasound was performed; two fetuses with a common heart were observed. In 10th week of pregnancy, two fetuses with two hearts and an attached thorax were observed. A diagnosis of thoracopagus was made, and the pregnancy was terminated., Conclusion(s): Conjoined twins conceived through assisted reproduction are extremely rare. This case, which occurred after transfer of cleavage-stage embryos, suggests that ovulation induction, ICSI, and assisted hatching may also play roles in addition to other factors commonly proposed to be responsible for conjoined twining, such as in vitro culture condition, culture time, and blastocyst-stage transfer., (Copyright © 2011. Published by Elsevier Inc.)

Slow-freezing and vitrification methods of human ovarian tissue cryopreservation were compared in terms of primordial follicle count and in vitro antimüllerian hormone (AMH) and estradiol production. Compared with fresh and slow-frozen ovaries, vitrified ovaries contained statistically significantly fewer primordial follicles and produced statistically significantly less AMH in vitro. Estradiol production from slow-frozen and vitrified ovaries was similar but statistically significantly lower than from fresh cultured strips., (Copyright © 2011. Published by Elsevier Inc.)

Objective: To analyze whether a change in three-dimensional structure of the zona pellucida could indicate suboptimal gamete quality., Design: Prospective study., Setting: Women's general hospital., Patient(s): A total of 72 patients who gave informed consent., Intervention(s): The birefringence of all oocytes was prospectively analyzed with an automatic user-independent polarization microscopy imaging system., Main Outcome Measure(s): Birefringence of the inner zona layer, preimplantation development, implantation, and pregnancy., Result(s): In approximately one third of all gametes (244/712), the system's automatic detection of the inner zona layer did not succeed. This phenomenon was a negative predictor of compaction (P<0.01), blastulation (P<0.001), and pregnancy (P<0.001). In cases of successful zona imaging, the score based on the birefringence of the inner zona layer was a strong predictor of blastocyst formation but not of embryo quality or pregnancy (P>0.05). Interestingly, antagonist protocol resulted in lower zona scores as compared with the long protocol (P<0.05)., Conclusion(s): Combining the information from both undetected and detected oocytes, zona imaging was a helpful tool in oocyte selection. This knowledge might further help to reduce both the time in culture and the number of concepti considered for transfer., (Copyright (c) 2010 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To analyze whether the use of a hyaluronan-enriched transfer medium (HETM) increases rates of implantation (IRs) and clinical pregnancy (CPRs), compared with the use of a conventional transfer medium after day 3 and day 5 embryo transfers., Design: Prospective randomized controlled trial., Setting: An assisted reproduction program in a private tertiary-care hospital in Turkey., Patient(s): A total of 1,282 consecutive fresh embryo transfer cycles (825 day 3 and 457 day 5) were randomly allocated into two groups. In 639 women, ET was effected with HETM, and in 643, it was effected with a conventional embryo transfer medium., Intervention(s): Embryo transfer using HETM or conventional embryo transfer medium., Main Outcome Measure(s): Clinical pregnancy rates and IRs were compared with regard to day of embryo transfer, women's age, quality of the transferred embryos, and presence of previous implantation failures., Result(s): Overall CPRs and IRs significantly increased with the use of HETM (CPR: 54.6% vs. 48.5%, odds ratio: 1.28, 95% confidence interval: 1.03-1.59; IR: 32% vs. 25%, odds ratio: 1.43, 95% confidence interval: 1.23-1.66, for HETM and control groups, respectively). The number needed to treat (NNT) for one additional pregnancy with routine use of HETM was 17. The beneficial effect was more prominent in women who were >35 years of age (NNT = 7), in women who had previous failed cycles (NNT = 7), and in women who had poor-quality embryos (NNT = 8)., Conclusion(s): The enrichment of transfer medium with hyaluronan increases CPRs and IRs, both for day 3 and day 5 embryo transfers. The beneficial effect was most evident in women who were >35 years of age, in women who had only poor-quality embryos available for transfer, and in women who had previous implantation failures.

Objective: Controlled ovarian hyperstimulation yields numerous oocytes with different morphologic features. The purpose of this study was to assess the effect of oocyte dysmorphism on the development and ploidy status of the derived embryo., Design: Retrospective study., Setting: Private assisted reproduction unit., Patient(s): A retrospective analysis was performed on 616 oocytes and 266 embryos of 65 infertile couples who had undergone preimplantation genetic diagnosis and aneuploidy screening for repeated implantation failures., Intervention(s): Oocytes with normal and abnormal morphology and the derived embryos were compared in terms of fertilization, cleavage, and blastocyst formation rates as well as the ploidy status., Result(s): Oocyte dysmorphism did not have an adverse effect on fertilization and cleavage rates and quality of day 3 embryos. Single cytoplasmic and multiple abnormalities of the oocyte significantly decreased the blastocyst formation rate of the cleaving embryo. Oocyte dysmorphism did not have a significant association with embryonic aneuploidy., Conclusions(s): Oocyte dysmorphism was not associated with a higher risk of aneuploidy in the developing embryo. Cytoplasmic dysmorphism or multiple morphologic abnormalities of the oocyte adversely affects the blastocyst formation potential of the derived embryo.

Objective: To compare the outcome of frozen-thawed ET cycles where embryos had been stored in conventional versus ionomeric resin-based, high-security straws (HSSs)., Design: Prospective, randomized study., Setting: Private assisted-reproduction unit., Patient(s): Three hundred and six freeze cycles, and 197 thaw cycles., Intervention(s): Day 3 embryos (n = 1,268) were frozen, and 517 were thawed using HSSs. Alternately, day 3 embryos (n = 1,228) were frozen, and 505 were thawed using conventional straws., Main Outcome Measure(s): Cryosurvival, cleavage and morulae formation rates, and clinical pregnancy, implantation, and multiple pregnancy rates., Result(s): Although cycle characteristics did not show any differences, the cryosurvival rate was higher in the HSS group (94.7%) than in the conventional straw group (86%), as was the morulae formation rate (58.7% versus 42.7%). Despite a similar number of embryos being transferred, the clinical pregnancy rate (PR) was higher in the HSS group, but the difference lacked statistical significance (42.5% versus 31.2). Implantation rates (19.4% versus 11.4%) and multiple PRs (41.8% versus 16.6%) were significantly higher in the HSS group than in the conventional straw group., Conclusion(s): High-security straws are high effective in human embryo cryopreservation, because they provide higher cryosurvival and implantation rates, as well as a lower risk of cross-contamination compared to conventional straws.

Objective: To compare the clinical outcomes of cryopreservation according to the indications for freezing and the outcomes of the fresh cycle from which the embryos were derived., Design: Retrospective study., Setting: Private assisted-reproduction unit., Patient(s): Three thousand, three hundred and sixty-eight embryos in 702 frozen-thawed embryo transfer (ET) cycles., Intervention(s): Clinical outcomes of frozen-thawed ET cycles in which embryos were derived from fresh conception cycles (n = 436), from fresh nonconception cycles (n = 180), or where the fresh cycle was cancelled due to impending ovarian hyperstimulation syndrome (OHSS) (n = 86)., Main Outcome Measure(s): Cryosurvival, clinical pregnancy, and implantation rates., Result(s): Despite similar cryosurvival rates and the transfer of a similar number of embryos, significantly higher clinical pregnancy and implantation rates were obtained in the fresh-conception and OHSS groups. The implantation potential of frozen-thawed embryos that were not selected in a prior fresh cycle was comparable to that of embryos selected for fresh transfer., Conclusion(s): The success of frozen-thawed ET depends on the outcome of fresh ET and the indications for cryopreservation. Success is similar to that of fresh ET cycles in patients who had all their embryos frozen due to impending OHSS.

A more detailed blastocyst grading system provides a better selection of blastocysts with the highest implantation potential. Grading systems will help to decrease the number of blastocysts to be transferred without compromising high implantation and pregnancy rates.

A retrospective study of 5,982 embryos in 619 blastocyst-stage embryo transfer cycles revealed that detection of multinucleated blastomeres either on day 2 or 3 signifies a poor prognosis for blastocyst formation and that no good-quality blastocyst can be expected from an embryo with more than one multinucleated blastomere. Patients should be counseled regarding a poor prognosis when multiple embryos with multinucleated blastomeres are present.

Objective: To compare the outcome of zona-intact versus zona-free blastocyst transfer., Design: Prospective, randomized study., Setting: Tertiary care private hospital IVF center., Patient(s): A total of 240 patients undergoing blastocyst stage ET (119 zona intact and 121 zona free)., Intervention(s): In vitro culture of embryos to the blastocyst stage was followed by random allocation to zona-intact or zona-free transfer., Main Outcome Measure(s): Treatment cycle characteristics, implantation, and pregnancy rates., Result(s): Transfer of zona-free blastocysts was associated with a higher implantation rate. Subgroup analysis, however, indicated that better outcome was achieved only in the group that received poor-quality blastocysts. Patients undergoing blastocyst transfer for the first time did not seem to benefit from zona-free blastocyst transfer., Conclusion(s): Zona-free blastocyst transfer increases the success of blastocyst-stage transfer in patients with poor-quality blastocysts.

Objective: To determine the feasibility and success of blastocyst-stage embryo transfers in patients having only fair and poor quality cleavage-stage embryos on day 3., Design: Prospective case study with historic controls., Setting: Tertiary care private hospital IVF center., Patient(s): A total of 158 day 5 embryo transfer cycles in patients with grade 3 and grade 4 cleavage-stage embryos. Control group consisted of 162 day 3 transfer cycles performed with embryos of similar quality., Intervention(s): In vitro culture of embryos up to the blastocyst stage., Main Outcome Measure(s): The percentage of cycles that culminated in the transfer of at least one blastocyst and implantation and pregnancy rate related to the day of transfer., Result(s): In the day 3 transfer group, a mean of 5.2 embryos were replaced per patient. This was significantly more than the mean of 2.4 embryos that could be replaced on day 5 (P <.001). The clinical pregnancy rate per embryo transfer was 27.2% and 33.5% in the two groups, respectively (P >.05). The implantation rate per embryo was significantly higher in the day 5 transfer group (15% vs. 5.9%). The multiple pregnancy and abortion rates were similar between the groups., Conclusion(s): Transfer of fair and poor quality embryos at the blastocyst stage is feasible and is associated with higher implantation rates as compared to transfer of similar quality embryos on day 3.

Objective: To determine the relationship between blastocyst quality and the results of embryo transfer at the blastocyst stage., Design: Retrospective case analysis., Setting: Tertiary care private hospital IVF center., Patient(s): A total of 350 blastocyst-stage embryo transfer cycles., Intervention(s): In vitro culture to the blastocyst stage was undertaken in 350 ICSI cycles where four or more cleavage-stage embryos were available on day 3., Main Outcome Measure(s): Relationship between blastocyst quality and implantation and clinical and multiple pregnancy rates., Result(s): Transfer of at least one grade 1 or grade 2 blastocyst or one hatching blastocyst was associated with very high implantation and pregnancy rates. However, transfer of grade 3 blastocysts yielded very low implantation and pregnancy rates., Conclusion(s): There appears to be a strong correlation between blastocyst quality and success of blastocyst transfer.

Objective: To evaluate the association between serum P levels on the day of hCG administration and the outcome of intracytoplasmic sperm injection (ICSI)., Design: Retrospective case study., Setting: Assisted reproduction unit of a tertiary care private hospital., Patient(s): Nine hundred eleven ICSI cycles that proceeded to ET were studied., Intervention(s): The decision to administer hCG was based on serum E2 levels and follicle size. Serum P was measured from frozen sera obtained on the day of hCG administration. Cycles were stratified according to serum P levels of <0.9 ng/mL (n = 298) or > or =0.9 ng/mL (n = 613). This cutoff level was selected because it yielded the highest sensitivity and specificity according to a receiver operator characteristic curve., Main Outcome Measure(s): Implantation and clinical pregnancy rates., Result(s): In cycles with high serum P levels, more oocytes were retrieved and more embryos were available for transfer. Clinical pregnancy rates per ET in the low and high P groups were 36.9% and 45.4%, respectively (P<.05). The implantation rate per embryo was similar in the two groups (14.9% and 16.4%, respectively, in cycles with P levels <0.9 vs > or =0.9 ng/mL). Abortion rates were 22.7 and 25.8%, respectively (P>.05)., Conclusion(s): Our data showed no adverse effect of high serum P levels on the day of hCG administration on implantation rates after ICSI and ET.