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Background: Women having experienced several consecutive failing IVF cycles constitute a critical and particular subset of patients, for which growing perception of irremediable failure, increasing costs and IVF treatment related risks necessitate appropriate decision making when starting or not a new cycle. Predicting chances of LB might constitute a useful tool for discussion between the patient and the clinician. Our essential objective was to dispose of a simple and accurate prediction model for use in routine medical practice. The currently available predictive models applicable to general populations cannot be considered as accurate enough for this purpose., Methods: Patients with at least four consecutive Failing cycles (CFCs) were selected. We constructed a predictive model of LB occurrence during the last cycle, by using a stepwise logistic regression, using all the baseline patient characteristics and intermediate stage variables during the four first cycles., Results: On as set of 151 patients, we identified five determinant predictors: the number of previous cycles with at least one gestational sac (NGS), the mean number of good-quality embryos, age, male infertility (MI) aetiology and basal FSH. Our model was characterized by a much higher discrimination as the existing models (C-statistics=0.76), and an excellent calibration., Conclusions: Couples having experienced multiple IVF failures need precise and appropriate information to decide to resume or interrupt their fertility project. Our essential objective was to dispose of a simple and accurate prediction model to allow a routine practice use. Our model is adapted to this purpose: It is very simple, combines five easily collected variables in a short calculation; it is more accurate than existing models, with a fair discrimination and a well calibrated prediction.

The aim of this study was, firstly, to define the different patterns of early cleavage (EC) observed at 26 h after either IVF or intracytoplasmic sperm injection (ICSI) and, secondly, to assess the predictive value of one of these patterns, even EC (EEC), on pregnancy rate in combination with day 2 embryo score. In the first part of the study, the relationship between three different EC patterns (EEC, uneven EC and EC with fragmentation of the day 2 embryo) and embryo morphology was determined. EEC was shown to be strongly associated with good embryo morphology. In the second part of the study, it was shown that EEC used in combination with embryo score improved selection of embryos for transfer. The presence of EEC significantly (P < 0.001) enhanced mean implantation rate in all transfer categories involving identically scored embryos, in both compulsory single embryo transfers and elective single embryo transfers. Multivariate analysis demonstrated that EEC and embryo score had strong complementary predictive value for pregnancy. Based on these findings, it was concluded that even though they are associated, EEC and embryo score could be combined to increase pregnancy rate, especially in elective single embryo transfer programmes.

In several trials, the GnRH antagonists regimens have been associated with a slightly lower pregnancy and implantation rate than the established GnRH agonist protocols. Several embryo classification systems have been developed to grade embryo quality, and a cumulative embryo score has been proposed to predict pregnancy. The cumulative embryo score is based on a 4-point embryo score in which all cleaved embryos were assigned 1 point and 1 additional point was added for each of the following features: absence of fragmentation (or fragmentation involving <20% of the embryonic surface), absence of irregularities in blastomere size or shape, and four-cell stage (regardless of cell morphology). This cumulative embryo score is highly correlated with embryo implantation rates. In a non prospective study concerning 641 IVF cycles with oocyte retrieval, pregnancy and implantation rates were statistically lower in the group of patients treated with GnRH antagonist. The explanation of this difference is the indication in IVF cycles: the women with tubal infertility and/or endometriosis had lower pregnancy and implantation rates in IVF cycles if an antagonist was administrated. There was no difference between the 2 groups in ICSI cycles. Subsequently, in IVF cycles, antagonist should not be administrated to women with tubal infertility and/or endometriosis.

Objectives: To evaluate the effect of in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) on total hCG, free ss-hCG, AFP and unconjugated estriol (uE3) used as markers for second-trimester Down syndrome maternal serum screening., Methods: Second-trimester maternal sera from 1515 singleton pregnancies (970 by IVF, 545 by ICSI) were compared with control sera (21 014 cases). Free ss-hCG, total hCG, AFP and uE3 were compared between the control group and the medically assisted reproduction groups. The percentages of at-risk patients (>/=1/250) were also compared., Results: No differences in values of the maternal serum markers were observed between the medically assisted and control groups. When maternal age was taken into account, the screen-positive rate for Down syndrome screening did not differ between the two groups., Conclusion: Patients undergoing assisted reproduction techniques can be counseled for maternal serum Down syndrome screening with the same efficacy as patients with naturally conceived pregnancies., (Copyright 2003 John Wiley & Sons, Ltd.)

The purpose of this study was to retrospectively compare the overall results and embryo quality in 102 cycles of in-vitro fertilization (IVF)-embryo transfer using normal frozen donor semen (group D) and 94 cycles of IVF-embryo transfer using husbands' teratozoospermic sperm (group T). Donor semen was purchased from men with proven fertility and normal semen parameters. Teratozoospermia was defined in group T as the presence of <20% of normal spermatozoa in semen on the day of oocyte retrieval. Exclusion criteria were a sperm count <10 x 10(6)/ml or with <10% progressive motility. Fertilization rate, transfer rate and number of transferred embryos per cycle were significantly lower in the teratozoospermic group (45 vs 72%, 66 vs 96%, 1.7 vs 2.9%, respectively). Pregnancy rate per cycle was also lower, but not significantly (18 vs 28%). However, pregnancy rate per transfer, implantation rate per transferred embryo and take home baby rate were comparable (27 vs 30%, 15 vs 15%, 21 vs 24%, respectively). Similarly, embryo quality in terms of number of embryos displaying fragmentations or irregular cells, cleavage stages and embryo scores were comparable. When group T was divided into two subgroups according to sperm count (group T1: sperm count = 10-20 x 10(6)/ml; group T2: sperm count >20 x 10(6)/ml), there was no difference between them with regard to fertilization rate, pregnancy rate or embryo quality. This study confirms low pregnancy rate per cycle in IVF-embryo transfer using teratozoospermic semen, but demonstrates for the first time that embryo quality and viability are not impaired. It is proposed that the poor pregnancy rate per cycle obtained is due only to the poor fertilization rate, and to the subsequent limited choice of embryos to be transferred.

The purpose of this study was to devise an embryo score to predict the likelihood of successful implantation after in-vitro fertilization (IVF). Unlike most studies dealing with the influence of embryo stage and morphology on pregnancy, our study was based on single rather than multiple embryo transfers. A total of 957 single embryo transfers were carried out. No delivery was obtained after any of the 99 transfers using 1-cell embryos or embryos obtained after delayed fertilization. In the remaining 858 transfers, the embryos had cleaved. Higher pregnancy rates were obtained with embryos displaying no irregular cells (11.7 versus 6.9%; P < 0.01) and embryos displaying no fragmentation (11.5 versus 8.1%; P < 0.05). The 4-cell embryos implanted 2-fold more often than embryos with more or less cells (15.6 versus 7.4%; P < 0.01). Based on these observations, we devised a 4-point embryo score in which embryos are assigned 1 point each if they (i) are cleaved, (ii) present no fragmentation, (iii) display no irregularities, and (iv) have four cells. Both pregnancy rate and take home baby rate were significantly correlated with embryo score. Each point of this score corresponds to a 4% increase in pregnancy rate. Interestingly, pregnancy rate was significantly lower in women aged > 38 years (8.2 versus 11.4%; P < 0.05), even though embryo quality was similar regardless of age. Single embryo transfer allowed us to define a simple and useful embryo score to choose the best embryo for transfer to optimize IVF and embryo transfer outcome. The use of this embryo score could decrease multiple pregnancies after multiple embryo transfers.

We report here the results of a study comparing the quality of the embryos obtained after conventional IVF and after ICSI (respectively 872 and 459 embryos for 184 and 108 cycles). In the ICSI group, the female age was lower than in the IVF group, the oestradiol level on the day of hCG injection was higher, so that the number of retrieved oocytes and the number of mature oocytes. The policy of transfer being the same in the two groups, the mean number of transferred embryos was identical. The percentage of embryos without anucleate fragments, the percentage of embryos without irregularities, the percentage of 1, 2, 3, 4 or 5-cell embryos and the distribution of embryos in the 5 embryo scores were similar. In both IVF and ICSI groups, the transfer score (sum of the embryo scores of each transferred embryo) was higher for the patients who achieved pregnancy.

The purpose of this study was to compare visual and computerized assisted semen analysis (CASA) in an in vitro fertilization program. Both methods were performed on the day of 316 oocyte retrievals. CASA was performed using a Hamilton 7.2 device adjusted in accordance with the settings defined by a group of 14 French centers. Despite a few discrepancies, the correlation between visual and CASA sperm counts was significant (p < 0.001), so that between the two total motility assessments. The same correlation (Pearson's test) was observed between the fertilization rate and the parameters obtained by visual analysis and CASA. VAP, VSL, VCL and ALH exhibited threshold values under which the mean fertilization rate was below 50%. This study demonstrates the satisfactory reliability of CASA although it cannot yet replace visual analysis.

Objective: To assess the value of subzonal insemination (SUZI) in cases of total or extreme asthenozoospermia., Design: The results of IVF after SUZI were assessed in six cycles (four couples) with documented asthenozoospermia., Setting: Institut de Médecine de la Reproduction, Marseille, France., Patients: Four couples underwent six retrieval cycles. In all cases asthenozoospermia was total (100% of immotile spermatozoa) or extreme (5% nonprogressive motility). Oligozoospermia and teratozoospermia were ruled out in all cases. In two cases electron microscopy revealed the absence of the central singlet in the flagellum axonemal complex and in one case a major dysplasia of the fibrous sheath in the flagellum principal piece., Results: The overall fertilization rate was 45%. The diploid embryo rate was 33%. Embryo quality was satisfactory. In five of six cycles, three embryos were transferred. Two triplet pregnancies were obtained corresponding to an implantation rate per transferred embryo of 40%., Conclusion: Total or extreme asthenozoospermia seems to be a good indication for SUZI.

The value of partial zona dissection (PZD) was assessed in a randomized protocol of in-vitro fertilization (IVF) including 30 couples (44 cycles) with at least two sperm defects. Couples were divided into three groups according to previous IVF status, i.e. group I: total failure of previous IVF; group II: marginal success of previous IVF, and group III: no previous IVF. Both PZD and untreated oocytes were inseminated using the swim-across method. Although PZD did not enhance the overall proportion of fertilized eggs resulting in diploid cleaving embryos per retrieved oocyte (14.7 versus 17.1%), this rate was higher with PZD than with IVF when previous IVF attempts had failed (group I: 16.1 versus 4.5%, P < 0.01). The rate was similar for PZD and IVF in group II, and lower for PZD than IVF in group III (15.1 versus 30.8%, P < 0.01). The higher polyspermy rate associated with PZD in groups in which classical IVF worked, could partially explain these results. The role of a possible deleterious effect of PZD on the oocytes is discussed. Out of the 44 cycles, 20 reached the embryo transfer stage and four pregnancies were obtained. In our opinion PZD should be carried out in cases of sperm defects only when previous IVF attempts have failed.

Failure of in vitro fertilization or very low cleavage rates may occur even though oocyte and semen parameters seem satisfactory. Quantified ultrastructural study of spermatozoa was performed in such cases of failure (n = 6) or low cleavage rate (< 20%; n = 4). Through 1 to 11 retrievals, the number of inseminated oocytes ranged from 14 to 145. The results were compared to those of six fertile men. Quantification was achieved by cataloguing cell defects of the spermatozoon heads and mid-/principal pieces of the flagella. Using the data from each specimen, the percentages of total cellular abnormalities in the head/mid-/principal pieces were established. At the level of the head overall percentages for six groups of defects were determined. The overall percentage of combined head abnormalities, defined as the presence of at least three of these six defects on the same spermatozoon head, was established. Statistical differences among control and patient groups were analyzed by nonparametric Mann-Whitney U test. The percentages of anomalies of the midpiece and of the principal piece were not significantly different between patients and controls. Motility assessed by spermogram was considered "functionally uncompromised." In eight patients the percentage of cell alterations of the head (93-100 vs 77.3 +/- 6.4%) and the percentage of combined anomalies of the head (78.1-100 vs 60.8 +/- 8.5%) were significantly different between patients and controls. In two cases, the percentages established for all head parameters considered were not globally different from those observed in controls. Thus in 8 cases of 10, electron microscopy with quantified analysis supplied valuable evidence about the poor quality of these sperm samples judged as normal under light microscopy and may provide an explanation for their impaired fertilizability.(ABSTRACT TRUNCATED AT 250 WORDS)

The purpose of this study was to evaluate a new method of in-vitro fertilization (IVF) in patients with severe sperm defects. Unlike the conventional swim-up method, spermatozoa and oocytes are placed in opposite corners of the bottom of the incubation dish so that sperm swimming is horizontal instead of vertical. Another difference between the swim-across and swim-up techniques is that the incubation medium is supplemented with 20% follicular fluid. After a randomized series (protocol I) of 15 IVF attempts had demonstrated that swim-across was more effective than swim-up in terms of fertilization and cleavage, we began a second series (protocol II) using only swim-across. A total of 124 couples with motile sperm counts less than 1 x 10(6) spermatozoa/ml of semen were included in protocol II. Clinical parameters (age, tubal damage) and number of recovered oocytes were recorded and compared in patients who did (group A: n = 94) and did not (group B: n = 74) achieve fertilization. In group A the fertilization rate was 36.7% and, out of the 94 transfers that were made, there were 21 clinical pregnancies and 12 full-term pregnancies with 16 live births. The number of oocytes collected (12 versus 7.7, P less than 0.001) and the incidence of tubal damage (50% versus 24.3%, P less than 0.001) was significantly higher in group A than in group B. Using logistic regression analysis, we showed a significant correlation between fertilization and progressive motility, percentage normal spermatozoa, number of recovered oocytes and tubal damage.(ABSTRACT TRUNCATED AT 250 WORDS)

Every sperm parameter has an effect on the chances of fertilization. When fertilization has been obtained with a sperm, the cleavage rate is identical regardless of the count, the mobility or the results of the migration test. On the contrary, in case of teratospermia, the cleavage rate of fertilizing sperms is significantly decreased. The rate of pregnancy by transfer is identical with normal sperm and sperm deficiency.