Recurrent implantation failure:gamete and embryo factorsMausumi Das, M.D., and Hananel E. G. Holzer, M.D.Division of Repro...
VIEWS AND REVIEWS(67%) compared with controls (36%) in patients with three or       suboptimal components of a culture sys...
Fertility and Sterility®been suggested that if oocyte maturation to the metaphase II        producing a unique DNA fingerpr...
VIEWS AND REVIEWSobserved in patients with a history of only one previous im-       patients, selecting the best embryos b...
Fertility and Sterility®to facilitate a successful ET (21), whereas bed rest after ET has   viability (83). Newer methods,...
VIEWS AND REVIEWS11.   Bungum M, Humaidan P, Axmon A, Spano M, Bungum L, Erenpreiss J, et al.            32.   The Practic...
Fertility and Sterility®53.   Petersen CG, Mauri AL, Baruffi RL, Oliveira JBA, Massaro FC, Elder K, et al.       68.   Haba...
Upcoming SlideShare
Loading in...5
×

Implantation Failure in IVF

5,029

Published on

Published in: Health & Medicine
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
5,029
On Slideshare
0
From Embeds
0
Number of Embeds
3
Actions
Shares
0
Downloads
93
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide

Implantation Failure in IVF

  1. 1. Recurrent implantation failure:gamete and embryo factorsMausumi Das, M.D., and Hananel E. G. Holzer, M.D.Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, McGill University, Montreal, Quebec,CanadaChromosomal abnormalities, sperm DNA damage, zona hardening, inadequate culture conditions, and suboptimal embryo development all play a sig-nificant role in the etiology of recurrent implantation failure. Evidence suggests that preimplantation genetic screening does not increase implantation orlive birth rates. Comparative genomic hybridization array and analysis of single nucleotide polymorphisms could enable a more comprehensive screeningof chromosomes. Assisted hatching may help to overcome zona hardening in selected cases. Optimal culture conditions and blastocyst transfer couldcontribute toward improving implantation and pregnancy rates. Novel embryo assessment and selection procedures, such as time-lapse imaging andmetabolomics, may help in better evaluation of embryo quality and viability and help in selecting embryos with the highest implantation potential.The safety and efficacy of emerging treatment modalities should be evaluated in prospective randomized clinical trials before being applied in routineclinical practice. (Fertil SterilÒ 2012;97:1021–7. Ó2012 by American Society for Reproductive Medicine.)Key Words: Implantation failure, IVF, embryo, oocyte, sperm, chromosomeD espite the immense strides that depends on the synchronization of var- inversions, and deletions, have been have been made in the field of ious factors such as the quality of the demonstrated in women with high- IVF many patients still experi- embryo, optimal culture conditions, order RIF (3). In support of these find-ence recurrent implantation failure. the receptivity of the endometrium, ings, Stern et al. (4) observed an overallBesides causing immense distress to and the maternal immune system. The chromosomal abnormality rate of 2.5%couples who require multiple cycles of aim of this article is to review the estab- (13/514) in patients with RIF. Mosttreatment, it significantly increases the lished etiologies affecting embryo de- of these abnormalities were chromo-cost of the procedure. Recurrent implan- velopment in patients with RIF and to somal translocations (reciprocal andtation failure (RIF) may be defined as the evaluate recent advances in oocyte Robertsonian). They proposed that bal-repeated transfer of morphologically and embryo selection, as well as current anced parental translocations may begood embryos to a normal uterus with- recommended management strategies. implicated in the pathogenesis of im-out achieving successful implantation plantation failure in IVF, and that ge-and a clinical pregnancy. Traditionally, ETIOLOGY netic evaluation should be consideredfailure to achieve a pregnancy after two Chromosomal abnormalities, inade- as part of the investigation of these cou-to six IVF cycles, in which more than quate culture conditions, suboptimal ples (4).10 high-grade embryos were transferred embryo development, zona hardening, Aneuploid embryos have decreasedto the uterus was defined as RIF (1). and improper ET technique all play an ability to undergo successful implanta-However, in most IVF programs, failure important role in the etiology of RIF. tion and result in a viable pregnancy,of three cycles in which reasonably but cannot be distinguished from nor-good embryos were transferred would mal embryos using standard morpho-warrant investigation (2). In spite of op- Chromosomal Abnormality logical criteria. Data obtained fromtimization of treatment protocols and It is now well established that a major embryos and oocytes of patients under-huge advancements in laboratory tech- cause of repeated implantation failure going preimplantation genetic screen-nologies, the management of RIF poses after IVF is a high frequency of chromo- ing (PGS) because of advanced age,a major challenge to clinicians and em- somal aneuploidy. An increased inci- recurrent pregnancy losses, or multiplebryologists universally. The process of dence of chromosomal abnormalities, failed IVF cycles, support the conceptembryo implantation in the uterus such as translocations, mosaicism, that many embryos and eggs obtained during IVF are intrinsically abnormalReceived February 2, 2012; accepted February 21, 2012; published online March 15, 2012. and thus fail to implant (5). Using fluo-M.D. has nothing to disclose. H.E.G.H. has nothing to disclose. rescence in-situ hybridization (FISH) onReprint requests: Hananel E. G. Holzer, M.D., Department of Ob & Gyn, McGill University Heath Cen- blastomeres from biopsied day 3 em- ter, McGill Reproductive center, 687 Pine Avenue West, Montreal, Quebec H4W 2A6, Canada (E-mail: hananel.holzer@muhc.mcgill.ca). bryos for chromosomes 13, 16, 18, 21, 22, X, and Y, Pehlivan et al. (6) foundFertility and Sterility® Vol. 97, No. 5, May 2012 0015-0282/$36.00Copyright ©2012 American Society for Reproductive Medicine, Published by Elsevier Inc. that there was a significantly higherdoi:10.1016/j.fertnstert.2012.02.029 rate of chromosomal abnormalitiesVOL. 97 NO. 5 / MAY 2012 1021
  2. 2. VIEWS AND REVIEWS(67%) compared with controls (36%) in patients with three or suboptimal components of a culture system that couldmore failed IVF attempts. In another study, using comparative lead to impaired embryo development have been describedgenomic hybridization (CGH), Voullaire et al. (7) detected (20). These include osmolality testing, pH measurements,chromosomal abnormalities in 76/126 (60%) single blasto- and sperm bioassay (20). In some instances of RIF, individ-meres biopsied from embryos before implantation in 20 ualized specific culture conditions may be required for opti-women with RIF after IVF. The abnormalities detected in their mal embryo development.study included aneuploidy for one or two chromosomes as Implantation rates and PRs after ET depend on the qualitywell as complex chromosomal abnormality. They suggested and developmental potential of embryos selected for transfer.that the disruption of the normal sequence of chromosome Suboptimal embryo quality has an adverse effect on implan-replication and segregation in early human embryos, caused tation and PRs. Evidence suggests that ET technique caneither by maternal cytoplasmic factors or mutations in cell influence the success or failure of embryo implantation. Uter-cycle control genes, may be a common cause of RIF. ine contractions, blood or mucous on the catheter tip, endo- A higher incidence of sperm chromosomal abnormalities metrial trauma, and expulsion of embryos have all beenin patients with normal karyotype and RIF has also been associated with unsuccessful ETs (21).reported. Pregnancy rates (PR) and implantation rates were re-ported to be significantly lower in patients with teratozoosper- MANAGEMENT OPTIONSmia. Rubio et al. (8) analyzed sperm aneuploidy and diploidy Various management options have been proposed to over-rates for chromosomes 13, 18, 21, X, and Y in patients with nor- come the challenges of chromosomal abnormality and subop-mal karyotypes using dual and triple-color FISH techniques. timal embryo development. Table 1 shows the variousThey reported an increased incidence of sex chromosome dis- etiological factors contributing toward defective embryo de-omies in couples with RIF after intracytoplasmic sperm injec- velopment and their proposed management strategies.tion (ICSI). In addition, centrosome anomalies resulting inchaotic mosaics were most likely of paternal origin (9, 10). Evidence suggests that sperm DNA damage is associated Chromosomal Abnormalitywith lower PRs after IUI and IVF (11). In addition, increased In view of the higher incidence of chromosomal anomalies,levels of sperm DNA damage have been linked with an parental karyotype is recommended as part of the work-upincreased risk of pregnancy loss after IVF and ICSI (12). There- in RIF (4). Preimplantation genetic screening has also been in-fore there is considerable evidence to suggest that chromo- creasingly used in the past decade, the rationale being that ansomal abnormalities, both maternal and paternal, play a key increased PR could be achieved by selecting only chromoso-role in the etiology of repeated implantation failure in IVF. mally normal embryos for transfer. The main biopsy methods used for PGS include removal of one or two polar bodies from the unfertilized oocyte or the zygote, removal of one or twoZona Hardening blastomeres at the cleavage stage, or removal of several cellsThe mammalian oocyte is surrounded by an acellular matrix, at the blastocyst stage (22). Polar body biopsy analyses mater-the zona pellucida (ZP), which is composed of glycoproteins, nal causes of chromosomal abnormality and is an indirectcarbohydrates, and ZP-specific proteins (13). It plays a role in method of screening for aneuploid embryos. It has, however,sperm binding, induction of the acrosome reaction, and pro-motes sperm–egg fusion (14). The zona hardens naturally af-ter fertilization to prevent polyspermic fertilization, protectsthe integrity of the preimplantation embryo, and facilitates TABLE 1oviductal transport (15). The zona is required during early Management options for factors affecting embryo development andcleavage stages to maintain the integrity of the inner cell implantation in recurrent implantation failure.mass (ICM), but it is usually shed during expansion of theblastocyst, allowing implantation to occur (16). Upon reach- Management optionsing the blastocyst stage, physical expansion of the embryonic Chromosomal abnormalitymass along with the action of lysins produced by the cleaved Preimplantation genetic screening Comparative genomic hybridization arrayembryo and/or the uterus, all play a role in zona hatching Single nucleotide polymorphisms(17–19). Failure of the ZP to rupture after blastocyst Zona hardeningexpansion, resulting in impaired hatching, could contribute Assisted hatchingto RIF (15). Prolonged exposure of oocytes and embryos to Suboptimal culture Optimal culture mediaartificial culture conditions may also adversely affect the Blastocyst transferembryos ability to undergo normal hatching and could Cocultureimpair successful implantation (15). ZIFT Assessment of embryo quality and viability Time-lapse imaging—EmbryoScope MetabolomicsEmbryo Culture and ET Technique ProteomicsThe use of high quality, standardized culture media is funda- Improving ET technique Note: ZIFT ¼ zygote intrafallopian transfer.mental to the success of any IVF program. Inadequate cul- Das. Recurrent implantation failure. Fertil Steril 2012.ture conditions could play a role in RIF. Assays to identify1022 VOL. 97 NO. 5 / MAY 2012
  3. 3. Fertility and Sterility®been suggested that if oocyte maturation to the metaphase II producing a unique DNA fingerprint for each embryo testedstage is completed just before the polar body biopsy, it may (33). However, a disadvantage of SNP microarrays is a lackresult in damage to the meiotic spindle of the oocyte (23). of diagnostic accuracy at individual SNP loci as well asCleavage stage biopsy is the most commonly used method high cost of microarrays and labeling techniques (33). In thefor screening preimplantation embryos for aneuploidy (24). future, PGS-FISH may be replaced by comprehensive proce-However, cleavage stage embryos have an increased inci- dures such as array CGH and SNP microarrays. However,dence of mosaicism (22). Biopsy at the blastocyst stage may the efficacy and practicality of these procedures in improvinghave a smaller risk of aneuploidy than embryo biopsy at the implantation and live birth rates in patients with RIF will havecleavage stage, because mosaic embryos have a higher pro- to be determined in well-designed prospective randomizedportion of aneuploid cells on day 2/3 and will not develop controlled trials before they can be widely applied in clinicalto the blastocyst stage (23). practice. Although initial studies suggested that PGS with FISHcould be used to achieve favorable implantation and PRs inpatients with RIF (6, 25), evidence from recent randomized Assisted Hatchingcontrolled trials does not support these findings (26, 27). In Elasticity and thinning of the ZP are essential prerequisites fora prospective randomized controlled trial, Blockeel et al. successful embryo hatching and implantation (15, 37). It has(26) observed that PGS did not increase the implantation been observed that cleaved embryos with a good prognosis forrates after IVF-ICSI in women with RIF. In this study, the in- implantation have reduced zona thickness (38). It has beenvestigators analyzed chromosomes 13, 16, 18, 21, 22, X, and suggested that an artificial opening made in the ZP mayY using FISH on blastomeres of day 3 cleavage stage embryos facilitate the hatching process (39). Cohen et al. (40)in the study group. There was a significant difference in live observed a higher implantation rate per ET after partialbirth rate between the PGS group (21%) and the control group zona dissection. The implantation window occurs 1–2 days(39%). The miscarriage rate did not differ between the two earlier in women undergoing ovarian stimulation than ingroups (26, 27). A recent meta-analysis of randomized natural cycles (41). Embryos with artificial gaps in the zonacontrolled trials demonstrated that in women with advanced initiate hatching earlier than zona intact embryos,maternal age as well as women with repeated implantation compensating for the reduced development rate in vitrofailure, PGS significantly lowered live birth rates after (42). It has also been proposed that breaching the integrityIVF (27). of the zona could enhance the transport of nutrients from The reasons that have been proposed for the inefficiency the incubating media, which in turn would augmentof PGS are possible damage from the biopsy procedure, failure embryo development and blastocyst formation (43). It couldrate from the technique, limitations of the FISH analysis, and also serve as a channel for a two-way exchange across theembryo mosaicism (27, 28). In addition, the efficacy of FISH is ZP of metabolites and growth factors (42).limited because only a few chromosomes can be detected The artificial rupture of the ZP is known as assisted hatch-simultaneously in a single biopsied cell. The lack of ing and aims to improve implantation and clinical PRs. Var-usefulness of PGS may be because the tested blastomere is ious techniques have been used to aid zona hatching. Thesenot representative for the whole embryo (29). The American involve the creation of an opening in the ZP either by me-Society of Reproductive Medicine (ASRM), the European chanical partial zona dissection (39), chemically by zona dril-Society of Human Reproduction and Embryology (ESHRE), ling with acid Tyrode (42), chemical zona thinning (44),and the British Fertility Society have concluded that PGS enzymatic treatment (45), laser-assisted hatching (46, 47),does not improve the live birth rates in patients with RIF, or by using a piezo-micromanipulator (48).advanced maternal age, or recurrent pregnancy loss (30–32). The clinical relevance of assisted hatching procedures in Alternative approaches have been proposed to overcome the management of RIF is controversial. Although some stud-the limitations of FISH for PGS. These include CGH or the ies have reported that assisted zona hatching improves PRsanalysis of single nucleotide polymorphisms (SNPs) (33, 34). and implantation rates in patients with RIF (49, 50), otherComparative genomic hybridization is a DNA-based method, investigators have not reported any advantage (46). Recentwhich is applicable to cells in any phase of the cell cycle (33). studies seem to suggest that assisted hatching may be ofThe CGH microarray enables a more comprehensive screening benefit in selected patients. In a prospective randomizedof chromosomes. Many chromosomal aneuploidies identified study, comparing chemical removal of ZP from day 5using CGH would not have been detected using FISH for five in vitro cultured human embryos by using acidic Tyrodesor nine chromosomes (35). Microarrays have an advantage solution versus no removal, the implantation rate per ETover conventional CGH because the evaluation of fluores- and the clinical PR were significantly higher in the ZP-freecence ratios is simple, rapid, and easily automated (33). A group (51). Stein et al. (52) reported that assisted hatchingproof-of-principle study concluded that chromosomal aneu- by partial zona dissection resulted in a significant increaseploidy of the oocyte can be accurately predicted by array in the implantation and clinical PRs in women older thanCGH analysis of both polar bodies (36). 38 years with RIF. Similarly, Petersen et al. (53) observed Single nucleotide polymorphisms are common polymor- that for patients with repeated implantation failures, the im-phic DNA sequences found throughout the genome. The plantation rate in those who received laser-thinned embryosprobes used for SNP microarrays provide genotype data in was significantly higher than in those whose embryos wereaddition to chromosome copy number information, thereby not laser thinned. Interestingly, this difference was notVOL. 97 NO. 5 / MAY 2012 1023
  4. 4. VIEWS AND REVIEWSobserved in patients with a history of only one previous im- patients, selecting the best embryos by culturing to the blas-plantation failure. In support of these findings, in a recent tocyst stage assumes even greater significance. In a prospec-meta-analysis of randomized control trials (five trials with tive randomized study, Levitas et al. (63) reported that in761 participants), assisted hatching was reported to be associ- patients with RIF with an adequate ovarian response, transferated with a significant improvement in clinical pregnancy of blastocyst stage embryos carries a significantly higher im-when performed in fresh embryos transferred to women plantation rate compared with ET on days 2–3. The multiplewith RIF (relative risk [RR] ¼ 1.73; 95% confidence interval PR was not significantly different between the two groups[CI] ¼ 1.37–2.17) (54). No increase was observed in clinical (63). In another study, Guerif et al. (64) also observed thatPRs when performed in fresh embryos transferred to unse- the live birth rates and implantation rates per cycle werelected or nonpoor prognosis women or to women of advanced higher after blastocyst transfer compared with day 2 ET.age. Assisted hatching was also related to increased multiple They suggested that improved embryo selection and uterinePRs in women with previous repeated implantation failure. receptivity may explain the additional benefit of ET at theHowever, due to the small sample size of the included studies, blastocyst stage for couples with RIF (64). However, it shouldthis meta-analysis was not able to draw any conclusions re- be noted that a percentage of fertilized eggs will never reachgarding live birth or miscarriage rates (54). the blastocyst stage. Proper selection of cases suitable for blastocyst transfer is therefore critical to reduce the number of cycle cancellations (63).Embryo CultureOptimum culture conditions are a prerequisite for satisfactory Stimulation Protocolsembryonic development and lack of these conditions maycontribute to RIF. Various coculture systems have been devel- Variations in ovarian stimulation protocols have been sug-oped as a means of improving embryo culture conditions. The gested in some studies as a means of improving embryo devel-main aim is to increase the metabolic chances of the human opment and quality. The use of GnRH antagonist protocols inembryo to achieve the blastocyst stage because this leads to controlled ovarian hyperstimulation (COH) has been shown toa high implantation rate and PR. The suggested favorable ef- improve pregnancy outcome in patients with a history of RIFfects of cocultures include the secretion of embryotrophic fac- with GnRH agonist protocols. The investigators proposed thattors, such as nutrients and substrates, growth factors and this was most likely due to improvement of the quality of thecytokines, and the removal of free radicals and potentially blastocysts generated (65). Natural cycle IVF has also beenharmful substances (55). Although multiple cell types have proposed as a means of improving implantation rates in pa-been used for coculturing embryos, ranging from human re- tients with RIF (66). Despite some personal experience withproductive tissues, such as oviducts (56), endometrium (57), natural cycle IVF and in vitro maturation of oocytes in pa-sequential oviduct-endometrial coculture (58), and cumulus- tients with RIF, the lack of randomized clinical studies ingranulosa cells (GC) (59–61), homologous endometrial cells this field does not allow any recommendations to be madeappear to be the most promising coculture system (57). with regard to their efficacy.Using coculture of embryos on homologous endometrialcells in patients with RIF, Jayot et al. (57) reported an Zygote Intrafallopian Transferoverall PR of 21% per transfer versus 8% in previous IVF-ET Zygote intrafallopian transfer (ZIFT) allows the early embryocycles. Similarly, using autologous endometrial coculture in to grow in the natural tubal environment and physiologicalpatients with RIF, Spandorfer et al. (62) reported a significant transport of the embryos into the uterine cavity. It also over-improvement in embryo quality and clinical PRs. However, comes the problem of technically difficult ET because of cer-the advantage of coculture systems remains controversial. In vical stenosis (2). Although initial nonrandomized studiesaddition, most IVF units do not have the necessary personnel implied that ZIFT may be of value in RIF (67), a subsequentor facilities to perform coculture on a regular basis. meta-analysis of randomized controlled trials failed to dem- onstrate any benefit for ZIFT (68). In fact, there was a trendBlastocyst Transfer toward increased risk of ectopic pregnancy (EP) with ZIFT (68). These findings led to the procedure being abandonedEmbryo transfer at the blastocyst stage has been proposed as by most units.a strategy to improve implantation rates and PRs in patientswith RIF. Blastocyst transfer is a more physiological approachas the human embryos usually enter the endometrial cavity 5 ET Techniquedays after fertilization, at the morula-blastocyst stage in nat- A meticulous ET technique is of utmost importance in achiev-ural conception cycles (2). Better embryo selection for transfer ing a successful pregnancy outcome. Studies show that avoid-and improved endometrial receptivity are obvious advantages ance of blood (69), mucus (70), bacterial contamination,of this approach. Some clinicians transfer several embryos trauma to the endometrium, touching the fundus, and exces-after RIF. Culturing embryos to the blastocyst stage helps in sive uterine contractions (71) are all associated with betterselecting embryos with the best implantation potential. PRs and implantation rates after ET. Several techniquesTherefore fewer embryos have to be transferred to achieve have been proposed to optimize the technique of ET. Methods,a successful pregnancy, thereby decreasing the risk of multi- such as a trial transfer (72), filled bladder (73), ultrasono-ple pregnancy. With single ET becoming the norm in younger graphic guidance (74), and use of soft catheters, all appear1024 VOL. 97 NO. 5 / MAY 2012
  5. 5. Fertility and Sterility®to facilitate a successful ET (21), whereas bed rest after ET has viability (83). Newer methods, such as vibrational spectros-not been shown to be of any benefit (75). copy, both Raman and near infrared, have been used to ana- lyze spent culture medium from human embryos, measuring bonds within functional groups of molecules at specific wave-Cytoplasmic Transfer lengths. Results from initial studies indicate that spectral pro-Ooplasmic factors play a role in the continued development files reflective of oxidative stress appear to have a goodof the zygote, especially during the early cleavage stage. Co- correlation with pregnancy outcome (84).hen et al. (76) transferred ooplasm from donor eggs at meta-phase II stage into developmentally compromised metaphaseII oocytes in patients with multiple implantation failure (76). CONCLUSIONThey noted that this led to an improvement in embryo mor- Regardless of the considerable improvement in treatment pro-phology. Cytoplasmic transfer from fertile donor oocytes or tocols and laboratory technologies, RIF still poses a significantzygotes into developmentally compromised oocytes from pa- challenge to clinicians and embryologists. Chromosomal ab-tients with RIF has led to the birth of several healthy babies normalities and suboptimal embryo development play a majorworldwide (77). It has been suggested that this procedure role in the etiology of RIF. Emerging technologies, such asmay correct an imbalance between anti- and pro-apoptotic CGH array and analysis of SNPs could enable a more compre-factors and/or correction of defective mitochondrial mem- hensive screening of chromosomes. Assisted hatching maybrane potential (78). However, the transferred cytoplasm help to overcome zona hardening in selected patients. Opti-could contain messenger RNAs, proteins. and mitochondria mal culture conditions and blastocyst transfer may contribute(77). In addition, it is not known whether the physiology of toward improving the implantation rates and PRs in RIF.the early embryo is affected. The procedure is still experimen- Novel embryo assessment and selection procedures, such astal and will require assessment of ooplasmic anomalies and time-lapse imaging and metabolomics, may help in betteroptimization of techniques before it can be applied in clinical evaluation of embryo quality and viability and help in select-practice. ing embryos with the highest implantation potential. It should be noted that only those treatment options that are evidence based should be offered to patients. The safety, efficacy, andNew Methods of Embryo Assessment practicality of new, emerging methods of treatment shouldAssessment of embryo quality is critical in selecting the best be evaluated in prospective randomized clinical trials beforeembryo(s) to transfer or cryopreserve. As visual assessment being accepted in clinical practice.of embryo quality using morphological criteria can be subjec-tive and requires considerable expertise, newer methods of as-sessing embryo quality and viability are being developed. REFERENCESEmerging techniques such as time-lapse imaging may lead 1. Tan BK, Vandekerckhove P, Kennedy R, Keay SD. Investigation and currentto better assessment of embryo quality and help in selecting management of recurrent IVF treatment failure in the UK. BJOG 2005;112: 773–80.embryos with the highest implantation potential. It has 2. Margalioth EJ, Ben-Chetrit A, Gal M, Eldar-Geva T. Investigation and treat-been suggested that time-lapse observations using an incuba- ment of repeated implantation failure following IVF-ET. Hum Reprod 2006;tor with an integrated optical microscope may minimize the 21:3036–43.changes in the culturing environment by integrating the cul- 3. Raziel A, Friedler S, Schachter M, Kasterstein E, Strassburger D, Ron-El R. In-ture, observation, and time-lapse recording of cells into one creased frequency of female partner chromosomal abnormalities in patientssystem. The removal of embryos from the incubator for inter- with high-order implantation failure after in vitro fertilization. Fertil Sterilmittent observation can therefore be avoided while enabling 2002;78:515–9. 4. Stern C, Pertile M, Norris H, Hale L, Baker HWG. Chromosome translocationsthe continuous monitoring of embryo development (79). in couples with in-vitro fertilization implantation failure. Hum Reprod 1999;There is evidence that time-lapse monitoring in the Embryo- 14:2097–101.Scope (Unisense FertiliTech) does not impair embryo quality 5. Patrizio P, Bianchi V, Lalioti MD, Gerasimova T, Sakkas D. High rate of bio-while allowing for morphological and spatial analysis of em- logical loss in assisted reproduction: it is in the seed, not in the soil. Reprodbryo development (80). However, besides being more expen- Biomed Online 2007;14(Spec No 1):23–6.sive than standard incubators, the culture preparation 6. Pehlivan T, Rubio C, Rodrigo L, Romero J, Remohi J, Simon C, et al. Impact of preimplantation genetic diagnosis on IVF outcome in implantation failureprocedure is more time consuming compared with conven- patients. Reprod Biomed Online 2003;6:232–7.tional culture methods (81). 7. Voullaire L, Wilton L, McBain J, Callaghan T, Williamson R. Chromosome ab- Different approaches are also being developed to test the normalities identified by comparative genomic hybridization in embryosculture environment of a developing embryo to gain impor- from women with repeated implantation failure. Mol Hum Reprod 2002;tant information regarding its viability. Metabolomic analysis 8:1035–41.of follicular fluid (FF) can provide valuable information about 8. Rubio C, Gil-Salom M, Simon C, Vidal F, Rodrigo L, Mínguez Y, et al. Inci-individual oocyte maturation and developmental potential. dence of sperm chromosomal abnormalities in a risk population: relation- ship with sperm quality and ICSI outcome. Hum Reprod 2001;16:2084–92.Various methods have been described, which include mea- 9. Delhanty JD. Mechanisms of aneuploidy induction in human oogenesis andsurement of oxygen (81), pyruvate, and glucose consumption early embryogenesis. Cytogenet Genome Res 2005;111:237–44.by the embryo in the culture medium (82). Amino acid 10. Obasaju M, Kadam A, Sultan K, Fateh M, Munn S. Sperm quality may eturnover, which appears to be correlated to blastocyst adversely affect the chromosome constitution of embryos that result fromdevelopment, can be measured as an indication of embryo intracytoplasmic sperm injection. Fertil Steril 1999;72:1113–5.VOL. 97 NO. 5 / MAY 2012 1025
  6. 6. VIEWS AND REVIEWS11. Bungum M, Humaidan P, Axmon A, Spano M, Bungum L, Erenpreiss J, et al. 32. The Practice Committee of the Society for Assisted Reproductive Technol- Sperm DNA integrity assessment in prediction of assisted reproduction tech- ogy, Practice Committee of the American Society for Reproductive Medi- nology outcome. Hum Reprod 2007;22:174–9. cine. Preimplantation genetic testing: a Practice Committee opinion. Fertil12. Zini A, Boman JM, Belzile E, Ciampi A. Sperm DNA damage is associated Steril 2008;90:S136–43. with an increased risk of pregnancy loss after IVF and ICSI: systematic review 33. Wells D, Alfarawati S, Fragouli E. Use of comprehensive chromosomal and meta-analysis. Hum Reprod 2008;23:2663–8. screening for embryo assessment: microarrays and CGH. Mol Hum Reprod13. Bleil JD, Wassarman PM. Structure and function of the zona pellucida: iden- 2008;14:703–10. tification and characterization of the proteins of the mouse oocytes zona 34. Wilton L. Preimplantation genetic diagnosis and chromosome analysis of pellucida. Dev Biol 1980;76:185–202. blastomeres using comparative genomic hybridization. Hum Reprod Update14. van Duin M, Polman JE, De Breet IT, van Ginneken K, Bunschoten H, 2005;11:33–41. Grootenhuis A, et al. Recombinant human zona pellucida protein ZP3 pro- 35. Wilton L, Voullaire L, Sargeant P, Williamson R, McBain J. Preimplantation duced by Chinese hamster ovary cells induces the human sperm acrosome aneuploidy screening using comparative genomic hybridization or fluores- reaction and promotes sperm-egg fusion. Biol Reprod 1994;51:607–17. cence in situ hybridization of embryos from patients with recurrent implan-15. De Vos A, Van Steirteghem A. Zona hardening, zona drilling and assisted tation failure. Fertil Steril 2003;80:860–8. hatching: new achievements in assisted reproduction. Cells Tissues Organs 36. Geraedts J, Montag M, Magli MC, Repping S, Handyside A, Staessen C, et al. 2000;166:220–7. Polar body array CGH for prediction of the status of the corresponding oo-16. Trounson AO, Moore NW. The survival and development of sheep eggs fol- cyte. Part I: clinical results. Hum Reprod 2011;26:3173–80. lowing complete or partial removal of the zona pellucida. J Reprod Fertil 37. Cohen J. Assisted hatching of human embryos. J Assist Reprod Genet 1991; 1974;41:97–105. 8:179–90.17. Schiewe M, Araujo E, Asch R, Balmaceda J. Enzymatic characterization of 38. Cohen J, Inge KL, Suzman M, Wiker SR, Wright G. Videocinematography of zona pellucida hardening in human eggs and embryos. J Assist Reprod fresh and cryopreserved embryos: a retrospective analysis of embryonic mor- Genet 1995;12:2–7. phology and implantation. Fertil Steril 1989;51:820–7.18. Gordon JW, Dapunt U. A new mouse model for embryos with a hatching 39. Malter HE, Cohen J. Blastocyst formation and hatching in vitro following deficiency and its use to elucidate the mechanism of blastocyst hatching. zona drilling of mouse and human embryos. Gamete Res 1989;24:67–80. Fertil Steril 1993;59:1296–301. 40. Cohen J, Alikani M, Malter HE, Adler A, Talansky BE, Rosenwaks Z. Partial19. Hammadeh M, Fischer-Hammadeh C, Ali K. Assisted hatching in assisted re- zona dissection or subzonal sperm insertion: microsurgical fertilization alter- production: a state of the art. J Assist Reprod Genet 2011;28:119–28. natives based on evaluation of sperm and embryo morphology. Fertil Steril20. Gardner DK, Reed L, Linck D, Sheehan C, Lane M. Quality control in human 1991;56:696–706. in vitro fertilization. Semin Reprod Med 2005;23:319–24. 41. Nikas G, Develioglu OH, Toner JP, Jones HW. Endometrial pinopodes indicate21. Schoolcraft WB, Surrey ES, Gardner DK. Embryo transfer: techniques and a shift in the window of receptivity in IVF cycles. Hum Reprod 1999;14:787–92. variables affecting success. Fertil Steril 2001;76:863–70. 42. Cohen J, Alikani M, Trowbridge J, Rosenwaks Z. Implantation enhancement22. Harton GL, Magli MC, Lundin K, Montag M, Lemmen J, Harper JC. ESHRE by selective assisted hatching using zona drilling of human embryos with PGD Consortium/Embryology Special Interest Group—best practice guide- poor prognosis. Hum Reprod 1992;7:685–91. lines for polar body and embryo biopsy for preimplantation genetic diagno- 43. Hershlag A, Feng HL. Effect of prefreeze assisted hatching on postthaw sur- sis/screening (PGD/PGS). Hum Reprod 2011;26:41–6. vival of mouse embryos. Fertil Steril 2005;84:1752–4.23. Ly KD, Agarwal A, Nagy ZP. Preimplantation genetic screening: does it help 44. Khalifa EA, Tucker MJ, Hunt P. Cruciate thinning of the zona pellucida for or hinder IVF treatment and what is the role of the embryo? J Assist Reprod more successful enhancement of blastocyst hatching in the mouse. Hum Re- Genet 2011;28:833–49. prod 1992;7:532–6.24. Goossens V, Harton G, Moutou C, Traeger-Synodinos J, Van Rij M, 45. Fong CY, Bongso A, Ng SC, Kumar J, Trounson A, Ratnam S. Blastocyst trans- Harper JC. ESHRE PGD Consortium data collection IX: cycles from January fer after enzymatic treatment of the zona pellucida: improving in-vitro fertil- to December 2006 with pregnancy follow-up to October 2007. Hum Reprod ization and understanding implantation. Hum Reprod 1998;13:2926–32. 2009;24:1786–810. 46. Valojerdi MR, Eftekhari-Yazdi P, Karimian L, Ashtiani SK. Effect of laser zona25. Wilding M, Forman R, Hogewind G, Di Matteo L, Zullo F, Cappiello F, et al. pellucida opening on clinical outcome of assisted reproduction technology Preimplantation genetic diagnosis for the treatment of failed in vitro in patients with advanced female age, recurrent implantation failure, or fertilization-embryo transfer and habitual abortion. Fertil Steril 2004;81: frozen-thawed embryos. Fertil Steril 2008;90:84–91. 1302–7. 47. Laufer N, Palanker D, Shufaro Y, Safran A, Simon A, Lewis A. The efficacy26. Blockeel C, Schutyser V, De Vos A, Verpoest W, De Vos M, Staessen C, et al. and safety of zona pellucida drilling by a 193-nm excimer laser. Fertil Steril Prospectively randomized controlled trial of PGS in IVF/ICSI patients with 1993;59:889–95. poor implantation. Reprod Biomed Online 2008;17:848–54. 48. Nakayama T, Fujiwara H, Yamada S, Tastumi K, Honda T, Fujii S. Clinical ap-27. Mastenbroek S, Twisk M, van der Veen F, Repping S. Preimplantation ge- plication of a new assisted hatching method using a piezo-micromanipulator netic screening: a systematic review and meta-analysis of RCTs. Hum Reprod for morphologically low-quality embryos in poor-prognosis infertile patients. Update 2011;17:454–66. Fertil Steril 1999;71:1014–8.28. Harper JC, Coonen E, Handyside AH, Winston RM, Hopman AH, 49. Antinori S, Selman HA, Caffa B, Panci C, Dani GL, Versaci C. Fertilization and Delhanty JD. Mosaicism of autosomes and sex chromosomes in morpholog- early embryology: zona opening of human embryos using a non-contact UV ically normal, monospermic preimplantation human embryos. Prenat Diagn laser for assisted hatching in patients with poor prognosis of pregnancy. 1995;15:41–9. Hum Reprod 1996;11:2488–92.29. Vanneste E, Voet T, Melotte C, Debrock S, Sermon K, Staessen C, et al. What 50. Chao K-H, Chen S-U, Chen H-F, Wu M-Y, Yang Y-S, Ho H-N. Assisted hatch- next for preimplantation genetic screening? High mitotic chromosome in- ing increases the implantation and pregnancy rate of in vitro fertilization stability rate provides the biological basis for the low success rate. Hum Re- (IVF)-embryo transfer (ET), but not that of IVF-tubal ET in patients with re- prod 2009;24:2679–82. peated IVF failures. Fertil Steril 1997;67:904–8.30. Harper J, Coonen E, De Rycke M, Fiorentino F, Geraedts J, Goossens V, et al. 51. Jelinkova L, Pavelkova J, Strehler E, Paulus W, Zivny J, Sterzik K. Improved im- What next for preimplantation genetic screening (PGS)? A position state- plantation rate after chemical removal of the zona pellucida. Fertil Steril ment from the ESHRE PGD Consortium steering committee. Hum Reprod 2003;79:1299–303. 2010;25:821–3. 52. Stein A, Rufas O, Amit S, Avrech O, Pinkas H, Ovadia J, et al. Assisted hatch-31. Anderson RA, Pickering S. The current status of preimplantation genetic ing by partial zona dissection of human pre-embryos in patients with recur- screening: British Fertility Society Policy and Practice Guidelines. Hum Fertil rent implantation failure after in vitro fertilization. Fertil Steril 1995;63: (Camb) 2008;11:71–5. 838–41.1026 VOL. 97 NO. 5 / MAY 2012
  7. 7. Fertility and Sterility®53. Petersen CG, Mauri AL, Baruffi RL, Oliveira JBA, Massaro FC, Elder K, et al. 68. Habana AE, Palter SF. Is tubal embryo transfer of any value? A meta-analysis Implantation failures: success of assisted hatching with quarter-laser zona and comparison with the Society for Assisted Reproductive Technology da- thinning. Reprod BioMed Online 2005;10:224–9. tabase. Fertil Steril 2001;76:286–93.54. Martins WP, Rocha IA, Ferriani RA, Nastri CO. Assisted hatching of human 69. Goudas VT, Hammitt DG, Damario MA, Session DR, Singh AP, Dumesic DA. embryos: a systematic review and meta-analysis of randomized controlled Blood on the embryo transfer catheter is associated with decreased rates of trials. Hum Reprod Update 2011;17:438–53. embryo implantation and clinical pregnancy with the use of in vitro fertiliza-55. Simon C, Mercader A, Garcia-Velasco J, Nikas G, Moreno C, Remohí J, et al. tion–embryo transfer. Fertil Steril 1998;70:878–82. Coculture of human embryos with autologous human endometrial epithe- 70. Egbase PE, al-Sharhan M, al-Othman S, al-Mutawa M, Udo EE, Grudzinskas JG. lial cells in patients with implantation failure. J Clin Endocrinol Metab Incidence of microbial growth from the tip of the embryo transfer catheter 1999;84:2638–46. after embryo transfer in relation to clinical pregnancy rate following in-vitro56. Yeung WSB, Ho PC, Lau EYL, Chan STH. Improved development of human fertilization and embryo transfer. Hum Reprod 1996;11:1687–9. embryos in vitro by a human oviductal cell co-culture system. Hum Reprod 71. Lesny P, Killick SR, Tetlow RL, Robinson J, Maguiness SD. Embryo transfer— 1992;7:1144–9. can we learn anything new from the observation of junctional zone contrac-57. Jayot S, Parneix I, Verdaguer S, Discamps G, Audebert A, Emperaire JC. tions? Hum Reprod 1998;13:1540–6. Coculture of embryos on homologous endometrial cells in patients with 72. Mansour R, Aboulghar M, Serour G. Dummy embryo transfer: a technique repeated failures of implantation. Fertil Steril 1995;63:109–14. that minimizes the problems of embryo transfer and improves the pregnancy58. Bongso A, Fong CY, Ng SC, Ratnam S. Human embryonic behavior in a se- rate in human in vitro fertilization. Fertil Steril 1990;54:678–81. quential human oviduct-endometrial coculture system. Fertil Steril 1994;61: 73. Sundstrom P, Wramsby H, Persson PH, Liedholm P. Filled bladder simplifies 976–8. human embryo transfer. Br J Obstet Gynaecol 1984;91:506–7.59. Plachot M, Antoine JM, Alvarez S, Firmin C, Pfister A, Mandelbaum J, et al. 74. Hurley VA, Osborn JC, Leoni MA, Leeton J. Ultrasound-guided embryo trans- Fertilization and early embryology: granulosa cells improve human embryo fer: a controlled trial. Fertil Steril 1991;55:559–62. development in vitro. Hum Reprod 1993;8:2133–40. 75. Botta G, Grudzinskas G. Is a prolonged bed rest following embryo transfer60. Quinn P, Margalit R. Beneficial effects of coculture with cumulus cells on useful? Hum Reprod 1997;12:2489–92. blastocyst formation in a prospective trial with supernumerary human 76. Cohen J, Scott R, Alikani M, Schimmel T, Munn S, Levron J, et al. Ooplasmic e embryos. J Assist Reprod Genet 1996;13:9–14. transfer in mature human oocytes. Mol Hum Reprod 1998;4:269–80.61. Freeman MR, Whitworth CM, Hill GA. Fertilization and early embryology: 77. Barritt JA, Willadsen S, Brenner C, Cohen J. Cytoplasmic transfer in assisted granulosa cell co-culture enhances human embryo development and reproduction. Hum Reprod Update 2001;7:428–35. pregnancy rate following in-vitro fertilization. Hum Reprod 1995;10: 78. Levy R, Elder K, Mnzo Y. Cytoplasmic transfer in oocytes: biochemical e e 408–14. aspects. Hum Reprod Update 2004;10:241–50.62. Spandorfer SD, Pascal P, Parks J, Clark R, Veeck L, Davis OK, et al. Autolo- 79. Nakahara T, Iwase A, Goto M, Harata T, Suzuki M, Ienaga M, et al. Evalua- gous endometrial coculture in patients with IVF failure: outcome of the first tion of the safety of time-lapse observations for human embryos. J Assist 1,030 cases. J Reprod Med 2004;49:463–7. Reprod Genet 2010;27:93–6.63. Levitas E, Lunenfeld E, Har-Vardi I, Albotiano S, Sonin Y, Hackmon-Ram R, 80. Cruz M, Gadea B, Garrido N, Pedersen KS, Martinez M, Perez-Cano I, et al. et al. Blastocyst-stage embryo transfer in patients who failed to conceive Embryo quality, blastocyst and ongoing pregnancy rates in oocyte donation in three or more day 2–3 embryo transfer cycles: a prospective, randomized patients whose embryos were monitored by time-lapse imaging. J Assist study. Fertil Steril 2004;81:567–71. Reprod Genet 2011;28:569–73.64. Guerif F, Bidault R, Gasnier O, Couet ML, Gervereau O, Lansac J, et al. Effi- 81. Nel-Themaat L, Nagy ZP. A review of the promises and pitfalls of oocyte and cacy of blastocyst transfer after implantation failure. Reprod Biomed Online embryo metabolomics. Placenta 2011;32(Suppl 3):S257–63. 2004;9:630–6. 82. Gardner DK, Lane M, Stevens J, Schoolcraft WB. Noninvasive assessment of65. Takahashi K, Mukaida T, Tomiyama T, Goto T, Oka C. GnRH antagonist im- human embryo nutrient consumption as a measure of developmental po- proved blastocyst quality and pregnancy outcome after multiple failures of tential. Fertil Steril 2001;76:1175–80. IVF/ICSI–ET with a GnRH agonist protocol. J Assist Reprod Genet 2004;21: 83. Houghton FD, Hawkhead JA, Humpherson PG, Hogg JE, Balen AH, 317–22. Rutherford AJ, et al. Non-invasive amino acid turnover predicts human em-66. Kadoch IJ. [Natural cycle IVF (nIVF) in women with implantation failure]. J Gy- bryo developmental capacity. Hum Reprod 2002;17:999–1005. necol Obstet Biol Reprod (Paris) 2004;33:S33–5. 84. Seli E, Sakkas D, Scott R, Kwok SC, Rosendahl SM, Burns DH. Noninvasive67. Levran D, Mashiach S, Dor J, Levron J, Farhi J. Zygote intrafallopian transfer metabolomic profiling of embryo culture media using Raman and near- may improve pregnancy rate in patients with repeated failure of implanta- infrared spectroscopy correlates with reproductive potential of embryos in tion. Fertil Steril 1998;69:26–30. women undergoing in vitro fertilization. Fertil Steril 2007;88:1350–7.VOL. 97 NO. 5 / MAY 2012 1027

×