ORIGINAL RESEARCH PAPER
A SIMPLE CRITERION FOR IMPROVING PREGNANCY RATE IN
INTRACYTOPLASMIC SPERM INJECTION BY ASSESSING THE EARLYCLEAVAGE
Dr. G. Manjula
Ph.D. Assistant professor of Clinical embryology, Dept of Reproductive Medicine and Surgery, Sri Ramachandra Institute of Higher Education and Research (SRIHER), (Deemed to be University). Porur, Chennai-600116, India.
Dr. N.Sanjeeva Reddy*
M.D., DGO, Professor and Head, Dept of Reproductive Medicine and Surgery Sri Ramachandra Institute of Higher Education and Research (SRIHER), (Deemed to be University). Porur, Chennai-600116, India.*Corresponding Author
INTRODUCTION
The success of assisted reproductive technologies (ART) depends mainly on the quality of the embryos and endometrial receptivity. The 1
successful delivery of a healthy baby and reduce the multiple pregnancies are the main goals of embryo selection in assisted reproductive technologies (ART) 2 Despite great improvements of assisted reproduction, IVF live birth rates remains relatively low.
Delayed childbearing and the well-known negative effect of age on reproduction is one explanation. Another explanation is that, we still cannot know how to select the embryo with the highest implantation potential for transfer.3 Identication of highest implantation potential of an embryo is of primary importance in assisted reproduction.4
Evaluation of morphology is presently considered the single most important predictive measure for assessing embryo viability . For 5
selecting the viable embryos many scoring and grading criteria have been developed.6 To improve embryo selection various advanced technologies (metabolomics, proteomics, timelapse algorithm-based selection (TLM), preimplantation genetic testing for aneuploidy
3 ,7
(PGT-A)) have been practiced as tools. These procedures are all more complex and time-consuming and it is very difcult to follow in routine practice. In addition, most of the randomized trials do not support their use. Transfer of more embryos has been the approach to increase pregnancy rates. This also increases the multiple pregnancy with increased medical risks, cost to the patient and society. In 2009, over 400,000 fresh In Vitro Fertilization (IVF) and ICSI cycles were performed in Europe. One out of every ve treated, resulted in a live birth. To achieve this birth rate, in 75% of the cycles more than one embryo were transferred. Twenty percent of the deliveries were multiple pregnancies. In 2012, close to 100,000 fresh IVF/ICSI 8, 9
cycles were performed in the US. The average number of embryos transferred was between 1.9 and 2.9 (dependingon the age of the patient). The implantation rate was 37.5% in the less than 35 yrs age group. In this same age group, a 40.7% live birth rate was achieved but
10, 9
almost 30% of the deliveries were twin deliveries. There are
11, 9
additional maternal and neonatal risks in multiple pregenancies. In order to prevent these unfavourable results brought about by ART, it is necessary to restrict the number of embryos for transfer. However, concerns have been raised that restricting the number of embryos for transfer might jeopardize the success rate of IVF treatment. So in order to reduce multiple pregnancies and achieve a maximal rate of implantation, selection of most viable embryo for transfer has become a high priority in assisted reproduction. One of the main problems in ART today is selection of best embryos for transfer. Therefore, it is important to increase our knowledge on embryo selection.It has been
shown that early-cleaved (EC) zygotes develops in to better quality embryos and gives a higher pregnancy rate compared with those cleaved later in IVF and ICSI cycles (Shoukir et al., 1997; Sakkas et al., 1998; Bos-Mikich et al., 2001; Lundin et al., 2001).12 With this in background, the study was conducted. The aim of this study was to establish a simple criterion for improving the pregnancy rate by assessing the early cleavage in ICSI.
MATERIALS AND METHODS
It was a prospective observational study conducted in the Department of Reproductive Medicine & Surgery, at a tertiary care centre from Oct 2010-Dec 2013. A total of 294 patients who underwent ICSI were included in the study in the age group of 21-45 years.
Inclusion criteria: All patients enrolled for ICSI during this study period were included in the study. The patient had only early cleavage embryos and the patient had only late cleavage embryos for transfer were included in the study.
Exclusion criteria: Patient had both early and late cleavage embryos for transfer was excluded from the study. Informed consent was taken before the enrolment of each participant and the Institutional ethical committee of Sri Ramachandra Institute of Higher Education and Research (SRIHER) approval was obtained (IEC/10/JULY/83/29).
Ovarian stimulation and ICSI procedure
Ovulation induction was performed using a long Gonadotrophin- Releasing Hormone (GnRH) analogue suppression protocol or a GnRH antagonist protocol using human menopausal gonadotrophins or recombinant Follicle-Stimulating Hormone (FSH).
Ovulation and nal maturation of the oocyte were induced with human chorionic gonadotrophin (hCG) when the leading follicle reached 18 mm in average diameter. Oocytes were aspirated 34-36 hours after hCG administration. Oocyte retrieval was performed by transvaginal ultrasound guided puncture. Removal of the surrounding cumulus cells was accomplished by a combined enzymatic and mechanical treatment carried out under a stereoscopic dissecting microscope.
Oocytes were denudated from cumulus oophorus by exposure to 80 IU/ml hyaluronidase enzyme in HEPES-buffered medium followed by mechanical removal of the corona radiate with the use of plastic pipette stripper tips. Motile sperms were isolated by a swim-up or gradient centrifugation. Ejaculated, testicular biopsy, cryopreserved ejaculated and cryopreserved testicular biopsy semen specimens were all
INTERNATIONAL JOURNAL OF SCIENTIFIC RESEARCH
Clinical Research
Volume-9 | Issue-2 | February-2020 | PRINT ISSN No. 2277 - 8179 | DOI : 10.36106/ijsr
ABSTRACT
Aim and Objective: The aim of this study was to establish a simple criterion for improving the pregnancy rate by assessing the early cleavage in Intra Cytoplasmic Sperm Injection (ICSI). Materials and Methods: A total of 294 patients enrolled for ICSI fullling the selection criteria were recruited for the study at a tertiary care assisted reproductive centre. ICSI was performed 2-3 h after oocyte aspiration with the prepared sperm. All embryos were checked for early cleavage at 27 hours post ICSI. They were divided into two groups. Group I embryos which cleaved before 27 hours after ICSI. Group II- embryos which cleaved after 27 hours. The pregnancy rates were compared between the two groups. Results: All the 294 patients were analysed. There was no difference in the mean age, duration of ovarian stimulation, number of oocytes retrieved, fertilization, cleavage rates and embryo quality between the two groups. Early cleavage was observed in 165 patients (56.12 %). Late cleavage was observed in 129 patients (43.88%). The pregnancy was conrmed in 129 patients out of 165 (78.20 %) in Group I and 50 patients out of 129 (38.80%) in Group II which was statistically signicant P <0.005. Conclusion: Simple selection criteria using the early cleavage embryo may improve the pregnancy rate in ICSI.
KEYWORDS
Early cleavage, embryo quality, intracytoplasmic sperm injection, ovarian stimulation, pregnancy rate.
60 International Journal of Scientific Research
included in the study. For the ICSI procedure, 1-2 μL washed spermatozoa was placed in 10% polyvinylpyr-rolidone (PVP; sage) .After denudation, a single sperm is injected into the cytoplasm of the oocyte.
Assessment of fertilization, embryo cleavage and embryo Transfer Fertilization assessments were performed 17±1 hour post injection.
Normally, fertilized oocytes should be spherical and have two polar bodies and two PNs. PNs should be juxtaposed, approximately the same size, centrally positioned in the cytoplasm with two distinctly clear, visible membranes. On the same day, early cleavage examination was performed on the zygotes at 27 hours after Intra Cytoplasmic Sperm Injection (ICSI). Embryos displaying two cells at inspection were designated as 'early cleavage'. The embryos that had not yet cleaved to the 2-cell stage after 27 hours were designated as 'late cleavage'. Embryo quality was evaluated under an inverted microscope. Two or three embryos were transferred on Day 2 or day 3 depending on the patient's age and embryo quality. The embryos that were not transferred were cryopreserved. The luteal phase was supported by vaginal supplementation of progesterone or intramuscular injection of progesterone. Pregnancy was determined by a serum β human Chorionic Gonodotropin (β h CG) test 14 days post transfer. The clinical pregnancy was conrmed by the presence of an intrauterine gestational sac with fetal cardiac activity by ultrasound examination at 4 weeks after embryo transfer. Patients were divided into two groups. Group I- Embryos which cleaved to two cells before 27 hours after injection. Group II- Embryos which cleaved to two cells after 27 hours. The pregnancy rates were compared between the two groups.
Statistical analysis: The collected data were analysed with SPSS 16.0 version. To describe about the data descriptive statistics frequency analysis, percentage analysis, means and standard deviation were used. For the numerical data nonparametric Mann–Whitney U test was used to nd the signicance. To nd the signicance in categorical data Chi - Square test was used. In all the statistical tools, the probability value of p<0.05 was considered as signicant level.
RESULTS
A total of 294 patients were analyzed. The baseline characteristics were shown in (table1). Early cleavage was observed in 165 patients (56.12%) and late cleavage was observed in 129 patients (43.88%).
Table 1: Comparison Of Baseline Characteristics
*p<0.05 is signicant #p>0.05 is not signicant
This table shows the base line characteristics and the type of cleavage among the study subjects. There was no signicant difference in age (p=0.116), duration of infertility (p=0.222), type of infertility (p=0.934) in both the groups. The study population was divided in to two groups based on age as ≤35 yrs and >35yrs. We observed statistically signicant difference in the age distribution among these two groups, (p<0.002) with early cleavage rate of 60.68% in patients
≤35 yrs and 38.33% in patients >35yrs (table1).
Table 2: Comparison Of Outcome Of Controlled Ovarian Stimulation
*p<0.05 is signicant #p>0.05 is not signicant
The number of MII oocytes, good quality oocytes, oocytes fertilised and good quality embryos were signicantly more with early cleavage group followed by late cleavage group (p<0.05) (table 2).
Table 3: Comparison Of Good Quality Embryos Between The Groups
*p<0.05 is signicant #p>0.05 is not signicant
So good quality oocytes signicantly inuence the cleavage of embryos with more early cleavage embryos. 76.73% of good quality embryos in early cleavage group and 23.27% in late cleavage group which was statistically signicant (P<0.0001) (table3).
The hypothesis that transfer of embryos formed from EC zygotes may yield a higher pregnancy rate than transfer of embryos from LC zygotes was tested. In our study the transfer of early cleavage embryos resulted in a signicantly higher pregnancy rate than those with late cleavage embryos. (78.20%) vs. (38.80%) (p<0.005) (g1).
Figure 1: Comparison Of Outcome Of Treatment DISCUSSION
Despite many parameters may inuence the outcome of ICSI, embryo selection is one of the most important factors that affect the outcome.
Many parameters have been used to make this decision, including pronuclear morphology, blastomere morphology, blastocyst grading and choosing most viable embryos to increase implantation, pregnancy, and live birth rates is of great signicance. The use of early cleaved embryos to select the best embryos was rst reported by Edwards et al. In our study the mean number of oocytes injected in EC 6
group were 13.14±6. and the mean number of oocytes fertilized were 10.72±5.5. But the mean number of oocytes injected in LC group were 7.84±5.5. and the mean number of oocytes fertilized were 5.78±4.3.
But in Haydar Nadir Çiray et al study in which the mean oocytes 4
injected were 11.8±6.9 and mean fertilized oocytes were 8.6±5.7. In our study the fertilization was achieved in 80% of the oocytes injected.
But in the Jing fu et al study the fertilization rate was slightly lower (67.7%) Our results showed signicantly higher fertilization rates, 13
seems to reect a good quality oocyte. In our study, we found early cleavage in 56.12% in ICSI. Similar ndings were studied by Eddesy
14
et al., with 46.20% Haydar Nadir Çiray et al, with 42.5% early cleavage in ICSI But in Isiklar et al study they found slightly lower 4
percentage of early cleavage in ICSI (25.6%) ICSI procedure is ideal 15
for this type of observation because it requires removal of cumulus–corona cells prior insemination. Nuclear maturity, cytoplasmic features and the time of sperm entry are thus precisely known. However, most of the studies examined transfers, in which 16
two or more embryos were transferred, of them at least one embryo had shown early cleavage. This makes it difcult to conclude to which embryo the pregnancy can be attributed. In our study two or three 14
embryos were transferred either all EC or LC embryos, which makes it possible to determine the relationship between early cleavage and pregnancy arising from one specic embryo category. In our study majority (69.37 %) were grade I embryos. Of this EC group yielded about 76.73% and LC group yielded 23.27% of good quality embryos which was statistically signicant (p<0.0001). This also correlates
Volume-9 | Issue-2 | February-2020 PRINT ISSN No. 2277 - 8179 | DOI : 10.36106/ijsr
Parameters Group I
N=165 (%)
Group II N=129
(%)
p value Age Age distribution(Yrs)
(Mean±SD)
30.7±4.8 31.9±5.2 #0.116 Age <35 Years-N=234 142(60.68) 92(39.32) *0.002 Age >35 Years –N=60 23(38.33) 37(61.67) Duration of infertility(Yrs)
(Mean±SD)
7.0±3.9 7.7±4.7 #0.222 Type of
infertility
Primary infertility- N=257
144(56.03) 113(43.97) #0.934 Secondary infertility-
N=37
21 (56.76) 16 (43.24)
Parameters Group I
N=165
Group II N=129
p value Oocytes injected(Mean±SD) 13.14±6. 7.84±5.5 *0.005 Oocytes fertilized(Mean±SD) 10.72±5.5 5.78±4.3 *0.005
Parameters Group I
N=165 (%)
Group II N=129 (%)
p value Good quality
embryo(1762)
1352(76.73%) 410(23.27%) *0.0001 Fertilization rate (%) 80.66% 72.33%c *0.001 Embryo
grading
Grade I(Mean±SD) 8.19±4.9 3.18±3.01 *0.005 Grade II(Mean±SD) 2.52±3.2 2.19±2.4 #0.641 Grade III(Mean±SD) 0.09±.6 0.50±1.3 *0.005
International Journal of Scientific Research 61
with the study conducted by Jing Fu et al where they found that 52.5%
had excellent quality embryos in EC group and 28.9% in the LC group (p<0.01). It can be the reason that the early cleaving embryos stem 13
from oocytes in which cytoplasmic and nuclear maturation are better synchronized . In the study by Fancsovits et al, where they reported 17
that the number of top quality embryos, regarding the number of cells and the morphology score, was signicantly higher in the EC group
18
(35.9%) than in the LC group of embryos (19.7%) It has been
19, 14,20,12,21
demonstrated that EC embryos have better morphology. The early cleaving embryos give rise to better embryo quality due to intrinsic, unknown factor within the oocyte. This unknown factor
15, 22, 23
improves the viability of embryos. In the study by Nagy et al.
(1994), cleavage to the two-cell stage was initially observed 20 h after ICSI, whereby 10 out of the 93 normally fertilized oocytes (11%) had cleaved to the two-cell stage. But in our study, fertilized oocytes were examined at 27 h after ICSI and at this stage (56.12%) had cleaved to
22
the two-cell stage. One of the possible important mechanisms of delaying cleavage may be delayed fertilization. Oocyte immaturity is the most important factor responsible for delayed fertilization. Since only metaphase II oocytes were injected in ICSI procedure, the possibility of oocyte immaturity was eliminated in the present study.
Although there may a difference in fertilization time between In vitro fertilization (IVF) and ICSI there seems to be no correlation between the time of fertilization and cleavage. In the previous study also found that the early cleavage of embryos to the two-cell stage is not entirely inuenced by the timing of fertilization, and is therefore more likely due to intrinsic factors within the oocyte or embryo that promote embryo cleavage after fertilization. Semen parameters may also affect
15, 22
fertilization and cleavage time. In our present study, we observed that a signicantly higher number of early cleaving embryos became good quality embryos (table 3) and indicating an indirect way of selecting the best quality viable embryos. Several other studies have also strongly supported this approach and showed the value of early
24,23,17
cleavage as a marker of embryo viability. We did not transfer mixed early cleavage embryos and late cleavage embryos together in order to evaluate the outcome of early cleavage clearly. Our study revealed that transfer of EC led to signicantly higher pregnancy rates as compared to LC, 78.2% versus 38.8%; (p<0.05). This was similar to studies by Tesarik et al., Salumets et al., Fancsovits et al., Hammoud et
25,24,18,26,27
al., Brezinova et al. The possibility that EC embryos might be a highly signicant biological indicator of embryo growth potential, may predict IVF outcome was rst proposed by., Sakkas et al and
22,23
Shoukir et al.
CONCLUSION
In conclusion, the assessment of early cleavage seems to be simple, easy, non invasive, effective and valuable criteria of assessing the embryo viability and using the early cleavage embryo may improve the pregnancy rate in ICSI.
ACKNOWLEDGEMENTS
Sincere thanks to the Faculty and staffs of the Dept of Reproductive Medicine & Surgery, Sri Ramachandra Institute of Higher Education and Research(SRIHER) (Deemed to be University), Chennai, India.
Special thanks to Dr. Muthaiah sinvaniah surulimuthu , Kanmani Fertility clinic, Chennai, Dr. P. Venkatachalam, Dept of Human Genetics, Sri Ramachandra Institute of Higher Education and Research(SRIHER) (Deemed to be University).
Conict of interest: None REFERENCES
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2. L.Scott1, A.Finn, T.O'Leary, S.McLellan and J.Hill (2007). Morphologic parameters of early cleavage-stage embryos that correlate with fetal development and deliver prospective and applied data for increased pregnancy rates. Human Reproduction, Vol.22, No.1 pp. 230–240.
3. Peter Kovacs & Harry J. Lieman.(2019).Which embryo selection method should be offered to the patients?. Journal of Assisted Reproduction and Genetics, 36:603–605.
4. Haydar Nadir Çiray, Levent Karagenç, Ulun Ulug, Faruk Bener, and Mustafa Bahçeci.(2006).Early cleavage morphology affects the quality and implantation potential of day 3 embryos. Fertil Steril, 85:358–65.
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12. Ciray HN, Ulug U, Bahceci M.(2004). Transfer of early-cleaved embryos increases implantation rate in patients undergoing ovarian stimulation and ICSI embryo transfer.
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13 Jing Fu, Xian-Jing Wang, Yong-Wei Wang, Jian Sun, Kristina Gemzell- Danielson, Xiao- Xi Sun.(2009).The inuence of early cleavage on embryo developmental potential and IVF/ICSI outcome J Assist Reprod Genet, 26:437–41.
14 Edessy M, Ali AEN, Fata A and Hamed W. (2013). Early cleavage of human embryos is a strong predictor for embryo implantation in ICSI. New Yor Science Journal, 6(12).
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Signicance of morphological attributes of the early embryo. Reproductive BioMedicine Online;Review, Vol 10. No 5. 669–681.
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(2008). How viable are zygotes in which the PN are still intact at 25 hours? Impact on the choice of embryo for transfer. Fertil Steril, 3 (90):551– 656.
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25. Tesarik J, Junca AM, Hazout A, Aubriot FX, Nathan C, Cohen-Bacrie P.(2000).Embryos with high implantation potential after intracytoplasmic sperm injection can be recognized by a simple, noninvasive examination of pronuclear morphology. Hum Reprod, 15: 1396- 1399.
26. Hammoud I, Vialard F, Casasnovas P, Lefebvre G, Vauthier- Brouzes D and Poirot C.
(2008).How viable are zygotes in which the PN are still intact at 25 hours? Impact on the choice of embryo for transfer. Fertil Steril, 3 (90):551– 656.
27. Brezinova J, Oborna I, Svobodova M and Fingerova H.(2009). Evaluation of day one embryo quality and IVF outcome - a comparison of two scoring systems.
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62 International Journal of Scientific Research
International Journal of Innovative Research in Medical Science (IJIRMS) Volume 05, Issue 04, April 2020,
https://doi.org/10.23958/ijirms/vol05-i04/863
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Original article
Effect of Oral Contraceptive Pill Pretreatment on Pregnancy Rates in Patients Stimulated with GnRH Antagonists and rFSH for ICSI
Dr. Soni Ashish Kumar 1, Dr. Reddy Sanjeeva N 2
1
Assistant Professor Reproductive Medicine and Surgery Sriramachandra Institute of Higher Education & Research Chennai
2
HOD Reproductive Medicine and Surgery Sriramachandra Institute of Higher Education & Research Chennai Corresponding author: Dr. Ashish Kumar Soni (MCh); E2 SMART Sriramachandra Medical Centre Porur Chennai (600116); [email protected]
Received 10 March 2020; Accepted 29 March 2020; Published 05 April 2020
Abstract
Background: After the recent introduction of GnRH antagonists in ovarian stimulation, OCP has been used for cycle scheduling purposes. Cycle programming has become more difficult with the use of GnRH antagonists, as stimulation initiation is dependent on the occurrence of menstruation. To overcome this limitation in the GnRH antagonist protocol, patients can be offered the use of pretreatment with oral contraceptive pills (OCP). Objective: To evaluate the effect of oral contraceptive pills (OCP) pretreatment on pregnancy rate in GnRH antagonist cycles. Design: Observational cohort study. Setting: Observational study performed at Sri Ramachandra institute of higher education
& research Chennai. Patients: Total 115 patients included in the study from January 2019 to December 2019.
All patients divided into two groups, oral contraceptives pretreated group (n-64) and oral contraceptives non treated group (n-51).
Results: All oral contraceptives pretreated patients required significantly higher dose of gonadotropins (4745±1476 versus 3659±1230;P
<0.0005) and significantly longer days of stimulations (12.2±1.2 versus 10.5±0.8;P <0.0005) in comparison to non-oral contraceptives treated group. There were no difference in total oocytes retrieved and fertilization rate. There were no other differences in cycle characteristics between groups. Implantation and pregnancy rates were not affected by OCP pretreatment. Conclusions: OCP pretreatment use for synchronization of follicles and cycle scheduling in GnRH-antagonist protocol, though it may be associated with longer stimulation and higher gonadotropin consumption but similar pregnancy rates.
Keyword: IVF, OCP, GnRH, Antagonist
Introduction
Gonadotropin-releasing hormone (GnRH) antagonist protocols are characterized by shorter stimulation period and use of lower quantities of gonadotropins as compared with the long GnRH- agonist protocol [1,3]. However, in a long GnRH-agonist protocol there is flexibility in the starting day of gonadotropin stimulation, which is lacking in the GnRH-antagonist protocol. To overcome this limitation in the GnRH antagonist protocol, patients can be offered the use of pretreatment with oral contraceptive pills (OCP)
[4,7]
. Moreover, a previous study has shown that OCP pretreatment before GnRH antagonist led to higher numbers of oocytes retrieved compared to the standard GnRH antagonist protocol [11]. On the other hand, longer stimulation periods and increased consumption of recombinant FSH (rFSH) were needed for stimulation [10,11]. The effect of this intervention on the probability of pregnancy has so far been examined only in a small randomized controlled trial (RCT).
The objective of the present study was to assess the effect of OCP pretreatment on pregnancy rates in patients stimulated with recombinant FSH (rFSH) and GnRH antagonist for IVF.
Materials and methods
Patients
Between Jan 2019 and Dec 2019, a GnRH-antagonist protocol was used in 115 patients . In 64 of these cycles, OCP pretreatment was administered for cycle scheduling. The use of pretreatment with OCP was for synchronisation of follicles before COH.
Ovarian stimulation protocols
OCP pretreatment was administered for 21 days, starting on cycle days 2–3. At the end of the OCP period prior to gonadotropin stimulation, vaginal ultrasound was performed to establish ovarian and uterine quiescence. Five days after OCP discontinuation, ovarian stimulation was commenced using rFSH at a starting dose
International Journal of Innovative Research in Medical Science (IJIRMS)
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of 225 to 300 IU/day depending on age, AFC, AMH and D2 FSH
& E2. The dose was adjusted after 5 days according to the patient’s individual E2 response and follicular development. In the non-OCP protocol, gonadotropin stimulation was started on day 2 or 3 of the menstrual cycle, with a similar policy for the starting dose as in the OCP protocol. In both protocols, GnRH-antagonist was started when the leading follicle reached ≥14 mm in diameter, and was continued until the day of human chorionic gonadotropin (hCG) administration. Ovulation was triggered with 250 mcg of rHCG when at least three follicles measuring 17 mm were detected by ultrasound scan. Oocyte collection, ICSI and luteal phase support were performed in the same manner in both protocols, in accordance with our hospital and laboratory standard of care and practice. Embryo transfer was deferred in patients who had an elevated progesterone on the day of hCG trigger (>1.5ng/ml), or who had risk of OHSS or women who had an agonist trigger for final oocyte maturation or who had thin endometrium. Embryo transfer was done in the rest of patients who had no risk for embryo transfer failure. Upto 3 embryos were transferred on the second day or third day after oocyte retrieval. Serum β hCG was measured on the 14th day of embryo transfer. Serum β hCG values more than 25mIU/ml was considered as positive test for pregnancy.
Transvaginal sonography was done after 2 weeks of serum beta
HCG estimation to confirm site of pregnancy, number of sacs and cardiac activity.
Statistical analysis
The collected data were analysed with SPP statistics software 23.0 version. To describe about the data descriptive statistics frequency analysis, percentage analysis were used for categorical variables and the mean & S.D were used continuous variables. To find significant difference between the bivariate samples in independent groups the unpaired t-test was used. To find the significance in categorical data Chi-Square test and Fishers exact test was used. In all above statistical tools the probability value 0.05 is considered as significant level.
Results
There were no differences within each age group between the pretreated OCP and non-OCP treated patients in demographic and baseline clinical parameters (Table 1&2). The IVF cycle characteristics and laboratory data are presented in Table 3. The stimulation for the patients taking the oral contraceptive was on average of longer duration than for the Non-OCP group and pregnancy rates similar in both groups.
Table 1: Demographic characteristics between the groups
DEMOGRAPHIC CHARACTERISTICS NON OCP GROUP (N=51) OCP GROUP B (N=64) P value
Age (years) 29.49±3.5 29.94±3.1 0.47
Duration of infertility (years) 7.8±4.4 7.1±3.8 0.66
BMI (kg/m2) 26.55±5.3 26.1±4.4 0.40
Table 2: Ovarian reserve between the groups
OVARIAN RESERVE NON OCP GROUP (N=51) OCP GROUP (N=64) P value
D2 FSH (mIU/ml) 6.6±2.2 6.6±2.2 0.95
D2 LH (mIU/ml) 4.9±2.9 4.5±2.0 0.34
D2 E2 (pg/ml) 48.07±17.5 48.7±23.7 0.94
AFC (n) 12.6±2.5 12.6±3.4 0.95
AMH (ng/ml) 2.3±0.9 2.4±1.01 0.49
Table 3: IVF cycle characteristics in OCP and non-OCP cycles
PARAMETERS NON OCP GROUP (N=51) OCP GROUP (N=64) P value
Duration of stimulation (Days 10.51±0.88 12.2±1.26 0.00
Total dose of Gn (IU) 3659.80±1230.8 4745.63±1476.01 0.000
ET (mm) 10.04±1.8 9.6±1.7 0.21
E2 – Trigger day (pg/ml) 3732.55±1745.99 2988.4±1434.13 0.014
P4 on the day of trigger (ng/ml) 1.13±0.5 1.0±0.2 0.14
NO.Oocytes 16.02±7.1 15.38±6.3 0.59
Fertilization rate(%) 68% 71% 0.72
Implantation rate(%) 41% 43% 0.81
Pregnancy rate(%) 29% 33% 0.64
There was no evidence of an ‘OCP effect’ on the number of oocytes retrieved, nor on the Fertilization, Implantation and Pregnancy rates.
Discussion
In this study we evaluated the effect of OCP pretreatment prior to GnRH-antagonist protocol for cycle scheduling in IVF treatment.
We found that OCP pretreatment was associated with a longer length of stimulation and an increase in the total dose of gonadotropins needed for stimulation. The OCP pretreatment did not affect the magnitude of the ovarian response in terms of the number of oocytes retrieved. The implantation and pregnancy rates were not affected by OCP pretreatment. Endometrial thickness was not affected by OCP.
There is limited body of data in the literature on the use OCP pretreatment prior to GnRH antagonist protocol including three prospective randomized studies [10,11]. However, these studie include relatively small numbers of patients and cycles. Overall, our findings on the effect of OCP pretreatment prior to GnRH antagonist protocol on cycle characteristics, magnitude of ovarian response and pregnancy outcome are in accordance with these studies [10,11]. In all studies including this study, longer stimulation period and higher total dose of gonadotropins were needed in the OCP pretreatment cycles [8–10]. Similar to our results, in two studies
[9,10]
, OCP pretreatment had no effect on the final number of mature follicles whereas in one study [11] the OCP pretreatment resulted in
International Journal of Innovative Research in Medical Science (IJIRMS)
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an increase in the number of mature follicles and in the number of oocytes retrieved. Finally, in our study as in previous studies, the implantation and pregnancy rates were not affected by the use of OCP pretreatment [9,10].
Conclusion
OCP pretreatment for cycle scheduling in GnRH-antagonist protocol is a valid modality with comparable IVF outcome to the non-OCP protocol. The longer stimulation and higher total dose of FSH are the only drawbacks that we found in this modification.
The weight of these drawbacks has to be measured against the gain in enabling cycle scheduling.
References
[1] Al-Inany H, Aboulghar M. GnRH antagonist in assisted reproduction: a Cochrane review. Hum Reprod 2002;17:874–85
[2] Hohmann FP, Macklon NS, Fauser BC. A randomized comparison of two ovarian stimulation protocols with gonadotropin-releasing hormone (GnRH) antagonist cotreatment for in vitro fertilization commencing recombinant follicle-stimulating hormone on cycle day 2 or 5 with the standard long GnRH agonist protocol. J Clin Endocinol Metab 2003;88:166–73
[3] Albano C, Felberbaum RE, Smitz J, Riethuller-Winzen H, Engel J, Diedrich K, et al. Ovarian stimulation with HMG: results of a prospective randomized phase III European study comparing the luteinizing hormone- releasing hormone (LHRH)-antagonist cetrorelix and the LHRH-agonist buserelin. European Cetrorelix Study Group. Hum Reprod 2000;15:526–31.
[4] Obruca A, Fischl F, Huber JC. Scheduling OPU in GnRH antagonist cycles. J Reprod Fertil 2000;4:37.
[5] Cedrin-Durnerin I, Grange-Dujardin D, Laffy A, Parneix I, Massin N, Galey J, et al. Recombinant human LH supplementation during GnRH antagonist administration in IVF/ICSI cycles: a prospective randomized study.
Hum Reprod 2004;19:1979–84
[6] Barmat LI, Chantilis SJ, Hurst BS, Dickey RP. A randomized prospective trial comparing gonadotropin- releasing hormone (GnRH) antagonist/recombinant follicle-stimulating hormone (rFSH) versus GnRH- agonist/rFSH in women pretreated with oral contraceptives before in vitro fertilization. Fertil Steril 2005;83:321–30.
[7] Meldrum D, Scott R, Levy MJ, Alper M, Noyes N. A pilot study to assess oral contraceptive (OC) pretreatment in women undergoing controlled ovarian hyperstimulation (COH) in ganirelix acetate cycles. Fertil Steril 2002;78(3 Suppl 1):S176 Abstract P-182.
[8] McCullagh P, Nelder JA. Generalised linear models.
London: Chapman and Hall; 1989.
[9] Rombauts L, Healy D, Norman RJ, on the behalf of the Orgalutran Scheduling Study Group. A comparative randomized trial to assess the impact of oral contraceptive pretreatment on follicular growth and hormone profiles in GnRH antagonist-treated patients.
Hum Reprod 2006;21:95–103.
[10] Kolibianakis EM, Papanikolaou EG, Camus M, Tournaye H, Van Steirteghem AC, Devroey P. Effect of oral contraceptive pill pretreatment on ongoing pregnancy rates in patients stimulated with GnRH antagonists and recombinant FSH for IVF. A randomized controlled trial. Hum Reprod 2006;21:352
[11] Huirne JA, Van Loenen ACD, Donnez J, Pirard C, Homburg R, Schats R, et al. Effect of an oral contraceptive pill on follicular development in IVF/ICSI patients receiving a GnRH antagonist: a randomized study. Reprod Biomed Online 2006b;13(2):235–45
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Effects of Laser Assisted Hatching on Pregnancy Outcomes of Frozen Embryo Transfer Cycles
1
Dr.Narmadha.R Lecturer in clinical Embryology ,
Department of Reproductive Medicine and Surgery, Sri Ramachandra Institute of Higher Education And
Research, Chennai- India
3
Dr.Manjula
Assistant Professor in clinical Embryology , Department of Reproductive Medicine and Surgery, Sri Ramachandra Institute of Higher Education And
Research, Chennai- India
2
Dr.N.Sanjeeva Reddy Professor and Head ,
Department of Reproductive Medicine and Surgery, Sri Ramachandra Institute of Higher Education And
Research, Chennai- India
4
Dr.Sindhuja.N.S Lecturer in clinical Embryology,
Department of Reproductive Medicine and Surgery, Sri Ramachandra Institute of Higher Education And
Research, Chennai- India
Abstract Back Ground:
The implantation of the embryo into the uterus requires hatching from its zona pellucida (ZP). The inability of the embryo to break its zona pellucida is considered as a factor for implantation failure. Assisted hatching (AH) is performed to make it easier for natural hatching to occur, also providing early embryo- endometrium contact, which favors the embryos implantation into the uterus.
Aim
To evaluate the effect of laser assisted hatching (LAH) on pregnancy rate in frozen embryo transfer cycle.
Materials & methods:
In a prospective observational study a total of 80 patients who underwent frozen embryo transfer(FET) cycles were included in the study. Patients were divided into Laser assisted hatching group (LAH) and no LAH group. In the LAH group, zona thinning was done with the help of laser just prior to the embryo transfer. In the control group no hatching was done before transfer.
The main outcome measures were pregnancy rate &
implantation rate.
Results:
The baseline characteristics of the 80 patients included in the study ie.,LAH group (n=40) vs no LAH group (n=40),the mean age ( 30.855.4 vs 333.9),mean BMI (25.64.1 vs 27.94.5),duration of infertility ( 6.184.1 vs 8.534.7) , number of embryos transferred (2.750.8 vs 2.70.72) respectively. Younger women <
30 years in no LAH group had higher pregnancy rate compared to the LAH group. Between the two groups, patients between 31-35 years in LAH group had higher pregnancy rate compared to no LAH group. The pregnancy rate (42.85% vs 54.5%) in LAH group of women >35years found lower than the no LAH group.
Conclusion:
LAH seems to be beneficial in women between 31- 35 years of age group, but LAH does not seem to be beneficial in women > 35 years of age. There is slight increase in pregnancy rates with laser assisted zona thinning in frozen transfer cycle, but it is not statistically significant.
Keywords:- Frozen Embryo Transfer, Zonapellucida, Laser Assisted Hatching.
I. INTRODUCTION
Hatching of the blastocyst is a critical step before implantation into the endometrium of the uterus. Failure to hatch is thought to be one of the factors limiting further embryo development
1,2. One of the main objectives of Assisted Reproductive Technologies (ART) is improving the embryo implantation rate.
3A glycoprotein layer, known as the zona pellucida (ZP), surrounds human embryos and permits only acrosome intact sperm to fertilize the oocyte by blocking the entry of multiple sperm. After fertilization the ZP compresses and shapes the embryo, protecting it from microorganisms and immune cells. At the blastocyst stage, the embryo breaks out of ZP to begin the developmental process; failure at this stage can prevent implantation
4.
A possible explanation for the low implantation rates is due to observed abnormalities in the hatching in some patients, in advanced maternal age and in frozen–thawed embryo transfer cycles
5.
Artificially disrupting the ZP known as assisted
hatching (AH) has been proposed as a method to help
improve embryo implantation rates in a selected group of
patients. A possible benefit of assisted hatching is that it
may facilitate an earlier contact between the embryo and
the endometrium, allowing for more exposure to important
modulators of growth
6.
Volume 5, Issue 9, September – 2020 International Journal of Innovative Science and Research Technology ISSN No:-2456-2165
IJISRT20SEP791 www.ijisrt.com 1224 Assisted Hatching using a 1.48-μm diode laser yields
a better outcome than AH using mechanical or chemical methods
7. Hiraoka et al have shown that vitrification can increase the hardness of zona, and the embryo implantation and clinical pregnancy rates in the half ZP thinning FET cycle was superior to that of a quarter ZP
8.
At present, there are clear benefits of LAH in the subset of Invitro fertilization (IVF) patient population with sub optimal prognosis including advanced reproductive age, repeated implantation failure, poor embryo quality and frozen/thawed embryo transfer cycles.
When compared with those with an intact zona pellucida human embryos that underwent laser-assisted hatching and transferred have increased implantation rates
9.
Our clinical study focused on the effect of laser zona thinning (laser-assisted hatching; LAH)
on the pregnancy outcomes of frozen–thawed ICSI-ET cycles.II. METHODOLOGY
The present study is a prospective observational study was conducted in the Department of Reproductive Medicine and Surgery ,Sri Ramachandra Medical college and Research Institute, porur, Chennai. A total of 80 patients who underwent frozen embryo transfer cycle were included in the study. Patients having ≤ 3 embryos on day 2 of embryo culture and patients planned for day 2 embryo transfer were excluded from the study.
Patients who underwent frozen transfer were selected in an alternating manner into laser assisted hatching group (LAH study group) and no LAH group (control group). In the LAH group (N= 40), zona thinning was done with the help of laser just prior to the embryo transfer. In the control group (N=40) no hatching was done before transfer.
Institutional Ethical Committee (IEC) approval was obtained to perform the study. Written and informed consent was obtained from the patients participating in the study in the prescribed format approved by IEC.
All Women enrolled in the study underwent controlled ovarian stimulation with antagonist protocol .Semen analysis was performed according to the World Health Organisation criteria (WHO, 2010). Oocyte retrieval was done at 36 hrs after hCG administration under transvaginal ultrasound guidance. Retrieved oocytes with cumulus cells are incubated for 2 hours. Later Oocytes were denuded and their maturity status was assessed . The spermatozoa used for intracytoplasmic sperm injection (ICSI) procedure was prepared by the double density gradient method. Matured oocytes were injected by the prepared sperms. On day 3 of the embryo culture the quality of all embryos were evaluated and graded according to the Istanbul consensus 2011
10.Blastocysts were examined and scored according to Gardner et al.2000
11.All grade 1 embryos were taken as good quality, grade 2 were taken as fair quality, only grade 3 embryos were taken as poor quality. Embryos were frozen and transfer was planned at a later date.
A. Laser Assisted Hatching
Laser assisted hatching was performed before Embryo transfer. Day 3 / Day 4/ Day 5 embryos underwent LAH by means of half zona thinning with a non-contact 670nm, 1.48 micrometer infra red diode laser system (Saturn Active 5). Before LAH quality of embryos were evaluated and graded (according to the Istanbul consensus 2011)
10.Embryos were placed in a culture media droplet over laid with mineral oil in a four well dish above a warm plate and positioned on the inverted microscope stage ,focused with 40x objective with the laser target located on the outer edge of the Zona Pellucida. Thickness of the ZP was measured before LAH. At least 10 , at most 20 shoots for 0.300 - 0.700 ms with the size of 10.4μm – 12.0μm was performed to the proper region of ZP where blastomeres are not adjacent to the inner membrane of embryos.The thickness of zona pellucida was measured after LAH.
B. Vitrification Protocol
Embryos were frozen on day 3/ day 4 after ICSI by vitrification. Only good quality day 3 embryos were frozen.
Good quality embryos were defined as (According to Istanbul consensus 2011). Those having regular blastomeres, <10% fragments and no multinucleated blastomeres, containing at least eight cells on day 3/ day4.
15-20l drops of vial 1(Equilibration solution) and Vial 2 (Vitrification solution) were dispensed into the lid of a 60mm dish. Allowing the dish to equilibrate at room temperature (25°C/37°C) ensuring that it achieves room temperature (approximately 10 minutes). Embryos were exposed to Vial 1 solution for 5-8 minutes and four drops of Vial 2 solution for 5 seconds each.( Sure life Vitrification medium).The embryos were placed on the cryolock and plunged into liquid nitrogen(-196
;C).
C. Warming Protocol
Embryo warming was performed. About 0.2 ml of vial 1 (1.0 M Sucrose), vial 2 (0.5 M Sucrose), vial 3 (0.25 M Sucrose) and vial 4 (MOPS )were added on the lid of a 60mm dish respectively. Allowing the dish to equilibrate at room temperature (25°C/37°C) ensuring that it achieves room temperature (approximately 5-10 minutes) Embryos were transferred into solution 1 and left for 3 minutes, solution 2 for 3 minutes and Solution 3 for 3 minutes and transferred them into solution 4 and left for 5 minutes. At the end of 5 minutes embryos were transferred into equilibrated Cleavage medium. Cryopreserved embryos were considered to be survived if >50% of the blastomere are intact.
D. Embryo Transfer
All the embryos to be transferred to a patient,
underwent laser assisted hatching. Embryos were
transferred within 20 minutes after hatching. Embryo
transfer was performed under trans abdominal ultrasound
guidance.
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E. Statistical AnalysisThe collected data was analysed with IBM.SPSS statistics software 16.0 Version. To describe about the data descriptive statistics frequency analysis, percentage analysis was used for categorical variables and for continuous variables the mean and S.D was used. To find the significance difference between the bivariate samples in Independent groups the unpaired sample t-test and analysis of variance test (ANOVA) were used. In all the above statistical tools the probability value .05 was considered as significant level.
III. OBSERVATIONANDRESULTS
A total of 80 patients who underwent frozen embryo transfer were included in the study, out of which 40 patients grouped under study group (LAH group), 40 patients grouped under control group (No LAH group) respectively.
The mean age was significantly different between the two groups and mean body mass index, duration of infertility, number of embryos transferred and survival rate were comparable between both the groups .Ovarian reserve markers such as follicle stimulating hormone(FSH), luteinizing hormone(LH), Estradiol(E2) were comparable between both the groups (Table 1) .
The mean zona pellucida (ZP) thickness before laser assisted thinning was 21.33 4.8 and the mean thickness after thinning was 10.9 3.6. Majority of the embryos had ZP thickness of >20 m before LAH and 11-20 m after LAH in study group.
(Table 2) shows the pregnancy rate when subgroups of ≤ 30 years , 31-35 years and > 35-years were compared.
Pregnancy rate is higher in study group in 31 – 35 years when compared with control group, but did not influence pregnancy rate statistically even though it was clinically significant (p= 0.534).
The statistical analyses, however, show only a trend but the results were not significantly different when we compared the pregnancy rates (42.5% vs 52.5%) , implantation rate (18.1% vs 28.7%) and clinical pregnancy rate (30% vs 45%) of the study (LAH group) and control group (LAH group) (Table 3).
Confounding factors like age, day of transfer ,quality of embryos which can influence pregnancy rate were analysed using logistic regression and was not statistically significant.
CHARACTERISTICS LAH (n=40 ) NO LAH (n=40) P value
Mean age 30.8 5.4 33.0 3.9 0.048
Mean BMI 25.6 4.1 27.9 4.5 0.48
Duration of infertility 6.18 4.1 8.53 4.9 -
FSH 6.9 2.31 10.87 18.8 0.190
LH 5.55 3.47 6.41 7.9 0.529
E2 56.8 38.2 49.8 21.6 0.319
No. of Embryos transferred 2.75 0.89 2.7 0.723 0.785
Survival rate 85.9% 91% 0.666
Table 1:- Patient’s Baseline Clinical Characteristics In The Laser And No Laser Group.
AGE LAH (n= 40) NO LAH (n= 40) P value
30 years
5/17 (29.4%) 6/11 (54.5%) 0.534
31-35 years 9/16 (56.2%) 9/18 (50%)
>35 years 3/7 (42.8%) 6/11 (54.5%)
Table 2: Pregnancy Rate Related To Age In The Laser And No Laser Group.
RESULTS LAH (n= 40) NO LAH (n= 40) P value
Pregnancy rate 17/40 (42.5%) 21/40 (52.5%) 0.377
Implantation rate 20/110 (18.1%) 31/108 (28.7%) 0.073
Clinical pregnancy rate 12 (30%) 18 (45%) 0.124
Biochemical 3 (7.55%) 1 (2.5%) 0.311
Miscarriage rate 2 (11.7%) 2 (9.5%) 1.0
Table 3: Pregnancy Outcomes in the Laser and No Laser Groups
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IV. DISCUSSIONImplantation rate of embryos remains relatively low despite the development in IVF and ICSI and has been indicated that only 15% of embryos were successfully transplanted into the uterine cavity in the 1990s
12.Selective application of LAH in ART may enhance hatching ability of the embryo. In the process of embryonic development embryo hatching ability plays an important role, the ZP exhibits good elasticity to become thin with the expansion of the blastocyst that ensures the success of a hatched embryo Thus , a potential mechanism to improve embryo implantation ability may be technological assurance of embryos at an earlier stage of hatching and early contact with the endometrium. The nutrient exchange between the liquid culture and embryos, may produce embryonic development and blastocyst formation which may be accelerated by zona thinning.
13,14Age of the female partner plays an important role in infertility which influences the ART procedures outcome.
The chance of conception significantly declines over the age of 35 years in women. In our study majority of the patients were in the age group of <30 years and was statistically significant this is because of early marriage among Indian women and seek infertility treatment earlier.
This can also be due to male factor infertility being the commonest cause . Hence there was early intervention in female partner.
Variation in day of freezing/thawing and the method of cryopreservation may influence clinical outcome. In our study we used vitrification method for freezing of embryos, and included all FET cycles with Day 3, Day 4, and Day-5 embryos, and survival rate was 85.9% which is less compared to study done by Cai Yun Wan et al
15. This may be because of variation in the day of freezing/thawing and also quality of the embryos that could affect the outcome.
The mean number of embryos transferred in our study group and no LAH were found to be ( 2.75 0.89 vs 2.75
0.89 ) .Among 40 patients in study and control group 69
embryos in study group, 77 embryos in control group were in cleavage stage , and 41 embryos in study group, 31 embryos in control group were in blastocyst stage respectively.
In our study 75% had ZP thickness >20
mbefore LAH with mean thickness of 21.33
4.8 . After LAH60% had ZP thickness 11-20
mwith mean thickness of 12.11
3.4 respectively. Gabrielsen et al showed assistedhatching may be of benefit for patients having embryos with thick zona pellucida. Thick zona pellucida and/ or decreased variation of the zona pellucida may be associated with advanced female age and poor embryo scores. Also video cinematographic evaluation of zona pellucida thickness variation (ZPTV) correlated strongly with pregnancy
16.
We studied effect of maternal age on pregnancy rate, even though we found more number of pregnancies in 31- 35 age group clinical significance could not be given in our study. Katalin Kanyo
et alin his study found that LAH significantly increased the pregnancy rates (18.36% vs.
11.36%, respectively, P = 0.03) in patients who were over 37 years of age
17. Whereas, Frydman et al found that LAH did not improve the IVF embryo transfer outcome in woman aged >37 years
18.
Valojerdi
et al showed that clinical pregnancy ratewas significantly lower with laser assisted zona thinning on vitrified-warmed cleavage stage embryos although it is widely accepted that it gives beneficial results
19. ,Whereas in our study only a trend of increased pregnancy rate was found.
There was no statistically significant difference in pregnancy rate between the groups. This has to be confirmed with the large sample size as our sample size is small. Comparing implantation rate in study and control group, it did not show any statistical significance even though there was marginal increase in control group this cannot be given importance as sample size is small.
Whereas in the prospective randomized study the implantation rate (34.2% versus 23.6%, P = 0.021) and clinical pregnancy rate (51.0% versus 35.3%, P = 0.034) were significantly higher in the LAH group than the control group
15. This is probably due to larger sample size and the study design.
In our study, we transferred both good and fair quality embryos in cleavage and blastocyst stage whereas in the study by Shaw-Jackson
et al high grade blastocysts weretransferred
20. This was not possible in our study as we had a mixed quality of embryos and this did not influence miscarriage rate.
Eight patients underwent 2 cycles of ET during our study period, they underwent first cycle without LAH and second cycle with LAH .Majority had day 5 transfer and out of which four patients had pregnancy.
There are various confounding factors such as maternal age, day of transfer, quality of embryos which influence pregnancy rate. Logistic regression analysis did not show any significance and did not influence pregnancy rate.
V. CONCLUSION
LAH seems to be beneficial in women between 31-35
years of age group, but LAH does not seem to be beneficial
in women > 35 years of age. Routine use of laser assisted
hatching does not increase pregnancy rate. However, the
decision to perform or not to perform LAH on older women
should be made on the merits of individual case. LAH may
be beneficial in older women with repeated implantation
failures.
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REFERENCES[1]. Cohen, J., Elsner, C., Kort, H., Malter, H., Massey, J., Mayer, M.P.,Wiemer, K., 1990. Impairment of the hatching process following IVF in the human and improvement of implantation by assisting hatching using micromanipulation. Hum. Reprod. 5, 7–13.
[2]. Cohen, J., 1991. Assisted hatching of human embryos.
J. In Vitro Fert.Embryo Transf. 8, 179–190.
[3]. Hammadeh, M.E., Fischer-Hammadeh, C., Ali, K.R., 2011. Assisted hatching in assisted reproduction: a state of the art. J. Assist.Reprod. Genet. 28, 119–128.
[4]. Carroll J, Depypere H, Matthews CD. Freeze-thaw- induced changes of the zona pellucida explains decreased rates of fertilization in frozen-thawed mouse oocytes. J Reprod Fertil.1990;90:547–553.
[5]. Cohen, J. (2007). Manipulating embryo development.
In Human Preimplantation Embryo Selection (eds K.
Elder & J. Cohen). Abingdon UK: Informa Healthcare, Informa UK.
[6]. J. Cohen, M. Alikani, H.E. Malter, A. Adler, B.E.
Talansky, Z. RosenwaksPartial zona dissection or subzonal sperm insemination: microsurgical fertilization alternatives based on evaluation of sperm and embryo morphology FertilSteril, 56 (1991), pp.
696–706
[7]. Martins WP, Rocha IA, Ferriani RA and Nastri CO:
Assisted hatching of human embryos: a systematic review and meta‐analysis of randomized controlled trials. Hum Reprod Update 17: 438-453, 2011.
[8]. Hiraoka K, Hiraoka K, Horiuchi T, Kusuda T, Okano S, Kinutani M and Kinutani K: Impact of the size of zona pellucida thinning area on vitrified-warmed cleavage-stage embryo transfers: a prospective, randomized study. J Assist Reprod Genet 26: 515-521, 2009.
[9]. Wright, G., S. Wiker, C. Elsner, H. Kort, J. Massey, D. Mitchell, A. Toledo, and J. Cohen. 1990.
Observations on the morphology of pronuclei and nucleoli in human zygotes and implications for cryopreservation. Hum.Reprod. 5: 109-115
[10]. Alpha scientists in reproductive medicine and ESHRE special interest group of embryology; The Istanbul consensus workshop on embryo assessment;
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[11]. Classification of blastocyst; Gardner classification [12]. KutluP,Atvar O and Vanioglu OF: Laser assisted zona
thinning technique has no beneficial effect on the ART outcomes of two different maternal age groups.J Assist Reprod Genet 27:457-461,2010.
[13]. Cohen J:Assisted hatching of human embryos.J In vitro fert embryo transfer 8: 179-190, 1991.
[14]. Malter HE and cohen J: Blastocyst formation and hatching in vitro following zona drilling of mouse and human embryos. Gamete Res 24: 67-80,1989.
[15]. Cai-Yun Wan , Cheng Song , Liang-Hui Diao 2014 Laser-assisted hatching improves clinical outcomes of vitrified–warmed blastocysts developed from low- grade cleavage-stage embryos: a prospective randomized study. Reproductive BioMedicine Online (2014) 28, 582–589.
[16]. Gabrielsen, A,Bhatnagar,P., Petersen,K.and Linderberg,S. (2000) Influence of zona pellucida thickness of human embryos on clinical pregnancy outcome following in vitro ferilisation treatment.
J.Assist.Reprod.Genet.,17, 323-328.
[17]. Katalin Kanyo, Jozsef Zeke, Rita Kriston, Zoltan Szücs, Sandor Cseh, Bence Somoskoiand Janos Konc.
2016 The impact of laser-assisted hatching on the outcome of frozen human embryo transfer cycles.
Zygote 24 (October), pp. 742–747.
[18]. Frydman, N., Madoux, S., Hesters, L., Duvernoy, C., Feyereisen, E., Le Du, A., Tachdijian, G., Frydman, R. & Fanchin, R. (2006). A randomized double-blind controlled study on the efficacy of laser zona pellucida thinning on libe birth rates in cases of advanced female age. Hum. Reprod. 21, 2131–5.
[19]. Valojerdi MR, Eftekhari-Yazdi P, Karimian L, Ashtiani SK. Effect of laser zona pellucida opening on clinical outcome of assisted reproduction technology in patients with advanced female age, recurrent implantation failure, or frozen-thawed embryos. Fertil Steril 2008; 90:84 – 91.
[20]. Shaw-Jackson, C., Bertrand, E., Becker, B., Colin, J., Beaudo- in-Chabot, C., Rozenberg, S., Autin, C., 2013. Vitrification of blastocysts derived from fair to poor quality cleavage stage embryos can produce high pregnancy rates after warming. J. Assist. Reprod.
Genet. 30, 1035–1042.
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Introduction
Pregnancy and childbirth are momentous events in the life of every woman, which are surrounded by many positive values ranging from the enhancement of self‑esteem to social approval. The physiological changes of pregnant women during pregnancy are the result of normal adaptations that a woman undergoes to better accommodate the embryo or fetus and ensure that the fetus grows properly and receives adequate nutrition.
[1,2]Psychological changes also depend upon whether the pregnancy was planned or unplanned, wanted or unwanted, becoming pregnant after a long period or after medical intervention such as In Vitro Fertilization (IVF), changes in role, changes in relationships, fear of being a good parent, fear of problems associated with the pregnancy or the baby, fear of childbirth and lack of support, and
Address for correspondence:
Dr. Singaravelu Rajeswari, Department of Obstetrics and Gynaecology Nursing, Faculty of Nursing, Sri Ramachandra Institute of Higher Education and Research, Formerly Sri Ramachandra University (Deemed to be University), Porur, Chennai - 600 116, Tamil Nadu, India.
E-mail: rajeswari.s@
sriramachandra.edu.in
Access this article online Website: www.ijnmrjournal.net DOI: 10.4103/ijnmr.IJNMR_207_18
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Abstract
Background: Progressive Muscle Relaxation (PMR) helps to improve the emotional state of antenatal mothers with stress and anxiety, which is necessary to keep the fetus healthy inside the womb. This study assesses the efficacy of progressive muscle repose on stress and anxiety among primigravidae.
Materials and Methods: A randomized controlled study was conducted from May 2015 to June 2017 with 250 primigravidae. The women were assigned using a lottery method to intervention and control groups, 125 in each group. Information on background variables, pregnancy outcome, maternal complications, fetal complications, and postpartum depression was collected during the interval following delivery. PMR was the intervention (video) installed on one‑to‑one basis for two consecutive days. Pearson correlation, ANOVA, and regression analysis were used to evaluate the data to determine pregnancy outcome and performance of PMR. Results: There was a significant reduction ((F3 = 24.81, p < 0.001) in all aspects of stress among the intervention and control groups during the posttest. The mean gestational age at birth was significantly different (F2 =6.08, p = 0.014) in the control group. There was significant increase in the occurrence of fetal complications such as birth asphyxia (F2 =5.67, p < 0.050), respiratory distress (F2 =8.68, p < 0.050), and jaundice (F2 =3.91, p < 0.050) in the control group. There was a negative correlation between PMR and stress (r= −0.22, p < 0.001), and PMR and state anxiety (r = −0.26, p < 0.001). There was an increased occurrence of maternal complications among the control group in comparison with the intervention group.
Conclusions: The study suggests that PMR practice is useful during pregnancy to decrease stress, anxiety, and for reducing the occurrence of postpartum complications.
Keywords: Anxiety, India, pregnancy outcome, progressive muscle relaxation, stress
Efficacy of Progressive Muscle Relaxation on Pregnancy Outcome among Anxious Indian Primi Mothers
Original Article
Singaravelu Rajeswari
1, Nellepalli SanjeevaReddy
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