Vol. 12, No. 3, 2007 Middle East Fertility Society Journal © Copyright Middle East Fertility Society Comparison of implantation and pregnancy rate using two methods of embryo selection: “Pronuclear morphology and embryo quality” and “embryo morphology alone” Robab Davar, M.D. Mehrdad Soleimani, Bs.C. Shamsi Beigi, M.D. Research and clinical center for infertility, Shahid Sadoughi University of medical sciences and health services, Yazd, Iran ABSTRACT Objective: Despite many advances in the field of reproductive medicine, with <30% of embryos that are transferred ever resulting in clinical pregnancies. This study compared implantation and pregnancy rate in two methods of embryo selection. Design: randomized double blind clinical trial Materials and Methods: Research and clinical center for infertility, Yazd, Iran Subject: In this randomized double blind clinical trial, 95 patients referring to the Yazd Research and Clinical Center for Infertility for IVF or ICSI treatment were included from March to December 2004. These patients randomly allocated in two groups. (A & B) In group A (Case), embryo selection was done by pronuclear morphology and embryo quality while in group B (Control), this process was done by embryo morphology methods alone. Oocytes were classified according to their quality. According to cause of infertility ICSI or IVF was done. Finally ≤ 4 embryos with best quality were selected and transferred to uterus. Main outcome measures: Implantation rate, Pregnancy Rate Results: In case group, 419 and in control group, 444 oocytes were collected. In case group 129 embryos and in control group 151 embryos were transferred. Number and percent of clinical pregnancies was 14 (31.11%) and 9 (18%) and implantation rate was 18 (13.95%) and 12 (7.94%) in case and control groups. Conclusion: Until to achievement of better methods and confirmation of blastocystic transferring, we can use from this method in Infertility center. Keywords: implantation, pronuclear morphology, pregnancy Despite many advances in the field of transferring multiple embryos (n = 2-6) in order to reproductive medicine, success rate of IVF and increase the likelihood of pregnancy, is a common embryo transfer in the human is low, with <30% of practice, which has led to an unacceptable level of embryos that are transferred ever resulting in multiple pregnancies. clinical pregnancies (1). Because of this Selection of the best embryo for transferring implantation rates relatively low, the practice of was the focus of multiple studies by scientists. Current techniques for this purpose are on the Corresponding Author: Robab Davar, M.D. ; Email: embryo morphology, its metabolic activity and [email protected], Research and clinical center for culture of them on the advance media to achieve infertility, Shahid Sadoughi University of medical sciences blastocystic phase. Researchers try to find the and health services, Bouali Avenue, Safayeh reliable markers for susceptibility of embryo life. P.O. Box: 89195-999, Postal Code: 8916877391, Yazd, Iran, Telephone: +98 351 8247085, Fax: +98 351 8247087 One of these markers is distance between pronucleus and their size, number and situation of 198 Davar et al. Two methods of embryo selection MEFSJ Diagram 1. The Z score describes the number, size and position of the nucleoli and the equality between the nuclei for these characteristics. Z-1 zygotes have equal numbers of nucleoli between 3-7 that are aligned at the pronuclear junctions. Z-2 zygotes have equality in size and number between the nuclei, but the nucleoli have not yet aligned at the pronuclear junction. Z-3 zygotes are characterized by inequality between the nuclei; unequal sized nucleoli, unequal numbers of nucleoli, or unequal alignment at the pronuclear junction. Z-4 zygotes are grossly abnormal and present with unequal sized nuclei, nuclei that have not aligned, small, and misplaced nuclei. nucleolus precursor bodies at the one-cell stage included from March to December 2004. These diagram no. 1 (5,12). This technique is a patients randomly allocated in two groups. noninvasive easy and suitable method for embryo Different questioners (A & B) for each group were selection (2, 3) overall the occurrence of pregnancy prepared and randomly were distributed to the is predictable only by the embryological factors patients. therefore clinical parameters is important as well in In group A, embryo selection was done by some cases. (4) pronuclear morphology(Scott PN scoring) (2 , 5) This study compared implantation and and embryo quality while in group B, this process pregnancy rate in two methods of embryo selection was done by embryo morphology methods by "pronuclear morphology and embryo quality" alone(3). ≤4 of the best selected embryo was and by "embryo morphology alone. transfer to the uterus. All women with age of less than 40 years old and any causes of infertility were included in our MATERIALS AND METHODS study. Variables such as age of patients, infertility duration, reason of infertility, chemical and clinical Patients pregnancy, and implantation rate were evaluated in this study. Oocyte quality (3) was documented as In this randomized double blind clinical trial, 95 immature (GV), immature (M I), mature (M II) and patients(45 in A group and 50 in B group) referring very mature (M II) and post mature. Pronuclear to the Yazd Research and Clinical Center for morphology was recorded Z1 – Z2 – Z3 and Z4 Infertility for IVF (in vitro fertilization) or ICSI pattern. Embryo morphology was assessed (Intra cytoplasmic sperm injection) treatment were according to 1: poor, 2: fair, 3: good, and 4: excellent. Vol. 12, No. 3, 2007 Davar et al. Two methods of embryo selection 199 Figure 1. Distribution of transferred embryos regarding the quality of embryo. (129 & 151 embryos respectively in case & control group). Z-test , * p = 0.15 , ** p = 0.048. In case group Embryo selection was done by both groups embryo morphology was evaluated in pronuclear morphology 16-18 h after ICSI or third day and 72 hours after ovum retrieval. Finally insemination and embryo quality in third day while ≤4 embryos with best quality were selected and in control group this process was done only by transferred to uterus. The best embryos were embryo quality in third day. All data were selected from Z1 or Z2 quality or and if there was collected via questioner, interview and no Z1 or Z2 embryo, from Z3, Embryo with Z4 examination during study with 6 weeks follow-up quality wasn’t transferred. Luteal phase support time. was done by 100 mg progesterone. Diagnosis of chemical pregnancy was done by β-hCG Methods measurement 14 days after transfer. Diagnosis of clinical pregnancy was performed In present study, at first, 0.5 cc GnRH-a was by detection of fetal heart beat in sonography 5 - 6 injected at mid Luteal phase of previous cycle weeks after transfer and implantation rate was (21st day) and its dosage were reduced to 0.25 cc measured by number of pregnancy sac per number on first day of cycle. Then HMG 2-3 Amp/day was of embryo transferred. started from second day of cycle. Monitoring of Data was entered in SPSS statistical software follicular growth was done by transvaginal and were analyzed by chi-square, Fisher Exact and sonography started from 9th day of the cycle and ANOVA tests and probabilities less that 0.05 were stradiol measurement. When one follicle ≥ 18 mm assigned significant. and 3 - 4 follicle ≥ 14 mm was developed and estradiol level was 600 pg/ml and 36 hours after hCG injection, ovum retrieval was done. Oocytes RESULTS were classified according to their quality. According to cause of infertility ICSI or IVF was In total, 95 IVF and ICSI cycle were analyzed done. in 10 months period. In case group, 419 (9.3 ± 6.4 In case group pronuclear morphology was in each cycle) and in control group, 444 oocytes assessed 16-18 hours after ICSI or insemination. In (8.8 ± 4.8 in each cycle) were collected. Overall, 275 200 Davar et al. Two methods of embryo selection MEFSJ Distribution of transferred embryos Figure 2. Distribution of 129 transferred embryos in case group according to PN morphology. oocytes in case and 283 oocytes in control group Mean age of women were 28.97 ± 4.5 and 28.97 ± were metaphase II mature oocytes. 4.3 years in case and control groups respectively. In case group 129 embryos and in control group Mean duration of infertility period were 7.95 ± 5.2 151 embryos were transferred. years in case and 7.92 ± 5 years in control group. There weren’t significant differences between two groups according to age, duration of infertility and Table 1. Situation of variables of samples in two groups of number of oocytes. (Table 1) present study Regarding the causes of infertility, there Case Control p-value weren’t significance differences between two groups. ART procedures (IVF or ICSI) were the Range of Infertility 1-20 1-19 - same in two groups. (P-value = 0.945) the result duration indicated that 15 chemical pregnancy occurred in Mean of Infertility 7.95 ± 5. 2 7.92 ± 5 0.973 duration ± SD (year) case group and 10 in control group. The chemical Range of ages 20-38 20-39 - pregnancy rates were 33.3% and 20%. In cases and Mean of ages ± SD 28.97 ± 4.5 28.92 ± 4.3 0.949 control group respectively. Numbers of clinical (year) pregnancies were 14 and 9 in case and control Range of oocyte were 3-30 3-22 - groups and theses rates were 31.1% and 18% gotten per each cycle Mean of oocyte per 9.31 ± 6.4 8.88 ± 4.8 0.710 respectively. Significant differences regarding the cycle ± SD clinical and chemical pregnancy weren’t seen Range of transferred 2-4 2-4 - between groups.