Uterine contractions at the time of embryo transfer: a hindrance to implantation?

OBJECTIVES: To investigate the hormonal control and the possible consequences of uterine contractions (UC) on IVF-ET outcome. MATERIALS AND METHODS: We studied prospectively 220 controlled ovarian hyperstimulation (COH) cycles for IVF-ET. Just before ET, women underwent 5-minute digital recordings of the uterus using US image analysis software for UC assessment. Plasma progesterone (P) and estradiol were measured. Four groups were defined according to UC frequency: < or = 3.0 (n = 53), 3.1 to 4.0 (n = 50), 4.1 to 5.0 (n = 43), and > 5.0 (n = 74) UC/minute, respectively. RESULTS: Patients, COH and embryology characteristics were comparable in all groups. Notwithstanding estradiol levels were not associated with UC characteristics, plasma P and UC frequency were negatively correlated (r = -0.34, P < 0.001). A stepwise decrease in clinical and ongoing pregnancy as well as implantation rates occurred from the lowest to the highest UC frequency groups (53%, 36%, 21%; 46%, 32%, 20%; 23%, 19%, 10%; and 14%, 11%, 4%; P < 0.001). Direction of UC did not affect ET outcome. CONCLUSIONS: The negative correlation between UC frequency and P levels supports the utero-relaxing properties of P. High frequency UC on the day of ET hinder IVF-ET outcome, possibly by expelling embryos out of the uterine cavity.     

Cytokines and embryo implantation

A neuromusculoskeletal model of the human arm was developed which contains both feedforward and feedback control, and thereby accounts for motor control of fast movements as well as interaction with external forces. The feedforward control component forms an approximate representation of the inverse dynamics of the arm and its interaction with the environment. The feedback control component compensates for errors in the representation of the inverse dynamics and for unexpected forces acting on the arm. Moreover, the control system provides a solution for the redundancy of the muscles. The system performance is adapted in a learning procedure according to a specified goal function. It is shown in the paper that good control of the nonlinear musculoskeletal model and neural control signals which are similar to electromyographic (EMG) data, are attained. The response of the arm to external forces is analysed and compared with experimental data on arm impedance.     

Mucin and proteoglycan functions in embryo implantation

OBJECTIVES: To assess the in vitro adherence of Candida albicans to heat-cured hard and soft denture-base materials with varying surface roughness, and to observe the effect of a mixed salivary pellicle on candidal adhesion to these surfaces. METHODS: In vitro adhesion assays on heat-cured acrylic resin (Trevalon), Molloplast B and Novus using the type strain of C. albicans (NCPF 3153A). Surfaces for the assays were prepared using clinically appropriate rotary instruments. Unstimulated, pooled and clarified whole saliva was used to assess its effect on adhesion. RESULTS: Significantly greater adhesion of C. albicans to rough rather than smooth surfaces was found (P < 0.001), as well as increased adhesion to the machined soft lining materials compared with acrylic. Pre-coating denture-base materials with saliva reduced candidal adhesion on all materials. CONCLUSIONS: Rough surfaces on denture-base materials promote the adhesion of C. albicans in vitro. However, saliva reduces adhesion of C. albicans and thus diminishes the effect of surface roughness and free surface energy differences between materials.     

Studies on the mechanism of embryo implantation

Implantation is a complex process accomplished by synchronization and interactions between embryo and endometrium by local exchange of signals including a number of cytokines and growth factors and direct cell-cell and cell-matrix contact. However, the research in early events of human implantation is still in its infancy. This presentation comprises the results of our attempts to investigate the mechanisms of human implantation process in its early stage by cell-biological method, including establishment of experimental implantation model in vitro. 1. Human trophoblast of early stage of gestation showed active cell locomotion, active endocytosis, and invasion of endometrial cell monolayer in mixed cultures. Trophoblast invasion was later arrested by transformed endometrial cells similar to decidual cells in vivo. These results appeared to indicate the interactions between trophoblast and endometrial cells in implantation. 2. Coculture system of rabbit preimplantation blastocyst and endometrial epithelium reformed from isolated endometrial epithelial cells on basement membrane matrix (Matrigel) simulated the in vivo rabbit implantation processes. This coculture system may provide a useful experimental implantation model. 3. A human trophoblast cell line was established from chorionic tissues of normal early pregnancy. These cells were cytotrophoblast-like morphology and endocrine functions. They formed the villous structures similar to those in vivo in culture on Matrigel and invasion of Matrigel was observed. These indicated the extracellular matrix may affect the morphology and function of invading trophoblast in implantation site. 4. Human endometrial epithelial single cells were cultured on Matrigel. Reconstruction of gland followed by epithelium formation quite similar to in vivo structures by migration and proliferation of isolated cells was demonstrated. Height of gland was promoted by estrogen and initiation of epithelization was upregulated by platelet-derived growth factors. This system revealed the extracellular matrix regulated morphogenesis of endometrial epithelium in vivo and is an essential substrate in experimental implantation model of endometrial epithelium. 5. Parallel cultures of endometrial epithelial cells on Matrigel were carried out with the IVF. ET patients to evaluate the endometrial morphology at time of ET. Endometrial cultures were initiated in previous cycles on Matrigel and the sera of patients were added to her own cultures from 1st day of IVF treatment cycle. Evaluation of reformed epithelium revealed the apparently unsuitable morphology for implantation in group of patients who eventually failed in pregnancy. This system may provide a useful measures in evaluation of endometrial receptivity and modality of treatment for endometrial aberrations. 6. Cyclic changes of extracellular matrix components in endometrium were investigated. Collagen I, III, IV, V were immunohistochemically estimated. Relative levels of all types of collagen except for collagen V declined at early secretory phase. In rodents, not only collagen but also laminin and fibronectin levels declined at early secretory phase. These changes may facilitate trophoblast invasion of endometrium. Collagen V distributed in myometrial surface was found to consist of subunit (alpha 1)2 alpha 2 and trophoblast growth was inhibited on substrate of alpha 1 subunit. Collagen V in myometrial surface may have a role in blocking trophoblast invasion. 7. HGF (hepatocyte growth factor) mRNA was demonstrated to be expressed during menstruation and secretory phase in endometrium distinctly and its receptor in endometrial epithelial cells and decidual cells. Positive correlation between plasma HGF levels and ultrasonographic thickness of endometrium was observed at late secretory phase. Recombinant HGF promoted proliferation of endometrial epithelial cells and decidual cells and upregulated initiation of endometrial epithelization of Matrigel.     

Involvement of trophoblast in embryo implantation: regulation by paracrine factors

In order to investigate the regulatory role of only one endometrial cell type on trophoblastic invasion, we explored the effects of culture medium conditioned by in vitro decidualised stromal cells (DCM) and of insulin-like growth factor binding protein-1 (IGFBP-1, the main secretory product of decidual cells) on the trophoblastic secretion of gelatinases and tissue inhibitor of metalloproteinases (TIMP-1). First trimester cytotrophoblastic cells (CTB) were obtained from abortions and cultured in vitro in presence or absence of DCM or IGFBP-1. Secreted gelatinases were analysed in the culture supernatants by zymography and by measurements of the total gelatinolytic activity. Tissue inhibitor of metalloproteinases (TIMP-1) was measured by a commercially available immunoassay. DCM inhibited the total gelatinolytic activity of CTB but increased trophoblastic MMP-9 and TIMP-1. In contrast, IGFBP-1 increased the total gelatinolytic activity and TIMP-1 and had no effect on MMP-2 and MMP-9. We conclude that a factor secreted by decidual cells (possibly TGFbeta) inhibits the total gelatinolytic activity of trophoblast by increasing TIMP-1 but other factors, as yet unidentified, increase MMP-2 and MMP-9 to an extent which does not shift the equilibrium between the gelatinases and TIMP-1 in favour of the gelatinases. In contrast to DCM, IGFBP-1 increases the total gelatinolytic activity probably by stimulating another gelatinase (stromelysin-1?) as MMP-2 and MMP 9 are unchanged by IGFBP-1. The possibility of an integrin mediated effect of IGFBP-1 on CTB is discussed.     

Surface changes of the rat embryo before implantation

Study of the rat embryo surface under the scanning electron microscope shows the superficial structure of the pellucid membrane as a perforated network cover which does not change throughout the preimplantation period (1 to 41/2 days). Dissolution of the pellucid membrane by brief ATP treatment reveals a zygotic surface which changes from day to day. The number and length of microvilli increase with development. At the early blastula stage there is a great heterogeneity of microvilli of different size and shape as well as large membranous ruffles mainly located at one pole of the embryo. The significance of these structures may relate to the changing metabolic requirements of the developing embryo and to the invasive properties of the trophoblast.     

Epithelial cell polarity and embryo implantation in mammals

At embryo implantation we are confronted with the fact that uterine and trophoblast epithelium make contact via their apical cell membranes. This epithelium-epithelium adhesion leading to definitive attachment of the embryo to the uterine wall, however, is far from being trivial and has been called a cell biological paradox. It has been proposed that some of the molecular events involved in epithelium-to-mesenchyme transformation might play a role in the interaction between uterine cells and trophoblast. As a mechanism to achieve uterine epithelium adhesiveness for trophoblast it is postulated that uterine cells partially modulate their epithelial phenotype. Data from recent in vitro experiments give support to this hypothesis and suggest that loss of apical-basal cell polarity might prepare the apical cell pole of uterine epithelium for cell-to-cell contact with trophoblast in vivo.     

Ongoing normal pregnancy after transfer of zona-free blastocysts: implications for embryo transfer in the human

Recent reports suggest that transfer of day 5 blastocysts improves implantation rates in in-vitro fertilization programmes. This paper reports a successful ongoing pregnancy after the transfer of zona-free day 6 expanded and hatching blastocysts. The patient was 37 years old and had undergone six stimulated and two thaw cycles previously, all of which had failed. Stimulation was by down-regulation and oocytes recovered transvaginally by ultrasound guidance. Two pronuclear embryos were co-cultured on Vero cells to day 6. The zonae of two hatching and two fully expanded blastocysts were removed using 0.5% pronase, and the zona-free blastocysts were then transferred. Pregnancy was confirmed on day 18 with a positive human chorionic gonadotrophin (HCG) and ultrasound at 6 weeks showed a single healthy fetal heart inside a clear sac. At 14 weeks a triple test (oestriol, J-HCG and alpha-fetoprotein) was normal and at 22 weeks a detailed ultrasound scan showed no congenital anomalies. This is the first report in the human of a normal ongoing pregnancy after the transfer of zona-free day 6 embryos.     

Age-dependent decrease in embryo implantation rate after in vitro fertilization

OBJECTIVE: To investigate the relation between the implantation rate per embryo after replacement in IVF-ET in relation to female age. DESIGN: Retrospective study using linear and biphasic models in a multivariate analysis. SETTING: Academic tertiary care institution. INTERVENTION(S): In vitro fertilization-ET and determination of gestational sacs at 6 to 7 weeks of pregnancy buy ultrasound. MAIN OUTCOME MEASURE(S): Implantation rate as defined by the number of gestational sacs per embryo replaced. RESULT(S): Woman's age and embryo morphology were strongly related to the implantation rate, indication for IVF-ET and cycle rank number also were related significantly but less strongly. A linear model was built describing the decrease in implantation rate with age, resulting in a decrease of approximately 7%. A biphasic model was tested also and performed significantly better, resulting in a yearly decrease of > 20% after 37 years of age. CONCLUSION(S): The most important independent factors related to the ability of embryos to implant are female age and embryo morphology. The best way to describe the relation with female age is biphasic model with a discontinuity at approximately 37 years of age.     

Embryo score to predict implantation after in-vitro fertilization: based on 957 single embryo transfers

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

Effect of methoxychlor on implantation and embryo development in the mouse

Methoxychlor (MXC) has been shown to have adverse effects on reproductive functions. However, it has not been fully determined whether the effects of MXC on reproduction are due to its estrogenic or antiestrogenic effects. Therefore, to further elucidate the estrogenic action of this pesticide in the mouse, we studied the effect of MXC on implantation and embryo development. MXC was found to initiate implantation in most delayed implanting mice at 400 microg/g body weight. However, at the higher dose of 800 microg/g body weight, MXC initiated implantation in only 50% of animals and the number of embryos implanting was significantly decreased (P < 0.05). It was determined that MXC inhibited implantation in intact pregnant mice only when given on Day 1 or Day 2 at 800 microg/g but not at lower doses or later in the preimplantation period. Embryonic development and transport were delayed on Days 3 and 4 in these animals. Finally, reciprocal embryo transfers with donor embryos recovered from MXC-treated animals (800 microg/g body weight on Day 1) transferred to untreated recipients resulted in no implantation compared to 79% implantation when donor embryos were treated with vehicle. These data indicate that MXC acts as an estrogen agonist at the level of the uterus and oviduct but as an antiestrogen in the ovary. In addition, MXC appears to alter normal preimplantation embryonic development. These results suggest the need for further studies to assess the mechanism of action of MXC in preimplantation embryos.     

Ethical aspects of in vitro fertilization and embryo transfer

In vitro fertilization and embryo transfer (IVF-ET) confronts moral reflection with a wide range of concerns. Some are similar to those raised by artificial insemination such as the procurement of sperm, the goods of marriage and donor gametes. Others are unique to IVF-ET such as surrogacy, the status of the embryo and cryopreservation.     

Multiple attempts at embryo transfer: does this affect in-vitro fertilization treatment outcome?

In this study, we retrospectively analysed data from 877 patients who had 1204 embryo transfer procedures following in-vitro fertilization (IVF) at Midland Fertility Services, UK, between January 1991 and December 1995 to investigate the factors contributing to failure of embryo transfer at first attempt and the impact of immediate retransfer of retained embryos on the treatment outcome. Embryos were significantly more likely to be retained when the embryo transfer catheter was contaminated with mucus (3.3 versus 17.8%, P = 0.000001) or blood (3.3 versus 12%, P = 0.00001) and when the transfer procedure was difficult compared with when it was easy (20.3 versus 0.8%, P = 0.00001). There was no significant difference in the clinical pregnancy rate between those who had all their embryos transferred at the first attempt (24.7%) and those who required more than one attempt (23.2%). The types of embryo transfer catheter used in the unit did not show any difference in terms of embryo retention. Although we recommend aspiration of cervical mucus in order to reduce the rate of retained embryos, there is no evidence from our study to suggest that pregnancy rate is compromised when embryos are retained, provided they are discovered and immediately retransferred into the uterine cavity. Immediate retransfer is more convenient to the patients and reduces the laboratory workload without compromising the treatment outcome.     

Children conceived by in vitro fertilisation after fresh embryo transfer

AIMS: To compare the outcome in in vitro fertilisation (IVF) children (after fresh embryo transfer) from multiple and singleton births with one another, and with normally conceived control children. METHODS: A cohort of 278 children (150 singletons, 100 twins, 24 triplets and four quadruplets), conceived by IVF after three fresh embryos had been transferred, born between October 1984 and December 1991, and 278 normally conceived control children (all singletons), were followed up for four years after birth. They were assessed for neonatal conditions, minor congenital anomalies, major congenital malformations, cerebral palsy and other disabilities. Control children, all born at term, were matched for age, sex and social class. RESULTS: The ratio of male:female births was 1.03. Forty six per cent of IVF children were from multiple births; 34.9% were from preterm deliveries; and 43.2% weighed less than 2500 g at birth. The IVF singletons were on average born one week earlier than the controls, weighed 400 g less, and had a threefold greater chance of being born by caesarean section. The higher percentage of preterm deliveries was largely due to multiple births and they contributed to neonatal conditions in 45.0% of all IVF children. The types of congenital abnormalities varied: 3.6% of IVF children and 2.5% of controls had minor congenital anomalies, and 2.5% of IVF children and none of the controls had major congenital malformations. The numbers of each specific type of congenital abnormality were small and were not significantly related to multiple births. IVF children (2.1%) and 0.4% of the controls had mild/moderate disabilities. They were all from multiple births, including two children with cerebral palsy who were triplets. CONCLUSIONS: The outcome of IVF treatment leading to multiple births is less satisfactory than that in singletons because of neonatal conditions associated with preterm delivery and disabilities in later childhood. A reduction of multiple pregnancies by limiting the transfer of embryos to two instead of three remains a high priority.     

Combined fresh and frozen embryo transfer resulting in a twin delivery

We report the delivery of non-identical twins resulting from the combined transfer of one fresh and one frozen embryo to a 31 year old patient. To our knowledge, this is the first reported case where both a fresh and a frozen embryo implanted in the same cycle led to non-identical twins. We conclude that supernumerary embryos after in-vitro fertilization should be frozen and used in subsequent cycles, with implantation potentials as high as fresh embryos. The possibility of mixing fresh and frozen embryos, though rarely needed, should be considered, particularly when there is only one fresh embryo available for transfer.     

A method for endoscopic embryo collection and transfer in the rabbit

Thirty-two rabbits were used for endoscopic embryo collection and transfer. For embryo collection midventral laparoscopy and transcervical endoscopy were combined for orthograd flushing of the oviducts and uterine horns. Transfer was performed transcervically under laparoscopic control. The mean number of corpora lutea counted in nine donors was 13.3 +/- 8.4. A total of 72 morulae/blastocysts were obtained. No embryos were recovered when only the uterine horns were flushed. 291 embryos were transcervically transferred to 23 recipients which resulted in 10 pregnant animals at day 12. Two of three slaughtered recipients showed together 4 implantation sites. Four animals delivered 12 pups.