Journal of Assisted Reproduction and Genetics, Vol. 9, No. 4, 1992
CLINICAL ASSISTED REPRODUCTION
Pregnancy Rate in an Oocyte Donation Program F. ZEGERS-HOCHSCHILD, 1'3 E. FERNANDEZ, 1 C. FABRES, 1 A. MACKENNA, 1 J. PRADO, 1 L. ROBLERO, 1 T. LOPEZ, 1 E. ALTIERI, 1 A. GUADARRAMA, 1 and F. ESCUDERO 1'2
Submitted: December 3, 1991 Accepted: April 15, 1992
Many pregnancies have been established and healthy babies born with this procedure confirming that the genetic difference between the embryo and the recipient mother allows implantation (4--7). Although well-designed comparatives studies have not been performed, results published so far suggest a higher pregnancy rate in vitro fertilization and embryo transfer (IVF-ET) of donated oocytes compared with the standard homologous procedure. In our IVF-ET program the mean number of oocytes retrieved per patient is 8.5. On the other hand, when the male partner is known to have fertilizing capacity a maximum of five oocytes is inseminated. Remnant oocytes are therefore available for donation after proper consent has been established by both the donor and the recipient. The purpose of this publication is to report the experience of our recently established oocyte donation (OD) program.
Oocyte donation programs offer an alternative treatment for infertile women with ovarian failure or abnormal ovarian function. Seventeen cycles of in vitro fertilization and embryo transfer with donated oocytes were performed in 13 women, with a mean age of 34.8 years. The hormonal replacement therapy consisted of a fixed dose of oral estradiol valerate, 6 mg daily, and intramuscular progesterone in oil, 100 mg daily. Estrogen and progesterone were continued for 10 more weeks after embryo transfer if pregnancy was established. After 13 embryo transfers, 8 pregnancies were obtained, for a pregnancy rate per transfer of 61.5%. Today seven pregnancies are progressing normally, including one set of twins. This results suggest that an oocyte donation program using a fixed and simple hormonal replacement therapy is an adequate treatment for these infertile couples. KEY WORDS: oocyte donation replacement protocol; results.
INTRODUCTION MATERIALS AND METHODS Since 1983 when Trounson et al. (1) reported a pregnancy following embryo transfer resulting from a donated oocyte, a new perspective for the establishment of parenthood was initiated in women with ovarian failure. In the last years several investigators have subsequently described indications, resuits and different hormone replacement therapies. Luften et al. (2) recommended a sequential steroid replacement therapy in women with ovarian failure trying to stimulate the normal steroid profile in the natural menstrual cycle. Serhal and Craft (3) in 1987 used with good results a simple protocol consisting of a fixed dose of estradiol valerate (Ez) followed by progesterone (P).
Oocyte Recipients Thirteen women were incorporated in an IVF program with donated oocytes. Their mean age was 34.8 years with a range of 29 to 42. Seven women were ovarian failures due to bilateral oophorectomy, five anovulatory women with repeatedly failed ovarian stimulation, and one patient had clinical and histological evidences of repeated empty follicle syndrome. Oocyte Donors Thirteen women participating in the IVF program with homologous gametes were invited to donate remnant oocytes, which were not to be used in their own fertilization process; the mean age in this group was 31.5 years.
1 Unit of Reproductive Medicine, Clinica Las Condes Hospital, Lo FonteciUa 441, Santiago, Chile. 2 World Health Organization Research Fellow (HRP) 3 To whom correspondence should be addressed.
1058-0468D2/0800-0350506.50/0© 1992PlenumPublishingCorporation
350
PREGNANCY RATE IN AN OOCYTE DONATION PROGRAM
Table I. Overall Results of OD Program N of cycles with ET Pregnancy rate/cycle Ongoing pregnancy rate/cycle Abortion rate/cycle"
13 (8/13) (7/13) (1/13)
61.5% 53.8% 7.7%
This patient discontinued HRT after 13hCG reached 292 IU/L with a normal doubling time.
Written informed consent was obtained and anonymity was maintained from donors and recipients. Hormonal Replacement Therapy (HRT) All women were treated with the same protocol which consisted of daily oral administration of 6 mg of estradiol (E~) valerate. As soon as the endometrium reached a minimum of 8 ml and a n E 2 concentration in plasma of at least 2000 pM/L, the patient waited for the donor to receive her human chorionic g o n a d o t r o p i n (hCG) injection prior to follicular aspiration. One day later, a daily intramuscular (im) injections of 100 mg of progesterone in oil was added. Controlled Ovarian Superovulation (COS) The onset of menstruation was programmed using follicular-phase norethindrone acetate, 10 mg daily (5 to 20 days), followed by 0.75 or 1 mg of subcutaneous leuprolide acetate, which was started 2 to 4 days before menstruation and followed by 150 to 300 IU im of human menopausal gonadotropin (hMG) on days 2 and 3 of the cycle continuing with 150 IU or more as required. The cycle was monitored by daily ultrasound and plasma estrogens;
351
10,000 IU of hCG was administered according to a defined clinical criterion. The luteal phase was supported by daily (im) injection of 50 mg of progesterone. Follicles were aspirated transvaginaly, 34 to 36 hr after hCG. After transvaginal aspiration, remnant oocytes were inseminated with sperm provided by the recipient's husband. The resulting embryos were transferred at approximately 48 hr after ovum pickup (OPU). Twelve ET were performed to the uterine cavity (IVF-ET) and one ET to the fallopian tube (TET). The beta subunit of hCG ([3hCG) was measured in plasma on days 12, 15, and 18 after ET. When positive, HRT was maintained at the same dose of E z and P for 10 more weeks.
RESULTS Seventeen cycles of OD were done in 13 women. ET was performed in 13 cycles corresponding to 12 women. The overall results of OD are shown in Table I. A description of the cycles of OD is provided in Table II. Twelve of thirteen patients had IVF-ET except for patient number 13, who had TET. ET was performed on day P + 4 except for subject number 10, which was transferred on day P+5.
DISCUSSION Although OD was initially indicated only in infertile women with ovarian failure, today indications
Table II. Clinical Data and Outcome of ET in OD Cycles N
Age
Indication for OD
Days of E2 before P
Endom. b (mm)
E2 b pmol/L
N embryos transferred
Outcome
1 2 3 4 5 6 7 8 9 10 11 12 13
29 37 33 37 29 29 29 42 34 41 37 36 31
bilat, oophorect. bilat, oophorect. bilat, oophorect. bilat, oophorect. bilat, oophorect. bilat, oophorect. bilat, oophorect. bilat, oophorect. repeat failed stimul. repeat failed stimul. repeat failed stimul. repeat failed stimul. empty follicle syndr.
16 8 14 16 12 8 13 15 8 12 19 15 12
8 10 9 8 10 11 9 8 12 10 12 8 12
4485 3764 6395 1058 3639 2427 3130 4550 3760 2013 8720 5330 2793
6 7 3 5 7 4 3 3 5 5 4 4 3
no pr. a twin pr. abortion pr. pr. no pr. pr. no pr. no pr. pr. pr. no pr. pr.
apr.: pregnancy. b endom, and E2: endometrium thickness and E2 concentration the day when P is started.
Journal of Assisted Reproduction and Genetics, Vol. 9, No. 4, 1992
352
include patients with abnormal ovarian function, as demonstrated by repeated failure to respond to
c o s (5). Navot et al. (8) describes three factors responsible for successful pregnancy in IVF: oocyte quality, endometrial adequacy, and synchronization of both. All these seem to be achieved with the HRT for OD in spite of the simplicity of the regimen used for endometrial preparation. It is interesting to observe that pregnancy can be obtained after a variable exposure of the endometrium to high E 2 levels. The length of the proliferative induced phase in conception cycles ranged between 8 and 19 days before P was added, which suggest that a proliferative endometrium can wait for a long period of time before it is transformed by the effect of P and receptivity is maintained. In seven of eight conception cycles, endometrium thickness ranged between 9 and 12 ram. with a mean E2 concentration in plasma at the end of the follicular phase of 4350.5 pM/L. Only one patients conceived with a maximum endometrium of 8 mm and an E2 of 1058 pM/L. In three women who did not conceive, endometrial thickness never reached more than 8 mm, in spite of exposure to a mean of 4788 pM/L of E2 for 15 days. This suggests that in those cases there was an endometrial abnormality responsible for the lack of implantation. Although most patients conceived with an endometrial thickness ranging between 9 and 12 mm, this cannot be considered as a guarantee for implantation since there are many other factors responsible for the establishment of pregnancy as the quality of the dividing conceptus, In the spontaneous conception cycle the dividing conceptus reaches the uterine cavity approximately 96 to 108 hr after ovulation (9). At this time, plasma E2 has dropped by 51.2% of the peak value reached during ovulation (mean concentration = 840 pM/ L). Furthermore, in conception cycles after standard IVF, the corresponding fall in E z is also approximately 61.6% (10,11). It is therefore interesting that the pregnancy rate per transfer can be as high as 61.5% with a HRT that maintains a fixed concentration of plasmatic E 2 throughout the whole replacement cycle.
ZEGERS-HOCHSCHILD ET AL.
We believe that couples suitable for OD can be treated successfully with this simple protocol of replacement therapy originally proposed by Serhal and Craft (3). In the light of the present information we feel that there are two important areas of future research. One is related to the hormonal requirement for the establishment of a receptive endometrium; the other is the role of genetic heterogeneity between the embryo and the host mother as a determining factor in the high implantation rate observed in these cases. REFERENCES 1. Trounson A, Leeton J, Besanko M, Wood C, Conti A: Pregnancy established in an infertile patient after transfer of a donated embryo fertilized in vitro. Br Med J 1983;286:835 2. Lutjen P, Trounson A, Leeton J, Findlay J, Wood C, Renau P: The establishment and maintenance of pregnancy using in vitro fertilization and embryo donation in an patient with primary ovarian failure. Nature 1984;307:174 3. Serhal P, Craft I: Ovum donation--a simplified approach. Fertil Steril 1987;48:265 4. Cameron I, Rogers P, Caro C, Harman J, Healy D, Leeton J: Oocyte donation: A review. Br J Obstet Gynecol 1989;96: 1071 5. Rosenwaks Z: Donor eggs: Their application in modern reproductive technologies. Fert Steril 1987;47:895 6. Kogosowski A, Yovel I, Lessing J, Amit A, Barak Y, David M, Peyser R: The establishment of an ovum donation programme using a simple fixed-dose estrogen-progesterone replacement regimen. J Vitro Fertil Embryo Transfer 1990;7: 244 7. De vroey P, Camus M, Van den Abbel E, Van Waesbergue L, Wisanto A, Van Steirteghem A: Establishment of 22 pregnancies after oocyte and embryo donation. Br J Obst Gynecol 1989;96:900 8. Navot D, Scott R, Droesch K, Veeck L, Liu H, Rosenwacks Z: The window of embryo transfer and the efficiency of human conception in vitro. Fertil Steril 1991;55:114 9. Crnxatto HB, D~az S, Fuentealba B, Croxatto HD, Carrillo D, Fabres C: Studies on the duration of egg transport in the human oviduct. I. The time interval between ovulation and egg recovery from the uterus in normal women. Fertil Steril 1972;23:447 10. Zegers-Hochschild F, Gomez Lira C, Parada M, Altieri E: A comparative study of follicular growth profile in conception and nonconception cycles. Fertil Steril 1984;41:244 11. Dor J, Rudak E, Mashiach S, Nebel L, Sen" D, Goldman B: Periovulatory 17 beta-estradiol changes and embryo morphologic features in conception and nonconceptional cycles after human in vitro fertilization. Fertil Steril 1986;45:63
Journal o f Assisted Reproduction and Genetics, Vol. 9, No. 4, 1992
CLINICAL ASSISTED REPRODUCTION
Pregnancy Rate in an Oocyte Donation Program F. ZEGERS-HOCHSCHILD, 1'3 E. FERNANDEZ, 1 C. FABRES, 1 A. MACKENNA, 1 J. PRADO, 1 L. ROBLERO, 1 T. LOPEZ, 1 E. ALTIERI, 1 A. GUADARRAMA, 1 and F. ESCUDERO 1'2
Submitted: December 3, 1991 Accepted: April 15, 1992
Many pregnancies have been established and healthy babies born with this procedure confirming that the genetic difference between the embryo and the recipient mother allows implantation (4--7). Although well-designed comparatives studies have not been performed, results published so far suggest a higher pregnancy rate in vitro fertilization and embryo transfer (IVF-ET) of donated oocytes compared with the standard homologous procedure. In our IVF-ET program the mean number of oocytes retrieved per patient is 8.5. On the other hand, when the male partner is known to have fertilizing capacity a maximum of five oocytes is inseminated. Remnant oocytes are therefore available for donation after proper consent has been established by both the donor and the recipient. The purpose of this publication is to report the experience of our recently established oocyte donation (OD) program.
Oocyte donation programs offer an alternative treatment for infertile women with ovarian failure or abnormal ovarian function. Seventeen cycles of in vitro fertilization and embryo transfer with donated oocytes were performed in 13 women, with a mean age of 34.8 years. The hormonal replacement therapy consisted of a fixed dose of oral estradiol valerate, 6 mg daily, and intramuscular progesterone in oil, 100 mg daily. Estrogen and progesterone were continued for 10 more weeks after embryo transfer if pregnancy was established. After 13 embryo transfers, 8 pregnancies were obtained, for a pregnancy rate per transfer of 61.5%. Today seven pregnancies are progressing normally, including one set of twins. This results suggest that an oocyte donation program using a fixed and simple hormonal replacement therapy is an adequate treatment for these infertile couples. KEY WORDS: oocyte donation replacement protocol; results.
INTRODUCTION MATERIALS AND METHODS Since 1983 when Trounson et al. (1) reported a pregnancy following embryo transfer resulting from a donated oocyte, a new perspective for the establishment of parenthood was initiated in women with ovarian failure. In the last years several investigators have subsequently described indications, resuits and different hormone replacement therapies. Luften et al. (2) recommended a sequential steroid replacement therapy in women with ovarian failure trying to stimulate the normal steroid profile in the natural menstrual cycle. Serhal and Craft (3) in 1987 used with good results a simple protocol consisting of a fixed dose of estradiol valerate (Ez) followed by progesterone (P).
Oocyte Recipients Thirteen women were incorporated in an IVF program with donated oocytes. Their mean age was 34.8 years with a range of 29 to 42. Seven women were ovarian failures due to bilateral oophorectomy, five anovulatory women with repeatedly failed ovarian stimulation, and one patient had clinical and histological evidences of repeated empty follicle syndrome. Oocyte Donors Thirteen women participating in the IVF program with homologous gametes were invited to donate remnant oocytes, which were not to be used in their own fertilization process; the mean age in this group was 31.5 years.
1 Unit of Reproductive Medicine, Clinica Las Condes Hospital, Lo FonteciUa 441, Santiago, Chile. 2 World Health Organization Research Fellow (HRP) 3 To whom correspondence should be addressed.
1058-0468D2/0800-0350506.50/0© 1992PlenumPublishingCorporation
350
PREGNANCY RATE IN AN OOCYTE DONATION PROGRAM
Table I. Overall Results of OD Program N of cycles with ET Pregnancy rate/cycle Ongoing pregnancy rate/cycle Abortion rate/cycle"
13 (8/13) (7/13) (1/13)
61.5% 53.8% 7.7%
This patient discontinued HRT after 13hCG reached 292 IU/L with a normal doubling time.
Written informed consent was obtained and anonymity was maintained from donors and recipients. Hormonal Replacement Therapy (HRT) All women were treated with the same protocol which consisted of daily oral administration of 6 mg of estradiol (E~) valerate. As soon as the endometrium reached a minimum of 8 ml and a n E 2 concentration in plasma of at least 2000 pM/L, the patient waited for the donor to receive her human chorionic g o n a d o t r o p i n (hCG) injection prior to follicular aspiration. One day later, a daily intramuscular (im) injections of 100 mg of progesterone in oil was added. Controlled Ovarian Superovulation (COS) The onset of menstruation was programmed using follicular-phase norethindrone acetate, 10 mg daily (5 to 20 days), followed by 0.75 or 1 mg of subcutaneous leuprolide acetate, which was started 2 to 4 days before menstruation and followed by 150 to 300 IU im of human menopausal gonadotropin (hMG) on days 2 and 3 of the cycle continuing with 150 IU or more as required. The cycle was monitored by daily ultrasound and plasma estrogens;
351
10,000 IU of hCG was administered according to a defined clinical criterion. The luteal phase was supported by daily (im) injection of 50 mg of progesterone. Follicles were aspirated transvaginaly, 34 to 36 hr after hCG. After transvaginal aspiration, remnant oocytes were inseminated with sperm provided by the recipient's husband. The resulting embryos were transferred at approximately 48 hr after ovum pickup (OPU). Twelve ET were performed to the uterine cavity (IVF-ET) and one ET to the fallopian tube (TET). The beta subunit of hCG ([3hCG) was measured in plasma on days 12, 15, and 18 after ET. When positive, HRT was maintained at the same dose of E z and P for 10 more weeks.
RESULTS Seventeen cycles of OD were done in 13 women. ET was performed in 13 cycles corresponding to 12 women. The overall results of OD are shown in Table I. A description of the cycles of OD is provided in Table II. Twelve of thirteen patients had IVF-ET except for patient number 13, who had TET. ET was performed on day P + 4 except for subject number 10, which was transferred on day P+5.
DISCUSSION Although OD was initially indicated only in infertile women with ovarian failure, today indications
Table II. Clinical Data and Outcome of ET in OD Cycles N
Age
Indication for OD
Days of E2 before P
Endom. b (mm)
E2 b pmol/L
N embryos transferred
Outcome
1 2 3 4 5 6 7 8 9 10 11 12 13
29 37 33 37 29 29 29 42 34 41 37 36 31
bilat, oophorect. bilat, oophorect. bilat, oophorect. bilat, oophorect. bilat, oophorect. bilat, oophorect. bilat, oophorect. bilat, oophorect. repeat failed stimul. repeat failed stimul. repeat failed stimul. repeat failed stimul. empty follicle syndr.
16 8 14 16 12 8 13 15 8 12 19 15 12
8 10 9 8 10 11 9 8 12 10 12 8 12
4485 3764 6395 1058 3639 2427 3130 4550 3760 2013 8720 5330 2793
6 7 3 5 7 4 3 3 5 5 4 4 3
no pr. a twin pr. abortion pr. pr. no pr. pr. no pr. no pr. pr. pr. no pr. pr.
apr.: pregnancy. b endom, and E2: endometrium thickness and E2 concentration the day when P is started.
Journal of Assisted Reproduction and Genetics, Vol. 9, No. 4, 1992
352
include patients with abnormal ovarian function, as demonstrated by repeated failure to respond to
c o s (5). Navot et al. (8) describes three factors responsible for successful pregnancy in IVF: oocyte quality, endometrial adequacy, and synchronization of both. All these seem to be achieved with the HRT for OD in spite of the simplicity of the regimen used for endometrial preparation. It is interesting to observe that pregnancy can be obtained after a variable exposure of the endometrium to high E 2 levels. The length of the proliferative induced phase in conception cycles ranged between 8 and 19 days before P was added, which suggest that a proliferative endometrium can wait for a long period of time before it is transformed by the effect of P and receptivity is maintained. In seven of eight conception cycles, endometrium thickness ranged between 9 and 12 ram. with a mean E2 concentration in plasma at the end of the follicular phase of 4350.5 pM/L. Only one patients conceived with a maximum endometrium of 8 mm and an E2 of 1058 pM/L. In three women who did not conceive, endometrial thickness never reached more than 8 mm, in spite of exposure to a mean of 4788 pM/L of E2 for 15 days. This suggests that in those cases there was an endometrial abnormality responsible for the lack of implantation. Although most patients conceived with an endometrial thickness ranging between 9 and 12 mm, this cannot be considered as a guarantee for implantation since there are many other factors responsible for the establishment of pregnancy as the quality of the dividing conceptus, In the spontaneous conception cycle the dividing conceptus reaches the uterine cavity approximately 96 to 108 hr after ovulation (9). At this time, plasma E2 has dropped by 51.2% of the peak value reached during ovulation (mean concentration = 840 pM/ L). Furthermore, in conception cycles after standard IVF, the corresponding fall in E z is also approximately 61.6% (10,11). It is therefore interesting that the pregnancy rate per transfer can be as high as 61.5% with a HRT that maintains a fixed concentration of plasmatic E 2 throughout the whole replacement cycle.
ZEGERS-HOCHSCHILD ET AL.
We believe that couples suitable for OD can be treated successfully with this simple protocol of replacement therapy originally proposed by Serhal and Craft (3). In the light of the present information we feel that there are two important areas of future research. One is related to the hormonal requirement for the establishment of a receptive endometrium; the other is the role of genetic heterogeneity between the embryo and the host mother as a determining factor in the high implantation rate observed in these cases. REFERENCES 1. Trounson A, Leeton J, Besanko M, Wood C, Conti A: Pregnancy established in an infertile patient after transfer of a donated embryo fertilized in vitro. Br Med J 1983;286:835 2. Lutjen P, Trounson A, Leeton J, Findlay J, Wood C, Renau P: The establishment and maintenance of pregnancy using in vitro fertilization and embryo donation in an patient with primary ovarian failure. Nature 1984;307:174 3. Serhal P, Craft I: Ovum donation--a simplified approach. Fertil Steril 1987;48:265 4. Cameron I, Rogers P, Caro C, Harman J, Healy D, Leeton J: Oocyte donation: A review. Br J Obstet Gynecol 1989;96: 1071 5. Rosenwaks Z: Donor eggs: Their application in modern reproductive technologies. Fert Steril 1987;47:895 6. Kogosowski A, Yovel I, Lessing J, Amit A, Barak Y, David M, Peyser R: The establishment of an ovum donation programme using a simple fixed-dose estrogen-progesterone replacement regimen. J Vitro Fertil Embryo Transfer 1990;7: 244 7. De vroey P, Camus M, Van den Abbel E, Van Waesbergue L, Wisanto A, Van Steirteghem A: Establishment of 22 pregnancies after oocyte and embryo donation. Br J Obst Gynecol 1989;96:900 8. Navot D, Scott R, Droesch K, Veeck L, Liu H, Rosenwacks Z: The window of embryo transfer and the efficiency of human conception in vitro. Fertil Steril 1991;55:114 9. Crnxatto HB, D~az S, Fuentealba B, Croxatto HD, Carrillo D, Fabres C: Studies on the duration of egg transport in the human oviduct. I. The time interval between ovulation and egg recovery from the uterus in normal women. Fertil Steril 1972;23:447 10. Zegers-Hochschild F, Gomez Lira C, Parada M, Altieri E: A comparative study of follicular growth profile in conception and nonconception cycles. Fertil Steril 1984;41:244 11. Dor J, Rudak E, Mashiach S, Nebel L, Sen" D, Goldman B: Periovulatory 17 beta-estradiol changes and embryo morphologic features in conception and nonconceptional cycles after human in vitro fertilization. Fertil Steril 1986;45:63
Journal o f Assisted Reproduction and Genetics, Vol. 9, No. 4, 1992
