1 Department of Reproductive Medicine, St Mary's Hospital, Manchester M13 0JH, 2 Directorate of Laboratory Medicine, Central Healthcare Trust, Manchester, 3 Department of Medical Oncology, Christie Hospital and Holt Radium Unit, Manchester, and 4 Department of Haematology, Manchester Royal Infirmary, Manchester, UK
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Abstract |
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Key words: acute myeloid leukaemia/cryopreserved embryos/cryopreserved semen/Hodgkin's disease/ICSI
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Introduction |
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Case 1 |
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Pituitary desensitization was achieved using buserelin acetate 0.5 mg i.m. daily, and ovarian stimulation commenced with 300 IU i.m. per day of FSH (Fostimon; Denfleet International Ltd, London, UK). With a serum oestradiol concentration of 4417 pg/ml and three follicles with a diameter of 20 mm, 10 000 IU of human chorionic gonadotrophin (HCG, Pregnyl; Organon, Laboratories Ltd, Cambridge, UK) was administered and oocytes recovered 35 h later. Five oocytes were retrieved and four metaphase-II stage oocytes subjected to ICSI (Van Steirteghem et al., 1993
). Two ampoules of semen were thawed and prepared using standard laboratory procedures (Horne et al., 1997
) and three oocytes fertilized normally. All three embryos were cryopreserved at the pronuclear stage (Horne et al; 1997
), based upon the high serum oestradiol concentration, to diminish the risk of developing ovarian hyperstimulation syndrome (OHSS) (Wada et al., 1992
). Embryos were replaced in a natural cycle; the LH surge was detected on cycle day 12 and two thawed embryos replaced on day 15. One of the three embryos thawed was degenerate and discarded.
Pregnancy was confirmed using a qualitative serum pregnancy test and an ultrasound scan at 7 weeks confirmed two gestational sacs and fetal poles containing two fetal hearts. Following an uneventful pregnancy, twin girls (weighing 3000 and 2400 g) were born following a Caesarean section at 38 weeks gestation.
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Case 2 |
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Pituitary desensitization was achieved using buserelin acetate 0.5 mg daily, and ovarian stimulation commenced with 150 IU per day of FSH. With a serum oestradiol concentration of 4237 pg/ml and three follicles with a diameter of 20 mm, 10000 IU of HCG (Pregnyl) was administered and oocyte recovery performed 35 h later. A total of 12 oocytes were retrieved and 10 metaphase II oocytes were subjected to ICSI. Five oocytes fertilized and were cryopreserved at the pronuclear stage, in order to reduce the risk of OHSS. One attempt at natural cycle frozen embryo replacement was abandoned when the two thawed embryos failed to divide (Horne et al, 1997
). In a second cycle, the remaining three embryos were thawed, one failed to divide and was discarded and two 4-cell embryos were replaced on day 15 of the cycle (3 days after the LH surge). Pregnancy was confirmed using a qualitative serum pregnancy test and an ultrasound scan at 7 weeks confirmed the presence of three gestational sacs and fetal poles containing fetal hearts, with the appearance of a trichorionic triamniotic pregnancy. Following an uneventful pregnancy, a Caesarean section was performed at 35 weeks, resulting in the birth of one female (2300 g) and two male (both weighing 2100 g) babies.
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Discussion |
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Spermatozoa cryopreserved during the course of chemotherapy and/or radiotherapy and subsequently used for assisted conception have been reported as safe (Carson et al., 1991). However, fears of potential genetic risks to offspring from using such semen have prompted calls for semen cryopreservation to be carried out before the start of chemotherapy and/or radiotherapy (Meistrich, 1993
; Rousseaux et al., 1993
; Robbins et al., 1997
) and this is now routine practice. Malignancies, as well as general body stresses, appear to adversely affect fertility potential even before treatment commences (Sanger et al., 1980
; Thachil et al., 1981
; Whitehead et al., 1982
; Hendry et al., 1983
; Agarwal and Newton, 1991
). However, the results of these two cases suggest the quality of the stored spermatozoa was good: percentage fertilization rate 57% (8/14) and a very high embryo viability with 100% implantation rate.
Sperm cryopreservation and storage is the most effective and reliable way of circumventing treatment-induced infertility in men. Long-term sperm banking began in this unit in 1977 and, up to 1998, 1464 men have banked semen for future use. A total of 19 clinical pregnancies, resulting in 22 live births, have so far been achieved using artificial inseminations with the husbands spermatozoa (AIH), IUI and IVF with or without ICSI (K.Fletcher, G.Horne, A.Atkinson, D.R.Brison, and B.A.Lieberman, unpublished data). A previous paper has also reported a successful live birth following frozenthawed embryos achieved by ICSI of cryopreserved testicular sperm cells extracted post-operatively after an orchidectomy for seminoma (Yavetz et al, 1997). The two cases reported here illustrate the successful use of two cryopreservation strategiesa programme of long-term sperm banking with subsequent assisted conception combined with embryo cryopreservation to diminish the risk of developing OHSS. With increased implantation rates of embryos following ICSI (zona-manipulated embryos in general), it is suggested that two instead of three embryos should be replaced electively to reduce the risk of multiple gestations (Staessen et al., 1995
; Tasdemir et al., 1995
; Slotnick and Ortega, 1996
; Lieberman, 1998
; Tarlatzis and Bili, 1998
). As shown in these cases, it is difficult to completely avoid multiple pregnancies, despite adherence to this policy.
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Notes |
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References |
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Submitted on May 11, 2000; accepted on September 29, 2000.