Infertility
Management of embryonic delays : alternative to the donation of ovocyte
Mrs. D. and Mr. B. come and consult for a primary infertility of 1 year. The interrogation of the 32-year-old patient has no suggestive infertility argument or signs of endometriosis. She does not smoke, does not take long-term treatment, has no allergies and is null. Fertility in the family is normal. Mr. B., 34, has no particular history and does not smoke.
Infertility is short (1 year), but it is never too early to make a baseline assessment. This assessment includes :
- an assessment of the ovarian reserve (J3 with serologies, FSH, LH estradiol, AMH, TSHus, prolactin and pelvic ultrasound with antral follicles and pelvic abnormalities);
- a spermatic count (spermogram, spermocytogram and survival test);
- a hysterosalgogul graph (after checking for no severe abnormality in spermatic balance).
Ms D's assessment. has a normal ovarian reserve with FSH = 7.3, LH = 4.2, estradiol = 35, AMH = 2.6 ng/ml and CFA = 16. The hysterograph is normal (the patient, motivated, did it before the spermatic balance of her spouse).
Mr. B’s assessment. However, it has an OATS (concentration 3.4 M/ml, total mobility 20%, typical form 6% and TMS 666,000 sperm).
The balance is supplemented by karyotypes (46 XX and 46 XY) and a testicular ultrasound that finds a varicocele grade 2 that will be embolised). Self-preservation by glitter is prescribed, and the health of life, which is assessed, is correct.
We are now 15 months away from trial (counting 3 months post-embolization of varicocele). Since there is a cause of infertility, IVF treatment with ICSI is initiated, with a "long daily agonist" stimulation and HMG 225. The patient responds well to the stimulation, and the Ovitrelle is triggered at S11. Nine oocytes are obtained by puncture. As the couple is young, we decide to plan a long culture with a transfer of a single embryo to J5. Eight oocytes are mature and 6 embryos are obtained. At J3, embryos are very late with 3-6 cells and a fragmentation of about 30%. At J6, there is only one young blastocyst that we decide to transfer. No pregnancy.
In the face of embryonic development anomalies, we change protocol and for an antagonistic protocol FSH 225 and we try to make an IMSI. IMSI has not been shown to be significantly superior to embryonic quality and pregnancy rates, but not inferior to ICSI. We believe, together with biologists, that this could nevertheless improve without the risk of being deleterious. The patient responds well to the stimulation, 9 oocytes are obtained: 7 mature and 6 more embryos. At J2, we have a top 411 embryo that we decide to transfer, but the other embryos are still late and fragmented. They're all going to block at J3... again, it's a failure.
These two attempts, with 2 different protocols, find a clear alteration of embryonic quality, with delays in development, fragmentation and early embryonic blockages leading to qualitative alteration of the oocyte. In addition, in an ultrasound, an endometrioma of 25 mm was developed on the left ovarian. The patient still has no endometriosis symptomatology, but this indicates an additional factor. An MRI does not find any other endometrioic damage outside of this endometrium. Due to the absence of symptomatology, limited impairment and permeability of the tubes, we decide with the surgical staff not to operate the patient at this time.
Regarding embryonic delays, the Tenon team published a small series showing that early transfer to stage 2PN can improve the chances of pregnancy. For this purpose, it is based on the assumption that embryos are not of poor quality but fragile, and would have difficulty developing in the ovens. So I choose to resume an antagonistic protocol FSH 300. The response to stimulation was still good and 10 oocytes were obtained, 7 mature and 5 embryos at stage 2PN to J1. The fertilization was again carried out by IMSI. Three 2PN embryos are transferred to J1, and an evolutionary singleton pregnancy is achieved. The pregnancy will go well and she will give birth to a little boy in 3 200 g.
One year after childbirth, the couple returns for a second child. The balance sheet is updated and a diagnostic hysteroscopy is performed to verify the absence of abnormalities following pregnancy. There are 2 vitrified embryos left at stage 2PN. Since the patient has become pregnant in a fresh transfer in a context of hyperestrogeny, I decide on a protocol substituted with 1 Provames® 2 mg per day by vaginal route. The endometrium is 8.9 mm at S11 and we begin progesterone the day before the transfer. The 2 embryos resist devitrification and are transferred. You get a second progressive singleton pregnancy and the couple will have a second little boy.
While this is a single case, it can be noted that in very early embryonic alteration suggesting an oocytic abnormality, transfer to the 2PN stage can lead to pregnancy. In fact, embryos are not necessarily qualitatively bad, but may not withstand ovens and could develop better in their natural environment.
The benefits of transfer to stage 2PN are:
- the possibility of giving all embryos a chance;
- the development of embryos in a physiological environment (although, in a natural design situation, at this stage, they should be in the trumpet and not in the uterus).
The drawbacks are:
- having to transfer 3 embryos to have a good chance of pregnancy;
- the increase in the cycles of frozen embryos can cause the couple to waste time with multiple failures, and the psychological impact that this creates;
- not knowing the quality of what is being transferred.
The 2PN transfer should be tried at least once before any oocyte donation in this situation.
