Hum. Reprod. Advance Access originally published online on March 23, 2006
Human Reproduction 2006 21(7):1777-1780; doi:10.1093/humrep/del080
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Successful monozygotic twin delivery following in vitro maturation of oocytes retrieved from a woman with polycystic ovary syndrome: Case Report
1 IVF NAMBA CLINIC, The Centre for Reproductive Medicine and Infertility and 2 IVF OSAKA CLINIC, Osaka, Japan
3 To whom correspondence should be addressed at: IVF NAMBA CLINIC, The Centre for Reproductive Medicine and Infertility, 1-17-28, Minamihorie, Nishi-ku, Osaka 550-0015, Japan. E-mail: murata{at}ivfnamba.com
 |
Abstract |
|---|
 Top Abstract IntroductionCase reportDiscussion References |
|---|
The incidence of monozygotic twinning (MZT) appears to be increasing within the field of assisted reproductive technology (ART), although the factors contributing to the phenomenon are still far from being identified. On the contrary, in vitro maturation (IVM) of oocytes is becoming more accepted and more and more babies have been born worldwide using this procedure. Assessing its safety and impact on monozygotic twinning (MZT), and following up the health of these babies, is essential. We report here a first case of successful monozygotic (MZ) twin delivery following IVM. The patient was a 28-year-old Japanese female, referred to the IVF clinic for primary infertility. Several previous cycles of ovarian stimulation had resulted in ovarian hyperstimulation syndrome (OHSS). The patient received norethisterone–mestranol to initiate the menstruation, and oocyte retrieval was performed 36 h after hCG. A total of 22 immature oocytes were obtained. Following incubation for 24 h in IVM medium, 50% of the oocytes were matured to the metaphase II (MII) stage. Nine oocytes were fertilized after ICSI with the husband’s sperm. Three day 3 embryos were transferred into the uterus on the fourth day following oocyte retrieval. Three weeks after embryo transfer, a single gestational sac was visualized in the uterus. At 7 weeks of gestation, two fetal poles with cardiac activity were seen in the single gestational sac. Serial ultrasound examinations revealed a MZ, monochorionic diamniotic pregnancy. After intensive perinatal monitoring, two healthy male infants were delivered by Caesarean section at 35 weeks of gestation.
Key words: IVF-ET/ in vitro maturation/monozygotic twinning/PCOS/prolonged in vitro culture
|
Introduction |
|---|
|
TopAbstractIntroductionCase reportDiscussion References |
|---|
Monozygotic (MZ) twins are considered to develop when a single fertilized ovum splits into two genetically identical embryos (Sills et al., 2000a
). However, the precise mechanism responsible for this division is poorly understood. Monozygotic twinning (MZT) is a rare phenomenon in humans and occurs in just approximately 0.4% of spontaneous pregnancies (Bulmer, 1970; MacGillivray, 1986). Early studies reported that the frequency of MZT was independent of race, age, parity or family history. However, there have been many reports that assisted reproductive technology (ART) significantly increases the incidence of MZT. The effects of ovulation induction (Derom et al., 1987), extended in vitro culture (Milki et al., 2003), zona pellucida manipulation (Tarlatzis et al., 2002) and multiple embryo transfer (Sills et al., 2000b) in the MZT process have been reviewed elsewhere (Sills et al., 2000a; Schachter et al., 2001) but still remain controversial. Two of the growing candidates linked to this phenomenon are culture conditions and prolonged in vitro culture.
In vitro maturation (IVM) of immature oocytes has been proposed as a potential alternative for conventional IVF treatment. The first report of a successful pregnancy following IVM of immature oocytes in a woman with anovulatory infertility was made in 1994 (Trounson et al., 1994). This procedure is performed in only a limited number of institutes worldwide. As the number of births from IVM is still relatively small, prospective and extensive follow-up is mandatory so as to assess its safety and the impact on embryonic development.
In this case report, we describe the first successful delivery of MZ twins resulting from IVM oocytes derived from an unstimulated ovary.
|
Case report |
|---|
|
TopAbstractIntroductionCase reportDiscussion References |
|---|
A 28-year-old nullgravida Japanese female was referred to the IVF NAMBA CLINIC with primary infertility. She had been married for 3 years and received several courses of ovulation induction with urinary FSH, resulting in repeated incidences of ovarian hyperstimulation syndrome (OHSS). Her basal body temperature indicated no ovulation, and an ultrasound scanning revealed bilateral polycystic ovaries. Following counselling, she opted for subsequent IVM treatment so as to reduce the risk of OHSS.
To initiate the treatment cycle, the patient received norethisterone–mestranol (Norluten-D®, Shionigi Pharm, Osaka, Japan). On the eighth day of withdrawal bleeding, small ovarian follicles were monitored by transvaginal ultrasonography (Toshiba, Tokyo, Japan), confirming that there was no dominant follicle. Endometrial thickness was 8 mm. The patient was given 10 000 IU of HCG (Profasi, Serono Japan, Tokyo, Japan) 36 h before oocyte retrieval (Chian et al., 1999).
Immature oocytes were aspirated with 17–19 gauge double needles (FS-IVF OSAKA-IVM2; Kitazato supply, Shizuoka, Japan) under the guidance of transvaginal ultrasonography. A portable aspiration pump was used with a pressure between 160 and 180 mmHg. The aspirates were collected in 10 ml tubes containing pre-warmed heparinized human tubule fluid (HTF) medium. The follicular aspirates were filtered (70 µm mesh, Falcon 1060; Becton Dickinson, NJ, USA) and washed with pretreatment medium (IVM-LAG; MediCult, Copenhagen, Denmark) to remove erythrocytes and small cellular debris. The remaining cells were then re-suspended in the medium, and the oocytes were isolated under a stereomicroscope. All oocyte-handling procedures were conducted in a mini-chamber under a 5% CO2 atmosphere at 37.5°C. Following oocyte collection, immature oocytes were transferred to maturation medium for in vitro culture. They were cultured in IVM medium (IVM®; MediCult) at 37.5°C in an atmosphere of 5% CO2, 5% O2 and 90% N2. The medium was supplemented with 10% patient’s serum collected from the patient 24 h after HCG administration. Patient blood was collected in a sterilized glass tube and allowed to coagulate at room temperature and then centrifuged at 1600 g for 5 min. Supernatant was collected and inactivated for 30 min at 56°C in a water bath, then added to the medium. Twenty-six hours post collection, the oocytes were denuded with hyaluronidase (Sigma Chemical, St. Louis, MO, USA) and mechanical pipetting. Mature oocytes [metaphase II (MII)] were identified by the presence of the first polar body.
Sperm were prepared by 90% Percoll separation at 300 g for 20 min. After Percoll separation, motile sperm were collected using a swim-up method with 10 ml of culture medium (universal IVF; MediCult). All MII oocytes were fertilized by ICSI. Zygotes were then cultured in the culture medium (universal IVF; MediCult), and fertilization was assessed 16–18 h after ICSI for the appearance of two distinct pronuclei and two polar bodies. Fertilized zygotes were transferred into culture medium (IVC-1, In Vitro Care, MD, Frederick, USA). Day 2 embryos with sufficient viability were exposed to protease solution (1 µg/ml Protease type XIV; Sigma Chemical) for 24 h (biochemical-assisted hatching; Lee et al., 1997; Fukuda et al., 2001b). Day 3 embryos were transferred on the fourth day after oocyte retrieval.
A total of 22 immature oocytes were obtained, and 11 oocytes reached the MII stage after 24 h of culture. Nine oocytes were fertilized after ICSI and cleaved. Three embryos (two eight-cell embryos of grade 1 and one nine-cell embryo of grade 1) were transferred 3 days after fertilization. On the day of embryo transfer, the endometrial thickness was 10 mm on ultrasound. Supernumerary high-grade embryos were cryopreserved by vitrification. Progesterone (Proge depot® 125 mg, Mochida, Tokyo, Japan) was administered i.m. on the day of embryo transfer. Transcutaneous estradiol (Estraderm, Kissei Pharm, Matsumoto, Japan; four sheets every 2 days) and transvaginal progesterone (400 mg of progesterone suppository daily, made in our pharmacy) were administered until 9 weeks of gestation.
Two weeks after embryo transfer (4+3/7 weeks of gestation), the serum hCG concentration was 294 IU/l and pregnancy was confirmed. Three weeks after embryo transfer (5+3/7 weeks of gestation), transvaginal ultrasound revealed a single intrauterine gestational sac (Figure 1). Follow-up ultrasound evaluation was performed every week. At 6 weeks of gestation, a single growing gestational sac was recognized, but it contained two distinct fetal poles, both with cardiac activity, suggesting a MZ twin pregnancy. The following week, two fetal poles in a single gestational sac were identified by two other physicians and a MZ twin pregnancy was diagnosed (Figure 2). At 10 weeks of gestation, this was reconfirmed and a thin septum between the two fetuses helped in the definite diagnosis of a monochorionic diamniotic twin pregnancy (Figure 3). A month later with continuing ultrasound, the patient was referred to an obstetrician. The obstetrical course was closely observed for complications, particularly those related to MZT such as twin–twin transfusion syndrome (TTTS). Mild discordancy of estimated fetal birthweight was recognized at 30 weeks of gestation by ultrasonography. Intensive examinations of fetal umbilical cord blood flow, amniotic fluid volume and cardiotocography were continued. At 35+4/7 weeks of gestation, selective Caesarean section was performed and two healthy male infants were delivered with 5 min Apgar scores of 8 and 10, respectively. The weights at birth were 2470 g and 1840 g, respectively. Monochorionic diamniotic placenta was confirmed by macroscopical inspection.
|
|
|
|
Discussion |
|---|
|
TopAbstractIntroductionCase reportDiscussion References |
|---|
The incidence of MZT appears to be increasing within the field of assisted human reproduction. Many hypotheses have been proposed in relation to this phenomenon. The East Flanders Prospective Twin Study first reported an increased risk of MZT after fertility treatment with ovulation induction (Derom et al., 1987
). Another study found that the MZT rate was higher after ovulation induction than other forms of ART and that perhaps exposure to gonadotropin might be the cause of the increase (Schachter et al., 2001). Associations with zona pellucida micromanipulation (assisted hatching, ICSI) and zona hardening (due to prolonged in vitro culture, blastocyst transfer, frozen embryo transfer and so on) have been described by several authors (Peramo et al., 1999; Behr et al., 2000; Van Langendonckt et al., 2000; da Costa et al., 2001; Sheiner et al., 2001b) in up to 5% of ongoing pregnancies. The ‘zona shearing’ hypothesis following these zona altering treatment has been most emphasized, where the inner cell mass (ICM) is trapped by an altered zona pellucida during the hatching process and divides into two identical embryos (Sills et al., 2000). But it is unlikely to provide the full answer to MZ outcomes after fertility treatment because recent studies reported no significant increase in MZT after zona micromanipulation (Sills et al., 2000b; Schachter et al., 2001), and even monozygosity can arise independently of the zona pellucida (Frankfurter et al., 2004). Growing evidence supports the existence of polarity within mammalian oocytes, and culture conditions could increase the risk of MZ by altering polar gradient formation within the oocyte and early embryo (Scott, 2002). It has been suggested that culture conditions can lead to MZT, that is, that excessive amount of glucose or free radicals induce apoptosis (Ménézo and Sakkas, 2002) or lower calcium activity by chelators included in the culture medium, which weakens interblastomeric bonds (Steinman and Valderrama, 2001). Factors contributing to this phenomenon might include prolonged in vitro culture, which is considered to be one of the main factors linked to MZT. IVM treatment has several potential advantages including lower treatment costs (less drugs and monitoring), reduced health risks (reduced incidence of OHSS) and increased convenience to the patient (fewer blood tests and ultrasonographic monitorings and no daily injections) compared with conventional IVF treatment. However, the main difference between IVM and conventional IVF is a longer period of in vitro culture before insemination and one more day of culture of immature oocytes. If MZT is mainly a phenomenon linked to prolonged culture, IVM might be one of the factors that increase its incidence. In our case, embryos were cultured in vitro for 4 days (1 day before fertilization and 3 days after ICSI), a period 1 day shorter than blastocyst stage transfer in ordinary IVF.
It is unknown whether biochemical-assisted hatching has any effect on MZT. As far as we know, there is no report of protease exposure affecting monozygosity and this is our first case of MZT after this procedure. Prospective follow-up is necessary to assess its impact on embryo development.
To date, 165 pregnancies from IVM oocytes have been reported in Europe (Medicult IVM network, http://www.medicult.com/). We have obtained 41 healthy babies from IVM oocytes since our first success in 1999 (Fukuda et al., 2001a). In addition, IVM has been actively performed in countries such as Korea and Canada, and obstetric outcomes have been evaluated (Cha et al., 2005; Le Du et al., 2005; Mikkelsen, 2005).
Approximately 500 live births following IVM are estimated to occur worldwide now (Chian, 2004), and this is the first reported case of MZT following IVM. The incidence is not as high as the MZT rate in ART (1–5%), which demonstrates that IVM itself does not increase the risk of MZT. However, due to the small number of babies born following IVM worldwide, it is still not possible to categorically state that IVM does not have an impact on MZT.
In conclusion, we report here a first case of MZT from IVM oocytes and successful delivery after intensive perinatal care. To elucidate the incidence of MZT following IVM, we recommend the worldwide experience of IVM be collated by a central body so as to fully assess the impact of this procedure on MZ twining, fetal development and the health of the babies born.
|
References |
|---|
|
TopAbstractIntroductionCase reportDiscussion References |
|---|
Behr B, Fisch JD, Racowsky C, Miller K, Pool TB, Milki AA. (2000) Blastocyst-ET and monozygotic twinning. J Assist Reprod Genet 17:349–351.[CrossRef][Web of Science][Medline]
Bulmer MG. (1970) The Biology of Twinning in Man (Oxford University Press, London).
Cha KY, Chung HM, Lee DR, Kwon H, Chung MK, Park LS, Choi DH, Yoon TK. (2005) Obstetric outcome of patients with polycystic ovary syndrome treated by in vitro maturation and in vitro fertilization-embryo transfer. Fertil Steril 83:1461–1465.[CrossRef][Web of Science][Medline]
Chian RC. (2004) In-vitro maturation of immature oocytes for infertile women with PCOS. Reprod Biomed Online 8:547–552 Review.[Web of Science][Medline]
Chian RC, Gulekli B, Buckett WM, Tan SL. (1999) Priming with human chorionic gonadotropin before retrieval of immature oocytes in women with infertility due to the polycystic ovary syndrome. N Engl J Med 341:624–1626.
da Costa AL AL, Abdelmassih S, de Oliveira FG, Abdelmassih V, Abdelmassih R, Nagy ZP, Balmaceda JP. (2001) Monozygotic twins and transfer at the blastocyst stage after ICSI. Hum Reprod 16:333–336.
Derom C, Vlietinck R, Derom R, Van den Berghe H, Thiery M. (1987) Increased monozygotic twinning rate after ovulation induction. Lancet 30:85441236–1238.
Frankfurter D, Trimarchi J, Hackett R, Meng L, Keefe D. (2004) Monozygotic pregnancies from transfers of zona-free blastocysts. Fertil Steril 82:483–485.[Medline]
Fukuda A, Kawada J, Tohnaka M, Yamazaki M, Iwamoto H, Nakaoka Y, Morimoto Y, Kanzaki H. (2001a) Successful pregnancies by intracytoplasmic sperm injection (ICSI) of in vitro matured oocytes from non-stimulated women. J Fertil Implant (Tokyo) 18:1–4.
Fukuda H, Tohnaka M, Kumagai A, Nishihara T, Fukuda A, Kawata A, Nakaoka Y, Iwamoto H, Morimoto Y, Kanzaki H, et al. (2001b) Clinical application of a novel procedure of assisted hatching, biochemical assisted hatching, using proteolytic enzyme. J Fertil Implant (Tokyo) 18:71–74.
Le Du A, Kadoch IJ, Bourcigaux N, Doumerc S, Bourrier MC, Chevalier N, Fanchin R, Chian RC, Tachdjian G, Frydman R, et al. (2005) In vitro oocyte maturation for the treatment of infertility associated with polycystic ovarian syndrome: the French experience. Hum Reprod 20:2420–424.
Lee DR, Yoon HS, Lee JE, Cho JH, Roh SI. (1997) A new simple assisted hatching technique. Assist Reprod Rev 8:188–195.
MacGillivray I. (1986) Epidemiology of twin pregnancy. Semin Perinatol 10:4–8.[Medline]
Ménézo YJ and Sakkas D. (2002) Monozygotic twinning: is it related to apoptosis in the embryo? Hum Reprod 17:247–248.
Mikkelsen AL. (2005) Strategies in human in-vitro maturation and their clinical outcome. Reprod Biomed Online 10:593–599 Review.[Web of Science][Medline]
Milki AA, Jun SH, Hinckley MD, Behr B, Giudice LC, Westphal LM. (2003) Incidence of monozygotic twinning with blastocyst transfer compared to cleavage-stage transfer. Fertil Steril 79:503–506.[CrossRef][Web of Science][Medline]
Peramo B, Ricciarelli E, Cuadros-Fernandez JM, Huguet E, Hernandez ER. (1999) Blastocyst transfer and monozygotic twinning. Fertil Steril 72:1116–1117.[CrossRef][Web of Science][Medline]
Schachter M, Raziel A, Friedler S, Strassburger D, Bern O, Ron-El R. (2001) Monozygotic twinning after assisted reproductive techniques: a phenomenon independent of micromanipulation. Hum Reprod 16:1264–1269.
Scott L. (2002) The origin of monozygotic twinnings. Reprod Biomed Online 5:276–284 Review.[Medline]
Sheiner E, Har-Vardi I, Potashnik G. (2001a) The potential association between blastocyst transfer and monozygotic twinning. Fertil Steril 75:217–218.[CrossRef][Web of Science][Medline]
Sheiner E, Kivilevitch Z, Levitas E, Sonin Y, Albotiano S, Har-Vardi I. (2001b) Monozygotic twins following blastocyst transfer: a report of two cases. Eur J Obstet Gynecol Reprod Biol 98:135–138.[CrossRef][Web of Science][Medline]
Sills ES, Tucker MJ, Palermo GD. (2000) Assisted reproductive technologies and monozygous twins: implications for future study and clinical practice. Twin Res 3:4217–223 Review.[CrossRef][Medline]
Sills ES, Tucker MJ, Palermo GD. (2000a) Assisted reproductive technologies and monozygous twins: implications for future study and clinical practice. Twin Res 3:217–223.[CrossRef][Medline]
Sills ES, Moomjy M, Zaninovic N, Veeck LL, McGee M, Palermo GD, Rosenwaks Z. (2000b) Human zona pellucida micromanipulation and monozygotic twinning frequency after IVF. Hum Reprod 15:890–895.
Steinman G and Valderrama E. (2001) Mechanisms of twinning. III. Placentation, calcium reduction and modified compaction. J Reprod Med 46:995–1002.[Web of Science][Medline]
Tarlatzis BC, Qublan HS, Sanopoulou T, Zepiridis L, Grimbizis G, Bontis J. (2002) Increase in the monozygotic twinning rate after intracytoplasmic sperm injection and blastocyst stage embryo transfer. Fertil Steril 77:196–198.[CrossRef][Web of Science][Medline]
Trounson A, Wood C, Kausche A. (1994) In vitro maturation and the fertilization and developmental competence of oocytes recovered from untreated polycystic ovarian patients. Fertil Steril 62:353–362.[Web of Science][Medline]
Van Langendonckt A, Wyns C, Godin PA, Toussaint-Demylle D, Donnez J. (2000) Atypical hatching of a human blastocyst leading to monozygotic twinning: a case report. Fertil Steril 74:1047–1050.[CrossRef][Web of Science][Medline]
Submitted on November 26, 2005; resubmitted on December 27, 2005; accepted on January 20, 2006.
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  S. Hashimoto, Y. Murata, M. Kikkawa, M. Sonoda, H. Oku, T. Murata, K. Sugihara, F. Nagata, Y. Nakaoka, A. Fukuda, et al. Successful delivery after the transfer of twice-vitrified embryos derived from in vitro matured oocytes: A Case Report Hum. Reprod., January 1, 2007; 22(1): 221 - 223. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||