Laser assisted hatching in good prognosis patients

undergoing in vitro fertilization-embryo transfer: a

randomized controlled trial
Arthur W. Sagoskin, M.D.,a Michael J. Levy, M.D.,a Michael J. Tucker, Ph.D.,a
Kevin S. Richter, Ph.D.,a and Eric A. Widra, M.D.a,b
a b
Shady Grove Fertility Reproductive Science Center, Rockville, Maryland, and Georgetown University Department of
Obstetrics and Gynecology, Washington, D.C.

Objective: To evaluate whether assisted hatching improves clinical outcomes of embryo transfers to good prognosis
patients, defined as patients ⱕ39 years with normal follicle-stimulating hormone (FSH) and E2 levels, no more than
one previous unsuccessful cycle of in vitro fertilization (IVF)– embryo transfer, and good embryo quality.
Design: Prospective randomized controlled trial.
Setting: Private assisted reproductive technology (ART) center.
Patient(s): One hundred ninety-nine good prognosis patients undergoing IVF– embryo transfer.
Intervention(s): In vitro fertilization followed by embryo transfer on day 3 after oocyte retrieval with or without
assisted hatching using a 1,480-nm wavelength infrared laser.
Main Outcome Measure(s): Clinical intrauterine pregnancy, spontaneous pregnancy loss, and live birth.
Result(s): Rates of clinical intrauterine pregnancy with fetal cardiac activity (53% vs. 54% per cycle), sponta-
neous pregnancy loss (13% vs. 16% per pregnancy), and live birth (47% vs. 46% per cycle) were very similar
between treatment cycles with laser-assisted hatching and control cycles in which embryos were transferred
without assisted hatching. There were no significant differences between treatment and control groups in any
measured clinical outcome parameters.
Conclusion(s): Assisted hatching does not improve clinical outcomes among good prognosis patients. (Fertil
Steril威 2007;87:283–7. ©2007 by American Society for Reproductive Medicine.)
Key Words: In vitro fertilization, embryo transfer, assisted hatching, laser micromanipulation, good prognosis,
implantation, pregnancy, live birth

The ability of a blastocyst to hatch, or escape, from the zona
pellucida (ZP) that surrounds and protects the embryo during
its first few days of development is one of many critical
events that must occur for successful reproduction. Implan-
tation of the embryo in the uterine lining is impossible unless
hatching occurs. It has been suggested that impaired hatch-
ing of embryos resulting from IVF contributes to low im-
plantation rates (1).
Intrinsic factors such as age (2), basal FSH and diagnosis
(3), the altered hormonal environment to which maturing
oocytes are exposed during ovarian stimulation (3, 4), or the
artificial conditions of the in vitro culture environment (5–7),
may induce abnormal thickening or hardening of the ZP,
making hatching more difficult. In vitro culture conditions
may also adversely effect quantitative or qualitative
trophectoderm-produced zona lysin secretion that has been
proposed as the primary mechanism of blastocyst hatching
(8). Intrinsic variation in lysin secretion independent of
Received March 8, 2006; revised and accepted July 5, 2006.
Presented in part at the 59th Annual Meeting of the Society for Repro-
ductive Medicine, San Antonio, TX, October 11–15, 2003.
Reprint requests: Kevin S. Richter, Ph.D., Shady Grove Fertility Repro-
ductive Science Center, 15001 Shady Grove Road, Suite 400, Rock-
ville, MD 20850 (FAX: 301-340-0623; E-mail: kevin.richter@integramed.
com.
assisted reproduction protocols may also contribute to the
inability of some blastocysts to successfully hatch.
Assisted hatching (AH), in which the ZP is artificially
breached or thinned to facilitate hatching, has been proposed
as a way of overcoming these intrinsic or assisted reproduc-
tive technology (ART)-induced barriers to hatching of oth-
erwise viable embryos (1). Studies using animal models have
demonstrated that AH can significantly increase rates of
embryo hatching (9 –12). Assisted hatching has also been
shown to significantly increase hatching rates of human
embryos (13–16). Studies using animal models have also
found that AH results in earlier hatching than occurs in
unmanipulated embryos (8, 9). Data from patients undergo-
ing IVF demonstrated that hCG is detectable in maternal
serum earlier when AH is performed than when it is not (17),
suggesting that human embryos also hatch earlier when
assisted. Facilitation of earlier embryonic hatching may be
particularly important given that the short window of endo-
metrial receptivity appears to be shifted 1–2 days earlier in
cycles with ovarian stimulation for ART compared to natural
cycles (18 –20).
A variety of different micromanipulation techniques, in-
cluding mechanical partial zona dissection (1, 21, 22), zona
drilling using acidic Tyrode’s solution (23, 24), laser drilling

0015-0282/07/$32.00 Fertility and Sterility姞 Vol. 87, No. 2, February 2007 283
doi:10.1016/j.fertnstert.2006.07.1498 Copyright ©2007 American Society for Reproductive Medicine, Published by Elsevier Inc.
(12, 25–27), and piezo-micromanipulation (28) have been
reported to improve ART outcomes among select groups of
patients. Two recent meta-analyses of studies evaluating
potential benefits of AH reported significant heterogeneity
among study results (29, 30), suggesting that effects of AH
may differ depending on patient characteristics. Both con-
cluded that there is strong evidence that AH increases preg-
nancy rates (PR) among patients with a history of previous
IVF failures. However, it remains uncertain whether AH is
beneficial to other patients. Other patient populations that
have been reported to benefit from AH include patients
whose embryos have thick zonae and patients with elevated
FSH (23), older patients (21, 24, 31–33), and patients using
cryopreserved embryos (34 –37).
Based on this evidence, our program routinely offers AH
to patients with a history of two or more previous IVF–
embryo transfer failures, patients aged 39 years or greater,
and patients with a basal serum FSH concentration greater
than 10 mIU/mL. However, there are indications that im-
paired hatching may be a direct result of ART treatment
(4 – 6, 8), and thus a potentially pervasive limitation of
IVF– embryo transfer implantation rates. If so, AH may also
benefit patients with a better prognosis. We therefore de-
signed this trial to test the hypothesis that AH of good quality
embryos in good prognosis patients would improve PR and
implantation rate.
MATERIALS AND METHODS
Patients undergoing IVF with cleavage stage (day 3) embryo
transfer at Shady Grove Fertility Reproductive Science Cen-
ter between August 2001 and March 2005 were enrolled
after discussion of the study and informed written consent.
Western Institutional Review Board (WIRB) approved the
study protocol. This study has been registered with Clinical-
Trials.gov [NCT00120549].
Inclusion criteria included first or second autologous IVF–
embryo transfer cycles, maximum female age 39 years,
maximum baseline FSH 10 mIU/mL, maximum baseline E2
75 pg/mL, ovulatory menstrual cycles, no uterine abnormal-
ity or communicating hydrosalpinx, and good embryo qual-
ity. Good embryo quality was defined by the presence of six
to eight cells, and a maximum of 20% fragmentation on day
3. Eligible diagnoses included tubal disease (excluding com-
municating hydrosalpinx), endometriosis, male factor in-
fertlity, or unexplained infertility. Patients diagnosed with
diminished ovarian reserve, polycystic ovarian syndrome
(PCOS), uterine or egg factor infertility were not eligible.
Patients with more than one previous unsuccessful IVF cycle
were also excluded.
Enrolled patients were randomly assigned to either the
treatment group (laser-assisted hatching [laser-AH]) or the
control group (no laser-AH). Treatment assignments were
determined by a computer-generated randomized series in a
2:1 ratio of treatments to controls.
284 Sagoskin et al. Assisted hatching in good prognosis patients
Assisted embryo hatching was performed using a
1,480-nm wavelength infrared laser (Zilos Laser System,
Hamilton Thorne Research, Beverly, MA). An approxi-
mately 20 ␮m defect was created in the ZP before transfer in
the treatment group, whereas those in the control group were
transferred with no laser-AH. The laser was set to deliver a
500-␮sec pulse of energy at 100% power, such that by
targeting a suitable area of the ZP with an area of periv-
itelline space beneath, a suitable 20-␮m hole could be drilled
with 6 –10 bursts of the laser. Embryo transfer was under-
taken with either of two soft compound catheters (Tucker
Embryo Catheter, Fertility Technology Resource Inc, Mari-
etta, GA; Wallace Embryo Replacement Catheter, Irvine
Scientific, Santa Ana, CA) under ultrasound guidance.
Implantation and pregnancy outcomes were determined
based on ultrasound identification of fetal cardiac activity
4 – 6 weeks after embryo transfer.
Cycle characteristics and clinical outcomes were com-
pared between treatment and control groups by t-test (nu-
merical variables) or ␹2 (categorical variables). The sample
size was calculated based on a ␤ ⫽ 0.08 and an ␣ ⫽ 0.05
with a predicted difference in implantation rate of 8% be-
tween treatments and controls.
RESULTS
A total of 203 patients were consented and enrolled in the
study. Three patients were excluded from subsequent anal-
ysis due to violations of inclusion criteria: elevated FSH
(n ⫽ 1); advanced maternal age (n ⫽ 1); or poor embryo
quality (n ⫽ 1). One patient was lost to follow-up and had no
pregnancy outcome data available and was therefore ex-
cluded from analysis. Patient and cycle characteristics are
compared among the 199 remaining patients in Table 1.
Mean patient age was 34 years. Mean FSH was 6.6
mIU/mL, and mean E2 was 34.7 pg/mL. On day 3 after
oocyte retrieval, before embryo transfer, mean cell number
among transferred embryos was 7.6, with 2.9% fragmenta-
tion. A mean of 2.1 embryos were transferred per cycle.
Treatment and control groups were comparable in terms of
age, baseline FSH and E2, proportion of cycles with intra-
cytoplasmic sperm injection (ICSI), cell number and frag-
mentation on day 3, and the number of embryos transferred.
Pregnancies with fetal cardiac activity occurred in 53.8%
of all treatment cycles, with an overall implantation rate of
34.0% of transferred embryos. Fifteen pregnancies (14.0%)
ended in spontaneous pregnancy loss, and 92 ended in live
birth (46.2% per cycle). Rates of pregnancy, implantation,
spontaneous pregnancy loss, and live birth were all very
similar between treatment and control cycles. There were no
statistically significant differences between the treatment and
control groups in any of the examined variables.
Vol. 87, No. 2, February 2007
 TABLE 1
Cycle characteristics and clinical outcomes compared between cycles with assisted hatching
(treatment) and those without assisted hatching (control).

Treatment (hatched) Control (unhatched) P value

Number enrolled 121 82

Number analyzed 118 81
Patient agea 34.0 ⫾ 3.3 34.0 ⫾ 3.2 .89
Baseline FSHa 6.6 ⫾ 1.5 6.6 ⫾ 1.6 .92
Baseline E2a 35.3 ⫾ 15.6 33.7 ⫾ 14.1 .51
ICSI 57/118 (48.3%) 38/81 (46.9%) .85
Day 3 cell numbera 7.6 ⫾ 0.6 7.7 ⫾ 0.8 .44
Day 3 fragmentation (%)a 3.3 ⫾ 3.6 2.5 ⫾ 3.0 .15
Number of embryos 254 170
Embryos per cyclea 2.2 ⫾ 0.4 2.1 ⫾ 0.3 .30
Positive hCG 73/118 (61.9%) 52/81 (64.2%) .75
Gestational sac 64/118 (54.2%) 45/81 (55.6%) .87
Fetal cardiac activity 63/118 (53.4%) 44/81 (54.3%) .92
Implantation (fca/embryo) 84/254 (33.1%) 60/170 (35.3%) .74
Multiple fca 21/63 (33.3%) 16/44 (36.4%) .91
Spontaneous abortion 8/63 (12.7%) 7/44 (15.9) .64
Live birth per cycle 55/118 (46.6%) 37/81 (45.7%) .90
Note: fca ⫽ fetal cardiac activity.
a
Values are means plus or minus one standard deviation.
Sagoskin. Assisted hatching in good prognosis patients. Fertil Steril 2007.

DISCUSSION have reported significantly improved implantation rate and

Many studies have evaluated the effects of AH on implan-
tation rates of embryos transferred after IVF. However, more
than 15 years after the introduction of AH into the practice
of assisted reproduction, the indications for its use still
remain poorly defined.
PR (21, 24, 31, 33), but other investigators have found no
benefit (40 – 43). One study reported no benefit for AH
among patients older than 36 years, but increased implanta-
tion and pregnancy with AH among patient 36 years or
younger (27).

Some studies have reported significant improvements in
implantation rate and PR with the application of AH to
treatment cycles by “poor prognosis” patients, defined by a
history of repeated IVF– embryo transfer failures, elevated
FSH, or advanced age (32, 38). However, pooled analysis of
such heterogeneous populations leaves ambiguity regarding
whether all of these different reasons for a poor prognosis are
responsive to AH. A more recent randomized study reported
no benefit for AH among patients classified as poor progno-
sis because of either advanced age or elevated FSH (39).
The population for whom the benefits of AH are best
documented are patients with a history of repeated IVF–
embryo transfer without successful implantation. Many stud-
ies have reported significantly improved implantation rate
and PR for these patients (21, 22, 24 –26, 28). Two recent
meta-analyses found that there was conclusive evidence for
improved success with AH among patients with repeat IVF
failures (29, 30), but uncertainty regarding other patient
populations. One of these meta-analyses reported a nearly
significant trend toward improved outcomes among older
women (29). Several studies of AH among older patients
An early randomized trial found that AH significantly
improved implantation rate and PR among patients with a
day 3 basal FSH ⬎15 mIU/mL (23). No study since has
investigated AH among patients designated as poor progno-
sis specifically because of elevated FSH level alone. Several
studies have investigated AH among cycles in which cryo-
preserved embryos were transferred. Some of these studies
have suggested that AH increases implantation and preg-
nancy among this patient population (34 –37). However,
other studies have reported that there is no benefit from AH
of cryopreserved embryos (39, 44). Embryos with thick ZP
reportedly benefit from AH (23), although this claim has
been refuted (27, 42). There is also evidence that AH im-
proves outcomes of transfers of later-developing blastocysts
(45), and of embryos with zonas that were difficult to pen-
etrate during ICSI (46).
Few studies have investigated AH among patients with a
relatively good prognosis. Studies of unselected populations
suggest that the benefits of AH may not be universal. An-
tinori et al. (25) reported significant improvement in implan-
tation and pregnancy among patients undergoing their first

Fertility and Sterility姞 285

IVF cycle. However, other randomized studies of unselected
patients found no benefit from AH (47, 48). Cohen et al. (23)
failed to demonstrate a significant benefit of nonselective
AH in a randomized study of patients with normal day 3
basal FSH levels. Only one previous study specifically ad-
dressed good prognosis patients, defined as either new pa-
tients 30 years or younger with normal FSH, endometrial
cavity, and semen parameters, or patients 35 years or
younger with prior IVF experience with good fertilization
and at least six embryos (49). No benefit to AH was found,
although statistical power was very limited, with AH per-
formed in fewer than 20 cycles.
The present study is the first prospective randomized trial
of its size to evaluate AH among selected patients with a
good prognosis, defined as patients 39 years or younger with
normal FSH and E2, no more than one previous unsuccessful
cycle of IVF– embryo transfer, and good embryo quality on
day 3 (the day when transfers were performed). Results
indicate no benefit for AH among this patient population.
Rates of implantation, pregnancy, spontaneous pregnancy
loss, and live birth were all very similar regardless of
whether or not embryos underwent AH before transfer.
Although AH did not improve treatment outcomes, there
was also no evidence that the laser-AH procedure harmed
embryos or reduced their developmental potential, with im-
plantation, pregnancy, and delivery rates as high in the AH
group as in the control group. Studies of mouse embryos,
reporting equivalent preimplantation development, equiva-
lent rates of implantation and birth, and anatomically and
immunohistochemically normal offspring with normal re-
productive capacity after laser drilling of the ZP compared to
unmanipulated controls, have also indicated that laser dril-
ling of the ZP is not harmful (50, 51). A follow-up of 143
children born after laser-AH found no increase in major or
minor congenital malformations or chromosomal aberrations
compared to the general population (52). Few studies have
compared different methods of AH, but at least two studies
have suggested that laser drilling is a safer alternative to
chemical drilling with acid Tyrode’s solution (53, 54). We
chose to use the laser for AH in the manner described, as it
allowed the most rapid and apparently least invasive ap-
proach to breaching the ZP. It is a technique that is not only
easy to master, but also can be consistently applied in an
easily quantifiable way.
This study thus confirms the safety of the laser-AH pro-
cedure. However, it suggests that there is no benefit to
performing AH on embryos of patients with a good progno-
sis. It is therefore recommended that AH be reserved for
poor prognosis conditions for which there is more conclusive
evidence of improved treatment outcomes.
REFERENCES
1. Cohen J, Elsner C, Kort H, Malter H, Massey J, Mayer MP, et al.
Impairment of the hatching process following IVF in the human and
improvement of implantation by assisting hatching using micromanip-
ulation. Hum Reprod 1990;5:7–13.
286 Sagoskin et al. Assisted hatching in good prognosis patients
2. Garside WT, Loret de Mola JR, Bucci JA, Tureck RW, Heyner S.
Sequential analysis of zona thickness during in vitro culture of human
zygotes: correlation with embryo quality, age, and implantation. Mol
Reprod Dev 1997;47:99 –104.
3. Loret De Mola JR, Garside WT, Bucci J, Tureck RW, Heyner S.
Analysis of the human zona pellucida during culture: correlation with
diagnosis and the preovulatory hormonal environment. J Assist Reprod
Genet 1997;14:332– 6.
4. Bertrand E, Van den Bergh M, Englert Y. Clinical parameters influ-
encing human zona pellucida thickness. Fertil Steril 1996;66:408 –11.
5. De Felici M, Siracusa G. “Spontaneous” hardening of the zona pellu-
cida of mouse oocytes during in vitro cultrue. Gamete Res 1982;6:
107–13.
6. De Felici M, Salustri A, Siracusa G. “Spontaneous” hardening of the
zona pellucida of mouse oocyte during in vitro culture. II. The effect of
follicular fluid and glycosaminoglycans. Gamete Res 1982;12:227–35.
7. Zhang X, Rutledge J, Armstrong DT. Studies on zona hardening in rat
oocytes that are matured in vitro in a serum-free medium. Mol Reprod
Dev 1991;28:292– 6.
8. Schiewe MC, Hazeleger NL, Sclimenti C, Balmaceda JP. Physiological
characterization of blastocyst hatching mechanisms by use of a mouse
antihatching model. Fertil Steril 1995;63:288 –94.
9. Malter HE, Cohen J. Blastocyst formation and hatching in vitro fol-
lowing zona drilling of mouse and human embryos. Gamete Res 1989;
24:67– 80.
10. Khalifa EA, Tucker MJ, Hunt P. Cruciate thinning of the zona pellucida
for more successful enhancement of blastocyst hatching in the mouse.
Hum Reprod 1992;7:532– 6.
11. Alikani M, Cohen J. Micromanipulation of cleaved embryos cultured in
protein-free medium: a mouse model for assisted hatching. J Exp Zool
1992;263:458 – 63.
12. Obruca A, Strohmer H, Sakkas D, Menezo Y, Kogosowski A, Barak Y,
et al. Use of lasers in assisted fertilization and hatching. Hum Reprod
1994;9:1723– 6.
13. Dokras A, Ross C, Gosden B, Sargent IL, Barlow DH. Micromanipu-
lation of human embryos to assist hatching. Fertil Steril 1994;61:
514 –20.
14. Mandelbaum J, Plachot M, Junca AM, Salat-Baroux J, Belaisch-Allart
J, Cohen J. The effects of partial zona dissection on in-vitro develop-
ment and hatching of human cryopreserved embryos. Hum Reprod
1994;9(Suppl 4):39.
15. Nakayama T, Fujiwara H, Tastumi K, Fujita K, Higuchi T, Mori T. A
new assisted hatching technique using a piezo-micromanipulator. Fertil
Steril 1998;69:784 – 8.
16. Blake DA, Forsberg AS, Johansson BR, Wikland M. Laser zona pel-
lucida thinning—an alternative approach to assisted hatching. Hum
Reprod 2001;16:1959 – 64.
17. Liu HC, Cohen J, Alikani M, Noyes N, Rosenwaks Z. Assisted hatching
facilitates earlier implantation. Fertil Steril 1993;60:871–5.
18. Develioglu OH, Hsiu JG, Nikas G, Toner JP, Oehninger S, Jones HW,
Jr. Endometrial estrogen and progesterone receptor and pinopode ex-
pression in stimulated cycles of oocyte donors. Fertil Steril 1999;71:
1040 –7.
19. Nikas G, Develioglu OH, Toner JP, Jones HW, Jr. Endometrial pinopo-
des indicate a shift in the window of receptivity in IVF cycles. Hum
Reprod 1999;14:787–92.
20. Mirkin S, Nikas G, Hsiu JG, Diaz J, Oehninger S. Gene expression
profiles and structural/functional features of the peri-implantation en-
dometrium in natural and gonadotropin-stimulated cycles. J Clin En-
docrinol Metab 2004;89:5742–52.
21. Stein A, Rufas O, Amit S, Avrech O, Pinkas H, Ovadia J, et al. Assisted
hatching by partial zona dissection of human pre-embryos in patients
with recurrent implantation failure after in vitro fertilization. Fertil
Steril 1995;63:838 – 41.
22. Chao KH, Chen SU, Chen HF, Wu MY, Yang YS, Ho HN. Assisted
hatching increases the implantation and pregnancy rate of in vitro
fertilization (IVF) – embryo transfer (ET), but not that of IVF–tubal ET
in patients with repeated IVF failures. Fertil Steril 1997;67:904 – 8.
Vol. 87, No. 2, February 2007
23. Cohen J, Alikani M, Trowbridge J, Rosenwaks Z. Implantation en-
hancement by selective assisted hatching using zona drilling of human
embryos with poor prognosis. Hum Reprod 1992;7:685–91.
24. Magli MC, Gianaroli L, Ferraretti AP, Fortini D, Aicardi G, Montanaro
N. Rescue of implantation potential in embryos with poor prognosis by
assisted zona hatching. Hum Reprod 1998;13:1331–5.
25. Antinori S, Panci C, Selman HA, Caffa B, Dani G, Versaci C. Zona
thinning with the use of laser: a new approach to assisted hatching in
humans. Hum Reprod 1996;11:590 – 4.
26. Antinori S, Selman HA, Caffa B, Panci C, Dani GL, Versaci C. Zona
opening of human embryos using a non-contact UV laser for assisted
hatching in patients with poor prognosis of pregnancy. Hum Reprod
1996;11:2488 –92.
27. Ali J, Rahbar S, Burjaq H, Sultan AM, Al Flamerzi M, Shahata MA.
Routine laser assisted hatching results in significantly increased clincal
pregnancies. J Assist Reprod Genet 2003;20:177– 81.
28. Nakayama T, Fujiwara H, Yamada S, Tastumi K, Honda T, Fujii S.
Clinical application of a new assisted hatching method using a piezo-
micromanipulator for morphologically low-quality embryos in poor-
prognosis infertile patients. Fertil Steril 1999;71:1014 – 8.
29. Edi-Osagie E, Hooper L, Seif MW. The impact of assisted hatching on
live birth rates and outcomes of assisted conception: a systematic
review. Hum Reprod 2003;18:1828 –35.
30. Sallam HN, Sadek SS, Agameya AF. Assisted hatching—a meta-
analysis of randomized controlled trials. J Assist Reprod Genet 2003;
20:332– 42.
31. Schoolcraft WB, Schlenker T, Jones GS, Jones HW, Jr. In vitro fertil-
ization in women age 40 and older: the impact of assisted hatching. J
Assist Reprod Genet 1995;12:581– 4.
32. Meldrum DR, Wisot A, Yee B, Garzo G, Yeo L, Hamilton F. Assisted
hatching reduces the age-related decline in IVF outcome in women
younger than age 43 without increasing miscarriage or monozygotic
twinning. J Assist Reprod Genet 1998;15:418 –21.
33. Montag M, van der Ven H. Laser-assisted hatching in assisted repro-
duction. Croat Med J 1999;40:398 – 403.
34. Tucker MJ, Cohen J, Massey JB, Mayer MP, Wiker SR, Wright G.
Partial dissection of the zona pellucida of frozen-thawed human em-
bryos may enhance blastocyst hatching, implantation, and pregnancy
rates. Am J Obstet Gynecol 1991;165:341–5.
35. Check JH, Hoover L, Nazari A, O’Shaughnessy A, Summers D. The
effect of assisted hatching on pregnancy rates after frozen embryo
transfer. Fertil Steril 1996;65:254 –7.
36. Tao J, Tamis R. Application of assisted hatching for 2-day-old, frozen-
thawed embryo transfer in a poor-prognosis population. J Assist Reprod
Genet 1997;14:128 –30.
37. Gabrielsen A, Agerholm I, Toft B, Hald F, Petersen K, Aagaard J, et al.
Assisted hatching improves implantation rates on cryopreserved-
thawed embryos. A randomized prospective study. Hum Reprod 2004;
19:2258 – 62.
38. Schoolcraft WB, Schlenker T, Gee M, Jones GS, Jones HW, Jr. As-
sisted hatching in the treatment of poor prognosis in vitro fertilization
candidates. Fertil Steril 1994;62:551– 4.
39. Primi MP, Senn A, Montag M, Van der Ven H, Mandelbaum J, Veiga
A, et al. A European multicentre prospective randomized study to
assess the use of assisted hatching with a diode laser and the benefit of
an immunosuppressive/antibiotic treatment in different patient popula-
tions. Hum Reprod 2004;19:2325–33.
Fertility and Sterility姞
40. Bider D, Livshits A, Yonish M, Yemini Z, Mashiach S, Dor J. Assisted
hatching by zona drilling of human embryos in women of advanced
age. Hum Reprod 1997;12:317–20.
41. Lanzendorf SE, Nehchiri F, Mayer JF, Oehninger S, Muasher SJ. A
prospective, randomized, double-blind study for the evaluation of as-
sisted hatching in patients with advanced maternal age. Hum Reprod
1998;13:409 –13.
42. Edirisinghe WR, Ahnonkitpanit V, Promviengchai S, Suwajanakorn S,
Pruksananonda K, Chinpilas V, et al. A study failing to determine
significant benefits from assisted hatching: patients selected for ad-
vanced age, zonal thickness of embryos, and previous failed attempts.
J Assist Reprod Genet 1999;16:294 –301.
43. Horng SG, Chang CL, Wu HM, Wang CW, Cheng CK, Huang HY, et
al. Laser-assisted hatching of embryos in women of advanced age after
in vitro fertilization: a preliminary report. Chang Gung Med J 2002;
25:531–7.
44. Ng EH, Naveed F, Lau EY, Yeung WS, Chan CC, Tang OS, et al. A
randomized double-blind controlled study of the efficacy of laser-
assisted hatching on implantation and pregnancy rates of frozen-thawed
embryo transfer at the cleavage stage. Hum Reprod 2005;20:979 – 85.
45. Tucker M, Graham J, Han T, Levy M, Sagoskin A, Stillman R.
Enhanced implantation of day-6 blastocysts following assisted hatching
with acidic tyrode’s medium. Fertil Steril 1999;72:s20 –1.
46. Ebner T, Moser M, Yaman C, Sommergruber M, Hartl J, Jesacher K, et
al. Prospective hatching of embryos developed from oocytes exhibiting
difficult oolemma penetration during ICSI. Hum Reprod
2002;17:1317–20.
47. Hellebaut S, De Sutter P, Dozortsev D, Onghena A, Qian C, Dhont M.
Does assisted hatching improve implantation rates after in vitro fertil-
ization or intracytoplasmic sperm injection in all patients? A prospec-
tive randomized study. J Assist Reprod Genet 1996;13:19 –22.
48. Tucker MJ, Morton PC, Wright G, Ingargiola PE, Sweitzer CL, Elsner
CW, et al. Enhancement of outcome from intracytoplasmic sperm
injection: does co-culture or assisted hatching improve implantation
rates? Hum Reprod 1996;11:2434 –7.
49. Hurst BS, Tucker KE, Awoniyi CA, Schlaff WD. Assisted hatching
does not enhance IVF success in good-prognosis patients. J Assist
Reprod Genet 1998;15:62– 4.
50. Germond M, Nocera D, Senn A, Rink K, Delacretaz G, Fakan S.
Microdissection of mouse and human zona pellucida using a 1.48-
microns diode laser beam: efficacy and safety of the procedure. Fertil
Steril 1995;64:604 –11.
51. Germond M, Nocera D, Senn A, Rink K, Delacretaz G, Pedrazzini T,
et al. Improved fertilization and implantation rates after non-touch zona
pellucida microdrilling of mouse oocytes with a 1.48 microm diode
laser beam. Hum Reprod 1996;11:1043– 8.
52. Kanyo K, Konc J. A follow-up study of children born after diode laser
assisted hatching. Eur J Obstet Gynecol Reprod Biol 2003;110:176 – 80.
53. Chatzimeletiou K, Picton HM, Handyside AH. Use of a non-contact,
infrared laser for zona drilling of mouse embryos: assessment of im-
mediate effects on blastomere viability. Reprod Biomed Online 2001;
2:178 – 87.
54. Hsieh YY, Huang CC, Cheng TC, Chang CC, Tsai HD, Lee MS.
Laser-assisted hatching of embryos is better than the chemical method
for enhancing the pregnancy rate in women with advanced age. Fertil
Steril 2002;78:179 – 82.
287