Atlas of Oocytes, Zygotes and Embryos in Reproductive Medicine PDF

Atlas of
Oocytes,
Zygotes and
Embryos in
Reproductive
Medicine
Atlas of
Oocytes,
Zygotes and
Embryos in
Reproductive
Medicine
MARC VAN DEN BERGH
Fertility Laboratory,
Kantonsspital Baden, Switzerland
THOMAS EBNER
Landes-, Frauen- und Kinderklinik,
Linz, Austria
KAY ELDER
Bourn Hall Clinic, Bourn,
Cambridge, UK
cambridge university press
Cambridge, New York, Melbourne, Madrid, Cape Town,
Singapore, São Paulo, Delhi, Mexico City
Cambridge University Press
The Edinburgh Building, Cambridge CB2 8RU, UK
Published in the United States of America by Cambridge University Press, New York
www.cambridge.org
Information on this title: www.cambridge.org/9781107004641
# Marc Van den Bergh, Thomas Ebner, Kay Elder 2012
This publication is in copyright. Subject to statutory exception

and to the provisions of relevant collective licensing agreements,
no reproduction of any part may take place without
the written permission of Cambridge University Press.
First published 2012
Printed in the United Kingdom at the University Press, Cambridge
A catalogue record for this publication is available from the British Library
Library of Congress Cataloging-in-Publication Data

Van den Bergh, Marc.
Atlas of oocytes, zygotes and embryos in reproductive medicine / Marc Van den Bergh,
Kay Elder, Thomas Ebner.
p. cm.
ISBN 978-1-107-00464-1
1. Fertilization in vitro, Human–Atlases. 2. Ovum–Atlases. 3. Zygotes–Atlases.
4. Human embryo–Atlases. I. Elder, Kay, 1946– II. Ebner, Thomas. III. Title.
RG135.V36 2012
618.178059900223–dc23
2011038744
ISBN 978-1-10700464-1 Hardback
Cambridge University Press has no responsibility for the persistence

or accuracy of URLs for external or third-party internet websites referred to
in this publication, and does not guarantee that any content on such
websites is, or will remain, accurate or appropriate.
Every effort has been made in preparing this book to provide accurate and up-to-date
information which is in accord with accepted standards and practice at the time of
publication. Although case histories are drawn from actual cases, every effort has been
made to disguise the identities of the individuals involved. Nevertheless, the authors,
editors and publishers can make no warranties that the information contained herein is
totally free from error, not least because clinical standards are constantly changing through
research and regulation. The authors, editors and publishers therefore disclaim all liability
for direct or consequential damages resulting from the use of material contained in this
book. Readers are strongly advised to pay careful attention to information provided by the
manufacturer of any drugs or equipment that they plan to use.
CONTENTS
List of tables page vi

Preface vii
Acknowledgements viii
List of abbreviations ix
Introduction 1
Part A Cleavage stage transfer (KSB, Switzerland) 9

1 No cause of female infertility identified (1–33) 10
2 Tubal infertility (34–40) 76
3 Cervical factors/fibroids (41–44) 90
4 Endometriosis (45–60) 98
5 Poor response/ovulatory dysfunction/age (61–71) 130
6 Polycystic ovarian syndrome (72–74) 152
7 Hyperprolactinaemia/hypothyroid (75–79) 158
8 Recurrent abortion (80) 168
Part B Extended culture (LFKK, Austria) 171

1 No cause of female infertility identified/unexplained (81–94) 172
2 Tubal infertility (95–98) 200
3 Endometriosis (99–102) 208
4 Polycystic ovarian syndrome (103–109) 216
5 Premature ovarian failure (110) 230
6 Translocation (111) 232
Index 234
TABLES
Table 1A KSB: Summary of clinical details of cases, ordered by cause of female

infertility page x
Table 1B LFKK: Summary of clinical details of cases, ordered by cause of female
infertility xiii
Table 2A KSB: Summary of clinical details of cases, ordered by cause of male
diagnosis xiv
Table 2B LFKK: Summary of clinical details of cases, ordered by cause of male
diagnosis xviii
Table 3A KSB: Summary of clinical details of cases, ordered by stimulation
protocol xix
Table 3B LFKK: Summary of clinical details of cases, ordered by stimulation
protocol xxiii
Table 4A KSB: Summary of clinical details of cases, ordered by oestradiol level on
day of hCG xxiv
Table 4B LFKK: Summary of clinical details of cases, ordered by oestradiol level on
day of hCG xxviii
Table 5A KSB: Summary of clinical details of cases, ordered by outcome xxix
Table 5B LFKK: Summary of clinical details of cases, ordered by outcome xxxiii
PREFACE
In common with many in vitro fertilization units Kinderwunsch Zentrum at the Landes- Frauen- und
worldwide, the County Hospital in Baden Kinderklinik (LFKK) Linz in Austria to provide a similar
(Kantonspittal Baden, KSB) has a long-standing set of cases that include images derived from extended
tradition of offering couples photographs of the culture to blastocyst stage. The atlas illustrates images
embryos that are to be transferred. In 2002, a drastic for the oocytes, zygotes and embryos that led to embryo
change in the Swiss law on reproductive medicine transfer in 111 clinical cases, and the complete set of
prohibited embryo freezing, and placed a limitation of images for each case is available on an accompanying
only three fertilized oocytes to be kept in culture for CD that contains over 2000 photographs.
transfer. This restriction prevented us from using This unique combination of a photographic atlas,
characteristics of cleaved embryos as selection criteria together with clinical details as well as access to a
and, instead, we began to look in more detail at features complete image database provides valuable insight into
of oocytes and zygotes as prognostic indicators. We thus the daily practical approach to controlled ovarian
created a large database of images in parallel with stimulation, gamete culture and selection as performed
compulsory data collection for the national Swiss IVF by two experienced and successful IVF teams. In order
register, FIVNAT-CH. All of the images collected during to facilitate searching and comparison of images with
treatment cycles were simultaneously placed within their reference to details of particular clinical and
clinical and historical context, providing a useful atlas of morphological features, we provide supplementary
human gametes, zygotes and embryos in parallel with tables that group the cases according to female infertility
the corresponding details and final outcome of each cause, semen parameters, stimulation protocol,
treatment cycle. The database contains all of the images gonadotropin dose, oestrogen levels and final outcome.
for each individual case, amounting to several thousand We hope that this collection will provide a helpful
photographs. The restrictions imposed by the Swiss law learning tool and reference base not only for students
limits the usefulness of extended culture to blastocyst but also for experienced embryologists and clinicians.
stage as an effective treatment strategy and, therefore, in ‘I think one’s feelings waste themselves in words; they
order to complement the KSB data with this important ought all to be distilled into actions which bring results.’
feature, we called upon the experience of the (Florence Nightingale)
ACKNOWLEDGEMENTS
Sincere thanks to Mr. Martin Schlintl for his help in editing and optimizing
images from Landes- Frauen-und Kinderklinik (LFKK) in Linz, Austria.
We would also like to thank Kantonsspital Baden A.G. (KSB), Switzerland,
LFKK, Austria and Bourn Hall Clinic, Cambridge for supporting the authors
in this project.
MVB
TE
KTE
ABBREVIATIONS
AMH anti-Mullerian hormone ICSI intracytoplasmic sperm injection

ART assisted reproductive technology IUI intrauterine insemination
ATS asthenoteratozoospermia IVF in vitro fertilization
BMI body mass index IVM in vitro maturation
BT blastocyst transfer LDP luteal (long) downregulation protocol
COC cumulus–oocyte complex LH luteinizing hormone
COH controlled ovarian hyperstimulation MH menstrual history
COI cause of infertility MPN multipronucleate
CFTR cystic fibrosis transmembrane conductance MZT monozygotic twins
regulator NAD no abnormality detected
Cx cervical NPB nucleolar precursor body
E oestradiol OATS oligoasthenoteratozoospermia
EEJ electroejaculation OCR oocyte retrieval
ET embryo transfer OHSS ovarian hyperstimulation syndrome
FBT frozen blastocyst transfer PB polar body
FDP follicular phase (short) downregulation PCO polycystic ovaries/polycystic ovarian
protocol syndrome
FET frozen embryo transfer PN pronuclear (scores)
FSH follicular stimulating hormone POF premature ovarian failure
GnRH gonadotropin releasing hormone PVP polyvinylpyrrolidone
GT gonadotropin PVS perivitelline space
GV germinal vesicle sER smooth endoplasmic reticulum
hCG human chorionic gonadotropin s/c subcutaneous (injection)
HMG human menopausal gonadotropin TE trophectoderm
HSG hysterosalpingogram TESE testicular sperm extraction
ICM inner cell mass ZP zona pellucida
TABLES
Table 1A Summary of clinical details of cases, ordered by cause of female infertility
Case Female COI Male F Age Stimulation Total E2 E2 No. of hCG Outcome
diagnosis (yrs) GT ng/mL pmol/L COC
1 None identified TESE (fresh) 24 LDP Not Not Not 11 Positive Biochemical pregnancy
recorded recorded recorded
2 None identified OATS 27 LDP 3300 3014 11066 9 Positive Live birth, healthy girl
3 None identified ATS 28 LDP 5450 1796 6593 9 Positive Live birth, healthy girl
4 None identified OATS 28 LDP 1800 2378 8730 8 Negative
5 None identified ATS 29 Antagonist 1650 2003 7352 12 Positive Ongoing singleton
6 None identified OATS 29 LDP 1950 3153 11575 9 Positive Twin pregnancy, 1st
trimester spontaneous
reduction to singleton
7 None identified Cryptozoospermia 30 LDP 3150 3379 12405 12 Positive Live birth, healthy boy
8 None identified TESE (frozen) 31 LDP 3450 3877 14231 5 Negative
9 None identified Severe OATS 31 LDP 3375 1885 6921 8 Positive Biochemical pregnancy
10 None identified Post-oncology, 32 LDP 3075 3533 12970 9 Negative

frozen sample
11 None identified Severe OATS 32 LDP 2325 4385 16099 9 Positive Ongoing singleton
12 None identified ATS 33 LDP 2100 1703 6253 5 Negative
13 None identified Severe OATS 33 Antagonist 1350 2745 10078 9 Positive Spontaneous abortion,
<12 wks
14 None identified Severe OATS 33 Antagonist 1350 1193 4378 4 Positive Ongoing singleton
16 None identified ATS 34 LDP 4125 4066 14927 9 Positive Ongoing singleton
19 None identified OATS 36 LDP 3375 1475 5416 7 Positive Live birth, healthy boy
21 None identified ATS 36 LDP 3000 898 3296 4 Positive Biochemical pregnancy
22 None identified Severe OATS 37 LDP 3150 1102 4046 16 Negative

Tables xi
Table 1A (cont.)
24 None identified OATS 38 LDP 2475 3074 11285 11 Positive Ongoing singleton
25 None identified Cryptozoospermia 38 LDP 1425 1197 4395 5 Positive Live birth, healthy girl
27 None identified ATS 38 LDP 2925 2459 9028 8 Positive Spontaneous abortion,
<12 wks
28 None identified OATS 38 LDP 2700 2852 10468 11 Positive Ongoing singleton
29 None identified Cryptozoospermia 38 LDP 2700 4120 15126 11 Positive Ongoing singleton
31 None identified Severe OATS 40 LDP 4500 2825 10369 11 Negative
32 None identified ATS 39 Antagonist 1800 615 2258 5 Positive Live birth, healthy boy
34 Tubal ATS 30 LDP 3750 1055 3872 5 Negative
35 Tubal ATS 30 LDP 3600 825 3030 5 Positive Ongoing singleton
36 Tubal OTS 36 LDP 2475 3135 11509 18 Positive Missed abortion,

6.5 wks
37 Tubal ATS 36 LDP 2925 1287 4726 9 Positive Live birth, healthy boy
38 Tubal, endometriosis ATS 33 LDP 2700 3624 13305 11 Negative
39 Tubal Asthenozoospermia 37 LDP 4650 1823 6692 4 Negative
40 Tubal Severe OATS 39 LDP 3225 1733 6361 4 Negative
41 Cervical Asthenozoospermia 37 LDP 4875 755 2773 5 Negative
42 Cervical Teratozoospermia 30 LDP 2700 2098 7700 10 Positive Missed abortion:

gestational sac,
no FH activity
43 Cervical, fibroids ATS 37 FDP 1875 3984 14624 13 Positive Biochemical pregnancy
44 Fibroids OATS 39 LDP 3375 1659 6090 9 Positive Biochemical pregnancy
45 Endometriosis TESE 29 LDP 2925 755 2771 5 Negative
46 Endometriosis, ATS 29 LDP 1875 3041 11165 12 Positive Ongoing singleton

cervical,
prolactinaemia
47 Endometriosis ATS 32 LDP 3600 4123 15135 14 Negative

xii Tables
Table 1A (cont.)
48 Endometriosis Severe OATS 32 LDP 3150 1605 5892 3 Negative
49 Endometriosis ATS 33 LDP 2250 1707 6265 11 Positive Live birth, healthy boy
50 Endometriosis Normozoospermia 34 LDP 2250 1307 4799 8 Negative
51 Endometriosis Teratozoospermia 34 FDP 3300 2025 7432 5 Positive Ongoing singleton
52 Endometriosis Teratozoospermia 35 FDP 5280 633 2325 3 Negative
53 Endometriosis Teratozoospermia 35 Antagonist 1500 632 2321 3 Negative
54 Endometriosis Asthenozoospermia 35 LDP 2326 4349 15966 10 Negative
55 Endometriosis, ATS 35 FDP 4800 2269 8328 8 Positive Twin live birth,
hyperprolactinaemia healthy boys
56 Endometriosis OATS, EEJ 36 Antagonist 2250 1208 4436 2 Negative
57 Endometriosis, poor TESE (fresh) 38 LDP 2925 636 2333 3 Negative

responder
58 Endometriosis, poor TESE (frozen) 38 FDP 3000 998 3663 1 Negative

responder
59 Endometriosis Normozoospermia 39 LDP 3300 2595 9528 3 Positive Spontaneous abortion,

10 wks
60 Endometriosis, age TESE (frozen) 42 LDP 4350 3613 13265 5 Negative
61 Poor responder Severe OATS 26 FDP 3000 2342 8597 5 Positive Live birth, healthy girl
62 Poor responder Normozoospermia 35 FDP 4500 1370 5029 5 Negative
63 Poor responder Cryptozoospermia 36 Antagonist 1500 549 2017 3 Negative
64 Poor responder Cryptozoospermia 37 FDP 3750 1133 4158 3 Negative
65 Poor responder TESE (frozen) 38 Antagonist 2400 667 2449 3 Negative
66 Poor responder Normozoospermia 39 FDP 6750 1826 6702 3 Negative
67 Poor responder Pre-vasectomy, 42 Antagonist 3300 1346 4943 5 Negative

frozen
68 Ovulatory Teratozoospermia 32 Antagonist 2025 2055 7432 5 Negative

dysfunction
69 Ovulatory Severe OATS 38 LDP 2250 2452 9003 11 Negative

dysfunction
70 Anovulation Normozoospermia 33 LDP 1875 3389 12442 16 Negative
71 Age ATS 39 LDP 2850 4592 16856 13 Negative
72 PCO ATS 31 LDP 2175 4709 17287 15 Negative
73 PCO TESE (frozen) 31 Antagonist 1688 1195 4386 4 Negative

Tables xiii
Table 1A (cont.)
74 PCO, endometriosis, ATS 36 Antagonist 1650 707 2595 5 Positive Live birth, healthy baby
tubal
75 Hyperprolactinaemia OATS 37 LDP 3600 857 3147 4 Positive Live birth, healthy girl
76 Hyperprolactinaemia OATS 40 FDP 3600 1473 5407 3 Negative
77 Hyperprolactinaemia ATS 29 LDP 2475 2285 8390 8 Negative
78 Hyperprolactinaemia Teratozoospermia 35 FDP 2700 2344 8606 8 Negative
79 Hypothyroid Mild ATS 30 LDP 2475 482 1768 5 Positive Twin live birth, boy and
girl
80 Recurrent abortion ATS 34 LDP 2925 1983 7278 10 Negative
Table 1B Summary of clinical details of cases, ordered by cause of female infertility
Female COI Male diagnosis Age Stimulation Total E2 E2 No. of hCG Outcome
(yrs) GT ng/mL pm/L COC
81 None identified Severe OATS 25 Antagonist 1350 1285 4717 11 Positive Ongoing singleton,
vanishing twin
82 None identified Teratozoospermia 27 LDP 1150 2390 8774 8 Positive Ongoing singleton
83 None identified ATS 28 LDP 1800 2138 7849 12 Positive Monozygotic twins
after single BT
84 None identified Teratozoospermia 29 Antagonist 1350 933 3425 10 Positive Ongoing singleton
85 None identified Teratozoospermia 32 Antagonist 1300 961 3528 7 Positive Ongoing singleton
86 None identified ATS 32 LDP 1950 1215 4460 10 Positive Ongoing twins
87 None identified TESE (frozen) 32 LDP 2100 1849 6788 5 Negative
88 None identified Severe OATS 34 LDP 1600 3897 14306 13 Positive Ongoing twins
89 None identified Teratozoospermia 34 LDP 1650 1251 4592 9 Positive Ongoing singleton
90 None identified ATS 34 Antagonist 1387 970 3561 6 Negative
92 None identified ATS 37 LDP 1650 1268 4655 9 Positive Ongoing twins
93 Unexplained ATS 32 LDP 1875 1960 7195 8 Positive Molar pregnancy 8/40
94 Unexplained, failed Normozoospermia 40 Antagonist 1725 1022 3752 9 Negative

IVF
xiv Tables
Table 1B (cont.)
Female COI Male diagnosis Age Stimulation Total E2 E2 No. of hCG Outcome
95 Tubal, Asthenozoospermia 25 LDP 1087.5 1647 6046 6 Negative

hyperprolactinaemia
96 Tubal Asthenozoospermia 32 LDP 1500 2622 9625 11 Negative Positive after

subsequent frozen BT
97 Tubal Teratozoospermia 33 LDP 1500 881 3234 8 Positive Ongoing singleton
98 Tubal Teratozoospermia 38 LDP 2475 3291 12081 20 Negative
99 Endometriosis Mild 27 Antagonist 1650 1703 6252 13 Positive Ongoing singleton

teratozoospermia
100 Endometriosis Asthenozoospermia 32 Antagonist 1350 1584 5815 10 Negative
101 Endometriosis III, Teratozoospermia 34 LDP 1500 3237 11883 9 Positive

tubal
102 Endometriosis, Teratozoospermia 41 Antagonist 3525 2584 9486 6 Negative

tubal
103 PCO Teratozoospermia 27 Antagonist 1050 1638 6013 6 Negative
104 PCO, Normozoospermia 32 LDP 2775 3162 11608 21 Positive Ongoing twins
hyperprolactinaemia
105 PCO (WHO I) Normozoospermia 32 Antagonist 2327 2211 8117 12 Positive Ongoing singleton
106 PCO Teratozoospermia 33 Antagonist 972 1157 4247 11 Positive Ongoing singleton
107 PCO ATS 34 Antagonist 1400 1115 4093 7 Negative
108 PCO Teratozoospermia 38 Antagonist 1387.5 3198 11740 11 Negative
109 PCO Teratozoospermia 40 LDP 875 4379 16075 8 Negative
110 POF Teratozoospermia 30 Antagonist 2400 274 1006 1 Negative
111 Translocation Teratozoospermia 34 LDP 975 2483 9115 14 Negative
Table 2A Summary of clinical details of cases, ordered by cause of male diagnosis
Male diagnosis Case Female COI F Age Protocol Total E2 E2 No. of hCG Outcome
(yrs) GT ng/mL pmol/L COC
Normozoospermia 50 Endometriosis 34 LDP 2250 1307 4799 8 Negative
Normozoospermia 59 Endometriosis 39 LDP 3300 2595 9528 3 Positive Spontaneous

abortion, 10 wks
Normozoospermia 62 Poor responder 35 FDP 4500 1370 5029 5 Negative
Normozoospermia 66 Poor responder 39 FDP 6750 1826 6702 3 Negative

Tables xv
Table 2A (cont.)
Normozoospermia 70 Anovulation 33 LDP 1875 3389 12442 16 Negative
Asthenozoospermia 39 Tubal 37 LDP 4650 1823 6692 4 Negative
Asthenozoospermia 41 Cervical 37 LDP 4875 755 2773 5 Negative
Asthenozoospermia 54 Endometriosis 35 LDP 2326 4349 15966 10 Negative
Teratozoospermia 42 Cervical 30 LDP 2700 2098 7700 10 Positive Missed abortion:

gestational sac,
no FH activity
Teratozoospermia 51 Endometriosis 34 FDP 3300 2025 7432 5 Positive Ongoing singleton
Teratozoospermia 52 Endometriosis 35 FDP 5280 633 2325 3 Negative
Teratozoospermia 53 Endometriosis 35 Antagonist 1500 632 2321 3 Negative
Teratozoospermia 78 Hyperprolactinaemia 35 FDP 2700 2344 8606 8 Negative
Teratozoospermia 68 Ovulatory 32 Antagonist 2025 2055 7432 5 Negative

dysfunction
Mild ATS 79 Hypothyroid 30 LDP 2475 482 1768 5 Positive Twin live birth,
boy and girl
ATS 3 None identified 28 LDP 5450 1796 6593 9 Positive Live birth,
healthy girl
ATS 5 None identified 29 Antagonist 1650 2003 7352 12 Positive Ongoing singleton
ATS 12 None identified 33 LDP 2100 1703 6253 5 Negative
ATS 16 None identified 34 LDP 4125 4066 14927 9 Positive Ongoing singleton
ATS 21 None identified 36 LDP 3000 898 3296 4 Positive Biochemical

pregnancy
ATS 27 None identified 38 LDP 2925 2459 9028 8 Positive Spontaneous

abortion, <12 wks
ATS 32 None identified 39 Antagonist 1800 615 2258 5 Positive Live birth,
healthy boy
ATS 34 Tubal 30 LDP 3750 1055 3872 5 Negative
ATS 35 Tubal 30 LDP 3600 825 3030 5 Positive Ongoing singleton
ATS 37 Tubal 36 LDP 2925 1287 4726 9 Positive Live birth,

healthy boy
ATS 38 Tubal, endometriosis 33 LDP 2700 3624 13305 11 Negative

xvi Tables
Table 2A (cont.)
ATS 43 Cervical, fibroids 37 FDP 1875 3984 14624 13 Positive Biochemical

pregnancy
ATS 46 Endometriosis, 29 LDP 1875 3041 11165 12 Positive Ongoing singleton

prolactinaemia,
cervical
ATS 47 Endometriosis 32 LDP 3600 4123 15135 14 Negative
ATS 49 Endometriosis 33 LDP 2250 1707 6265 11 Positive Live birth, healthy
boy
ATS 55 Endometriosis, 35 FDP 4800 2269 8328 8 Positive Twin live birth,
ATS 71 Age 39 LDP 2850 4592 16856 13 Negative
ATS 72 PCO 31 LDP 2175 4709 17287 15 Negative
ATS 74 PCO, endometriosis, 36 Antagonist 1650 707 2595 5 Positive Live birth, healthy
tubal baby
ATS 77 Hyperprolactinaemia 29 LDP 2475 2285 8390 8 Negative
ATS 80 Recurrent abortion 34 LDP 2925 1983 7278 10 Negative
OATS 2 None identified 27 LDP 3300 3014 11066 9 Positive Live birth, healthy
girl
OATS 4 None identified 28 LDP 1800 2378 8730 8 Negative
OATS 6 None identified 29 LDP 1950 3153 11575 9 Positive Twin pregnancy,
1st trimester
spontaneous
reduction to
singleton
OATS 19 None identified 36 LDP 3375 1475 5416 7 Positive Live birth,
healthy boy
OATS 24 None identified 38 LDP 2475 3074 11285 11 Positive Ongoing singleton
OATS 28 None identified 38 LDP 2700 2852 10468 11 Positive Ongoing singleton
OATS 36 Tubal 36 LDP 2475 3135 11509 18 Positive Missed abortion,

6.5 wks
OATS 44 Fibroids 39 LDP 3375 1659 6090 9 Positive Biochemical

pregnancy
Tables xvii
Table 2A (cont.)
OATS, EEJ 56 Endometriosis 36 Antagonist 2250 1208 4436 2 Negative
OATS 75 Hyperprolactinaemia 37 LDP 3600 857 3147 4 Positive Live birth,

healthy girl
OATS 76 Hyperprolactinaemia 40 FDP 3600 1473 5407 3 Negative
Severe OATS 9 None identified 31 LDP 3375 1885 6921 8 Positive Biochemical
pregnancy
Severe OATS 11 None identified 32 LDP 2325 4385 16099 9 Positive Ongoing singleton
Severe OATS 13 None identified 33 Antagonist 1350 2745 10078 9 Positive Spontaneous
abortion, <12 wks
Severe OATS 14 None identified 33 Antagonist 1350 1193 4378 4 Positive Ongoing singleton
Severe OATS 22 None identified 37 LDP 3150 1102 4046 16 Negative
Severe OATS 31 None identified 40 LDP 4500 2825 10369 11 Negative
Severe OATS 40 Tubal 39 LDP 3225 1733 6361 4 Negative
Severe OATS 48 Endometriosis 32 LDP 3150 1605 5892 3 Negative
Severe OATS 61 Poor responder 26 FDP 3000 2342 8597 5 Positive Live birth,
healthy girl
Severe OATS 69 Ovulatory 38 LDP 2250 2452 9003 11 Negative

dysfunction
Cryptozoospermia 7 None identified 30 LDP 3150 3379 12405 12 Positive Live birth,
healthy boy
Cryptozoospermia 25 None identified 38 LDP 1425 1197 4395 5 Positive Live birth,
healthy girl
Cryptozoospermia 29 None identified 38 LDP 2700 4120 15126 11 Positive Ongoing singleton
Cryptozoospermia 63 Poor responder 36 Antagonist 1500 549 2017 3 Negative
Cryptozoospermia 64 Poor responder 37 FDP 3750 1133 4158 3 Negative
TESE (fresh) 1 None identified 24 LDP Not Not Not 11 Positive Biochemical
recorded recorded recorded pregnancy
TESE (frozen) 8 None identified 31 LDP 3450 3877 14231 5 Negative
TESE (fresh) 45 Endometriosis 29 LDP 2925 755 2771 5 Negative
TESE (fresh) 57 Endometriosis, poor 38 LDP 2925 636 2333 3 Negative

responder
TESE (frozen) 58 Endometriosis, poor 38 FDP 3000 998 3663 1 Negative

responder
TESE (frozen) 60 Endometriosis, age 42 LDP 4350 3613 13265 5 Negative

xviii Tables
Table 2A (cont.)
TESE (frozen) 65 Poor responder 38 Antagonist 2400 667 2449 3 Negative
TESE (frozen) 73 PCO 31 Antagonist 1688 1195 4386 4 Negative
Post-oncology, 10 None identified 32 LDP 3075 3533 12970 9 Negative

frozen sample
Pre-vasectomy, 67 Poor responder 42 Antagonist 3300 1346 4943 5 Negative

frozen
Table 2B Summary of clinical details of cases, ordered by cause of male diagnosis
Male diagnosis Female COI Age Stimulation Total E2 E2 No. of hCG Outcome
Normozoospermia 94 Unexplained, failed 40 Antagonist 1725 1022 3752 9 Negative

IVF
Normozoospermia 104 PCO, 32 LDP 2775 3162 11608 21 Positive Ongoing twins
hyperprolactinaemia
Normozoospermia 105 PCO (WHO I) 32 Antagonist 2327 2211 8117 12 Positive Ongoing singleton
Asthenozoospermia 95 Tubal, 25 LDP 1087.5 1647 6046 6 Negative

hyperprolactinaemia
Asthenozoospermia 96 Tubal 32 LDP 1500 2622 9625 11 Negative Positive after

subsequent frozen
BT
Asthenozoospermia 100 Endometriosis 32 Antagonist 1350 1584 5815 10 Negative
ATS 83 28 LDP 1800 2138 7849 12 Positive Monozygotic twins

after single BT
ATS 86 32 LDP 1950 1215 4460 10 Positive Ongoing twins
ATS 90 34 Antagonist 1387 970 3561 6 Negative
ATS 92 37 LDP 1650 1268 4655 9 Positive Ongoing twins
ATS 93 Unexplained 32 LDP 1875 1960 7195 8 Positive Molar pregnancy

8/40
ATS 107 PCO 34 Antagonist 1400 1115 4093 7 Negative
Mild 99 Endometriosis 27 Antagonist 1650 1703 6252 13 Positive Ongoing singleton

teratozoospermia
Teratozoospermia 82 27 LDP 1150 2390 8774 8 Positive Ongoing singleton
Teratozoospermia 84 29 Antagonist 1350 933 3425 10 Positive Ongoing singleton
Teratozoospermia 85 32 Antagonist 1300 961 3528 7 Positive Ongoing singleton

Tables xix
Table 2B (cont.)
Male diagnosis Female COI Age Stimulation Total E2 E2 No. of hCG Outcome
Teratozoospermia 89 34 LDP 1650 1251 4592 9 Positive Ongoing singleton
Teratozoospermia 97 Tubal 33 LDP 1500 881 3234 8 Positive Ongoing singleton
Teratozoospermia 98 Tubal 38 LDP 2475 3291 12081 20 Negative
Teratozoospermia 101 Endometriosis III, 34 LDP 1500 3237 11883 9 Positive

tubal
Teratozoospermia 102 Endometriosis, 41 Antagonist 3525 2584 9486 6 Negative

tubal
Teratozoospermia 103 PCO 27 Antagonist 1050 1638 6013 6 Negative
Teratozoospermia 106 PCO 33 Antagonist 972 1157 4247 11 Positive Ongoing singleton
Teratozoospermia 108 PCO 38 Antagonist 1387.5 3198 11740 11 Negative
Teratozoospermia 109 PCO 40 LDP 875 4379 16075 8 Negative
Teratozoospermia 110 POF 30 Antagonist 2400 274 1006 1 Negative
Teratozoospermia 111 Translocation 34 LDP 975 2483 9115 14 Negative
Severe OATS 81 None identified 25 Antagonist 1350 1285 4717 11 Positive Ongoing singleton,
vanishing twin
Severe OATS 88 None identified 34 LDP 1600 3897 14306 13 Positive Ongoing twins
TESE (frozen) 87 None identified 32 LDP 2100 1849 6788 5 Negative
Table 3A Summary of clinical details of cases, ordered by stimulation protocol
Stimulation Case Female COI Male F Age Total E2 E2 No. of hCG Outcome
diagnosis (yrs) GT pmol/L ng/mL COC
Antagonist 5 None identified ATS 29 1650 7352 2003 12 Positive Ongoing singleton
Antagonist 13 None identified Severe OATS 33 1350 10078 2745 9 Positive Spontaneous
abortion, <12 wks
Antagonist 14 None identified Severe OATS 33 1350 4378 1193 4 Positive Ongoing singleton
Antagonist 32 None identified ATS 39 1800 2258 615 5 Positive Live birth, healthy
boy
Antagonist 53 Endometriosis Teratozoospermia 35 1500 2321 632 3 Negative
Antagonist 56 Endometriosis OATS, EEJ 36 2250 4436 1208 2 Negative
Antagonist 63 Poor responder Cryptozoospermia 36 1500 2017 549 3 Negative

xx Tables
Table 3A (cont.)
Antagonist 65 Poor responder TESE (frozen) 38 2400 2449 667 3 Negative
Antagonist 67 Poor responder Pre-vasectomy, 42 3300 4943 1346 5 Negative

frozen
Antagonist 68 Ovulatory Teratozoospermia 32 2025 7432 2055 5 Negative

dysfunction
Antagonist 73 PCO TESE (frozen) 31 1688 4386 1195 4 Negative
Antagonist 74 PCO, endometriosis, ATS 36 1650 2595 707 5 Positive Live birth, healthy
tubal baby
FDP 43 Cervical, fibroids ATS 37 1875 14624 3984 13 Positive Biochemical

pregnancy
FDP 51 Endometriosis Teratozoospermia 34 3300 7432 2025 5 Positive Ongoing singleton
FDP 52 Endometriosis Teratozoospermia 35 5280 2325 633 3 Negative
FDP 55 Endometriosis, ATS 35 4800 8328 2269 8 Positive Twin live birth,
FDP 58 Endometriosis, poor TESE (frozen) 38 3000 3663 998 1 Negative

responder
FDP 61 Poor responder Severe OATS 26 3000 8597 2342 5 Positive Live birth, healthy
girl
FDP 62 Poor responder Normozoospermia 35 4500 5029 1370 5 Negative
FDP 64 Poor responder Cryptozoospermia 37 3750 4158 1133 3 Negative
FDP 66 Poor responder Normozoospermia 39 6750 6702 1826 3 Negative
FDP 76 Hyperprolactinaemia OATS 40 3600 5407 1473 3 Negative
FDP 78 Hyperprolactinaemia Teratozoospermia 35 2700 8606 2344 8 Negative
LDP 1 None identified TESE (fresh) 24 Not Not Not 11 Positive Biochemical
LDP 2 None identified OATS 27 3300 11066 3014 9 Positive Live birth, healthy
girl
LDP 3 None identified ATS 28 5450 6593 1796 9 Positive Live birth, healthy
girl
LDP 4 None identified OATS 28 1800 8730 2378 8 Negative
LDP 6 None identified OATS 29 1950 11575 3153 9 Positive Twin pregnancy,
1st trimester
spontaneous
reduction to
singleton
LDP 7 None identified Cryptozoospermia 30 3150 12405 3379 12 Positive Live birth, healthy
boy
Tables xxi
Table 3A (cont.)
LDP 8 None identified TESE (frozen) 31 3450 14231 3877 5 Negative
LDP 9 None identified Severe OATS 31 3375 6921 1885 8 Positive Biochemical
pregnancy
LDP 10 None identified Post-oncology, 32 3075 12970 3533 9 Negative

frozen sample
LDP 11 None identified Severe OATS 32 2325 16099 4385 9 Positive Ongoing singleton
LDP 12 None identified ATS 33 2100 6253 1703 5 Negative
LDP 16 None identified ATS 34 4125 14927 4066 9 Positive Ongoing singleton
LDP 19 None identified OATS 36 3375 5416 1475 7 Positive Live birth, healthy
boy
LDP 21 None identified ATS 36 3000 3296 898 4 Positive Biochemical

pregnancy
LDP 22 None identified Severe OATS 37 3150 4046 1102 16 Negative
LDP 24 None identified OATS 38 2475 11285 3074 11 Positive Ongoing singleton
LDP 25 None identified Cryptozoospermia 38 1425 4395 1197 5 Positive Live birth, healthy
girl
LDP 27 None identified ATS 38 2925 9028 2459 8 Positive Spontaneous

abortion, <12 wks
LDP 28 None identified OATS 38 2700 10468 2852 11 Positive Ongoing singleton
LDP 29 None identified Cryptozoospermia 38 2700 15126 4120 11 Positive Ongoing singleton
LDP 31 None identified Severe OATS 40 4500 10369 2825 11 Negative
LDP 34 Tubal ATS 30 3750 3872 1055 5 Negative
LDP 35 Tubal ATS 30 3600 3030 825 5 Positive Ongoing singleton
LDP 36 Tubal ATS 36 2475 11509 3135 18 Positive Missed abortion,

6.5 wks
xxii Tables
Table 3A (cont.)
LDP 37 Tubal ATS 36 2925 4726 1287 9 Positive Live birth, healthy
boy
LDP 38 Tubal, endometriosis ATS 33 2700 13305 3624 11 Negative
LDP 39 Tubal Asthenozoospermia 37 4650 6692 1823 4 Negative
LDP 40 Tubal Severe OATS 39 3225 6361 1733 4 Negative
LDP 41 Cervical Asthenozoospermia 37 4875 2773 755 5 Negative
LDP 42 Cervical Teratozoospermia 30 2700 7700 2098 10 Positive Missed abortion:

gestational sac,
no FH activity
LDP 44 Fibroids OATS 39 3375 6090 1659 9 Positive Biochemical

pregnancy
LDP 45 Endometriosis TESE 29 2925 2771 755 5 Negative
LDP 46 Endometriosis, ATS 29 1875 11165 3041 12 Positive Ongoing singleton

prolactinaemia,
cervical
LDP 47 Endometriosis ATS 32 3600 15135 4123 14 Negative
LDP 48 Endometriosis Severe OATS 32 3150 5892 1605 3 Negative
LDP 49 Endometriosis ATS 33 2250 6265 1707 11 Positive Live birth, healthy
boy
LDP 50 Endometriosis Normozoospermia 34 2250 4799 1307 8 Negative
LDP 54 Endometriosis Asthenozoospermia 35 2326 15966 4349 10 Negative
LDP 57 Endometriosis, poor TESE (fresh) 38 2925 2333 636 3 Negative

responder
LDP 59 Endometriosis Normozoospermia 39 3300 9528 2595 3 Positive Singleton clinical

pregnancy,
spontaneous
abortion 10 wks
LDP 60 Endometriosis, age TESE (frozen) 42 4350 13265 3613 5 Negative
LDP 69 Ovulatory Severe OATS 38 2250 9003 2452 11 Negative

dysfunction
LDP 70 Anovulation Normozoospermia 33 1875 12442 3389 16 Negative
LDP 71 Age ATS 39 2850 16856 4592 13 Negative
LDP 72 PCO ATS 31 2175 17287 4709 15 Negative
LDP 75 Hyperprolactinaemia OATS 37 3600 3147 857 4 Positive Live birth, healthy
girl
Tables xxiii
Table 3A (cont.)
LDP 77 Hyperprolactinaemia ATS 29 2475 8390 2285 8 Negative
LDP 79 Hypothyroid Mild ATS 30 2475 1768 482 5 Positive Twin live birth,
boy and girl
LDP 80 Recurrent abortion ATS 34 2925 7278 1983 10 Negative
Table 3B Summary of clinical details of cases, ordered by stimulation protocol
Stimulation Female COI Male diagnosis Age Total E2 E2 No. of hCG Outcome
(yrs) GT pm/L ng/mL COC
Antagonist 81 None identified Severe OATS 25 1350 4717 1285 11 Positive Ongoing singleton,
vanishing twin
Antagonist 84 None identified Teratozoospermia 29 1350 3425 933 10 Positive Ongoing singleton
Antagonist 85 None identified Teratozoospermia 32 1300 3528 961 7 Positive
Antagonist 90 None identified ATS 34 1387 3561 970 6 Negative
Antagonist 94 Unexplained, failed Normozoospermia 40 1725 3752 1022 9 Negative

IVF
Antagonist 99 Endometriosis Mild 27 1650 6252 1703 13 Positive Ongoing singleton

teratozoospermia
Antagonist 100 Endometriosis Asthenozoospermia 32 1350 5815 1584 10 Negative
Antagonist 102 Endometriosis, Teratozoospermia 41 3525 9486 2584 6 Negative

tubal
Antagonist 103 PCO Teratozoospermia 27 1050 6013 1638 6 Negative
Antagonist 105 PCO (WHO I) Normozoospermia 32 2327 8117 2211 12 Positive Ongoing singleton
Antagonist 106 PCO Teratozoospermia 33 972 4247 1157 11 Positive Ongoing singleton
Antagonist 107 PCO ATS 34 1400 4093 1115 7 Negative
Antagonist 108 PCO Teratozoospermia 38 1387.5 11740 3198 11 Negative
Antagonist 110 POF Teratozoospermia 30 2400 1006 274 1 Negative
LDP 82 None identified Teratozoospermia 27 1150 8774 2390 8 Positive Ongoing singleton
LDP 83 None identified ATS 28 1800 7849 2138 12 Positive Monozygotic twins
after single BT
LDP 86 None identified ATS 32 1950 4460 1215 10 Positive Ongoing twins
LDP 87 None identified TESE (frozen) 32 2100 6788 1849 5 Negative
LDP 88 None identified Severe OATS 34 1600 14306 3897 13 Positive Ongoing twins
xxiv Tables
Table 3B (cont.)
Stimulation Female COI Male diagnosis Age Total E2 E2 No. of hCG Outcome
LDP 89 None identified Teratozoospermia 34 1650 4592 1251 9 Positive Ongoing singleton
LDP 92 None identified ATS 37 1650 4655 1268 9 Positive Ongoing twins
LDP 93 Unexplained ATS 32 1875 7195 1960 8 Positive Molar pregnancy

8/40
LDP 95 Tubal, Asthenozoospermia 25 1087.5 6046 1647 6 Negative

hyperprolactinaemia
LDP 96 Tubal Asthenozoospermia 32 1500 9625 2622 11 Negative Positive after

subsequent frozen
BT
LDP 97 Tubal Teratozoospermia 33 1500 3234 881 8 Positive Ongoing singleton
LDP 98 Tubal Teratozoospermia 38 2475 12081 3291 20 Negative
LDP 101 Endometriosis III, Teratozoospermia 34 1500 11883 3237 9 Positive

tubal
LDP 104 PCO, Normozoospermia 32 2775 11608 3162 21 Positive Ongoing twins
hyperprolactinaemia
LDP 109 PCO Teratozoospermia 40 875 16075 4379 8 Negative
LDP 111 Translocation Teratozoospermia 34 975 9115 2483 14 Negative
Table 4A Summary of clinical details of cases, ordered by oestradiol level on day of hCG
E2 E2 Total Case Female COI Male F Age Stimulation No. of hCG Outcome
ng/mL pmol/L GT (yrs) COC
482 1768 2475 79 Hypothyroid Mild ATS 30 LDP 5 Positive Twin live birth,
boy and girl
549 2017 1500 63 Poor responder Cryptozoospermia 36 Antagonist 3 Negative
615 2258 1800 32 None identified ATS 39 Antagonist 5 Positive Live birth,
healthy boy
632 2321 1500 53 Endometriosis Teratozoospermia 35 Antagonist 3 Negative
633 2325 5280 52 Endometriosis Teratozoospermia 35 FDP 3 Negative
636 2333 2925 57 Endometriosis, poor TESE (fresh) 38 LDP 3 Negative

responder
667 2449 2400 65 Poor responder TESE frozen 38 Antagonist 3 Negative

Tables xxv
Table 4A (cont.)
707 2595 1650 74 PCO, endometriosis, ATS 36 Antagonist 5 Positive Live birth,
tubal healthy baby
755 2771 2925 45 Endometriosis TESE 29 LDP 5 Negative
755 2773 4875 41 Cervical Asthenozoospermia 37 LDP 5 Negative
825 3030 3600 35 Tubal ATS 30 LDP 5 Positive Ongoing

singleton
857 3147 3600 75 Hyperprolactinaemia OATS 37 LDP 4 Positive Live birth,

healthy girl
898 3296 3000 21 None identified ATS 36 LDP 4 Positive Biochemical

pregnancy
998 3663 3000 58 Endometriosis, poor TESE (frozen) 38 FDP 1 Negative

responder
1055 3872 3750 34 Tubal ATS 30 LDP 5 Negative
1102 4046 3150 22 None identified Severe OATS 37 LDP 16 Negative
1133 4158 3750 64 Poor responder Cryptozoospermia 37 FDP 3 Negative
1186 4353 2700 17 None identified ATS 34 LDP 10 Negative
1193 4378 1350 14 None identified Severe OATS 33 Antagonist 4 Positive Ongoing
singleton
1195 4386 1688 73 PCO TESE (frozen) 31 Antagonist 4 Negative
1197 4395 1425 25 None identified Cryptozoospermia 38 LDP 5 Positive Live birth,
healthy girl
1208 4436 2250 56 Endometriosis OATS, EEJ 36 Antagonist 2 Negative
1287 4726 2925 37 Tubal ATS 36 LDP 9 Positive Live birth,

healthy boy
1307 4799 2250 50 Endometriosis Normozoospermia 34 LDP 8 Negative
1346 4943 3300 67 Poor responder Pre-vasectomy, 42 Antagonist 5 Negative

frozen
1370 5029 4500 62 Poor responder Normozoospermia 35 FDP 5 Negative
1384 5081 2700 26 None identified OATS 38 LDP 2 Negative
1473 5407 3600 76 Hyperprolactinaemia OATS 40 FDP 3 Negative
1475 5416 3375 19 None identified OATS 36 LDP 7 Positive Live birth,
healthy boy
1605 5892 3150 48 Endometriosis Severe OATS 32 LDP 3 Negative
1659 6090 3375 44 Fibroids OATS 39 LDP 9 Positive Biochemical

pregnancy
xxvi Tables
Table 4A (cont.)
1707 6265 2250 49 Endometriosis ATS 33 LDP 11 Positive Live birth,

healthy boy
1733 6361 3225 40 Tubal Severe OATS 39 LDP 4 Negative
1796 6593 5450 3 None identified ATS 28 LDP 9 Positive Live birth,
healthy girl
1823 6692 4650 39 Tubal Asthenozoospermia 37 LDP 4 Negative
1826 6702 6750 66 Poor responder Normozoospermia 39 FDP 3 Negative
1885 6921 3375 9 None identified Severe OATS 31 LDP 8 Positive Biochemical
pregnancy
1962 7278 2925 80 Recurrent abortion ATS 34 LDP 10 Negative
2003 7352 1650 5 None identified ATS 29 Antagonist 12 Positive Ongoing

singleton
2055 7432 2025 68 Ovulatory Teratozoospermia 32 Antagonist 5 Negative

dysfunction
2025 7432 3300 51 Endometriosis Teratozoospermia 34 FDP 5 Positive Ongoing

singleton
2098 7700 2700 42 Cervical Teratozoospermia 30 LDP 10 Positive Missed abortion:

gestational sac,
no FH activity
2269 8328 4800 55 Endometriosis, ATS 35 FDP 8 Positive Twin live birth,
2285 8390 2475 77 Hyperprolactinaemia ATS 29 LDP 8 Negative
2342 8597 3000 61 Poor responder Severe OATS 26 FDP 5 Positive Live birth,
healthy girl
2344 8606 2700 78 Hyperprolactinaemia Teratozoospermia 35 FDP 8 Negative
2452 9003 2250 69 Ovulatory Severe OATS 38 LDP 11 Negative

dysfunction
2459 9028 2925 27 None identified ATS 38 LDP 8 Positive Spontaneous

abortion,
<12 wks
2595 9528 3300 59 Endometriosis Normozoospermia 39 LDP 3 Positive Spontaneous

abortion, 10 wks
2745 10078 1350 13 None identified Severe OATS 33 Antagonist 9 Positive Spontaneous
abortion,
<12 wks
Tables xxvii
Table 4A (cont.)
2825 10369 4500 31 None identified Severe OATS 40 LDP 11 Negative
2852 10468 2700 28 None identified OATS 38 LDP 11 Positive Ongoing

singleton
2943 10803 2475 18 None identified Severe OATS 34 LDP 8 Positive Ongoing
singleton
3014 11066 3300 2 None identified OATS 27 LDP 9 Positive Live birth,
healthy girl
3041 11165 1875 46 Endometriosis, ATS 29 LDP 12 Positive Ongoing

prolactinaemia, singleton
cervical
3074 11285 2475 24 None identified OATS 38 LDP 11 Positive Ongoing

singleton
3135 11509 2475 36 Tubal OTS 36 LDP 18 Positive Missed abortion,

6.5 wks
3153 11575 1950 6 None identified OATS 29 LDP 9 Positive Twin pregnancy,
1st trimester
spontaneous
reduction to
singleton
3379 12405 3150 7 None identified Cryptozoospermia 30 LDP 12 Positive Live birth,
healthy boy
3389 12442 1875 70 Anovulation Normozoospermia 33 LDP 16 Negative
3533 12970 3075 10 None identified Post-oncology, 32 LDP 9 Negative

frozen sample
3613 13265 4350 60 Endometriosis, age TESE (frozen) 42 LDP 5 Negative
3624 13305 2700 38 Tubal, endometriosis ATS 33 LDP 11 Negative
3877 14231 3450 8 None identified TESE (frozen) 31 LDP 5 Negative
3984 14624 1875 43 Cervical, fibroids ATS 37 FDP 13 Positive Biochemical

pregnancy
4066 14927 4125 16 None identified ATS 34 LDP 9 Positive Ongoing

singleton
4120 15126 2700 29 None identified Cryptozoospermia 38 LDP 11 Positive Ongoing

singleton
xxviii Tables
Table 4A (cont.)
4123 15135 3600 47 Endometriosis ATS 32 LDP 14 Negative
4349 15966 2326 54 Endometriosis Asthenozoospermia 35 LDP 10 Negative
4385 16099 2325 11 None identified Severe OATS 32 LDP 9 Positive Ongoing
singleton
4592 16856 2850 71 Age ATS 39 LDP 13 Negative
4709 17287 2175 72 PCO ATS 31 LDP 15 Negative
Not Not Not 1 None identified TESE (fresh) 24 LDP 11 Positive Biochemical
Table 4B Summary of clinical details of cases, ordered by oestradiol level on day of hCG
E2 E2 Total Case Female COI Male diagnosis Age Stimulation No. of hCG Outcome
ng/mL pm/L GT (yrs) COC
274 1006 2400 110 POF Teratozoospermia 30 Antagonist 1 Negative
881 3234 1500 97 Tubal Teratozoospermia 33 LDP 8 Positive Ongoing singleton
933 3425 1350 84 None identified Teratozoospermia 29 Antagonist 10 Positive Ongoing singleton
961 3528 1300 85 None identified Teratozoospermia 32 Antagonist 7 Positive Ongoing singleton
970 3561 1387 90 None identified ATS 34 Antagonist 6 Negative
1022 3752 1725 94 Unexplained, Normozoospermia 40 Antagonist 9 Negative

failed IVF
1115 4093 1400 107 PCO ATS 34 Antagonist 7 Negative
1157 4247 972 106 PCO Teratozoospermia 33 Antagonist 11 Positive Ongoing singleton
1215 4460 1950 86 None identified ATS 32 LDP 10 Positive Ongoing twins
1251 4592 1650 89 None identified Teratozoospermia 34 LDP 9 Positive Ongoing singleton
1268 4655 1650 92 None identified ATS 37 LDP 9 Positive Ongoing twins
1285 4717 1350 81 None identified Severe OATS 25 Antagonist 11 Positive Ongoing singleton,
vanishing twin
1389 5099 1650 91 None identified Severe OATS 37 LDP 6 Positive Ongoing singleton
1584 5815 1350 100 Endometriosis Asthenozoospermia 32 Antagonist 10 Negative
1638 6013 1050 103 PCO Teratozoospermia 27 Antagonist 6 Negative
1647 6046 1087.5 95 Tubal, Asthenozoospermia 25 LDP 6 Negative

hyperprolactinaemia
Tables xxix
Table 4B (cont.)
E2 E2 Total Case Female COI Male diagnosis Age Stimulation No. of hCG Outcome
ng/mL pm/L GT (yrs) COC
1703 6252 1650 99 Endometriosis Mild 27 Antagonist 13 Positive Ongoing singleton

teratozoospermia
1849 6788 2100 87 None identified TESE (frozen) 32 LDP 5 Negative
1960 7195 1875 93 Unexplained ATS 32 LDP 8 Positive Molar pregnancy

8/40
2138 7849 1800 83 None identified ATS 28 LDP 12 Positive Monozygotic twins
after single BT
2211 8117 2327 105 PCO (WHO I) Normozoospermia 32 Antagonist 12 Positive Ongoing singleton
2390 8774 1150 82 None identified Teratozoospermia 27 LDP 8 Positive Ongoing singleton
2483 9115 975 111 Translocation Teratozoospermia 34 LDP 14 Negative
2584 9486 3525 102 Endometriosis, Teratozoospermia 41 Antagonist 6 Negative

tubal
2622 9625 1500 96 Tubal Asthenozoospermia 32 LDP 11 Negative Positive after

subsequent frozen
BT
3162 11608 2775 104 PCO, Normozoospermia 32 LDP 21 Positive Ongoing twins
hyperprolactinaemia
3198 11740 1387.5 108 PCO Teratozoospermia 38 Antagonist 11 Negative
3237 11883 1500 101 Endometriosis III, Teratozoospermia 34 LDP 9 Positive

tubal
3291 12081 2475 98 Tubal Teratozoospermia 38 LDP 20 Negative
3897 14306 1600 88 None identified Severe OATS 34 LDP 13 Positive Ongoing twins
4379 16075 875 109 PCO Teratozoospermia 40 LDP 8 Negative
Table 5A Summary of clinical details of cases, ordered by outcome
Outcome hCG Case Female COI Male F Age Stimulation Total E2 E2 No. of
(yrs) GT pmol/L ng/mL COC
Live birth, Positive 2 None identified OATS 27 LDP 3300 11066 3014 9
healthy girl
Live birth, Positive 3 None identified ATS 28 LDP 5450 6593 1796 9
healthy girl
Live birth, Positive 7 None identified Cryptozoospermia 30 LDP 3150 12405 3379 12
healthy boy
Live birth, Positive 19 None identified OATS 36 LDP 3375 5416 1475 7
healthy boy
xxx Tables
Table 5A (cont.)
Live birth, Positive 25 None identified Cryptozoospermia 38 LDP 1425 4395 1197 5
healthy girl
Live birth, Positive 32 None identified ATS 39 Antagonist 1800 2258 615 5
healthy boy
Live birth, Positive 37 Tubal ATS 36 LDP 2925 4726 1287 9

healthy boy
Live birth, Positive 49 Endometriosis ATS 33 LDP 2250 6265 1707 11

healthy boy
Live birth, Positive 61 Poor responder Severe OATS 26 FDP 3000 8597 2342 5
healthy girl
Live birth, Positive 74 PCO, endometriosis, ATS 36 Antagonist 1650 2595 707 5
healthy baby tubal
Live birth, Positive 75 Hyperprolactinaemia OATS 37 LDP 3600 3147 857 4

healthy girl
Twin live Positive 79 Hypothyroid Mild ATS 30 LDP 2475 1768 482 5
birth, boy
and girl
Twin live Positive 55 Endometriosis, ATS 35 FDP 4800 8328 2269 8

birth, healthy hyperprolactinaemia
boys
Twin Positive 6 None identified OATS 29 LDP 1950 11575 3153 9

pregnancy,
1st trimester
spontaneous
reduction to
singleton
Ongoing Positive 5 None identified ATS 29 Antagonist 1650 7352 2003 12

singleton
Ongoing Positive 11 None identified Severe OATS 32 LDP 2325 16099 4385 9
singleton
Ongoing Positive 14 None identified Severe OATS 33 Antagonist 1350 4378 1193 4
singleton
Ongoing Positive 16 None identified ATS 34 LDP 4125 14927 4066 9

singleton
Ongoing Positive 18 None identified Severe OATS 34 LDP 2475 10803 2943 8
singleton
Ongoing Positive 24 None identified OATS 38 LDP 2475 11285 3074 11

singleton
Ongoing Positive 28 None identified OATS 38 LDP 2700 10468 2852 11

singleton
Ongoing Positive 29 None identified Cryptozoospermia 38 LDP 2700 15126 4120 11

singleton
Tables xxxi
Table 5A (cont.)
Ongoing Positive 35 Tubal ATS 30 LDP 3600 3030 825 5

singleton
Ongoing Positive 46 Endometriosis, ATS 29 LDP 1875 11165 3041 12

singleton prolactinaemia,
cervical
Ongoing Positive 51 Endometriosis Teratozoospermia 34 FDP 3300 7432 2025 5

singleton
Spontaneous Positive 59 Endometriosis Normozoospermia 39 LDP 3300 9528 2595 3

abortion, 10
wks
Spontaneous Positive 27 None identified ATS 38 LDP 2925 9028 2459 8

abortion,
<12 wks
Spontaneous Positive 13 None identified Severe OATS 33 Antagonist 1350 10078 2745 9
abortion,
<12 wks
Missed Positive 36 Tubal OTS 36 LDP 2475 11509 3135 18

abortion, 6.5
wks
Missed Positive 42 Cervical Teratozoospermia 30 LDP 2700 7700 2098 10

abortion:
gestational
sac, no FH
activity
Biochemical Positive 1 None identified TESE (fresh) 24 LDP Not Not Not 11
pregnancy recorded recorded recorded
Biochemical Positive 9 None identified Severe OATS 31 LDP 3375 6921 1885 8
pregnancy
Biochemical Positive 21 None identified ATS 36 LDP 3000 3296 898 4

pregnancy
Biochemical Positive 43 Cervical, fibroids ATS 37 FDP 1875 14624 3984 13

pregnancy
Biochemical Positive 44 Fibroids OATS 39 LDP 3375 6090 1659 9

pregnancy
Negative 4 None identified OATS 28 LDP 1800 8730 2378 8
Negative 8 None identified TESE (frozen) 31 LDP 3450 14231 3877 5
Negative 10 None identified Post-oncology, 32 LDP 3075 12970 3533 9

frozen sample
Negative 12 None identified ATS 33 LDP 2100 6253 1703 5

xxxii Tables
Table 5A (cont.)
Negative 22 None identified Severe OATS 37 LDP 3150 4046 1102 16
Negative 31 None identified Severe OATS 40 LDP 4500 10369 2825 11
Negative 34 Tubal ATS 30 LDP 3750 3872 1055 5
Negative 38 Tubal, endometriosis ATS 33 LDP 2700 13305 3624 11
Negative 39 Tubal Asthenozoospermia 37 LDP 4650 6692 1823 4
Negative 40 Tubal Severe OATS 39 LDP 3225 6361 1733 4
Negative 41 Cervical Asthenozoospermia 37 LDP 4875 2773 755 5
Negative 45 Endometriosis TESE 29 LDP 2925 2771 755 5
Negative 47 Endometriosis ATS 32 LDP 3600 15135 4123 14
Negative 48 Endometriosis Severe OATS 32 LDP 3150 5892 1605 3
Negative 50 Endometriosis Normozoospermia 34 LDP 2250 4799 1307 8
Negative 52 Endometriosis Teratozoospermia 35 FDP 5280 2325 633 3
Negative 53 Endometriosis Teratozoospermia 35 Antagonist 1500 2321 632 3
Negative 54 Endometriosis Asthenozoospermia 35 LDP 2326 15966 4349 10
Negative 56 Endometriosis OATS, EEJ 36 Antagonist 2250 4436 1208 2
Negative 57 Endometriosis, poor TESE (fresh) 38 LDP 2925 2333 636 3

responder
Negative 58 Endometriosis, poor TESE (frozen) 38 FDP 3000 3663 998 1

responder
Negative 60 Endometriosis, age TESE (frozen) 42 LDP 4350 13265 3613 5
Negative 62 Poor responder Normozoospermia 35 FDP 4500 5029 1370 5
Negative 63 Poor responder Cryptozoospermia 36 Antagonist 1500 2017 549 3
Negative 64 Poor responder Cryptozoospermia 37 FDP 3750 4158 1133 3
Negative 65 Poor responder TESE frozen 38 Antagonist 2400 2449 667 3
Negative 66 Poor responder Normozoospermia 39 FDP 6750 6702 1826 3

Tables xxxiii
Table 5A (cont.)
Negative 67 Poor responder Pre-vasectomy, 42 Antagonist 3300 4943 1346 5

frozen
Negative 68 Ovulatory Teratozoospermia 32 Antagonist 2025 7432 2055 5

dysfunction
Negative 69 Ovulatory Severe OATS 38 LDP 2250 9003 2452 11

dysfunction
Negative 70 Anovulation Normozoospermia 33 LDP 1875 12442 3389 16
Negative 71 Age ATS 39 LDP 2850 16856 4592 13
Negative 72 PCO ATS 31 LDP 2175 17287 4709 15
Negative 73 PCO TESE (frozen) 31 Antagonist 1688 4386 1195 4
Negative 76 Hyperprolactinaemia OATS 40 FDP 3600 5407 1473 3
Negative 77 Hyperprolactinaemia ATS 29 LDP 2475 8390 2285 8
Negative 78 Hyperprolactinaemia Teratozoospermia 35 FDP 2700 8606 2344 8
Negative 80 Recurrent abortion ATS 34 LDP 2925 7278 1983 10
Table 5B Summary of clinical details of cases, ordered by outcome
Outcome hCG Female COI Male diagnosis Age Stimulation Total E2 E2 No. of
Ongoing twins Positive 86 None identified ATS 32 LDP 1950 4460 1215 10
Ongoing twins Positive 88 None identified Severe OATS 34 LDP 1600 14306 3897 13
Ongoing twins Positive 92 None identified ATS 37 LDP 1650 4655 1268 9
Ongoing twins Positive 104 PCO, Normozoospermia 32 LDP 2775 11608 3162 21
hyperprolactinaemia
Monozygotic twins Positive 83 None identified ATS 28 LDP 1800 7849 2138 12
after single BT
Ongoing singleton, Positive 81 None identified Severe OATS 25 Antagonist 1350 4717 1285 11
vanishing twin
Ongoing singleton Positive 82 None identified Teratozoospermia 27 LDP 1150 8774 2390 8
Ongoing singleton Positive 84 None identified Teratozoospermia 29 Antagonist 1350 3425 933 10
Ongoing singleton Positive 85 None identified Teratozoospermia 32 Antagonist 1300 3528 961 7
Ongoing singleton Positive 89 None identified Teratozoospermia 34 LDP 1650 4592 1251 9
xxxiv Tables
Table 5B (cont.)
Outcome hCG Female COI Male diagnosis Age Stimulation Total E2 E2 No. of
Ongoing singleton Positive 91 None identified Severe OATS 37 LDP 1650 5099 1389 6
Ongoing singleton Positive 97 Tubal Teratozoospermia 33 LDP 1500 3234 881 8
Ongoing singleton Positive 99 Endometriosis Mild 27 Antagonist 1650 6252 1703 13

teratozoospermia
Ongoing singleton Positive 105 PCO (WHO I) Normozoospermia 32 Antagonist 2327 8117 2211 12
Ongoing singleton Positive 106 PCO Teratozoospermia 33 Antagonist 972 4247 1157 11
Molar pregnancy 8/40 Positive 93 Unexplained ATS 32 LDP 1875 7195 1960 8
Positive after frozen Negative 96 Tubal Asthenozoospermia 32 LDP 1500 9625 2622 11
BT, subsequent cycle
Negative 87 None identified TESE (frozen) 32 LDP 2100 6788 1849 5
Negative 90 None identified ATS 34 Antagonist 1387 3561 970 6
Negative 94 Unexplained, failed Normozoospermia 40 Antagonist 1725 3752 1022 9

IVF
Negative 95 Tubal, Asthenozoospermia 25 LDP 1087.5 6046 1647 6

hyperprolactinaemia
Negative 98 Tubal Teratozoospermia 38 LDP 2475 12081 3291 20
Negative 100 Endometriosis Asthenozoospermia 32 Antagonist 1350 5815 1584 10
Positive 101 Endometriosis III, Teratozoospermia 34 LDP 1500 11883 3237 9

tubal
Negative 102 Endometriosis, Teratozoospermia 41 Antagonist 3525 9486 2584 6

tubal
Negative 103 PCO Teratozoospermia 27 Antagonist 1050 6013 1638 6
Negative 107 PCO ATS 34 Antagonist 1400 4093 1115 7
Negative 108 PCO Teratozoospermia 38 Antagonist 1387.5 11740 3198 11
Negative 109 PCO Teratozoospermia 40 LDP 875 16075 4379 8
Negative 110 POF Teratozoospermia 30 Antagonist 2400 1006 274 1
Negative 111 Translocation Teratozoospermia 34 LDP 975 9115 2483 14

Introduction
Clinical embryologists invest a major part of their routine procedure at KSB, and the additional cases from
working day in observing oocytes, zygotes and embryos Austria that demonstrate extended culture to the
in order to optimize the chance of selecting an embryo blastocyst stage therefore add a significant and important
that has the greatest potential of leading to the birth of a dimension to the atlas. The inclusion of cases, images
healthy baby after transfer (Puissant et al., 1987). and descriptions from two entirely separate, independent
Through gradually evolving processes that are largely IVF units also provide an excellent opportunity to
based upon experience, in vitro fertilization (IVF) compare and contrast all of the different parameters
laboratories invariably develop their own systems of of clinical assessment and controlled ovarian
assessment and scoring. In 2011, two major professional hyperstimulation that are theoretically common to
societies, Alpha (Scientists in Reproductive Medicine) all assisted reproductive technology (ART) practices,
and the European Society for Human Reproduction and yet can be applied with differences that may be
and Embryology (ESHRE) Special Interest Group for quite subtle.
Embryology reached a consensus on gamete and embryo The 111 cases are divided into two groups: those that
assessment, which was published as the Istanbul ended in transfer of cleavage stage embryos (KSB) and
Consensus or I.C. (Alpha Scientists in Reproductive those that were placed into extended culture, aiming for
Medicine and ESHRE Special Interest Group of blastocyst transfer (LFKK). Each set of cases was
Embryology, 2011). Practice guidelines that include categorized in the first instance on the basis of female
assessment of embryo morphology have also been indication for treatment. Because female age is accepted
proposed by ASEBIR, the Spanish Embryologists’ Society as the most important contributory factor in the
(Torello et al., 2005), and by the UK’s Association of prognosis for a successful outcome, the cases were sorted
Clinical Embryologists (ACE) in collaboration with the according to female age within each category. For easy
British Fertility Society (Cutting et al., 2008). Although it reference, supplementary summary tables have been
is universally recognized that assessment and scoring of provided so that cases with specific parameters can be
gametes and embryos is largely a matter of experience, identified, for instance, semen parameters, stimulation
which requires a relatively long learning period and is protocol, total gonadotropin dose, oestradiol level, and
known to be subject to substantial intra-observer number of oocytes retrieved.
variation (Arce et al., 2006; Baxter Bendus et al., 2006;
Paternot et al., 2009), dedicated teaching makes it
possible to achieve excellent levels of agreement Cause of infertility, indication
regarding embryo classification. This atlas has been for treatment
compiled as a teaching tool, providing a full collection of 1. No female cause of infertility (COI) identified: male
oocytes and embryos at each stage of development, infertility, or ‘idiopathic’ infertility
placed within the context of clinical and treatment
parameters associated with each couple. The cases Semen assessment was carried out according to the
illustrated were gathered from routine patient treatment fourth edition of the WHO guidelines (1999), with
cycles at two centres: Kantonsspital Baden A.G., the following limits for parameters defined:
Switzerland (KSB) and Kinderwunsch Zentrum Landes- Normozoospermia: >20 x 106/mL
Frauen- und Kinderklinik (LFKK) in Linz, Austria. >50% type AþB or >25% type A
Because of restrictions imposed by legislation in >14% normal forms
Switzerland, blastocyst culture and transfer is not a Oligospermia: <20 x 106/mL
2 Introduction
Asthenospermia: < 50% type AþB or < 25% type A follicular response ascertained by vaginal ultrasound and
Type A fast progressive motility the assessment of oestradiol levels.
Type B non-linear motility
Type C non-progressive motility
Type D immotile
Short gonadotropin releasing hormone
Teratozoospermia: <14% normal forms agonist protocol (follicular phase
Cryptozoospermia: <100 single spermatozoa in the downregulation, FDP)
entire ejaculate The GnRH agonist was administered from day 1 or 2 of
OATS: oligoasthenoteratozoospermia the cycle, and ovarian stimulation initiated on day 2.
The male factor diagnosis is based upon two
diagnostic semen assessments prior to the initiation Gonadotropin releasing hormone antagonist
of treatment; in some cases, the parameters found on protocol
the day of oocyte retrieval differed from those that Human menopausal gonadotropin (Menopur®, Ferring
were used to define the diagnosis. Pharmaceuticals, Saint-Prex, Switzerland) or
recombinant FSH (Puregon®, Aesca Pharma, Vienna,
2. Endometriosis: diagnosed and graded according to Austria) was started on day 3 of the cycle, and GnRH
the revised ASRM guidelines for staging and antagonist ganirelix (Orgalutran®; Organon, Vienna,
classification (Practice Committee of the American Austria or Ganirelix®, Gentaur, Zürich, Switzerland)
Society for Reproductive Medicine, 2006). was administered after 5–6 days of stimulation, when a
3. Tubal damage: confirmed by hysterosalpingogram or 12–13 mm follicle was detected by ultrasound
laparoscopy monitoring.
4. Polycystic ovarian syndrome (PCO): defined Ovulation was induced with 10 000 IU human
according to the Rotterdam Criteria (2003) chorionic gonadotropin (hCG) (Pregnyl®, Aesca
(Rotterdam ESHRE/ASRM, 2004) Pharma, Vienna, Austria or Organon, Pfäffikon,
5. Poor response/ovulatory dysfunction/anovulation/ Switzerland), and vaginal oocyte retrieval was carried out
premature ovarian failure (POF) under ultrasound guidance 36 hours after hCG
6. Hyperprolactinaemia administration.
7. Cervical factors KSB: all cases reported are intracytoplasmic sperm
8. ‘Other’: fibroids, translocation injection (ICSI) cycles, and cumulus cells were removed
immediately after oocyte collection using SynVitro
Hyadase (Medicult Origio GmbH, Berlin, Germany).
Clinical and laboratory protocols After complete enzymatic and mechanical denudation,
germinal vesicle (GV) oocytes were discarded, and
Controlled ovarian hyperstimulation
metaphase I were separated from metaphase II oocytes.
Long gonadotropin releasing hormone agonist These were placed in 30 mL drops of universal IVF
protocol (luteal downregulation protocol, LDP) medium under a layer of liquid paraffin oil (Medicult
Pituitary downregulation was achieved with the use of Origio) in a 3001 Falcon dish, and cultured in an
either the gonadotropin releasing hormone (GnRH) atmosphere of 5% O2, 5% CO2 and 90% N2 until the
agonist goserelin (Zoladex®, AstraZeneca, Zug, time of injection, 5–6 hours after retrieval. Metaphase
Switzerland), depot injection of 3.6 mg on day 21, or I oocytes that had matured to metaphase II, on the basis
buserelin (Suprecur®, Sanofi-Aventis, Frankfurt am of an extruded polar body, were also injected.
Main, Germany). Ovarian stimulation was carried out LFKK: cumulus–oocyte complexes (COC) were
with either menotropin (Humegon®, Organon, Pfäffikon, collected in BM1 medium (Eurobio, Les Ulis, France) and
Switzerland), human menopausal gonadotropin (HMG) incubated for 2–3 hours prior to IVF or ICSI. Denudation
(Menopur®, Ferring, Kiel, Germany) or recombinant for ICSI was performed after brief exposure to 80 IU
follicular stimulating hormone (FSH) (Puregon®, Aesca hyaluronidase (Origio, Berlin, Germany) 2–3 hours after
Pharma, Vienna, Austria). Stimulation was initiated with oocyte retrieval. ICSI was carried out on all oocytes with
a routine starting dose of not less than 150 IU human the first polar body (PB) extruded (metaphase II)
menopausal gonadotropin/FSH and adapted to the immediately after enzymatic and mechanical denudation.
Introduction 3
Sperm preparation to additional treatment where appropriate, for example,

a ready-to-use ionophore in case of previous ICSI failure
KSB: all semen samples were routinely prepared by
(GM508 Cult-active®, Gynemed Lensahn, Germany) or
centrifugation over a two-layer (40%/100%) density
preincubation with theophylline (GM501 SpermMobil,
gradient at 500 g for 20 minutes. The 100% layer was
Gynemed, Lensahn, Germany) in order to increase
washed twice with 5 mL of universal IVF medium
motility in samples obtained by testicular sperm
(Medicult Origio GmbH, Berlin, Germany) and
extraction (TESE).
centrifuged for 10 minutes at 500 g. Cryptozoospermic
samples were washed twice with universal IVF medium,
similar to the density gradient washing steps. The Intracytoplasmic sperm injection
injection dishes (BD Falcon 353655 Becton Dickinson, The technique of ICSI has been described in detail
Allschwil, Switzerland) contained a central 20 mL droplet (Ebner et al., 2001). Briefly, micromanipulation was
of SpermSlowTM (Medicult Origio GmbH, Berlin, performed on an inverted microscope (x200
Germany), surrounded by six 20 mL droplets of flushing magnification, Olympus, Vienna, Austria) with Hoffman
medium (Medicult Origio GmbH, Berlin, Germany), modulation contrast (Modulation Optics Inc.,
overlayed with liquid paraffin. A small amount of the Greenvale, NY, USA), an electronically controlled heated
sperm preparation was added to a drop and incubated stage and hydraulic micromanipulators (Luigs and
for 20 minutes prior to the injection. If available, Neumann, Ratingen, Germany). Injection was performed
hyaluronan-bound spermatozoa were selected and exclusively with the PB at the six o’clock position, using
immobilized by tail crushing as described in detail by Microtech pipettes (Gynemed, Lensahn, Germany).
Van den Bergh et al. (1995, 1998). Testicular spermatozoa A similar micromanipulation set-up was used at KSB,
were preferentially prepared and cultured in universal consisting of a combination of electronically guided
IVF medium 24 hours before the oocyte collection, but micromanipulators (Transferman NK and CellTram
were not treated further (Emiliani et al., 2000, 2001; Vario microinjectors, Vaudaux-Eppendorf AG, Basel,
Van den Bergh et al., 2009). Switzerland) installed on a Leica DMI 3000 B with
LFKK: normozoospermic ejaculates were incubated in modulation contrast and Leica MATS heating stage.
a sperm selecting chamber (Zech-selector, AssTIC Images were captured using the Leica DFC295 camera
Medizintechnik GmbH, Leutsch, Austria), a device that and processed with the Leica application suite (Leica
consists of two concentric wells overlaid by a U-ring Microsystems, Heerburg, Switzerland).
and a cover glass. Progressively motile spermatozoa
migrate from the ejaculate in the outer well to
Culture conditions
concentrate in the medium-filled inner well via a
capillary bridge created by the overlying U-ring. After KSB: oocytes were cultured individually in 20 mL
approximately 1–2 hours, a 500 mL sperm sample can be universal IVF medium (Medicult Origio GmbH, Berlin,
aspirated from the central chamber, analysed and used Germany) overlaid with liquid paraffin, from the time of
for insemination. This method results in the retrieval until pronuclear observation 18 hours after
accumulation of an adequate number of motile sperm injection.
without exposure to centrifugation stress Zygotes were transferred on day 1 into Medicult ISM1
(Ebner et al., 2011a). medium for further culture. An optimal pH of 7.3 was
Samples to be used for ICSI were prepared by a mini obtained in Forma Scientific water-jacked Series II
swim-up technique, and then incubated on the injection incubators in an atmosphere of 5% O2, 5% CO2 and 90%
dish (Falcon type 1006) in 10 mL droplets of fresh BM1- N2. Because of the restrictions imposed by the Swiss law
medium. Two small droplets of a polyvinylpyrrolidone on reproductive medicine, a maximum of three selected
(PVP) solution (MediCult, Copenhagen, Denmark) were zygotes were kept in culture; in general, only two zygotes
also prepared in the same dish. This constellation of were cultured further, in order to keep the overall
droplets under mineral oil avoids potential multiple pregnancy rate below 20% as defined in our ISO
contamination of the PVP by debris carried over from 9001:2008 certified quality management system. Surplus
the sperm suspension. The sperm samples were subjected zygotes were cryopreserved.
4 Introduction
LFKK: oocytes and embryos were cultured Oocyte and embryo assessment/image captions
individually in small drops (10 mL) of either sequential
Embryologists are presented daily with oocytes of
medium (EmbryoAssist® and BlastAssist®, MediCult,
varying qualities, the majority of which result from
Copenhagen, Denmark) or global medium (GM501
desynchronization between nuclear and cytoplasmic
Cult®; Gynemed, Lensahn, Germany), using Falcon type
maturation. At one extreme, cytoplasmic fusion between
351016 culture dishes and a K-MINC-1000 benchtop
two oogonia may lead to so-called giant oocytes, which
incubator (Cook, Brisbane, Australia). The gas mixture
are diploid or, before meiosis, tetraploid, and thus
consisted of 5% O2, 6% CO2 and the remainder N2.
cannot be used for ICSI (Rosenbusch et al., 2002). In
After evaluation of all prognostic markers assessed
other cases, oocytes may be ‘over-mature’, having aged
from day 0 to day 5, a maximum of two embryos/
either in the follicle or in the incubator (Miao et al.,
blastocysts were chosen for intrauterine transfer.
2009).
Embryos were loaded into an Gynetics catheter
In order to facilitate discussion among scientists,
(Gynemed, Lensahn, Germany) using <10 mL of
oocyte anomalies may be classified into extra- and
BlastAssist medium 2 or GM501 Cult, inserted
intracytoplasmic dysmorphisms (Alpha (Scientists in
transcervically and then expelled approximately 1 cm
Reproductive Medicine) and ESHRE Special Interest
from the fundus. The embryo transfer procedure was
Group of Embryology, 2011). Extracytoplasmic
performed without sedation or anaesthesia.
anomalies represent a heterogeneous group of
All images were produced using the Octax EyeWare®
dysmorphisms that include first PB morphology
(MTG, Altdorf, Germany) at a magnification of x400. In
(Ciotti et al., 2004; Ebner et al., 2000, 2002), perivitelline
occasional cases where the expanding blastocyst was
space (PVS) size (Xia, 1997) and granularity (Farhi et al.,
larger than the image section, Adobe Photoshop CS5 was
2002; Hassan-Ali et al., 1998), discolouration (Esfandiari
used to automatically calculate an image from four to six
et al., 2006), zona pellucida (ZP) defects (Esfandiari
raw images.
et al., 2005) and shape anomalies (Ebner et al., 2008b).
The majority of these morphological phenomena seem to
Luteal support
have a negligible effect on further outcome.
KSB: Utrogestan vaginal tablets (300 mg) and Aspirin The same holds true for the vast majority of
Cardio 100 (Bayer, Zürich, Switzerland) were intracytoplasmic anomalies, for example, inclusions or
administered daily from the day after follicular puncture refractile bodies (Otsuki et al., 2007), dense central
until the result of a pregnancy test was known. granulation (Kahraman et al., 2000), vacuoles (Ebner
LFKK: a total of 9000 IU hCG (Pregnyl®, Organon, et al., 2005) and aggregation of the smooth endoplasmic
Vienna, Austria) was injected over a period of three days: reticulum (sER) (Ebner et al., 2008a; Otsuki et al., 2004).
the day of ovum pick-up (3000 IU), the day of embryo Any impact of these dysmorphisms on further
transfer (3000 IU) and then three (1500 IU) and six pre-implantation development is closely related to the
(1500 IU) days post-transfer. The hCG was not size and the number of anomalies. The only exception to
administered to patients at risk of ovarian this is clustering of the sER, which, according to reported
hyperstimulation syndrome (OHSS). Progesterone was consequences, is the most detrimental of the observed
also administered from the day after follicular puncture intracytoplasmic features (Ebner et al., 2008a; Otsuki
until the day of the pregnancy test, using either in-house et al., 2004).
prepared vaginal suppositories (400 mg) or vaginal The KSB has a policy whereby no specific scoring
tablets (300 mg) (Utrogestan®, Meda Pharma, Vienna, system is used but, instead, a clear and simple description
Austria). is provided, in order to allow the readers to attribute a
Serum hCG levels were measured 17 days after score based upon their own preferred system. Readers of
intrauterine transfer. Clinical pregnancy was determined this atlas should also refer to the details provided in the
by visualization of at least one gestational sac with guidelines for minimum gamete and embryo assessment
positive fetal heart activity 4 weeks after embryo transfer. standards suggested by the I.C. (Alpha (Scientists in
Biochemical pregnancies were diagnosed if no fetal Reproductive Medicine) and ESHRE Special Interest
heartbeat was detected. Group of Embryology, 2011).
Introduction 5
The descriptive parameters provided by the KSB cases in Reproductive Medicine) and ESHRE
include: Special Interest Group of Embryology, 2011).
1. Zona pellucida thickness
Although the I.C. suggests that ZP thickness Pronuclear assessment
measurement adds no benefit to assessment, we have
The detailed assessment of pronuclei 16–18 hours after
previously found that this parameter may be
sperm injection or oocyte insemination provides a
correlated to oestradiol levels at the time of ovulation
considerable amount of useful information about the
induction, and a thick ZP is sometimes apparent in
further potential of the embryo. In countries where ART
cases with reduced fertilization rates in the presence of
is governed by restrictive legislation, pronuclear and
normal semen parameters (Bertrand et al., 1996).
oocyte morphology are the only tools at the disposal of
Therefore, we systematically annotate a ZP of
the embryologist, especially in situations where a
atypically thick appearance.
maximum of three zygotes can be kept in culture and
2. Perivitelline space
embryo freezing is forbidden. Scott and Smith (1998)
The size and appearance of the PVS is mentioned,
were the first to correlate zygote morphology with rates
although we have been unable to use this as a
of implantation and pregnancy. The basis of their
prognostic feature.
grading system was a combination of pronuclear size
3. First polar body
with number and distribution of nucleoli. Changes in
The presence of the first PB is used to confirm that
cytoplasmic appearance (Ebner et al., 2003) and
the oocyte has reached the metaphase II stage but, in
progression to first cleavage division were also
our opinion, the morphology of the first PB is
considered as part of the scheme (Sakkas at al., 1998).
relevant only when its size is atypically large.
However, this scoring system was quite complex and the
Metaphase II oocytes with large first PBs were not
requirement for multiple observations made it rather
used for therapy because of the potential aneuploidy
impractical. Consequently, these authors (Scott, 2003;
risk.
Scott et al., 2000) reconsidered their scoring system and
4. Cytoplasmic dysmorphism
introduced a simple single-observation score (so-called
The cytoplasm of the human oocyte often
Z-score). The revised system took into account nuclear
contains a variety of inclusions, among which discs
size and alignment, together with number and
or aggregates of sER and vacuoles are easy to
distribution of nucleoli. The zygotes of best prognosis
recognize. Other inclusions appear in the form of
showed nucleoli that were aligned at the pronuclear
refractile bodies, dense or degenerate areas of
junction, a finding that was in line with observations
cytoplasm, and ‘clustering’, as described in the I.C.
reported by others (Tesarik and Greco, 1999).
Clustering is easily recognized, even with a simple
Irrespective of the type of scoring system applied on
binocular light microscope, and is associated with
day 1, zygotes showing pronuclei that are either
poor oocyte quality. Inclusions are described as
unequal in size or peripherally located, and those
‘major’ or ‘minor’ on the basis of their size and
with non-abutted pronuclei are considered to be
number.
abnormal.
The presence of sER aggregates may be associated
The KSB developed a system of classifying pronuclear
with an abnormal outcome (Ebner et al., 2008a;
morphology in three groups:
Otsuki et al., 2004) and must be reported; if the
abnormalities persist, the oocytes should not be used (i) Symmetric or synchronous configuration, with
for therapy. Vacuoles observed at the oocyte stage nucleoli or nucleolar precursor bodies (NPBs)
tend to persist and are also associated with a poor aligned in an equatorial plane facing each other,
prognosis. However, vacuoles may appear on day 1 corresponding to the Z1-score (see previous
during the stage of pronuclear formation, and discussion).
disappear at the cleavage stage. The presence of (ii) Symmetric or synchronous configuration without
vacuoles impairs fertilization and interferes with alignment of the NPBs, corresponding to the
cleavage planes (Istanbul Consensus, (Alpha Scientists Z2-score.
6 Introduction
(iii) All other configurations are described as fragmentation corresponds to severe fragmentation
asynchronous, and as mentioned before, are (>25%) as defined by the I.C.
associated with a lower developmental and On day 4 of pre-implantation development, the
implantation potential. presence and degree of compaction are assessed in order
to allow adequate prediction of blastocyst formation
The terms synchronous, symmetric and aligned
(Ebner et al., 2009).
correspond with the Z-patterns O, 1 and 3 as described
by Tesarik and Greco, 1999; however, the observation of
fewer than three or four aligned NPBs was considered to Blastocyst assessment
be prognostic of lower competence compared with
Viable blastocyst stage embryos were scored strictly
between three and seven aligned NPBs. To date, the
according to the guidelines published by Gardner et al.
factors that may influence pronuclear morphology
(2000). In brief, the implantation potential of a given
remain unclear, and no correlation has been found with
blastocyst is assessed on the basis of three parameters:
the spermatozoon selected for intracytoplasmic
blastocoel expansion, quality of the inner cell mass
injection. From more than 4000 pronuclear (PN) scores
(ICM), and quality of the trophectoderm (TE), based
collected in our database, we were able to observe a lower
upon cell number and cohesion. It should be noted that
frequency of synchronous patterns in older women, and
it is only possible to assess the quality of both cell
in cycles in which controlled ovarian hyperstimulation
lineages from the full blastocyst stage onwards, that is,
continued for more than 12 days.
Gardner scores III–VI (described as follows). A distinct
ICM cannot be detected in early blastocysts (scores I–II).
Exclusion of fragments and blastomeres (Kovacic et al.,
Assessment of cleavage stage embryos
2004) and other abnormalities (Ebner et al., 2011a) were
Assessment of cleavage stage embryos on days 2–3 post also recorded as part of the assessment.
insemination is based mainly on blastomere number and
I Early blastocyst: the blastocoel occupies less than half
symmetry, as well as degree of fragmentation (Johansson
the volume of the embryo.
et al., 2003). A correlation has been found between
II Blastocyst: the blastocoel occupies half the volume of
blastomere size and irregularity and the presence of
the embryo or more.
multinucleated cells (Hardarson et al., 2001).
III Full blastocyst: the blastocoel completely fills the
In the timescale of normal in vitro development, a
embryo, but the zona pellucida has not thinned.
good quality embryo is expected to have four
IV Expanded blastocyst: the volume of the blastocoel is
blastomeres of equal size at least 41 hours after injection
larger than that of the embryo, and the zona
or eight cells 65 hours after ICSI, with no or minimal
pellucida is thinning.
fragmentation; blastomeres are geometrically aligned in a
V Hatching blastocyst: the TE has started to herniate
pyramidal fashion. The daily practice at KSB is to
through the zona pellucida.
perform the ICSI procedure around 2 p.m., and a
VI Hatched blastocyst: the blastocyst has completely
subsequent fertilization check is systematically carried
escaped from the zona pellucida.
out at 7.30 a.m., that is, 17.5 hours post-ICSI, a timescale
that is within the suggested 17 1 hour proposed by The morphology of the ICM and TE are then assessed
the I.C. under an inverted microscope:
It is widely accepted that a significant degree of
fragmentation is associated with reduced developmental
potential. Our previous experience with home-made, Inner cell mass Trophectoderm
glucose-free media also demonstrated that the grade of
A Tightly packed, A Many cells forming a
fragmentation is influenced by the type of culture
many cells cohesive epithelium
medium and system (Van den Bergh, 2010). An accurate
B Loosely grouped, B Few cells forming a loose
estimate of the percentage of fragmentation is difficult to
several cells epithelium
ascertain, and should be expressed as a percentage of the
C Very few cells C Very few large cells
blastomere volume. Our description of significant
Introduction 7
REFERENCES
Alpha (Scientists in Reproductive Medicine) and ESHRE Special Ebner T, Vanderzwalmen P, Shebl O, et al. Morphological
Interest Group of Embryology. The Istanbul consensus aspects of human blastocysts and the impact of
workshop on embryo assessment: proceedings of an expert vitrification. Journal of Reproductive Medicine and
meeting. Human Reproduction 2011; 26: 1270–1283; Endocrinology 2011b; 8: 13–20.
Reproductive Biomedicine Online 2011; 22(6): 632–646. Ebner T, Yaman C, Moser M, et al. Prognostic value of first
Arce JC, Ziebe S, Lundin K, et al. Interobserver agreement polar body morphology on fertilization rate and embryo
and intraobserver reproducibility of embryo quality quality in intracytoplasmic sperm injection. Human
assessments. Human Reproduction 2006; 21(8): Reproduction 2000; 15: 427–430.
2141–2148. Ebner T, Yaman C, Moser M, et al. A prospective study on
Baxter Bendus AE, Mayer JF, Shipley SK, Catherino WH. oocyte survival rate after ICSI: influence of injection
Interobserver and intraobserver variation in day 3 embryo technique and morphological features. Journal of Assisted
grading. Fertility and Sterility 2006; 86(6): 1608–1615. Reproduction and Genetics 2001; 18: 623–628.
Bertrand E, Van den Bergh M, Englert Y. Clinical parameters Emiliani S, Van den Bergh M, Vannin AS, et al. Increased
influencing human zona pellucida thickness. Fertility and sperm motility after in-vitro culture of testicular biopsies
Sterility 1996; 66(3): 408–411. from obstructive azoopsermic patients results in better
Ciotti PM, Notarangelo L, Morselli-Labate AM, et al. First post-thaw recovery rate. Human Reproduction 2000; 15
polar body morphology before ICSI is not related to (11): 2371–2374.
embryo quality or pregnancy rate. Human Reproduction Emiliani S, Van den Bergh M, Vannin AS, et al. Evidence of
2004; 19: 2334–2339. reduced single-stranded testicular sperm DNA from
Cutting R, Morroll D, Roberts SA, et al. Elective single embryo obstructive azoospermic men after 3 days of in-vitro
transfer: guidelines for practice. British Fertility Society culture. Human Reproduction 2001; 16(6): 1200–1203.
and Association of Clinical Embryologists. Human Esfandiari N, Burjaq H, Gotlieb L, Casper RF. Brown oocytes:
Fertility 2008; 11(3): 131–146. implications for assisted reproductive technology. Fertility
Ebner T, Moser M, Shebl O, et al. Morphological analysis at and Sterility 2006; 86: 1522–1525.
compacting stage is a valuable prognostic tool for ICSI Esfandiari N, Ryan EAJ, Gotlieb L, Casper RF. Successful
patients. Reproductive Biomedicine Online 2009; 18: 61–66. pregnancy following transfer of embryos from oocytes
Ebner T, Moser M, Shebl O, Sommerguber M, Tews G. with abnormal zona pellucida and cytoplasm
Prognosis of oocytes showing aggregation of smooth morphology. Reproductive Biomedicine Online 2005; 11:
endoplasmic reticulum. Reproductive Biomedicine Online 620–623.
2008a; 16: 113–118. Farhi J, Nahum H, Weissman A, et al. Coarse granulation in
Ebner T, Moser M, Sommergruber M, et al. First polar body the perivitelline space and IVF-ICSI outcome.
morphology and blastocyst formation rate in ICSI Journal of Assisted Reproduction and Genetics 2002; 19:
patients. Human Reproduction 2002; 17: 2415–2418. 545–549.
Ebner T, Moser M, Sommergruber M, et al. Presence, but not Gardner DK, Lane M, Stevens J, Schlenker T, Schoolcraft WB.
type or degree of extension, of a cytoplasmic halo has a Blastocyst score affects implantation and pregnancy
significant influence on preimplantation development outcome: towards a single blastocyst transfer. Fertility and
and implantation behaviour. Human Reproduction 2003; Sterility 2000; 73: 1155–1158.
18: 2406–2412. Hardarson T, Hanson C, Sjögren A, Lundin K. Human
Ebner T, Moser M, Sommergruber M, et al. Occurrence and embryos with unevenly sized blastomeres have lower
developmental consequences of vacuoles throughout pregnancy and implantation rates: indications for
preimplantation development. Fertility and Sterility 2005; aneuploidy and multinucleation. Human Reproduction
83: 1635–1640. 2001; 16(2): 313–318.
Ebner T, Shebl O, Moser M, et al. An easy sperm processing Hassan-Ali H, Hisham-Saleh A, El-Gezeiry D, et al.
technique allowing for exclusive accumulation and later Perivitelline space granularity: a sign of human
usage of DNA strand break-free spermatozoa. menopausal gonadotrophin overdose in intracytoplasmic
Reproductive Biomedicine Online 2011a; 22: 37–43. sperm injection. Human Reproduction 1998; 13: 3425–
Ebner T, Shebl O, Moser M, Sommergruber M, Tews G. 3430.
Developmental fate of ovoid oocytes. Human Johansson M, Hardarson T, Lundin K. There is a cutoff limit in
Reproduction 2008b; 23: 62–66. diameter between a blastomere and a small anucleate
8 Introduction
fragment. Journal of Assisted Reproduction and Genetics Scott L. Pronuclear scoring as a predictor of embryo
2003; 20: 309–313. development. Reproductive Biomedicine Online 2003;
Kahraman S, Yakin K, Dönmez E, et al. Relationship between 6: 201–214.
granular cytoplasm of oocytes and pregnancy outcome Scott LA, Alvero R, Leondires M, Miller B. The morphology of
following intracytoplasmic sperm injection. Human human pronuclear embryos is positively related to
Reproduction 2000; 15: 2390–2393. blastocyst development and implantation. Human
Kovacic B, Vlaisavljevic V, Reljic M, Cizek-Sajko M. Reproduction 2000; 15: 2394–2403.
Developmental capacity of different morphological types Scott LA, Smith S. The successful use of pronuclear embryo
of day 5 human morulae and blastocysts. Reproductive transfers the day following oocyte retrieval. Human
Biomedicine Online 2004; 8: 687–694. Reproduction 1998; 13: 1003–1013.
Miao YL, Kikuchi K, Sun QY, Schatten H. Oocyte aging: Tesarik J, Greco E. The probability of abnormal
cellular and molecular changes, developmental potential preimplantation development can be predicted by a single
and reversal possibility. Human Reproduction Update static observation on pronuclear stage morphology.
2009; 15: 573–585. Human Reproduction 1999; 14: 1318–1323.
Otsuki J, Nagai Y, Chiba K. Lipofuscin bodies in human Torello MJ, Ardoy M, Calderon G, et al. Criterios ASEBIR
oocytes as an indicator of oocyte quality. Journal of de valoracion morfologica de Oocitos, Embriones tempranos
Assisted Reproduction and Genetics 2007; 24: 263–270. y Blastocistos. AEBIR Congress, Zaragoza, November
Otsuki J, Okada A, Morimoto K, Nagai Y, Kubo H. The 2005.
relationship between pregnancy outcome and smooth Van den Bergh M, Bertrand E, Biramane J, Englert Y.
endoplasmic reticulum clusters in MII human oocytes. Importance of breaking a spermatozoon’s tail before
Human Reproduction 2004; 19: 1591–1597. intracytoplasmic injection: a prospective randomized
Paternot G, Devroe J, Debrock S, D’Hooghe T, Spessens C. trial. Human Reproduction 1995; 10(11): 2819–2820.
Intra- and interobserver analysis in the morphology Van den Bergh M, Emiliani S, Biramane J, Vannin AS,
assessment of early stage embryos. Reproductive Biology Englert Y. A first prospective study of the individual
and Endocrinology 2009; 7: 105. straight line velocity of the spermatozoan and its
Practice Committee of the American Society for Reproductive influences on the fertilisation rate after intracytoplasmic
Medicine: Endometriosis and Infertility. Fertility and injection. Human Reproduction 1998; 13(11):
Sterility 2006; 86(5, Suppl 1): S156–S160. 3103–3107.
Puissant F, Van Rysselberge M, Barlow P, Deweze J, Leroy F. Van den Bergh M, Fahy-Deshe M, Hohl MK. Pronuclear
Embryo scoring as a prognostic tool in IVF treatment. zygote score after intracytoplasmic injection of
Human Reproduction 1987; 2(8): 705–708. hyaluronan-bound spermatozoa: a prospective
Rosenbusch B, Schneider M, Gläser B, Brucker C. Cytogenetic randomized study. Reproductive Biomedicine Online
analysis of giant oocytes and zygotes to assess their 2009; 19(6): 796–801.
relevance for the development of digynic triploidy. Van den Bergh M, Fahy Deshe M, Hohl M. Factors affecting
Human Reproduction 2002; 17: 2388–2393. pronuclear Z-score. 8th Biennial Alpha Meeting, Budapest,
Rotterdam ESHRE/ASRM-sponsored PCOS consensus 2010.
workshop group: Revised 2003 consensus on diagnostic World Health Organization. Laboratory manual for the
criteria and long-term health risks related to polycystic examination of human semen and sperm-cervical mucus
ovary syndrome (PCOS). Human Reproduction 2004; interaction. 4th ed. Cambridge University Press,
19(1): 41–47. Cambridge, UK, 1999.
Sakkas D, Shoukir Y, Chardonnens D, Bianchi PG, Campana A. Xia P. Intracytoplasmic sperm injection: correlation of oocyte
Early cleavage of human embryos to the two-cell stage grade based on polar body, perivitelline space and
after intracytoplasmic sperm injection as an indicator of cytoplasmic inclusions with fertilization rate and embryo
embryo viability. Human Reproduction 1998; 13: 182–187. quality. Human Reproduction 1997; 12: 1750–1755.
Part A
Cleavage stage transfer
(KSB, Switzerland)
Case 1 4 years 1 infertility Diagnosis: azoospermia
Female partner Male partner

Age 24, kitchen assistant Age 39, statistician
Tubal status: unexplored Congenital bilateral absence of vas deferens
MH: oligo-amenorrhoea Karyotype normal 46 XY
Endocrine status: normal CFTR-gene: no mutations found
Non-smoker, no alcohol abuse No microdeletions
Non-smoker, no alcohol abuse
Semen assessment: fresh testicular spermatozoa used for ICSI

Previous treatments: none
Cycle: ICSI 2010
Stimulation protocol Long protocol, GnRH agonist, depot 3.6 mg

Days of stimulation Carried out at external centre, not recorded
Daily dose 2 75 IU HMG
Total dose Not known
Oestradiol at the time of hCG administration Not recorded
Number of follicles 15 mm Not recorded
Total number of retrieved oocytes 11

Metaphase II 9
Metaphase I 0
Germinal vesicles 2
Atretic oocytes 0
Injected 9
Lysed 0
Diploid 2
Monoploid 4
Polyploid 0
Cryopreserved 0
Replaced 2-cell embryo and 6-cell embryo
Outcome: biochemical pregnancy

Case 1 11
1.O1 1.O7
1.Z1 1.Z7
1.E1 1.E7
Oocytes
1.O1 Metaphase II oocyte, thick zona pellucida, large perivitelline space, granular cytoplasm but no
inclusions
1.O7 Metaphase II oocyte, thick zona pellucida, large perivitelline space, granular cytoplasm but no
inclusions
Zygotes
1.Z1 Abutted pronuclei, nucleoli almost fully aligned, large and few in number
1.Z7 Second pronuclei not clearly observed
Embryos
1.E1 Two-cell embryo, one large fragment, both blastomeres are multinucleated
1.E7 Six-cell embryo, blastomeres unequal in size
Case 2 2 years 1 infertility Diagnosis: male factor

Age 27, kindergarten nurse Age 33, mechanic
Tubal status: patent Bilateral orchidopexy at age 10
MH: normal Non-smoker, no alcohol abuse
Semen assessment: oligoasthenoteratozoospermia

Volume 3.2 mL
pH 8.2
Concentration 8 106/mL
Motility: Type A 0%
Type B 27%
Type C 36%
Type D 27%
Normal forms 0%

Cycle: ICSI 2010

Days of stimulation 13
Daily dose 58 2 75 IU HMG, 5 3 75 IU HMG
Total dose 3300 IU
Oestradiol at the time of hCG administration 11066 pmol/L
Number of follicles 15 mm 14

Metaphase II 9
Metaphase I 0
Germinal vesicles 0
Atretic oocytes 0
Injected 9
Lysed 0
Diploid 7
Monoploid 1
Polyploid 0
Cryopreserved 5 zygotes
Transferred 4-cell embryo and 3-cell embryo
Outcome: live birth, healthy girl.

Case 2 13
2.O2 2.O8
2.Z2 2.Z8
2.E2 2.E8
Oocytes
2.O2 Metaphase II oocyte, deformed zona pellucida, minor cytoplasmic inclusions
2.O8 Normal metaphase II oocyte
Zygotes
2.Z2 Pronuclei close but not abutted, sparse and large nucleoli, not aligned
2.Z8 Pronuclei abutted, asynchronous nucleoli
Embryos
2.E2 Four-cell embryo, blastomeres slightly unequal in size, minor fragmentation
2.E8 Three-cell embryo, poorly or partially cleaved, large fragments

Age 28, gardener Age 30, self-employed
Tubal status: patent Non-smoker, no alcohol abuse
MH: normal
Semen assessment: oligoasthenoteratozoospermia (based on two previous assessments)

Volume 1.5 mL
pH 7.7
Motility: Type A 30%
Type B 22%
Type C 8%
Type D 78%
Normal forms 3%
Previous treatments:
2007 IUI 3 Not pregnant
Cycle: ICSI 2010
Stimulation protocol Long protocol. GnRH agonist, depot 3.6 mg

Daily dose 10 3 75 IU, 8 4 75 IU HMG
Total dose 5450 IU

Metaphase II 9
Metaphase I 0
Germinal vesicles 0
Atretic oocytes 0
Injected 9
Lysed 0
Diploid 9
Monoploid 0
Polyploid 0
Transferred 2 4-cell embryos
Outcome: live birth, healthy girl

Case 3 15
3.O3 3.O6
3.Z3 3.Z6
3.E3 3.E6
Oocytes
3.O3 Metaphase II oocyte, atypical thick zona pellucida, one distinct cytoplasmic inclusion
3.O6 Metaphase II oocyte, atypical thick zona pellucida, several small cytoplasmic inclusions
Zygotes
3.Z3 Abutted pronuclei, nucleoli synchronous and aligned, considerable cytoplasmic retraction
3.Z6 Abutted pronuclei, nucleoli synchronous and starting to align, considerable cytoplasmic retraction
Embryos
3.E3 Four-cell embryo, unequal blastomeres, no fragments

Age 28, cook Age 28, clerk
Tubal status: patent History/examination: NAD
MH: normal Non-smoker, no alcohol consumption
1994: cranial trauma, hospitalized
1997: chlamydia infection
Psychiatric follow-up for depression
Smoker, no alcohol consumption

Volume 4 mL
pH 7.4
Concentration 3.9 106/mL
Motility : Type A 18%
Type B 16%
Type C 8%
Type D 58%
Normal forms 3%
2007–2009 IUI 4 Not pregnant
Cycle: ICSI 2010

Total dose 1800 IU
Metaphase II 4
Metaphase I 1
Germinal vesicles 3
Atretic oocytes 0
Injected 5 (1 metaphase I, matured to metaphase II)
Lysed 0
Diploid 5
Monoploid 0
Polyploid 0
Outcome: not pregnant

Case 4 17
4.O2 4.O4
4.Z2 4.Z4
4.E2 4.E4
Oocytes
4.O2 Oval-shaped oocyte with minor cytoplasmic inclusions
4.O4 Minor cytoplasmic inclusions
Zygotes
4.Z2 Abutted pronuclei, synchronous nucleoli aligned, vacuoles, severely retracted cytoplasm
4.Z4 Abutted pronuclei, asynchronous nucleoli aligned, severely retracted cytoplasm
Embryos
4.E2 Four-cell embryo, unequal blastomeres, vacuole in upper blastomere, large fragments
4.E4 Four-cell embryo unequal blastomeres, large fragments
Case 5 1 infertility Diagnosis: male factor

Age 29, salesperson Age 34, salesperson
Tubal status: patent Neurodermatitis
MH: normal Ex-smoker, no alcohol abuse
Treated for thyroid cancer
Ex-smoker, no alcohol abuse
Semen assessment: asthenoteratozoospermia

Volume 4.5 mL
pH 8.3
Type B 20%
Type C 13%
Type D 55%
Normal forms 3%
2007–2009 IUI x 5, þ1 cancelled Not pregnant
Cycle: ICSI 2010
Stimulation protocol Antagonist protocol, GnRH antagonist, day 6–11

Total dose 1650 IU

Metaphase II 11
Metaphase I 1
Germinal vesicles 0
Atretic oocytes 0
Injected 12 (1 metaphase I, matured to metaphase II: 5.O12)
Lysed 3
Diploid 5
Monoploid 0
Polyploid 2
Cryopreserved 3
Outcome: ongoing singleton pregnancy

Case 5 19
5.O1 5.O3
5.Z1 5.Z3
5.E1 5.E3
Oocytes
5.O1 Metaphase II ooycte, minor cytoplasmic inclusions
5.O3 Metaphase II oocyte, atypical thick zona pellucida, small degenerative cytoplasmic area
Zygotes
5.Z1 Abutted pronuclei with difference in size, nucleoli large and starting to align
5.Z3 Abutted pronuclei, nucleoli large and starting to align
Embryos
5.E1 Four-cell embryo, unequal blastomeres, limited amount of small grouped fragments
5.E3 Four-cell embryo, slightly unequal blastomeres, minor fragments

Age 29, employed Age 29, unemployed
Tubal status: patent Smoker, no alcohol consumption
MH: normal
2007: spontaneous abortion
Penicillin allergy
Semen assessment: oligoteratozoospermia

Volume 1.8 mL
pH 8.3
Type B 21%
Type C 13%
Type D 39%
Normal forms 2%
Cycle: ICSI 2010

Total dose 1950 IU

Metaphase II 6
Metaphase I 1
Germinal vesicles 0
Atretic oocytes 2
Diploid 5
Monoploid 0
Polyploid 2
Outcome: ongoing twin pregnancy with spontaneous reduction to singleton, ongoing pregnancy after first
trimester bleeding.
Case 6 21
6.O1 6.O7
6.Z1 6.Z7
6.E1 6.E7
Oocytes
6.O1 Atypical thick zona, area of degenerated cytoplasm
6.O7 Three to four small cytoplasmic inclusions
Zygotes
6.Z1 Abutted pronuclei, nucleoli asynchronous
6.Z7 Abutted pronuclei, nucleoli synchronous and aligned
Embryos
6.E1 Two-cell embryo, retarded, almost equal blastomeres, considerable fragmentation
grouped in one area
6.E7 Three-cell embryo, retarded, unequal blastomeres, a few large fragments

Age 30, trustee Age 35, carpenter
Tubal status: not investigated History/examination: NAD
Semen assessment: subsequently cryptozoospermia at the time of oocyte recovery

Volume 2 mL
pH 7.4
Motility: Type A 3%
Type B 13%
Type C 11%
Type D 73%
Normal forms 2%

Cycle: ICSI 2010

Total dose 3150 IU

Metaphase II 11
Metaphase I 1
Germinal vesicles 0
Atretic oocytes 0
Injected 12 (1 metaphase I, matured to metaphase II, did not
fertilise after ICSI)
Lysed 1
Diploid 9
Monoploid 1
Polyploid 0
Transferred 3 embryos
Outcome: live birth, healthy boy

Case 7 23
7.O2 7.O5 7.O7
7.Z2 7.Z5 7.Z7
7.E2 7.E5 7.E7
Oocytes
7.O2 Metaphase II oocyte, atypical thick zona pellucida
7.O7 Metaphase II oocyte, thick zona pellucida
Zygotes
7.Z2 Pronuclei abutted, large asynchronous nucleoli, few in number
7.Z5 Pronuclei abutted, nucleoli aligned
7.Z7 Pronuclei abutted, nucleoli aligned
Embryos
7.E2 Four-cell embryo, blastomeres of unequal size, small number of grouped fragments
7.E5 Uncleaved zygote (transferred at patient’s request)
7.E7 Three-cell embryo, blastomeres of unequal size, large number of fragments

Age 31, dental assistant Age 38
Tubal status: patent 2 children with a previous partner
MH: normal 2008: seminoma with metastasis, partial
Latex allergy orchidectomy þ chemotherapy
Non-smoker, no alcohol abuse 2008: testicular biopsy cryopreserved
Smoker, no alcohol abuse
Previous treatment: none

Cycle: ICSI with thawed testicular spermatozoa, 2010

Daily dose 9 3 75 IU HMG, 4 4 75 IU HMG, 1 3 75
IU HMG
Total dose 3450 IU

Metaphase II 5
Metaphase I 0
Germinal vesicles 0
Atretic oocytes 0
Injected 5
Lysed 2
Diploid 2
Monoploid 0
Polyploid 0
Cryopreserved 0
Transferred 4-cell embryo and retarded 2-cell embryo

Case 8 25
8.O1 8.O2 8.O3
8.Z1 8.Z2 8.Z3
8.E2 8.E3
Oocytes
8.O1 Metaphase II oocyte with area of typical condensed smooth endoplasmic reticulum
8.O2 Metaphase II oocyte, atypical thick zona pellucida, no cytoplasmic inclusions
8.O3 Metaphase II oocyte, thick zona pellucida, oval-shaped large perivitelline space, minor cytoplasmic inclusions
Zygotes
8.Z1 Oocyte with condensed smooth endoplasmic reticulum, failed to fertilize
8.Z2 Pronuclei abutted, nucleoli asynchronous, significant cytoplasmic contraction
8.Z3 Pronuclei abutted, nucleoli different in number and size and asynchronous, significant cytoplasmic contraction
Embryos
8.E2 Four-cell embryo, blastomeres differ little in size, minimal fragmentation
8.E3 Two-cell embryo, small and large fragments, satellite nuclei around the nucleus of the upper blastomere
Case 9 1 year 1 infertility Diagnosis: male factor

Age 31, laboratory technician Age 35, office employee
Tubal status: patent L. cryptorchidism, not treated
MH: normal Non-smoker, moderate alcohol
Non-smoker, no alcohol consumption consumption
Semen assessment: severe oligoasthenoteratozoospermia

Volume 3.0 mL
pH 7.9
Motility: Type A 0%
Type B 16%
Type C 17%
Type D 67%
Normal forms 0%

Cycle: ICSI 2010

Total dose 3375 IU

Metaphase II 8
Metaphase I 0
Germinal vesicles 0
Atretic oocytes 0
Injected 8
Diploid 6
Monoploid 2
Polyploid 0

Case 9 27
9.O1 9.O2
9.Z1 9.Z2
9.E1 9.E2
Oocytes
9.O1 Atypical thick zona pellucida, large perivitelline space
9.O2 Atypical thick zona pellucida
Zygotes
9.Z1 Pronuclei abutted, nucleoli synchronous but not fully aligned
9.Z2 Pronuclei abutted, nucleoli synchronous and aligned
Embryos
9.E1 Five-cell embryo, unequal blastomeres and large fragments
9.E2 Four-cell embryo, unequal blastomeres and large fragments
Remarks: vacuoles are present in several zygotes.


Age 32, housewife Age 39, cook
Tubal status: not explored 1998: Addison’s disease
MH: oligodysmenorrhoea 1998: hemiorchidectomy þ semen
Two live births by Caesarian section cryopreservation, ongoing radiotherapy
Heterozygote for cystic fibrosis Non-carrier of CF-mutations
Smoker, no alcohol abuse Smoker, no alcohol abuse
Semen assessment: thawed ejaculated spermatozoa used for ICSI, oligoasthenozoospermia

Volume 5.5 mL
pH 7.9
Motility: Type A 6%
Type B 10%
Type C 15%
Type D 69%
Normal forms Not assessed

Cycle: ICSI 2010

Total dose 3075 IU

Metaphase II 8
Metaphase I 0
Germinal vesicles 1
Atretic oocytes 0
Injected 8
Lysed 0
Diploid 6
Monoploid 0
Polyploid 1

Case 10 29
10.O2 10.O3 10.O4
10.Z2 10.Z3 10.Z4
10.E2 10.E3
Oocytes
10.O2 Metaphase II oocyte, abnormal thick zona pellucida, major cytoplasmic inclusion
10.O3 Metaphase II oocyte, thick zona pellucida, minor cytoplasmic inclusions
10.O4 Metaphase II oocyte, abnormal shape, septum in the zona pellucida
Zygotes
10.Z2 Abutted pronuclei, synchronous nucleoli starting to align, cytoplasmic contraction
10.Z3 Abutted pronuclei, nucleoli almost aligned, but different in size and number
10.Z4 Abnormal shaped oocyte that failed to fertilize
Embryos
10.E2 Four-cell embryo, no fragmentation, unequal blastomeres
10.E3 Six-cell embryo, unequal blastomeres, some large fragments

Age 32, salesperson Age 45, personal trainer
Tubal status: not explored 2002: seminoma, hemiorchidectomy þ
MH: normal radiotherapy
Non-smoker, no alcohol abuse Non-smoker, no alcohol abuse

Volume 3 mL
pH 7.7
Motility: Type A 1%
Type B 3%
Type C 1%
Type D 95%
Normal forms 0%

Cycle: ICSI 2010

Days of stimulation 11 (10 þ 1)
Daily dose 10 3 75 IU HMG, 1 75 IU HMG
Total dose 2325 IU

Metaphase II 9
Metaphase I 0
Germinal vesicles 0
Atretic oocytes 0
Injected 9
Lysed 0
Diploid 8
Monoploid 1
Polyploid 0

Case 11 31
11.O1 11.O3
11.Z2 11.Z3
11.E1 11.E3
Oocytes
11.O1 Metaphase II oocyte, minor cytoplasmic inclusions
11.O3 Metaphase II oocyte, fragmented polar body, no cytoplasmic inclusions
Zygotes
11.Z1 Pronuclei abutted, large asynchronous nucleoli
11.Z3 Pronuclei abutted, large synchronous nucleoli aligned, a single nucleolus not aligned
Embryos
11.E1 Two- to three-cell embryo, retarded, large number of small grouped fragments
11.E3 Four-cell embryo, nearly equal blastomeres, minimal fragmentation

Age 33, business economist Age 46, engineer
MH: normal 2008: chlamydia infection
2008: chlamydia infection Non-smoker, no alcohol consumption
Non-smoker, no alcohol consumption
Semen assessment: teratozoospermia

Volume 3.5 mL
pH 7.9
Type B 26%
Type C 3%
Type D 44%
Normal forms 7%
2009 ICSI Not pregnant
2009 FET Not pregnant
Cycle: ICSI 2010

Total dose 2100 IU

Metaphase II 4
Metaphase I 0
Germinal vesicles 1
Atretic oocytes 0
Injected 4
Lysed 0
Diploid 2
Monoploid 2
Polyploid 0
Cryopreserved 4
Transferred 2-cell embryo (remaining one did not cleave)

Case 12 33
12.O2 12.O4
12.Z2 12.Z4
12.E2 12.E4
Oocytes
12.O4 Metaphase II oocyte, distinct cytoplasmic inclusion at the 11 o’clock position
Zygotes
12.Z2 Abutted pronuclei, synchronous nucleoli but not aligned, significant cytoplasmic retraction
12.Z4 Abutted pronuclei, synchronous nucleoli but not aligned
Embryos
12.E2 Two-cell retarded embryo, large fragment present
12.E4 Uncleaved zygote

Age 33, salesperson Age 39, tax consultant
Tubal status: not explored Cyptorchidism treated at age 11

Volume 4.8 mL
pH 8.0
Motility: Type A 0%
Type B 9%
Type C 13%
Type D 78%
Normal forms 0%
2009 ICSI Severe hyperstimulation, cycle cancelled
Cycle: ICSI 2010
Stimulation protocol GnRH antagonist from day 7 to day 11

Total dose 1350 IU

Metaphase II 7
Metaphase I 1
Germinal vesicles 1
Atretic oocytes 0
Injected 7
Lysed 0
Diploid 4
Monoploid 0
Polyploid 1
Outcome: singleton clinical pregnancy, first trimester spontaneous abortion

Case 13 35
13.O1 13.O2
13.Z1 13.Z2
13.E1 13.E2
Oocytes
13.O1 Metaphase II oocyte, atypical thick zona pellucida, distinct cytoplasmic inclusions
13.O2 Metaphase II oocyte, atypical thick zona pellucida, distinct cytoplasmic inclusion
Zygotes
13.Z1 Abutted pronuclei, nucleoli synchronous but not aligned
13.Z2 Abutted pronuclei, nucleoli synchronous and aligned, persistent cytoplasmic inclusion and
vacuoles
Embryos
13.E1 Two-cell embryo, retarded, slightly unequal blastomeres, minor fragments
13.E2 Three-cell embryo, retarded, unequal blastomeres, cell membranes unclear, minor fragments

Age 33, salesperson Age 39, tax consultant
Tubal status: not explored Cryptorchidism treated at age 11
MH: normal Smoker, no alcohol abuse
Spontaneous abortion post-ICSI 2010

Volume 6 mL
pH 8.0
Motility: Type A 0%
Type B 9%
Type C 12%
Type D 66%
Normal forms 0%
2009 ICSI Severe hyperstimulation, cycle cancelled
2010 ICSI Spontaneous abortion (Case 13)
Cycle: ICSI 2010
Stimulation protocol GnRH antagonist from day 7 to day 11

Total dose 1350 IU

Metaphase II 4
Metaphase I 0
Germinal vesicles 0
Atretic oocytes 0
Injected 4
Lysed 0
Diploid 2
Monoploid 2
Polyploid 0

Case 14 37
14.O1 14.O4
14.Z1 14.Z4
14.E1 14.E4
Oocytes
14.O1 Metaphase II oocyte, atypical thick zona pellucida, distinct cytoplasmic inclusions
14.O4 Metaphase II oocyte, atypical thick zona pellucida, area of degenerated cytoplasm
Zygotes
14.Z1 Abutted pronuclei, sparse and large asynchronous nucleoli, aligned in left pronucleus
14.Z4 Abutted pronuclei, pronuclei and nucleoli difficult to visualise due to degenerative area
Embryos
14.E4 Three-cell embryo, retarded, unequal blastomeres, cell membranes unclear, minor fragments
Case 15 7 years 2 infertility Diagnosis: male subfertility

Age 34, pharmacist Age 28, teacher
MH: dysmenorrhoea 2 children with previous partner
2003: live birth, natural conception Non-smoker, no alcohol abuse
2004: ovarian drilling

Volume 5 mL
pH 7.6
Motility: Type A 3%
Type B 77%
Type C 3%
Type D 17%
Normal forms 3%
2007–2008 Timed intercourse 4 cycles Not pregnant
2009 Timed intercourse 3 Not pregnant
Cycle: ICSI 2009


Metaphase II 4
Metaphase I 1
Germinal vesicles 1
Atretic oocytes 0
Injected 4
Lysed 0
Diploid 4
Monoploid 0
Polyploid 0

Case 15 39
15.O1 15.O2
15.Z1 15.Z2
15.E1 15.E2
Oocytes
15.O1 Metaphase II oocyte, thick zona pellucida, large area of degenerative cytoplasm
Zygotes
15.Z1 Abutted pronuclei, nucleoli almost aligned, large and few in number
15.Z2 Abutted pronuclei, nucleoli almost aligned, large and few in number
Embryos
15.E1 Six-cell embryo, blastomeres of unequal size, large fragments present
15.E2 Four-cell embryo, blastomeres of unequal size, small number of large fragments

Age 34, office employee Age 34, office employee
Tubal status: not explored History/examination: NAD
MH: normal Treated for depression
Non-smoker, no alcohol abuse Non-smoker

Volume 5 mL
pH 7.8
Motility: Type A 0%
Type B 2%
Type C 21%
Type D 67%
Normal forms 2%

Cycle: ICSI 2010

Total dose 4125 IU

Metaphase II 6
Metaphase I 2
Germinal vesicles 1
Atretic oocytes 0
Injected 6
Lysed 0
Diploid 6
Monoploid 0
Polyploid 0

Case 16 41
16.O4 16.O5
16.Z4 16.Z5
16.E4 16.E5
Oocytes
16.O4 Metaphase II oocyte, thick zona pellucida, central area with minor inclusions and
degenerated cytoplasm
Zygotes
16.Z4 Abutted pronuclei, nucleoli aligned, some small cytoplasmic vacuoles, cytoplasm retracted
16.Z5 Abutted pronuclei, nucleoli aligned, cytoplasm retracted
Embryos
16.E4 Four-cell embryo, poorly cleaved, blastomeres of unequal size, large fragments
16.E5 Four-cell embryo, blastomeres differ slightly in size, some grouped fragments

Age 32, housewife Age 34, machinist
Tubal status: patent Kartagener’s syndrome
MH: dysmenorrhoea 2009: L. varicocelectomy
Non-smoker, no alcohol abuse Ex-smoker, no alcohol abuse

Volume 4 mL
pH 7.8
Motility: Type A 2%
Type B 10%
Type C 32%
Type D 56%
Normal forms 2%

Cycle: ICSI 2010

Total dose 2700 IU

Metaphase II 9
Metaphase I 0
Germinal vesicles 1
Atretic oocytes 0
Injected 9
Lysed 0
Diploid 9
Monoploid 0
Polyploid 0
Cryopreserved 7

Case 17 43
17.O3 17.O8
17.Z3 17.Z8
17.E3 17.E8
Oocytes
17.O3 Metaphase II oocyte, atypical thick zona pellucida, cytoplasmic inclusion
17.O8 Metaphase II oocyte, atypical thick zona pellucida, cytoplasmic inclusion
Zygotes
17.Z3 Abutted pronuclei, synchronous nucleoli almost aligned but different in number
17.Z8 Abutted pronuclei, nucleoli synchronous and aligned but different in number and size
Embryos
17.E3 Four- to five-cell embryo, unequal blastomeres, considerable number of grouped fragments
17.E8 Three-cell embryo, retarded, unequal blastomeres, small number of grouped fragments
Remarks: inclusions and degenerative cytoplasm found in most of the oocytes.

Case 18 2 years 1 infertility Diagnosis: severe male factor

Age 34, salesperson Age 33, salesperson
Tubal status: unknown Smoker, no alcohol consumption
MH: normal

Volume 6.5 mL
pH 7.8
Concentration *106/mL
Motility: Type A 0%
Type B 7%
Type C 8%
Type D 85%
Normal forms 2%
* Not assessed: diagnosis cryptozoospermia

Cycle: ICSI 2010

Total dose 2475 IU

Metaphase II 8
Metaphase I 0
Germinal vesicles 0
Atretic oocytes 0
Injected 8
Lysed 2
Diploid 5
Monoploid 1
Polyploid 0

Case 18 45
18.O3 18.O6
18.Z3 18.Z6
18.E3 18.E6
Oocytes
18.O3 Metaphase II, minor degenerative cytoplasmic area, granules in perivitelline space
18.O6 Metaphase II, minor cytoplasmic inclusions
Zygotes
18.Z3 Pronuclei abutted, nucleoli synchronous and aligned, larger nucleoli in lower pronucleus
18.Z6 Pronuclei abutted, nucleoli synchronous and aligned
Embryos
18.E3 Four-cell embryo, unequal blastomeres, minimal fragmentation
18.E6 Four-cell embryo, unequal blastomeres, considerable number of grouped fragments

Age 36, paediatric nurse Age 38, computer scientist

Volume 3 mL
pH 8.3
Type B 30%
Type C 6%
Type D 45%
Normal forms 3%
Cycle: ICSI 2010

Total dose 3375 IU

Metaphase II 5
Metaphase I 2
Germinal vesicles 0
Atretic oocytes 0
Injected 7 (2 metaphase I, matured to metaphase II: O6, O7)
Lysed 0
Diploid 4
Monoploid 2
Polyploid 1

Case 19 47
19.O2 19.O5 19.O7
19.Z2 19.Z5 19.Z7
19.E2 19.E5
Oocytes
19.O2 Metaphase II, atypical thick zona pellucida, minor cytoplasmic inclusions
19.O5 Metaphase II, atypical thick and asymmetric zona pellucida, one major cytoplasmic inclusion
19.07 Post-in vitro maturation metaphase II
Zygotes
19.Z2 Abutted pronuclei, nucleoli synchronous but not aligned, large and few in number
19.Z5 Abutted pronuclei, nucleoli synchronous, aligned, large and few in number
19.Z7 Triploid zygote resulting from post in vitro matured oocyte
Embryos
19.E2 Three-cell embryo, large number of grouped fragments
19.E5 Four- to five-cell embryo, some large fragments
Remarks: metaphase I matured to metaphase II oocytes (19.O6 and O7) resulted in 1PN and 3PN zygotes, respectively.

Age 36, commercial agent Age 31, mechanic
Tubal status: patent Bilateral orchidopexy at young age

Volume 1.5 mL
pH 7.4
Motility: Type A 0%
Type B 1%
Type C 2%
Type D 97%
Normal forms 9%
Cycle: ICSI 2010

Total dose 3150 IU

Metaphase II 12
Metaphase I 2
Germinal vesicles 0
Atretic oocytes 0
Injected 14 (2 metaphase I, matured to metaphase II,
1 fertilized after ICSI)
Lysed 2
Diploid 8
Monoploid 2
Polyploid 0

Case 20 49
20.O1 20.O5
20.Z1 20.Z5
20.E1 20.E5
Oocytes
20.1O Metaphase II ooycte, thick zone pellucida, large perivitelline space
20.O5 Metaphase II ooycte, several minor cytoplasmic inclusions
Zygotes
20.Z1 Abutted pronuclei, sparse and large asynchronous nucleoli
20.Z5 Abutted pronuclei, synchronous nucleoli starting to align
Embryos
20.E1 Two-cell embryo, retarded, cell membranes not clearly separated
20.E5 Three- to four-cell embryo, several large fragments

Age 36, salesperson Age 34, mechanic
MH: normal Polytrauma after motorbike accident
Smoker, no alcohol abuse at age 5
Semen assessment: severe oligoasthenoteratozoospermia in two previous diagnostic assessments

Volume 1 mL
pH 8.3
Type B 30%
Type C 20%
Type D 26%
Normal forms 0%

Cycle: ICSI 2010

Total dose 3000 IU
Number of follicles 15 mm

Metaphase II 3
Metaphase I 0
Germinal vesicles 0
Atretic oocytes 1
Injected 3
Lysed 3
Diploid 0
Monoploid 0
Polyploid 0
Cryopreserved 1 zygote

Case 21 51
21.O2 21.O3
21.Z2 21.Z3
21.E2 21.E3
Oocytes
21.O2 Metaphase II oocyte, large perivitelline space
21.O3 Metaphase II oocyte, distinct cytoplasmic inclusion
Zygotes
21.Z2 Pronuclei abutted, nucleoli synchronous and almost fully aligned
21.Z3 Pronuclei abutted, nucleoli synchronous, not completely aligned
Embryos
21.E2 Four-cell embryo, unequal blastomeres, some large fragments
21.E3 Five-cell embryo, unequal blastomeres, one large fragment.

Age 28, tailor Age 37, thermal bath cleaner
MH: normal Normal karyotype 46, XY
Non-smoker, no alcohol abuse Non-smoker, no alcohol abuse

Volume 3 mL
pH 8.3
Motility: Type A 0%
Type B 0%
Type C 11%
Type D 89%
Normal forms 0%
2007 ICSI Live birth, healthy baby
2010 FET 2 Not pregnant
Cycle: ICSI 2010

Total dose 3150 IU

Metaphase II 11
Metaphase I 4
Germinal vesicles 1
Atretic oocytes 0
Lysed 0
Diploid 10
Monoploid 2
Polyploid 1

Case 22 53
22.O3 22.O8
22.Z3 22.Z8
22.E3 22.E8
Oocytes
22.O3 Metaphase II ooycte, thick zona pellucida, minor cytoplasmic inclusions
22.O8 Metaphase II ooycte, thick zona pellucida, minor cytoplasmic inclusions
Zygotes
22.Z3 Abutted pronuclei, large nucleoli aligned, few in number
22.Z8 Abutted pronuclei, nucleoli almost aligned
Embryos
22.E3 Five-cell embryo, blastomeres of unequal size, no fragments
22.E8 Four-cell embryo, blastomeres slightly different in size, no fragments
Case 23 5 years 2 infertility Diagnosis: moderate male factor

Age 37, postmistress Age 27, engineer
1992: live birth, natural conception
2003: carcinoma in situ, cone biopsy
2005: live birth, natural conception
Semen assessment: asthenoteratozoospermia, based on two previous diagnostic assessments

Volume 3 mL
pH 7.5
Type B 26%
Type C 13%
Type D 40%
Normal forms 1%
Cycle: ICSI 2010

Total dose 3150 IU

Metaphase II 4
Metaphase I 0
Germinal vesicles 1
Atretic oocytes 0
Injected 4
Lysed 0
Diploid 3
Monoploid 0
Polyploid 0
Cryopreserved 1
Transferred Single embryo transfer: 2-cell retarded embryo

Case 23 55
23.O1 23.O2
23.O3 23.Z1
23.Z2 23.E1
Oocytes
23.O1 Metaphase II oocyte, atypical thick zona pellucida, minor cytoplasmic inclusions
23.O2 Oocyte with two clear polar bodies before injection
23.O3 Metaphase II oocyte with condensed smooth endoplasmic reticulum
Zygotes
23.Z1 Pronuclei abutted, nucleoli starting to align, nearly synchronous, large perivitelline space
23.Z2 Pronuclei abutted, unequal nucleoli, vacuoles
Embryos
23.E1 Retarded two-cell embryo, unequal blastomeres, many small fragments
Remarks: single embryo transfer at request of the couple (did not want twins).

Age 38, financial analyst Age 47, financial advisor
MH: normal Non-smoker, moderate alcohol consumption

Volume 5 mL
pH 8.0
Motility: Type A 7%
Type B 5%
Type C 6%
Type D 82%
Normal forms 4%
2007 FET Live birth, healthy girl
2010 FET Spontaneous abortion
Cycle: ICSI 2010

Total dose 3150 IU

Metaphase II 6
Metaphase I 1
Germinal vesicles 4
Atretic oocytes 0
Injected 6
Lysed 0
Diploid 3
Monoploid 1
Polyploid 2
Cryopreserved No freezing
Transferred Single embryo transfer

Case 24 57
24.O2 24.O4 24.O5
24.Z2 24.Z4 24.Z5
24.E2 24.E4 24.E5
Oocytes
24.O5 Metaphase II oocyte, large perivitelline space, major cytoplasmic inclusion
Zygotes
24.Z2 Abutted pronuclei, asynchronous nucleoli
24.Z4 Pronuclei close together, different in size, asynchronous nucleoli, aligned in left pronucleus
24.Z5 Pronuclei abutted, asynchronous nucleoli, not aligned, persistent cytoplasmic inclusion
Embryos
24.E2 Two-cell retarded embryo on day 2; day 5 pseudoblastocyst not cryopreserved
24.E4 Two-cell retarded embryo on day 2; day 5 pseudoblastocyst not cryopreserved
24.E5 Four-cell embryo, equal blastomeres, no fragments (transferred)
Remarks: as permitted by the law, three zygotes were kept in culture, single embryo transfer was performed on day 2;
remaining embryos were kept in culture, but no blastocysts were developed. Images of all zygotes on day 3 and 5 are
available on the CD.
Case 25 2 years 2 infertility Diagnosis: cryptozoospermia

Age 30, nurse Age 38, land surveyor
Tubal status: patent Hypogonadotropic hypogonadism
MH: normal Cryptorchidy
Non-smoker, no alcohol abuse R. orchidectomy
Semen assessment: cryptozoospermia

Volume 3.5 mL
pH 7.8
Concentration Very rare motile spermatozoa
Motility: Type A 0%
Type B 0%
Type C 10%
Type D 10%
Normal forms *%
*Not assessed
2007 FET Spontaneous abortion
2007 FET Live birth, healthy girl
Cycle: ICSI 2010
Stimulation protocol Short protocol, GnRH agonist from day 1 to day 7

Total dose 1425 IU

Metaphase II 3
Metaphase I 0
Germinal vesicles 2
Atretic oocytes 0
Injected 3
Lysed 0
Diploid 3
Monoploid 0
Polyploid 0

Case 25 59
25.O1 25.O2 25.O3
25.Z1 25.Z2 25.Z3
25.E1 25.E2
Oocytes
25.O1 Metaphase II oocyte, no cytoplasmic inclusions
25.O2 Metaphase II oocyte, oval shape, no cytoplasmic inclusions
25.O3 Metaphase II oocyte with major cytoplasmic inclusion or vacuole
Zygotes
25.Z1 Pronuclei abutted but unequal in size, nucleoli asynchronous and not aligned
25.Z2 Pronuclei abutted, unequal in size, nucleoli asynchronous, large, not aligned, cytoplasmic retraction
25.Z3 Pronuclei abutted, unequal nucleoli, cytoplasmic retraction
Embryos
25.E1 Four-cell embryo, no fragments, blastomeres nearly equal, two small vacuoles in the upper blastomere
25.E2 Five-cell embryo, unequal blastomeres, no fragments, oval-shaped zona pellucida

Age 38, clerk Age 42, representative
Tubal status: patent 2005: varicocele treated
Semen assessment: oligoasthenoteratozoospermia, based on two previous diagnostic assessments

Volume 3.1 mL
pH 7.8
Type B 7%
Type C 6%
Type D 71%
Normal forms 4%
2007 ICSI Live birth, healthy boy
Cycle: ICSI 2010

Total dose 2700 IU

Metaphase II 1
Metaphase I 1
Germinal vesicles 0
Atretic oocytes 0
Diploid 2
Monoploid 0
Polyploid 0
Cryopreserved 0

Case 26 61
26.O1 26.O2
26.Z1 26.Z2
26.E1 26.E2
Oocytes
26.01 Atypical thick zona pellucida, persisting cytoplasmic vacuoles
26.02 Atypical thick zona pellucida
Zygotes
26.Z1 Abutted pronuclei, nucleoli asynchronous, not aligned
26.Z2 Abutted pronuclei, nucleoli asynchronous, not aligned
Embryos
26.E1 Retarded two-cell embryo with persisting vacuole
26.E2 Four-cell embryo, unequal blastomeres, large fragments

Age 38, housewife Age 40, clerk
MH: normal Varicocoele, not treated
2005: early spontaneous abortion Non-smoker, no alcohol abuse
2007: late miscarriage

Volume 3.5 mL
pH 7.5
Type B 27%
Type C 7%
Type D 37%
Normal forms 6%
Cycle: ICSI 2010

Days of stimulation 13, starting on day 6
Total dose 2925 IU

Metaphase II 5
Metaphase I 2
Germinal vesicles 1
Atretic oocytes 0
Lysed 0
Diploid 3
Monoploid 1
Polyploid 0
Cryopreserved 0
Transferred 1 blastocyst
Outcome: spontaneous abortion of a singleton pregnancy, <12 weeks

Case 27 63
27.O1 27.O2 27.O3
27.Z1 27.Z2 27.Z3
27.E1.D5 27.E2.D5 27.E3.D5
Oocytes
27.O2 Metaphase II oocyte, large perivitelline space, minor cytoplasmic inclusions
27.O3 Metaphase II oocyte, large perivitelline space, minor cytoplasmic inclusions
Zygotes
27.Z1 Abutted pronuclei, nucleoli almost fully aligned, cytoplasmic retraction
27.Z2 Abutted pronuclei, nucleoli asynchronous, numerous vacuoles
27.Z3 Abutted pronuclei, nucleoli asynchronous, numerous vacuoles
Embryos
27.E1.D5 Day 5 blastocyst, no clear inner cell mass observed
27.E2.D5 Embryo arrested at the 16-cell stage
27.E3.D5 Early blastocyst, with poorly organized inner cell mass
Remarks: in cases where there is only one surplus zygote, we suggest blastocyst transfer in order to avoid
cryopreservation of a single zygote.

Age 38, bookkeeper Age 38, computer scientist
Tubal status: patent Non-smoker, no alcohol consumption
MH: normal
Treated for hypertension and depression

Volume 3 mL
pH 8.3
Motility: Type A 2%
Type B 66%
Type C 15%
Type D 17%
Normal forms 0%
2008–2009 IUI Not pregnant
Cycle: ICSI 2010

Total dose 2700 IU

Metaphase II 8
Metaphase I 2
Germinal vesicles 0
Atretic oocytes 1
Injected 10 (2 metaphase I, matured to metaphase II: O9 and
O10)
Lysed 1
Diploid 6
Monoploid 1
Polyploid 3

Case 28 65
28.O2 28.O7 28.O9
28.Z2 28.Z7 28.Z9
28.E2 28.E7
Oocytes
28.O2 Metaphase II, very large perivitelline space containing granules
28.O7 Metaphase II, large perivitelline space containing granules
28.O9 Metaphase II, metaphase I at oocyte retrieval
Zygotes
28.Z2 Abutted pronuclei, nucleoli synchronous and almost fully aligned, retracted cytoplasm
28.Z7 Abutted pronuclei, nucleoli synchronous and almost fully aligned, retracted cytoplasm
28.Z9 Tripronuclear zygote after injection of in vitro matured oocyte
Embryos
28.E2 Four-cell embryo, slightly unequal blastomeres, minimal fragments
28.E7 Four-cell embryo, unequal blastomeres, grouped fragments and some larger fragments
Remarks: all oocytes had a large perivitelline space; matured 28.O9 resulted in a 3PN zygote, matured 28.O10 lysed
after injection.

Age 38, office employee Age 38, office employee
Live birth with previous partner
Semen assessment: cryptozoospermia, 10–15 motile spermatozoa per ejaculate

Volume 3 mL
pH 8.2
Concentration *106/mL
Motility: Type A *
Type B *
Type C *
Type D *
Normal forms *
* Not assessed: concentration too low

Cycle: ICSI 2010

Total dose 2700 IU

Metaphase II 9
Metaphase I 0
Germinal vesicles 2
Atretic oocytes 0
Injected 9
Lysed 0
Diploid 6
Monoploid 2
Polyploid 0

Case 29 67
29.O5 29.O6
29.Z5 29.Z6
29.E5 29.E6
Oocytes
29.O5 Metaphase II oocyte, minor cytoplasmic inclusions, area with degenerated cytoplasm
Zygotes
29.Z5 Abutted pronuclei, synchronous nucleoli almost fully aligned, cytoplasm retracted
29.Z6 Abutted pronuclei, synchronous nucleoli almost fully aligned, cytoplasm retracted
Embryos
29.E5 Two-cell embryo, retarded, unequal blastomeres, no fragments
29.E6 Two-cell embryo, retarded, equal blastomeres, no fragments

Age 38, banker Age 45, mathematician
Semen assessment: oligoasthenoteratozoospermia, based on two previous assessments

Volume 2.5 mL
pH 7.8
Type B 16%
Type C 13%
Type D 33%
Normal forms 12%

Cycle: ICSI 2010

Total dose 3000 IU

Metaphase II 3
Metaphase I 0
Germinal vesicles 2
Atretic oocytes 0
Injected 3
Lysed 0
Diploid 3
Monoploid 0
Polyploid 0
Cryopreserved 0

Case 30 69
30.O1 30.O2 30.O3
30.Z1 30.Z2 30.Z3
30.E1 30.E2 30.E3
Oocytes
30.O1 Metaphase II oocyte, no particular features
30.O2 Metaphase II oocyte, major inclusions
30.O3 Metaphase II oocyte, atypical thick zona pellucida, slightly degenerative cytoplasm
Zygotes
30.Z1 Abutted pronuclei, asynchronous nucleoli, not aligned, several vacuoles present, cytoplasmic retraction
30.Z2 Abutted pronuclei, large and sparse asynchronous nucleoli
30.Z3 Abutted pronuclei, different in size, sparse asynchronous nucleoli, several vacuoles present
Embryos
30.E1 Four-cell embryo, unequal blastomeres, several fragments
30.E2 Partially cleaved zygote, major inclusion still apparent, not transferred
30.E3 Four-cell embryo, unequal blastomeres, upper left blastomere contains an inclusion, some large fragments,
cytoplasm with degenerative aspect

Age 40, public relations assistant Age 45, management consultant
Tubal status: patent Erectile dysfunction
Semen assessment: severe oligoasthenozoospermia

Volume 2 mL
pH 8.3
Type B 12%
Type C 20%
Type D 54%
Normal forms 10%
2006 ICSI Live birth, healthy baby
2008 FET 2 Twin pregnancy, miscarriage
2009 FET 2 Not pregnant (1 cycle cancelled)
Cycle: ICSI 2009

Total dose 4500 IU

Metaphase II 10
Metaphase I 1
Germinal vesicles 0
Atretic oocytes 0
Injected 10
Lysed 0
Diploid 6
Monoploid 2
Polyploid 0
Cryopreserved 4

Case 31 71
31.O6 31.O8
31.Z6 31.Z8
31.E6 31.E8
Oocytes
31.O6 Metaphase II oocyte, atypical thick zona pellucida, central area with degenerated cytoplasm
Zygotes
31.Z6 Pronuclei abutted, large asynchronous nucleoli different in number, cytoplasm retracted
31.Z8 Pronuclei abutted, large nucleoli starting to align
Embryos
31.E8 Four-cell embryo, unclear cell membranes, unequal blastomeres, minor fragments
Remarks: there were many oocytes with areas of degenerated cytoplasm.

Case 32 2 years 2 infertility Diagnosis: cervical factor þ
male factor

Age 39, teacher Age 37, engineer
Tubal status: patent Teratozoospermia

Volume 4.5 mL
pH 7.4
Motility: Type A 8%
Type B 61%
Type C 7%
Type D 24%
Normal forms 1%
2003 IUI 3 Not pregnant 2006 FET 2 Not pregnant
2004 ICSI Not pregnant 2007 ICSI Not pregnant
2004 FET Not pregnant 2007 ICSI Live birth, healthy boy
2005 ICSI Not pregnant 2009 FET Not pregnant
2005 FET Live birth, healthy boy
Cycle: 2009 ICSI
Stimulation protocol GnRH antagonist, day 6 to day 8

Total dose 1800 IU

Metaphase II 4
Metaphase I 1
Germinal vesicles 0
Atretic oocytes 0
Injected 5 (1 metaphase I, matured to metaphase II: not fertilized)
Lysed 0
Diploid 4
Monoploid 0
Polyploid 0

Case 32 73
32.O2 32.O3
32.Z2 32.Z3
32.E2 32.E3
Oocytes
32.O2 Metaphase II oocyte, no special features
32.O3 Metaphase II oocyte, one minor cytoplasmic inclusion
Zygotes
32.Z2 Abutted pronuclei, asynchronous nucleoli, not aligned
32.Z3 Abutted pronuclei, synchronous nucleoli, starting to align
Embryos
32.E3 Three-cell embryo, unequal blastomeres, no fragments

Age 41, social worker Age 43, dentist
Tubal status: patent Smoker, some alcohol consumption
MH: normal
2005, 2006: spontaneous abortions 2

Volume 4 mL
pH 8.1
Motility: Type A 9%
Type B 19%
Type C 16%
Type D 56%
Normal forms 2%
Cycle: ICSI 2010
Stimulation protocol Long protocol, GnRH agonist, daily 0.1 mg s/c

Total dose 2250 IU

Metaphase II 5
Metaphase I 1
Germinal vesicles 0
Atretic oocytes 0
Diploid 4
Monoploid 0
Polyploid 3
Cryopreserved 1
Replaced 2 4-cell embryos and 1 3-cell embryo

Case 33 75
33.O1 33.O5 33.O6
33.Z1 33.Z5 33.Z6
33.E1 33.E5 33.E6
Oocytes
33.O1 Normal metaphase II, fragmented polar body
33.O5 Presence of two polar bodies before injection
33.O6 Large polar body, reduced perivitelline space
Zygotes
33.Z5 Abutted pronuclei, asynchronous nucleoli, vacuole near pronuclei
Embryos
33.E5 Two-cell retarded embryo, two small satellite nuclei near left pronucleus
33.E6 Four-cell embryo, very unequal blastomeres, considerable grouped fragmentation
Case 34 2 years 2 infertility Diagnosis: tubal factor þ male
factor

Age 30, social assistant Age 31, dentist
2002, 2003: spontaneous abortions 2 History/examination: NAD
Salpingectomy Smoker
Cone biopsy
Semen assessment: asthenoteratozoospermia in two previous diagnostic assessments

Volume 0.8 mL
pH 7.5
Motility: Type A 6%
Type B 33%
Type C 19%
Type D 42%
Normal forms 2%
2008 FET Perinatal death of a boy at 25 weeks due to amnion infection
Cycle: ICSI 2009

Total dose 3750 IU
Oestradiol at the time of hCG administration 3872
Metaphase II 5
Metaphase I 0
Germinal vesicles 0
Atretic oocytes 0
Injected 5
Lysed 0
Diploid 4
Monoploid 1
Polyploid 0

Case 34 77
34.O1 34.O5 34.Z1
34.Z3 34.Z4 34.Z5
34.E1 34.E5
Oocytes
34.O1 Normal metaphase II oocyte
34.O5 Small perivitelline space
Zygotes
34.Z3 Monopronuclear zygote with severe vacuolization
34.Z4 Zygote with abutted pronuclei and severe vacuolization
Embryos
34.E1 Four-cell embryo, unequal blastomeres and large grouped fragments
34.E5 Six-cell embryo, unequal blastomeres and large grouped fragments
Case 35 2 infertility Diagnosis: tubal factor þ male factor

Age 31, social assistant Age 32, dentist
2002, 2003: spontaneous abortions 2 History/examination: NAD
Salpingectomy Smoker
Cone biopsy

Volume 1.5 mL
pH 7.6
Type B 14%
Type C 5%
Type D 53%
Normal forms 2%
2008 FET Perinatal death of a boy at 25 weeks due to amnion infection
2009 ICSI Not pregnant (see Case 34)
Cycle: ICSI 2010

Total dose 3600 IU

Metaphase II 4
Metaphase I 1
Germinal vesicles 0
Atretic oocytes 0
Lysed 0
Diploid 1
Monoploid 3
Polyploid 0
Cryopreserved 0
Transferred 2-cell embryo
Outcome: ongoing pregnancy

Case 35 79
35.O2 35.O4
35.O5 35.Z4
35.Z5 35.E5
Oocytes
35.O2 Oocyte with two polar bodies (second polar body out of focal plane)
35.O4 Misshapen oocyte with two polar bodies
35.O5 Normal metaphase II, relatively small perivitelline space
Zygotes
35.Z4 Zygote with distorted zona pellucida and severe vacuolization
Embryos
35.E5 Two-cell embryo, retarded, unequal blastomeres, large fragments, vacuoles
factor

Age 36, salesperson Age 52, locksmith
Ectopic pregnancy, L. salpingectomy History/examination: NAD
Right hydrosalpynx 3 children with previous partner

Volume 2 mL
pH 7.9
Concentration 43 106/ml
Type B 2%
Type C 2%
Type D 24%
Normal forms 3%
2008 Timed intercourse, ovulation induction with HMG Not pregnant
Cycle: ICSI 2010

Total dose 2475 IU

Metaphase II 14
Metaphase I 0
Germinal vesicles 3
Atretic oocytes 0
Injected 14
Lysed 0
Diploid 11
Monoploid 3
Polyploid 0
Outcome: missed abortion at 6.5 weeks, gestational sac with no FH activity

Case 36 81
36.O5 36.O11
36.Z5 36.Z11
36.E5 36.E11
Oocytes
36.O5 Metaphase II, small cytoplasmic inclusions
36.O11 Metaphase II, small cytoplasmic inclusions
Zygotes
36.Z5 Pronuclei abutted, nucleoli asynchronous, not aligned
36.Z11 Pronuclei abutted, nucleoli synchronous, not aligned
Embryos
36.E5 Two- to three-cell embryo, considerable number of grouped fragments
36.E11 Four-cell embryo, unequal blastomeres, minimal number of fragments
factor

Age 36, laboratory technician Age 36, computer scientist
Adhesions on L. tube History/examination: NAD
Semen assessment: asthenoteratozoospermia (based on two diagnostic assessments)

Volume 2 mL
pH 8.1
Type B 24%
Type C 8%
Type D 48%
Normal forms 5%
Cycle: ICSI 2010

Total dose 2925 IU

Metaphase II 7
Metaphase I 2
Germinal vesicles 0
Atretic oocytes 0
Injected 9 (2 metaphase I, matured to metaphase II: O8, O9)
Lysed 0
Diploid 6
Monoploid 0
Polyploid 1
Cryopreserved 4

Case 37 83
37.O1 37.O3 37.O8
37.Z1 37.Z3 37.Z8
37.E1 37.E3
Oocytes
37.O3 Metaphase II oocyte, atypical thick zona pellucida, fragmented polar body
37.O8 Metaphase II oocyte, metaphase I at oocyte retrieval
Zygotes
37.Z1 Abutted pronuclei, nucleoli synchronous and almost aligned, vacuole at the 1 o’clock position
37.Z3 Abutted pronuclei, nuclei synchronous but not aligned
37.Z8 Tripronuclear zygote resulting from matured metaphase I oocyte
Embryos
37.E1 Two-cell retarded embryo, slightly unequal blastomeres, grouped fragments
37.E3 Four-cell embryo, almost equal blastomeres, minor fragments
Case 38 1 year 1 infertility Diagnosis: tubal factor

Age 33, care expert Age 45, physiotherapist
Tubal status: L. tube partially patent History/examination: NAD
Endometriosis
Semen assessment: asthenoteratozoospermia in two previous diagnostic assessments

Volume 2 mL
pH 7.7
Type B 13%
Type C 6%
Type D 22%
Normal forms 8%

Cycle: ICSI 2010

Total dose 2700 IU

Metaphase II 3
Metaphase I 3
Germinal vesicles 5
Atretic oocytes 0
Injected 5 (2 metaphase I, matured to metaphase II, both
fertilized after ICSI)
Lysed 0
Diploid 4
Monoploid 1
Polyploid 0
Cryopreserved 2

Case 38 85
38.O2 38.O3 38.O5
38.Z2 38.Z3 38.Z5
38.E3 38.E5
Oocytes
38.O2 Metaphase II oocyte with areas of cytoplasmic degeneration
38.O3 Metaphase II oocyte, no particular features
38.O5 Metaphase II oocyte, post-in vitro maturation, area of cytoplasmic degeneration
Zygotes
38.Z2 Monopronuclear zygote
38.Z3 Abutted pronuclei, asynchronous nucleoli, cytoplasmic retraction
38.Z5 Abutted pronuclei, nucleoli synchronous and starting to align, appearance of a vacuole (persists in a blastomere at
the cleavage stage)
Embryos
38.E3 Two-cell retarded embryo, unequal blastomeres, minimal number of fragments
38.E5 Three-cell retarded embryo, unequal blastomeres, vacuole in the left blastomere
Remarks: there were many oocytes with areas of cytoplasmic degeneration.

Case 39 4 years 2 infertility Diagnosis: tubal damage þ
male factor

Age 37, bank employee Age 41, bank employee
2007: L. adhesiolysis, treated for Non-smoker, no alcohol consumption
Stage I endometriosis
2008: spontaneous abortion after natural conception
Treated for depression
Stopped smoking 7 years ago, moderate alcohol
consumption
Semen assessment: asthenozoospermia, based on two previous diagnostic assessments

Volume 3.5 mL
pH 7.7
Motility: Type A 9%
Type B 71%
Type C 2%
Type D 8%
Normal forms 20%
2009 ICSI Biochemical pregnancy
Cycle: ICSI 2010

Daily dose 3 4, 2 5, 5 6 75 IU HMG
Total dose 4650 IU
Metaphase II 3
Metaphase I 1
Germinal vesicles 0
Atretic oocytes 0
Injected 4
Diploid 3
Monoploid 1
Polyploid 0
Transferred 4-cell embryo and non-cleaved zygote

Case 39 87
39.O3 39.O4
39.Z3 39.Z4
39.E3 39.E4
Oocytes
39.O3 Thick zona pellucida
39.O4 Thick zona pellucida, oval-shaped oocyte
Zygotes
39.Z3 Abutted pronuclei, synchronous nucleoli almost aligned, vacuolized cytoplasm
Embryos
39.E3 Four-cell embryo, equal blastomeres, minimal fragmentation
39.E4 Uncleaved zygote
Case 40 4 years 2 infertility Diagnosis: tubal factor þ
male factor

Age 39, teacher Age 42, lawyer
Tubal status: not patent Non-smoker, no alcohol abuse
MH: dysmenorrhoea
Abdominal adhesions
Live birth 1988, previous partner

Volume 3.5 mL
pH 7.9
Motility: Type A 6%
Type B 49%
Type C 7%
Type D 38%
Normal forms 2%
Cycle: ICSI 2010

Total dose 3225 IU

Metaphase II 4
Metaphase I 0
Germinal vesicles 0
Atretic oocytes 0
Injected 4
Lysed 0
Diploid 3
Monoploid 1
Polyploid 0

Case 40 89
40.O1 40.O2
40.Z1 40.Z2
40.E1 40.E2
Oocytes
Zygotes
40.Z1 Pronuclei abutted, asynchronous nucleoli aligned in the left pronucleus, cytoplasmic
retraction
40.Z2 Pronuclei abutted, nucleoli synchronous and almost aligned, cytoplasmic retraction
Embryos
40.E1 Four-cell embryo, slightly unequal blastomeres, minimal fragmentation
40.E2 Four-cell embryo, slightly unequal blastomeres, small number of grouped fragments
Case 41 4 years 1 infertility Diagnosis: tubal factor þ
cervical factor þ male factor

Age 37, salesperson Age 40, economist
Endometriosis stage I Orchidopexy
L. tubal obstruction Non-smoker, no alcohol abuse
2006: tubal surgery
Cervical factor
Semen assessment: asthenozoospermia

Volume 1.5 mL
pH 7.9
Type B 15%
Type C 10%
Type D 57%
Normal forms 16%
2006–2007 IUI 4 Not pregnant, cancelled cycles 2
Cycle: ICSI 2010
Stimulation protocol Long protocol, GnRH agonist, 0.1 mg s/c daily

Daily dose 5 4 75, 3 5 75, 5 6 75 IU HMG
Total dose 4875 IU

Metaphase II 3
Metaphase I 1
Germinal vesicles 1
Atretic oocytes 0
Injected 4 (O4 =metaphase I at OCR, metaphase II at ICSI,
MPN fertilization after ICSI)
Lysed 0
Diploid 2
Monoploid 1
Polyploid 1
Cryopreserved 0

41.O1 41.O2 41.O3
41.O4 41.Z1 41.Z2
41.E1 41.E2
male factor

Age: 30, florist Age 34, purchasing manager
Cervical stenosis

Volume 3 mL
pH 7.9
Type B 8%
Type C 9%
Type D 40%
Normal forms 4%
Cycle: ICSI 2010
Stimulation protocol Long protocol, GnRH-agonist, depot 3.6 mg

Total dose 2700 IU

Metaphase II 7
Metaphase I 3
Germinal vesicles 0
Atretic oocytes 0
Injected 10 (3 metaphase I, matured to metaphase II at ICSI)
Lysed 0
Diploid 8
Monoploid 1
Polyploid 1
Cryopreserved 6
Transferred polyfragmented embryo and 4-cell embryo
Outcome: missed abortion (gestational sac, no FH activity)

Case 42 93
42.02 42.09
42.Z2 42.Z9
42.E2 42.E9
Oocytes
42.O2 Metaphase II oocyte with area of cytoplasmic degeneration in region of polar body
42.O9 Post-matured metaphase I oocyte
Zygotes
42.Z2 Abutted pronuclei, nucleoli synchronous and almost aligned, cytoplasmic retraction
Embryos
42.E2 Polyfragmented embryo, transferred on wish of the couple, cytoplasmic retraction
42.E9 Four-cell embryo, unequal blastomeres and some large fragments
Remarks: majority of oocytes have areas of cytoplasmic degeneration, all three post-matured
metaphase I oocytes were fertilized; oocyte 42.O9 was kept for transfer based on the
pronuclear morphology.
fibroid uterus þ male factor

Age 37, musician Age 40, computer scientist
Tubal status: not explored Orchidopexy for cryptorchidism
MH: normal
Myomectomy

Volume 3 mL
pH 7.9
Motility: Type A 0%
Type B 29%
Type C 9%
Type D 62%
Normal forms 4%
Cycle: ICSI 2010
Stimulation protocol Short protocol, GnRH agonist, 0.1 mg s/c daily

Total dose 1875 IU

Metaphase II 11
Metaphase I 1
Germinal vesicles 0
Atretic oocytes 1
Injected 1
Lysed 0
Diploid 9
Monoploid 0
Polyploid 1

Case 43 95
43.01 43.O10
43.Z1 43.Z10
43.E1 43.E10
Oocytes
43.O1 Central patch with moderate degenerative cytoplasm, thick zona pellucida
43.O10 Central patch with moderate degenerative cytoplasm, thick zona pellucida
Zygotes
43.Z10 Abutted pronuclei, nucleoli synchronous and almost aligned, small vacuole
below the pronuclei
Embryos
43.E1 Four-cell embryo, slightly unequal blastomeres, no fragmentation
43.E10 Retarded two-cell embryo with minor fragments
Remarks: transfer of thawed zygotes in a subsequent cycle resulted in ongoing pregnancy.


Age 39, housewife Age 47, computer specialist
Tubal status: patent 1971: mumps
MH: normal 1974: orchitis
2009: fundal myomectomy 1985: hernia repair
2009: endometrial polypectomy Non-smoker, no alcohol consumption

Volume 6 mL
pH 8
Type B 10%
Type C 5%
Type D 71%
Normal forms 3%
Cycle: ICSI 2010

Total dose 3375 IU

Metaphase II 6
Metaphase I 0
Germinal vesicles 1
Atretic oocytes 2
Injected 6
Diploid 4
Monoploid 1
Polyploid 0

Case 44 97
44.01 44.03
44.Z1 44.Z3
44.E1 44.E3
Oocytes
44.O3 Oval-shaped oocyte, atypical thick zona pellucida, large perivitelline space
Zygotes
Embryos
44.E1 Three- to four-cell embryo, unequal blastomeres, large fragments
Case 45 3 years 1 infertility Diagnosis: male factor þ
endometriosis

Age 29, housewife Age 41, bank employee
Tubal status: patent Bilateral testicular atrophy of unknown origin
MH: dysmenorrhoea Azoospermia
2006: endometriosis Stage 1, treated Elevated FSH, normal testosterone
Non-smoker, no alcohol abuse Normal, karyotype 46, XY
Semen assessment: testicular biopsy: no motile spermatozoa,

hypo-osmotic swelling showed positive spermatozoa available for injection
2009 TESE–ICSI Not pregnant
Cycle: ICSI with thawed testicular sperm, 2010
Stimulation protocol Long procotol, GnRH agonist, depot 3.6 mg

Total dose 2925 IU
Oestradiol at the time of hCG administration 2771 pmol7L

Metaphase II 5
Metaphase I 0
Germinal vesicles 0
Atretic oocytes 0
Injected 5
Lysed 0
Diploid 1
Monoploid 3
Polyploid 0
Cryopreserved 0
Transferred 1

Case 45 99
45.02 45.04
45.05 45.Z4
45.Z5 45.E5
Oocytes
45.O2 Dysmorphic ellipsoid metaphase II oocyte with large area of central necrosis
45.O4 Misshapen metaphase II oocyte, distorted vacuolization
45.O5 Dysmorphic metaphase II oocyte, ellipsoid shape
Zygotes
45.Z4 Atretic unfertilized oocyte with severe vacuolization
45.Z5 Two indistinct pronuclei, nucleoli not visualized
Embryos
45.E5 Three-cell embryo, blastomeres of unequal size, no fragments
Remarks: majority of oocytes had degenerative cytoplasm.

Case 46 3 years 1 infertility Diagnosis: endometriosis þ cervical
factors þ hyperprolactinaemia þ
male factor
Age 29, salesperson Age 34, coachbuilder
Endometriosis stage 1 History/examination: NAD
2009: endometrioma L. ovary treated
Cervical factor

Volume 2 mL
pH 7.8
Type B 16%
Type C 3%
Type D 42%
Normal forms 0%
Cycle: ICSI 2010

Total dose 1875 IU

Metaphase II 12
Metaphase I 0
Germinal vesicles 0
Atretic oocytes 0
Injected 12
Lysed 1
Diploid 11
Monoploid 0
Polyploid 0
Cryopreserved 9
Replaced 2 4-cell embryos

Case 46 101
46.02 46.07
46.Z2 46.Z7
46.E2 46.E7
Oocytes
46.O2 Metaphase II oocyte, no abnormalities
46.O7 Metaphase II oocyte, atypical thick zona pellucida, no cytoplasmic inclusions
Zygotes
46.Z2 Abutted pronuclei, nucleoli synchronous and aligned, large and different in number
46.Z7 Abutted pronuclei, large nucleoli not fully synchronous, aligned in the left pronucleus
Embryos
46.E2 Four-cell embryo, slightly unequal blastomeres, considerable number of grouped small
fragments
46.E7 Four-cell embryo, nearly equal blastomeres, small grouped fragments on the left and larger
fragments on the right
Case 47 6 years 1 infertility Diagnosis: endometriosis
stage III þ male factor

Age 32, salesperson Age 38, mechanic
Tubal status: patent Cryptorchidy, corrected by orchidopexy
MH: anovulation, dysmenorrhoea, endometriosis Non-smoker, no alcohol consumption
2005, 2009: endometriosis treated
2007: ovarian cyst removed

Volume 7 mL
pH 8.0
Type B 13%
Type C 14%
Type D 49%
Normal forms 3%
Cycle: ICSI 2010

Total dose 3600 IU
Metaphase II 8
Metaphase I 2
Germinal vesicles 2
Atretic oocytes 2
Diploid 7
Monoploid 2
Polyploid 1

Case 47 103
47.01 47.05
47.Z1 47.Z5
47.E1 47.E5
Oocytes
47.O1 Enlarged perivitelline space
Zygotes
Embryos
47.E1 Three-cell embryo, retarded, grouped small fragments
47.E5 Eight-cell embryo, anomalous rapid cleavage, grouped small fragments
Case 48 1 infertility Diagnosis: endometriosis þ male factor

Age 32, farmer Age 44, farmer
Tubal status: patent 1 child with previous partner
Factor V Leiden resistance
Minimal bilateral endometriosis
2009: adhesiolysis

Volume 3 mL
pH 8.1
Motility: Type A 7%
Type B 23%
Type C 3%
Type D 67%
Normal forms 0%

Cycle: ICSI 2010

Total dose 3150 IU

Metaphase II 3
Metaphase I 0
Germinal vesicles 0
Atretic oocytes 0
Injected 3
Lysed 0
Diploid 1
Monoploid 0
Polyploid 0
Cryopreserved 0

Case 48 105
48.O1 48.02
48.Z1 48.Z2
48.Z3 48.E1
Oocytes
48.O1 Metaphase II, minor cytoplasmic inclusion, granules in perivitelline space
48.O2 Metaphase II, major cytoplasmic inclusion, condensed smooth endoplasmic reticulum
Zygotes
48.Z1 Abutted pronuclei, asynchronous nucleoli, retracted cytoplasm
48.Z2 Not fertilized
48.Z3 Not fertilized
Embryos
48.E1 Three-cell embryo, slightly unequal blastomeres, minimal fragmentation
Case 49 3 years 1 infertility Diagnosis: endometriosis þ
tubal factor þ male factor

Age 33, waitress Age 34, not recorded
L. tube not fully patent History/examination: NAD
Endometriosis stage 1 Non-smoker, no alcohol abuse
Subclinical hypothyroidism
MH: normal

Volume 5 mL
pH 7.4
Type B 21%
Type C 18%
Type D 47%
Normal forms 2%
Cycle: ICSI 2009

Total dose 2250 IU

Metaphase II 11
Metaphase I 0
Germinal vesicles 0
Atretic oocytes 0
Injected 11
Lysed 0
Diploid 7
Monoploid 0
Polyploid 0

Case 49 107
49.O9 49.O10
49.Z9 49.Z10
49.E9 49.E10
Oocytes
49.O9 Metaphase II oocyte, minor area with degenerative cytoplasm, minor cytoplasmic inclusions
Zygotes
49.Z10 Abutted pronuclei, nucleoli synchronous, almost aligned
Embryos
49.E9 Four- to five-cell embryo, significant number of fragments, unequal blastomeres
49.E10 Four-cell embryo, slightly unequal blastomeres, small number of grouped fragments
tubal factor

Age 34, florist Age 41, plumber
Tubal status: not patent History/examination: NAD
Stage IV endometriosis with tubal pathology Non-smoker, no alcohol consumption
MH: dysmenorrhoea
2009: laparotomy, myomectomy

Volume 4.5 mL
pH 7.8
Motility: Type A 0%
Type B 57%
Type C 16%
Type D 27%
Normal forms 14%
Cycle: ICSI 2010

Total dose 2250 IU

Metaphase II 4
Metaphase I 0
Germinal vesicles 4
Atretic oocytes 0
Injected 4
Lysed 0
Diploid 4
Monoploid 0
Polyploid 0

Case 50 109
50.O1 50.O2
50.Z1 50.Z2
50.E1 50.E2
Oocytes
50.O1 Atypical thick zona pellucida, minor cytoplasmic inclusions
50.O2 Atypical thick zona pellucida, minor cytoplasmic inclusions, small perivitelline space
Zygotes
50.Z1 Abutted pronuclei, nucleoli synchronous and aligned, retracted cytoplasm
Embryos
50.E1 One blastomere and large number of small fragments, not transferred
50.E2 Four-cell embryo, unequal blastomeres and considerable amount of fragmentation

Age 34, farmer Age 38, farmer
Endometriosis
AMH: 0.7 mg/L

Volume 5.5 mL
pH 7.9
Type B 23%
Type C 8%
Type D 44%
Normal forms 3%
2009 3 IUI Not pregnant
Cycle: ICSI 2010
Stimulation protocol Short protocol, GnRH agonist, day 1 to day 12

Daily dose 4 75 IU HMG from day 2 on
Total dose 3300 IU

Metaphase II 4
Metaphase I 1
Germinal vesicles 0
Atretic oocytes 0
Injected 4
Lysed 2
Diploid 2
Monoploid 0
Polyploid 0
Cryopreserved 0

Case 51 111
51.O3 51.O4
51.Z3 51.Z4
51.E3 51.E4
Oocytes
51.O3 Metaphase II oocyte, thick zona pellucida, central area with degenerative cytoplasm
Zygotes
51.Z3 Abutted pronuclei different in size, asynchronous nucleoli different in size and number
51.Z4 Abutted pronuclei, nucleoli starting to align
Embryos
51.E3 Four-cell embryo, blastomeres almost equal in size, no fragments
51.E4 Four-cell embryo, blastomeres almost equal in size, some large fragments between the
blastomeres
Case 52 1 infertility Diagnosis: endometriosis þ
male factor

Age 35, economist Age 37, clerk
Tubal status: adhesions History/examination: NAD
Raised FSH levels, reduced ovarian reserve Non-smoker, no alcohol abuse
2008: adhesions and endometriosis Stage IV
treated
2010: endometrial polypectomy

Volume 3.5 mL
pH 8.2
Type B 35%
Type C 3%
Type D 30%
Normal forms 1%
2009 IUI Not pregnant
2009 IUI Cycle cancelled, no ovarian response
Cycle: ICSI 2010

Daily dose 6 75 IU HMG from day 2 onwards
Total dose 5280 IU
Metaphase II 1
Metaphase I 0
Germinal vesicles 1
Atretic oocytes 1
Injected 1
Lysed 0
Diploid 1
Monoploid 0
Polyploid 0
Cryopreserved 0

Case 52 113
52.O1 52.Z1
52.E1
Oocytes
52.O1 Metaphase II oocyte, single but distinct cytoplasmic inclusion
Zygotes
52.Z1 Abutted pronuclei, large and sparse nucleoli, not synchronous
Embryos
52.E1 Three-cell embryo, unequal blastomeres, single large fragment
Case 53 1 infertility Diagnosis: endometriosis þ male factor

Age 35, economist Age 37, IT controller
Tubal status: adhesions History/examination: NAD
MH: reduced ovarian reserve, elevated FHS Non-smoker, no alcohol abuse
2008: endometriosis Stage IV þ adhesions treated
2010: endometrial polypectomy

Volume 3.5 mL
pH 7.9
Type B 19%
Type C 5%
Type D 29%
Normal forms 1%
2009 Timed intercourse Not pregnant
2009 IUI Cycle cancelled, no ovarian response
Cycle: ICSI 2010

Daily dose 2 75 IU HMG from day 2 on
Total dose 1500 IU

Metaphase II 3
Metaphase I 0
Germinal vesicles 0
Atretic oocytes 0
Injected 3
Lysed 0
Diploid 0
Monoploid 2
Polyploid 1
Cryopreserved 0
Transferred None
Outcome: no embryo transfer

Case 53 115
53.O1 53.Z1
53.O2 53.Z2
53.O3 53.Z3
Oocytes
53.O1 Metaphase II oocyte, with two polar bodies before injection, cytoplasmic inclusions
53.O2 Metaphase II oocyte, with two polar bodies before injection
53.O3 Metaphase II oocyte, with two polar bodies before injection, cytoplasmic inclusions
Zygotes
53.Z1 Monoploid activated oocyte
53.Z2 Monoploid activated oocyte
53.Z3 Triploid zygote, one large and two smaller pronuclei
male factor

Age 35, salesperson Age 42, logistics assistant
MH: dysmenorrhoea Non-smoker, no alcohol abuse
2010: endometriosis Stage 1 treated

Volume 3.5 mL
pH 8.4
Type B 54%
Type C 10%
Type D 25%
Normal forms 14%
Cycle: ICSI 2010

Daily dose 7 3 75 IU HMG, 2 2 75 IU HMG, 2 1 75
IU HMG
Total dose 2326 IU

Metaphase II 8
Metaphase I 2
Germinal vesicles 0
Atretic oocytes 0
Injected 10 (2 metaphase I, matured to metaphase II: 1 failed to
fertilize, 1 MPN fertilization)
Lysed 0
Diploid 7
Monoploid 1
Polyploid 3

Case 54 117
54.O6 54.O7
54.Z6 54.Z7
54.E6 54.E7
Oocytes
54.O7 Metaphase II oocyte, thick zona pellucida, small perivitelline space, cytoplasmic inclusions
Zygotes
54.Z6 Abutted pronuclei, asynchronous nucleoli, aligned in the right pronucleus
Embryos
54.E6 Four-cell embryo, blastomeres of unequal size, considerable number of ungrouped fragments
54.E7 Six-cell embryo, blastomeres almost equal in size, no fragmentation
Case 55 3 years 1 infertility Diagnosis: endometriosis,
hyperprolactinaemia þ
male factor
Age 35, salesperson Age 41, chief executive officer
Tubal status: patent Children with a previous partner
Endometriosis
Hyperprolactinaemia
Semen assessment: severe asthenoteratozoospermia

Volume 2 mL
pH 8
Type B 20%
Type C 13%
Type D 43%
Normal forms 0%
2009 ICSI No fertilization
Cycle: ICSI September 2009
Stimulation protocol Short protocol, GnRH agonist, 0.1 mg s/c day 1 to day 16
Days of stimulation 14, starting on day 2
Total dose 4800 IU

Metaphase II 4
Metaphase I 4
Germinal vesicles 0
Atretic oocytes 0
Injected 5 (1 metaphase I, matured to metaphase II, 3 PN after ICSI)
Lysed 0
Diploid 4
Monoploid 0
Polyploid 1
Outcome: live birth, healthy twin boys

Case 55 119
55.O1 55.O2
55.Z1 55.Z2
55.E1 55.E2
Oocytes
Zygotes
55.Z1 Abutted pronuclei, sparse large nucleoli, few in number and asynchronous
55.Z2 Abutted pronuclei, nucleoli asynchronous
Embryos
55.E1 Four-cell embryo, blastomeres slightly unequal, significant number of grouped fragments
poor responder þ male factor

Age 36, IT support Age 41, IT support
2008: endometriosis treated Paraplegic after multiple trauma in 2006
2008: uterine fibroids treated 2 children with previous partner before 2006
Semen assessment: in 20 mL medium after electro-ejaculation

Volume 22 mL
pH Not assessed
* Concentration 15 106/mL
Type B 12%
Type C 7%
Type D 59%
Normal forms Not assessed
* after two-layer gradient preparation
2009 ICSI Failure of fertilization
Cycle: ICSI 2009

Total dose 2250 IU
Metaphase II 1
Metaphase I 1
Germinal vesicles 0
Atretic oocytes 0
Injected 2 (1 metaphase I, matured to metaphase II, fertilized
after ICSI)
Lysed 0
Diploid 2
Monoploid 0
Polyploid 0
Cryopreserved 0

Case 56 121
56.O1 56.O2
56.Z1 56.Z2
56.E1 56.E2
Oocytes
56.O1 Metaphase II oocyte, large perivitelline space, septum
56.O2 Metaphase II oocyte, septum, minor cytoplasmic inclusions
Zygotes
56.Z1 Pronuclei close together, not abutted, different in size, nucleoli aligned
56.Z2 Pronuclei different in size, not clearly visible, nucleoli asynchronous
Embryos
56.E2 Two-cell embryo with 50% of the perivitelline space filled with grouped fragments
Remarks: only two metaphase II oocytes were found in each of previous cycles.
Case 57 1 infertility Diagnosis: post-vasectomy 15 years
ago þ low ovarian responder

Tubal status: patent 1995: vasectomy
MH: normal 2010: inguinal hernia repair
Endometriosis
Semen assessment: testicular biopsy was performed two days before the oocyte retrieval; prepared tissue was
kept in culture until the time of injection.
Cycle: ICSI 2010

Total dose 2925 IU

Metaphase II 3
Metaphase I 0
Germinal vesicles 0
Atretic oocytes 0
Injected 3
Lysed 0
Diploid 2
Monoploid 1
Polyploid 0
Cryopreserved 0

57.O1 57.O2 57.O3
57.Z1 57.Z2 57.Z3
57.E1 57.E3
Case 58 1 infertility Diagnosis: post-vasectomy 15 years
ago þ low ovarian responder

Tubal status: patent 1995: vasectomy
MH: normal 2010: inguinal hernia repair
Endometriosis
Semen assessment: cryopreserved testicular biopsy sample used for intracytoplasmic sperm injection
Cycle: ICSI 2010
Stimulation protocol Short protocol, GnRH agonist, 0.1 mg s/c day 1

to day 11
Total dose 3000 IU

Metaphase II 1
Metaphase I 0
Germinal vesicles 0
Atretic oocytes 0
Injected 1
Lysed 1
Diploid 0
Monoploid 1
Polyploid 0
Cryopreserved 0
Transfer No embryo transfer
Outcome: no embryos transferred

Case 58 125
58.O1
58.Z1
Oocytes
58.O1 Metaphase II oocyte, thick zona pellucida, minor and major
cytoplasmic inclusions
Zygotes
58.Z1 Lysed oocyte
Stage III

Age 39, teacher Age 32, technician
2004: endometriosis Stage III treated 2005: surgery for varicocele
2007: adhesiolysis þ endometriosis treated Non-smoker, no alcohol consumption
2010: chlamydia infection
Hypothyroid, with substitution therapy
MH: normal
Semen assessment: normozoospermia

Volume 2 mL
pH 7.8
Type B 40%
Type C 10%
Type D 24%
Normal forms 18%
Cycle: ICSI 2010

Total dose 3300 IU

Metaphase II 3
Metaphase I 0
Germinal vesicles 0
Atretic oocytes 0
Injected 3
Lysed 0
Diploid 3
Monoploid 0
Polyploid 0
Cryopreserved 0
Outcome: singleton clinical pregnancy, fetal sac, FH activity, spontaneous abortion at 10 weeks.
Case 59 127
59.O1 59.O2 59.O3
59.Z1 59.Z2 59.Z3
59.E1 59.E2 59.E3
Oocytes
59.O1 Metaphase II oocyte, thick zona pellucida, large perivitelline space
59.O2 Metaphase II oocyte, thick zona pellucida, cytoplasmic inclusion
59.O3 Oval-shaped metaphase II, with condensed smooth endoplasmic reticulum, zona septum
Zygotes
59.Z1 Abutted pronuclei, nucleoli asynchronous, difficult to visualize
59.Z2 Abutted pronuclei, nucleoli slightly asynchronous, almost aligned, different in size and number
59.Z3 Abutted pronuclei, nucleoli difficult to visualize
Embryos
59.E1 Retarded two-cell embryo, equal blastomeres, significant fragmentation
59.E2 Retarded three-cell embryo, large and grouped small fragments
59.E3 Retarded two-cell embryo, top blastomere with inclusions, grouped fragments
Case 60 1 infertility Diagnosis: Stage III endometriosis þ
age þ post-vasectomy

Age 42, medical doctor Age 38, chimney sweep
Tubal status: unknown 2004: bilateral vasectomy
Endometriosis Stage III
Semen assessment: thawed testicular spermatozoa used for ICSI

2009 ICSI þ TESE Not pregnant
Cycle: ICSI 2010

Total dose 4350 IU

Metaphase II 5
Metaphase I 0
Germinal vesicles 0
Atretic oocytes 0
Injected 5
Lysed 2
Diploid 2
Monoploid 1
Polyploid 0
Cryopreserved 0

Case 60 129
60.O2 60.O3
60.Z2 60.Z3
60.E2 60.E3
Oocytes
60.O2 Metaphase II oocyte, some degenerated cytoplasm
Zygotes
60.Z2 Unclear abutted pronuclei, asynchronous nucleoli, not aligned
60.Z3 Abutted pronuclei, asynchronous nucleoli, not aligned, small inclusion and vacuole at the
7 o’clock position
Embryos
60.E3 Four-cell embryo, slightly unequal blastomeres, no fragments
Case 61 1 infertility Diagnosis: male factor þ poor
responder

Age 26, assistant pharmacist Age 31, factory worker

Volume 6 mL
pH 7.7
Motility: Type A 6%
Type B 24%
Type C 5%
Type D 65%
Normal forms 0%
Cycle: ICSI 2010
Stimulation protocol Short protocol, GnRH agonist from day 2

Total dose 3000 IU

Metaphase II 3
Metaphase I 1
Germinal vesicles 1
Atretic oocytes 0
Injected 4 (1 metaphase I, matured to metaphase II (O4),
fertilized and was transferred)
Lysed 0
Diploid 3
Monoploid 1
Polyploid 0
Cryopreserved 0
Transferred 2 embryos, day 3 (3 embryos cultured to day 3)

61.03 61.04
61.Z3 61.Z4
61.E3 61.E4
Case 62 4 years 2 infertility Diagnosis: low responder þ
ovulatory dysfunction

Age 35, paediatrician Age 38, biologist
2006: natural conception with spontaneous
abortion
2006: spontaneous pregnancy, miscarried

Volume 3 mL
pH 7.9
Type B 21%
Type C 3%
Type D 51%
Normal forms 15%
2009 ICSI 2 Not pregnant
Cycle: ICSI 2010
Stimulation protocol Short protocol, GnRH agonist, 0.1 mg s/c from day 1
Daily dose 10 6 75 IU HMG
Total dose 4500 IU

Metaphase II 4
Metaphase I 0
Germinal vesicles 0
Atretic oocytes 1
Injected 4
Lysed 1
Diploid 2
Monoploid 1
Polyploid 0
Cryopreserved 0

Case 62 133
62.01 62.04
62.Z1 62.Z4
62.E1 62.E4
Oocytes
62.O1 Metaphase II oycte, thick zona pellucida
62.O4 Metaphase II oocyte, major cytoplasmic inclusion
Zygotes
62.Z1 Abutted pronuclei, nucleoli large and asynchronous
62.Z4 Pronuclei abutted, nucleoli asynchronous, retracted cytoplasm, cytoplasmic inclusion still
present
Embryos
62.E1 Two-cell embryo, unequal blastomeres, grouped fragments, four cells at the time of transfer
62.E4 Three-cell embryo, some fragments, unclear cell membranes, four cells at the time of transfer
Remarks: because of the repeated low response, the patient opted for oocyte donation in her next
cycle, resulting in an ongoing twin pregnancy.
Case 63 9 years 1 infertility Diagnosis: severe male factor þ
female: poor responder

Age 36, machine operator Age 40, land surveyor
Tubal status: not investigated Elevated FSH
MH: normal Hypergonadotropism
Non-smoker, no alcohol consumption Small testicular volume
Non-smoker
Semen assessment: cryptozoospermia; 20 motile spermatozoa per ejaculate

Cycle: ICSI 2010
Stimulation protocol GnRH antagonist, 0.25 mg from day 6 to day 10

Daily dose 4 75 IU HMG from day 6 to day 10
Total dose 1500 IU

Metaphase II 2
Metaphase I 1
Germinal vesicles 0
Atretic oocytes 0
Injected 2
Lysed 0
Diploid 2
Monoploid 0
Polyploid 0
Cryopreserved 0

Case 63 135
63.01 63.02
63.Z1 63.Z2
63.E1 63.E2
Oocytes
63.O1 Metaphase II oocyte, large perivitelline space, degenerated cytoplasmic areas, cytoplasmic
inclusions
63.O2 Metaphase II oocyte, large perivitelline space, cytoplasmic inclusions
Zygotes
63.Z1 Pronuclei abutted, large asynchronous nucleoli, few in number
63.Z2 Pronuclei not abutted but close together, synchronous nucleoli, different in size
Embryos
63.E1 Two-cell embryo, retarded, equal blastomeres, minimal or no fragments
63.E2 Two-cell embryo, retarded, blastomeres almost equal, no fragments
Case 64 5 years 1 infertility Diagnosis: poor responder þ
male factor

Age 37, pharmacist Age 41, cheese maker
Tubal status: patent Orchidopexy at age 7
Semen assessment: cryptozoospermia, two motile and four immotile spermatozoa in 100 microscope fields
Volume 3 mL
pH 8.0
Motility: Type A *
Type B *
Type C *
Type D *
Normal forms *
* Not assessed: concentration too low
2005 ICSI No pregnancy
2005 ICSI No pregnancy
2005 FET No pregnancy
Cycle: 2010 ICSI
Stimulation protocol Short protocol, GnRH agonist, 0.1 mg from day 1

Days of stimulation 10 (start day 2)
Total dose 3750 IU

Metaphase II 2
Metaphase I 0
Germinal vesicles 1
Atretic oocytes 0
Injected 2
Lysed 0
Diploid 2
Monoploid 0
Polyploid 0
Cryopreserved 0
Transferred partially cleaved 1-cell embryo and 6-cell embryo

Case 64 137
64.01 64.02
64.Z1 64.Z2
64.E1 64.E2
Oocytes
64.O1 Metaphase II oocyte, atypical thick zona, minor cytoplasmic inclusions
64.O2 Metaphase II oocyte, atypical thick zona, minor cytoplasmic inclusions
Zygotes
64.Z1 Abutted pronuclei, different in size, asynchronous nucleoli, aligned in the right pronucleus
64.Z2 Abutted pronuclei, synchronous nucleoli, aligned
Embryos
64.E1 Six-cell cleaving embryo, slightly unequal blastomeres, some fragments
64.E2 Uncleaved or partially cleaved zygote, one large blastomere with two pronuclei
male factor

Age 38, pharmaceutical representative Age 41, cook
Tubal status: not explored Bilateral absence of vas deferens
MH: normal Bilateral partial absence of caput
Non-smoker, no alcohol abuse epididymus
CFTR-mutation
Semen assessment: ICSI carried out using thawed testicular spermatozoa

2010 ICSI cancelled No ovarian response
2010 ICSI No oocytes recovered
Cycle: ICSI 2010
Stimulation protocol GnRH antagonist, day 6, 7 and 8

Total dose 2400 IU

Metaphase II 2
Metaphase I 1
Germinal vesicles 0
Atretic oocytes 0
Injected 3 (1 metaphase 1, matured to metaphase II, fertilized
after ICSI)
Lysed 0
Diploid 2
Monoploid 0
Polyploid 0
Cryopreserved 0

Case 65 139
65.01 65.03
65.Z1 65.Z3
65.E1 65.E3
Oocytes
65.O3 Metaphase II oocyte, thick zona pellucida, central area with degenerative cytoplasm
Zygotes
65.Z1 Pronuclei close together, different in size, asynchronous nucleoli
65.Z3 Pronuclei abutted, asynchronous nucleoli, different in size and number
Embryos
65.E1 Three-cell retarded embryo, blastomeres of unequal size, minimal fragmentation
65.E3 Five-cell embryo, blastomeres of unequal size, some large fragments
Case 66 9 years 2 infertility Diagnosis: male factor þ poor
responder

Age 39, stage manager Age 29, film producer
Tubal status: patent One pregnancy with previous partner
2005: treated for endometriosis Stage IV
2005: ovarian cyst removal
2009: adhesiolysis
Semen assessment: oligoasthenoteratozoospermia, based on two previous diagnostic assessments

Volume 5 mL
pH 7.4
Type B 52%
Type C 9%
Type D 4%
Normal forms 6%
Cycle: ICSI 2010

Total dose 6750 IU
Metaphase II 1
Metaphase I 2
Germinal vesicles 0
Atretic oocytes 0
Injected 2 (1 metaphase I, matured to metaphase II, diploid
after ICSI)
Lysed 0
Diploid 1
Monoploid 0
Polyploid 1
Cryopreserved 0
Replaced 3-cell embryo

Case 66 141
66.01 66.Z1
66.02 66.Z2
66.03 66.E2
Oocytes
66.O1 Metaphase II oocyte, dark and thick zona pellucida, large polar body
66.O2 Metaphase II oocyte (metaphase I at oocyte retrieval), oval shape, thick and dark zona
pellucida, cytoplasm with area of degeneration
66.O3 Metaphase II oocyte, thick and dark zona pellucida, areas of cytoplasmic degeneration
Zygotes
66.Z1 Triploid zygote, second polar body not extruded
Embryos
66.E2 Three-cell embryo, some large fragments and considerable number of grouped fragments
Remarks: all oocytes have thick, dark zona pellucida and cytoplasm.
age factor þ post-vasectomy

Age 42, medical assistant in radiology Age 40, medical doctor
Tubal status: not explored 2000: vasectomy
MH: normal Smoker, moderate alcohol consumption
2008: myomectomy
Semen assessment: thawed pre-vasectomy semen sample

Volume 0.2 mL
pH Not recorded
Type B 13%
Type C 17%
Type D 52%
Normal forms Not recorded
2009 ICSI No metaphase II oocytes
Cycle: ICSI 2010
Stimulation protocol Antagonist protocol, GnRH antagonist, day 6 to day

11
Daily dose 11 3 75 IU HMG
Total dose 3300 IU

Metaphase II 5
Metaphase I 0
Germinal vesicles 0
Atretic oocytes 0
Injected 5
Lysed 1
Diploid 4
Monoploid 0
Polyploid 0
Transferred 2 4-cell embryos and 3-cell embryo

Case 67 143
67.01 67.02 67.04
67.Z1 67.Z2 67.Z4
67.E1 67.E2 67.E4
Oocytes
67.O1 Metaphase II oocyte, granules under the zona pellucida
67.O2 Metaphase II oocyte, minor area of degenerative cytoplasm
Zygotes
67.Z1 Pronuclei abutted but vague, asynchronous nucleoli, not aligned
67.Z2 Pronuclei abutted but vague, few asynchronous nucleoli, not aligned
67.Z4 Pronuclei abutted, nucleoli synchronous and starting to align
Embryos
67.E1 Four-cell embryo, equal blastomeres, no fragments
67.E4 Three-cell embryo, large number of fragments
Case 68 Primary infertility Diagnosis: ovulatory dysfunction

Age 32, salesperson Age 36, project leader
Tubal status: patent Children with a previous partner
MH: amenorrhoea Thrombophilia
Morbus Basedow (GRAVES disease, Herpes genitalis
autoimmune hyperthyroidism) Non-smoker, no alcohol abuse

Volume 4.5 mL
pH 7.4
Motility: Type A 8%
Type B 61%
Type C 7%
Type D 24%
Normal forms 1%
Cycle: ICSI 2010
Stimulation protocol GnRH antagonist from day 8 to 12

Daily dose 3 75 IU HMG from day 3 to day 12, 2025 total

Metaphase II 4
Metaphase I 0
Germinal vesicles 0
Atretic oocytes 1
Injected 4
Lysed 0
Diploid 3
Monoploid 1
Polyploid 0

Case 68 145
68.01 68.02
68.Z1 68.Z2
68.E1 68.E2
Oocytes
68.O1 Metaphase II, atypical thick zona pellucida, minor cytoplasmic inclusions
68.O3 Metaphase II, atypical thick zona pellucida, single large cytoplasmic inclusion
Zygotes
68.Z1 Abutted pronuclei, nucleoli synchronous and starting to align
68.Z3 Abutted pronuclei, nucleoli asynchronous, cytoplasmic inclusion still present
Embryos
68.E1 Four-cell embryo, blastomeres very unequal in size, considerable number of fragments
68.E3 Four-cell embryo, blastomeres differ very little in size, small number of grouped fragments
Remarks: patient conceived in a subsequent fresh ICSI cycle

Case 69 1 infertility Diagnosis: ovulatory dysfunction þ
male factor

Age 38, salesperson Age 42, legal assistant
Tubal status: unexplored History/examination: NAD
MH: short cycles, oligomenorrhoea Non-smoker, no alcohol consumption
Tonsillectomy

Volume 3 mL
pH 8
Motility: Type A 3%
Type B 12%
Type C 8%
Type D 77%
Normal forms 1%

Cycle: ICSI 2010

Total dose 2250 IU

Metaphase II 6
Metaphase I 3
Germinal vesicles 1
Atretic oocytes 1
Lysed 0
Diploid 7
Monoploid 0
Polyploid 0

Case 69 147
69.05 69.06
69.Z5 69.Z6
69.E5 69.E6
Oocytes
69.O5 Metaphase II with minimal cytoplasmic inclusions
69.O6 Metaphase II with minimal cytoplasmic inclusions
Zygotes
69.Z6 Abutted pronuclei, nucleoli synchronous and almost aligned
Embryos
69.E5 Retarded two-cell embryo, unequal blastomeres, significant fragmentation
69.E6 Four-cell embryo with very unequal blastomeres and many large fragments
Case 70 4 years 2 infertility Diagnosis: ovulatory dysfunction

Age 33, laboratory technician Age 34, IT technician
Tubal status: normal History/examination: NAD

Volume 3.5 mL
pH 8.5
Type B 7%
Type C 0%
Type D 23%
Normal forms 13%
2005–2006 Timed intercourse 4 Not pregnant
2006 IUI 2 1 spontaneous abortion, 1 live birth
Cycle: ICSI 2010

Total dose 1875 IU

Metaphase II 9
Metaphase I 3
Germinal vesicles 4
Atretic oocytes 0
Injected 12 (3 metaphase I, matured to metaphase II: O10,
O11, O12)
Lysed 1
Diploid 9
Monoploid 0
Polyploid 1

Case 70 149
70.06 70.09
70.Z6 70.Z9
70.E6 70.E9
Oocytes
70.O6 Metaphase II oocyte, granular cytoplasm, no degenerative areas
70.O9 Metaphase II oocyte, granular cytoplasm, no degenerative areas, one inclusion
Zygotes
70.Z6 Abutted pronuclei, synchronous nucleoli, not aligned, some large nucleoli
70.Z9 Abutted pronuclei, asynchronous nucleoli, aligned in the lower pronucleus, some large
nucleoli
Embryos
70.E6 Two- to three-cell retarded embryo with very unequal blastomeres and large fragments
70.E9 Four-cell embryo, slightly unequal blastomeres, some grouped fragments
Transfer of thawed zygotes from oocytes 3 and 4 resulted in ongoing singleton pregnancy.
Case 71 4 years 1 infertility Diagnosis: age þ male factor

Age 39, assistant manager Age 42, computer scientist

Volume 4.5 mL
pH 8.2
Type B 31%
Type C 13%
Type D 44%
Normal forms 3%
2009 ICSI 2 Not pregnant
Cycle: ICSI 2010

Total dose 2850 IU

Metaphase II 11
Metaphase I 0
Germinal vesicles 1
Atretic oocytes 1
Injected 11
Lysed 1
Diploid 7
Monoploid 0
Polyploid 0

Case 71 151
71.06 71.09
71.Z6 71.Z9
71.E6 71.E9
Oocytes
Zygotes
71.Z6 Abutted pronuclei, nucleoli asynchronous, starting to align in left pronucleus
Embryos
71.E6 Four-cell embryo, almost equal blastomeres, very few fragments
Case 72 1 infertility Diagnosis: polycystic ovarian syndrome
þ male factor

Age 31, employee Age 37, unemployed computer scientist
Tubal status: patent Cryptorchidism, treated with drugs at age 12
MH: normal 1997: L. hernia repair
Cone biopsy 2008: multiple myeloma
Non-smoker, no alcohol consumption Non-smoker, no alcohol consumption

Volume 3 mL
pH 7.4
Type B 29%
Type C 21%
Type D 37%
Normal forms 7%
2009 Planned intercourse in Clomid cycles Not pregnant
Cycle: ICSI 2010

Daily dose 10 2 75 HMG, 3 3 75 IU HMG
Total dose 2175 IU

Metaphase II 10
Metaphase I 2
Germinal vesicles 2
Atretic oocytes 1
Lysed 0
Diploid 7
Monoploid 0
Polyploid 3
Cryopreserved 5

Case 72 153
72.06 72.O10 72.O11
72.Z6 72.Z10 72.Z11
72.E6 72.E10
Oocytes
72.O6 Metaphase II, atypical thick zona pellucida
72.O10 Metaphase II, atypical thick zona pellucida
72.O11 Metaphase II (Metaphase I at oocyte retrieval), atypical thick zona pellucida
Zygotes
72.Z6 Abutted pronuceli, nucleoli synchronous and nearly aligned
72.Z10 Abutted pronuceli, nucleoli synchronous and aligned
72.Z11 Polyploid zygote resulting from post-in vitro matured oocyte, vacuoles present
Embryos
72.E6 Four-cell embryo, slightly unequal blastomeres, large fragments equally distributed
72.E10 Five-cell embryo, unequal blastomeres, significant number of grouped fragments
Case 73 2 years 1 infertility Diagnosis: polycystic ovarian
syndrome þ male factor

Age 31, teacher Age 51, teamleader
Tubal status: not explored Children with previous partner
MH: amenorrhoea 1995: vasectomy
Polycystic ovaries on ultrasound R. epididymectomy after infection at young age
Smoker, no alcohol consumption R. testicular atrophy
Semen assessment: testicular sperm extraction with preparation of a thawed sample, only type C spermatozoa
available for injection
Cycle: ICSI 2010
Stimulation protocol Antagonist protocol, 0.25 mg day 15 to 19

Daily dose 7 75 IU HMG, 5 113 IU HMG, 7 2 75 IU HMG
Total dose 1688 IU

Metaphase II 2
Metaphase I 0
Germinal vesicles 2
Atretic oocytes 0
Injected 2
Lysed 0
Diploid 2
Monoploid 0
Polyploid 0
Cryopreserved 0

Case 73 155
73.O1 73.O2
73.Z1 73.Z2
73.E1 73.E2
Oocytes
73.O1 Metaphase II oocyte, many small cytoplasmic inclusions and granules in the perivitelline space
73.O2 Metaphase II oocyte, many small cytoplasmic inclusions and granules in the perivitelline space
Zygotes
73.Z1 Abutted pronuclei, large asynchronous nucleoli, not aligned
73.Z2 Abutted pronuclei, large asynchronous nucleoli, not aligned, retracted cytoplasm
Embryos
73.E1 Four-cell embryo with unequal blastomeres and some large fragments
syndrome þ tubal factor þ
male factor

Age 36, receptionist Age 36, car mechanic
Tubal status: blocked Seminal fructose level: low
MH: polycystic ovaries Smoker, no alcohol abuse
2009: treated for salpingitis
and endometriosis

Volume 2 mL
pH 7.5
Motility: Type A 1.6%
Type B 70%
Type C 6.4%
Type D 22%
Normal forms 7%
2009 Thaw cycle Not pregnant
2009 Thaw cycle Not pregnant
Cycle: ICSI 2010

Daily dose 2 75 IU HMG, day 1 to day 11
Total dose 1650 IU
Metaphase II 3
Metaphase I 0
Germinal vesicles 2
Atretic oocytes 0
Injected 3
Lysed 0
Diploid 2
Monoploid 1
Polyploid 0
Cryopreserved 0
Outcome: live birth, healthy baby

Case 74 157
74.02 74.03
74.Z2 74.Z3
74.E2 74.E3
Oocytes
74.O2 Metaphase II oocyte, distinct minor cytoplasmic inclusions
74.O3 Metaphase II oocyte, distinct minor cytoplasmic inclusions
Zygotes
74.Z2 Pronuclei not fully abutted, nucleoli large, different and few in number, almost fully aligned,
vacuole present
74.Z3 Pronuclei abutted, nucleoli asynchronous, aligned in the right pronucleus, two cytoplasmic
vacuoles
Embryos
74.E2 Four-cell embryo, blastomeres slightly unequal, no fragments
74.E3 Two-cell embryo, blastomeres unequal in size, left blastomere multinucleated, vacuoles present
Remarks: 74.E3 had four cells at the time of transfer, three hours after the described observation.
Case 75 4 years 2 infertility Diagnosis: hyperprolactinaemia
þ male factor

Age 37, medical secretary Age 34, taxi driver
Tubal status: normal History/examination: NAD

Volume 3 mL
pH 7.9
Type B 41%
Type C 0%
Type D 36%
Normal forms 8%
2005 IUI 1 Not pregnant 2009 ICSI Singleton pregnancy,
2006 IUI 2 Live birth, healthy baby spontaneous abortion
2008 IUI 3 Not pregnant 2009 FET Not pregnant
Cycle: ICSI 2010

Total dose 3600 IU

Metaphase II 4
Metaphase I 0
Germinal vesicles 0
Atretic oocytes 0
Injected 4
Lysed 0
Diploid 4
Monoploid 0
Polyploid 0
Cryopreserved 2

Case 75 159
75.O1 75.O2 75.O4
75.Z1 75.Z2 75.Z4
75.E1 75.E2
Oocytes
75.O4 Metaphase II oocyte
Zygotes
75.Z1 Abutted pronuclei, asynchronous nucleoli, starting to align in the left nucleolus
75.Z2 Pronuclei close together, asynchronous nucleoli, large and few in number
75.Z4 Asynchronous sparse and large nucleoli, two vacuoles present
Embryos
75.E1 Four-cell embryo, nearly equal blastomeres, minimal fragmentation
Case 76 1 infertility Diagnosis: male factor þ moderate
hyperprolactinaemia

Age 40, medical doctor Age 76, computer scientist
Tubal status: not investigated Non-smoker, no alcohol abuse
MH: normal
Moderate hyperprolactinaemia, treated

Volume 1.5 mL
pH 7.9
Type B 35%
Type C 17%
Type D 37%
Normal forms 2%
Cycle: ICSI 2010

Total dose 3600 IU

Metaphase II 1
Metaphase I 1
Germinal vesicles 1
Atretic oocytes 0
Injected 2 (1 metaphase I, matured to metaphase II, polyploid
after ICSI)
Lysed 0
Diploid 1
Monoploid 0
Polyploid 1
Cryopreserved 0

Case 76 161
76.O1 76.O2
76.Z1 76.Z2
76.E1
Oocytes
76.O1 Metaphase II oocyte, thick zona pellucida, area of degenerative cytoplasm
76.O2 Metaphase II oocyte (metaphase I at oocyte retrieval), thick zona pellucida, degenerative
cytoplasm
Zygotes
76.Z1 Abutted pronuclei, nucleoli synchronous and aligned, retracted cytoplasm
76.Z2 Triploid zygote from in vitro matured and injected metaphase I oocyte
Embryos
76.E1 Three-cell embryo, grouped small fragments and one large fragment
Case 77 3 years 1 infertility Diagnosis: hyperprolactinaemia
þ male factor

Age 29, salesperson Age 31, team leader
Tubal status: patent 2002: epididymitis
Treated for hyperprolactinaemia

Volume 3.5 mL
pH 7.7
Motility: Type A 4%
Type B 28%
Type C 14%
Type D 54%
Normal forms 6%
Cycle: ICSI 2010

Total dose 2475 IU

Metaphase II 7
Metaphase I 1
Germinal vesicles 0
Atretic oocytes 0
Injected 7
Lysed 0
Diploid 7
Monoploid 0
Polyploid 0

Case 77 163
77.O5 77.O6
77.Z5 77.Z6
77.E5 77.E6
Oocytes
77.O6 Metaphase II oocyte, no cytoplasmic inclusions, zona pellucida deformed
Zygotes
77.Z5 Abutted pronuclei, few nucleoli, slightly asynchronous, aligned in upper pronucleus
77.Z6 Abutted pronuclei, few nucleoli, almost aligned
Embryos
77.E5 Four-cell embryo, equal blastomeres, minor fragments
77.E6 Four-cell embryo, equal blastomeres, minor fragments

Age 35, housewife Age 38, IT technician
1999: live birth, healthy child
Minor hyperprolactinaemia

Volume 2 mL
pH 7.9
Type B 22%
Type C 14%
Type D 29%
Normal forms 3%
Cycle: ICSI 2010

Days of stimulation to day 9, starting on day 2
Total dose 2700 IU

Metaphase II 7
Metaphase I 1
Germinal vesicles 0
Atretic oocytes 0
Injected 0
Lysed 0
Diploid 3
Monoploid 1
Polyploid 0
Cryopreserved 1
Transferred 4- to 6-cell embryo and 4-cell embryo

Case 78 165
78.O4 78.O7
78.Z4 78.Z7
78.E4 78.E7
Oocytes
Zygotes
78.Z4 Abutted pronuclei, slightly different in size, asynchronous nucleoli
78.Z7 Abutted pronuclei, nucleoli synchronous but not aligned, cytoplasmic retraction
Embryos
78.E4 Four- to six-cell embryo, unequal blastomeres, some large fragments

Age 30, factory employee Age 29, driver
Hypothyroid, treated
2008: natural conception, spontaneous abortion
at 9 weeks

Volume 1.5 mL
pH 8.5
Type B 10%
Type C 6%
Type D 54%
Normal forms 6%
Cycle: ICSI 2010

Total dose 2475 IU

Metaphase II 2
Metaphase I 0
Germinal vesicles 2
Atretic oocytes 1
Injected 2
Lysed 0
Diploid 2
Monoploid 0
Polyploid 0
Cryopreserved 0
Outcome: twin live birth, healthy boy and healthy girl

Case 79 167
79.O1 79.O2
79.Z1 79.Z2
79.E1 79.E2
Oocytes
79.O1 Metaphase II oocyte, ellipsoid shaped, large perivitelline space, minor cytoplasmic inclusions
79.O2 Metaphase II ooycte, ellipsoid shaped, large perivitelline space, minor cytoplasmic inclusions
Zygotes
79.Z1 Abutted pronuclei, nucleoli not synchronous, large vacuole present
79.Z2 Abutted pronuclei, nucleoli almost fully aligned
Embryos
79.E1 Four-cell embryo, blastomeres of unequal size, minor fragments present
79.E2 Four-cell embryo, blastomeres of unequal size, considerable number of grouped fragments
Case 80 2 infertility Diagnosis: recurrent abortion þ
tubal factor

Age 34, seamstress Age 33, floor layer
Tubal status: damaged Chronic prostatitis
1994, 1995, 1997: spontaneous abortions 3
Suspected antiphospholipid syndrome
Previous chlamydia infection
L. hydrosalpinx

Volume 5.5 mL
pH 8.0
Type B 13%
Type C 10%
Type D 53%
Normal forms 5%
Cycle: ICSI 2010

Total dose 2925 IU

Metaphase II 7
Metaphase I 1
Germinal vesicles 0
Atretic oocytes 2
Lysed 0
Diploid 6
Monoploid 0
Polyploid 1
Cryopreserved 4

Case 80 169
80.O1 80.O3
80.Z1 80.Z3
80.E1 80.E3
Oocytes
80.O1 Metaphase II, thick zona pellucida, large perivitelline space
80.O3 Metaphase II, thick zona pellucida, minor cytoplasmic inclusions
Zygotes
80.Z3 Abutted pronuclei, nucleoli synchronous and aligned, distinct cytoplasmic inclusion
Embryos
80.E3 Four-cell embryo, almost equal blastomeres, some large fragments
Remarks: 80.O9 condensed smooth endoplasmic reticulum, not injected; 80.O10 very large polar
body as well as normal sized polar body, not injected.
Part B
Extended culture
(LFKK, Austria)

Age 25, nurse Basal AMH: 2.79 ng/mL Age 31, male nurse
Tubal status: patent Basal FSH: 5.2 IU/L Unilateral seminoma
MH: partial Basal LH: 3.2 IU/L
amenorrhoea Basal oestradiol: 25.2 ng/mL
BMI: 22.3 Midluteal progesterone: 4.3 ng/mL
Occasional smoker, no Midluteal prolactin: 14.6 ng/mL
alcohol consumption
Semen assessment: oligoasthenozoospermia

Volume 6 mL Non-progressive motility 5%
Concentration 0.2 106/mL Immotile 45%
Total sperm number 1.2 106 Normal forms Not assessed
Progressive motility 50%
External ICSI 1 Failed fertilization
ICSI with single ET 1 Not pregnant
Cycle: ICSI 2010
Stimulation protocol Antagonist protocol (follitropin beta and cetrorelix)

Daily dose 150 IU until ovulation induction
Total dose 1350 IU
Oestradiol at ovulation induction 1285 ng/mL
Progesterone at ovulation induction 0.7 ng/mL
LH at ovulation induction 1.9 IU/L
Total number of COCs 11

Metaphase II 10
Metaphase I 1
Prophase I 0
Atretic oocytes 0
Injected/inseminated 10
2 PN 9
0 PN 1
1 PN 0
3 PN 0
Degenerated oocytes 0
Culture medium Embryo- and BlastAssist
Cryopreservation None
Transfer Grade IVBA, IVAB blastocysts
Outcome: ongoing singleton pregnancy, vanishing twin

Case 81 173
81.O1 81.Z1 81.D2–1
81.D3–1 81.D4–1 81.D5–1
Oocyte 1 81.01 Normal oocyte with intact first polar body

Zygote 1 81.Z1 Zygote with pronuclear pattern 2 and large halo
Day 2 81.D2–1 Four-cell embryo with moderate fragmentation
Day 3 81.D3–1 Six-cell embryo with moderate fragmentation
Day 4 81.D4–1 Ten-cell embryo initiating compaction, unevenly sized blastomeres
Blastocyst 1 81.D5–1 Blastocyst grade IVBA
81.02 81.Z2 81.D2–2
81.D3–2 81.D4–2 81.D5–2
Oocyte 2 81.O2 Oocyte with refractile body (out of focus)

Zygote 2 81.Z2 Zygote initiating pronuclear membrane breakdown
Day 3 81.D3–2 Ten-cell embryo with moderate fragmentation
Day 4 81.D4–2 Fully compacted embryo with fragments excluded
Blastocyst 2 81.D5–2 Blastocyst grade IVAB

Age 27, hairdresser Basal AMH: 4.36 ng/mL Age 36, tinsmith
Tubal status: patent Basal FSH: 10.8 IU/L History/examination: NAD
MH: cycle = 5/27–29 Basal LH: 6.7 IU/L
BMI: 20.8 Basal oestradiol: 42.1 ng/mL
Occasional smoker, no Midluteal progesterone: 13.6 ng/mL
alcohol consumption Midluteal prolactin: 14.9 ng/mL

Volume 4.0 mL
Total sperm number 168 106
Non-progressive motility 12%
Immotile 33%
Normal forms 3%
Cycle: ICSI 2010
Stimulation protocol Long protocol (recombinant follitropin beta)

Daily dose 150–150–150–100 IU until ovulation induction
Total dose 1150 IU

Metaphase II 7
Metaphase I 0
Prophase I 1
Atretic oocytes 0
2 PN 7
0 PN 0
1 PN 0
3 PN 0
Culture medium GM501
Cryopreservation 4 blastocysts
Transfer Grade IVAA blastocyst

Case 82 175
82.O1 82.Z1
82.D2–1 82.D3–1
82.D4–1 82.D5–1
Oocyte 82.O1 Normal oocyte with fragmented first polar body

Zygote 82.Z1 Zygote with pronuclear pattern 0B
Day 2 82.D2–1 Four-cell embryo without fragmentation
Day 3 82.D3–1 Six-cell embryo with signs of compaction
Day 4 82.D4–1 Fully compacted embryo with slight vacuolization (2-, 3- and 6 o’clock positions)
Blastocyst 82.D5–1 Blastocyst grade IVAA with cytoplasmic strings (12- and 2 o’clock positions)

Age 28, salesperson Basal AMH: 3.11 ng/mL Age 29, barber
Tubal status: patent Basal FSH: 11.3 IU/L
MH: cycle = 5/28 Basal LH: 5.9 IU/L
Non-smoker, no alcohol Midluteal progesterone: 8.0 ng/mL
consumption Midluteal prolactin: 11.3 ng/mL

Volume 5.2 mL
Total sperm number 161.2 106
Immotility 85%
Normal forms 4%
Timed intercourse 1
IUI 2
Cycle: ICSI 2010
Stimulation protocol Long protocol (buserelin and HMG)

Daily dose 225–225–150 IU until ovulation induction
Total dose 1800 IU
Metaphase II 8
Metaphase I 1
Prophase I 0
Atretic oocytes 3
2 PN 6
0 PN 1
1 PN 0
3 PN 0
Transfer Grade VAA blastocyst
Outcome: monozygotic twins after single blastocyst transfer

Case 83 177
Note traceability of refractile bodies
83.O1 83.Z1
83.D2–1 83.D3–1
83.D4–1 83.D5–1
Oocyte 83.O1 Oocyte with numerous refractile bodies

Zygote 83.Z1 Zygote with pronuclear pattern 5
Day 2 83.D2–1 Four-cell embryo without fragments
Day 3 83.D3–1 Eight-cell embryo
Day 4 83.D4–1 Fully compacted embryo
Blastocyst 83.D5–1 Blastocyst grade VAA with hatching site (out of focus)
at the 3 o’clock position

Age 29, physiotherapist Basal AMH: 8.15 ng/mL Age 39, technician
MH: amenorrhoea Basal LH: 10.0 IU/L
BMI: 16.6 (very low) Basal oestradiol: 40 ng/mL

Volume 1.2 mL
Immotility 29%
Normal forms 3%
ICSI with single ET 1 Bad quality embryos
Single FBT 1 Not pregnant
Cycle: ICSI 2010

Daily dose 150–150–150–150–100–150–125–125–125–125 IU
Total dose 1350 IU
Metaphase II 8
Metaphase I 1
Prophase I 1
Atretic oocytes 0
2 PN 4
0 PN 0
1 PN 1
3 PN 3
Degenerated oocytes
Transfer Grade IVAC blastocyst
Outcome: ongoing singleton pregnancy after single blastocyst transfer

Case 84 179
84.O1 84.Z1
84.D2–1 84.D3–1
84.D4–1 84.D5–1
Oocyte 84.O1 Oocyte with incomplete extrusion of first polar body (probably telophase I)
Day 2 84.D2–1 Four-cell embryo with minor fragmentation and uneven blastomeres
Day 3 84.D3–1 Ten-cell embryo with uneven blastomeres
Day 4 84.D4–1 Twelve-cell embryo with vacuolized blastomere (9 o’clock position)
Blastocyst 84.D5–1 Blastocyst grade IVAC

Age 32, housewife Basal AMH: 1.47 ng/mL Age 48, architect
Smoker (15 per day), no Midluteal progesterone: 15.7 ng/mL

Volume 3.5 mL Non-progressive motility 0%
Concentration 13 106/mL Immotile 28%
Total sperm number 45.5 106 Normal forms 4%
ICSI with double BT 1 Biochemical pregnancy
Frozen ET 1 Not pregnant
IUI 1 Not pregnant
Cycle: ICSI 2010

Daily dose 175–175–150–150–150–175–150–175 IU
Total dose 1300 IU
Metaphase II 6
Metaphase I 1
Prophase I 0
Atretic oocytes 0
2 PN 5
0 PN 1
1 PN 0
3 PN 0

Case 85 181
85.O1 85.Z1
85.D2–1 85.D3–1
85.D4-1 85.D5–1
Oocyte 85.O1 Large refractile body (7 mm)

Zygote 85.Z1 Pronuclear pattern 3, accumulation of inclusions, refractile body
(9 o’clock position)
Blastocyst 85.D5–1 Grade IVAA blastocyst, refractile body in trophectoderm at
the 11 o’clock position

Age 32, secretary Basal AMH: 4.37 ng/mL Age 34, private teacher

Volume 4.8 mL
Immotile 72%
Normal forms 5%
Cycle: ICSI 2010

Total dose 1950 IU

Metaphase II 8
Metaphase I 1
Prophase I 1
Atretic oocytes 0
2 PN 7
0 PN 2
1 PN 0
3 PN 0
Transfer Grade VAA and grade I blastocysts
Outcome: ongoing twin pregnancy after double blastocyst transfer

Case 86 183
86.O1 86.Z1 86.D2–1
86.D3–1 86.D4–1 86.D5–1
Oocyte 1 86.O1 Oocyte with dark central granulation

Zygote 1 86.Z1 Zygote with pronuclear pattern 0B showing dark central granulation
Day 3 86.D3–1 Twelve-cell embryo
Day 4 86.D4–1 Early morula with two small vacuoles at the 6 o’clock position
Blastocyst 86.D5–1 Grade VAA blastocyst (diameter 200 mm) with hatching site at the 4–5 o’clock position
86.02 86.Z2 86.D2–2
86.D3–2 86.D4–2 86.D–5
Oocyte 2 86.O2 Good quality oocyte with minor inclusions

Zygote 2 86.Z2 Zygote with pronuclear pattern 5
Day 4 86.D4–2 Twelve-cell embryo initiating compaction
Blastocyst 2 86.D5–2 Blastocyst grade I
Case 87 3 years 1 infertility Diagnosis: azoospermia

Age 32, lawyer Basal AMH: 1.79 ng/mL Age 37, clinician
Non-smoker, no alcohol Basal oestradiol: 20 ng/mL
consumption Midluteal progesterone: 12.7 ng/mL
Midluteal prolactin: 27.0 ng/mL
Semen assessment: Azoospermia: cryopreserved TESE biopsy

Concentration 0.4 106/mL Immotile 94%
Cycle: ICSI 2010

Daily dose 225–225–150 IU until day of ovulation induction (4 days with 225)
Total dose 2100 IU

Metaphase II 4
Metaphase I 0
Prophase I 1
Atretic oocytes 0
Injected/inseminated 4 (using theophylline)
2 PN 4
0 PN 0
1 PN 0
3 PN 0

Case 87 185
87.O1 87.Z1
87.D2–1 87.D3–1
87.D4–1 87.D5–1
Oocyte 87.O1 Normal oocyte with fragmented polar body

Zygote 87.Z1 Pronuclear pattern 0B, small vacuole below pronuclei
Day 2 87.D2–1 Four-cell embryo with unusual arrangement of blastomeres
Blastocyst 87.D5–1 Blastocyst grade IVAA

Age 34, home nurse Basal AMH: 3.02 ng/mL Age 36, principal (ministry)
Hyperthyroidism Basal oestradiol: 20 ng/mL
Resection of uterine septum Midluteal progesterone: 10.9 ng/mL
BMI: 31.7 Midluteal prolactin: 12.8 ng/mL
Non-smoker, no alcohol
consumption
Semen assessment: severe OATS

Concentration 0.1/mL Immotility 47%
Fresh TESE and ICSI (external) 1 No fertilization
Cryo-TESE and ICSI (double ET) 1 Impaired embryo development
ICSI with ejaculated sperm (single ET) 1 Low fertilization (1/11)
Cycle: ICSI 2010, ionophore and theophylline treatment
Stimulation protocol Long protocol (buserelin and follitropin beta)

Daily dose 200–200–150 IU until day of ovulation induction
Total dose 1600 IU
Metaphase II 10
Metaphase I 1
Prophase I 1
Atretic oocytes 1
Injected/inseminated 10 (4 with ionophore, 6 without ionophore)
2 PN 4 (3 from ionophore group)
0 PN 6 (1 from ionophore group)
1 PN 0
3 PN 0
Cryopreservation 1 blastocyst
Transfer Grade IVAB and grade VAA blastocysts
Outcome: ongoing twin pregnancy

Case 88 187
88.O1 88.Z1 88.D2–1
88.D3–1 88.D4–1 88.D5–1
Oocyte 1 88.O1 Oocyte with small refractile body

Zygote 1 88.Z1 Pronuclear pattern 0B
Day 2 88.D2–1 Four-cell embryo with unevenly sized blastomeres and small vacuoles in largest cell
Day 3 88.D3–1 Eight-cell embryo with vacuole (out of focus) at the 9 o’clock position
Day 4 88.D4–1 Fourteen-cell embryo initiating compaction
Blastocyst 1 88.D5–1 Blastocyst grade IVAB (190 mm)
88.02 88.Z2 88.D2–2
88.D3–2 88.D4–2 88.D5–2
Oocyte 2 88.O2 Oocyte showing numerous refractile bodies

Zygote 2 88.Z2 Pronuclear pattern 3
Day 2 88.D2–2 Five-cell embryo
Day 3 88.D3–2 Eight-cell embryo with minor fragmentation
Day 4 88.D4–2 Incompletely compacted embryo (2 o’clock position)
Blastocyst 2 88.D5–2 Blastocyst grade VAA with hatching site at the 4 o’clock position (196 mm)

Age 34, nurse Basal AMH: 1.78 ng/mL Age 40, consultant
MH: Cycle 5/24–26 Basal LH: 5.8 IU/L
Hypothyroid Basal oestradiol: 6.5 ng/mL
Non-smoker, no alcohol Midluteal prolactin: 1.4 ng/mL
consumption

Volume 4.2 mL
Concentration 100/mL
Immotile 70%
Normal forms 6%
IUI 3
Cycle: ICSI 2010
Stimulation protocol Long protocol (buserelin and follitropin alpha)

Daily dose 187.5–187.5–150 IU until ovulation induction (last day 75 IU)
Total dose 1650 IU
Progesterone at ovulation 0.2 ng/mL
induction
Metaphase II 9
Metaphase I 0
Prophase I 0
Atretic oocytes 0
2 PN 6
0 PN 2
1 PN 1
3 PN 0
Transfer Grade IVBA and grade IIIAC (ovoid) blastocysts
Case 89 189
Note traceability of refractile body and vacuoles in oocyte 1
89.O1 89.Z1 89.D2–1
89.D3–1 89.D4–1 89.D5–1

Oocyte 1 89.O1 Oocyte with one refractile body
Zygote 1 89.Z1 Pronuclear pattern 0B, accumulation of inclusions, refractile body (9 o’clock position)
Day 2 89.D2–1 Good quality four-cell embryo with small vacuoles in one cell
Day 3 89.D3–1 Eight-cell embryo with small vacuoles in one blastomere
Day 4 89.D4–1 Incompletely compacted embryo (7 o’clock position)
Blastocyst 1 89.D5–1 Grade IVBA blastocyst, refractile body in inner cell mass, vacuole at the
10 o’clock position in trophectoderm
89.02 89.Z2 89.D2–2
89.D3–2 89.D4–2 89.D5–2

Oocyte 2 89.O2 Ovoid oocyte
Zygote 2 89.Z2 Ovoid zygote with pronuclear pattern 5
Day 2 89.D2–2 Good quality four-cell embryo
Day 3 89.D3–2 Good quality ten-cell embryo
Day 4 89.D4–2 Early morula
Blastocyst 2 89.D5–2 Ovoid blastocyst grade IIIAC

Age 34, bank assisstant Basal AMH: 8.73 ng/mL Age 42, builder
Non-smoker, no alcohol Midluteal progesterone:
consumption 12.1 ng/mL
Midluteal prolactin:
27.5 ng/mL

Volume 1.2 mL
Immotile 89%
Normal forms 6%

Cycle: ICSI 2010
Stimulation protocol Antagonist protocol (follitropin alpha and cetrorelix)

Daily dose 187–150 IU until ovulation induction
Total dose 1387 IU
Metaphase II 6
Metaphase I 0
Prophase I 0
Atretic oocytes 0
2 PN 5
0 PN 1
1 PN 0
3 PN 0

Case 90 191
Note traceability of large vacuole
90.O1 90.Z1 90.D2–1
90.D3–1 90.D4–1 90.D5–1a
90.D5–1b
Oocyte 90.O1 Oocyte with large vacuole (17 mm) with inclusions
Zygote 90.Z1 Pronuclear pattern 2
Day 2 90.D2–1 Five-cell embryo without fragments and one cell further cleaved (8 o’clock position)
Day 3 90.D3–1 Compacting eight-cell embryo
Blastocyst 90.D5–1a Image detail showing the vacuole in trophectoderm adjacent to inner cell mass
Blastocyst 90.D5–1b Same blastocyst grade VAA (198 mm)

Age 37, nurse Basal FSH: 7.3 IU/L Age 42, civil servant
Tubal status: patent Basal LH: 6.0 IU/L History/examination: NAD
MH: cycle = 5/30 Basal oestradiol: 35.8 ng/mL
Hyperprolactinaemia Midluteal progesterone: 8.0 ng/mL
Basal AMH: 2.72 ng/mL Non-smoker, no alcohol consumption

Volume 1 mL
Total sperm number 20%
Immotile 60%
Normal forms 2%
2006 ICSI with single ET Live birth, healthy boy
Cycle: ICSI 2010

Daily dose 300–225–225–150 IU until day of ovulation induction
Total dose 1650 IU
Metaphase II 6
Metaphase I 0
Prophase I 0
Atretic oocytes 0
2 PN 5
0 PN 0
1 PN 0
3 PN 0
Transfer Grade IVBB blastocyst
Case 91 193
91.O1 91.Z1
91.D2–1 91.D3–1
91.D4–1 91.D5–1
Oocyte 91.O1 Normal oocyte with freshly extruded first polar body
Day 2 91.D2–1 Four-cell embryo with 25% fragmentation
Day 3 91.D3–1 Eight-cell embryo with moderate fragmentation
Day 4 91.D4–1 Fully compacted embryo with extruded fragments
Blastocyst 91.D5–1 Grade IVBB blastocyst (194 mm)

Age 37, housewife Basal AMH: 2.14 ng/mL Age 42, plumber
MH: cycle = 28 d, Basal LH: 5.4 IU/L
dysmenorrhoea Basal oestradiol: 40 ng/mL
consumption

Volume 1 mL
Immotile 88%
Normal forms 6%
Natural conception 2007 Live birth, healthy boy
Cycle: ICSI 2010

Daily dose 225–150–225–150 IU until ovulation induction
Total dose 1650 IU
Metaphase II 8
Metaphase I 0
Prophase I 1
Atretic oocytes 0
2 PN 4
0 PN 4
1 PN 0
3 PN 0
Transfer Day 3: 8-cell Grade A, 8-cell Grade B

Case 92 195
92.O1 92.Z1 92.D2–1
92.D3–1 92.02 92.Z2
92.D2–2 92.D3–2
Oocyte 1 92.O1 Small oocyte with large first polar body

Zygote 1 92.Z1 Zygote with pronuclear pattern 0B
Day 3 92.D3–1 Eight-cell embryo with cytoplasmic granularity
Oocyte 2 92.O2 Slightly ovoid oocyte
Day 3 92.D3–2 Eight-cell embryo initiating compaction
Case 93 6 years 2 infertility
Diagnosis: unexplained (unilateral tubal blockage)

Age 32, salesperson Basal AMH: 3.0 ng/mL Age 38, electrician
Tubal status: unilateral Basal FSH: 4.4 IU/L History/examination: NAD
blockage Basal LH: 5.3 IU/L
MH: cycle = 5–6/28 Basal oestradiol: 24.6 ng/mL
BMI = 19.6 Midluteal progesterone: 20.4 ng/mL
Smoker (7 per day), no Midluteal prolactin: 10.6 ng/mL
alcohol consumption

Concentration 92 106/mL Immotility 79%
2004 Spontaneous conception (same partner) Live birth of a healthy girl
Cycle: ICSI 2010

Daily dose 225–150 IU until ovulation induction (1 day 225 IU)
Total dose 1875 IU

Metaphase II 7
Metaphase I 1
Prophase I 0
Atretic oocytes 0
2 PN 5
0 PN 1
1 PN 0
3 PN 0
Outcome: molar pregnancy, eighth week of gestation

Case 93 197
93.O1 93.Z1
93.D2–1 93.D3–1
93.D4–1 93.D5–1
Oocyte 93.O1 Normal oocyte with intact first polar body

Zygote 93.Z1 Pronuclear membrane breakdown
Day 2 93.D2–1 Seven-cell embryo without fragments
Day 3 93.D3–1 Ten-cell embryo with minor fragmentation, initiating compaction
Blastocyst 93.D5–1 Grade VAA blastocyst (192 mm) with hatching site at the 6 o’clock position
Case 94 4 years 1 infertility Diagnosis: unexplained

Age 40, teacher Basal AMH: 1.12 ng/mL Age 40, freelance technician
MH: cycle regular Basal LH: 7.8 IU/L
Non-smoker, no alcohol Midluteal progesterone:
consumption 12.4 ng/mL
Midluteal prolactin:
13.6 ng/mL

Total sperm number 216 106 Normal forms 14%
External IVF 1 Failed IVF
External ICSI 1 Delayed embryo development
Cycle: ICSI 2010
Stimulation protocol Antagonist protocol (HMG and cetrorelix)

Total dose 1725 IU

Metaphase II 8
Metaphase I 1
Prophase I 0
Atretic oocytes 0
2 PN 5
0 PN 3
1 PN 0
3 PN 0
Cryopreservation 1 ovoid blastocyst
Transfer 2 morulae with exclusion of blastomeres
Case 94 199
94.O1 94.Z1 94.D2–1
94.D3–1 94.D4–1 94.D5–1

Oocyte 1 94.O1 Oocyte showing numerous small inclusions
Day 3 94.D3–1 Eight-cell embryo without fragmentation
Day 4 94.D4–1 Fourteen-cell embryo initiating compaction
Morula 1 94.D5–1 Early morula with excluded blastomere (7 o’clock position)
94.02 94.Z2 94.D2–2
94.D3–2 94.D4–2 94.D5–2
Oocyte 2 94.O2 Oocyte with small first polar body, refractile body and larger inclusions
Day 2 94.D2–2 Six-cell embryo with minor fragmentation
Day 3 94.D3–2 Ten-cell embryo initiating compaction, blastomeres of uneven size
Day 4 94.D4–2 Ten-cell embryo with developmental arrest
Morula 2 94.D5–2 Morula with excluded blastomere and fragments
Case 95 2 years 2 infertility Diagnosis: bilateral tubal
blockage

Age 25, unskilled worker Basal AMH: 9.04 ng/mL Age 26, electrician
Tubal status: bilateral Basal FSH: 5.1 IU/L Child with previous
blockage Basal LH: 4.8 IU/L partner
MH: oligomenorrhoea Basal oestradiol: 39.9 ng/mL
consumption

ICSI with single BT 1
Frozen double BT 1 Live birth, healthy boy
Cycle: ICSI 2010
Stimulation protocol Long protocol (buserelin and follitropin alpha)

Daily dose 150–150–150–112.5–112.5–112.5–112.5–112.5–75 IU
Total dose 1087.5 IU
Metaphase II 4
Metaphase I 2
Prophase I 0
Atretic oocytes 0
2 PN 4
0 PN 0
1 PN 0
3 PN 0

Case 95 201
Note traceability of refractile body
95.O1 95.Z1
95.D2–1 95.D3–1
95.D4–1 95.D5–1
Oocyte 95.O1 Oocyte with large refractile body (8 mm)

Day 3 95.D3–1 Ten-cell embryo
Day 4 95.D4–1 Fully compacted embryo with refractile body at the 1 o’clock position
Blastocyst 95.D5–1 Blastocyst grade VAA (187 mm) with hatching site (out of focus) at
the 1 o’clock position
blockage

Age 32, clinician Basal AMH: 2.34 ng/mL Age 39, carpenter
Tubal status: bilateral Basal FSH: 7.1 IU/L History/examination: NAD
MH: cycle = 6/26 Basal oestradiol: 29.6 ng/mL
consumption

Volume 1 mL
Immotile 70%
Normal forms 12%
External ICSI with double ET 3
Cycle: ICSI 2010

Total dose 1500 IU
Metaphase II 6
Metaphase I 4
Prophase I 1
Atretic oocytes 0
2 PN 3
0 PN 3
1 PN 0
3 PN 0
Outcome: not pregnant after single blastocyst transfer

Case 96 203
Note: traceability of large refractile body.
96.O1 96.Z1
96.D2–1 96.D3–1
96.D4–1 96.D5–1
Oocyte 96.O1 Oocyte with large refractile body (12 mm)

Day 2 96.D2–1 Six-cell embryo without fragments
Day 4 96.D4–1 Early blastocyst grade I
Blastocyst 96.D5–1 Blastocyst grade IVAA (201 mm) with inner cell mass free of refractile body
Case 97 2 years 2 infertility Diagnosis: salpingectomy þ
male factor

Age 33, hairdresser Basal AMH: 1.05 ng/mL Age 40, papermill worker
Tubal status: absent Basal FSH: 3.3 IU/L
MH: cycle = 4–5/25–28 Basal LH: 4.8 IU/L
Uterine septum Basal oestradiol: 27 ng/mL
TSH: 1.84 Midluteal prolactin: 7.6 ng/mL
Smoker (20 cigarettes per day), Spontaneous pregnancies in June
no alcohol consumption 1995 and 1996 (different partner)

Volume 1.6 mL
Immotility 34%
Normal forms 4%
Cycle: IVF/ICSI 2010
Stimulation protocol Long protocol (buserelin and follitropin alpha-150)

Total dose 1500 IU

Metaphase II 7
Metaphase I 0
Prophase I 0
Atretic oocytes 1
2 PN 5
0 PN 2
1 PN 0
3 PN 0
Cryopreservation 2 blastocysts, Grade IVAA and grade IVBA
Transfer Morula without fragments, day 4

Case 97 205
97.O1 97.Z1
97.D2–1 97.D3–1
97.D4–1
Oocyte 1 97.O1 Oocyte with slightly ovoid zona pellucida

Day 2 97.D2–1 Ovoid five-cell embryo without fragments
Day 4 97.D4–1 Morula
blockage þ male factor

Age 38, unskilled worker Basal AMH: 5.11 ng/mL Age 43, locksmith
Tubal status: bilateral Basal FSH: 7.7 IU/L History/examination:
blockage Basal LH: 5.78 IU/L NAD
MH: cycle = 28 days Basal oestradiol: 38.5 ng/mL
(dysmenorrhoea) Midluteal progesterone: 7.6 ng/mL
Non-smoker, no
alcohol consumption


Total dose 2475 IU
Total number of COCs 20 (5 IVF)

Metaphase II 13
Metaphase I 0
Prophase I 2
Atretic oocytes 0
2 PN 10 (plus 2 in IVF)
1 PN 0
3 PN 1
Cryopreservation 3 blastocysts and 2 compacted embryos
Transfer No fresh BT because of OHSS
Outcome: not pregnant after double frozen blastocyst transfer

Case 98 207
98.O1 98.Z1 98.D2–1
98.D3–1 98.D4–1 98.D5–1a 98.D5–1b
Oocyte 1 98.O1 Oocyte with dark central granulation

Day 3 98.D3–1 Six-cell embryo with uneven blastomeres
Blastocyst 1 98.D5–1a Early blastocyst grade II
Blastocyst 1 98.D5–1b after vitrification Re-expanded blastocyst grade IVAB 2 hours
after warming
98.02 98.Z2 98.D2–2
98.D3–2 98.D4–2 98.D5–2a 98.D5–2b
Oocyte 2 98.O2 Normal oocyte

Day 2 98.D2–2 Four-cell embryo with with uneven blastomeres
Day 3 98.D3–2 Eight-cell embryo with uneven blastomeres
Day 4 98.D4–2 Incompletely compacted embryo
Blastocyst 2 98.D5–2a Early blastocyst grade I with early blastocoel at the
5 o’clock position
Blastocyst 2 after vitrification Re-expanded blastocyst grade IIIAB 2 hours
98.D5–2b after warming
Case 99 2 years 1 infertility Diagnosis: Stage II
endometriosis

Age 27, nurse Basal AMH: 4.11 ng/mL Age 33, civil servant
MH: cycle = 5/30–45 days Basal LH: 5.5 IU/L
BMI: 24.7 Non-smoker, no Basal oestradiol: 22 ng/mL
alcohol consumption Midluteal progesterone: 8.5 ng/mL
Midluteal prolactin: 17.4 ng/mL
Semen assessment: mild teratozoospermia

Volume 2.6 mL
Total number of sperm 244.4 106
Immotile 58%
Normal forms 9%
Stimulation protocol Antagonist protocol (follitropin alpha and ganirelix)

Daily dose 187.5–187.5–150 IU until day of ovulation induction
(2 days 187.5 IU)
Total dose 1650 IU
Total number of COCs 13 (6 for IVF)

Metaphase II 7
Metaphase I 0
Prophase I 0
Atretic oocytes 0
1 PN 1
3 PN 0
Cryopreservation 3 blastocysts and 1 fully compacted embryo

Case 99 209
99.O1 99.Z1
99.D2–1 99.D3–1
99.D4–1 99.D5–1
Oocyte 99.O1 Large refractile body (6 mm)

Zygote 99.Z1 Pronuclear membrane breakdown
Day 2 99.D2–1 Four-cell embryo with minor fragmentation
Day 3 99.D3–1 Ten-cell embryo with minor fragmentation
Blastocyst 99.D5–1 Grade IVAA blastocyst

Age 32, special pedagogue Basal AMH: 3.37 ng/mL Age 35, carpenter
MH: cycle = 4–5/26 days Basal LH: 2.0 IU/L
Non-smoker, no Midluteal progesterone: 1.3 ng/mL

Volume 4.3 mL
Immotile 94%
Normal forms 14%
Cycle: ICSI 2010
Stimulation protocol Antagonist protocol (HMG and cetrorelix)

Total dose 1350 IU

Metaphase II 7
Metaphase I 0
Prophase I 3
Atretic oocytes 0
2 PN 6
0 PN 0
1 PN 1
3 PN 0
Cryopreservation 1 early blastocyst
Transfer 1 morula day 5

Case 100 211
100.01 100.Z1
100.D2–1 100.D3–1
100.D4–1 100.D5–1
Oocyte 100.O1 Oocyte with few inclusions

Day 3 100.D3–1 Five-cell embryo with unevenly sized blastomeres
Blastocyst 100.D5–1 Morula
Case 101 6 years 1 infertility Diagnosis: Stage III
endometriosis þ tubal damage

Age 34, salesperson (flowers) Basal AMH: 5.05 ng/mL Age 34, product executive
Tubal status: bilateral blockage Basal FSH: 12.7 IU/L History/examination: NAD
Dyspareunia Basal oestradiol: 25.7 ng/mL
Occasional smoker, no alcohol Midluteal prolactin: 9.8 ng/mL
consumption

Volume 1.4 mL
Immotility 58%
Normal forms 8%

Cycle: ICSI 2010

Daily dose 150–150 IU until day of ovulation induction
Total dose 1500 IU
Metaphase II 8
Metaphase I 0
Prophase I 0
Atretic oocytes 1
2 PN 5
0 PN 3
1 PN 0
3 PN 0
Transfer Grade IVAB blastocyst

Case 101 213
101.O1 101.Z1
101.D2–1 101.D3–1
101.D4–1 101.D5–1
Oocyte 101.O1 Normal oocyte with minor inclusions

Zygote 101.Z1 Zygote with large halo and pronuclear pattern 2
Day 3 101.D3–1 Eight-cell embryo without fragmentation
Blastocyst 101.D5–1 Grade IVAB blastocyst
Case 102 3 years 2 infertility Diagnosis: Stage II
endometriosis þ bilateral
tubal blockage
Age 41, unskilled worker Basal AMH: 0.76 ng/mL Age 38, unskilled worker
Tubal status: bilateral Basal FSH: 7.9 IU/L
MH: cycle = 24–26 d Basal oestradiol: 169 ng/mL
Non-smoker, no Midluteal prolactin: 13.9 ng/mL
alcohol consumption

Volume 1.4 mL
Immotility 57%
Normal forms 5%
Natural conception 2 Missed abortions 2
IUI 2 Not pregnant
ICSI with double ET 1 Not pregnant
Cycle: ICSI 2010
Stimulation protocol Antagonist protocol (HMG and cetrorelix) with late ovulation induction
Daily dose 300–300–300–225 IU until ovulation induction (2 days, 300 IU)
Total dose 3525 IU
Number of follicles 15 mm 5 (two follicles at 25 and 24 mm)
Metaphase II 5
Metaphase I 0
Prophase I 1
Atretic oocytes 0
Injected/inseminated 5 (2 overmature)
2 PN 3 (from younger oocytes)
0 PN 2 (from overmature oocytes)
1 PN 0
3 PN 0
Transfer Day 3: 12-cell and 5-cell embryos

Case 102 215
102.O1 102.Z1 102.D2–1
102.D3–1 102.02 102.Z2
102.D2–2 102.D3–2
Oocyte 1 102.O1 Oocyte with two refractile bodies

Day 2 102.D2–1 Eight-cell embryo with one larger blastomere
Day 3 102.D3–1 Twelve-cell embryo with unevenly sized blastomeres and minor fragmentation
Oocyte 2 102.O2 Normal oocyte with minor inclusions

Day 2 102.D2–2 Two-cell embryo with minor fragmentation
Day 3 102.D3–2 Five-cell embryo with minor fragmentation
Case 103 1 year 1 infertility Diagnosis: polycystic ovarian
syndrome þ male factor

Age 27, secretary Basal AMH: 13.08 ng/mL Age 25, technician
MH: secondary amenorrhoea Basal LH: 7.9 IU/L
Hypothyroidism Basal oestradiol: 51.7 ng/mL
consumption

Previous treatments: timed intercourse 3

Cycle: ICSI 2010
Stimulation protocol Antagonist protocol (follitropin beta and ganirelix)

Daily dose 150–125–125–100–125–125–175–125 IU
Total dose 1050 IU
Metaphase II 5
Metaphase I 1
Prophase I 0
Atretic oocytes 0
2 PN 3
0 PN 2
1 PN 0
3 PN 0
Cryopreservation 2 fully compacted embryos on day 5
Transfer Grade IVAB blastocyst

Case 103 217
103.01 103.Z1
103.D2–1 103.D3–1
103.D4–1 103.D5–1
Oocyte 103.O1 Oocyte showing central granulation

Day 3 103.D3–1 Eight-cell embryo with minor fragmentation
Blastocyst 103.D5–1 Blastocyst grade IVAB
syndrome þ failed IVF

Age 32, nurse Basal AMH: 0.93 ng/mL Age 50, male nurse
MH: oligomenorrhoea Basal LH: 7.0 IU/L
Liposuction 6 Midluteal prolactin: 41 ng/mL
Depression
Non-smoker, no
alcohol consumption

IVF 1 Failed IVF
ICSI with single ET 1 70% immature oocytes
Cycle: ICSI 2010

Daily dose 225–225–150 IU until ovulation induction (5 days, 225 IU)
Total dose 2775 IU
Metaphase II 13
Metaphase I 1
Prophase I 7
Atretic oocytes 0
2 PN 8
0 PN 3
1 PN 2
3 PN 0
Transfer Grade IVAA blastocyst and grade IVAB blastocyst

Case 104 219
Note traceability of large vacuole in oocyte 2
104.01 104.Z1 104.D2–1
104.D3–1 104.D4–1 104.D5–1

Oocyte 1 104.O1 Oocyte with refractile body (5 mm) and minor inclusions
Day 4 104.D4–1 Blastocyst grade II
Blastocyst 1 104.D5–1 Grade IVAA blastocyst (204 mm)
104.02 104.Z2 104.D2–2
104.D3–2 104.D4–2 104.D5–2
Oocyte 2 104.O2 Oocyte with large vacuole (20 mm)

Day 3 104.D3–2 Compacting eight-cell embryo
Day 4 104.D4–2 Incompletely compacted embryo
Blastocyst 2 104.D5–2 Blastocyst grade IVAB with no vacuole in inner cell mass
syndrome (WHO Type I)

Age 32, teacher Basal AMH: 5.06 ng/mL Age 32, technician
MH: amenorrhoea Basal LH: 0.4 IU/L
Hypothyroid Basal oestradiol: 20 ng/mL
Non-smoker, no Midluteal prolactin: 7.5 ng/mL
alcohol consumption

Volume 3.8 mL
Immotile 43%
Normal forms 13%
IUI 1
ICSI with single ET 1
ICSI with double BT 1 Live birth, healthy girl
Cycle: IVF 2010
Stimulation protocol Antagonist protocol (HMG and ganirelix)

Daily dose 300 IU until day of ovulation induction last day on 225 IU
Total dose 2327 IU
2 PN 5
0 PN 2
1 PN 2
3 PN 2
Cryopreservation 1 compacting embryo on day 5

Case 105 221
105.Z1 105.D2–1
105.D3–1 105.D4–1
105.D5–1

Day 3 105.D3–1 Ten-cell embryo with minor fragmentation, initiating compaction
Blastocyst 105.D5–1 Grade IVAA blastocyst
syndrome

Age 33, architect Basal AMH: 21.80 ng/mL Age 38, lawyer
MH: oligomenorrhoea Basal LH: 11.3 IU/L

ICSI with double ET 1 Not pregnant
ICSI with double BT 1 Live birth, healthy boy
Frozen ET 1 Not pregnant
Cycle: ICSI 2010
Stimulation protocol Antagonist protocol

Daily dose 112–112–150–112–150–112–112–112 IU
Total dose 972 IU

Metaphase II 8
Metaphase I 3
Prophase I 0
Atretic oocytes 0
2 PN 7
0 PN 1
1 PN 0
3 PN 0
Transfer Grade IVBA blastocyst
Outcome: ongoing singleton pregnancy after single blastocyst transfer

Case 106 223
106.01 106.Z1
106.D2–1 106.D3–1
106.D4–1 106.D5–1
Oocyte 106.O1 Normal oocyte with large polar body

Blastocyst 106.D5–1 Grade IVBA blastocyst
syndrome

Age 34, manager Basal AMH: 8.32 ng/mL Age 39, technician
MH: dysmenorrhoea Basal LH: 4.2 IU/L
Mild hyperprolactinaemia Basal oestradiol: 39.8 ng/mL
Occasional smoker Midluteal prolactin: 28.8 ng/mL
(8 per day), no alcohol
consumption


Natural conception 2008 Spontaneous abortion
Cycle: ICSI 2010

Daily dose 125–150–125–150–150–125–150–125–150–150 IU
Total dose 1400 IU

Metaphase II 4
Metaphase I 3
Prophase I 0
Atretic oocytes 0
2 PN 4
0 PN 0
1 PN 0
3 PN 0

Case 107 225
107.01 107.Z1
107.D2–1 107.D3–1
107.D4–1 107.D5–1
Oocyte 107.O1 Normal oocyte with minor inclusions

Day 2 107.D2–1 Four-cell embryo with one cell in cleavage
Day 3 107.D3–1 Six-cell embryo in cleavage
Blastocyst 107.D5–1 Blastocyst grade VAA with hatching site not imaged
syndrome

Age 38, housewife Basal AMH: 8.87 ng/mL Age 40, cook
MH: cycle = 21–60 days Basal LH: 2.0 IU/L
Hyperinsulinaemia, Basal oestradiol: 61 ng/mL
diabetes mellitus Midluteal progesterone: 0.3 ng/mL
Hyperprolactinaemia Midluteal prolactin: 45 ng/mL
BMI: 23.7
consumption

Sperm concentration 208 106/mL Immotile 38%

Spontaneous pregnancy 2004 Miscarriage at 17 weeks’ gestation
Cycle: ICSI 2010
Stimulation protocol Antagonist protocol (follitropin alpha, HMG and cetrorelix)

Daily dose 150–112.5–150–112.5–150–150–150-(150)-225–187.5–225 IU (for 9 days)
Total dose 1387.5 IU (1 day injection error) plus 2025 IU
Metaphase II 8
Metaphase I 0
Prophase I 3
Atretic oocytes 0
2 PN 6
0 PN 2
1 PN 0
3 PN 0
Cryopreservation 2 blastocysts and 1 fully compacted embryo
Transfer No fresh BT because of OHSS, grade IVAA blastocyst after vitrification
and warming
Outcome: not pregnant after frozen single blastocyst transfer

Case 108 227
108.01 108.Z1 108.D2–1
108.D3–1 108.D4–1 108.D5–1a
108.D5–1b
Oocyte 108.O1 Optimal oocyte

Day 3 108.D3–1 Eight-cell embryo with minimal fragmentation, one cell in cleavage (9–11 o’clock position)
Blastocyst 108.D5–1a Blastocyst grade IVAA
Blastocyst after vitrification Blastocyst grade IVAA, not re-expanded, with fragments extruded into the
and warming 108.D5–1b perivitelline space
Case 109 3 years 2º infertility Diagnosis: polycystic ovarian
syndrome

Age 40, nurse Basal AMH: 11.97 ng/mL Age 45, technician
MH: irregular cycles, 6–8 weeks Basal LH: 8.8 IU/L
Spontaneous conception Midluteal progesterone: 1.9 ng/mL
and live birth, previous partner Midluteal prolactin: 19.8 ng/mL
consumption

Volume 3 mL
Immotile 48%
Normal forms 14%
Cycle: ICSI 2010
Stimulation protocol Long protocol (buserelin and follitropin beta)

Daily dose 150–125–100–100–100–100–75–50–75 IU
Total dose 875 IU
Metaphase II 8
Metaphase I 0
Prophase I 0
Atretic oocytes 0
2 PN 6
0 PN 1
1 PN 1
3 PN 0
Transfer No fresh BT because of OHSS; single frozen/thawed
blastocyst transferred in a subsequent cycle

Case 109 229
Note: traceability of smaller inclusions
109.01 109.Z1 109.D2–1
109.D3–1 109.D4–1 109.D5–1a
109.D5–1b
Oocyte 109.O1 Normal oocyte with minor inclusion

Zygote 109.Z1 Pronuclear pattern 4, presence of spontaneously formed vacuoles
Day 2 109.D2–1 Four-cell embryo without fragments, in preparation for cleavage
Day 4 109.D4–1 Ten-cell embryo with compaction initiated
Blastocyst 109.D5–1a Grade I blastocyst with early blastocoel formation at the 4 and 10 o’clock positions
Vitrified/warmed blastocyst Grade I blastocyst, two hours after warming
109.D5–1b
Case 110 2 years 1 infertility Diagnosis: low ovarian
response

Age 30, teacher Basal AMH: 0.36 ng/mL Age 32, technician
Smoker (8/day), no Midluteal progesterone: 12.3 ng/mL

Volume 2.6 mL
Immotility 20%
Normal forms 16%
Cycle: IVF 2010
Timed intercourse 2 Not pregnant
IUI 1 Not pregnant

Total dose 2400 IU

2 PN 1
0 PN 0
1 PN 0
3 PN 0
Transfer No fresh BT because of suboptimal endometrium,
single frozen/thawed BT in subsequent cycle
Outcome: not pregnant after frozen single blastocyst transfer

Case 110 231
110.Z1 110.D2–1 110.D3–1
110.D4–1 110.D5–1a
110.D5–1b
Zygote 110.Z1 Extreme form of oval-shaped zygote, pronuclear pattern 0A

Day 2 110.D2–1 Oval four-cell embryo
Day 3 110.D3–1 Oval eight-cell embryo
Day 4 110.D4–1 Fully compacted oval embryo
Blastocyst 110.D5–1a Grade IIIAB blastocyst (210 108 mm)
Blastocyst after vitrification Same blastocyst fully re-expanded 2 hours after warming
and warming 110.D5–1b
Case 111 2 years 2 infertility Diagnosis: male factor, female
carrier of Robertsonian
translocation (TL rob [14, 21])
Age 34, architect AMH: 6.15 ng/mL Age 42, clinician
MH: cycle = 2–3/30 Basal LH: 9.7 IU/L
BMI: 18.3 Basal oestradiol: 24 ng/mL
TSH: 4.4 Midluteal progesterone:
Non-smoker, no alcohol 19.1 ng/mL

Volume 3 mL
Sperm concentration 48 106/mL
Immotile 33%
Normal forms 6%
Spontaneous pregnancy in June 2010, induced abortion due to trisomy 21
Cycle: ICSI 2010, with polar body biopsy
Stimulation protocol Long protocol (FSH)

Daily dose 150–112.5–112.5–112.5–112.5–75 IU until ovulation
induction
Total dose 975 IU

Metaphase II 12
Metaphase I 0
Prophase I 2
Atretic oocytes 0
2 PN 10
0 PN 1
1 PN 1
3 PN 0
Transfer Fully compacted embryo, day 4

Case 111 233
111.01 111.Z1
111.D2–1 111.D3–1
111.D4–1
Oocyte 1 111.O1 Oocyte with minor incorporations

Day 3 111.D3–1 Ten-cell embryo with minor fragmentation
Day 4 111.D4–1 Fully compacting embryo
INDEX
abortion, recurrent, with tubal post vasectomy, 122–6, 128–30, teratozoospermia, 92–3
factor, 168–9 142–4, 154–6 with endometriosis and
adhesions, tubal, 82, 86 hyperprolactinaemia, 100–2
age, maternal, infertility and, 150–2 blastocoel, 207, 229 with fibroids plus ATS, 94–6
assessment blastocyst cervical stenosis, 92
embryo, 4–6 assessment of, 6 chemotherapy, male infertility after,
Istanbul Consensus, 1, 5 grade I, 183, 203, 229 24–8
semen, parameters, 1 grade II, 207, 219 chlamydia infection
asthenospermia, definition, 2 grade IIIAA, 209 both partners, 32
asthenozoospermia, plus female grade IIIAB, 231 female, 16, 126, 168
factor re-expanded, 207, 231 cleavage, anomalous rapid, 103
cervical and tubal, 90–2 grade IVAA, 181, 203, 219 cone biopsy, 76, 78, 152
endometriosis, 210–12 grade IVAB, 187, 213, 217 carcinoma in situ, 54
endometriosis and tubal, 108 re-expanded, 207 controlled ovarian hyperstimulation
ATS grade IVAC, 179 (COH), 2
no female factor, 18–20, 38–40, grade IVBA, 189, 223 cryptorchidism, 26, 34, 56, 94, 102,
42–3, 54–5, 176–8, 182–4, grade IVBB, 193 152
194–6 grade VAA, 177, 201, 225 cryptozoospermia, 58
plus female factor vacuole, 191 OATS, 34, 36
age, 150–2 blastomeres severe OATS, 26
cervical, 72–4 assessment of, 6 cryptozoospermia, 22–4, 58–60, 66–8
cervical and fibroids, 94–6 large, 137 definition, 2
cervical, endometriosis and multinucleated, 6, 11, 157 plus poor responder, 134–8
hyperprolactinaemia, 100–2 satellite nuclei in, 25 cytoplasmic degeneration, 37, 85,
endometriosis, 102–4 slightly unequal, 13, 89, 137 141
endometriosis and tubal, 106–8 unequal, 15, 79, 139 large area, 39, 123
hyperprolactinaemia, 162–4, uneven, 199, 207 minor, 44, 143
190–2 unusual arrangement, 185 moderate, 95
PCOS, 152–4, 224–6 vacuole, 17, 59, 61, 85, 157, 179, small area, 19
tubal, 76–7, 78–80, 82–4, 196–8, 187, 189 cytoplasmic dysmorphism, 4, 5
200–4 very unequal, 145 cytoplasmic granules, 149, 195
tubal and endometriosis, 84–5, with inclusions, 127 cytoplasmic inclusions
86–8 BMI distinct, 113, 169
severe plus endometriosis and low female, 178, 220 few, 211
hyperprolactinaemia, 118–20 major, 29, 91
azoospermia caput epididymus, partial absence, minor, 13, 83, 131, 183, 225
no female factor, 10–12, 184–6 138 perivitelline space, 155
plus female factor cervical factor persistent, 35
endometriosis, 98–9 plus male factor several small, 15
poor responder, 138–40 ATS, 72–4 single distinct, 15
Index 235
small, 81, 155 in cleavage, 225 short, 2

cytoplasmic retraction, 41, 85, 133 oval-shaped, 231 antagonist protocol, 2
considerable, 15 partially cleaved, 13
severe, 17 poorly cleaved, 41 hernia repair, 96, 124, 152
cytoplasmic strings, 175 retarded, 20, 79, 135 herpes genitalis, male, 144
cytoplasmic vacuoles, 87, 157 transfer techniques, 4 hydatiform mole, 196
major, 59 vacuolization, 19, 77, 99, 175, 187 hydrosalpinx, 80, 168
vacuolization, slight, 175 hypergonadotropism, 134
diagnosis endometrial polypectomy, 96, 112, hyperprolactinaemia, 192, 224, 226
female 114 plus male factor
cases by, at KSB, x endometriosis ATS, 162–4
cases by, at LFKK, xiii and age, post vasectomy, 128–30 OATS, 160–2
male and hyperprolactinaemia plus OTS, 158–60
cases by, at KSB, xiv severe ATS, 118–20 hypogonadotropic hypogonadism, 58
cases by, at LFKK, xviii and poor responder, 120–1
parameters for, 2 and tubal factor plus male factor ICSI
downregulation asthenozoospermia, 108–10 protocols, 2
follicular phase, 2 ATS, 106–8 techniques, 3
luteal, 2 teratozoospermia, 212–16 idiopathic infertility, semen
grade I, 90 assessment parameters, 1
ectopic pregnancy, 80 grade IV, 140 Istanbul Consensus, 1, 5
embryo plus male factor
anomalous rapid cleavage, 103 asthenozoospermia, 116–18, Kartagener’s syndrome, 42
assessment, 4–6 210–12
consensus on, 5 ATS, 102–4 low responder
Instanbul Consensus, 1 azoospermia, 98–9 plus male factor
cell membranes earlier varicocele, 126–8 post vasectomy, 122–4
not clearly separated, 49 severe OATS, 104–6 teratozoospermia, 230–2
unclear, 35 teratozoospermia, 110–16, with ovulatory dysfunction,
compacted fully, 175, 213, 223 208–10 132–3
compacted incompletely, 189, 207, stage I, 86 luteal downregulation protocol
219 endoplasmic reticulum, smooth (LDP), 2
compacting, 219 condensed, 105, 169 luteal support, 4
compaction initiated, 229 typical condensed, 25
compaction initiating, 173, 203, epididymectomy, 154 male infertility
205, 217, 221 epididymitis, 162 cases by cause of, at KSB, xiv
developmental arrest, 199 erectile dysfunction, 70 cases by cause of, at LFKK, xviii
fragmentation see also particular causes.
considerable, 20, 21, 43, 45, 75, female infertility molar pregnancy, 196
81, 101, 109, 117, 121, 141, cases by cause of, at KSB, x morula, 199, 205
145, 151, 167 cases by cause of, at LFKK, xiii early, 183, 227
large, 13, 91, 147 see also particular causes. myomectomy, 142
minimal, 25, 81, 139 follicular phase downregulation
minor, 13, 83, 209, 233 (FPD), 2 normozoospermia
polyfragmented, 93 definition, 1
significant, 107, 153 GnRH nucleoli
small, 19 agonist protocol aligned, 95
small amount, 89 long, 2 asynchronous, 13, 81, 139
236 Index
nucleoli (cont.) large refractile body, 201 perivitelline space

few, 11, 91, 135, 157 lysed, 125 cytoplasmic inclusions, 155
large, 11, 113, 149 misshapen, 79 enlarged, 103
not aligned, 13, 77, 151 monoploid, 115 fragments in, 227
sparse, 13, 113, 159 normal, 13, 79, 173, 207, 225 granules, 64, 105, 155
starting to align, 15, 111, 145 optimal, 227 large, 11, 91, 135
synchronous, 67, 77 oval-shaped, 16, 87, 141, 189 reduced, 75
variable, 43, 101 refractile body, 215 relatively small, 79
large, 181 small, 77
OAS retrieval, 2 polar body
no female factor, 28–30, 172–4 septum, 121 clear, 55
severe, no female factor, 70–1 orchidopexy, 48, 136 first, large, 5
OATS asthenozoospermia, 90 fragmented, 31, 83, 175
after radiotherapy, 30–2 ATS, 94, 102 incomplete extrusion, 179
earlier cryptorchidism, 12–14, OATS, 12 large, 75, 91, 141
34–8, 48–50 orchitis, 96 not extruded, 141
earlier varicocele, 60–2 OTS two, 79
no female factor, 14–18, 40–2, no female factor, 20–2, 64–6, very large, 169
46–7, 52–4, 56–7, 68–70, 180–2 polyploidy, 153
74–6, 192–3 plus female factor poor responder
plus female factor hyperprolactinaemia, 158–60 plus male factor
endometriosis, 96–8 PCOS, 216 cryptozoospermia, 134–40
hyperprolactinaemia, 160–2 tubal, 80–2 OATS, 140–1
poor responder, 140–1 outcome severe OATS, 130–1
tubal, 88–90 cases by, at KSB, xxix with age, post vasectomy,
OATS severe cases by, at LFKK, xxxiii 142–4
no female factor, 26–7, 44–6, 50–2, ovarian cyst, 102, 140 with endometriosis, 120–1
186–8 ovarian drilling, 38 pronuclei
plus female factor ovarian reserve, reduced, 112, abutted, 15, 81, 143
endometriosis, 104–6 114 abutted, but vague, 143
ovulatory dysfunction, 146–8 ovulation, induction of, 2 assessment of, 5–6
poor responder, 130–1 ovulatory dysfunction, 132–3 asynchronous and few, 119
oestradiol no male factor, 148–9 close, not abutted, 13
level on day of hCG plus male factor indistinct, 99
cases by, at KSB, xxiii severe OATS, 146–8 variable, 19, 137
cases by, at LFKK, xxiv teratozoospermia, 144–5 prostatitis, 168
zona pellucida thickness and, 5 protocol
oligospermia, definition, 1 paraplegia, as male factor, 120 clinical and laboratory
oocyte PCOS controlled ovarian
abnormal shape, 29 no male factor, 218–22 hyperstimulation (COH), 2
anomalies, 4–6 plus male factor sperm preparation, 3
condensed sER, 105 ATS, 152–4, 224–6 stimulation
culture conditions, 3 OTS, 216 cases by, at KSB, xix
ellipsoid shaped, 167 post vasectomy, 154–6 cases by, at LFKK, xxiii
freshly extruded polar body, 193 teratozoospermia, 222–4, pseudoblastocyst, 57
granules, 207 226–30
incomplete extrusion of polar PCOS and tubal factor, plus radiotherapy, male infertility
body, 179 teratozoospermia, 156–7 following, 28, 30
Index 237
refractile bodies PCOS, 226–30 normospermia, 126

large, 181, 201 PCOS and tubal, 156–7 OATS, 60
numerous, 177 translocation, x, 232 teratozoospermia, 62
small, 187 tubal, 204–8 vas deferens, absent, 10, 138
testicular atrophy, 98, 154 vasectomy, 122, 124, 128, 154
salpingectomy, 76, 78, 80 testicular biopsy pre-vasectomy semen, 142
salpingitis, 156 sperm retrieval by, 122, 124
satellite nuclei, 75 testicular volume, small, 134 zona pellucida
semen translocation with teratozoospermia, asymmetric, 47
assessment parameters, 1 x, 232 atypical thick, 83, 145
preparation, 3 triploidy, 115, 141 deformed, 13
seminal fructose, low, 156 post-IVM, 47 granules under, 143
seminoma, 24, 30, 172 tubal and cervical factors oval-shaped, 59
smooth endoplasmic reticulum plus asthenozoospermia, 90–2 septum, 29, 127
condensed, 105, 169 tubal factor thick, 11, 95, 131
typical condensed, 25 plus male factor atypical, 15
sperm ATS, 76–7, 78–80, 82–5, 86–8, thickness, 5
preparation, 3 196–8, 200–4 zygote
retrieval OATS, 88–90 halo, 173, 213
in paraplegia, 120 OTS, 80–2 monopronuclear, 77
testicular biopsy for, 122 teratozoospermia, 204–8 oval-shaped, 189
stimulation protocol extreme, 231
cases by, at KSB, xix unexplained infertility, 198–200 partially cleaved, 69, 137
cases by, at LFKK, xxiii uterine septum, 186, 204 polyploid, 153
subfertility, male, 38, 52–4, 62–3 pronuclear membrane breakdown,
vacuoles 173, 209
teratozoospermia, 92–3 blastocyst, 191 pronuclear pattern
definition, 2 large, 219 0A, 231
no female factor, 32–4, 62–3, morula, 183 0B, 175, 219
174–6, 178–80 oocyte, large, 191 1, 221
plus female factor traceability of, 191, 219 2, 203
endometriosis, 110–18, zygote, 17, 129, 229 3, 207
208–10 numerous, 63 4, 229
endometriosis and tubal, persistent, 35 5, 211, 217
212–16 severe vacuolization, 77 triploid, 47, 115, 141
hyperprolactinemia, 164–6 slight vacuolization, 175 tripronuclear, 65, 83
hypothyroid, 166–8, 188–90 varicocele uncleaved, 87, 137
low responder, 230–2 ATS, 42 vacuole, 129, 137

Atlas of Oocytes, Zygotes and Embryos in Reproductive Medicine PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Atlas of Oocytes, Zygotes and Embryos in Reproductive Medicine PDF

Uploaded by

Copyright:

Available Formats

Atlas of

# Marc Van den Bergh, Thomas Ebner, Kay Elder 2012

This publication is in copyright. Subject to statutory exception

First published 2012

Printed in the United Kingdom at the University Press, Cambridge

Library of Congress Cataloging-in-Publication Data

ISBN 978-1-10700464-1 Hardback

Cambridge University Press has no responsibility for the persistence

List of tables page vi

Part A Cleavage stage transfer (KSB, Switzerland) 9

Part B Extended culture (LFKK, Austria) 171

Table 1A KSB: Summary of clinical details of cases, ordered by cause of female

AMH anti-Mullerian hormone ICSI intracytoplasmic sperm injection

Table 1A Summary of clinical details of cases, ordered by cause of female infertility

4 None identified OATS 28 LDP 1800 2378 8730 8 Negative

8 None identified TESE (frozen) 31 LDP 3450 3877 14231 5 Negative

10 None identified Post-oncology, 32 LDP 3075 3533 12970 9 Negative

12 None identified ATS 33 LDP 2100 1703 6253 5 Negative

15 None identified ATS 34 LDP 2475 2025 7435 6 Negative

17 None identified ATS 34 LDP 2700 1186 4353 10 Negative

20 None identified OATS 36 LDP 3150 3379 12403 14 Negative

22 None identified Severe OATS 37 LDP 3150 1102 4046 16 Negative

23 None identified ATS 37 LDP 3150 2840 10426 5 Negative

26 None identified OATS 38 LDP 2700 1384 5081 2 Negative

30 None identified OATS 38 LDP 3000 3701 13586 5 Negative

31 None identified Severe OATS 40 LDP 4500 2825 10369 11 Negative

33 None identified OATS 41 LDP 2250 3925 14408 6 Negative

34 Tubal ATS 30 LDP 3750 1055 3872 5 Negative

35 Tubal ATS 30 LDP 3600 825 3030 5 Positive Ongoing singleton

36 Tubal OTS 36 LDP 2475 3135 11509 18 Positive Missed abortion,

38 Tubal, endometriosis ATS 33 LDP 2700 3624 13305 11 Negative

39 Tubal Asthenozoospermia 37 LDP 4650 1823 6692 4 Negative

40 Tubal Severe OATS 39 LDP 3225 1733 6361 4 Negative

41 Cervical Asthenozoospermia 37 LDP 4875 755 2773 5 Negative

42 Cervical Teratozoospermia 30 LDP 2700 2098 7700 10 Positive Missed abortion:

44 Fibroids OATS 39 LDP 3375 1659 6090 9 Positive Biochemical pregnancy

45 Endometriosis TESE 29 LDP 2925 755 2771 5 Negative

46 Endometriosis, ATS 29 LDP 1875 3041 11165 12 Positive Ongoing singleton

47 Endometriosis ATS 32 LDP 3600 4123 15135 14 Negative

48 Endometriosis Severe OATS 32 LDP 3150 1605 5892 3 Negative

50 Endometriosis Normozoospermia 34 LDP 2250 1307 4799 8 Negative

51 Endometriosis Teratozoospermia 34 FDP 3300 2025 7432 5 Positive Ongoing singleton

52 Endometriosis Teratozoospermia 35 FDP 5280 633 2325 3 Negative

53 Endometriosis Teratozoospermia 35 Antagonist 1500 632 2321 3 Negative

54 Endometriosis Asthenozoospermia 35 LDP 2326 4349 15966 10 Negative

56 Endometriosis OATS, EEJ 36 Antagonist 2250 1208 4436 2 Negative

57 Endometriosis, poor TESE (fresh) 38 LDP 2925 636 2333 3 Negative

58 Endometriosis, poor TESE (frozen) 38 FDP 3000 998 3663 1 Negative

59 Endometriosis Normozoospermia 39 LDP 3300 2595 9528 3 Positive Spontaneous abortion,

60 Endometriosis, age TESE (frozen) 42 LDP 4350 3613 13265 5 Negative

62 Poor responder Normozoospermia 35 FDP 4500 1370 5029 5 Negative

63 Poor responder Cryptozoospermia 36 Antagonist 1500 549 2017 3 Negative

64 Poor responder Cryptozoospermia 37 FDP 3750 1133 4158 3 Negative

65 Poor responder TESE (frozen) 38 Antagonist 2400 667 2449 3 Negative

66 Poor responder Normozoospermia 39 FDP 6750 1826 6702 3 Negative

67 Poor responder Pre-vasectomy, 42 Antagonist 3300 1346 4943 5 Negative

68 Ovulatory Teratozoospermia 32 Antagonist 2025 2055 7432 5 Negative

69 Ovulatory Severe OATS 38 LDP 2250 2452 9003 11 Negative

70 Anovulation Normozoospermia 33 LDP 1875 3389 12442 16 Negative

71 Age ATS 39 LDP 2850 4592 16856 13 Negative

72 PCO ATS 31 LDP 2175 4709 17287 15 Negative

73 PCO TESE (frozen) 31 Antagonist 1688 1195 4386 4 Negative

76 Hyperprolactinaemia OATS 40 FDP 3600 1473 5407 3 Negative