自然週期vs誘導排卵      誘導排卵並不明顯提高胚胎染色體異常率 

自然週期vs誘導排卵      胚胎異常率均隨女性年齡而增加， 

自然週期vs誘導排卵      整倍體囊胚的植入率相同。

誘導排卵對胚胎非整倍體風險或胚胎生殖潛力沒有明顯副作用。

• Embryonic aneuploidy rates are equivalent in natural cycles and gonadotropin-stimulated cycles
• Aneuploidy rates were equivalent in unstimulated and stimulated IVF cycles. 
• The prevalence of aneuploidy in natural cycles increased with the age of the female partner in a manner identical to that seen in stimulated IVF cycles. 
• Implantation rates of euploid blastocysts were equivalent in natural and stimulated IVF cycles.
• No measurable toxic effect of gonadotropin administration on aneuploidy risk or embryonic reproductive potential. 

• The overall sustained implantation rate (SIR) did not differ for patients in the natural cycle group (60.0%) as compared to superovulatory controls (63.8%)
• Patients less than 35 years of age had an SIR of 61.7% in the natural cycle group versus 66.5% in the control group (P=.45). 
• There were no differences in SIR between patients that were 35 to 37 years of age in natural cycle (53.3%) versus gonadotropin control cycle patients (62.9%, P=.52). 
• Patients between the ages of 38 and 40 had SIR of 69.2% and 60.2%, in study and control groups, respectively (P=.65). 
• The SIR similarly did not vary for patients ages 41–42 in the natural cycle group and the superovulatory control group (33.3% vs. 61.4%, P=.33), or greater than 42 years of age (50.0% vs. 50.0%, P>.99). 

在所有年齡層  囊胚持續著床率比較

第5天優質囊胚>第 5 天中等囊胚>5 天差等囊胚>第 6 天胚胎 

第 5 天囊胚著床率與年齡>36歲有輕微負相關

第 6 天囊胚著床率與年齡>36歲有較明顯負相關

質量最佳的整倍體第 5 天胚胎在所有年齡的著床率高達 80%。

質量一般/較差的第 5 天胚胎和第 6 天胚胎的著床率約 50% 

 https://www.sciencedirect.com/science/article/pii/S1472648321002923

There was a clinically significant higher sustained implantation rate at all ages for euploid day 5 good quality embryos compared with day 5 fair, day 5 poor and day 6 embryos.

• For all ages the sustained implantation rates for day 5 good quality blastocysts were higher than for day 5 fair, day 5 poor and day 6 blastocysts. 
• At a maternal age of 36 years the best-fit sustained implantation rates were 86% for day 5 good quality blastocysts, 64% for day 5 fair, 63% for day 5 poor, and 51% for all day 6 blastocysts analysed as one group. 
• The best-fit sustained implantation rates for age 33 compared to age 39 years were 86% versus 80% for day 5 good, 71% versus 62% for day 5 fair, 59% versus 55% for day 5 poor, and 81% versus 46% for all day 6.
• The best quality euploid day 5 embryos had a SIR of 80–90% at all ages. 
• Even fair/poor quality day 5 embryos and day 6 embryos had a SIR of approximately 50% or greater. 
• euploid blastocyst transfers a reasonable performance goal is an overall SIR of 60–65% per embryo and a LBR of 50–60% per embryo. 

 誘導排卵成效與下列有關

• dehydroepiandrosterone DHEA (n = 1,336); 
• testosterone (n = 418); 
• high- vs. low-dose gonadotropin (n = 957); 
• delayed-start protocol with gonadotropin hormone-releasing hormone antagonist (n = 398); 

 誘導排卵成效與下列無關

• letrozole (n = 612); 
• clomiphene citrate (1,113); 
• growth hormone (311); l
• uteal phase stimulation (n = 57); 
• dual triggering (n = 139); dual stimulation (168); 
• luteinizing hormone (979); 
• oestradiol pretreatment (n = 552); 
• corifollitropin alfa (n = 561).

Therapeutic management in women with a diminished ovarian reserve: a systematic review and meta-analysis of randomized controlled trials

https://www.fertstert.org/article/S0015-0282(24)02256-8/fulltext

PGS應用是否能提高累積懷孕率與年齡有關

對於>35歲以上較能提高懷孕率，主因在於囊胚染色體異常率較高

年輕<35歲病患因為囊胚染色體異常率較低 ，PGS對於提高累積懷孕率較無明顯影響

Success rates with preimplantation genetic testing for aneuploidy in good prognosis patients are dependent on age

https://www.fertstert.org/article/S0015-0282(24)02261-1/abstract

To evaluate cumulative live birth after preimplantation genetic testing for aneuploidy (PGT-A) with next generation sequencing (NGS) compared with morphology alone among patients aged 21–40 years undergoing single blastocyst transfer.

• A total of 56,469 retrieval cycles were included in the analysis. Retrieval cycles were stratified based on age (<35, 35–37, and 38–40 years) and exposure to PGT-A with NGS. 
• the use of PGT-A was associated with a slightly lower cumulative live birth in individuals aged <35 years (risk ratio [RR]: 0.96; 95% CI: 0.93–0.99) compared with no PGT, 
• but higher cumulative live birth in ages 35–37 years (RR: 1.04; 95% CI: 1.00–1.08), 
• and 38–40 years (RR: 1.14; 95% CI: 1.07–1.20). 
• PGT-A was associated with higher cumulative live birth in individuals aged ≥35 years 
• was similar to no PGT in individuals aged <35 years. 
• Miscarriage was significantly less likely in individuals aged ≥35 years using PGT-A compared with no PGT-A.

精蟲頭部型態跟下列因素有關

1. acrosome formation頂體形成 
2. proacrosomal vesicles  前頂體囊泡 (PAV) 
3. manchette 
4. perinuclear theca 核週膜 (PT)
5. chromatin condensation染色質凝聚 
6. linker of nucleoskeleton 核骨架連接子
7. cytoskeleton complex細胞骨架 (LINC) 複合物 
8. ‘histone-to-protamine (HTP) transition‘組蛋白到魚精蛋白 (HTP) 轉變

精蟲頭部型態正常與否與ICSI結果有關

卵子冷凍相關知識

• 多數研究表明胚胎的品質不會受到冷凍保存時間的影響。人類胚胎長期冷凍保存不會影響懷孕結果。
• 未成熟GV與成熟M-II期玻璃化冷凍存活率無明顯差異。
• 解凍後卵母細胞的受精率也與新鮮自體卵胞漿內精子注射週期相當（70% 對 72%）。
• 玻璃化冷凍卵母細胞的每個胚胎的植入率(43% vs. 35%) 和每次移植的臨床懷孕率(57% vs. 44%) 明顯較高於與新鮮卵母形成胚胎植入。但活產/持續懷孕率並沒有統計上顯著差異（39% vs. 35%）。
• 每顆凍卵解凍受孕植入之活產嬰兒機率約6.4%。
• 使用自體卵母細胞玻璃化冷凍加熱的治療效果與使用新鮮卵母細胞的週期一樣好。
• MI階段卵子解凍後僅有44%可成熟至MII 階段， GV階段卵子解凍後僅有4% 能成熟至MII階段。

 https://www.fertstert.org/article/S0015-0282(15)02037-3/fulltext

l         Most studies dicate that the quality of embryos is not influenced by the duration during cryo-storage. 

l          Long-term cryo-storage of human embryos did not affect the pregnancy outcome. 

l          There is no significant difference in the survival rate between oocytes vitrified at the  immature GV stage and those vitrified at the mature M-II stage. 

l          Postthaw oocyte fertilization rates were also comparable to fresh autologous intracytoplasmic sperm injection cycles (70% vs. 72%). 

l          Implantation rates per embryo transferred (43% vs. 35%) and clinical pregnancy rates per transfer (57% vs. 44%) were significantly higher with vitrified–warmed compared with fresh oocytes. 

l          However, there was no statistically significant difference in live birth/ongoing pregnancy (39% vs. 35%). 

l          The overall vitrified–warmed oocyte to live born child efficiency was 6.4%.

l          Treatment outcomes using autologous oocyte vitrification and warming are as good as cycles using fresh oocytes. 

l          only 44% of the oocytes vitrified at the MI stage subsequently matured to the MII stage in vitro after warming, and only 4% of the oocytes vitrified at the GV stage did so.

 

 

 

冷凍卵子相關實證結果與常見問題

 

隨著科技的進步，卵子冷凍技術已十分成熟並也是現今試管嬰兒療程標準步驟之一。

相關常見問體列舉如下:

 

接受卵子冷凍的女性的預期活產率是多少？

自體冷凍保存卵子和新鮮卵子每次移植的持續懷孕率相同（分別為 38.6% 和 36%，P>.05）。

若你30歲冷凍卵子  等你40歲才解凍植入,該週期懷孕率大致與你30歲植入相同‧

 

凍卵取卵時的年齡如何影響結果？

卵母細胞效率隨著年齡的增加而降低（每顆卵子解凍後懷孕率依年齡成反比）

<30 歲女性每顆卵子解凍後懷孕率為7.4%，

30-34 歲女性每顆卵子解凍後懷孕率為7.0%，

35-37 歲女性每顆卵子解凍後懷孕率為6.5%，

38-40 歲女性每顆卵子解凍後懷孕率為5.2%。

41-42 歲女性的有效率為 2.4 %，

 

Age (y)	Cycles	Oocytes	Children (fresh ET)	Vitrified blastocysts	Children (cryo ET)a	Total children	Children per oocyte (%)
<30	2,085	34,017	1,339	4,484	1,611	2,950	8.67
30–34	5,715	83,597	3,257	10,409	3,601	6,858	8.20
35–37	4,189	53,794	2,097	5,404	1,844	3,941	7.33
38–40	4,148	46,582	1,573	2,928	509	2,082	4.47
41–42	1,831	18,584	379	544	85	464	2.49
43–44	778	7,318	67	81	11	78	1.06

Fertil Steril .2016 Feb;105(2):459-66.

 

 

卵子經歷冷凍解凍過程是否會對其品質及其後續受精所得之胚胎發育造成影響？

卵子受孕率而言: 新鮮卵子受孕率高於冷凍卵子(85% vs 80%)

第三天高品質胚胎比率: 新鮮卵子形成率高於冷凍卵子(38% vs 30%)

囊胚比率: 新鮮卵子形成率高於冷凍卵子(41% vs 36%)

 

新鮮胚胎植入 vs. 冷凍胚胎植入 vs. 解凍卵子所得胚胎植入，何者為優？

懷孕率最好的是使用冷凍胚胎的解凍植入，次佳的是使用解凍卵子所得胚胎植入，最差的是新鮮胚胎的植入。

主因為新鮮植入週期中使用大量誘導排卵的藥物，造成子宮內膜提早成熟 (黃體化)，子宮內膜基因表現改變等現象，進而影響胚胎著床。

而在解凍植入週期中，因為前段並無使用大量藥物劑量，進而子宮內膜所受之影響也較少。使用解凍卵子所得的胚胎和新鮮胚胎相比，縱使品質上較差，但在植入後仍有較佳的懷孕率和著床率。

(Fertil Steril 2016;106:615–22. 2016)

 

新生兒併發症是否有差異?

新鮮卵子或冷凍卵子在懷孕期和新生兒健康結果沒有顯著差異。

 

應該冷凍多少卵子才能達到合理的活產機會？

卵子細胞效率會隨著年齡的增長而降低，目前沒有足夠的證據來可達到合理的活產機率

部分研究估計，要實現70% 的活產機會，30-34 歲的女性需要冷凍保存14 個成熟卵母細胞，35-37 歲的女性需要冷凍保存15 個成熟卵母細胞，38-40 歲的女性需冷凍保存26 個成熟卵母細胞。

部分研究估計，<35 歲女性每個加熱的卵母細胞產生活產的機率為 2.6%，而 >35 歲女性的活產機率為 1.3%。他們計算出，35 歲以下的女性需要 38.8 個卵母細胞才能達到活產，而 35 歲以上的女性則需要 77 個卵母細胞。

 

冷凍自體卵子 vs 捐贈卵子

通常捐贈卵子多較為年輕 懷孕續自然比冷凍字體卵子為高‧若年齡卵巢功能相若ㄉ狀況下  懷孕率應無差異‧

但冷凍技術日新月異，10年前得冷凍技術應該降目前的冷凍技術略低，懷孕率應該也較低

 

結論，

隨著高齡與晚婚  冷凍卵子逐漸成為女性必須考慮之治療，建議應趁早施行相關保存，若已婚卻選擇晚點懷孕可優先考慮取卵後受孕形成胚胎再冷凍，若未婚女性或男方無法於取卵時提供精子的狀況下再選擇卵子冷凍。建議至少取卵2次以上，累積25-30顆以上卵子為妥‧

 

新鮮卵子授精相比，凍卵解凍後進行卵胞漿內精子注射會導致胚胎受孕率降低，胚胎品質下降，囊胚形成率較低。但鮮胚植入之懷孕率最低

新鮮卵子授精形成胚胎冷凍再解凍植入懷孕率>卵子冷凍再解凍受孕形成胚胎再植入懷孕率>鮮卵子胚

冷凍卵子不論是在受精率(80% vs 85%)、培養至第三天優質胚胎(31% vs 39%) 或是第五天囊胚發育率(36% vs 41%) 都遜於新鮮卵子。

Freeze-all, oocyte vitrification, or fresh embryo transfer? Lessons from an egg-sharing donation program 

Fertil Steril
2016;106:615–22. 2016

• Decreased embryo quality and lower rates of blastocyst formation were observed among embryos derived from vitrified oocytes. 
• The highest pregnancy and implantation rates were noted for the Thaw Cycles Group, followed by the Banked Donor Egg Group; 
• the Fresh Cycles Group had the lowest rates. 
• Conclusion(s): Oocyte vitrification followed by intracytoplasmic sperm injection leads to lower embryo developmental competence compared with when fresh insemination methods are used. 
• However, pregnancy and implantation rates are higher when embryos are transferred into a ‘‘more receptive’’ endometrium, free of the adverse effects of gonadotropin. 

•  1PN 囊胚中的核前體 (NPB) 數量明顯高於 1PN（原核）停滯胚胎的數量。
• 原核面積和直徑、NPB的數量也與其胚胎發育潛力有關。
• PN 面積>750m2-----胚胎品質較高  懷孕率較高
• NPB> 12-----胚胎品質較高  懷孕率較高

• the nucleolar precursor body (NPB) count in 1PN blastocysts was significantly higher compared to that of the 1PN(Pronucleous) arrested embryos,
• Pronuclear area and diameter, the number of NPB is also associated with their developmental potential.

https://www.cambridge.org/core/journals/zygote/article/are-the-number-of-nucleolar-precursor-body-and-size-of-pronuclear-correlated-with-embryo-development-and-ploidy-status-in-1pn-zygotes-an-analysis-through-the-timelapse-monitoring-and-preimplantation-genetic-testing/ED3FC799FD9F027FF7C588C397DCA60E