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Manjula et al., Int J Med Res health Sci. 2014;3(3):621-626

International Journal of Medical Research
&
Health Sciences
www.ijmrhs.com Volume 3 Issue 3 Coden: IJMRHS Copyright @2014 ISSN: 2319-5886
Received: 29
th
Apr 2014 Revised: 13
th
Jun 2014 Accepted: 24
th
Jun 2014
Research Article
ROLE OF EARLY CLEAVAGE IN PREDICTING SUCCESS OF INTRA CYTOPLASMIC SPERM
INJECTION IN ASSISTED REPRODUCTIVE TECHNOLOGIES
*Manjula Gopalakrishnan
1
, Sanjeeva Reddy Nellapalli
2
, Muthiah sinvaniah surulimuthu
3
1
Embryologist,
2
Professor & Head, Department of Reproductive Medicine, Sri Ramachandra University, Chennai
3
Embryologist, Kanmani Fertility clinic, Chennai
*Corresponding author email: [email protected], [email protected]
ABSTRACT
Aim and Objective: The present study is aimed to carry out the impact of early cleavage over late cleavage in
assessing the pregnancy outcome using of Intra Cytoplasmic Sperm Injection (ICSI) in assisted reproductive
technologies. Materials and Methods A total of 154 patients enrolled for Intra Cytoplasmic Sperm Injection
(ICSI) fulfilling the selection criteria were recruited for the study at a tertiary care assisted reproductive centre.
ICSI was performed 35 h after oocyte aspiration with the prepared sperm. All embryos were checked for early
cleavage at 27 hours post intra cytoplasmic sperm injection. They were divided into two groups. Group I-
Embryos which cleaved before 27 hours after Intra Cytoplasmic Sperm Injection (ICSI). Group II- Embryos
which cleaved after 27 hours. The pregnancy rates were compared between the two groups. Results: All the 154
patients were analysed. There was no difference in the mean age, duration of ovarian stimulation, number of
oocytes retrieved, fertilization, cleavage rates and embryo quality between the two groups. Early cleavage was
observed in 98 patients (63.64 %). Late cleavage was observed in 56 patients (36.36%). The clinical pregnancy
was confirmed in 59 patients (60.20%) in Group I and 20 patients (35.71%) in Group II which was statistically
significant P <0.001. Conclusion: Early cleavage is a strong predictor of embryo quality and can predict ICSI
outcome.
Keywords: Clinical pregnancy, Early cleavage, Embryo quality, Intracytoplasmic sperm injection, Ovarian
stimulation.
INTRODUCTION
Assisted reproductive technology (ART) is a general
term referring to methods used to achieve pregnancy
by artificial or partially artificial means. All
treatments or procedures that include the in vitro
handling of both human oocytes and sperms or of
embryos for the purpose of establishing a pregnancy.
It is a reproductive technology used primarily in
infertility treatments. Different methods of embryo
transfer have been followed in this treatment are fresh
embryo transfer and frozen embryo transfer.
The success of assisted reproductive technologies
(ART) depends primarily on the quality of the
embryos transferred and endometrial receptivity.
Routinely the selection of embryos for transfer is
based on embryo morphology and developmental
stage. Sometimes, implantation may not occur after
transferring good quality embryos to a receptive
endometrium.
1
Other methods of selection of
embryos include pronuclear morphology, oocyte and
pronuclear polarity, blastomere symmetry and
blastocyst culture.
2
Pronuclear zygote morphology
DOI: 10.5958/2319-5886.2014.00407.X
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Manjula et al., Int J Med Res health Sci. 2014;3(3):621-626
may vary during the dynamic process of syngamy.
3
According to previous studies, selection of embryos
on the basis of cell number and quality at the time of
transfer is of more significant benefit.
4
Other
morphological features such as variation in zona
thickness and the presence of multinucleated
blastomeres have also been affect the implantation
and pregnancy.
5
Some authors scored blastocyst on
the basis of inner cell mass and trophectodermal cells
and selecting high quality blastocyst, which leads to
higher pregnancy and implantation rates.
6
Several
biochemical methods have been used to assess the
human embryo quality, such as O
2
consumption,
pyruvate uptake, glucose uptake, lactate production
and secretion of platelet-activating factor production
or amino acid turnover.
7
These procedures are all
more complex and time-consuming and it is very
difficult to follow in routine practice. There is still a
need for an easy, simple, and more efficient method
of viable embryo selection. A recent study showed
that assessment of the time of cleavage to the two cell
stage was a reliable parameter for the selection of
embryos with the highest capability of implantation
and successful pregnancy after transfer.
8
The aim of
the present study was done to evaluate the impact of
early cleavage over late cleavage in assessing
pregnancy outcome using Intra Cytoplasmic sperm
injection.
MATERIALS AND METHODS
It was a prospective observational study conducted in
the Department of Reproductive Medicine, at a
tertiary care centre from Oct 2010-May 2012. A total
of 154 patients who underwent Intra Cytoplasmic
Sperm Injection (ICSI) were included in the study in
the age group of 21-45 years. Inclusion criteria: All
patients enrolled for ICSI during this study period
were included in the study. The patient has only early
cleavage embryos and the patient having only late
cleavage embryos for transfer were included in the
study. Exclusion criteria: Patient having both early
and late cleavage embryos for transfer was excluded
from the study. Informed consent was taken before
the enrollment of each participant and the
Institutional ethical committee approval was obtained
(IEC/10/JULY/83/29).
Two stimulation protocols were used in this study;
The A gonadotropin-releasing hormone (GnRH)
agonist protocol- A gonodotropin releasing hormone
agonist is an analogue that activates the receptors
resulting in increased secretion of Follicle stimulating
hormone (FSH), Luteinizing hormone (LH). The
GnRH antagonist protocol -A gonadotropin-releasing
hormone antagonist is an analogue that blocks the
GnRH receptor resulting in an immediate drop in
gonadotropin (FSH, LH). In the GnRH agonist
protocol, pituitary down regulation was done with
GnRH agonists. Once the patient was down regulated
completely (had menses, E2 <30 pg/ml) gonadotropin
injections (recombinant follicle stimulating
hormone/human menopausal gonadotropin) were
given until the day of hCG administration. The doses
were adjusted according to the patient's ovarian
response. In the GnRH antagonist protocol, without
down regulation gonadotropin injections were
administrated daily from the second day of the
menstrual cycle. The doses were adjusted according
to the patient's individual ovarian response. Once the
dominant follicle reached 14 mm in mean diameter,
GnRH antagonist was administered subcutaneously at
a dose of 0.25 mg daily until the day of hCG
administration. In both groups, ovulation was induced
by the administration of either recombinant h CG or
urinary h CG when at least two follicles reached 18
mm in diameter, and oocyte retrieval was performed
3436 hours later. Oocytes were retrieved
transvaginally under ultrasound- guidance. Motile
sperms were isolated by a swim-up or gradient
centrifugation. Ejaculated, testicular biopsy;
cryopreserved ejaculated and cryopreserved testicular
biopsy semen specimens were all included in the
study. Intra Cytoplasmic Sperm Injection (ICSI) was
performed 35 h after oocyte aspiration with the
prepared sperm. Normal fertilization was confirmed
by the presence of two pronuclei and two polar
bodies 1620 h (day1) after Intra Cytoplasmic Sperm
Injection (ICSI). Normally fertilized oocytes
(Zygotes) were spherical and had two polar bodies
and two PNs. PNs had approximately the same size,
centrally positioned in the cytoplasm with two
distinctly clear, visible membranes. The presence of
nucleolar precursor bodies, their number and size
aligned at the PN junction were assessed. On the
same day, early cleavage examination was performed
on the zygotes within 27 hours after Intra
Cytoplasmic Sperm Injection
(ICSI). Embryos displaying two cells at inspection
were designated as 'early cleavage'. The embryos that
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Manjula et al., Int J Med Res health Sci. 2014;3(3):621-626
had not yet cleaved to the 2-cell stage after 27 hours
were designated as 'late cleavage'. Two or three
embryos were transferred on Day2 depending on the
patients age and embryo quality. The embryos that
were not transferred were cryopreserved. The luteal
phase was supported by vaginal supplementation of
progesterone or intramuscular injection of
progesterone.
Pregnancy was determined by a serum human
Chorionic Gonodotropin ( h CG) test 14 days post
transfer. The clinical pregnancy was confirmed by the
presence of an intrauterine gestational sac with fetal
cardiac activity by ultrasound examination at 4 weeks
after embryo transfer. Patients were divided into two
groups. Group I- Embryos which cleaved to two cells
before 27 hours after injection. Group II- Embryos
which cleaved to two cells after 27 hours. The
pregnancy rates were compared between the two
groups.
Statistical analysis: The collected data were
analysed with SPSS 16.0 version. To describe about
the data descriptive statistics frequency analysis,
percentage analysis, means and standard deviation
were used. For the numerical data nonparametric
MannWhitney U test was used to find the
significance. To find the significance in categorical
data Chi - Square test was used. In all the statistical
tools, the probability value of p<0.05 was considered
as significant level.
RESULTS
A total of 154 patients were analyzed. The baseline
characteristics were shown in (Table1). About 65% of
the patients were in the age group of 26-35 years.
Early cleavage was observed in 98 patients (63.64 %)
and late cleavage was observed in 56 patients
(36.36%) (Table 1). In our study 71.78% of MII
oocytes retrieved in the early cleavage and 28.22% in
the late cleavage group (P<0.0001) (Fig 1). The
results showed that the good quality embryos were
significantly higher in the early cleavage group than
in the late cleavage group (78.30% vs. 21.70%)
(P<0.0001) (Fig 2). The transfer of early cleavage
embryos resulted in a significantly higher pregnancy
rate than those with late cleavage embryos. (66.33%
vs. 39.29%) (p<0.001) (Fig 3) The clinical pregnancy
was confirmed in 60.20% in the early cleavage group
and 35.71% in the late cleavage group which was
statistically significant p <0.001. (Fig 4)
Table 1: Baseline Characteristics
Parameters Early Cleavage
(Group I)
Late Cleavage
(Group II)
Mean Age
(years) 31 4 32 5
Mean Duration of
Infertility (years) 7 4 8 5
No of oocytes
retrieved 15 8 11 8
No of MII
Oocytes retrieved 12 7 8 7
No of Grade I
Embryos 7 5 4 4
No of patients 98 (63.64 %) 56 (36.36%)
Fig 1: Comparison of early cleavage and late
cleavage with No. of MII oocytes retieved
Fig 2: Comparison of early cleavage and late
cleavage with good quality embryo
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Manjula et al., Int J Med Res health Sci. 2014;3(3):621-626
had not yet cleaved to the 2-cell stage after 27 hours
were designated as 'late cleavage'. Two or three
embryos were transferred on Day2 depending on the
patients age and embryo quality. The embryos that
were not transferred were cryopreserved. The luteal
phase was supported by vaginal supplementation of
progesterone or intramuscular injection of
progesterone.
Pregnancy was determined by a serum human
Chorionic Gonodotropin ( h CG) test 14 days post
transfer. The clinical pregnancy was confirmed by the
presence of an intrauterine gestational sac with fetal
cardiac activity by ultrasound examination at 4 weeks
after embryo transfer. Patients were divided into two
groups. Group I- Embryos which cleaved to two cells
before 27 hours after injection. Group II- Embryos
which cleaved to two cells after 27 hours. The
pregnancy rates were compared between the two
groups.
Statistical analysis: The collected data were
analysed with SPSS 16.0 version. To describe about
the data descriptive statistics frequency analysis,
percentage analysis, means and standard deviation
were used. For the numerical data nonparametric
MannWhitney U test was used to find the
significance. To find the significance in categorical
data Chi - Square test was used. In all the statistical
tools, the probability value of p<0.05 was considered
as significant level.
RESULTS
A total of 154 patients were analyzed. The baseline
characteristics were shown in (Table1). About 65% of
the patients were in the age group of 26-35 years.
Early cleavage was observed in 98 patients (63.64 %)
and late cleavage was observed in 56 patients
(36.36%) (Table 1). In our study 71.78% of MII
oocytes retrieved in the early cleavage and 28.22% in
the late cleavage group (P<0.0001) (Fig 1). The
results showed that the good quality embryos were
significantly higher in the early cleavage group than
in the late cleavage group (78.30% vs. 21.70%)
(P<0.0001) (Fig 2). The transfer of early cleavage
embryos resulted in a significantly higher pregnancy
rate than those with late cleavage embryos. (66.33%
vs. 39.29%) (p<0.001) (Fig 3) The clinical pregnancy
was confirmed in 60.20% in the early cleavage group
and 35.71% in the late cleavage group which was
statistically significant p <0.001. (Fig 4)
Table 1: Baseline Characteristics
Parameters Early Cleavage
(Group I)
Late Cleavage
(Group II)
Mean Age
(years) 31 4 32 5
Mean Duration of
Infertility (years) 7 4 8 5
No of oocytes
retrieved 15 8 11 8
No of MII
Oocytes retrieved 12 7 8 7
No of Grade I
Embryos 7 5 4 4
No of patients 98 (63.64 %) 56 (36.36%)
Fig 1: Comparison of early cleavage and late
cleavage with No. of MII oocytes retieved
Fig 2: Comparison of early cleavage and late
cleavage with good quality embryo
623
Manjula et al., Int J Med Res health Sci. 2014;3(3):621-626
had not yet cleaved to the 2-cell stage after 27 hours
were designated as 'late cleavage'. Two or three
embryos were transferred on Day2 depending on the
patients age and embryo quality. The embryos that
were not transferred were cryopreserved. The luteal
phase was supported by vaginal supplementation of
progesterone or intramuscular injection of
progesterone.
Pregnancy was determined by a serum human
Chorionic Gonodotropin ( h CG) test 14 days post
transfer. The clinical pregnancy was confirmed by the
presence of an intrauterine gestational sac with fetal
cardiac activity by ultrasound examination at 4 weeks
after embryo transfer. Patients were divided into two
groups. Group I- Embryos which cleaved to two cells
before 27 hours after injection. Group II- Embryos
which cleaved to two cells after 27 hours. The
pregnancy rates were compared between the two
groups.
Statistical analysis: The collected data were
analysed with SPSS 16.0 version. To describe about
the data descriptive statistics frequency analysis,
percentage analysis, means and standard deviation
were used. For the numerical data nonparametric
MannWhitney U test was used to find the
significance. To find the significance in categorical
data Chi - Square test was used. In all the statistical
tools, the probability value of p<0.05 was considered
as significant level.
RESULTS
A total of 154 patients were analyzed. The baseline
characteristics were shown in (Table1). About 65% of
the patients were in the age group of 26-35 years.
Early cleavage was observed in 98 patients (63.64 %)
and late cleavage was observed in 56 patients
(36.36%) (Table 1). In our study 71.78% of MII
oocytes retrieved in the early cleavage and 28.22% in
the late cleavage group (P<0.0001) (Fig 1). The
results showed that the good quality embryos were
significantly higher in the early cleavage group than
in the late cleavage group (78.30% vs. 21.70%)
(P<0.0001) (Fig 2). The transfer of early cleavage
embryos resulted in a significantly higher pregnancy
rate than those with late cleavage embryos. (66.33%
vs. 39.29%) (p<0.001) (Fig 3) The clinical pregnancy
was confirmed in 60.20% in the early cleavage group
and 35.71% in the late cleavage group which was
statistically significant p <0.001. (Fig 4)
Table 1: Baseline Characteristics
Parameters Early Cleavage
(Group I)
Late Cleavage
(Group II)
Mean Age
(years) 31 4 32 5
Mean Duration of
Infertility (years) 7 4 8 5
No of oocytes
retrieved 15 8 11 8
No of MII
Oocytes retrieved 12 7 8 7
No of Grade I
Embryos 7 5 4 4
No of patients 98 (63.64 %) 56 (36.36%)
Fig 1: Comparison of early cleavage and late
cleavage with No. of MII oocytes retieved
Fig 2: Comparison of early cleavage and late
cleavage with good quality embryo
624
Manjula et al., Int J Med Res health Sci. 2014;3(3):621-626
Fig 3: Pregnancy rate in early cleavage and late
cleavage group.
Fig 4: The clinical pregnancy rate in early
cleavage and late cleavage group.
DISCUSSION
In the present study , the effect of the early cleavage
of transferred embryos were evaluated aiming to
increase the pregnancy rate and prevent multiple
pregnancies.In the previous studies, transfer of more
embryos has been the approach to increase pregnancy
rates. However, this also increases the multiple
pregnancy with increased medical risks, cost to the
patient and society
1
. Some authors they found that the
selection of embryos at the time of transfer based on
cell number and quality was more benefit.
4- 6
Good
quality embryos must exhibit appropriate kinetics and
synchrony of cell division
10
. In normal-developing
embryos, cell division occurs in every 1820 h. If
we observed a group of four cell embryos at the time
of transfer, it was not possible to distinguish which
has just cleaved to the four cells or which has been at
the four cells for several hours. Hence, selection of
the more advanced embryo was difficult to assess.
4- 6
Cleavage stage embryos range from the 2-cell to the
compacted morula composed of 816 cells.
10
The types of cleavage on day 3 embryos were
classified according to blastomere number as rapid
cleavage (>9 cells), normal cleavage (7-8 cells), or
slow cleavage (<6 cells). On the basis of quality of
embryos on day 3 were classified as good embryos
(<20 % fragmentation and an even blastomere) or
poor embryos (>20% fragmentation and an uneven
blastomere)
.15
Embryos which are dividing either too
slow or too fast may have metabolic and/or
chromosomal defects.
10
Recent time-lapse studies
found that not only the timing of cleavage, but also
the time between each cell division is also important.
In cleavage stage embryos if all blastomeres divide in
exact synchrony, only 2-, 4- or 8-cell embryos would
be observed. However, we frequently observed 3-, 5-,
6-, 7- or 9-cell embryos, which is an indication of
asynchronous development of embryos.
10
Some
authors found that implantation increased fourfold in
embryos with low glycolytic activity.
1
Selection of
embryos by pronuclear assessment has some
drawbacks. Accurate pronuclear assessment needs
considerable manipulation of zygotes outside the
incubator
8
. According to some studies the blastocyst
transfer has been successfully used as a means of
embryo selection. It is not in routine use because of
lack of experience in prolonged embryo culture, as
well as anxieties about those patients whose embryos
arrest before blastocyst formation
8
. Although several
factors influence the result of an assisted reproductive
technology (e.g. stimulation response, endometrial
receptivity, oocyte maturity, culture conditions),
embryo quality is also one of the most important
factors
9
. More recently they showed the assessment
of the time of cleavage to the two cell stage was a
reliable parameter for the selection of viable embryos
with the highest capability of implantation and
successful pregnancy after transfer
8
. The early
cleaving embryos give rise to better embryo quality
due to intrinsic, unknown factor within the oocyte.
This unknown factor improves the viability of
embryos.
1,4,7
One of the possible important
mechanisms of delaying cleavage may be delayed
fertilization. Oocyte immaturity is the most important
factor responsible for delayed fertilization. Since only
metaphase II oocytes were injected in Intra
Cytoplasmic Sperm Injection (ICSI) procedure, the
possibility of oocyte immaturity was eliminated in the
present study. Although there may a difference in
fertilization time between In vitro fertilization (IVF)
624
Manjula et al., Int J Med Res health Sci. 2014;3(3):621-626
Fig 3: Pregnancy rate in early cleavage and late
cleavage group.
Fig 4: The clinical pregnancy rate in early
cleavage and late cleavage group.
DISCUSSION
In the present study , the effect of the early cleavage
of transferred embryos were evaluated aiming to
increase the pregnancy rate and prevent multiple
pregnancies.In the previous studies, transfer of more
embryos has been the approach to increase pregnancy
rates. However, this also increases the multiple
pregnancy with increased medical risks, cost to the
patient and society
1
. Some authors they found that the
selection of embryos at the time of transfer based on
cell number and quality was more benefit.
4- 6
Good
quality embryos must exhibit appropriate kinetics and
synchrony of cell division
10
. In normal-developing
embryos, cell division occurs in every 1820 h. If
we observed a group of four cell embryos at the time
of transfer, it was not possible to distinguish which
has just cleaved to the four cells or which has been at
the four cells for several hours. Hence, selection of
the more advanced embryo was difficult to assess.
4- 6
Cleavage stage embryos range from the 2-cell to the
compacted morula composed of 816 cells.
10
The types of cleavage on day 3 embryos were
classified according to blastomere number as rapid
cleavage (>9 cells), normal cleavage (7-8 cells), or
slow cleavage (<6 cells). On the basis of quality of
embryos on day 3 were classified as good embryos
(<20 % fragmentation and an even blastomere) or
poor embryos (>20% fragmentation and an uneven
blastomere)
.15
Embryos which are dividing either too
slow or too fast may have metabolic and/or
chromosomal defects.
10
Recent time-lapse studies
found that not only the timing of cleavage, but also
the time between each cell division is also important.
In cleavage stage embryos if all blastomeres divide in
exact synchrony, only 2-, 4- or 8-cell embryos would
be observed. However, we frequently observed 3-, 5-,
6-, 7- or 9-cell embryos, which is an indication of
asynchronous development of embryos.
10
Some
authors found that implantation increased fourfold in
embryos with low glycolytic activity.
1
Selection of
embryos by pronuclear assessment has some
drawbacks. Accurate pronuclear assessment needs
considerable manipulation of zygotes outside the
incubator
8
. According to some studies the blastocyst
transfer has been successfully used as a means of
embryo selection. It is not in routine use because of
lack of experience in prolonged embryo culture, as
well as anxieties about those patients whose embryos
arrest before blastocyst formation
8
. Although several
factors influence the result of an assisted reproductive
technology (e.g. stimulation response, endometrial
receptivity, oocyte maturity, culture conditions),
embryo quality is also one of the most important
factors
9
. More recently they showed the assessment
of the time of cleavage to the two cell stage was a
reliable parameter for the selection of viable embryos
with the highest capability of implantation and
successful pregnancy after transfer
8
. The early
cleaving embryos give rise to better embryo quality
due to intrinsic, unknown factor within the oocyte.
This unknown factor improves the viability of
embryos.
1,4,7
One of the possible important
mechanisms of delaying cleavage may be delayed
fertilization. Oocyte immaturity is the most important
factor responsible for delayed fertilization. Since only
metaphase II oocytes were injected in Intra
Cytoplasmic Sperm Injection (ICSI) procedure, the
possibility of oocyte immaturity was eliminated in the
present study. Although there may a difference in
fertilization time between In vitro fertilization (IVF)
624
Manjula et al., Int J Med Res health Sci. 2014;3(3):621-626
Fig 3: Pregnancy rate in early cleavage and late
cleavage group.
Fig 4: The clinical pregnancy rate in early
cleavage and late cleavage group.
DISCUSSION
In the present study , the effect of the early cleavage
of transferred embryos were evaluated aiming to
increase the pregnancy rate and prevent multiple
pregnancies.In the previous studies, transfer of more
embryos has been the approach to increase pregnancy
rates. However, this also increases the multiple
pregnancy with increased medical risks, cost to the
patient and society
1
. Some authors they found that the
selection of embryos at the time of transfer based on
cell number and quality was more benefit.
4- 6
Good
quality embryos must exhibit appropriate kinetics and
synchrony of cell division
10
. In normal-developing
embryos, cell division occurs in every 1820 h. If
we observed a group of four cell embryos at the time
of transfer, it was not possible to distinguish which
has just cleaved to the four cells or which has been at
the four cells for several hours. Hence, selection of
the more advanced embryo was difficult to assess.
4- 6
Cleavage stage embryos range from the 2-cell to the
compacted morula composed of 816 cells.
10
The types of cleavage on day 3 embryos were
classified according to blastomere number as rapid
cleavage (>9 cells), normal cleavage (7-8 cells), or
slow cleavage (<6 cells). On the basis of quality of
embryos on day 3 were classified as good embryos
(<20 % fragmentation and an even blastomere) or
poor embryos (>20% fragmentation and an uneven
blastomere)
.15
Embryos which are dividing either too
slow or too fast may have metabolic and/or
chromosomal defects.
10
Recent time-lapse studies
found that not only the timing of cleavage, but also
the time between each cell division is also important.
In cleavage stage embryos if all blastomeres divide in
exact synchrony, only 2-, 4- or 8-cell embryos would
be observed. However, we frequently observed 3-, 5-,
6-, 7- or 9-cell embryos, which is an indication of
asynchronous development of embryos.
10
Some
authors found that implantation increased fourfold in
embryos with low glycolytic activity.
1
Selection of
embryos by pronuclear assessment has some
drawbacks. Accurate pronuclear assessment needs
considerable manipulation of zygotes outside the
incubator
8
. According to some studies the blastocyst
transfer has been successfully used as a means of
embryo selection. It is not in routine use because of
lack of experience in prolonged embryo culture, as
well as anxieties about those patients whose embryos
arrest before blastocyst formation
8
. Although several
factors influence the result of an assisted reproductive
technology (e.g. stimulation response, endometrial
receptivity, oocyte maturity, culture conditions),
embryo quality is also one of the most important
factors
9
. More recently they showed the assessment
of the time of cleavage to the two cell stage was a
reliable parameter for the selection of viable embryos
with the highest capability of implantation and
successful pregnancy after transfer
8
. The early
cleaving embryos give rise to better embryo quality
due to intrinsic, unknown factor within the oocyte.
This unknown factor improves the viability of
embryos.
1,4,7
One of the possible important
mechanisms of delaying cleavage may be delayed
fertilization. Oocyte immaturity is the most important
factor responsible for delayed fertilization. Since only
metaphase II oocytes were injected in Intra
Cytoplasmic Sperm Injection (ICSI) procedure, the
possibility of oocyte immaturity was eliminated in the
present study. Although there may a difference in
fertilization time between In vitro fertilization (IVF)
625
Manjula et al., Int J Med Res health Sci. 2014;3(3):621-626
and Intra Cytoplasmic Sperm Injection (ICSI), there
seems to be no correlation between the time of
fertilization and cleavage
1
. Semen parameters may
also affect fertilization and cleavage time.
1
Different
morphological abnormalities of the oocytes caused by
the reduced blood supply of the follicle during
stimulation resulting in oxygen deficiency leads to
reduced viability.
3
In our present study, we observed
that a significantly higher number of early cleaving
embryos became good quality embryos (Fig 2) and
indicating an indirect way of selecting the best quality
viable embryos. Several other studies have also
strongly supported this approach and showed the
value of early cleavage as a marker of embryo
viability.
5,7,11
In the recent study they found
significantly more embryos in the best category
showing signs of early cleavage (51.1%) compared
with the Non-early cleavage (38.7%)
.13
A number of
reports have been published and found that the
transfer of an early cleavage embryo resulted in a
significantly higher pregnancy rate.
5, 11, 12
The results
from our study were similar to these reported studies
(Fig 3). We did not transfer mixed early cleavage
embryos and late cleavage embryos together in order
to evaluate the outcome of early cleavage clearly.
One of the recent studies supported this approach
15
.
Many articles in the literature deal with the
importance of early cleavage to improve embryo
selection before transfer and help to reduce multiple
pregnancies
13
. In the previous study, they found the
clinical pregnancy rate was significantly higher in the
early cleavage group than in late cleavage group
14
. In
the present study, we investigated that a significantly
higher pregnancy rate and the clinical pregnancy rates
when early cleaved embryos were transferred
compared with late cleavage embryos. (66.33 versus
39.29% and 60.20 versus 35.71% respectively). (Fig
3 and Fig 4).Our data strongly support the previously
published studies dealing with early cleavage.
5, 11, 14
So from our study the assessment of early cleavage
seems to be a simple, easy, non invasive, effective
and valuable method of assessing the embryo
viability with higher clinical pregnancy rate.
CONCLUSION
In conclusion the assessment of early cleavage is a
strong predictor of embryo quality and can predict
ICSI outcome. Therefore, early cleavage criteria can
be included for selecting embryos with a higher
potential of implantation and successful pregnancy
while avoiding multiple pregnancies.
ACKNOWLEDGEMENTS
Sincere thanks to the Faculty and staffs of the Dept of
Reproductive Medicine, Sri Ramachandra University,
Chennai, India. Special thanks to Dr. P.
Venkatachalam, Dept of Human Genetics, Sri
Ramachandra University.
Conflict of interest: None
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