Depending on different stimulation protocols and varying patient response, about 70–80% of the oocytes are metaphase II at egg retrieval. When the contribution of the immature oocytes is higher, particularly when over 50%, this is cause of great distress to physicians and patients. In standard in vitro fertilization, the proportion of mature oocytes can be determined only on the day of fertilization assessment, whereas in the case of ICSI this becomes obvious immediately after cumulus removal, allowing insemination of only mature oocytes. In the present study, we aimed to assess the impact of a high proportion of immature oocytes present at retrieval on ICSI outcome. Patients who underwent the ICSI procedure were classified retrospectively according to the proportion of immature oocytes at the time of retrieval. Term outcomes were fertilization, implantation, and pregnancies. Couples treated by ICSI from September 1993 to December 2001 were included in this study. In order to exclude confounding factors related to maternal age or severe male factor, only women ≤35 years of age and only ejaculated spermatozoa were used. Ovarian stimulation was performed with a GnRH-agonist/antagonist and gonadotropins, with oocytes retrieved approximately 36 hours after hCG administration. ICSI was then performed only on MII oocytes in a standard fashion. Fertilization was assessed 16–18 hours after insemination and good quality embryos were transferred to the patients either on day 3 or day 5. Patients were stratified into three groups: with 100% maturation (complete), those with 50% of the oocytes matured (partial), and those with only 30% mature (minimal). A total of 2,368 ICSI cycles using ejaculated spermatozoa were assessed, with a similar maternal age in all groups and an overall average maternal age of 32.1 ± 3 yrs (range 18–35 yrs). The number of cycles for the complete maturation group was 388 (16.4%), for the partial maturation was 116 (4.9%), and for the minimal maturation was 31 (1.3%). The total number of oocytes retrieved was 3,274, 624, and 87, respectively, while the average number of oocytes injected was 8.4, 5.5, and 3.9. The fertilization rates and patterns were not different among the three cohorts, being 73.5, 69.7, and 76.9%, respectively, and the implantation rate was directly related to number of mature oocytes (28.9, 31.8, and 23.8%). Proportional differences were found in the pregnancy (46.4, 50.0, and 29.0%; P < 0.01) and in delivery rates (44.3, 44.8, and 25.8%; P < 0.01). Thus, while the outcomes for the complete and partial maturation gorups were comparable, the minimal maturation group had a lower rate of success. Within the cohort of oocytes retrieved the proportion of those at the MII stage did not affect fertilization outcome as long as at least half of them were mature. Only when ∼33% of mature oocytes was present was when the ICSI outcome compromised. Although the lower number of mature oocytes did not impair quality of any embryos eventually produced as judged by the rates of implantation, this still impairs pregnancy outcome because of a lower number of embryos transferred.
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