VKVAMERICANVKVAMERICAN Micromanuplation Techniques (ICSI, AH, PGD..) BASAK BALABAN, BSc American Hospital of Istanbul Assisted Reproduction Unit AMERICANHOSPITAL

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Micromanuplation Techniques

(ICSI, AH, PGD..)

Micromanuplation Techniques

(ICSI, AH, PGD..)BASAK BALABAN, BScBASAK BALABAN, BSc

American Hospital of IstanbulAmerican Hospital of Istanbul

Assisted Reproduction UnitAssisted Reproduction Unit

AMERICANAMERICANHOSPITALHOSPITAL

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Evolution of ICSI Evolution of ICSI IVFIVF- Low fertilization & CPR for male factor - Low fertilization & CPR for male factor

subfertilitysubfertility Late 1980s.....Late 1980s..... PZD PZD (Partial zona dissection), (Partial zona dissection), ZDZD (zona (zona

drillling): male factor subfertilitydrillling): male factor subfertility SUZISUZI (Subzonal microinjection of (Subzonal microinjection of

spermatozoa into the PVS): male factor spermatozoa into the PVS): male factor subfertilitysubfertility

1992.......1992....... ICSIICSI (Intracytoplasmic sperm injection): (Intracytoplasmic sperm injection):

severe male factor infertilitysevere male factor infertility

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Evolution of ICSIEvolution of ICSI ICSI ICSI Intracytoplasmic injection of one Intracytoplasmic injection of one

motile spermatozoon for each Metaphase motile spermatozoon for each Metaphase II oocyteII oocyte

**Improved modifications into the procedure**Improved modifications into the procedure

Reducing the concentration of hyaluronidase used for Reducing the concentration of hyaluronidase used for cumulus-corona radiata removalcumulus-corona radiata removal

Selecting a motile spermatozoon that was immobilized prior Selecting a motile spermatozoon that was immobilized prior to the injection to the injection

Aspiration of cytoplasm to ensure rapture of the oocyte Aspiration of cytoplasm to ensure rapture of the oocyte membranemembrane

Joris et al., HR 1998

Equipment needed for ICSI MICROMANUPLATOR


Joysticks,motor controls

Joystick, heater

Equipment needed for ICSI


Indications of ICSI

ESHRE Capri Workshop Group, HR 2007

Distribution of ICSI applications


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Outcome of ICSIOutcome of ICSI Perinatal Risks:Perinatal Risks: IVF& ICSI outcomes are IVF& ICSI outcomes are

similar (Neri 2006)similar (Neri 2006) Twins & singletons born after IVF & ICSI Twins & singletons born after IVF & ICSI

have a 2-fold increased risk for perinatal have a 2-fold increased risk for perinatal mortality, preterm delivery and low birth mortality, preterm delivery and low birth weight and a 3-fold risk for very low weight and a 3-fold risk for very low birthweight (Helmerhorst, Jackson 2004). birthweight (Helmerhorst, Jackson 2004). Vanishing twins after MET, or infertility Vanishing twins after MET, or infertility itself can be the cause? (Pinborg 2005, itself can be the cause? (Pinborg 2005, Schieve 2002). Schieve 2002).


Congenital Abnormalities

IVF&ICSI similar malformation rates(Hansen, Lie 2005), but higher when compared with general population (Katalinic 2004, Belva 2007)


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Outcome of ICSIOutcome of ICSI Long-term follow up:Long-term follow up: Singleton IVF&ICSI 5 year- Singleton IVF&ICSI 5 year-

olds are comparable with their naturally olds are comparable with their naturally concieved peers. In 150 8-year old ICSI children, concieved peers. In 150 8-year old ICSI children, pubertal staging,neurological status, need for pubertal staging,neurological status, need for more remedial therapy, surgery or hospitalization more remedial therapy, surgery or hospitalization were comparable with 147 matched were comparable with 147 matched spontaneously concieved controls(Belva 2007). spontaneously concieved controls(Belva 2007). However considering higher risk of congenital However considering higher risk of congenital (male-urogenital) anomalies in relation to sperm (male-urogenital) anomalies in relation to sperm quality and source, particular interest should be quality and source, particular interest should be given to the use of sperm from testicular biopsy given to the use of sperm from testicular biopsy with non-obstructive pathology(Wennerholm with non-obstructive pathology(Wennerholm 2006) 2006)


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Outcome of ICSIOutcome of ICSI Imprinting diseases:Imprinting diseases: Reports of Angelman and Reports of Angelman and

Beckwith-Wiedeman syndromes in children born Beckwith-Wiedeman syndromes in children born after IVF&ICSI suggest a possible risk of in-vitro after IVF&ICSI suggest a possible risk of in-vitro culture procedures(Maher 2003), and hormone culture procedures(Maher 2003), and hormone stimulation(mild COH suggested). A systematic stimulation(mild COH suggested). A systematic survey aimed at those syndromes and defined survey aimed at those syndromes and defined phenotypes linked to imprinting genes may phenotypes linked to imprinting genes may clarify whether epigenetic anomalies play a role clarify whether epigenetic anomalies play a role in ART(or subfertility) more often than in general in ART(or subfertility) more often than in general population(Ludwig 2005)population(Ludwig 2005)


Natural cycle results taken from National Vital Stat. Report 2002,2004

Genetic and Epigenetic Charecteristics of ICSI children

Palermo et al.,RBM Online 2008

Obstetric outcome: 229 ICSI, 194 naturally conceived singleton PR were age matched(37.8)No diff. in: Uncomplicated vaginal, caesarean delivery,Gestational age, frequency of low birth rate, malformationsLong term (5 years) physical and psychological outcome: No diff. in the full scale IQ assessment, general health e.g. Common diseases, chronic illnesses, surgical intervention, physicaldevelopment

Genetic and Epigenetic Charecteristics of ICSI children

Palermo et al.,RBM Online 2008

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ASSISTED HATCHING The older patient, certain embryos ,

thawed embryos, or everyone ?

ASSISTED HATCHING The older patient, certain embryos ,

thawed embryos, or everyone ?

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WHY PERFORM ASSISTED HATCHING ?

WHY PERFORM ASSISTED HATCHING ?

The ratio of lysin production to ZP thickness could The ratio of lysin production to ZP thickness could determine whether the embryo will lyse the zona and determine whether the embryo will lyse the zona and perform the ***HATCHING****perform the ***HATCHING****procedureprocedure

Suboptimal culture conditions and or advanced maternal Suboptimal culture conditions and or advanced maternal age may cause deficiencies in lysin secretion which could age may cause deficiencies in lysin secretion which could impairimpair effective effective hatchinghatching

The trophectoderm of some embryos may not be able to The trophectoderm of some embryos may not be able to secrete the hatching factor and lysin production could be secrete the hatching factor and lysin production could be influenced by influenced by thethe patient’s age patient’s age (Cohen J. 1992)(Cohen J. 1992)

Uterin lysins action could also be impaired in some patientsUterin lysins action could also be impaired in some patients (Mandelbaum J.1996 )(Mandelbaum J.1996 )

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INDICATIONS FOR ASSISTED HATCHING

INDICATIONS FOR ASSISTED HATCHING

AHAH has been proposed as a method for improving has been proposed as a method for improving the capacity of the embryos to implant by the capacity of the embryos to implant by facilitating facilitating the the hatching processhatching process (Cohen 1992 )(Cohen 1992 )

WomenWomen/embryos /embryos with poor prognosiswith poor prognosis

** Advanced age Advanced age

* Thick ZP (more then 15 microns-Cohen J. 1992 )* Thick ZP (more then 15 microns-Cohen J. 1992 )

* Repeated implantation patients* Repeated implantation patients

* Embryos with extensive fragmentation* Embryos with extensive fragmentation

* Frozen-thawed embryos with cell death* Frozen-thawed embryos with cell death

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WHEN TO PERFORM ASSISTED HATCHING ?WHEN TO PERFORM ASSISTED HATCHING ?

When breaches are made in the ZP of early cleavage IVF When breaches are made in the ZP of early cleavage IVF embryos,embryos, embryonic cell loss may occur through the embryonic cell loss may occur through the zona as a result of uterine contractions after replacement zona as a result of uterine contractions after replacement of the embryosof the embryos

It is advisable to manIt is advisable to maniippuulate the embryos for AH after the late the embryos for AH after the adherence between blastomeres has increased just adherence between blastomeres has increased just before compactionbefore compaction (6-8 cell stage) (Dale,1991)(6-8 cell stage) (Dale,1991)

It is very critical to achieve zona slitting or drilling with It is very critical to achieve zona slitting or drilling with rotating the embryo until the area where the largest PVS rotating the embryo until the area where the largest PVS is visible in order not to give any harm to blastomeres is visible in order not to give any harm to blastomeres near the zona bordernear the zona border

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METHODS OF ASSISTED HATCHING

METHODS OF ASSISTED HATCHING

Mechanical (partial zona dissection )Mechanical (partial zona dissection ) Chemical (Acid Thyrode, Pronase)Chemical (Acid Thyrode, Pronase) Laser assisted hatching Laser assisted hatching

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PARTIAL ZONA DISSECTIONPARTIAL ZONA DISSECTION

The zona pellucida is pierced with a very thin The zona pellucida is pierced with a very thin glass microneedle through both sides,glass microneedle through both sides, the the needle tip position being controlled in needle tip position being controlled in perivitelline space by eyeperivitelline space by eye

Then the suction of the holding pipette is Then the suction of the holding pipette is stopped and the holding pipette is rubbed stopped and the holding pipette is rubbed against the trapped area of the zona until this against the trapped area of the zona until this area has been completely abraded.area has been completely abraded.

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THREE DIMENTIONAL PARTIAL ZONA DISSECTION

THREE DIMENTIONAL PARTIAL ZONA DISSECTION

Differs from conventional partial Differs from conventional partial dissection by an additional second dissection by an additional second cut for a cross shaped opening cut for a cross shaped opening rather then a single slit openingrather then a single slit opening

The second cut is made by passing The second cut is made by passing through the ZP under the first slit through the ZP under the first slit opening and ending in the same opening and ending in the same positions as the first cut.positions as the first cut. A cross-A cross-shaped opening can be seen when shaped opening can be seen when rotating the embryo and focusing rotating the embryo and focusing on the surface of ZPon the surface of ZP

Beneficial particularly for PGD and Beneficial particularly for PGD and clinically proved to be safe and clinically proved to be safe and efficient efficient

Cieslak J. F&S 1999.Cieslak J. F&S 1999.

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MethodNo.

cyclesMean

age (y)PR (%)

IR (%)

Multiple PR (%)

Abortion (%)

3-dimensional PZD

188 34.042.0*

17.6 24.0 6.3

Conventional PZD

186 33.833.3*

14.7 35.5 6.5

P = .0834

Clinical outcome of three-dimensional partial zona dissection and conventional partial zona dissection

Cieslak Fertil Steril 1999Cieslak Fertil Steril 1999

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ACID TYRODE’S ASSISTED HATCHING

ACID TYRODE’S ASSISTED HATCHING

The micropipette with acidic The micropipette with acidic Tyrode’s solution is brought Tyrode’s solution is brought close to the ZP and the solution is close to the ZP and the solution is expelled over a small area until expelled over a small area until ZP is dissolved through to the ZP is dissolved through to the insideinside

The embryos have to be rinsed in The embryos have to be rinsed in fresh medium for several times fresh medium for several times after the procedure to avoid after the procedure to avoid acidic solutionacidic solution

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Zona thinning of cleavage stage embryos or total zona removal of blastocysts by pronase

Zona thinning of cleavage stage embryos or total zona removal of blastocysts by pronase

Enzymatic digestion of the Enzymatic digestion of the ZP for blastocyst stage ZP for blastocyst stage embryos first described by embryos first described by Fong (1997)Fong (1997)

Blastocysts transferred to Blastocysts transferred to 10IU/ml pronase solution and 10IU/ml pronase solution and incubated for 1 minute at incubated for 1 minute at 3737ooC and 5 % CO2 for initial C and 5 % CO2 for initial stretching and softening of stretching and softening of the ZP the ZP

After the observation of zona After the observation of zona expansion and the increase expansion and the increase in PVS they were transferred in PVS they were transferred to culture media and washed to culture media and washed several times just before the several times just before the complete dissappearance of complete dissappearance of the zonathe zona Fong Fong et alet al. HR. HR 19971997

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Zona manipulated blastocyst transfers on day 5Zona manipulated blastocyst transfers on day 5ParameterParameter OutcomeOutcome

No. ET cyclesNo. ET cycles 1919

Age (years)Age (years) 32,632,6

No. attemptsNo. attempts 2,12,1

No. M-II oocytesNo. M-II oocytes 11,911,9

No. Blastocysts transferredNo. Blastocysts transferred 2,52,5

Blastulation rateBlastulation rate 68 %68 %

Clinical pregnancy rateClinical pregnancy rate 53 %53 %

Implantation rateImplantation rate 33 %33 %

Multiple birthsMultiple births 40 %40 %

Fong et alFong et al.. H HR R 19981998

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ZI Blastocyst Transfer

ZF Blastocyst Transfer

p Value

Mean female Age (y)

31.5 31.8 NS

Duration of infertility (y)

8.0 7.3 NS

# of blastocysts transferred

3.3 3.5 NS

Clinical PR/ET 38.1% 48.7% <0.05

Implantation/ embryo

21.6% 30.8% <0.05

Multiple PR 48.5% 53.9% NS

Urman Urman & Balaban,& Balaban, F F&S &S 20022002

ZONA INTACT VS ZONA FREE BLAST TRANSFERZONA INTACT VS ZONA FREE BLAST TRANSFER

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LASER ASSISTED HATCHINGLASER ASSISTED HATCHING

** ** It is important that the It is important that the laser is accurately laser is accurately controlled and produces controlled and produces precise ZP openings precise ZP openings without thermal or without thermal or mutagenic effectsmutagenic effects

Contact lasers Contact lasers Non-contact lasersNon-contact lasers

****Safety and efficacy Safety and efficacy of both systems of both systems have been demonstrated in have been demonstrated in clinical practiceclinical practice

**Laser AH enables a rapid **Laser AH enables a rapid no-touch microdrilling no-touch microdrilling which might be efficient, which might be efficient, precise, safer and precise, safer and chemical free for AHchemical free for AH

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Total LAH

Partial LAH

Quarter LAH

No. 77 158 87

Mean age 37.8 38.9 37.2

Mean no.of ET 2.76 2.70 2.68

PR (%) 14.6* 20.9* 29.0

IR (%) 2.8 9.1 8.1

CPR (%) 5.2 18.3 22.1

Miscarriage rate (%) 49.2 17.6 19.5

A comparison between quarter, partial and total laser assisted hatching in selected infertility patients

Mantoudis et al Hum Reprod 2001Mantoudis et al Hum Reprod 2001P<0.001

PZDAcid

tyrode

Diode laser

Pronase zona

thinningControl

s

No. of ET cycles 239 191 219 145 188

Mean age 34.4 34.6 35.0 34.5 29.8

No. of oocytes retrieved 9,6 9,8 9,5 9,7 12,3

G1 + G2 embryos (%) 57 58.3 58.5 59.0 65

No. of ET 3,8 3,9 4,0 3,7 3,4

IR (%) 18,6 17,4 18,9 19,1 21,6

CPR(%) 49.3 46.0 48.4 46.8 48.4

Balaban et alBalaban et al.. H HRR 2002 2002

A comparison of four different techniques of assisted hatching

Retrospective, selected patients

Feng et al.,F&S 2008 in press

AH results in better CPR and IR

Retrospective, selected group,Laser or AT is superior to PZD

Hseih 2002, Makrakis 2006, Lanzendorf 2007 shows superiority of LAH

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AH for cryo-thawed embryosAH for cryo-thawed embryos

ControlControl AH.AH.%CPR%CPR % IR% IR % Clin. Preg% Clin. Preg % Imp% Imp

Tucker Tucker 19911991

%16%16 %9%9

Hoover Hoover 19951995

Case reportCase report

Check Check 19961996

%15.2%15.2 %5.3%5.3 %30.4%30.4 %13.7%13.7

Tao 1997Tao 1997 Case reportCase report

Gabrielsen HR 2004: AH sig. increased IR (AT)Ng HR 2005: No difference in IR(Laser)Petersen RBM 2006: No difference in CPR&IR (Laser)Sifer HR 2006: No dif.in IR(pronase)Valojerdi F&S 2007: LAH sig.increased CPR&IRGe RBM 2008: LAH sig. İncreases CPRNg 2008: LAH sig.increases IR&OPR

LAH improves CPR&IR in FET

Balaban et al.,HR 2006No dif. in patient,or thawedembryo charecteristics

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PZD 3D-PZD

Laser

Pronase thinning Total ZP removal

Acid Tyrode’s

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Assisted Hatching on assisted conception (IVF&ICSI)(Review)

Assisted Hatching on assisted conception (IVF&ICSI)(Review)

Seif MMW et al., Cochrane Database of Seif MMW et al., Cochrane Database of Systematic Reviews 2006- CD001894Systematic Reviews 2006- CD001894

23 randomised control trials consisting of 2668 women23 randomised control trials consisting of 2668 women reported on 849 pregnancy outcomes, reported on 849 pregnancy outcomes, primary outcomeprimary outcome LBR, LBR, secondarysecondaryoutcomeoutcome CPR, IR,MPR,miscarriage, ectopic p, MZ twinning, congenital & CPR, IR,MPR,miscarriage, ectopic p, MZ twinning, congenital &

chromosomal abn., embryo damage chromosomal abn., embryo damage

CPR

Cochrane review, 2006

1st.attempt:1st.attempt: No dif. No dif.

Repeat attempt:Repeat attempt: Sig. in Sig. in favourof AHfavourof AH

Age:Age: No diff.for <35/>35 No diff.for <35/>35

Prognosis:Prognosis: Sig. improved Sig. improved CPR for good and poor CPR for good and poor prognosis patientsprognosis patients

Live birth rate


1st./repeated attempt:1st./repeated attempt: Nosig. difference Nosig. differenceICSI/IVF: ICSI/IVF: No difference No differenceMethod of AH:Method of AH: No difference No difference Prognosis:Prognosis: No difference No differenceAge:Age: Insufficient data Insufficient data

Miscarriage rate

Cochrane review, 2006No dif. in any subgroups

MPR


No sig. diff. for:No sig. diff. for:1st./repeat attept, prognosis1st./repeat attept, prognosis, , Age:Age: insuffcient datainsuffcient data

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Other secondary outcomesOther secondary outcomes

MZT:MZT:4 trials;4 trials;*Hurst:2/3 for AH- 0/3 in control*Hurst:2/3 for AH- 0/3 in control*Lanzendorf, Ng, Isik: No MZT*Lanzendorf, Ng, Isik: No MZT Ectopic Pregnancy:Ectopic Pregnancy: 3 trials; 3 trials;*Lanzerdorf:1 in control, 0 in AH*Lanzerdorf:1 in control, 0 in AH*Hellebaut, Hurst: 0*Hellebaut, Hurst: 0 Congenital and/or chromosomal abnormalities:Congenital and/or chromosomal abnormalities: 2 2

trials by Lanzendorf and Hurst reported absencetrials by Lanzendorf and Hurst reported absence Embryo damage:Embryo damage: 3 trials: Hurst, Lanzendorf, Stein 3 trials: Hurst, Lanzendorf, Stein

reported absencereported absence Blastocyst development:Blastocyst development: No trials No trials

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Prospective randomised trials published after the cochrane dataProspective randomised trials published after the cochrane data Ma S F&S 2006:Ma S F&S 2006: Similar CPR, sig. higher IR in Similar CPR, sig. higher IR in

woman >35woman >35 Frydman HR 2006:Frydman HR 2006: No dif. in CPR and LBR for No dif. in CPR and LBR for

women >37 and <3PIFwomen >37 and <3PIF Sagoskin F&S 2007:Sagoskin F&S 2007: No dif. in CPR and LBR for No dif. in CPR and LBR for

good prognosis patientsgood prognosis patients Dayal F&S 2007:Dayal F&S 2007: Improved CPR and IR for woman Improved CPR and IR for woman

with 1 PIFwith 1 PIF Valojerdi F&S 2007:Valojerdi F&S 2007: No dif. in CPR and IR for No dif. in CPR and IR for

women >37 and >2 PIFwomen >37 and >2 PIF Ge HS RBM Online 2007:Ge HS RBM Online 2007: No dif. in CPR and IR for No dif. in CPR and IR for

unselected groupsunselected groups

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Preimplantation Genetical Diagnosis/ScreeningPreimplantation Genetical Diagnosis/Screening High risk PGD(PGD):High risk PGD(PGD): Patients of transmitting a Patients of transmitting a

genetic or chromosomal abnormality to their genetic or chromosomal abnormality to their children, which includes single gene children, which includes single gene defects(autosomal recessive/ dominant, X linked defects(autosomal recessive/ dominant, X linked disorders), and chromosomal disorders), and chromosomal abnormalities(translocations, structural abnormalities(translocations, structural aberrations, etc..)aberrations, etc..)

Low risk PGD(PGS):Low risk PGD(PGS): Infertile patients undergoing Infertile patients undergoing IVF with the aim of increasing the IVF PRs.IVF with the aim of increasing the IVF PRs.(Advanced maternal age, RIFs, normal karyotypes (Advanced maternal age, RIFs, normal karyotypes with repeated miscarriages)with repeated miscarriages)

ESHRE PGD Guidelines Thornhill et al.,HR 2005

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Stages of embryo biopsyStages of embryo biopsy Polar body (1st.and/2nd.):Polar body (1st.and/2nd.): 1st.PB removal 36-42hr post- 1st.PB removal 36-42hr post-

HCG injection(Verlinsky 1990), and/ 2nd.PB removal 18-HCG injection(Verlinsky 1990), and/ 2nd.PB removal 18-22hr. Post-insemination22hr. Post-insemination..

** Limitations:** Limitations: Only allows maternally derived chromosomal Only allows maternally derived chromosomal aneuploidies& translocations. Paternal distribution cannnot be aneuploidies& translocations. Paternal distribution cannnot be diagnosed, technically risky if PBs are fragmented)diagnosed, technically risky if PBs are fragmented)

Cleavage stage blastomere biopsy:Cleavage stage blastomere biopsy: Applied on the Applied on the morning of day 3 post insemination(6-8cell stage). It’s morning of day 3 post insemination(6-8cell stage). It’s acceptable to exclude the biopsy of poor quality embryos acceptable to exclude the biopsy of poor quality embryos

** (A single biopsied blastomere don’t represent the actual ** (A single biopsied blastomere don’t represent the actual karyotype.While approx. 30% abnormal embs. are mosaics, karyotype.While approx. 30% abnormal embs. are mosaics, mosaicism alone causes only 5% of diag.errors as in most mosaicism alone causes only 5% of diag.errors as in most mosaics almost all cells are abnormal. Colls, 2007)mosaics almost all cells are abnormal. Colls, 2007)

Blastocyst (trophoectoderm) biopsy:Blastocyst (trophoectoderm) biopsy: On the morning of On the morning of day 5/6 post-inseminationday 5/6 post-insemination. .

** (Clinical application very recent, limited data: De Boer,2004. ** (Clinical application very recent, limited data: De Boer,2004. Appplicability on a large scale needs validation)Appplicability on a large scale needs validation)

ESHRE PGD Guidelines Thornhill et al.,HR 2005PGDIS Guidelines RBM Online 2007

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Recommendations Recommendations Insemination:Insemination: Only ICSI for PCR cases(to eliminate the risk of Only ICSI for PCR cases(to eliminate the risk of

paternal contamination), ICSI & IVF for FISH cases paternal contamination), ICSI & IVF for FISH cases Culture medium:Culture medium: Standard IVF culture medium with single embryo Standard IVF culture medium with single embryo

cultureculture Biopsy medium:Biopsy medium: Calcium, magnesium free medium. Media suppl. Calcium, magnesium free medium. Media suppl.

with sucrose to shrink the cells and allow more space in ZP with sucrose to shrink the cells and allow more space in ZP No.of cells to remove:No.of cells to remove: No concensus.. The decision to remove 1/2 No concensus.. The decision to remove 1/2

cells is based on cell no. and accuracy & reliability of the cells is based on cell no. and accuracy & reliability of the diagnostic test used. If 2 cells are going to be removed, it’s diagnostic test used. If 2 cells are going to be removed, it’s recommended only for embryos recommended only for embryos ≥6 cell embryos. (Goessen et al., ≥6 cell embryos. (Goessen et al., HR 2008 decreased blast. formation, similar LBR. With two cells HR 2008 decreased blast. formation, similar LBR. With two cells removed, efficiency of PCR analysis reduced, although FISH removed, efficiency of PCR analysis reduced, although FISH analysis not effected. De Vos et al., HR 2009 decreased blast. analysis not effected. De Vos et al., HR 2009 decreased blast. formation, and LBR). formation, and LBR).

1st. & 2nd. PB Biopsy

Montag et al., RBM Online 2008

Blastomere biopsy by pushing

Blastomere biopsy by aspiration

Wang et al.,F&S 2008

Trophectoderm biopsy

De boer et al.,F&S 2004

Documents

VKVAMERICANVKVAMERICAN Micromanuplation Techniques (ICSI, AH, PGD..) BASAK BALABAN, BSc American Hospital of Istanbul Assisted Reproduction Unit AMERICANHOSPITAL