Laser Use in Laser Use in ARTART

Aygul Demirol, M.DAygul Demirol, M.D

Medical Director, CLINIC Medical Director, CLINIC Women Health, Infertility Women Health, Infertility

and IVF Centerand IVF Center

Ankara/TurkeyAnkara/Turkey

Laser Use in ARTLaser Use in ART Assisted Hatching Assisted Hatching

((Strohmer,1992;Antinori,1996;Montoidis,2001, Hisieh 2002, Strohmer,1992;Antinori,1996;Montoidis,2001, Hisieh 2002,

Primi 2004)Primi 2004) PGD –Microdissection of ZP with a laser PGD –Microdissection of ZP with a laser

system simlifies subsequent polar body system simlifies subsequent polar body biopsy or removal of blastomersbiopsy or removal of blastomers (Veiga,1997;Boada,1998;Montag,1998, Rienzi 2004, Nagy 2005) (Veiga,1997;Boada,1998;Montag,1998, Rienzi 2004, Nagy 2005)

Defragmantation Defragmantation Necrotic blastomere removalNecrotic blastomere removal Sperm immobilization Sperm immobilization (Tadir,1989, Ebner 2001)(Tadir,1989, Ebner 2001)

Laser Assisted ICSILaser Assisted ICSI( Nagy,2001;Abdelmassih,2002, ( Nagy,2001;Abdelmassih,2002, Rienzi 2004, Demirol 2006)Rienzi 2004, Demirol 2006)

The introduction of assisted hatching by

J. Cohen (HR 1990) offered an additional tool for assisting

implantation in patients undergoing ART

Assisted Hatching (AH)

Different Techniques for Different Techniques for Assisted HatchingAssisted Hatching

MechanicalMechanical Acid Tyrode Acid Tyrode Thinning of zona by proteaseThinning of zona by protease LaserLaser

Laser Use in Assisted Laser Use in Assisted HatchingHatching

Mechanical and chemical Mechanical and chemical techniques might have minimal techniques might have minimal adverse effects on embryos adverse effects on embryos (injury to the embryos??)(injury to the embryos??)

Rapid, no-touch microdrilling, Rapid, no-touch microdrilling, efficient, precise, safer and efficient, precise, safer and chemical freechemical free

Laser Assisted HatchingLaser Assisted Hatching

Routine Laser AH results significantly Routine Laser AH results significantly increased clinical pregnancy rates increased clinical pregnancy rates (Ali (Ali et al.,J Assist Rep Genet,2003)et al.,J Assist Rep Genet,2003)

Selective assisted hacthing using four Selective assisted hacthing using four different tecniques yields similar different tecniques yields similar implantation and pregnancy rates implantation and pregnancy rates ((Balaban et al.,HR,2002)Balaban et al.,HR,2002)

Laser AH did not improve the Laser AH did not improve the pregnancy rate and implantation rate pregnancy rate and implantation rate of frozen thawed embryo transfer of frozen thawed embryo transfer cycles cycles ( Ng et al. HR,2005)( Ng et al. HR,2005)

Laser Assisted HatchingLaser Assisted Hatching

LA hatching of embryos is more effective LA hatching of embryos is more effective than the chemical method in enhancing than the chemical method in enhancing the IR and PR of women with advancing the IR and PR of women with advancing age. 1.48 non-touch diode laser is easier, age. 1.48 non-touch diode laser is easier, faster and safe faster and safe

(Montag et al., CMJ;1999,Hsieh et al.,FS;2002)(Montag et al., CMJ;1999,Hsieh et al.,FS;2002)

No increase in the incidence of No increase in the incidence of chromosomal aberrations and congenital chromosomal aberrations and congenital abnormalities in 134 chidren born after abnormalities in 134 chidren born after using this technique using this technique (Kanyo and Konc,Eur J Ob (Kanyo and Konc,Eur J Ob Gyn,2003)Gyn,2003)

Clinical pregnancy rates arising from Clinical pregnancy rates arising from quarter LAH is higher in comparision quarter LAH is higher in comparision with partial and total LAH with partial and total LAH (Mantoudis;HR,2001) (Mantoudis;HR,2001)

Laser Assisted Hatching vs Laser Assisted Hatching vs Chemical Assisted Hatching: Chemical Assisted Hatching:

prospective studyprospective study

601 embryos from 141 patients aged 601 embryos from 141 patients aged ≥ 38 yrs, first IVF cycle≥ 38 yrs, first IVF cycle

85 patients in laser group and 56 85 patients in laser group and 56 patients in chemical grouppatients in chemical group

Laser assisted hatching using 1.48 Laser assisted hatching using 1.48 µµm non-contact diado laserm non-contact diado laser

Chemical assisted hatching using Chemical assisted hatching using acid Tyrode’s solutionacid Tyrode’s solution

Hsieh et al., 2002, Fertil Steril 2002; 78: 179-182

Hsieh et al., 2002, Fertil Steril 2002; 78: 179-182

Balaban et al. 2002, Hum Reprod; 17: 1239-1243

H. Sallam et al, 2003, meta analysis

F&S 2007

F&S 2007

Comparison of quarter, partial and total laser AH in selected infertility patients

Different types of laser AH

Mantoudis 2001, HR

Mantoudis et al, 2001 Hum Reprod; 16: 2182-2186

Mantoudis et al, 2001 Hum Reprod; 16: 2182-2186

Cochrane Database Syst Rev.

2006 Jan 25;(1):CD001894.

Clinical pregnancy rate per woman

Twenty-four trials reported clinical pregnancy data, including 954 clinical pregnancies in 2889 women. The odds ratio for clinical pregnancy per woman randomised was 1.29 (95% CI 1.10 to 1.52), significantly in favour of assisted hatching (p<0.001)

Few trials reported live birth data, with data available from only six of the 23 trials. Overall, 163 live birth events were reported (i.e. not includng individual births from multiples) There was no evidence of a significant difference between the odds of a live birth in women who underwent assisted hatching compared with those in the control group (random effects odds ratio 1.19, 95% CI 0.81 to 73)

Cochrane Database Syst Rev. 2006 Jan 25;(1):CD001894

Live birth rate

F&S 2007

F&S 2007

Laser Assisted AHALaser Assisted AHA

Laser Assisted Zona Drilling Laser Assisted Zona Drilling for PGDfor PGD

Procedure makes polar body biopsy more Procedure makes polar body biopsy more accurate and effective accurate and effective (Montag et al.,FS;1998)(Montag et al.,FS;1998)

Sucessful outcomes demonstrate the Sucessful outcomes demonstrate the efficacy and safety of the laser assisted efficacy and safety of the laser assisted embryo biopy to facilitate PGD embryo biopy to facilitate PGD (Han et (Han et al.,FS;2003)al.,FS;2003)

The use of laser in cases of PGD is an The use of laser in cases of PGD is an easier procedure and results more intact easier procedure and results more intact blastomers in comparison with using acid blastomers in comparison with using acid Tyrode medium.Since similar pregnancy Tyrode medium.Since similar pregnancy rates are obtained ,it is adventageous to rates are obtained ,it is adventageous to use laser for zona drilling use laser for zona drilling

(Joris et al.,HR;2003)(Joris et al.,HR;2003)

Comparison of the Results of Human Comparison of the Results of Human Embryo Biopsy and Outcome of PGD Embryo Biopsy and Outcome of PGD

After Zona Drilling Using Acid Tyrode After Zona Drilling Using Acid Tyrode Medium or a LaserMedium or a Laser

Zona pellucida opennig with AT or Zona pellucida opennig with AT or Laser for Laser for PGD;Results of embryo biopsy and PGD;Results of embryo biopsy and PGD in two periods comparedPGD in two periods compared

Fewer blastocyts were intact with ATD 95.2% Fewer blastocyts were intact with ATD 95.2% vs 98.3%vs 98.3%

Ongoing PR and ongoing IR did not differOngoing PR and ongoing IR did not differ The use of LZD in cases of PGD is an easier The use of LZD in cases of PGD is an easier

procedure and results in more intact procedure and results in more intact blastomeres.Since similar pregnancy rates blastomeres.Since similar pregnancy rates obtained,it is adventageous to use laser obtained,it is adventageous to use laser

Further follow up is necessary to prove the Further follow up is necessary to prove the safety of the procedure safety of the procedure (Joris et al.,HR2003)(Joris et al.,HR2003)

Laser PGDLaser PGD

Laser DFRGLaser DFRG

Laser Sperm Laser Sperm ImmobilizasyonImmobilizasyon

Laser assisted sperm Laser assisted sperm immobilization prior to immobilization prior to

ICSIICSI Potentially useful alternative to Potentially useful alternative to

the conventional mechanical the conventional mechanical approachapproach

Some studies showed the Some studies showed the effectiveness of this method effectiveness of this method (Montag 2000, Ebner 2001)(Montag 2000, Ebner 2001)

Making laboratory work simpler, Making laboratory work simpler, quicker without lowering quicker without lowering fertilizationfertilization

The application of a single laser shot to the far end of the sperm tail causes a curling of the sperm tail only in viable sperm, similar to the reaction observed in the hypo-osmotic swelling test.

Removal of necrotic blastomeres from partially damaged frozen-thawed embryos before transferincreased rates of pregnancy (45.7% vs. 17.1%), ongoing pregnancy (40.0% vs. 11.4%) and ongoingimplantation (16.2% vs. 4.3%) compared with the control group, in which necrotic blastomeres were not removed.

Effect of ZP openning on Effect of ZP openning on clinical outcome of ART in clinical outcome of ART in

patients with patients with advanced ageadvanced age, , RIFRIF or or frozen/thawfrozen/thaw

Prospective randomized trialProspective randomized trial IVF OR ICSIIVF OR ICSI Advanced age (≥37 yr) (n=410)Advanced age (≥37 yr) (n=410) RIF (≥2) (n=796)RIF (≥2) (n=796) Frozen/thawed ET (n=180)Frozen/thawed ET (n=180)

Valojerdi et al, F&S in press

Results with advanced age Results with advanced age and RIF:and RIF:

Advanced ageAdvanced age PR (LAH : PR (LAH :

15.1%)15.1%) PR (non LAH : PR (non LAH :

21%)21%) IR (LAH : 6.5%)IR (LAH : 6.5%) IR (non LAH : IR (non LAH :

9.1%)9.1%)

RIFRIF PR (LAH : 27.1%)PR (LAH : 27.1%) PR (non LAH : PR (non LAH :

26.9%)26.9%) IR (LAH : 11.6%)IR (LAH : 11.6%) IR (non LAH : IR (non LAH :

12.9%)12.9%)

Valojerdi et al, F&S in press

NO DIFFERENCE

Results with Results with frozen/thawed ET:frozen/thawed ET:

PR (LAH 31.2% & non LAH 11.1% PR (LAH 31.2% & non LAH 11.1% p 0.001)p 0.001)

IR (LAH 12.8% & non LAH 4.2% IR (LAH 12.8% & non LAH 4.2% p 0.000)p 0.000)

Valojerdi et al, F&S in press

Laser assisted Laser assisted ICSIICSI

NEW ECHNIQUENEW ECHNIQUE

Conventional ICSIConventional ICSI

Is highly efficient in achieving Is highly efficient in achieving high normal fertilizationhigh normal fertilization

May be associated with May be associated with degeneration of oocytesdegeneration of oocytes

- - Technical conditionsTechnical conditions

- Oolemma fragility- Oolemma fragility (Nagy,1995;Palermo,1996)(Nagy,1995;Palermo,1996)

- - Difficulty in oolemma breakageDifficulty in oolemma breakage (Vanderzwalmen,1996)(Vanderzwalmen,1996)

- Resistant zona pellucida - Resistant zona pellucida ( Nagy,1995)( Nagy,1995)

ICSIICSI

Especially if few oocytes Especially if few oocytes retrievedretrieved

High degeneration rateHigh degeneration rate Poor embryo qualityPoor embryo quality

maymay effect the pregnancy and effect the pregnancy and

implantation ratesimplantation rates

NEGATIVELY!NEGATIVELY!

ICSIICSI

Severe mechanical stress or Severe mechanical stress or difficulty in penetration during difficulty in penetration during ICSI may damage or ICSI may damage or disorganize the cytoskelon of disorganize the cytoskelon of MII oocytes MII oocytes (Dumoulin,2001;Ebner,2001)(Dumoulin,2001;Ebner,2001)

Types Oolemma Membrane Types Oolemma Membrane BreakgeBreakge

Sudden breakageSudden breakage Type A1:Type A1: Breakage occurs at the beginning of Breakage occurs at the beginning of

the ICSI the ICSI

Type A2:Type A2: Breakage occurs more deeply in the Breakage occurs more deeply in the ooplasmooplasm

Normal breakage Normal breakage Type BType B

Difficult BreakageDifficult Breakage Type C,D and EType C,D and E when strong aspiration and/or when strong aspiration and/or

reposition of injection needle is required to reposition of injection needle is required to break the membranebreak the membrane

Difficult Breakage Difficult Breakage PatternPattern

May serve a marker for a May serve a marker for a dysfunction of zona pellucida dysfunction of zona pellucida

(Ebner et al.,HR,2002)(Ebner et al.,HR,2002)

Laser SystemsLaser Systems

Contact type- ER:YAG Contact type- ER:YAG ((Obruca,1997)Obruca,1997)

Noncontact - Ho:YSGG UV Laser Noncontact - Ho:YSGG UV Laser (Liow,1996)(Liow,1996)

1480 mm diode laser 1480 mm diode laser (Germond,1996;Rink,1996;Montag,1998;Blake,2001)(Germond,1996;Rink,1996;Montag,1998;Blake,2001)

1480 mm Diode Laser1480 mm Diode Laser Works without physically touching Works without physically touching

the cellsthe cells Has no detectable detrimental Has no detectable detrimental

effects on living cells especially effects on living cells especially used with short pulse duration less used with short pulse duration less than 5 ms and laser power 100 mW than 5 ms and laser power 100 mW (Catzimeletiou,2001;Nagy,2001)(Catzimeletiou,2001;Nagy,2001)

Is easy to handle ;No mutagenic Is easy to handle ;No mutagenic effecteffect

The distance between perivitelline The distance between perivitelline space and oolemma should be space and oolemma should be maximum point of laser drillingmaximum point of laser drilling

Innermost layer of ZP kept intactInnermost layer of ZP kept intact

Laser Assisted ICSI (LA-Laser Assisted ICSI (LA-ICSI)ICSI)

Using laser beam generated by a Using laser beam generated by a 1480 mm diode laser 1480 mm diode laser

A channel with smaller diameter A channel with smaller diameter (5-6 (5-6 mmic)mmic) was drilled was drilled

Three to five pulses of Three to five pulses of 10-15 msec10-15 msec (depending to the charesteristic of (depending to the charesteristic of ZP)ZP)

The injection pipette is introduced The injection pipette is introduced through this channel and through this channel and microinjection is performed as usualmicroinjection is performed as usual

Laser-assisted ICSILaser-assisted ICSI

Drilling a microhole on the ZP of Drilling a microhole on the ZP of the oocytes by laser beam just the oocytes by laser beam just prior to ICSIprior to ICSI

Penetration of the microneedle Penetration of the microneedle without any traumawithout any trauma

EASY and DIFFICULT ICSIEASY and DIFFICULT ICSI

Laser Assisted ICSILaser Assisted ICSI

Case reports of LA-ICSICase reports of LA-ICSI Repeated ICSI Repeated ICSI

failure caused by failure caused by oocyte degenerationoocyte degeneration

In LA-ICSI cycle, In LA-ICSI cycle, Survival of 8 Survival of 8 oocytes out of 13 oocytes out of 13 injected, normal injected, normal fertilization in 5 fertilization in 5 oocytesoocytes

Clinical pregnancy Clinical pregnancy was establishedwas established

Rienzi et al, 2001 Rienzi et al, 2001 Fertil SterilFertil Steril

Two previous failed Two previous failed IVF cycles with high IVF cycles with high degeneration of degeneration of oocytesoocytes

In LA-ICSI cycle, 11 In LA-ICSI cycle, 11 MII ocytes of same MII ocytes of same patient, 5 oocytes patient, 5 oocytes with conventional with conventional ICSI, 6 oocytes with ICSI, 6 oocytes with LA-ICSILA-ICSI

High fertilization and High fertilization and better embryo quality better embryo quality resulted in pregnancy resulted in pregnancy with LA-ICSIwith LA-ICSI

Nagy et al, 2001 RBM Nagy et al, 2001 RBM Online Online

Randomized study related to LA-Randomized study related to LA-ICSIICSI

32 patients (32 cycles), previous 32 patients (32 cycles), previous failed ICSI cycles with high failed ICSI cycles with high degeneration of oocytesdegeneration of oocytes

Oocytes of the same patients Oocytes of the same patients randomly dividedrandomly divided

LA-ICSI and conventional ICSI(C-LA-ICSI and conventional ICSI(C-ICSI)ICSI)

201 oocytes in LA-ICSI group and 201 oocytes in LA-ICSI group and 137 oocytes in C-ICSI137 oocytes in C-ICSIAbdelmassih et al, 2002 Hum Reprod; 17:

2694-2699

Randomized study related to LA-Randomized study related to LA-ICSIICSI

ResultsResults Survival rates significantly higher in Survival rates significantly higher in

LA-ICSILA-ICSI Sudden breakage of the oocytes Sudden breakage of the oocytes

membrane significantly low in LA-membrane significantly low in LA-ICSIICSI

Normal fertilization rate not different Normal fertilization rate not different between the groupsbetween the groups

The parcentage of excellent quality The parcentage of excellent quality embryos significantly higher in LA-embryos significantly higher in LA-ICSIICSIAbdelmassih et al, 2002 Hum Reprod; 17:

2694-2699

LA-ICSILA-ICSI Complete or incomplete degeneration Complete or incomplete degeneration

of oocytes may impair the changes of of oocytes may impair the changes of pregnancy by reducing the number of pregnancy by reducing the number of embryos embryos (Lui et al.,1995)(Lui et al.,1995)

More sensitive oocytes not only More sensitive oocytes not only degenerate but the developing degenerate but the developing embryos may be poorer quality as a embryos may be poorer quality as a result of the sublethal demaging result of the sublethal demaging force of the traumatic injectionforce of the traumatic injection

This may be responsible for the This may be responsible for the observation that embryo quality was observation that embryo quality was poorer after C-ICSI and better after poorer after C-ICSI and better after LA-ICSILA-ICSI

(Nagy et al.,2001; Abdelmassih,2002)(Nagy et al.,2001; Abdelmassih,2002)

Laser Assisted ICSI can be Laser Assisted ICSI can be appliedapplied toto

Oocytes showing an increased Oocytes showing an increased elasticity of the oolemma elasticity of the oolemma (Rienzi,2001;Abdelmassih,2002)(Rienzi,2001;Abdelmassih,2002)

In oocytes showing an inherent In oocytes showing an inherent fragility of the membrane fragility of the membrane ((Abdelmassih,2002;Nagy.2002) Abdelmassih,2002;Nagy.2002)

To rescue oocytes after failed To rescue oocytes after failed fertilization with conventional fertilization with conventional IVFIVF ( Eroğlu,2002)( Eroğlu,2002)

Oocytes showing normal Oocytes showing normal membrane responsemembrane response ( (Nagy, Nagy, 2004;Moser,2004)2004;Moser,2004)

Comparison of the laser-Comparison of the laser-assisted ICSI and assisted ICSI and

conventional ICSI results in conventional ICSI results in recurrent ICSI failure recurrent ICSI failure

patients with fewpatients with few oocytes are oocytes are

availableavailable Aygul Demirol, Tamer Sari and Aygul Demirol, Tamer Sari and Timur GTimur Guurgan.rgan.

CLINIC IVF Center, Ankara-CLINIC IVF Center, Ankara-TURKEYTURKEY

ESHRE 2003, oral ESHRE 2003, oral presentation presentation

Use of laser-assisted (ICSI) in patients with a history of poor ICSI outcomeand limited metaphase II oocytes

A.Demirol, M. Benkhalifa, T. Sari, T. Gurgan

Fertil Steril 2006, 86: 256

ObjectiveObjective

To investigate if laser assisted To investigate if laser assisted ICSI (LA-ICSI) improves the ICSI (LA-ICSI) improves the cycle outcome in recurrent cycle outcome in recurrent conventional ICSI failure conventional ICSI failure patients which few oocytes are patients which few oocytes are availableavailable

For evaluation of the outcome, For evaluation of the outcome, we compared the results of LA-we compared the results of LA-ICSI and C-ICSI on the sibling ICSI and C-ICSI on the sibling oocytesoocytesDemirol et al, F&S 2006

Material and methodsMaterial and methods

Forty patients (forty ICSI cyles)Forty patients (forty ICSI cyles) Four or less M II oocytes were retrievedFour or less M II oocytes were retrieved Two or more failed ICSI cyclesTwo or more failed ICSI cycles Mean age 38.6 yrsMean age 38.6 yrs

Demirol et al, F&S 2006

Material and methods Material and methods

M II oocytes from the same patients M II oocytes from the same patients were randomized into two groupswere randomized into two groups

Group I: laser assisted ICSI (L-ICSI) Group I: laser assisted ICSI (L-ICSI) and group II: conventional ICSI (C-and group II: conventional ICSI (C-ICSI)ICSI)

Oocytes were retrieved by Oocytes were retrieved by transvaginal USG guided 36 hours transvaginal USG guided 36 hours after HCG administrationafter HCG administration

Stored in incubator at 37 Stored in incubator at 37 00C with 5% C with 5% COCO22 for 2-4 hours for 2-4 hours

Demirol et al, F&S 2006

To ensure the maximum To ensure the maximum safetysafety

The greatest care was exercised during the The greatest care was exercised during the procedureprocedure

The distance between the perivitelline space The distance between the perivitelline space and oolemma was the maximum at the point and oolemma was the maximum at the point of laser drillingof laser drilling

The innermost layer of the zona The innermost layer of the zona pellucida(ZP) (pellucida(ZP) (~~0.50.5µµm) was kept intact m) was kept intact

very short pulse duration (<2 ms) was very short pulse duration (<2 ms) was appliedapplied

No visible sign of oolemma reaction was No visible sign of oolemma reaction was observedobserved

Demirol et al, F&S, 2006

LA-ICSI was performed in LA-ICSI was performed in the following manner-Ithe following manner-I

Oocytes and spermatozoa were placed into Oocytes and spermatozoa were placed into an injection dish as usualan injection dish as usual

Single and immobilized spermatozoon was Single and immobilized spermatozoon was aspirated into the injection pipetteaspirated into the injection pipette

Prior to microinjection, the oocyte to be Prior to microinjection, the oocyte to be injected was secured on the holding injected was secured on the holding pipette so that the maximum possible pipette so that the maximum possible distance was present between the inner distance was present between the inner surface of the ZP and surface of the ZP and oolemma(perivitelline space)at the 3 oolemma(perivitelline space)at the 3 o’clock position (where the injection o’clock position (where the injection needle would penetrate into the oocyte)needle would penetrate into the oocyte)

Demirol et al, F&S 2006

LA-ICSI was performed in LA-ICSI was performed in the following manner-IIthe following manner-II

Using a laser beam generated by a Using a laser beam generated by a 1480 nm diado laser (Saturn 2 Laser 1480 nm diado laser (Saturn 2 Laser System, Research Instruments, UK)System, Research Instruments, UK)

A channel with small diameter (5-6 A channel with small diameter (5-6 µµm) was drilled with 3-5 low energy m) was drilled with 3-5 low energy pulses, always using <2 ms of pulse pulses, always using <2 ms of pulse durationduration

The injection pipette was introduced The injection pipette was introduced through this channel and ICSI was through this channel and ICSI was performed as usual performed as usual

Demirol et al, F&S, 2006

Material and methodsMaterial and methods

Group IGroup I:: 64 oocytes, 64 oocytes, laser-laser-assisted ICSI (L-ICSI)assisted ICSI (L-ICSI)

In group IIIn group II:: 52 oocytes 52 oocytes,, conventional ICSI (conventional ICSI (C-ICSIC-ICSI)) was was performed as described performed as described previously (Van Steirteghem previously (Van Steirteghem et al., 1993)et al., 1993)

Demirol et al, F&S, 2006

Material and methodsMaterial and methods After injection, oocytes incubated in After injection, oocytes incubated in

IVF medium (Vitrolife) and covered IVF medium (Vitrolife) and covered with mineral oilwith mineral oil

Fertilization was controlled 16-18 h Fertilization was controlled 16-18 h after the injection (Nagy et al., 1998)after the injection (Nagy et al., 1998)

Fertilized oocytes were transferred Fertilized oocytes were transferred to G-1 medium(Vitrolife) and on day to G-1 medium(Vitrolife) and on day 2 they were transferred to G-2 2 they were transferred to G-2 mediummedium (Vitrolife)(Vitrolife)

Demirol et al, F&S, 2006

Material and methodsMaterial and methods

Embryos were classified on Embryos were classified on day 3 according to the day 3 according to the number of blastomers and number of blastomers and percentage of fragmentationpercentage of fragmentation

Demirol et al, F&S, 2006

ResultsResultsin LA-ICSI groupin LA-ICSI group

Fertilization rate Fertilization rate embryos with > 6 cells embryos with > 6 cells <10% fragmentation<10% fragmentation

Embryos < 4 cellsEmbryos < 4 cells

D3Significantly

higher

D3Significantly

lower

Demirol et al, F&S, 2006

LA-ICSI related studiesLA-ICSI related studies Nagy et al, 2001Nagy et al, 2001 Rienzi et al, 2001Rienzi et al, 2001 Abdelmassih et al, 2002Abdelmassih et al, 2002 Demirol et al, 2006Demirol et al, 2006

With high degeneration rate,failed ICSI cycles

Lower degeneration and higher embryo quality

Resulted in

Take home massages-ITake home massages-I

The introduction of laser The introduction of laser technology seems to be a helpful technology seems to be a helpful to simplify the various technique to simplify the various technique of gameteof gamete

The question of safety is always The question of safety is always an important point when an important point when introducing a new techiqueintroducing a new techique

Take home massages-IITake home massages-II

Laser is currently being used in Laser is currently being used in assisted hatching and embryo assisted hatching and embryo biopsy for PGDbiopsy for PGD

Laser assisted ICSI widens the Laser assisted ICSI widens the potential applications of laser potential applications of laser devicesdevices