Transport of Gametes and Fertilization

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Chapter 2

Transport of Gametes and Fertilization

Chapter 1 describes the origins and maturation of male and female gametes and the hormonal conditions that make such maturation possible. It also describes the cyclic, hormonally controlled changes in the female reproductive tract that ready it for fertilization and the support of embryonic development. This chapter first explains the way the egg and sperm cells come together in the female reproductive tract so that fertilization can occur. It then outlines the complex set of interactions involved in fertilization of the egg by a sperm.

Ovulation and Egg and Sperm Transport

Ovulation

Toward the midpoint of the menstrual cycle, the mature graafian follicle, containing the egg that has been arrested in prophase of the first meiotic division, has moved to the surface of the ovary. Under the influence of follicle-stimulating hormone (FSH) and luteinizing hormone (LH), the follicle expands dramatically. The first meiotic division is completed, and the second meiotic division proceeds until the metaphase stage, at which the second meiotic arrest occurs. After the first meiotic division, the first polar body is expelled. By this point, the follicle bulges from the surface of the ovary. The apex of the protrusion is the stigma.

The stimulus for ovulation is the surge of LH secreted by the anterior pituitary at the midpoint of the menstrual cycle (see Fig. 1.16). Within hours of exposure to the LH surge, the follicle reorganizes its program of gene expression from one directed toward development of the follicle to one producing molecules that set into gear the processes of follicular rupture and ovulation. Shortly after the LH peak, local blood flow increases in the outer layers of the follicular wall. Along with the increased blood flow, plasma proteins leak into the tissues through the postcapillary venules, with resulting local edema. The edema and the release of certain pharmacologically active compounds, such as prostaglandins, histamine, vasopressin, and plasminogen activator, provide the starting point for a series of reactions that result in the local production of matrix metalloproteinases—a family of lytic enzymes that degrade components of the extracellular matrix. At the same time, the secretion of hyaluronic acid by cells of the cumulus results in a loosening of the cells surrounding the egg. The lytic action of the matrix metalloproteinases produces an inflammatorylike reaction that ultimately results in rupture of the outer follicular wall about 28 to 36 hours after the LH surge (Fig. 2.1). Within minutes after rupture of the follicular wall, the cumulus oophorus detaches from the granulosa, and the egg is released from the ovary.

Ovulation results in the expulsion of both antral fluid and the ovum from the ovary into the peritoneal cavity. The ovum is not ovulated as a single naked cell, but as a complex consisting of (1) the ovum, (2) the zona pellucida, (3) the two- to three-cell-thick corona radiata, and (4) a sticky matrix containing surrounding cells of the cumulus oophorus. By convention, the adhering cumulus cells are designated the corona radiata after ovulation has occurred. Normally, one egg is released at ovulation. The release and fertilization of two eggs can result in fraternal twinning.

Some women experience mild to pronounced pain at the time of ovulation. Often called mittelschmerz (German for “middle pain”), this pain may accompany slight bleeding from the ruptured follicle.

Egg Transport

The first step in egg transport is capture of the ovulated egg by the uterine tube. Shortly before ovulation, the epithelial cells of the uterine tube become more highly ciliated, and smooth muscle activity in the tube and its suspensory ligament increases as the result of hormonal influences. By ovulation, the fimbriae of the uterine tube move closer to the ovary and seem to sweep rhythmically over its surface. This action, in addition to the currents set up by the cilia, efficiently captures the ovulated egg complex. Experimental studies on rabbits have shown that the bulk provided by the cellular coverings of the ovulated egg is important in facilitating the egg’s capture and transport by the uterine tube. Denuded ova or inert objects of that size are not so readily transported. Capture of the egg by the uterine tube also involves an adhesive interaction between the egg complex and the ciliary surface of the tube.

Even without these types of natural adaptations, the ability of the uterine tubes to capture eggs is remarkable. If the fimbriated end of the tube has been removed, egg capture occurs remarkably often, and pregnancies have even occurred in women who have had one ovary and the contralateral uterine tube removed. In such cases, the ovulated egg would have to travel free in the pelvic cavity for a considerable distance before entering the ostium of the uterine tube on the other side.

When inside the uterine tube, the egg is transported toward the uterus, mainly as the result of contractions of the smooth musculature of the tubal wall. Although the cilia lining the tubal mucosa may also play a role in egg transport, their action is not obligatory because women with immotile cilia syndrome are often fertile.

While in the uterine tube, the egg is bathed in tubal fluid, which is a combination of secretion by the tubal epithelial cells and transudate from capillaries just below the epithelium. In some mammals, exposure to oviductal secretions is important to the survival of the ovum and for modifying the composition of the zona pellucida, but the role of tubal fluid in humans is less clear.

Tubal transport of the egg usually takes 3 to 4 days, whether or not fertilization occurs (Fig. 2.2). Egg transport typically occurs in two phases: slow transport in the ampulla (approximately 72 hours) and a more rapid phase (8 hours) during which the egg or embryo passes through the isthmus and into the uterus (see p. 51). By a poorly understood mechanism, possibly local edema or reduced muscular activity, the egg is temporarily prevented from entering the isthmic portion of the tube, but under the influence of progesterone, the uterotubal junction relaxes and permits entry of the ovum.

By roughly 80 hours after ovulation, the ovulated egg or embryo has passed from the uterine tube into the uterus. If fertilization has not occurred, the egg degenerates and is phagocytized. (Implantation of the embryo is discussed in Chapter 3.)

Sperm Transport

Sperm transport occurs in both the male reproductive tract and the female reproductive tract. In the male reproductive tract, transport of spermatozoa is closely connected with their structural and functional maturation, whereas in the female reproductive tract, it is important for spermatozoa to pass to the upper uterine tube, where they can meet the ovulated egg.

After spermiogenesis in the seminiferous tubules, the spermatozoa are morphologically mature but are nonmotile and incapable of fertilizing an egg (Fig. 2.3). Spermatozoa are passively transported via testicular fluid from the seminiferous tubules to the caput (head) of the epididymis through the rete testis and the efferent ductules. They are propelled by fluid pressure generated in the seminiferous tubules and are assisted by smooth muscle contractions and ciliary currents in the efferent ductules. Spermatozoa spend about 12 days in the highly convoluted duct of the epididymis, which measures 6 m in the human, during which time they undergo biochemical maturation. This period of maturation is associated with changes in the glycoproteins in the plasma membrane of the sperm head. By the time the spermatozoa have reached the cauda (tail) of the epididymis, they are capable of fertilizing an egg.

On ejaculation, the spermatozoa rapidly pass through the ductus deferens and become mixed with fluid secretions from the seminal vesicles and prostate gland. Prostatic fluid is rich in citric acid, acid phosphatase, zinc, and magnesium ions, whereas fluid of the seminal vesicle is rich in fructose (the principal energy source of spermatozoa) and prostaglandins. The 2 to 6 mL of ejaculate (semen, or seminal fluid) typically consists of 40 to 250 million spermatozoa mixed with alkaline fluid from the seminal vesicles (60% of the total) and acid secretion (pH 6.5) from the prostate (30% of the total). The pH of normal semen ranges from 7.2 to 7.8. Despite the numerous spermatozoa (>100 million) normally present in an ejaculate, a number as small as 25 million spermatozoa per ejaculate may be compatible with fertility.

In the female reproductive tract, sperm transport begins in the upper vagina and ends in the ampulla of the uterine tube, where the spermatozoa make contact with the ovulated egg. During copulation, the seminal fluid is normally deposited in the upper vagina (see Fig. 2.3), where its composition and buffering capacity immediately protect the spermatozoa from the acid fluid found in the upper vaginal area. The acidic vaginal fluid normally serves a bactericidal function in protecting the cervical canal from pathogenic organisms. Within about 10 seconds, the pH of the upper vagina is increased from 4.3 to as much as 7.2. The buffering effect lasts only a few minutes in humans, but it provides enough time for the spermatozoa to approach the cervix in an environment (pH 6.0 to 6.5) optimal for sperm motility.

The next barriers that the sperm cells must overcome are the cervical canal and the cervical mucus that blocks it. Changes in intravaginal pressure may suck spermatozoa into the cervical os, but swimming movements also seem to be important for most spermatozoa in penetrating the cervical mucus.

The composition and viscosity of cervical mucus vary considerably throughout the menstrual cycle. Composed of cervical mucin (a glycoprotein with a high carbohydrate composition) and soluble components, cervical mucus is not readily penetrable. Between days 9 and 16 of the cycle, however, its water content increases, and this change facilitates the passage of sperm through the cervix around the time of ovulation; such mucus is sometimes called E mucus. After ovulation, under the influence of progesterone, the production of watery cervical mucus ceases, and a new type of sticky mucus, which has a much decreased water content, is produced. This progestational mucus, sometimes called G mucus, is almost completely resistant to sperm penetration. A highly effective method of natural family planning makes use of the properties of cervical mucus.

There are two main modes of sperm transport through the cervix. One is a phase of initial rapid transport, by which some spermatozoa can reach the uterine tubes within 5 to 20 minutes of ejaculation. Such rapid transport relies more on muscular movements of the female reproductive tract than on the motility of the spermatozoa themselves. These early-arriving sperm, however, appear not to be as capable of fertilizing an egg as do those that have spent more time in the female reproductive tract. The second, slow phase of sperm transport involves the swimming of spermatozoa through the cervical mucus (traveling at a rate of 2 to 3 mm/hour), their storage in cervical crypts, and their final passage through the cervical canal as much as 2 to 4 days later.

Relatively little is known about the passage of spermatozoa through the uterine cavity, but the contraction of uterine smooth muscle, rather than sperm motility, seems to be the main intrauterine transport mechanism. At this point, the spermatozoa enter one of the uterine tubes. According to some more recent estimates, only several hundred spermatozoa enter the uterine tubes, and most enter the tube containing the ovulated egg.

Once inside the uterine tube, the spermatozoa collect in the isthmus and bind to the epithelium for about 24 hours. During this time, they are influenced by secretions of the tube to undergo the capacitation reaction. One phase of capacitation is removal of cholesterol from the surface of the sperm. Cholesterol is a component of semen and acts to inhibit premature capacitation. The next phase of capacitation consists of removal of many of the glycoproteins that were deposited on the surface of the spermatozoa during their tenure in the epididymis. Capacitation is required for spermatozoa to be able to fertilize an egg (specifically, to undergo the acrosome reaction; see p. 29). After the capacitation reaction, the spermatozoa undergo a period of hyperactivity and detach from the tubal epithelium. Hyperactivation helps the spermatozoa to break free of the bonds that held them to the tubal epithelium. It also assists the sperm in penetrating isthmic mucus, as well as the corona radiata and the zona pellucida, which surround the ovum. Only small numbers of sperm are released at a given time. This may reduce the chances of polyspermy (see p. 31).

On their release from the isthmus, the spermatozoa make their way up the tube through a combination of muscular movements of the tube and some swimming movements. The simultaneous transport of an egg down and spermatozoa up the tube is currently explained on the basis of peristaltic contractions of the uterine tube muscles. These contractions subdivide the tube into compartments. Within a given compartment, the gametes are caught up in churning movements that over 1 or 2 days bring the egg and spermatozoa together. Fertilization of the egg normally occurs in the ampullary portion (upper third) of the uterine tube. Estimates suggest that spermatozoa retain their function in the female reproductive tract for about 80 hours.

After years of debate concerning the possibility that mammalian spermatozoa may be guided to the egg through attractants, more recent research suggests that this could be the case. Mammalian spermatozoa have been found to possess odorant receptors of the same family as olfactory receptors in the nose, and they can respond behaviorally to chemically defined odorants. Human spermatozoa also respond to cumulus-derived progesterone and to yet undefined chemoattractants emanating from follicular fluid and cumulus cells. Human spermatozoa are also known to respond to a temperature gradient, and studies on rabbits have shown that the site of sperm storage in the oviduct is cooler than that farther up the tube where fertilization occurs. It seems that only capacitated spermatozoa have the capability of responding to chemical or thermal stimuli. Because many of the sperm cells that enter the uterine tube fail to become capacitated, these spermatozoa are less likely to find their way to the egg.

Formation and Function of the Corpus Luteum of Ovulation and Pregnancy

While the ovulated egg is passing through the uterine tubes, the ruptured follicle from which it arose undergoes a series of striking changes that are essential for the progression of events leading to and supporting pregnancy (see Fig. 1.8). Soon after ovulation, the basement membrane that separates the granulosa cells from the theca interna breaks down, thus allowing thecal blood vessels to grow into the cavity of the ruptured follicle. The granulosa cells simultaneously undergo a series of major changes in form and function (luteinization). Within 30 to 40 hours of the LH surge, these cells, now called granulosa lutein cells, begin secreting increasing amounts of progesterone along with some estrogen. This pattern of secretion provides the hormonal basis for the changes in the female reproductive tissues during the last half of the menstrual cycle. During this period, the follicle continues to enlarge. Because of its yellow color, it is known as the corpus luteum. The granulosa lutein cells are terminally differentiated. They have stopped dividing, but they continue to secrete progesterone for 10 days.

In the absence of fertilization and a hormonal stimulus provided by the early embryo, the corpus luteum begins to deteriorate (luteolysis) late in the menstrual cycle. Luteolysis seems to involve both the preprogramming of the luteal cells to apoptosis (cell death) and uterine luteolytic factors, such as prostaglandin F2. Regression of the corpus luteum and the accompanying reduction in progesterone production cause the hormonal withdrawal that results in the degenerative changes of the endometrial tissue during the last days of the menstrual cycle.

During the regression of the corpus luteum, the granulosa lutein cells degenerate and are replaced with collagenous scar tissue. Because of its white color, the former corpus luteum now becomes known as the corpus albicans (“white body”).

If fertilization occurs, the production of the protein hormone chorionic gonadotropin by the future placental tissues maintains the corpus luteum in a functional condition and causes an increase in its size and hormone production. Because the granulosa lutein cells are unable to divide and cease producing progesterone after 10 days, the large corpus luteum of pregnancy is composed principally of theca lutein cells. The corpus luteum of pregnancy remains functional for the first few months of pregnancy. After the second month, the placenta produces enough estrogens and progesterone to maintain pregnancy on its own. At this point, the ovaries can be removed, and pregnancy would continue.

Fertilization

Fertilization is a series of processes rather than a single event. Viewed in the broadest sense, these processes begin when spermatozoa start to penetrate the corona radiata that surrounds the egg and end with the intermingling of the maternal and paternal chromosomes after the spermatozoon has entered the egg.

Penetration of the Corona Radiata

When the spermatozoa first encounter the ovulated egg in the ampullary part of the uterine tube, they are confronted by the corona radiata and some remnants of the cumulus oophorus, which represents the outer layer of the egg complex (Fig. 2.4). The corona radiata is a highly cellular layer with an intercellular matrix consisting of proteins and a high concentration of carbohydrates, especially hyaluronic acid. It is widely believed that hyaluronidase emanating from the sperm head plays a major role in penetration of the corona radiata, but the active swimming movements of the spermatozoa are also important.

Attachment to and Penetration of the Zona Pellucida

The zona pellucida, which is 13 µm thick in humans, consists principally of four glycoproteins—ZP1 to ZP4. ZP2 and ZP3 combine to form basic units that polymerize into long filaments. These filaments are periodically linked by cross-bridges of ZP1 and ZP4 molecules (Fig. 2.5). The zona pellucida of an unfertilized mouse egg is estimated to contain more than 1 billion copies of the ZP3 protein.

After they have penetrated the corona radiata, spermatozoa bind tightly to the zona pellucida by means of the plasma membrane of the sperm head (see Fig. 2.4). Spermatozoa bind specifically to a sialic acid molecule, which is the terminal part of a sequence of four sugars at the end of O-linked oligosaccharides that are attached to the polypeptide core of the ZP3 molecule. Molecules on the surface of the sperm head are specific binding sites for the ZP3 sperm receptors on the zona pellucida. More than 24 molecules have been proposed, but the identity of the zona-binding molecules remains unknown. Interspecies molecular differences in the sperm-binding regions of the ZP3 molecule may serve as the basis for the inability of spermatozoa of one species to fertilize an egg of another species. In mammals, there is less species variation in the composition of ZP3; this may explain why penetration of the zona pellucida by spermatozoa of closely related mammalian species is sometimes possible, whereas it is rare among lower animals.

On binding to the zona pellucida, mammalian spermatozoa undergo the acrosomal reaction. The essence of the acrosomal reaction is the fusion of parts of the outer acrosomal membrane with the overlying plasma membrane and the pinching off of fused parts as small vesicles. This results in the liberation of the multitude of enzymes that are stored in the acrosome (Box 2.1).

The acrosomal reaction in mammals is stimulated by the ZP3 molecule acting through G proteins in the plasma membrane on the sperm head. In contrast to the sperm receptor function of ZP3, a large segment of the polypeptide chain of the ZP3 molecule must be present to induce the acrosomal reaction. An initiating event of the acrosomal reaction is a massive influx of calcium (Ca++) through the plasma membrane of the sperm head. This process, accompanied by an influx of sodium (Na+) and an efflux of hydrogen (H+), increases the intracellular pH. Fusion of the outer acrosomal membrane with the overlying plasma membrane soon follows. As the vesicles of the fused membranes are shed, the enzymatic contents of the acrosome are freed and can assist the spermatozoa in making their way through the zona pellucida.

After the acrosomal reaction, the inner acrosomal membrane forms the outer surface covering of most of the sperm head (see Fig. 2.4D). Toward the base of the sperm head (in the equatorial region), the inner acrosomal membrane fuses with the remaining postacrosomal plasma membrane to maintain membrane continuity around the sperm head.

Only after completing the acrosomal reaction can the spermatozoon successfully begin to penetrate the zona pellucida. Penetration of the zona is accomplished by a combination of mechanical propulsion by movements of the sperm’s tail and digestion of a pathway through the action of acrosomal enzymes. The most important enzyme is acrosin, a serine proteinase that is bound to the inner acrosomal membrane. When the sperm has made its way through the zona and into the perivitelline space (the space between the egg’s plasma membrane and the zona pellucida), it can make direct contact with the plasma membrane of the egg.

Binding and Fusion of Spermatozoon and Egg

After a brief transit period through the perivitelline space, the spermatozoon makes contact with the egg. In two distinct steps, the spermatozoon first binds to and then fuses with the plasma membrane of the egg. Binding between the spermatozoon and egg occurs when the equatorial region of the sperm head contacts the microvilli surrounding the egg. Molecules on the plasma membrane of the sperm head, principally sperm proteins called fertilins and cyritestin, bind to α6 integrin and CD9 protein molecules on the surface of the egg. The acrosomal reaction causes a change in the membrane properties of the spermatozoon because, if the acrosomal reaction has not occurred, the spermatozoon is unable to fuse with the egg. Actual fusion between spermatozoon and egg, mediated by integrin on the membrane of the oocyte, brings their plasma membranes into continuity.

After initial fusion, the contents of the spermatozoon (the head, the midpiece, and usually the tail) sink into the egg (Fig. 2.6), whereas the sperm’s plasma membrane, which is antigenically distinct from that of the egg, becomes incorporated into the egg’s plasma membrane and remains recognizable at least until the start of cleavage. Although mitochondria located in the sperm neck enter the egg, they do not contribute to the functional mitochondrial complement of the zygote. In humans, the sperm contributes the centrosome, which is required for cell cleavage.

Prevention of Polyspermy

When a spermatozoon has fused with an egg, the entry of other spermatozoa into the egg (polyspermy) must be prevented, or abnormal development is likely to result. Two blocks to polyspermy, fast and slow, are typically present in vertebrate fertilization.

The fast block to polyspermy, which has been best studied in sea urchins, consists of a rapid electrical depolarization of the plasma membrane of the egg. The resting membrane potential of the egg changes from about −70 to +10 mV within 2 to 3 seconds after fusion of the spermatozoon with the egg. This change in membrane potential prevents other spermatozoa from adhering to the egg’s plasma membrane. The fast block in mammals is short-lived, lasting only several minutes, and may not be as heavily based on membrane depolarization as that in sea urchins. This time is sufficient for the egg to mount a permanent slow block. The exact nature of the fast block in the human egg is still not well defined.

Very soon after sperm entry, successive waves of Ca++ pass through the cytoplasm of the egg. The first set of waves, spreading from the site of sperm-egg fusion, is involved in stimulating completion of the second meiotic division of the egg. Later waves of Ca++ initiate recruitment of maternal RNAs in the egg and act on the cortical granules as they pass by them. Exposure to Ca++ causes the cortical granules to fuse with the plasma membrane and to release their contents (hydrolytic enzymes and polysaccharides) into the perivitelline space. The polysaccharides released into the perivitelline space become hydrated and swell, thus causing the zona pellucida to rise from the surface of the egg.

The secretory products of the cortical granules diffuse into the porous zona pellucida and hydrolyze the sperm receptor molecules (ZP3 in the mouse) in the zona. This reaction, called the zona reaction, essentially eliminates the ability of spermatozoa to adhere to and penetrate the zona. The zona reaction has been observed in human eggs that have undergone in vitro fertilization. In addition to changes in the zona pellucida, alterations in sperm receptor molecules on the plasma membrane of the human egg cause the egg itself to become refractory to penetration by other spermatozoa.

Decondensation of the Sperm Nucleus

In the mature spermatozoon, the nuclear chromatin is very tightly packed, in large part because of the —SS— (disulfide) cross-linking that occurs among the protamine molecules complexed with the DNA during spermatogenesis. Shortly after the head of the sperm enters the cytoplasm of the egg, the permeability of its nuclear membrane begins to increase, thereby allowing cytoplasmic factors within the egg to affect the nuclear contents of the sperm. After reduction of the —SS— cross-links of the protamines to sulfhydryl (—SH) groups by reduced glutathione in the ooplasm, the protamines are rapidly lost from the chromatin of the spermatozoon, and the chromatin begins to spread out within the nucleus (now called a pronucleus) as it moves closer to the nuclear material of the egg.

Remodeling of the sperm head takes about 6 to 8 hours. After a short period during which the male chromosomes are naked, histones begin to associate with the chromosomes. During the period of pronuclear formation, the genetic material of the male pronucleus becomes demethylated, whereas methylation in the female genome is maintained.

Completion of Meiosis and the Development of Pronuclei in the Egg

After penetration of the egg by the spermatozoon, the nucleus of the egg, which had been arrested in metaphase of the second meiotic division, completes the last division and releases a second polar body into the perivitelline space (see Fig. 2.6).

The nucleus of the oocyte moves toward the cortex as the result of the action of myosin molecules acting on a network of actin filaments that connect one pole of the mitotic spindle to the cortex. The resulting contraction draws the entire mitotic apparatus toward the surface of the cell (Fig. 2.7). This determines the location at which both the first and second polar bodies are extruded.

A pronuclear membrane, derived largely from the endoplasmic reticulum of the egg, forms around the female chromosomal material. Cytoplasmic factors seem to control the growth of the female and the male pronuclei. Pronuclei appear 6 to 8 hours after sperm penetration, and they persist for about 10 to 12 hours. DNA replication occurs in the developing haploid pronuclei, and each chromosome forms two chromatids as the pronuclei approach each other. When the male and female pronuclei come into contact, their membranes break down, and the chromosomes intermingle. The maternal and paternal chromosomes quickly become organized around a mitotic spindle, derived from the centrosome of the sperm, in preparation for an ordinary mitotic division. At this point, the process of fertilization can be said to be complete, and the fertilized egg is called a zygote.

What is Accomplished by Fertilization?

The process of fertilization ties together many biological loose ends, as follows:

1. It stimulates the egg to complete the second meiotic division.

2. It restores to the zygote the normal diploid number of chromosomes (46 in humans).

3. The genetic sex of the future embryo is determined by the chromosomal complement of the spermatozoon. (If the sperm contains 22 autosomes and an X chromosome, the embryo is a genetic female, and if it contains 22 autosomes and a Y chromosome, the embryo is a male. See Chapter 16 for further details.)

4. Through the mingling of maternal and paternal chromosomes, the zygote is a genetically unique product of chromosomal reassortment, which is important for the viability of any species.

5. The process of fertilization causes metabolic activation of the egg, which is necessary for cleavage and subsequent embryonic development to occur.

Clinical Vignette

A 33-year-old woman who has had her uterus surgically removed desperately wants her own child. She is capable of producing eggs because her ovaries remain functional. She and her husband want to attempt in vitro fertilization and embryo transfer. They find a woman who, for $20,000, is willing to allow the couple’s embryo to be transferred to her uterus and to serve as a surrogate mother during the pregnancy. Induction of superovulation is successful, and the physicians are able to fertilize eight eggs in vitro. Three embryos are implanted into the surrogate mother. The remaining embryos are frozen for possible future use. The embryo transfer is successful, and the surrogate mother becomes pregnant with twins. The twins are born, but the surrogate mother feels that she has bonded with them so much that she should have the right to raise them. The extremely wealthy genetic parents take the case to court, but before the case comes to trial they are both killed in an airplane accident. The surrogate mother now claims that she should get the large inheritance in the name of her twins, but the father’s sister, equally aware of the financial implications, claims that she should care for the twins. The issue of what to do with the remaining five frozen embryos also comes up.

This case is fictitious, but all of its elements have occurred on an isolated basis. How would you deal with the following legal and ethical issues?

Summary

image Ovulation is stimulated by a surge of LH and FSH in the blood. Expulsion of the ovum from the graafian follicle involves local edema, ischemia, and collagen breakdown, with a possible contribution by fluid pressure and smooth muscle activity in rupturing the follicular wall.

image The ovulated egg is swept into the uterine tube and transported through it by ciliary action and smooth muscle contractions as it awaits fertilization by a sperm cell.

image Sperm transport in the male reproductive tract involves a slow exit from the seminiferous tubules, maturation in the epididymis, and rapid expulsion at ejaculation, where the spermatozoa are joined by secretions from the prostate and seminal vesicles to form semen.

image In the female reproductive tract, sperm transport involves entry into the cervical canal from the vagina, passage through the cervical mucus, and transport through the uterus into the uterine tubes, where capacitation occurs. The meeting of egg and sperm typically occurs in the upper third of the uterine tube.

image The fertilization process consists of several sequential events:

image Attachment of the spermatozoon to the zona pellucida is mediated by the ZP3 protein, which also stimulates the acrosomal reaction.

image The acrosomal reaction involves fusion of the outer acrosomal membrane with the plasma membrane of the sperm cell and the fragmentation of the fused membranes, thus leading to the release of the acrosomal enzymes. One of the acrosomal enzymes, acrosin, is a serine proteinase, which digests components of the zona pellucida and assists the penetration of the swimming spermatozoa through the zona.

image After fusion of the spermatozoa to the egg membrane, a rapid electrical depolarization produces the first block to polyspermy in the egg. This is followed by a wave of Ca++ that causes the cortical granules to release their contents into the perivitelline space and ultimately to inactivate the sperm receptors in the zona pellucida.

image Sperm penetration stimulates a rapid intensification of respiration and metabolism of the egg.

image Within the egg, the nuclear material of the spermatozoon decondenses and forms the male pronucleus. At the same time, the egg completes the second meiotic division, and the remaining nuclear material becomes surrounded by a membrane, to form the female pronucleus.

image After DNA replication, the male and female pronuclei join, and their chromosomes become organized for a mitotic division. Fertilization is complete, and the fertilized egg is properly called a zygote.

image Treatment of infertility by in vitro fertilization and embryo transfer is a multistage process involving stimulating gamete production by drugs such as clomiphene citrate, obtaining eggs by laparoscopic techniques in the woman, storing gametes by freezing, performing in vitro fertilization and culture of embryos, preserving the embryo, and transferring the embryo to the mother (Clinical Correlation 2.1).

Clinical Correlation 2.1   Treatment of Infertility by In Vitro Fertilization and Embryo Transfer

Certain types of infertility caused by inadequate numbers or mobility of spermatozoa or by obstruction of the uterine tubes are now treatable by fertilizing an ovum in vitro and transferring the cleaving embryo into the reproductive tract of the woman. The sequential application of various techniques that were initially developed for the assisted reproduction of domestic animals, such as cows and sheep, is required. The relevant techniques are (1) stimulating gamete production, (2) obtaining male and female gametes, (3) storing gametes, (4) fertilizing eggs, (5) culturing cleaving embryos in vitro, (6) preserving embryos, and (7) introducing embryos into the uterus (Fig. 2.8).

Stimulation of Gamete Production

Ovulation is stimulated by altering existing hormonal relationships. For women who are anovulatory (do not ovulate), these techniques alone may be sufficient to allow conception.

Several methods have been used to stimulate gamete production. Earlier methods employed clomiphene citrate, a nonsteroidal antiestrogen that suppresses the normal negative feedback by estrogens on gonadotropin production by the pituitary (see Fig. 1.15). This method has been largely supplanted by the administration of various combinations of recombinant gonadotropin (follicle-stimulating hormone or luteinizing hormone, or both) preparations, sometimes in combination with gonadotropin-releasing hormone agonists. These treatments result in multiple ovulation, a desired outcome for artificial fertilization because fertilizing more than one egg at a time is more efficient. Sometimes women who use these methods for the induction of ovulation produce multiple children, however, and many quintuplet to septuplet births have been recorded. Other methods of inducing ovulation are the application of human menopausal gonadotropins or the pulsatile administration of gonadotropin-releasing hormone. These techniques are more expensive than the administration of clomiphene.

Obtaining Gametes

For artificial insemination in vivo or artificial fertilization in vitro, spermatozoa are typically collected by masturbation. The collection of eggs requires technological assistance. Ongoing monitoring of the course of induced ovulation is accomplished by the application of imaging techniques, especially diagnostic ultrasound.

The actual recovery of oocytes involves their aspiration from ripe follicles. Although originally accomplished by laparoscopy (direct observation by inserting a laparoscope through a small slit in the woman’s abdominal wall), visualization is now done with the assistance of ultrasound. An aspiration needle is inserted into each mature follicle, and the ovum is gently sucked into the needle and placed into culture medium in preparation for fertilization in vitro.

In Vitro Fertilization and Embryo Culture

Three ingredients for successful in vitro fertilization are as follows: (1) mature eggs; (2) normal, active spermatozoa; and (3) an appropriate culture environment. Having oocytes that are properly mature is one of the most important factors in obtaining successful in vitro fertilization. The eggs aspirated from a woman are sometimes at different stages of maturity. Immature eggs are cultured for a short time to become more fertilizable. The aspirated eggs are surrounded by the zona pellucida, the corona radiata, and a varying amount of cumulus oophorus tissue.

Fresh or frozen spermatozoa are prepared by separating them as much as possible from the seminal fluid. Seminal fluid reduces their fertilizing capacity, partly because it contains decapacitating factors. After capacitation, which in a human can be accomplished by exposing spermatozoa to certain ionic solutions, defined numbers of spermatozoa are added to the culture in concentrations of 10,000 to 500,000/mL. Rates of fertilization in vitro vary from one center to another, but 75% represents a realistic average.

In cases of infertility caused by oligospermia (too few spermatozoa) or excessively high percentages of abnormal sperm cells, multiple ejaculates may be obtained over an extended period. These are frozen and pooled to obtain adequate numbers of viable spermatozoa. In some cases, a few spermatozoa are microinjected into the perivitelline space inside the zona pellucida. Although this procedure can compensate for very small numbers of viable spermatozoa, it introduces the risk of polyspermy because the normal gating function of the zona pellucida is bypassed. A more recent variant on in vitro fertilization is direct injection of a spermatozoon into an oocyte (Fig. 2.9). This technique has been used in cases of severe sperm impairment.

The initial success of in vitro fertilization is determined the next day by examination of the egg. If two pronuclei are evident (Fig. 2.10), fertilization is assumed to have occurred.

The cleavage in vitro of human embryos is more successful than that of most other mammalian species. The embryos are usually allowed to develop to the two- to eight-cell stage before they are considered ready to implant into the uterus.

Typically, all the eggs obtained from the multiple ovulations of the woman are fertilized in vitro during the same period. Practical reasons exist for doing this. One is that because of the low success rate of embryo transfer, implanting more than one embryo (commonly up to three) into the uterus at a time is advisable. Another reason is financial and also relates to the low success rate of embryo transfer. Embryos other than those used during the initial procedure are stored for future use if the first embryo transfer proves unsuccessful. Such stockpiling saves a great deal of time and thousands of dollars for the patient.

Embryo Transfer into the Mother

Transfer of the embryo into the mother is technically simple; yet this is the step in the entire operation that is subject to the greatest failure rate. Typically, only 30% of embryo transfer attempts result in a viable pregnancy.

Embryo transfer is commonly accomplished by introducing a catheter through the cervix into the uterine cavity and expelling the embryo or embryos from the catheter. The patient remains quiet, preferably lying down for several hours after embryo transfer.

The reasons for the low success rate of embryo transfers are poorly understood, but the number of completed pregnancies after normal fertilization in vivo is also likely to be only about one third. If normal implantation does occur, the remainder of the pregnancy is typically uneventful and is followed by a normal childbirth.

Intrafallopian Transfer

Certain types of infertility are caused by factors such as hostile cervical mucus and pathological or anatomical abnormalities of the upper ends of the uterine tubes. A simpler method for dealing with these conditions is to introduce male and female gametes directly into the lower end of a uterine tube (often at the junction of its isthmic and ampullary regions). Fertilization occurs within the tube, and the early events of embryogenesis occur naturally. The method of gamete intrafallopian transfer (GIFT) has resulted in slightly higher percentages of pregnancies than the standard in vitro fertilization and embryo transfer methods.

A variant on this technique is zygote intrafallopian transfer (ZIFT). In this variant, a cleaving embryo that has been produced by in vitro fertilization is implanted into the uterine tube.

image Other techniques used for the treatment of infertility are gamete intrafallopian transfer (GIFT), which is the transfer of gametes directly into the uterine tube, and zygote intrafallopian transfer (ZIFT), with is the transfer of zygotes into the uterine tube. These techniques can be used with biological and surrogate mothers.