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 American Journal of  Medical Science and 
Innovation (AJMSI)

Comparison of  Recombinant Cumulase with Bovine Derived Hyaluronidase for Oocyte 
Denudation before ICSI in Sibling Oocytes  

M. Fakih1, B. R. Daoud2, K. Khalil3, M. Fawaz4 , J. Kashir5 , M. A. Akhtar6*

Volume 3 Issue 2, Year 2024
ISSN: 2834-0086 (Online)

DOI: https://doi.org/10.54536/ajfst.v3i2.3662
https://journals.e-palli.com/home/index.php/ajfst

Article Information ABSTRACT

Received: August 18, 2024

Accepted: September 23, 2024

Published: October 11, 2024

Assisted Reproductive Technology (ART) with Intra-cytoplasmic Sperm Injection (ICSI) 
commonly utilizes Bovine-Derived Hyaluronidase for oocyte denudation. The emergence 
of  Recombinant Cumulase as an alternative merit an examination of  its impact upon 
ICSI outcomes. We compared the effects of  Recombinant Cumulase and Bovine-Derived 
Hyaluronidase on oocyte denudation during ICSI, investigating impact upon fertilization 
rates, blastulation rates, and euploidy rates, aiming to improve clinical practice and optimize 
ART for patient outcomes. This was a retrospective observational study involving 59 patients 
undergoing ICSI conducted at First IVF Fertility Centre, Abu Dhabi, United Arab Emirates. 
Oocytes from each patient were divided one group which employed Recombinant Cumulase, 
and the other group utilised Bovine-Derived hyaluronidase. Parameters such as age, number 
of  oocytes retrieved, denudation outcomes, and euploidy rates were assessed to determine 
enzyme impact. Comparative analysis revealed no substantial difference in fertilisation rates 
or embryo development (blastocyst rate) between recombinant Cumulase and bovine-
derived Hyaluronidase. However, the recombinant Cumulase group exhibited signifi cantly 
higher (p<0.05) rates of  normal euploid embryos (Recombinant Cumulase-48.5%; Bovine 
Derived Hyaluronidase- 38.0%), indicating a potential advantage. However, the results 
are from small cohort and need to be validated with large sample size. Selecting enzymes 
for ART procedures is challenging. Although no signifi cant differences were observed in 
fertilisation rates, the Recombinant Cumulase group treated oocytes exhibited yielding 
higher normal euploid embryo rates. Not many studies have looked at the Euploidy rates 
with use of  different enzymes for oocyte denudation. Further investigations are essential to 
refi ne best practices and advance patient outcomes in assisted reproduction.

Keywords
Bovine-Derived Hyaluronidase, 
Euploidy, Intracytoplasmic 
Sperm Injection (ICSI), 
Pregnancy Rate, Recombinant 
Cumulase

1 Consultant Gynaecological Endocrinology & Reproductive Medicine and Chairman, First IVF Fertility Centre and Fakih IVF 
Centre Abu Dhabi, United Arab Emirates.
2 First IVF Fertility Centre Abu Dhabi, United Arab Emirates.
3 Reproductive Medicine and Infertility, First IVF Fertility Centre Abu Dhabi, United Arab Emirates.
4 First IVF Fertility Centre Abu Dhabi, United Arab Emirates.
5 Department of  Biological sciences, College of  Medicine and Health Sciences, Centre for Biotechnology, Khalifa University, Abu 
Dhabi, United Arab Emirates.
6 Reproductive Medicine, RCOG accredited sub specialist in Reproductive Medicine, Fakih IVF Fertility Centre Abu Dhabi, United 
Arab Emirates
*Corresponding author’s e-mail: muhammad.akhtar@fakihivf.com

INTRODUCTION
Reproductive health is a right of  every citizen (Mukurunge 
et al., 2023). Infertility impacts approximately 15%  
of  couples and has been present in around 20-30 % 
of   males worldwide (Al Khaldi et al., 2023).  Assisted 
Reproductive Technology (ART) has witnessed 
remarkable advancements, particularly with the Intra-
Cytoplasmic Sperm Injection (ICSI) as a groundbreaking 
technique in addressing a myriad of  infertility factor 
(Evison et al., 2009). Within the intricate process of  
ICSI, a critical procedural step involves the denudation 
of  oocytes, whereby the cumulus cells encapsulating the 
oocyte are removed, facilitating clear visualisation and 
assessment of  oocyte maturity and quality (de Moura 
et al., 2017). Hyaluronidase is an endoglycosidase that 
breaks down hyaluronic acid into monosaccharides by 
cleaving its glycosidic bonds; additionally, to some extent, 
it also breaks down other acid mucopolysaccharides in the 
connective tissue. (Jung et al., 2020). Traditionally, bovine-
derived Hyaluronidase has been the primary enzyme 
utilised for degrading the hyaluronic acid-rich cumulus 
cell matrix, coupled with mechanical pipetting for cell 
removal (de Moura et al., 2017). However, concerns 

surround the purity of  bovine-derived Hyaluronidase and 
the potential risk of  pathogenic transmission associated 
with its use, prompting a quest for alternative enzymes 
for oocyte denudation in the ICSI procedure (Evison 
et al., 2009). In the past, medical hyaluronidase was 
extracted from bovine or sheep testicles and used without 
purifi cation. However, the mammalian hyaluronidase 
obtained in this way was low in purity and contained 
components that could cause an immune response. 
Subsequently, purifi cation of  mammalian hyaluronidase 
was implemented as a processing step, and microbial 
hyaluronidase obtained from Streptococcus agalactiae 
bacteria was also used to reduce side effects. (Jung et al., 
2020). The emergence of  Cumulase, a recombinant form 
of  Hyaluronidase, presents a promising alternative. Its 
manufactured origin potentially mitigates concerns related 
to pathogenic transmission and purity associated with 
bovine-derived Hyaluronidase (Furuhashi et al., 2010). 
Given the signifi cant impact that the choice of  enzyme for 
oocyte denudation may have on successful fertilisation, 
subsequent embryo development, and clinical outcomes, 
an in-depth exploration into the comparative impacts 
of  recombinant and bovine-derived Hyaluronidase is 



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warranted (Tsampras et al., 2022). Cumulase acts as a 
protease, breaking down the protein matrix enveloping 
the cumulus cells, while Hyaluronidase disintegrates the 
hyaluronic acid binding the cumulus cells together (de 
Moura et al., 2017). Studies comparing the effi cacy of  
recombinant Cumulase and bovine derived Hyaluronidase 
for denudation have yielded varying results. Some suggest 
that recombinant Cumulase is more effective in removing 
cumulus cells and improving fertilisation rates, while 
others report no signifi cant differences between the 
two enzymes. Nonetheless, both enzymes are widely 
employed in clinical practice due to their demonstrated 
safety and effectiveness (Taylor et al., 2006, de Moura et 
al., 2017). Despite encouraging outcomes from the use of  
recombinant Cumulase® as part of  assisted reproductive 
technology (ART) ICSI treatment program, it is pertinent 
to conduct a comparison with conventional bovine-
derived Hyaluronidase to affi rm its effi cacy in UAE 
population. This study, conducted in the Fertility Centre 
in United Arab Emirates (UAE), aims to scrutinise the 
effectiveness and safety of  two types of  hyaluronidases 
currently available on the market: Cumulase, which is 
recombinant, and hyaluronidase (SAGE) derived from 
bovine source (Furuhashi et al., 2010, Tsampras et al., 
2022). We focus on examining how these two forms 
of  enzymes may impact not only fertilisation rates and 
blastocyst development rate (blastulation rate) but also 
whether these effects extend to variations in euploidy 
rates, potentially infl uencing the Clinical Pregnancy Rate 
(CPR) and Live birth rate (LBR). We examined the effects 
of  these enzymatic agents on sibling oocytes, fertilisation 
rates, blastulation rates, and crucially, euploidy rates. The 
evaluation of  these outcomes is vital for clinicians to 
make informed decisions and optimise the ART process 
for improved patient outcomes. This study endeavours 
to signifi cantly contribute to the understanding of  
enzymatic impacts on the ICSI process, guiding clinical 
practices in ART for improving successful pregnancy. 
Understanding the effects of  these enzymatic agents on 
fertilisation rates, blastulation rates, and, importantly, 
euploidy rates is imperative in optimising the ICSI process 
for improvement in clinical outcomes.

MATERIALS AND METHODS
It is a retrospective observational study at the First IVF 
Fertility Centre, Abu Dhabi, United Arab Emirates 
between September 2022 and August 2023.The data 
utilised in this research was sourced from the internal 
data management system, Meditex IVF (Germany). The 
dataset was acquired by fi ltering and selecting patients 
who fulfi lled predetermined inclusion criteria from the 
Meditex database. We included patients aged between 
23-45 years old, who underwent intracytoplasmic sperm 
injection (ICSI) pre genetic testing (PGTA) procedure as 
part of  their planned ART treatment and had undergone 
oocyte denudation using recombinant cumulase or bovine 
derived hyaluronidase (same patient had half  of  its oocytes 
denuded with recombinant cumulase and the other half  

with bovine derived Hyaluronidase- performed by a single 
senior embryologist) with  recorded data on fertilisation, 
embryo development with blastocyst (day 5/6 embryo) 
formation and embryo biopsy for genetic result with 
normal (euploid) and aneuploid (abnormal) embryos. We 
excluded patients with missing or incomplete data for the 
relevant outcome measures or key variables of  interest or 
who received alternative enzymes or additives (e.g. calcium 
ionophore) that could confound the comparison between 
recombinant cumulase and recombinant hyaluronidase or 
oocytes treated with only one of  the above denudation 
enzyme or patients who were subjected to non-standard 
IVF or ICSI protocols that might introduce variability 
in the outcomes. Procedure in embryology laboratory 
involved meticulous timed denudation process was used 
to eliminate the cumulus cells surrounding the oocytes. 
In this study, we used one of  the two enzymes for the 
denudation process with either recombinant cumulase 
(Cooper surgical, USA) or bovine derived hyaluronidase 
(Cooper surgical, USA)., for sibling oocytes from the same 
patient.  The process of  denudation was conducted by a 
senior embryologist to ensure consistency and minimize 
variability as per ASRM guidance. The removal of  the 
cumulus cell-oocyte complex (CCOC) was done using 
either bovine-derived hyaluronidase (Cooper surgical, 
USA) or Recombinant cumulase (Cooper surgical, USA). 
The oocytes underwent exposure to either recombinant 
cumulase or bivine derived hyaluronidase approximately 
three hours after collection, with the exposure lasting 
no longer than a minute. Subsequently, any remaining 
substances were gently aspirated using a glass pipette, 
followed by full denudation using a 140 μm fl exipet (RI 
EZ-Tip 140) immersed in warm HEPES-buffered oocyte 
wash solution for approximately two minutes, with a 
maximum duration of  fi ve minutes. Post-denudation, 
the oocytes were transferred to a SAGE culture dish 
with media and four milliliters of  oil. The maturity of  
the oocytes (with MII oocytes) was assessed before being 
returned to the incubator, and the Intracytoplasmic 
Sperm Injection (ICSI) procedure was carried out 30 
minutes later only for mature MII oocytes. The evaluation 
of  fertilisation status was conducted 14 to 18 hours post-
ICSI, where the presence of  pronuclei (PN) was examined. 
Normal fertilisation was identifi ed when two separate 
pronuclei, each with nucleoli, were observed (2PN). Eggs 
were discerned by their cytoplasm appearing diffuse or 
non-indicating a breakdown in the vitelline membrane. 
All oocytes were inseminated by ICSI after 40 hrs. of  
trigger dose in Handling Origio media w/HEPES under 
magnifi cation of  x400 using an inverted microscope 
(Olympus IX-73, Japan) and micromanipulator 
(Narishigie, Japan). After ICSI insemination, oocytes 
were group cultured in pre-equilibrated droplets of  25 µL 
of  Sage 1-step medium (Cooper Surgical Group, USA) 
overlaid with mineral oil (sage, Cooper Surgical, USA) in a 
MEA-tested dish. All embryos were incubated in a bench 
top incubator (K-System) at 37oC under atmosphere 
around 5.5% CO2, 5.0% O2 and 89.5% N2, and pH of  



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7.28 to 7.32. Fertilisation was checked 16-18 h after ICSI. 
Embryo development was evaluated only on day 5. On 
day 5 embryos were graded according to Gardener’s 
classifi cations (Gardner et al., 2000, Gardner et al., 2016) 
with blastocyst expansion graded on a numerical scale 
between 1 and 6. A trophectoderm biopsy was carried 
out on day 5 or 6 followed by vitrifi cation (Cryotech, 
Japan). Blastocysts of  grade 5 BB or better were biopsied 
and vitrifi ed. Biopsied trophectoderm cells were lysed 
and DNA was amplifi ed by Multiple Displacement 
Amplifi cation (MDA) (Harper et al., 2010;Cinnioglu 
et al., 2019). Library preparation was performed from 
the amplifi ed DNA then processed on Illumina’s 
Next Generation Sequencer, the MiSeq. Analysis was 
performed using Bluefuse analysis software. Numerical 
and structural chromosomal abnormalities were reported. 
The primary endpoints of  this process included assessing 
oocyte integrity post-denudation (with mature MII oocyte) 
as well as evaluating fertilisation rates, characterised 
by the presence of  2 pro nuclei (PN) and blastulation 
rates. The secondary endpoint involved determining 
the euploidy rate using next generation sequencing 
(NGS) on trophectoderm cells. All statistical analyses 
were carried out using SAS® software. Our approach 
involved conducting a comprehensive descriptive analysis 
to summarise and delineate the data succinctly. Essential 
summary statistics were computed for each enzyme group 
separately as well as for the entire dataset, encompassing 
measures including mean, median, and standard deviation 
for all collected variables. These calculations facilitated 
a comprehensive grasp of  both the central tendencies 
and the spread of  data within each group. Our primary 
objective was to ascertain whether a signifi cant disparity 
existed in the rates of  successful fertilisation between the 
two enzyme groups. A chi-square test of  independence 
was employed to assess the relationship between the type 
of  enzyme used and the defi nitive outcome of  successful 
fertilisation. This statistical test allowed us to determine 
whether the observed variations in proportions were 
statistically signifi cant or merely incidental. 

RESULTS AND DISCUSSION
59 patients underwent oocyte denudation using either 
Recombinant cumulase or bovine-derived Hyaluronidase. 
The total number of  oocytes denuded was 690 (350 
recombinant cumulase group and 340 in bovine derived 
hyaluronidase group). Mean patient age was 36±6 years, 
with an average of  16±9 oocytes retrieved per patient 
(Table 1)

Table 1: Summary of  Characteristics and Outcomes of  
Oocyte Denudation with Recombinant Cumulase and 
Bovine-Derived Hyaluronidase.
Characteristic
Mean ± std

All patients
(N=59)

Min-max

Age (years) 36 ± 6.0 23 – 47
Oocytes retrieved 16 ± 9 4 - 45

Recombinant
cumulase

Bovine derived 
hyaluronidase

Mean ± std.
Number of  
oocytes injected

6 ± 3.1 5.8 ± 3.2

Number of  
oocytes fertilised

4.2 ± 2.4 4.2 ± 2.8

Number of  
Blastocyst

2.3 ± 2.0 2.3 ± 2.2

Number of  
Euploid embryos 

1.1 ± 1.2 0.9 ± 1.2

The table displays the mean ± standard deviation values 
for various parameters for all patients. 
The comparison of  fertilisation and embryo development 
outcomes between recombinant cumulase and bovine 
derived hyaluronidase used in oocyte denudation for 
Intracytoplasmic Sperm Injection (ICSI), are shown in 
Figure 1.

Figure 1: Comparison of  Fertilisation and Embryo 
Development rates (%) between recombinant Cumulase 
and bovine-derived Hyaluronidase in Oocyte Denudation 
following ICSI.
The graph presents differences associated with various 
key parameters, including the number of  oocytes injected, 
fertilised, resulting blastocysts, and normal embryos. 
Each parameter’s signifi cance level is displayed, offering 
insights into the statistical signifi cance or insignifi cance 
of  differences observed between the two enzymatic 
treatments concerning fertilisation and subsequent embryo 
development outcomes during the ICSI procedure. 
Fertilisation rate (71.0% vs 73.8%) and blastocyst rate 
(54.4% vs 54.6%) between Recombinant cumulase 
and Bovine derived hyaluronidase treated oocytes 
respectively, was insignifi cant. However, Recombinant 
cumulase treated oocytes exhibited a signifi cantly higher 
proportion (p<0.05) of  euploid embryos compared 
to oocytes treated with Bovine derived hyaluronidase 
(48.5% vs 38.0%) (Figure 1; Table 2).



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Table 2: Summary of  fertilisation and embryo 
development of  oocytes treated with Recombinant 
cumulase and Bovine derived hyaluronidase.
Recombinant Cumulase
Injected Fertilised Blastocyst Euploid
350 250 136 66
Bovine derived hyaluronidase
Injected Fertilised Blastocyst Euploid
340 251 137 52

Discussion
The cumulus-corona-oocyte complex, composed 
of  cumulus granulosa cells embedded in a matrix 
of  hyaluronan oligosaccharide chains cross-linked 
by hyaluronan binding proteins and proteoglycans, 
surrounds each oocyte and must be removed prior 
to intracytoplasmic sperm injection (ICSI). Oocyte 
denudation is a very important step in assisted reproductive 
technologies (ART). The purpose is to remove the 
surrounding cumulus cells from the oocyte to facilitate 
fertilization and subsequent embryo development. This 
was traditionally achieved using enzymatic digestion of  
the matrix with a bovine-derived hyaluronidase followed 
by mechanical denudation through pipetting. (Evison et al., 
2009). Additionally, animal-derived combinations might 
contain proteins impacting human oocytes differently, 
inducing varied responses between Bovine derived 
hyaluronidase types and batches. (Ishizuka et al., 2014). 
Plant-derived preparations, like coronase were used as 
safer alternatives to minimize negative effects associated 
with bovine-derived enzymes (Parinaud et al., 1998). A 
human recombinant hyaluronidase (Cumulase) has been 
developed with the intent of  circumventing the problems 
and concerns associated with the animal origin and lack 
of  purity of  the bovine-derived form of  the enzyme. 
(Evison et al., 2009). In this study, oocyte denudation was 
compared between recombinant cumulase and bovine 
derived hyaluronidase with sibling oocytes form the same 
patient to see not only fertilization, blastocyst formation 
but importantly having euploid embryos which would 
increase the success of  ART. The absence of  variance 
in exposure time between both groups would strengthen 
the fi ndings, highlighting the consistency and reliability 
of  the fi ndings. Successful denudation was confi rmed 
by observing the extrusion of  the body indicating 
maturation. The endpoints of  this process included 
assessing oocyte integrity post-denudation, as well as 
evaluating fertilisation rates, characterized by the presence 
of  2 pro nuclei (PN) and blastocyst (blastulation) rates. 
But importantly to look at euploidy rates through NGS 
analysis, on trophectoderm cells. The utilization of  
Recombinant cumulase compared with bovine derived 
hyaluronidase showed higher euploidy rates, although the 
number of  patients were small. Further elucidation on 
the underlying factors of  bovine-derived hyaluronidase 
contributing to variations in euploidy rates is warranted 
for a comprehensive understanding of  its impact on 

assisted reproduction outcomes. However, it’s important 
to note that this observation is important but has to be 
assessed with caution based on the sample size. Further 
investigation with a larger sample size in a prospective 
study in the future is necessary to elucidate whether there 
is a notable difference in euploidy rates between the two-
enzyme treatment. The inclusion of  euploidy testing in 
the study holds considerable importance as it provides 
insights into the chromosomal integrity of  embryos, 
thereby infl uencing clinical outcomes. However, the 
discussion concerning the results obtained from Next 
Generation Sequencing (NGS) is somewhat limited 
and warrants further elaboration. Delving deeper into 
the implications of  euploidy rates derived from NGS 
data could shed light on their association with clinical 
pregnancy rates (CPR) or live birth rates (LBR), thus 
offering valuable insights into the overall effectiveness 
of  the techniques employed in the study. As outlined 
in an earlier study reported that recombinant cumulase 
has a signifi cant increase in fertilization compared to 
bovine derived hyaluronidase, (Evison et al., 2009). 
In our study, fertilisation rates fertilization appeared 
slightly lower in the Recombinant Cumulase group 
(71.4%) compared to Bovine-Derived Hyaluronidase 
(73.8%), although the blastocyst formation rates showed 
negligible differences (54.4% for Recombinant Cumulase 
vs. 54.6% for Bovine-Derived Hyaluronidase). This study 
shows there was a signifi cant difference in the effect of  
oocyte denudation time on embryo quality at assisted 
reproductive technology clinic. the denudation time of  
3-4 hours group showed the highest result. There was 
no signifi cant difference in the effect of  intracytoplasmic 
sperm injection (ICSI) time on embryo quality at assisted 
reproductive technology clinic. (Tjahyadi et al., 2022). 
We followed the denudation times as per this study. The 
longstanding use of  Bovine-Derived Hyaluronidase in 
oocyte denudation raised concerns regarding low purity 
and variable concentrations, potentially risking prolonged 
exposure and consequent DNA damage to oocytes. (Jung 
et al., 2020). Various studies comparing Recombinant 
Cumulase and Bovine-Derived Hyaluronidase highlighted 
Recombinant Cumulase safety and non-inferior effi ciency, 
showcasing similar or improved parameters in fertilisation 
and embryo growth. (Taylor et al., 2006, Vos et al., 2008). 
This study emphasized Recombinant Cumulase ‘s effi cacy 
and safety advantages over bovine derived forms. (Evison 
et al., 2009) A study by on porcine oocytes confi rmed the 
suitability of  human recombinant Hyaluronidase for 
denudation without detrimental effects on oocyte quality. 
a human recombinant hyaluronidase, was found to be 
effective for oocyte denudation prior to microinjection, 
ICSI. Although animal-derived hyaluronidases are used to 
reduce the cost, they carry several risks from impurities 
as they are extracted from the testicles of  animals and 
may contain various other proteins. (Lee et al., 2021).  
Methodological variations across studies, including 
denudation techniques, enzyme concentrations, and 
exposure times, limit direct comparisons. Lower enzyme 



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concentrations potentially improved blastocyst rates 
and reduced costs, but further validation in laboratory 
settings is necessary3. Additionally, reports on increased 
Ca2+ levels and decreased embryonic potential associated 
with Bovine derived hyaluronidase require further 
investigation. (Ashibe et al., 2021). Another study showed 
no signifi cant differences in survival, fertilisation, or 
embryo development among varied Bovine derived 
hyaluronidase concentrations and mechanical denudation 
methods. (Van de Velde et al., 1997).  This review reported 
comparable fertilisation rates between recombinant 
and Bovine-Derived Hyaluronidase, aligning with our 
observations. (Rubino et al., 2016). A systematic review 
and meta-analysis from three RCTs involving 2445 
oocytes collected from 200 women were analysed, 
the available moderate to high quality trials found no 
statistical difference in fertilisation rate, embryo quality 
and live birth rate between the use of  recombinant or 
bovine hyaluronidase for oocyte denudation before ICSI. 
(Tsampras et al., 2022). However, none of  the RCTs 
looked at Euploidy rates. Our study showed similar 
fi ndings as the above systematic review and meta-analysis 
but we looked at the Euploid embryos. Interestingly, the 
percentage of  normal euploid embryos was relatively 
higher in the Recombinant Cumulase group (48.5%) 
compared to Bovine-Derived Hyaluronidase (38.0%). 
While the results suggest promising trends favoring 
Recombinant cumulase in terms of  higher normal euploid 
embryo rates, additional research with larger sample 
size is required to validate these fi ndings and elucidate 
the underlying mechanisms. Our fi ndings suggest that 
the choice of  the enzyme may not signifi cantly affect 
fertilisation rates or subsequent embryo development. 
However, ongoing research on denudation techniques, 
enzyme concentrations, and exposure times remains 
pivotal for each embryology laboratory and should 
constantly be monitored. Future studies should 
encompass confounding factors affecting oocyte quality 
and embryonic development, aiming to establish optimal 
enzyme concentrations, exposure durations, and cost-
effective approaches towards higher live birth rates.

CONCLUSION
This comparative study compared the effects of  
recombinant cumulase and bovine-derived Hyaluronidase 
on oocyte denudation for ICSI in sibling oocytes from the 
same patient performed by a single senior embryologist. 
Results from the analysis of  59 patients showed no 
substantial differences in fertilisation rates or embryo 
development between the two enzymes. However, 
Recombinant cumulase demonstrated a statistically 
signifi cant increase in normal euploid embryos, indicating 
a potential advantage over bovine-derived Hyaluronidase. 
Euploid rates had not been looked when comparing these 
two enzymes for denudation. However, the sample size 
of  our study is small and fi ndings have to be viewed with 
caution. A larger prospective study comparing these two 
enzymes for oocyte denudation should be performed with 

euploidy rate as an end point. These fi ndings emphasise the 
complexity of  enzyme selection in assisted reproduction 
and underline the necessity for ongoing research to 
optimise techniques for improving live birth rates in 
ART treatments. Further comprehensive investigations 
are imperative to ascertain subtle differences between 
enzymatic approaches and refi ne best practices in assisted 
reproduction for enhanced patient outcomes.

Strengths and limitations
The strength of  this study is robust retrospective design 
with a substantial cohort with sibling oocytes of  the same 
patient to have an accurate comparison, standardised 
denudation techniques, and assessment of  euploidy 
rates. The procedure was performed by a single senior 
embryologist. The limitation is inherent confounders in 
retrospective analysis, smaller sample size and geographic-
specifi c data

Ethics approval and consent to participate.
This study was conducted in strict adherence to ethical 
principles and guidelines. The research protocol and 
data collection procedures were approved by the 
Internal Research Ethics Committee of  the First IVF 
Fertility Centre (Committee REC - FIVF-001) and the 
International Review Board of  the Emirates of  Abu 
Dhabi (ADHRTC-2023-114). All efforts were made to 
safeguard the confi dentiality and privacy of  their personal 
information throughout the study. 

Acknowledgement
The authors thank Ms. Leyla Depret-Bixio biostatistician 
for her support in this study.

Competing interest
The author(s) declares no confl ict of  interest.

Funding
There has been no funding received for this study.

Data Availability Statement
The data supporting the fi ndings of  this study are stored 
in software Meditex IVF (Germany), which is designed 
specifi cally for In-Vitro Fertilization (IVF) clinics. 
Meditex IVF (Germany) serves as a tool for managing and 
documenting patient data within Assisted Reproduction 
organisations. However, it’s important to note that there 
are restrictions on accessing this data due to licensing 
agreements for this study. Therefore, the data cannot be 
accessed publicly. Nevertheless, the authors of  the study 
are willing to provide access to the data upon request.

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