BACKGROUND

Although infertility is a serious concern in survivors of pediatric cancers, little is known about the influence of the degree of sexual maturation at the time of irradiation on spermatogenic recovery after treatment. Thus, we address this question in a non-human primate model, the rhesus monkey (Macaca mulatta).

METHODS

Two pubertal (testis size 3 and 6.5 ml, no sperm in ejaculate) and four prepubertal (testis size 1 ml, no sperm in ejaculate) macaques were submitted to a single fraction of testicular irradiation (10 Gy). Unilateral autologous transfer of cryopreserved testis cells was performed 2 months after irradiation. Testicular volume, histology and semen parameters were analyzed to assess irradiation effects and testicular recovery.

RESULTS

Irradiation provoked acute testis involution only in the two pubertal monkeys. Subsequently, testis sizes recovered and sperm was present in the ejaculates. Longitudinal outgrowth of seminiferous tubules continued, and, in testes without autologous cell transfer, 4–22% of tubular cross sections showed spermatogenesis 2 years after irradiation. In contrast, the four prepubertal monkeys showed neither a detectable involution as direct response to irradiation, nor a detectable growth of seminiferous tubules later. However, two of these animals showed spermarche 2 years after irradiation, and 8–12% of tubules presented spermatogenesis. One prepubertally irradiated monkey presented fast growth of one testis after cell transfer, and showed spermarche 1 year after irradiation. The infused testis had spermatogenesis in 70% of the tubules. The contralateral testis remained smaller.

CONCLUSION

We conclude that irradiation before puberty has a severe detrimental effect on outgrowth of seminiferous tubules. But, within the seminiferous epithelium, spermatogenetic recovery occurs at a low rate with no detectable relation to the maturity of the epithelium at irradiation. We also show that autologous testis cell transplantation can enhance spermatogenesis, but only in isolated cases.

BACKGROUND

The purpose of this study was to optimize the electrophoretic conditions that should be used for the effective isolation of functional human spermatozoa and to determine whether this method of isolating cells was associated with oxidative stress and DNA damage.

METHODS

Human spermatozoa were prepared by repeated centrifugation, discontinuous density gradient centrifugation and electrophoresis followed by assessments of sperm quality.

RESULTS

Systematic analysis of optimal electrophoresis conditions demonstrated that field strength was positively correlated with sperm recovery rates but negatively correlated with sperm movement, irrespective of whether the current or the voltage was held constant. This loss of functionality observed at high power settings was not associated with a major increase in superoxide generation or the induction of oxidative DNA damage. In contrast, discontinuous Percoll gradient centrifugation was shown to produce a significant rise in oxidative DNA base adduct expression in live cells (P < 0.05). As a result of these analyses, optimized electrophoretic conditions were defined that permitted sperm recovery rates of around 20%. These electrophoretically isolated cells were not only free of oxidative stress but exhibited significantly enhanced motility (P < 0.01) and vitality (P < 0.001) compared with the original samples.

CONCLUSIONS

We conclude that while field strength is positively correlated with sperm recovery rates; it is negatively associated with sperm motility. Optimized conditions are described that represent a balance between these opposing forces and permit the isolation of highly motile, vital sperm populations, free from the oxidative DNA damage associated with conventional density gradient centrifugation technologies.

BACKGROUND

Couples with recurrent miscarriage (RM) have an increased risk of one of the partners carrying a structural chromosome abnormality. On the basis of four independent risk factors, an evidence-based model was developed, which allows limiting karyotyping to high-risk couples. The aim of this study was to assess the level of adoption of selective karyotyping, its clinical consequences and the factors at the patient and hospital level that determine adoption.

METHODS

A retrospective cohort study was performed in nine Departments of Obstetrics and Gynaecology, the Netherlands, in 2006. Selective karyotyping was defined as offering karyotyping to high-risk couples and refraining from karyotyping in low-risk couples. Data were collected for risk factors as described in the model for selective karyotyping, cytogenetic results as a measure for clinical consequences, and information about determinants and costs.

RESULTS

A total of 530 couples were included; 252 (48%) high-risk couples and 278 (52%) low-risk couples. Among the high-risk couples, 186 (74%) were offered karyotyping. Although not advised, karyotyping was still performed in 198 (71%) low-risk couples. Overall, selective karyotyping was offered to 50% of the couples. The main determinants for adoption of the model were maternal age, obstetric history, treatment by specialists in RM and the number of patients per centre. If selective karyotyping was adopted adequately, a potential reduction of 34% of all karyotyping tests performed is possible.

CONCLUSION

Selective karyotyping is applied in only half of the couples with RM in daily practice. Implementation of selective karyotyping should be a topic of future research.

BACKGROUND

Peripheral natural killer (pNK) and uterine NK (uNK) cells have been associated with reproductive failure. We systematically reviewed the literature to assess whether numbers or activity of pNK or uNK cells predicted subsequent pregnancy and outcome.

METHODS

We searched the electronic MEDLINE database from 1950 to April 2010 for relevant publications by using MeSH terms ‘natural killer cells’, ‘reproduction’ and ‘pregnancy complications’. We included studies that measured pre-pregnancy pNK and uNK cell numbers or activity in women with recurrent miscarriage (RM) or infertility, and reported subsequent pregnancy outcomes of miscarriage or failure to conceive after assisted reproductive technology (ART).

RESULTS

The search identified 783 publications and 12 fulfilled the inclusion criteria. There were too few women entered into the observational studies to assess whether high pNK cell percentages or activity predicted subsequent miscarriage in women with idiopathic RM (numbers: n = 32, OR 17, 95% CI 0.82–350.6, activity: n = 92, OR 2.51, 95% CI 0.16–40.29), or implantation failure (n = 203, OR 1.35, 95% CI 0.28–6.46), or miscarriage in infertile women after ART (n = 79, OR 2.48, 95% CI 0.50–12.32). Similarly, the studies of uNK cells were not large enough to assess whether abnormal uNK cell density predicted subsequent miscarriage in women with idiopathic RM (n = 72, OR 1.33, 95% CI 0.16–11.11). None of the uNK cell studies in women with infertility reported pregnancy outcomes dichotomized for uNK cell numbers.

CONCLUSIONS

The prognostic value of measuring pNK or uNK cell parameters remains uncertain. More studies are needed to confirm or refute the role of NK cell assessments as a predictive test for screening women who may benefit from immunotherapy.

BACKGROUND

The aim of this study was to determine the relationship between nutrient utilization by the human embryo and its subsequent viability after transfer.

METHODS

The embryos of 50 patients having single blastocyst transfer were cultured individually from Day 3 in 10 µl drops of medium G2 under Ovoil in 5%O₂, 6%CO₂, 89%N₂. Patient inclusion in the study was maternal age ≤38. Embryos were moved to fresh drops of medium every 24 h. Spent media samples, including controls containing no embryo, were coded, frozen and subsequently analysed blind. Analysis of glucose was performed by microfluorimetry. The sex of children born was recorded.

RESULTS

Clinical pregnancy and live birth rates were 58 and 56%, respectively. Glucose consumption by embryos which resulted in a pregnancy was significantly higher on both Day 4 and Day 5 than that by embryos which failed to develop post-transfer (P< 0.01). Furthermore, on Day 4 female embryos consumed 28% more glucose compared with males (P< 0.05). Glucose uptake was independent of embryo grade.

CONCLUSIONS

The rapid screening of glucose metabolism by the human embryo on Day 4 and 5 may prove to be a useful metric in the development of algorithms for the selection of embryos for transfer in human IVF. Also, the observed sex-related metabolic difference provides preliminary data to support the hypothesis that male and female human embryos differ in their physiology due to the presence of two active X chromosomes and an altered proteome for a finite time during the preimplantation period.

BACKGROUND

Intact frozen-thawed embryos have a greater potential than damaged embryos to establish successful pregnancies. This study aimed to determine whether elevated concentrations of sucrose during freezing would increase the proportion of patients with ≥50% of embryos intact after thawing (primary outcome), and improve clinical outcome.

METHODS

In a two arm, parallel group, pragmatic trial, IVF/ICSI couples were randomized prospectively to have their supernumerary embryos frozen in a medium containing 0.1 M sucrose (control; n = 99) or 0.3 M sucrose (intervention; n = 102).

RESULTS

More control (74/99) than intervention (63/102) couples had at least one embryo thawed (P = 0.07). Significantly more (P = 0.005) intervention (53/63) than control (45/74) couples had ≥50% of embryos intact. Freezing in a medium containing 0.3 M sucrose increased by 3.4-fold [95% confidence interval (CI) (1.45, 7.82)] the likelihood of a couple having ≥50% of their embryos intact. In the fresh cycle, live birth rate per transfer was similar in the control (35/95) and intervention (36/93) groups (P = 0.91). More control (19/63) than intervention (9/59) couples had a live birth after frozen embryo transfer (P = 0.08). When fresh and frozen cycles were combined, fewer intervention (n = 102) than control (n = 99) couples had at least one live birth (42 versus 53%). The difference in cumulative live birth rate was not significant [hazard ratio = 0.75, 95% CI (0.49, 1.13); P = 0.17].

CONCLUSIONS

Increasing the concentration of sucrose in the freezing medium improves embryo survival, but this is not reflected by increased cumulative birth rates.

Clinical Trials Registration number: ISRCTN93314892.

BACKGROUND

Freezing/vitrifying and thawing/warming of embryos may impair the successful hatching process of the embryo out of its zona pellucida (ZP) and its following implantation into the uterus. Theoretically, assisted hatching (AH) may facilitate the hatching process and subsequently increase implantation rates (IRs).

METHODS

In this prospective randomized controlled trial (RCT), the hypothesis was tested that the IR per embryo transferred is higher after transfer (ET) of frozen/vitrified-thawed/warmed embryos with thinned ZP after AH by modified quarter laser-assisted zona thinning (mQLAZT) when compared with ET of frozen/vitrified-thawed/warmed embryos without mQLAZT. Patients with frozen/vitrified embryos were randomized at the time of thawing/warming to a study group (with mQLAZT) or a control group (without mQLAZT). After thawing/warming, embryos were kept in culture for 24h, and mQLAZT was performed prior to ET.

RESULTS

A total of 647 thawing cycles were randomized to either the mQLAZT group (n = 324) or the control group (n = 323). Reproductive outcome data were available for 302 cycles in the mQLAZT group and 317 cycles in the control group. Transfer could be performed in 73.5% and in 71.9% of the thawing/warming cycles in the mQLAZT group and the control group (P = 0.78), respectively. No significant differences were observed between the mQLAZT group and the control group for the IR [13.3%; 15.6%; rate ratio 0.85; 95% confidence interval (CI), 0.596–1.224], the ongoing IR (10.5 and 13.5%, P = 0.25) and the live birth rate [10.5%;13.3%; rate ratio 0.79; (95% CI), 0.530–1.189] per embryo transferred.

CONCLUSIONS

In this RCT, mQLAZT did not improve the IR per embryo transferred in frozen/vitrified-thawed/warmed embryo transfer cycles.

ClinicalTrials.govID NCT00593775.

BACKGROUND

The aim of this study was to compare the oncologic and reproductive outcomes of patients with borderline ovarian tumours (BOTs) who were treated with cystectomy or unilateral salpingo-oophorectomy (USO).

METHODS

The medical records of patients with BOTs who were treated between 1997 and 2009 were reviewed retrospectively. The recurrence rates were compared between the USO and cystectomy groups. The reproductive outcomes were assessed by telephone interviews.

RESULTS

Patients with BOTs underwent a USO (n= 117) or cystectomy (n= 38). There were 12 patients who had recurrences: 1 patient had an invasive recurrence and 11 had borderline recurrences. The recurrence rate in the USO group (6.0%) was lower than in the cystectomy group (13.2%); however, this difference was not statistically significant (P= 0.110). All of the patients with recurrences were successfully treated with surgery and there was no clinical evidence of disease. Of the 116 patients contacted by telephone, 113 (97.4%) resumed menstruation following the surgery, and 45 of the 52 patients (86.5%) who attempted to conceive had successful pregnancies. USO (89.2%), like cystectomy (85.7%), resulted in excellent pregnancy rates for patients with BOTs.

CONCLUSIONS

A USO is an appropriate treatment for women with BOTs who wish to preserve fertility. However, a cystectomy is a satisfactory fertility-sparing therapy when a cystectomy is the only surgical option.

BACKGROUND

Gynaecological laparoscopic surgery outcomes can be compromised by the formation of de novo adhesions. This randomized, double-blind study was designed to assess the efficacy and safety of 4% icodextrin solution (Adept^®) in the reduction of de novo adhesion incidence compared to lactated Ringer's solution (LRS).

METHODS

Patients undergoing laparoscopic surgery for removal of myomas or endometriotic cysts were treated with randomized solution as an intra-operative irrigant and 1l post-operative instillate. De novo adhesion incidence (number of sites with adhesions), severity and extent were independently scored at a second-look procedure and the efficacy of the two solutions compared. The effect of surgical covariates on adhesion formation was also investigated. Initial exploratory analysis of individual anatomical sites of clinical importance was progressed.

RESULTS

Of 498 patients randomized, 330 were evaluable (160 LRS – 75% myomectomy/25% endometriotic cysts; 170 Adept – 79% myomectomy/21% endometriotic cysts). At study completion, 76.2% LRS and 77.6% Adept had ≥1 de novo adhesion. The mean (SD) number of de novo adhesions was 2.58 (2.11) for Adept and 2.58 (2.38) for LRS. The treatment effect difference was not significant (P = 0.909). Assessment of surgical covariates identified significant influences on the mean number of de novo adhesions regardless of treatment, including surgery duration (P = 0.048), blood loss in myomectomy patients (P = 0.019), length of uterine incision in myomectomy patients (P < 0.001) and number of suture knots (P < 0.001). There were 15 adverse events considered treatment-related in the LRS patients (7.2%) and 18 in the Adept group (8.3%). Of 17 reported serious adverse events (9 LRS; 8 Adept) none were considered treatment-related.

CONCLUSIONS

The study confirmed the safety of Adept in laparoscopic surgery. The proportion of patients with de novo adhesion formation was considerably higher than previous literature suggested. Overall there was no evidence of a clinical effect but various surgical covariates including surgery duration, blood loss, number and size of incisions, suturing and number of knots were found to influence de novo adhesion formation. The study provides direction for future research into adhesion reduction strategies in site specific surgery.

BACKGROUND

The relationship between the use of oral contraception (OC) and endometriosis remains controversial. We therefore compared various characteristics of OC use and the surgical diagnosis of endometriosis histologically graded as superficial peritoneal endometriosis (SUP), ovarian endometrioma (OMA) or deep infiltrating endometriosis (DIE).

METHODS

This cross-sectional study included 566 patients without visible endometriosis at surgery as controls, and 410 patients with histologically proven endometriosis, categorized by their worst lesions as SUP n = 47, OMA n = 120 and DIE n = 243. Personal data, including on OC use, were prospectively collected during standardized interviews. Statistical analysis was performed using unconditional logistic regression.

RESULTS

Past OC users had an increased incidence of endometriosis (adjusted odd ratios (OR) = 2.79, 95% confidence interval (CI) 1.74–5.12, P = 0.002) of any revised American Fertility Society stage. Women who had previously used OC for severe primary dysmenorrhea were even more frequently diagnosed with endometriosis (adjusted OR = 5.6, 95% CI 3.2–9.8), especially for DIE (adjusted OR = 16.2, 95% CI 7.8–35.3). Women who had previously used OC for other reasons also had an increased risk of endometriosis, but to a lesser extent (adjusted OR = 2.6, 95% CI 1.8–4.1). The age at which OC was initiated, duration of OC use and free interval from last OC use were not significantly different between control and endometriosis women, irrespective of histological grading. Current OC users did not show an increased prevalence of endometriosis (OR = 1.22, 95% CI 0.6–2.52).

CONCLUSIONS

Our data indicate that a history of OC use for severe primary dysmenorrhea is associated with surgical diagnosis of endometriosis, especially DIE, later in life. However, this does not necessarily mean that use of OC increases the risk of developing endometriosis. Past use of OC for primary dysmenorrhea may serve as a marker for women with endometriosis and DIE.

BACKGROUND

To investigate the long-term changes in health-related quality of life (HRQOL) after uterine artery embolization (UAE) for symptomatic fibroids, we conducted a prospective cohort study.

METHODS

Eighty-two women completed the validated uterine fibroid symptom and QOL (UFS-QOL) questionnaire before UAE. Short-term results after a median of 8 months (range: 3–20) have been published previously. Patients were asked to complete the questionnaire again after a median of 6.3 years (range: 5–7.6). Secondary outcome measures were the frequency of additional surgical or endovascular procedures due to treatment failure and the menstrual status.

RESULTS

A total of 4/82 patients (5%) were lost to follow-up. Of the remaining 78 patients, 11 underwent surgery or repeat UAE (hysterectomy n = 6, myomectomy n = 1, UAE n = 4) at a median of 13 months (range: 5–70) after UAE. Two patients failed clinically but did not undergo a second intervention. The overall treatment failure rate 6 years after UAE was 17%. Clinical long-term follow-up regarding symptom control and quality of life was available in the remaining 65 patients. Symptom severity scores decreased from a median of 37.50 (quartile range, QR: 28.13–53.13) to 0.00 (QR: 0.00–10.94) (P < 0.001), whereas the HRQOL total score increased from a median of 64.66 (QR: 46.34–79.10) to 100.00 (QR: 96.12–100.00) (P< 0.001). Both scores also improved significantly compared with short-term results (P= 0.006 and P= 0.041). Permanent amenorrhea was observed in five patients at a median of 18 months (range: 10–46) after UAE and at a mean patient age of 50 years.

CONCLUSIONS

UAE leads to durable relief of fibroid-related symptoms and sustained improvement in HRQOL. After 6 years, clinical failure can be expected in 17%, and most of these patients require secondary invasive treatment.

BACKGROUND

To study the effect of metformin before and during assisted reproductive technology (ART) on the clinical pregnancy rate (CPR) in non-obese women with polycystic ovary syndrome (PCOS).

METHODS

A multi-centre, prospective, randomized, double-blind study was conducted in eight IVF clinics in four Nordic countries. We enrolled 150 PCOS women with a body mass index <28 kg/m², and treated them with 2000 mg/day metformin or identical placebo tablets for ≥12 weeks prior to and during long protocol IVF or ICSI and until the day of pregnancy testing. The primary outcome measure was CPR. Secondary outcome measures included spontaneous pregnancy rates during the pretreatment period, and the live birth rate (LBR).

RESULTS

Among IVF treated women (n = 112), biochemical pregnancy rates were identical in both groups (42.9%), and there were no significant differences in the metformin versus the placebo group in CPR [39.3 versus 30.4%; 95% confidence interval (CI): –8.6 to 26.5]. The LBR was 37.5 versus 28.6% (95% CI: –8.4 to 26.3). However, prior to IVF there were 15 (20.3%) spontaneous pregnancies in the metformin group and eight (10.7%) in the placebo group (95% CI: –1.9 to 21.1; P = 0.1047). According to intention to treat analyses (n = 149); significantly higher overall CPR were observed in the metformin versus placebo group (50.0 versus 33.3%; 95% CI: –1.1 to 32.3; P = 0.0391). LBR was also significantly higher with use of metformin versus placebo (48.6 versus 32.0; 95% CI: 1.1 to 32.2; P = 0.0383). No major unexpected safety issues or multiple births were reported. More gastrointestinal side effects occurred in the metformin group (41 versus 12%; 95% CI: 0.15 to 0.42; P < 0.001).

CONCLUSIONS

Metformin treatment for 12 weeks before and during IVF or ICSI in non-obese women with PCOS significantly increases pregnancy and LBRs compared with placebo. However, there was no effect on the outcome of ART per se.

Trial registration: ClinicalTrials.gov Identifier: NCT00159575.

BACKGROUND

In Brazil, access to infertility care, including assisted reproductive technology (ART) is restricted. This is a second report of a study which evaluated the availability and access of low-income couples to ART services. The objective was to assess the perspective of health professionals and patients with respect to access to ART procedures within the public health network

METHODS

Qualitative case studies were conducted in five centres offering ART in the public sector. Semi-structured interviews were conducted with 19 health professionals based at these centres and 48 patients (men and women). Data were analysed using thematic content analysis.

RESULTS

All services implemented ART procedures using resources already available. In all except one centre, patients had to pay for the drugs used for the procedures and, in some cases, a fee to cover operative costs and supplies. These charges were incompatible with the financial possibilities of the majority of the low-income Brazilian population. The waiting time for access to ART varied between 3 months and 6 years. In the perspective of both patients and health professionals, the government should help centres to offer ART procedures at no cost to low-income populations.

CONCLUSIONS

The low-income Brazilian population has limited access to ART procedures at the public services. The implementation of ART services cannot be based only on initiatives of the professionals involved but must be part of public health policies. One possible solution is to provide ART at lower cost, making it accessible for a large part of the population.

BACKGROUND

Fertility expectations for patients with Turner's syndrome (TS) have clearly changed in the last three decades. However, medical risks during pregnancy are supposed to be highly increased. The aim of the study was to assess clinical outcome and obstetrical complications in a series of patients with TS in an oocyte donor programme.

METHODS

A retrospective study was carried out on 24 women with TS seeking a pregnancy in the Fertility Clinic of the Erasme Hospital from 1992 up until March 2011.

RESULTS

Twenty-three patients with TS were included in an oocyte donation cycle. Forty-nine oocyte donation cycles were performed, which led to 45 fresh and 10 frozen-thawed embryo transfers. Altogether, 18 pregnancies were obtained, 10 deliveries (9 singletons and 1 pair of twins), 3 miscarriages and 5 biochemical pregnancies. The clinical pregnancy rate per transfer was 24.4% in fresh cycles and 20% in frozen replacement cycles. Complications of pregnancy occurred in 5 of 10 pregnancies (50%), which led to three premature deliveries because of pregnancy-induced hypertensive disorders. The mean birthweight (g) (±SD) for singletons and twins was 2728 ± 577 and 2335 ± 318, respectively. Four babies were below the 10th percentile. No cardiac complications were observed in any of the pregnant women.

CONCLUSIONS

Pregnancy rates after oocyte donation in patients with TS are comparable with those previously published but a high risk of pregnancy hypertensive disorders and a high risk of low birthweight can be highlighted from our study. Strict inclusion criteria and single embryo transfer are necessary to minimize complications during pregnancy in this high-risk group.

BACKGROUND

Serum antibodies against major outer membrane protein (MOMP) and heat shock protein 60 (HSP60) from Chlamydia trachomatis are correlated with sequelae following infection. Since bacterial and human HSP60 share considerable sequence homology, cross-reactivity to human HSP60 is suggested as being involved in tubal factor infertility (TFI). The aim was to investigate whether antibodies to human HSP60 are associated with TFI, and to evaluate antibody testing in TFI diagnosis.

METHODS

Serum levels of antibodies against chlamydial MOMP and HSP60 from C. trachomatis, Salmonella enterica Enteritidis, Campylobacter jejuni and human HSP60 were analysed by enzyme-linked immunosorbent assay in three groups of infertile women: women with TFI (n= 70), controls with normal fallopian tubes (control group 1, n= 92) and a subgroup of women with normal fallopian tubes and sero-positive for either chlamydial MOMP or chlamydial HSP60 (control group 2, n= 28).

RESULTS

Serum levels of immunoglobulin (Ig)G1 and IgG3 antibodies against MOMP and HSP60 from C. trachomatis were elevated in patients with TFI compared with non-TFI individuals (group 1; P <0.001), while levels of IgG3 against MOMP and IgG1 against HSP60 were higher in the TFI group compared with control group 2 (P= 0.04 and P= 0.03, respectively). Levels of antibodies against human HSP60 did not differ between groups.

CONCLUSIONS

Our findings confirm an association between TFI and antibodies to MOMP and HSP60 from C. trachomatis, suggesting antibody testing as a supplement in TFI diagnosis. No connection was observed between TFI and antibodies to human HSP60, pointing to an infectious rather than an autoimmune inflammation as the cause of TFI.