STUDY QUESTION

Does surgical and low-dose progestin treatment differentially affect endometriosis-associated severe deep dyspareunia in terms of sexual functioning, psychological status and health-related quality of life?

SUMMARY ANSWER

Surgery and progestin treatment achieved essentially similar benefits at 12-month follow-up, but with different temporal trends.

WHAT IS ALREADY KNOWN

Conservative surgery and hormonal therapies have been used independently for endometriosis-associated deep dyspareunia with inconsistent results.

STUDY DESIGN, SIZE, DURATION

Patient preference, parallel cohort study with 12-month follow-up. The effect of conservative surgery at laparoscopy versus treatment with a low dose of norethisterone acetate per os (2.5 mg/day) in women with persistent/recurrent severe deep dyspareunia after first-line surgery was compared.

PARTICIPANTS/MATERIALS AND SETTING, METHODS

A total of 51 patients chose repeat surgery and 103 progestin treatment. Variations in sexual function, psychological well-being and quality of life were measured by means of the Female Sexual Function Index (FSFI), the Hospital Anxiety and Depression Scale (HADS) and the Endometriosis Health Profile-30 (EHP-30).

MAIN RESULTS AND THE ROLE OF CHANCE

Four women in the surgery group and 21 women in the progestin group withdrew from the study for various reasons. Total FSFI scores, anxiety and depression scores and EHP-30 scores improved immediately after surgery, but worsened with time, whereas the effect during progestin use increased more gradually, but progressively, without overall significant between-group differences at 12-month follow-up. A tendency was observed towards a slightly better total FSFI score after surgery at the end of the study period.

LIMITATIONS, REASONS FOR CAUTION

Treatments were not randomly allocated, and distribution of participants as well as of dropouts between study arms was unbalanced. However, the possibility of choosing the treatment allowed assessment of the maximum potential effect size of the interventions.

WIDER IMPLICATIONS OF THE FINDINGS

Both surgery and medical treatment with progestins are valuable options for improving the detrimental impact of endometriosis-associated dyspareunia on sexual functioning and quality of life. Women should be aware of the pros and cons of both options to decide which one best suits their needs.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by a research grant from the University of Milan School of Medicine (PUR number 2009-ATE-0570). None of the authors have a conflict of interest.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/28/5/1221?rss=1

STUDY QUESTION

Will sequential administration of highly purified (hp)-HMG after corifollitropin alfa in a GnRH antagonist protocol benefit women with poor ovarian response according to the Bologna criteria?

SUMMARY ANSWER

Corifollitropin alfa followed by hp-HMG in a GnRH antagonist protocol results in very promising pregnancy rates, albeit only in young (<40 years old) poor ovarian responders fulfilling the Bologna criteria.

WHAT IS KNOWN ALREADY

Poor ovarian responders fulfilling the Bologna criteria have a very poor prognosis in terms of successful IVF outcome. Although a recent study demonstrated low pregnancy rates in this group of patients after treatment with corifollitropin alfa followed by recombinant FSH in a GnRH antagonist protocol, previous studies showed that the addition of LH activity in 36- to 39-year-old women significantly increases implantation rates.

STUDY DESIGN, SIZE, DURATION

In this retrospective pilot study, we included poor ovarian responders fulfilling the Bologna criteria treated with a completely novel protocol, with corifollitropin alfa followed by hp-HMG in a GnRH antagonist setting. Overall, 51 patients were treated within a period of 1 year (August 2011–August 2012).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Patients received 150 μg corifollitropin alfa on second day of the menstrual cycle followed by a fixed daily dose of 0.25 mg of GnRH antagonist on Day 7 of the cycle onwards. On the ninth day of the cycle, a daily fixed dose of 300 IU hp-HMG was administered until the day of ovulation triggering. The primary outcome was ongoing pregnancy rate per patient.

MAIN RESULTS AND THE ROLE OF CHANCE

Among 47 eligible women, 29 patients were <40 years old and 18 patients were ≥40 years old. No differences were observed in endocrine profile, number of cycles with oocyte retrieval (66 versus 67%) and cycles with embryo transfer (62 versus 61%) in women <40 versus ≥40 years old, respectively. However, 8 of the 29 women <40 years old had an ongoing pregnancy (28%) compared with 0 of 18 patients who were ≥40 years of age (P = 0.017).

LIMITATIONS, REASONS FOR CAUTION

Owing to the specific retrospective study design, bias cannot be ruled out and these results should not be extrapolated to other treatment protocols for poor ovarian responders. Therefore, caution should be taken when interpreting the results.

WIDER IMPLICATIONS OF THE FINDINGS

The promising results from this pilot study of corifollitropin alfa followed by hp-HMG stimulation indicate a potential beneficial effect in young poor ovarian responders fulfilling the Bologna criteria. The data provide the rationale for performing a randomized controlled trial to determine if there is sound evidence for a clinical introduction of this protocol.

STUDY FUNDING/COMPETING INTEREST(S)

No conflicts of interest to declare. No specific funding was received for this study.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/28/5/1254?rss=1

STUDY QUESTION

Which baseline patient characteristics can help assisted reproductive technology practitioners to identify patients who are suitable for in-vitro maturation (IVM) treatment?

SUMMARY ANSWER

In patients with polycystic ovary syndrome (PCOS) who undergo oocyte IVM in a non-hCG-triggered system, circulating anti-Müllerian hormone (AMH), antral follicle count (AFC) and total testosterone are independently related to the number of immature oocytes and hold promise as outcome predictors to guide the patient selection process for IVM.

WHAT IS ALREADY KNOWN

Patient selection criteria for IVM treatment have been described in normo-ovulatory patients, although patients with PCOS constitute the major target population for IVM. With this study, we assessed the independent predictive value of clinical and endocrine parameters that are related to oocyte yield in patients with PCOS undergoing IVM.

STUDY DESIGN, SIZE, DURATION

Cohort study involving 124 consecutive patients with PCOS undergoing IVM whose data were prospectively collected. Enrolment took place between January 2010 and January 2012. Only data relating to the first IVM cycle of each patient were included.

PARTICIPANTS/MATERIALS, SETTING, METHOD

Patients with PCOS underwent oocyte retrieval for IVM after minimal gonadotrophin stimulation and no hCG trigger. Correlation coefficients were calculated to investigate which parameters are related to immature oocyte yield (patient's age, BMI, baseline hormonal profile and AMH, AFC). The independence of predictive parameters was tested using multivariate linear regression analysis. Finally, multivariate receiver operating characteristic (ROC) analyses for cumulus oocyte complexes (COC) yield were performed to assess the efficiency of the prediction model to select suitable candidates for IVM.

MAIN RESULTS AND THE ROLE OF CHANCE

Using multivariate regression analysis, circulating baseline AMH, AFC and baseline total testosterone serum concentration were incorporated into a model to predict the number of COC retrieved in an IVM cycle, with unstandardized coefficients [95% confidence interval (CI)] of 0.03 (0.02–0.03) (P < 0.001), 0.012 (0.008–0.017) (P < 0.001) and 0.37 (0.18–0.57) (P < 0.001), respectively. Logistic regression analysis shows that a prediction model based on AMH and AFC, with unstandardized coefficients (95% CI) of 0.148 (0.03–0.25) (P < 0.001) and 0.034 (–0.003–0.07) (P = 0.025), respectively, is a useful patient selection tool to predict the probability to yield at least eight COCs for IVM in patients with PCOS. In this population, patients with at least eight COC available for IVM have a statistically higher number of embryos of good morphological quality (2.9 ± 2.3; 0.9 ± 0.9; P < 0.001) and cumulative ongoing pregnancy rate [30.4% (24 out of 79); 11% (5 out of 45); P = 0.01] when compared with patients with less than eight COC. ROC curve analysis showed that this prediction model has an area under the curve of 0.7864 (95% CI = 0.6997–0.8732) for the prediction of oocyte yield in IVM.

LIMITATIONS, REASONS FOR CAUTION

The proposed model has been constructed based on a genuine IVM system, i.e. no hCG trigger was given and none of the oocytes matured in vivo. However, other variables, such as needle type, aspiration technique and whether or not hCG-triggering is used, should be considered as confounding factors. The results of this study have to be confirmed using a second independent validation sample.

WIDER IMPLICATIONS OF THE FINDINGS

The proposed model could be applied to patients with PCOS after confirmation through a further validation study.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by a research grant by the Institute for the Promotion of Innovation by Science and Technology in Flanders, Project number IWT 070719.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/28/5/1261?rss=1

STUDY QUESTION

What are the appropriate conditions to vitrify the macaque ovarian cortex in a large-volume, closed system that will preserve functional pre-antral follicles?

SUMMARY ANSWER

The combination of glycerol, ethylene glycol (EG) and polymers with cooling in liquid nitrogen (LN₂) vapor and a two-step warming procedure was able to preserve tissue and follicle morphology as well as function of a small population of secondary follicles in the macaque ovarian cortex following vitrification in a closed system.

WHAT IS KNOWN ALREADY

For prepubertal cancer patients or those who require immediate cancer therapy, ovarian tissue cryopreservation offers the only hope for future fertility. However, the efficacy of live birth from the transplantation of cryopreserved ovarian tissue is still unclear. In addition, live birth from cryopreserved ovarian tissue has only been demonstrated after tissue autotransplantation, which poses the risk of transmitting metastatic cancer cells back to the cancer survivor in certain cancers.

STUDY DESIGN, SIZE, DURATION

Non-human primate model, n = 4, randomized, control versus treatment. End-points were collected from tissue histology, tissue culture (48 h) and isolated secondary follicle culture (6 weeks).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Two vitrification solutions (VSs) containing EG + glycerol (VEG) and EG + dimethylsulfoxide (VED) were examined for vitrification, devitrification and thermodynamic properties. Once the optimal VS was determined, macaque ovarian cortical pieces (3 x 3 x 0.5 mm³) were divided into fresh and two vitrified groups (VEG and VED). For the vitrification groups, tissues were exposed to 1/4, 1/2 and 1x VS for 5 min/step as well as 1x VS + polymers for 1 min at 37°C, loaded into high-security straws with 1 ml of VS + polymers, heat sealed and cooled in LN₂ vapor. Samples were warmed in a 40°C water bath and cryoprotective agents were diluted with 1, 0.5, 0.25 and 0 M sucrose. Tissues were fixed for histological analysis and cultured with bromodeoxyuridine (BrdU). Secondary follicles from VEG tissues were encapsulated and cultured (n = 24/treatment/animal). Follicle health, diameter and steroid [progesterone, androstenedione (A₄), estradiol (E₂)] production were analyzed weekly.

MAIN RESULTS AND THE ROLE OF CHANCE

Dense stroma and intact pre-antral follicles were observed using VS containing 27% glycerol, 27% EG and 0.8% polymers with cooling in LN₂ vapor and a two-step warming. Higher cooling and warming rates led to fracturing. BrdU uptake was evident in granulosa cells of growing follicles in fresh and vitrified tissues. Secondary follicles from fresh tissues (70 ± 12%) and tissues vitrified with VEG (52 ± 2%) showed similar survival rates (all data: mean ± SEM; P > 0.05). For both groups, the initial follicle diameter was similar and increased (P < 0.05) by Week 3, but diameters in vitrified follicles were smaller (P < 0.05) by Week 6 (566 ± 27 µm) than those of the fresh follicles (757 ± 26 µm). Antrum formation rates were lower (P < 0.05) for vitrified (37 ± 6%) relative to fresh (64 ± 8%) follicles. There was no significant change in levels in culture media of E₂, P₄ and A₄ between fresh and VEG groups at any time point during culture.

LIMITATIONS, REASONS FOR CAUTION

Only in vitro studies are reported. Future in vivo tissue transplantation studies will be needed to confirm long-term function and fertility potential of vitrified ovarian tissues.

WIDER IMPLICATIONS OF THE FINDINGS

This is the first demonstration of antral follicle development during 3D culture following ovarian tissue vitrification in a closed system using primate ovarian tissue. While diminished antrum formation and slower growth in vitro reflect residual cryodamage, continued development of ovarian tissue vitrification based on cryobiology principles using a non-human primate model will identify safe, practical and efficient protocols for eventual clinical use. Tissue function following heterotopic transplantation is currently being examined.

STUDY FUNDING/COMPETING INTEREST(S)

National Institutes of Health (NIH) Oncofertility Consortium UL1 RR024926 (1RL1-HD058293, HD058295, PL1 EB008542), the Eunice Kennedy Shriver NICHD/NIH (U54 HD018185) and ONPRC 8P51OD011092-53. G.M.F. works for the company that makes the polymers used in the current study.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/28/5/1267?rss=1

STUDY QUESTION

Can the ability of the endometriosis fertility index (EFI) to predict non-assisted reproductive technology (ART) pregnancy after endometriosis surgery be confirmed by an external validation study?

SUMMARY ANSWER

The significant relationship between the EFI score and the time to non-ART pregnancy observed in our study represents an external validation of this scoring system.

WHAT IS KNOWN AND WHAT THIS PAPER ADDS

The EFI was previously developed and tested prospectively in a single center, but up to now no external validation has been published. Our data provide validation of the EFI in an external fertility unit on a robust scientific basis, to identify couples with a good prognosis for spontaneous conception who can therefore defer ART treatment, regardless of their revised American Fertility Society (rAFS) endometriosis staging.

DESIGN

Retrospective cohort study where the EFI was calculated based on history and detailed surgical findings, and related to pregnancy outcome in 233 women attempting non-ART conception immediately after surgery; all data used for EFI calculation and analysis of reproductive outcome had been collected prospectively as part of another study.

PARTICIPANTS AND SETTING

The EFI score was calculated (score 0–10) for 233 women with all rAFS endometriosis stages (minimal–mild, n = 75; moderate–severe, n = 158) after endometriosis surgery (1 September 2006–30 September 2010) in a university hospital-based reproductive medicine unit with combined expertise in reproductive surgery and medically assisted reproduction. All participants attempted non-ART conception immediately after surgery by natural intercourse, ovulation induction with timed intercourse or intrauterine insemination (with or without ovulation induction or controlled ovarian stimulation).

DATA ANALYSIS METHOD

All analyses were performed for three different definitions of pregnancy [overall (any HCG >25 IU/l), clinical and ongoing >20 weeks]. Six groups were distinguished (EFI scores 1–3, 4, 5, 6, 7+8, 9+10), and Kaplan–Meier (K–M) estimates for cumulative pregnancy rate were calculated. Subjects were censored when they were lost to follow-up, had subsequent surgery for endometriosis, started ovarian suppression or underwent ART. As K–M estimates might overestimate the actual event rate, cumulative incidence estimates treating ART as competing event were also calculated. Cox regression analysis was used to assess the performance of EFI and constituting variables. Performance of the score (prediction, discrimination) was quantified with the following methods: mean squared error of prediction (Brier score), areas under the receiver-operating curve and global concordance index C.

MAIN RESULTS AND THE ROLE OF CHANCE

There was a highly significant relationship between the EFI and the time to non-ART pregnancy (cumulative overall pregnancy rate, P = 0.0004), with the K–M estimate of cumulative overall pregnancy rate at 12 months after surgery equal to 45.5% [95% confidence interval (CI) 39.47–49.87]—ranging from 16.67% (95% CI 5.01–47.65) for EFI scores 0–3, to 62.55% (95% CI 55.18–69.94) for EFI scores 9–10. For each increase of 1 point in the EFI score, the relative risk of becoming pregnant increased by 31% (95% CI 16–47%; i.e. hazard ratio 1.31). The ‘least function score’—which assesses the tubal/ovarian function at conclusion of surgery—was found to be the most important contributor to the total EFI score among all the other variables (age, duration of infertility, prior pregnancy, AFS endometriosis lesion and total score).

BIAS, CONFOUNDING AND OTHER REASONS FOR CAUTION

The EFI score had a moderate performance in the prediction of the pregnancy rate. Indeed, the decrease in prediction error was rather small, as shown by the decrease in Brier score from 0.213 to 0.198, and low estimates for R&sup2; (13%) and C (0.629).

GENERALIZABILITY TO OTHER POPULATIONS

As the EFI was validated externally in our own European population after initial testing by Adamson and Pasta (Endometriosis fertility index: the new, validated endometriosis staging system. Fertil Steril 2010;94:1609-1615) in an American population, it appears that the EFI can be used clinically to counsel infertile endometriosis patients receiving reproductive surgery in specialized centers about their post-operative conception options.

STUDY FUNDING/COMPETING INTEREST(S)

This research was supported by funds obtained via the Clinical Research Fund of the University Hospitals Leuven, Belgium, via the Ferring Chair in Reproductive Medicine and Surgery, and the Serono Chair in Reproductive Medicine granted to the Leuven University Fertility Center. The authors have no conflicts of interest to declare.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/28/5/1280?rss=1

STUDY QUESTION

Can biological scientists working in medically assisted reproduction (MAR) have a role as health-care workers and, if so, how do they engage in the emotional labour commonly associated with health-care work?

SUMMARY ANSWER

The scientists at Fertility Associates (FA) in New Zealand perform the technical and emotional cares associated with health-care work in an occupationally specific manner, which we refer to as a hybrid care style. Their emotional labour consists of managing difficult patients, ‘talking up’ bad news, finding strategies to sustain hope and meaning, and ‘clicking’ or ‘not clicking’ with individual patients.

WHAT IS KNOWN ALREADY

Effective emotional labour is a key component of patient-centred care and is as important to the experience of high-quality MAR as excellent clinical and scientific technique.

STUDY DESIGN, SIZE, DURATION

This is a qualitative study based on open-ended interviews and ethnographic observations with 14 staff in 2 laboratories conducted over 2 separate periods of 3 weeks duration in 2007. Analysis of fieldnotes and interviews was conducted using thematic analysis and an NVivo qualitative database and compared for consistency across each interviewer.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The participants were consenting biological scientists working in one of the two laboratories. Semi-structured interviews were conducted in ‘quiet’ work times, and supervised access was allowed to all parts of the laboratories and meeting places. Opportunities for participant review of results and cross comparison of independent analysis by authors increases the faithfulness of fit of this account to laboratory life.

MAIN RESULTS AND THE ROLE OF CHANCE

The study suggests that emotional labour is a part of routinized scientific labour in MAR laboratories for FA.

LIMITATIONS, REASONS FOR CAUTION

This is a qualitative study and thus the findings are not generalizable to populations beyond the study participants.

WIDER IMPLICATIONS OF THE FINDINGS

While little has been published of the emotional component of scientist's working lives, there may be a New Zealand style of doing scientific work in MAR laboratories which is patient centred and which incorporates much higher patient contact and involvement than is experienced in other laboratories.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by a research grant from the University of Otago and was also partly funded by a Marsden Grant administered by the Royal Society of New Zealand.

TRIAL REGISTRATION NUMBER

N/A.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/28/5/1289?rss=1

STUDY QUESTION

Do different concentrations of FSH in the assisted reproductive technology (ART) procedure in vitro or in vivo affect the developmental competence of oocytes, the embryos and the offspring conceived from these embryos?

SUMMARY ANSWER

Improper FSH treatment (200 IU/l in vitro, 10 IU/ml in vivo and 200 IU/ml in vivo) impairs the development competence of oocyte and embryo, but does not influence offspring physiology and behavior.

WHAT IS KNOWN ALREADY

Exogenous FSH has been widely used in the field of ART. However, the effects of different concentrations of FSH on the developmental competence of oocytes, embryos and the offspring conceived from these embryos, are still unknown.

STUDY DESIGN, SIZE, DURATION

In a prospective study, a total of 45 mice at 8–10 weeks of age were primed in vivo with different dosages of FSH (9 mice in the 10 IU/ml, 10 mice in the 50 IU/ml, 10 mice in the 100 IU/ml and 16 mice in the 200 IU/ml groups). Fresh MII oocytes were retrieved from ovaries: this was designated as in vivo group. Thirty six mice at 8–10 weeks of age were sacrificed by cervical dislocation to obtain ovaries without FSH treatment (9 mice in the 0 IU/l, 9 mice in the 50 IU/l, 8 mice in the 100 IU/l and 10 mice in the 200 IU/l groups), and then the immature oocytes were collected from these ovaries and cultured in vitro matured medium supplemented with 0, 50, 100 and 200 IU/l FSH: this was designated as in vitro group.

MATERIALS, SETTING, METHODS

Spindle assembly of matured MII oocytes was stained via an immunofluorescence method and the oocytes ratio of normal spindle was analyzed. The developmental competence of the resulting fertilized embryos in the pre- and post-implantation stages was examined in in vitro and in vivo groups. Furthermore, physiological index, including reproductive potential and body weight, of the offspring was investigated by mating experiments and behavior index, including learning, memory, probing and intelligence, was tested by Morris water maze in in vitro and in vivo groups.

MAIN RESULTS AND THE ROLE OF CHANCE

In the in vitro groups, the oocyte maturation competence, normal spindle assembly, blastocyst formation and implantation, as well as viable pup production were all impaired in the group treated with 200 IU/l FSH (P < 0.05). No differences were observed among the other three groups (P > 0.05). In the in vivo groups, 10 IU/ml FSH but not 200 IU/ml treatment influenced blastocyst formation and viable pup production (P < 0.05), although the high proportion of spindle assembly abnormality was only observed in the 200 IU/ml FSH treatment group (P < 0.05). Furthermore, there were no significant differences in terms of physiological index (reproductive potential and body weight) and behavior index (learning, memory, probing and intelligence) in offspring from in vitro and in vivo groups (P > 0.05).

LIMITATIONS, REASONS FOR CAUTION

The mouse model was used in this study. The results of the mouse follicle growth and oocyte development in responding to different concentrations of FSH are not 100% transferable to human, because of the physiological differences between mouse and human.

WIDER IMPLICATIONS OF THE FINDINGS

The findings indicated that FSH application in the field of ART is safe to the resulted offspring, but it should be more carefully used for each women in ART cycles because the inappropriate FSH concentration would decrease the oocyte developmental competence.

STUDY FUNDING/COMPETING INTEREST(S)

This work was partially supported by the Ministry of Science and Technology of China Grants (973 program; 2011CB944504), the Program for Changjiang Scholars and Innovative Research Team in University of Ministry of Education of China (30825038), the National Natural Science Funds for Young Scholar (31000661) and by the Joint Research Fund for Overseas, Hong Kong and Marco Scholars (31128013/C120205). None of the authors has any conflicts of interest.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/28/5/1309?rss=1

STUDY QUESTION

Does the health status of infants fathered by nonmosaic Klinefelter syndrome (KS) patients whose partners underwent ICSI with sperm obtained from testicular dissection reveal any genetic risk for the offspring?.

SUMMARY ANSWER

KS patients undergoing testicular sperm extraction (TESE) are capable of conceiving healthy children.

WHAT IS KNOWN ALREADY

Paternity has been successfully achieved in nonmosaic KS patients (47,XXY karyotype) by ICSI using either ejaculated or testicular spermatozoa. A crucial concern is the potential transmission of genetic abnormalities to the offspring. Some studies reported that 47,XXY spermatogonia are capable of completing spermatogenesis leading to the production of mature spermatozoa with increased aneuploidies. Other authors showed that where focal spermatogenesis is present in nonmosaic KS males, it originates from euploid germ cells and, therefore, produces normal mature gametes. In support of this finding, at present, the great majority of children born from nonmosaic KS patients are chromosomally normal.

STUDY DESIGN, SIZE, DURATION

From April 2004 to June 2010, 38 azoospermic patients with nonmosaic KS were examined for the presence of testicular spermatozoa. Spermatozoa were retrieved from 15 patients and 26 ICSI cycles were done (16 with cryopreserved sperm). There were 15 pregnancies leading to the birth of 16 babies who were karyotyped at amniocentesis and after birth.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants were recruited from couples attending the European Hospital, Rome, and Clinica MAR&Gen, Granada, for infertility treatment. Both the European Hospital and Clinica MAR&Gen are private clinics. Testicular tissue was extracted with TESE or micro-TESE. After retrieval, fresh sperm was used for ICSI or it was cryopreserved for future use.

MAIN RESULTS AND THE ROLE OF CHANCE

Spermatozoa were retrieved from 15 patients (14 TESE and 1 micro-TESE) out of 38 (39.5%). A total of 26 ICSI cycles were performed: 10 with fresh and 16 with cryopreserved-thawed sperm. Mean ages (y) of patients with positive and negative sperm retrieval were, respectively, 34.8 ± 1.72 and 35.6 ± 4.08 (NS, nonsignificant). Comparing ICSI cycles performed with fresh sperm (n = 10) to those performed with frozen–thawed sperm (n = 16): Fertilization rates per injected oocyte were 53.0% (44 of 83) and 47.8% (32 of 67), respectively (NS). The cleavage rate per injected oocyte was 90.6% (29 of 32) versus 68.2% (30 of 44); P = 0.026. Clinical outcomes were not significantly different between the fresh and the frozen–thawed sperm group: clinical pregnancy rates were 7 of 10 (70.0%) and 8 of 16 (50.0%); implanted embryos (per transferred embryo) were 8 of 23 (34.8%) and 8 of 29 (27.6%); delivery rates were 6 of 10 (60.0%) and 5 of 16 (31.3%). Sixteen babies were born, all of them are healthy with a normal karyotype, eight from the fresh sperm group and eight from the frozen–thawed sperm group.

LIMITATIONS, REASONS FOR CAUTIONS

The small numbers available for study mean that only common problems can be excluded.

WIDER IMPLICATIONS OF THE FINDINGS

This study provides further reassurance that KS men can father healthy children and that pre-implantation genetic diagnosis on embryos conceived with their sperm is not strongly indicated. However, until conclusive information is available, such couples should be offered extensive genetic counseling.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was obtained for the present study. None of the authors has any conflict of interest to declare.

TRIAL REGISTRATION NUMBER

Not applicable.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/28/5/1155?rss=1

STUDY QUESTION

Do human blastocysts which subsequently implant release factors that regulate endometrial epithelial cell gene expression and adhesion to facilitate endometrial receptivity?

SUMMARY ANSWER

Blastocysts which subsequently implanted released factors that altered endometrial epithelial gene expression and facilitated endometrial adhesion while blastocysts that failed to implant did not.

WHAT IS KNOWN ALREADY

Human preimplantation blastocysts are thought to interact with the endometrium to facilitate implantation. Very little is known of the mechanisms by which this occurs and to our knowledge there is no information on whether human blastocysts facilitate blastocyst attachment to the endometrium.

STUDY DESIGN, SIZE, DURATION

We used blastocyst-conditioned medium (BCM) from blastocysts that implanted (n = 28) and blastocysts that did not implant (n = 28) following IVF. Primary human endometrial epithelial cells (HEECs) (n = 3 experiments) were treated with BCM and the effect on gene expression and adhesion to trophoblast cells determined. We compared the protein production of selected genes in the endometrium of women with normal fertility (n = 40) and infertility (n = 6) during the receptive phase.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We used real-time RT–PCR arrays containing 84 genes associated with the epithelial to mesenchymal transition. We validated selected genes by real-time RT–PCR (n = 3) and immunohistochemistry in the human endometrium (n = 46). Adhesion assays were performed using HEECs and a trophoblast cell line (n = 3).

MAIN RESULTS AND THE ROLE OF CHANCE

Blastocysts that implanted released factors that differentially altered mRNA levels for six genes (>1.5 fold) compared with blastocysts that did not implant. A cohort of genes was validated at the protein level: SPARC and Jagged1 were down-regulated (P < 0.01), while SNAI2 and TGF-B1 were up-regulated (P < 0.05) by implanted compared with non-implanted BCM. Jagged-1 (P < 0.05) and Snai-2 protein (P < 0.01) showed cyclical changes in the endometrium across the cycle, and Jagged-1 staining differed in women with normal fertility versus infertility (only) (P < 0.01). HEEC adhesion to a trophoblast cell line was increased after treatment with implanted BCM compared with untreated control (P < 0.05).

LIMITATIONS, REASONS FOR CAUTION

This is an in vitro study and it would be beneficial to validate our findings using a physiological model, such as mouse.

WIDER IMPLICATIONS OF THE FINDINGS

This new strategy has identified novel pathways that may be important for human preimplantation blastocyst–endometrial interactions and opens the possibility of examining and manipulating specific pathways to improve implantation and pregnancy success.

STUDY FUNDING/COMPETING INTEREST

This study was supported by the National Health and Medical Research Council of Australia (Fellowship support #550905, #611827) and project grants by Monash IVF, Australia. There are no conflicts of interest to be declared.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/28/5/1161?rss=1

STUDY QUESTION

What is the nature of cellular Corin expression in human gestational tissues?

SUMMARY ANSWER

CORIN is expressed in non-pregnant late secretory phase endometrium, first trimester human implantation sites and is up-regulated with decidualization ex vivo.

WHAT IS KNOWN ALREADY

Adequate trophoblast invasion and spiral artery remodeling/transformation is critical for successful implantation. CORIN, best known for its role in activating atrial natruietic peptide (ANP) to regulate blood pressure, has recently been proposed to be centrally involved in trophoblast invasion and spiral artery remodeling. It is postulated that ANP, activated by CORIN, promotes trophoblast invasion and that a deficiency causes pre-eclampsia. Mice deficient in either Corin or ANP displayed poor trophoblast invasion, impaired spiral artery remodeling and phenocopied human pre-eclampsia. However, the precise cellular localization of CORIN within human gestational tissues has not been well characterized.

STUDY DESIGN, SIZE, DURATION

We measured CORIN protein localization in a number of human gestational tissues relevant to early embryo/placental implantation: non-pregnant (NP) endometrial biopsies (n = 5 per phase of the menstrual cycle), first trimester placental bed biopsies (n = 12) and pre-term control (n = 10) and severe early onset preeclamptic placentas (n = 15). Endometrial stromal cells were isolated from human endometrial biopsies (n = 5) and induced to decidualize ex vivo. Finally, CORIN concentrations were measured in serum obtained from pregnant women during the first trimester of whom, 56 subsequently ended up with a healthy term delivery (controls), 18 developed fetal growth restriction (FGR) and 21 had a miscarriage.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We performed immunohistochemistry to assess CORIN localization. Changes in Corin mRNA expression in human endometrial stromal cells decidualized ex vivo were measured by quantitative RT–PCR, and levels of CORIN within human sera were measured by ELISA.

MAIN RESULTS AND THE ROLE OF CHANCE

CORIN was expressed in both NP late secretory phase endometrium and first trimester decidua within placental bed biopsies. Importantly, decidualization of primary human endometrial cells ex vivo significantly increased Corin expression (P < 0.05). CORIN was also detected within the villous cytotrophoblast, but there was no change in mRNA levels in placentas complicated by severe preterm pre-eclampsia when compared with pre-term controls. Although CORIN was detected in first trimester serum, levels did not change across gestation, nor could they predict miscarriage or FGR (other disorders of impaired placental invasion).

LIMITATIONS, REASONS FOR CAUTION

Owing to the fact that we utilized early pregnancy human specimens, this is mainly a descriptive study with a limited amount of functional experiments.

WIDER IMPLICATIONS OF THE FINDINGS

This is the first study to thoroughly characterize Corin mRNA and protein expression in human gestational tissue. Our findings support recent data from murine studies collectively suggesting that CORIN plays a critical role in trophoblast migration and spiral artery remodeling during early pregnancy in humans. Therefore, further studies of CORIN biology in early pregnancy may identify new therapeutic targets to improve implantation quality in early pregnancy and potentially reduce the rates of pregnancy complications caused by inadequate implantation (pre-eclampsia, FGR and miscarriage).

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by The National Health and Medical Research Council of Australia (Salary support #490970, #490995). The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript. The authors declare that no competing interests exist.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/28/5/1172?rss=1

STUDY QUESTION

Is it possible to evaluate first trimester brain ventricle development in human pregnancies using an innovative virtual reality (VR) application and to analyze the relation of the embryonic volume (EV) and brain ventricle fluid volume (BVFV) with gestational age (GA), crown-rump length (CRL) and the Carnegie stage?

SUMMARY ANSWER

Volumetry and staging of the human embryo using a VR application make it possible to obtain unique information about in-vivo embryonic normal and abnormal development and about the sizes of the ventricles and body.

WHAT IS KNOWN ALREADY

Human brain development is complex and has a rapidly changing anatomy during the first trimester of pregnancy. New insights will enable early detection of cerebral pathology.

STUDY DESIGN, SIZE, DURATION

In a prospective cohort study, we weekly performed three-dimensional (3D) ultrasound examinations in 112 uncomplicated pregnancies between 6 + 0 and 12 + 6 weeks GA.

MATERIALS, SETTING, METHODS

The examinations resulted in 696 3D ultrasound scans that were transferred to the I-Space VR system and analyzed using V-Scope volume rendering software. V-Scope is used to create a ‘hologram’ of the ultrasound image and allows depth perception and interaction with the rendered objects. The CRL measurements were performed with a tracing tool, and the volume measurements were automatically performed with a segmentation algorithm. The embryos were staged according to the internal and external characteristics of the Carnegie staging system. All longitudinal outcomes were analyzed using repeated measures ANOVA.

MAIN RESULTS AND THE ROLE OF CHANCE

CRL could be measured in 91% of the datasets and ranged from 2.5 to 79.0 mm. EV could be measured in 66% of the datasets and ranged from 2.4 to 23 812.0 mm&sup3;, whereas the BVFV could be measured in 38% of the datasets and ranged from 10.4 to 226.3 mm&sup3;. Finally, in 74% of the datasets, the embryos were staged according to the Carnegie criteria, starting as early as stage 12. Reference charts of volumes versus GA, CRL and stage were constructed. There was no significant relationship between the CRL or EV and the birthweight.

LIMITATIONS, REASONS FOR CAUTIONS

The low success rate is a limitation of this study that can be explained mainly by non-targeted scanning of the embryonic head.

WIDER IMPLICATIONS OF THE FINDINGS

The I-Space VR system and the V-Scope software enable automatic EV and BVFV measurements and 3D observations of embryonic development in the first trimester. This allows in-vivo staging of human embryos based on both internal and external morphological characteristics.

STUDY FUNDING, COMPETING INTERESTS

None.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/28/5/1181?rss=1

STUDY QUESTION

Does the application of three different artificial activating stimuli lead to a difference in pre- and post-implantation embryo development in the wobbler mouse, a mouse model with oocyte activation deficient round-headed sperm cells similar to human globozoospermia?

SUMMARY ANSWER

No gross differences were found between strontium chloride, electrical pulses or ionomycin with respect to the pre- and post-implantation development in the wobbler mouse.

WHAT IS KNOWN ALREADY

Fertilization failure following intra-cytoplasmic sperm injection (ICSI) occurs in 1–3% of the ICSI cycles in human assisted reproduction technology (ART) and has been successfully overcome by different artificial activating stimuli. No comparison has been made yet in terms of their efficiency and safety.

STUDY DESIGN, SIZE, DURATION

Calcium release and embryo development were compared between oocytes fertilized by wobbler and wild-type (WT) sperm following ICSI with or without three different artificial activating agents. Preimplantation development was assessed on 70 injected oocytes on average per group. On average, 10 foster mothers were used per activating group to compare post-implantation development.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We used the wobbler mouse model that possesses oocyte activation deficient round-headed sperm cells. First, the calcium release following ICSI using wobbler sperm was compared with that of WT sperm. Outcome measures were the percentage of oocytes that showed calcium release and their mean amount of calcium rises. Secondly, the pre- and post-implantation development was assessed following ICSI with wobbler sperm plus artificial oocyte activation using either: (i) strontium chloride (Wob-Sr), (ii) electrical pulses (Wob-E) or (iii) ionomycin (Wob-I). Outcome measures were the activation, cleavage and blastocyst rates and the assessment of blastocyst quality by differential staining. Following mouse embryo transfer, pregnancy and birth rates as well as mean litter sizes were examined. Finally, pups were followed up until 8 weeks of age and then mated with fertile controls to assess their fertility.

MAIN RESULTS AND THE ROLE OF CHANCE

The percentage of oocytes showing calcium rises as well as the number of calcium rises per oscillating oocyte were significantly lower in the wobbler group when compared with the WT group (9.3 versus 96% and 2.1 calcium rises versus 31 calcium rises) (P < 0.001). The fertilization rate was significantly lower in the wobbler group (11.4%) when compared with the WT group (92.1%) and the artificial activation groups (strontium chloride: 99%, electrical pulses: 99% and ionomycin: 81%, respectively) (P < 0.001). Post-implantation development did not differ significantly between the WT and artificial activation groups, with pregnancy rates in favor of strontium chloride and electrical pulses. The weight of the male pups did not differ between the study groups, whereas the weight of the female pups originating from Wob-Sr embryos was significantly lower at weeks 2, 3 and 4 when compared with female pups originating from WT embryos. However, the latter difference was not observed at later time points, nor in the other artificial activating groups. All offspring mated successfully with fertile controls.

LIMITATIONS, REASONS FOR CAUTION

Results in animal models should be extrapolated with caution to a subfertile human population. Also, ionomycin is currently the most widely used artificial oocyte activating agent in human ART.

WIDER IMPLICATIONS OF THE FINDINGS

The low frequency of observed calcium rises and the low activation rate make the wobbler mouse a highly suitable model to study oocyte activation deficiency. Strontium chloride and electrical pulses were more efficient means to restore fertilization rates and to support pre- and post-implantation embryonic development than ionomycin.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by the Flemish foundation of Scientific Research (FWO-Vlaanderen) (aspirant clinical research mandate to F.V.M., fundamental clinical research mandate to P.D.S.); and Ghent University grant (KAN-BOF E/01321/01 to B.H.). The authors have no competing interests to declare.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/28/5/1190?rss=1

STUDY QUESTION

What pre-freeze and post-thaw morphological parameters can be used to predict live birth outcomes after frozen–thawed blastocyst transfer cycles?

SUMMARY ANSWER

Pre-freeze blastocoele expansion and trophectoderm (TE) grade and post-thaw degree of re-expansion are the most significant predictors of live birth in frozen–thawed blastocyst transfer cycles.

WHAT IS KNOWN ALREADY

Currently, blastocoele re-expansion after thawing is used to indicate blastocyst cryosurvival and reproductive potential. The predictive roles of other pre-freeze and post-thaw morphological parameters are neglected.

STUDY DESIGN, SIZE, DURATION

This was a retrospective study of all the patients who received a frozen–thawed single blastocyst transfer (n = 1089) at our clinic between March 2008 and October 2011.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Pre-freeze morphological parameters analyzed for all blastocysts included grade of blastocoele expansion, inner cell mass and TE. A group of blastocysts (n = 243) were also graded for post-thaw parameters: degree of blastocoele re-expansion, viability and cell contour. Univariate and multivariate generalized estimating equations (GEEs) models were used to identify the confounders that statistically significantly affected live birth outcomes and to investigate the independent effect of significant pre-freeze and post-thaw morphological parameters. Stepwise logistic regression analysis was used to select the best independent morphological predictors of live birth. Pearson correlations and linear regression analyses were performed to determine the relationship between morphological parameters and possible covariates.

MAIN RESULTS AND THE ROLE OF CHANCE

Multivariate GEE models estimated that the odds of live birth increased by ~36% for each grade of expansion (P = 0.0061) and decreased by 29% for blastocysts with grade B TE compared with grade A TE (P = 0.0099). Furthermore, the odds of live birth increased by ~39% (P = 0.0042) for each 10% increase in degree of re-expansion. Blastocoele expansion and TE grade were selected as the most significant pre-freeze morphological predictors of live birth and degree of re-expansion was selected as the best post-thaw parameter for prediction of live birth.

LIMITATIONS, REASONS FOR CAUTION

Blastocysts with poorer grades of morphology were not cryopreserved or transferred, limiting the ability to generalize our findings for grades of morphology not included in this study.

WIDER IMPLICATIONS OF THE FINDINGS

Blastocysts with higher pre-freeze grades of expansion and TE, irrespective of day of cryopreservation, should be given priority when thawing. Subsequently, re-expanding blastocysts, assessed within 2–4 h, with >60% viability should be transferred.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was obtained for this study. There was no competing interest.

TRIAL REGISTRATION NUMBER

not applicable.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/28/5/1199?rss=1

STUDY QUESTION

Is it feasible to identify factors that significantly affect the clinical outcome of IVF-ICSI cycles and use them to reliably design a predictor of implantation?

SUMMARY ANSWER

The Bayesian network (BN) identified top-history embryos, female age and the insemination technique as the most relevant factors for predicting the occurrence of pregnancy (AUC, area under curve, of 0.72). In addition, it could discriminate between no implantation and single or twin implantations in a prognostic model that can be used prospectively.

WHAT IS KNOWN ALREADY

The key requirement for achieving a single live birth in an IVF-ICSI cycle is the capacity to estimate embryo viability in relation to maternal receptivity. Nevertheless, the lack of a strong predictor imposes several restrictions on this strategy.

STUDY DESIGN, SIZE, DURATION

Medical histories, laboratory data and clinical outcomes of all fresh transfer cycles performed at the International Institute for Reproductive Medicine of Lugano, Switzerland, in the period 2006–2008 (n = 388 cycles), were retrospectively evaluated and analyzed.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Patients were unselected for age, sperm parameters or other infertility criteria. Before being admitted to treatment, uterine anomalies were excluded by diagnostic hysteroscopy.

To evaluate the factors possibly related to embryo viability and maternal receptivity, the class variable was categorized as pregnancy versus no pregnancy and the features included: female age, number of previous cycles, insemination technique, sperm of proven fertility, the number of transferred top-history embryos, the number of transferred top-quality embryos, the number of follicles >14 mm and the level of estradiol on the day of HCG administration. To assess the classifier, the indicators of performance were computed by cross-validation. Two statistical models were used: the decision tree and the BN.

MAIN RESULTS AND THE ROLE OF CHOICE

The decision tree identified the number of transferred top-history embryos, female age and the insemination technique as the features discriminating between pregnancy and no pregnancy. The model achieved an accuracy of 81.5% that was significantly higher in comparison with the trivial classifier, but the increase was so modest that the model was clinically useless for predictions of pregnancy. The BN could more reliably predict the occurrence of pregnancy with an AUC of 0.72, and confirmed the importance of top-history embryos, female age and insemination technique in determining implantation. In addition, it could discriminate between no implantation, single implantation and twin implantation with the AUC of 0.72, 0.64 and 0.83, respectively.

LIMITATIONS, REASONS FOR CAUTION

The relatively small sample of the study did not permit the inclusion of more features that could also have a role in determining the clinical outcome. The design of this study was retrospective to identify the relevant features; a prospective study is now needed to verify the validity of the model.

WIDER IMPLICATIONS OF THE FINDINGS

The resulting predictive model can discriminate with reasonable reliability between pregnancy and no pregnancy, and can also predict the occurrence of a single pregnancy or multiple pregnancy. This could represent an effective support for deciding how many embryos and which embryos to transfer for each couple. Due to its flexibility, the number of variables in the predictor can easily be increased to include other features that may affect implantation.

STUDY FUNDING/COMPETING INTERESTS

This study was supported by a grant, CTI Medtech Project Number: 9707.1 PFLS-L, Swiss Confederation. No competing interests are declared.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/28/5/1210?rss=1