STUDY QUESTION

What are the obstetric and neonatal outcomes of deliveries after oocyte donation (OD) in women with Turner syndrome (TS)?

SUMMARY ANSWER

Pregnancies among women with TS carry a substantial risk, particularly for hypertensive disorders. Potentially life-threatening complications occurred in 3.3% of pregnancies. The neonatal outcomes were generally reassuring, with similar rates of preterm birth and low birthweight (LBW) as after conventional IVF and better than previously reported in deliveries after OD in women with TS.

WHAT IS KNOWN ALREADY

OD pregnancies in women with TS are known to be high-risk pregnancies.

STUDY DESIGN, SIZE, DURATION

This retrospective cohort study included 106 women with TS who delivered after OD (n = 122 deliveries, n = 131 newborns) in three Nordic countries (Finland, Denmark, Sweden) between 1992 and 2011.

PARTICIPANTS, SETTING AND METHODS

Women with TS who delivered after OD in three Nordic countries were identified (n = 110). Four women declined to participate or were lost to follow-up, thus 106 women were included in the study. The medical data from fertility clinics, antenatal clinics and the hospitals where the women had been treated and/or delivered were scrutinized.

MAIN RESULTS AND THE ROLE OF CHANCE

In this cohort, the karyotype was 45,X in 44% of the women with TS. Ten women (9.4%) had a known cardiac defect before pregnancy. Single embryo transfer was performed in 70.3% of the cases and the multiple birth rate was 7.4%. In total, 35.0% of the pregnancies were associated with a hypertensive disorder including pre-eclampsia in 20.5%. Potentially life-threatening complications occurred in four pregnancies (3.3%), including one woman with aortic dissection, one with mild regurgitation of the tricuspid and mitral valve, one with a mechanical heart valve who developed HELLP syndrome (haemolysis, elevated liver enzymes, low platelets) and one who underwent a post-partum hysterectomy due to severe haemorrhaging. Neonatal outcomes were reassuring, with a preterm birth rate of 8.0% and LBW rate of 8.8% in singletons. Major birth defects were found in 3.8% of the children. The perinatal mortality was 2.3% (3/131), including a set of extremely preterm twins.

LIMITATIONS, REASONS FOR CAUTION

Although this study was performed over a period of almost 20 years in three different countries, with a low drop-out rate and little missing data, much larger series are needed to assess rare events. This study also lacks an appropriate control group.

WIDER IMPLICATIONS OF THE FINDINGS

This study suggests that cardiovascular evaluation before and during pregnancy may contribute to favourable obstetric outcomes in many cases. Maternal outcomes were in agreement with the literature while neonatal outcomes were generally better than previously reported. The outcomes were consistent across the three countries, supporting generalizability to similar populations.

STUDY FUNDING/COMPETING INTEREST(S)

No conflict of interest was reported. The study was supported by grants from the Gothenburg Medical Society, the Medical Care Executive Board of the Region Västra Götaland, grants from the ALF agreement at the Sahlgrenska University Hospital, the Hjalmar Svensson foundation, NFOG Nordic Fund, the Finnish Society of Paediatric and Adolescent Gynecology and Liv och hälsa Foundation in Finland. The Nordic Expert group's research work was unconditionally supported by MSD Finland, Norway and Denmark.

TRIAL REGISTRATION NUMBER

None.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/28/6/1598?rss=1

STUDY QUESTION

Does prolonged exposure of the endometrium to hCG, as experienced after ovulation induction in an assisted reproduction technology (ART) cycle, affect functional measures of endometrial receptivity?

SUMMARY ANSWER

Prolonged endometrial hCG exposure detrimentally affects the manner in which the endometrium can respond to hCG secreted by the blastocyst.

WHAT IS KNOWN ALREADY

Prolonged hCG exposure down-regulates endometrial LH–CG receptor (LHCGR) expression in a baboon model. HCG exposure during the proliferative phase of oocyte-donation cycles and frozen embryo transfer cycles is associated with a lower pregnancy rate.

STUDY DESIGN, SIZE, DURATION

LHCGR was examined in endometria of women undergoing ART cycles (GnRH agonist/antagonist) and across the menstrual cycle in normally cycling fertile women. To determine whether prolonged hCG exposure affects the subsequent endometrial response to hCG, endometrial epithelial cells (HES cell line and primary cultures of human endometrial epithelial cells) were exposed to a low dose of hCG (0.5–5 IU) for up to 5 days, to mimic the chronic exposure during an ART cycle, and subsequently exposed to an acute ‘blastocyst mimic’ dose of hCG (20 IU).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Endometrial tissues were collected at hCG + 2 (n = 37) from women undergoing ART between August 2006 and August 2008, and across the cycle from women with known fertility (n = 40). LHCGR localization and staining intensity were determined by immunohistochemistry and semi-quantitative scoring. HES cells were treated with hCG as above and analyzed for LHCGR localization (immunocytochemistry), phosphorylation of extracellular signal-regulated kinase (ERK) 1/2 (western immunoblotting), adhesion to trophoblast-like matrices (adhesion assays) and tight junction integrity (trans-epithelial resistance assessment).

MAIN RESULTS AND THE ROLE OF CHANCE

Endometrial epithelial LHCGR staining was significantly lower in women stimulated with a GnRH agonist protocol who did not become pregnant in that cycle versus the natural menstrual cycle (P < 0.05). Chronic low-dose hCG exposure in vitro mediated a down-regulation and internalization of the LHCGR in endometrial epithelial cells. Prolonged exposure to chronic low-dose hCG (3–5 days) abrogated ERK 1/2 phosphorylation, adhesion to extracellular matrices and changes in tight junction integrity in response to a subsequent acute high dose (20 IU) of hCG.

LIMITATIONS, REASONS FOR CAUTION

Studies using cell lines and primary cultures of cells in vitro are not fully representative of the complex endometrial milieu in vivo.

WIDER IMPLICATIONS OF THE FINDINGS

These data reinforce the clinical observations that precocious or prolonged hCG exposure may detrimentally affect endometrial receptivity and provide a mechanistic basis for these clinical findings. The data appear to support the notion that in women for whom ART has not succeeded, a different, minimally stimulated approach without exposure to exogenous hCG may improve outcomes.

STUDY FUNDING/COMPETING INTEREST(S)

The authors have no competing interests. This work was supported by a Lalor postdoctoral fellowship (J.E.), NHMRC of Australia, Fellowship No. 1002028 (L.A.S.), Program grant (No. 494802) and by the Victorian Government's Operational Infrastructure Funding.

TRIAL REGISTRATION NUMBER

N/A.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/28/6/1610?rss=1

STUDY QUESTION

What are women's experiences with tailored use of combined oral contraceptive pills (COCPs)?

SUMMARY ANSWER

Some women reported very positive experiences with tailored use of COCPs, others did not like the unpredictability about when they would bleed and some women reported increased anxiety about possible pregnancy.

WHAT IS KNOWN ALREADY

While many studies have investigated views toward extended use of COCPs, little research has examined women's actual experiences with these regimens.

STUDY DESIGN, SIZE, DURATION

This was a semi-structured qualitative interview study that was part of a larger randomized trial of a standard (21 daily pills followed by a 7-day pill-free interval) versus a tailored regimen (daily pills until 3-consecutive-day bleeding triggers a 3-day pill-free interval) of Microgynon 30® mcg (Ethinyl estradiol 30 mcg, Levonorgestrel 150 mcg).

PARTICIPANTS/MATERIALS, SETTINGS, METHODS

Interviews were conducted with 26 women (17 in the tailored group and 9 who switched their assigned treatment group) . Data were analyzed using thematic analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

Women discussed positive changes associated with tailored use of COCPs, as well as some negative consequences. The major themes identified in the interview data were: ease of tailored regimen; changes in cycle-related symptoms; adjustment to reduced/absent bleeding and unpredictability about bleeding.

LIMITATIONS, REASONS FOR CAUTION

The sample comprised mainly young, nulliparous women. The majority of women were using COCPs at the start of the study.

WIDER IMPLICATIONS OF THE FINDINGS

Clinicians discussing extended-use regimes with patients should mention that women may need time to adjust to an extended-use regime. Future research should attempt to identify predictors of response to extended use of COCPs.

STUDY FUNDING/COMPETING INTERESTS

This work was funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-0906-11154). The authors have no conflict of interests to declare.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/28/6/1620?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

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

What is the risk of relapse for women with endometrial hyperplasia treated with levonorgestrel-releasing intrauterine system (LNG-IUS) or oral progestogens?

SUMMARY ANSWER

Relapse of complex endometrial hyperplasia after initial regression occurs often and it occurs less often in women treated with LNG-IUS than with oral progestogens.

WHAT IS KNOWN ALREADY

The LNG-IUS and oral progestogens are used to treat women with endometrial hyperplasia and achieve regression. There is uncertainty over whether further surveillance for these women is necessary as the risk for relapse is unknown.

STUDY DESIGN, SIZE, DURATION

A cohort study of 219 women with complex non-atypical or atypical endometrial hyperplasia who were treated and achieved initial regression with LNG-IUS (n = 153) or oral progestogens (n = 66) from August 1998 until December 2007 and followed up for >5 years. The mean length of follow-up was 74.7 ± SD 31.8 months for the LNG-IUS versus 87.6 ± SD 42.2 months for the oral progestogen group.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We evaluated the proportion of women who relapsed or had hysterectomy after initial regression with LNG-IUS compared with oral progestogens by logistic regression and adjusting for confounding. The time from regression to relapse was explored through a survival analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

Relapse of hyperplasia occurred in 13.7% (21/153) of women treated with LNG-IUS compared with 30.3% (20/66) of women treated with oral progestogens [adjusted odds ratio (OR) = 0.34, 95% confidence interval (CI): 0.17–0.7, P = 0.005]. Relapse rates over long-term follow-up were lower for complex non-atypical hyperplasia compared with atypical hyperplasia for both LNG-IUS (12.7%, 18/142 versus 27.3%, 3/11, respectively; P ≤ 0.001) and oral progestogens (28.3%, 17/60 versus 50%, 3/6, respectively; P ≤ 0.001). The survival analysis indicates that relapse occurred less often with LNG-IUS at 12, 24, 36, 48, 60 and >60 months of follow-up (hazard ratio 0.37, 95% CI: 0.2–0.7, P = 0.0013). There were no events of relapse after 48 months from regression with oral progestogens, but 5 women treated with LNG-IUS relapsed after 60 months when treatment was discontinued. Hysterectomy rates were lower in the LNG-IUS than oral progestogen group during follow-up (19.6%, 30/153 versus 31.8%, 21/66, respectively, OR = 0.52, 95% CI: 0.27–1, P = 0.05). Endometrial cancer was diagnosed in 2 (11.8%) women who had hysterectomy (n = 17) because of relapse.

LIMITATIONS, REASONS FOR CAUTION

We are unable to accurately estimate the cancer risk in women who relapse during follow-up as only 17 out of 41 who relapsed underwent hysterectomy.

WIDER IMPLICATIONS OF THE FINDINGS

Relapse of endometrial hyperplasia after initial regression occurs often and long-term follow-up is advised.

STUDY FUNDING/COMPETING INTEREST(S)

Ioannis D. Gallos and this study were funded through a grant from Wellbeing of Women (ELS022). No competing interests.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/28/5/1231?rss=1

STUDY QUESTION

What is the inter-/intra-observer agreement and diagnostic accuracy among gynaecological and non-gynaecological ultrasound specialists in the prediction of pouch of Douglas (POD) obliteration (secondary to endometriosis) at offline analysis of two-dimensional videos using the dynamic real-time transvaginal ultrasound (TVS) ‘sliding sign’ technique?

SUMMARY ANSWER

The inter-/intra-observer agreement and diagnostic accuracy for the interpretation of the TVS ‘sliding sign’ in the prediction of POD obliteration was found to be very acceptable, ranging from substantial to almost perfect agreement for the observers who specialized in gynaecological ultrasound.

WHAT IS KNOWN ALREADY

Women with POD obliteration at laparoscopy are at an increased risk of bowel endometriosis; therefore, the pre-operative diagnosis of POD obliteration is important in the surgical planning for these women. Previous studies have used TVS to predict POD obliteration prior to laparoscopy, with a sensitivity of 72–83% and specificity of 97–100%. However, there have not been any reproducibility studies performed to validate the use of TVS in the prediction of POD obliteration pre-operatively.

STUDY DESIGN, SIZE, DURATION

This was a reproducibility study which involved the offline viewing of pre-recorded video sets of 30 women presenting with chronic pelvic pain, in order to determine POD obliteration using the TVS ‘sliding sign’ technique. The videos were selected on real-time representative quality/quantity; they were not obtained from sequential patients. There were a total of six observers, including four gynaecological ultrasound specialists and two fetal medicine specialists. The study was conducted over a period of 1 month (March 2012–April 2012).

PARTICIPANTS/MATERIALS, SETTING, METHODS

The four gynaecological ultrasound observers performed daily gynaecological scanning, while the other two observers were primarily fetal medicine sonologists. Each sonologist viewed the TVS ‘sliding sign’ video in two anatomical locations (retro-cervix and posterior uterine fundus), i.e. 60 videos in total. The POD was deemed not obliterated, if ‘sliding sign’ was positive in both anatomical locations (i.e. anterior rectum/rectosigmoid glided smoothly across the retro-cervix/posterior fundus, respectively). If the ‘sliding sign’ was negative (i.e. anterior rectum/rectosigmoid did not glide smoothly over retro-cervix/posterior fundal region, respectively), the POD was deemed obliterated. Diagnostic accuracy and inter-observer agreement among the six sonologists was evaluated. The same sonologist was also asked to reanalyse the same videos, albeit in a different order, at least 7 days later to assess for intra-observer agreement. A separate analysis of the inter- and intra-observer correlation was also performed to determine the agreement among the four observers who specialized in gynaecological ultrasound. Cohen's coefficient <0 meant that there was poor agreement, 0.01–0.20 slight agreement, 0.21–0.40 fair agreement, 0.41–0.60 moderate agreement, 0.61–0.80 substantial agreement and 0.81–0.99 almost perfect agreement.

MAIN RESULTS AND THE ROLE OF CHANCE

Agreement (Cohen's ) between all six observers for the interpretation of the ‘sliding sign’ for both sets of videos in both regions (retro-cervix and fundus) ranged from 0.354 to 0.927 (fair agreement to almost perfect agreement) compared with 0.630–0.927 (substantial agreement to almost perfect agreement) when only the gynaecological sonologists were included. The overall multiple rater agreement for the interpretation of the ‘sliding sign’ for both video sets and both regions was Fleiss' 0.454 (P-value <0.01) for all six observers and 0.646 (P-value <0.01) for the four gynaecological ultrasound specialists. The multiple rater agreement for all six or all four observers was higher for the retro-cervical region versus the fundal region (Fleiss' 0.542 versus 0.370 and 0.732 versus 0.560, respectively). The intra-observer agreement among the six observers for the interpretation of the ‘sliding sign’ and prediction of POD obliteration ranged from Cohen's 0.60–0.95 and 0.46–1.0 (P-value <0.01), respectively. After excluding the fetal medicine specialists, the intra-observer agreement for the interpretation of the ‘sliding sign’ and the prediction of POD obliteration ranged from Cohen's 0.71–0.95 and 0.67–1.0, respectively, indicating substantial to almost perfect agreement. When comparing the four gynaecological observers for the prediction of POD obliteration using the TVS ‘sliding sign’ (after excluding cases with the POD outcome classified as ‘unsure’ by the observers), the results for accuracy, sensitivity, specificity, positive and negative predictive value were 93.1–100, 92.9–100, 90.9–100, 77.8–100 and 97.7–100%, respectively.

LIMITATIONS, REASONS FOR CAUTION

The ‘gold standard’ for the diagnosis of POD obliteration is laparoscopy; however, laparoscopic data were available only for 24 out of 30 (80%) TVS ‘sliding sign’ cases included in this study. Although this should not affect the inter- and intra-observer agreement findings, the ability to draw conclusions regarding the diagnostic accuracy of the TVS ‘sliding sign’ in the prediction of POD obliteration is somewhat limited. In addition, the diagnostic accuracy findings should be interpreted with the caveat that the cases classified as ‘unsure’ for the prediction of POD obliteration were excluded from the analysis.

WIDER IMPLICATIONS OF THE FINDINGS

We have validated the dynamic real-time TVS ‘sliding sign’ technique for the prediction of POD obliteration, and this simple ultrasound-based test appears to have very acceptable inter-/intra-observer agreement for those who are experienced in gynaecological ultrasound. Given that women with POD obliteration at laparoscopy have an increased risk of bowel endometriosis and requirement for bowel surgery, the TVS ‘sliding sign’ test should be considered in the pre-operative imaging work-up for all women with suspected endometriosis, to allow for appropriate surgical planning. We believe the TVS ‘sliding sign’ technique may be easily learned by sonologists/sonographers who are familiar with performing gynaecological ultrasound, and that further studies are required to confirm the diagnostic accuracy of this new ultrasound technique amongst sonologists/sonographers with various levels of experience.

STUDY FUNDING/COMPETING INTEREST(S)

This study received no specific grant from any funding agency in the public, commercial or not-for-profit sectors and the authors declare no competing interests.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/28/5/1237?rss=1

STUDY QUESTION

Does treatment for the resolution of ectopic pregnancy (EP) affect subsequent spontaneous fertility [occurrence of an intrauterine pregnancy (IUP)]?

SUMMARY ANSWER

There is no significant difference in 2 years subsequent fertility neither between methotrexate and conservative surgery for less active EP nor between conservative and radical surgery for the most active EP.

WHAT IS KNOWN ALREADY

No randomized trial has compared radical and conservative surgery treatments. A recent review of the Cochrane database did not conclude about fertility due to insufficient data. Prospective studies from EP registries in two regions of France (Auvergne and Greater Lille) have suggested that fertility is similar after medical treatment and conservative surgery and lower after radical surgery.

STUDY DESIGN, SIZE, DURATION

This randomized controlled trial included all women with an ultrasound-confirmed EP. Women were divided into two arms according to the activity of the EP (defined by Fernandez's score). In arm 1 (less active ectopic pregnancies, i.e. Fernandez's score <13 and no haemodynamic failure), medical treatment was considered practicable, and women were randomly allocated to conservative surgery with a systematic post-operative i.m. methotrexate injection within 24 h or to an i.m. methotrexate injection alone. In arm 2 (active ectopic pregnancies), medical treatment was considered impracticable, and, thus, all women had to undergo surgery; they were randomly allocated to either a radical or conservative procedure, the latter including a post-operative methotrexate injection. Sample sizes (n = 210 in arm 1 and n = 230 in arm 2) were computed to provide a statistical power of 80% to detect a 20% difference in subsequent cumulative fertility rates between treatments in each arm. The total duration of the trial was 5 years.

PARTICIPANTS/MATERIALS, SETTINGS, METHODS

The trial took place in 17 centres in France from 2005 to 2009. Two hundred and seven women were included in arm 1 and 199 in arm 2. Cumulative fertility curves were drawn with the Kaplan–Meier method and compared with the log-rank test. Hazard ratios (HRs) were computed with the Cox model. Analysis was performed according to the intention-to-treat principle.

MAIN RESULTS

Arm 1: cumulative fertility curves were not significantly different between medical treatment and conservative surgery. HR was 0.85 (0.59–1.22) P = 0.37. The 2-year rates of IUP were 67% after medical treatment and 71% after conservative surgery. Arm 2: cumulative fertility curves were not significantly different between conservative and radical surgery. HR was 1.06 (0.69–1.63) P = 0.78. The 2-year rates of IUP were 70% after conservative surgery and 64% after radical surgery.

LIMITATIONS, REASONS FOR CAUTION

Inclusion in this trial was more difficult than expected, especially in arm 2 in which women were reluctant to radical surgery. In consequence, the sample size was slightly lower than planned. However, due to a lower proportion of lost to follow-up than expected (10% instead of 15%), the statistical power remained very close to 80%.

WIDER IMPLICATIONS OF THE FINDINGS

As it is a multicentre randomized trial, the results may be generalized with satisfactory confidence. The results of this trial invite gynaecologists to reconsider the management of EP and to modify balance between considerations of initial recovery and preservation of fertility.

Trial registration number

NCT00137982 on the WHO International Clinical Trials Registry Platform.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/28/5/1247?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

Is lactoferrin (LF) (detected in oviductal secretion) able to bind to oocytes and sperm and modulate gamete interaction?

SUMMARY ANSWER

LF binds to zona pellucida (ZP) and spermatozoa (depending upon the capacitation stage and acrosome status) and inhibits gamete interaction in vitro.

WHAT IS KNOWN ALREADY

Proteins from human oviductal tissue secretion modulate gamete interaction and parameters of sperm function in vitro and some of them bind to sperm, but they remain to be isolated and identified.

STUDY DESIGN, SIZE, DURATION

Proteins were isolated from human oviductal tissue secretion using their sperm membrane binding ability. One of the isolated proteins was identified as human LF and immunolocalized in tubal tissues. LF expression was analyzed in native oviductal fluid and oviduct epithelial cells (at different phases of the menstrual cycle: proliferative, periovulatory and secretory). In addition, the LF binding sites on spermatozoa (at different capacitation and acrosome reaction stages) and on ZP and the dose-dependent effect of LF on gamete interaction were investigated. All experiments were performed at least three times.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Tubal tissues obtained from premenopausal patients (scheduled for hysterectomy, n = 23) were cultured in DMEM/Ham's F12 medium and conditioned media (CM) were collected. Motile spermatozoa were obtained by swim-up from normozoospermic semen samples from healthy donors (n = 4). An affinity chromatography with sperm membrane extracts was used to isolate proteins from CM. Isolated proteins were analyzed by sodium dodecyl sulfate–polyacrylamide gel electrophresis and further identified by nano liquid chromatography tandem mass spectrometry peptide sequencing. The presence of LF in oviductal tissue was investigated by immunohistochemistry and immunofluorescence and was detected in native oviductal fluid and oviduct epithelial cells homogenates by western blot. LF binding sites on gametes were investigated by incubating gametes with the protein coupled to fluorescein isothiocyanate (FITC). The acrosome reaction was assessed with Pisum sativum agglutinin conjugated with rhodamine. The effect of increasing concentrations of LF (0.1–100 µg/ml) on gamete interaction was evaluated by a sperm–ZP binding assay, using human oocytes donated by women undergoing IVF procedures.

MAIN RESULTS AND THE ROLE OF CHANCE

A protein isolated by the affinity column was identified as human LF. LF was immunolocalized in human oviductal tissue and detected in oviductal fluid and oviduct epithelial cell homogenates. In the latter case, LF expression was highest at the periovulatory phase of the menstrual cycle (P < 0.01). Different LF binding patterns were observed on spermatozoa depending upon capacitation stage and if the acrosome reaction had occurred. Unstained sperm were most prevalent before capacitation, but after incubation for 6 h under capacitating conditions and in acrosome-reacted sperm LF binding was observed, mainly localized in the equatorial segment and post-acrosomal region of the sperm head. LF binding studies on ZP showed homogenous staining. LF caused a dose-dependent significant inhibition of sperm–ZP interaction, and the effect was already significant (P < 0.01) with the lowest LF concentration used.

LIMITATIONS, REASONS FOR CAUTION

This study has investigated the effect of LF only on human gamete interaction in vitro and thus has some limitations. Further investigations of the potential mechanisms involved in LF action both on gamete function in vitro and in vivo in animal models are needed to confirm the role of this protein in the reproductive process.

WIDER IMPLICATIONS OF THE FINDINGS

The present data indicate that human oviductal LF expression is cycle dependent and inhibited gamete interaction in vitro. No previous data were available about potential direct effects of LF on gamete interaction. It could be thought that the protein is involved in the regulation of the reproductive process, perhaps contributing to prevent polyspermy. Thus, further research is needed to clarify the potential role of LF in the regulation of the fertilization process.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by grants from FONCYT (PICT 01095, S.A.G., M.J.M) and SECyT UNR (PIDBIO238, S.A.G). The authors have no conflict of interest to declare.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/28/5/1297?rss=1