A group of experts gathered in Indianapolis in December 2011 to address lingering concerns related to uterus transplantation (UTn). They represent a multi-national group of four research teams who have worked for over 15 years on bringing UTn to reality for patients. Presented here are a set of parameters that must be considered in order for UTn to become an acceptable procedure in the human setting. UTn has been proposed as a potential solution to absolute uterine factor infertility (AUFI). Causes of AUFI include congenital uterine factors (i.e. absence or malformation) or acquired uterine factors (e.g. hysterectomy for uncontrollable hemorrhage) rendering a woman ‘unconditionally infertile’. Current estimates are that in the USA, up to 7 million women with AUFI may be appropriate candidates for UTn. As a result of a first human attempt in 2000, investigators have responded with a plethora of publications demonstrating successful UTn attempts, including pregnancies, in various autogeneic, syngeneic and allogeneic animal models. Before UTn can become an accepted procedure, it must satisfy defined criteria for any surgical innovation, i.e. research background, field strength and institutional stability. Equally important, UTn must satisfy accepted bioethical principles (respect for autonomy, beneficence, non-maleficence and justice) and their application (informed consent, appropriate assessment of risk and benefit and fair selection of individuals). Furthermore, we believe that a defined number of transplants should not be exceeded worldwide without a successful term delivery, to minimize proceeding in futility using current techniques. Even if UTns were to become relatively common, the following research objectives should be continuously pursued: (i) additional pregnancies in a variety of large animal/primate models (to search for unanticipated consequences), (ii) continuous assessment of women diagnosed with AUFI regarding UTn, (iii) continuous assessment using ‘borrowed’ psychological tools from transplant centers, adoption agencies and assisted reproductive technology centers with potential recipients and (iv) continuous careful ethical reflection, assessment and approval.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/28/2/288?rss=1

STUDY QUESTION

Is DNA methyltransferase 1 (DNMT1) dysfunction involved in epigenetic deregulation of placentae from embryos obtained by assisted reproduction technologies (ARTs)?

SUMMARY ANSWER

DNMT1 expression in growing placentae of in vitro produced (IVP) embryos is compromised and associated with pregnancy loss.

WHAT IS KNOWN ALREADY

DNMT1 maintains the methylation profile of genes during cell division. The methylation status of genes involved in placenta development is altered in embryos obtained in vitro. Disturbances in the epigenetic regulation of gene expression during placentogenesis could be involved in the frequent developmental arrest and loss of IVP embryos.

STUDY DESIGN, SIZE, DURATION

Forty sheep were naturally mated (Group 1, CTR). IVP blastocysts (2–4 per ewe) were surgically transferred to the remaining 46 recipient sheep 6 days after oestrus (Group 2). Twenty-one recipients from Group 1 and 27 recipients from Group 2 were allowed to deliver in order to compare embryo survival in both groups at term (150 days). From the remaining recipients (n = 38), fetuses and placentae of both groups were recovered by paramedian laparotomy at Days 20, 22, 24, 26 and 28 of gestation.

MATERIALS, SETTING, METHODS

Immediately after collection, early placental tissues (chorion-allantois) were snap frozen in liquid nitrogen and DNMT1 expression and activity was evaluated. mRNA levels (for DNMT1, HDAC2, PCNA, DMAP1, MEST, IGF2, CDKN1C, H19) and the methylation status of H19 were also analyzed. Furthermore, embryo size and survival rate were measured.

MAIN RESULTS AND THE ROLE OF CHANCE

Our study shows that DNMT1 expression was reduced in early placentae from sheep IVP embryos. This reduction was associated with growth arrest and subsequent death of the sheep embryos. Conversely, normal levels of DNMT1 and its cofactors were observed in placentae from IVP embryos that survived this developmental bottleneck. Although DNA methylation machinery was severely compromised in IVP placentae only up to Day 24, the low DNMT1 enzymatic activity that persisted after this stage in IVP placentae was not lethal for the developing embryos.

LIMITATIONS, REASONS FOR CAUTION

The studied genes represent only a small fraction of genes regulating DNA methylation. Further studies are needed to evaluate changes in the expression and methylation status of other genes that may lead to developmental arrest of IVP embryos. As this is the only study evaluating the functionality of DNMT1 machinery in placentae from ART embryos, studies on other species are needed to confirm if our observation may be applicable to all mammalian embryos produced in vitro.

WIDER IMPLICATIONS OF THE FINDINGS

The knowledge about compromised activity of DNMT1 in placentae obtained from IVP embryos should stimulate detailed studies on the metabolic requirements of oocytes and embryos in order to adequately enrich the culture media.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by the European Research Council (FP7/2007–2013)/Programme IDEAS GA no. 210103 to G.E.P. No competing interests are declared.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/28/2/298?rss=1

STUDY QUESTION

Does the selection of sperm for ICSI based on their ability to bind to hyaluronan improve the clinical pregnancy rates (CPR) (primary end-point), implantation (IR) and pregnancy loss rates (PLR)?

SUMMARY ANSWER

In couples where ≤65% of sperm bound hyaluronan, the selection of hyaluronan-bound (HB) sperm for ICSI led to a statistically significant reduction in PLR.

WHAT IS KNOWN AND WHAT THIS PAPER ADDS

HB sperm demonstrate enhanced developmental parameters which have been associated with successful fertilization and embryogenesis. Sperm selected for ICSI using a liquid source of hyaluronan achieved an improvement in IR. A pilot study by the primary author demonstrated that the use of HB sperm in ICSI was associated with improved CPR. The current study represents the single largest prospective, multicenter, double-blinded and randomized controlled trial to evaluate the use of hyaluronan in the selection of sperm for ICSI.

DESIGN

Using the hyaluronan binding assay, an HB score was determined for the fresh or initial (I-HB) and processed or final semen specimen (F-HB). Patients were classified as >65% or ≤65% I-HB and stratified accordingly. Patients with I-HB scores ≤65% were randomized into control and HB selection (HYAL) groups whereas patients with I-HB >65% were randomized to non-participatory (NP), control or HYAL groups, in a ratio of 2:1:1. The NP group was included in the >65% study arm to balance the higher prevalence of patients with I-HB scores >65%. In the control group, oocytes received sperm selected via the conventional assessment of motility and morphology. In the HYAL group, HB sperm meeting the same visual criteria were selected for injection. Patient participants and clinical care providers were blinded to group assignment.

PARTICIPANTS AND SETTING

Eight hundred two couples treated with ICSI in 10 private and hospital-based IVF programs were enrolled in this study. Of the 484 patients stratified to the I-HB > 65% arm, 115 participants were randomized to the control group, 122 participants were randomized to the HYAL group and 247 participants were randomized to the NP group. Of the 318 patients stratified to the I-HB ≤ 65% arm, 164 participants were randomized to the control group and 154 participants were randomized to the HYAL group.

MAIN RESULTS AND THE ROLE OF CHANCE

HYAL patients with an F-HB score ≤65% demonstrated an IR of 37.4% compared with 30.7% for control [n = 63, 58, P > 0.05, (95% CI of the difference –7.7 to 21.3)]. In addition, the CPR associated with patients randomized to the HYAL group was 50.8% when compared with 37.9% for those randomized to the control group (n = 63, 58, P > 0.05). The 12.9% difference was associated with a risk ratio (RR) of 1.340 (RR 95% CI 0.89–2.0). HYAL patients with I-HB and F-HB scores ≤65% revealed a statistically significant reduction in their PLR (I-HB: 3.3 versus 15.1%, n = 73, 60, P = 0.021, RR of 0.22 (RR 95% CI 0.05–0.96) (F-HB: 0.0%, 18.5%, n = 27, 32, P = 0.016, RR not applicable due to 0.0% value) over control patients. The study was originally planned to have 200 participants per arm providing 86.1% power to detect an increase in CPR from 35 to 50% at α = 0.05 but was stopped early for financial reasons. As a pilot study had demonstrated that sperm preparation protocols may increase the HB score, the design of the current study incorporated a priori collection and analysis of the data by both the I-HB and the F-HB scores. Analysis by both the I-HB and F-HB score acknowledged the potential impact of sperm preparation protocols.

BIAS, CONFOUNDING AND OTHER REASONS FOR CAUTION

Selection bias was controlled by randomization. Geographic and seasonal bias was controlled by recruiting from 10 geographically unique sites and by sampling over a 2-year period. The potential for population effect was controlled by adjusting for higher prevalence rates of >65% I-HB that naturally occur by adding the NP arm and to concurrently recruit >65% and ≤65% I-HB subjects. Monitoring and site audits occurred regularly to ensure standardization of data collection, adherence to the study protocol and subject recruitment. Subgroup analysis based on the F-HB score was envisaged in the study design.

GENERALIZABILITY TO OTHER POPULATIONS

The study included clinics using different sperm preparation methods, located in different regions of the USA and proceeded in every month of the year. Therefore, the results are widely applicable.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by Biocoat, Inc., Horsham, PA, USA. The statistical analysis plan and subsequent analyses were performed by Sherrine Eid, a biostatistician. The manuscript was prepared by Kathryn C. Worrilow, Ph.D. and the study team members. Biocoat, Inc. was permitted to review the manuscript and suggest changes, but the final decision on content was exclusively retained by the authors. K.C.W is a scientific advisor to Biocoat, Inc. S.E. is a consultant to Biocoat, Inc. D.W. has nothing to disclose. M.P., S.S., J.W., K.I., C.K. and T.E. have nothing to disclose. G.D.B. is a consultant to Cooper Surgical and Unisense. J.L. is on the scientific advisory board of Origio.

TRIAL REGISTRATION NUMBER

NCT00741494.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/28/2/306?rss=1

STUDY QUESTION

Do higher leptin levels and lower adiponectin levels predict subsequent development of endometriosis?

SUMMARY ANSWER

Plasma leptin and adiponectin levels were not associated with laparoscopically confirmed endometriosis when collected prior to disease diagnosis.

WHAT IS KNOWN ALREADY

Case–control studies have identified altered levels of the inflammatory adipokines leptin and adiponectin in women with endometriosis, but it remains unclear whether inflammation results in endometriosis or whether the presence of endometriosis creates an inflammatory state.

STUDY DESIGN, SIZE, DURATION

Nested, matched, case–control study within the prospective Nurses' Health Study II (NHS II) cohort. Blood samples were collected between 1996 and 1999 from 29 611 female nurses within the cohort. Women who reported endometriosis before blood collection were excluded.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Plasma leptin and adiponectin levels were assayed by ELISA. Three hundred and fifty cases of laparoscopically confirmed endometriosis were matched 1:2 with 694 controls of comparable race, age, infertility history, menopausal status and time of blood draw. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated using unconditional logistic regression models adjusting for matching factors and BMI.

MAIN RESULTS AND THE ROLE OF CHANCE

After adjusting for BMI, there were no statistically significant associations between endometriosis and leptin [RR = 1.2; 95% CI = 0.7–2.0; P-value, test for linear trend (P_trend) = 0.72], adiponectin (RR = 0.8; 95% CI = 0.5–1.2; P_trend = 0.48) or the leptin to adiponectin ratio (RR = 0.8; 95% CI = 0.4–1.4; P_trend = 0.14) when comparing the upper with the lower quartile. Results were unaltered when analyses were stratified by BMI or restricted to cases diagnosed ≥4 years after blood draw. To evaluate statistical significance and limit the role of chance to the gold standard of 5%, we present 95% CIs about the RRs, and for P-values calculated for linear tests of trend and tests of heterogeneity, we have set the α-level to be 0.05 (i.e. <0.05 is considered to be statistically significant).

LIMITATIONS AND REASONS FOR CAUTION

A limitation of this study is the inability to differentiate the time of endometriosis ‘diagnosis’ from the time of disease ‘onset’ due to the impossibility in identifying a precise time point at which the disease process was first initiated at a molecular or cellular level. Additional limitations include lack of information regarding stage of endometriosis and the possibility of asymptomatic disease in the control population.

WIDER IMPLICATIONS OF THE FINDINGS

The mean age at diagnosis of endometriosis in the study population is 41.7, ~10 years older than the mean age of diagnosis in the general population. While this may limit the generalizability of the results, there is no reason to suspect that the association between adipokines and endometriosis risk should differ at a younger age of diagnosis in an adult population.

STUDY FUNDING

This study was supported by research grants HD48544, HD52473 and HD57210 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The NHS II is supported by the Public Health Service grant CA50385 from the National Cancer Institute, NIH, U.S. Department of Health and Human Services. H.R.H. is supported by NIH training grant T32 ES007069 and MCHB grant number 5T76MC00001 (formerly MCJ201).

Source:
http://humrep.oxfordjournals.org/cgi/content/short/28/2/315?rss=1

STUDY QUESTION

Can plasma microRNAs be used as a non-invasive diagnostic test for the detection of endometriosis?

SUMMARY ANSWER

Plasma miR-17-5p, miR-20a and miR-22 are down-regulated in women with endometriosis compared with those without endometriosis in mainland China.

WHAT IS KNOWN ALREADY

There is currently a pressing need to develop a non-invasive diagnostic test for endometriosis. Altered circulating microRNA profiles have already been linked to various disease states.

STUDY DESIGN, SIZE, AND DURATION

This was a prospective laboratory study in a tertiary-referral university hospital in Beijing, PR China, between January 2012 and May 2012. Twenty-three women with histologically proven endometriosis and 23 endometriosis-free controls were enrolled in this study.

PARTICIPANTS/MATERIALS, SETTING, AND METHODS

Laparoscopic inspection of the abdominopelvic cavity was performed for each patient, and peripheral blood samples were collected before laparoscopy. Microarray-based microRNA expression profiling was used to identify differentially expressed microRNAs in plasma samples between women with and without endometriosis, and quantification of selected microRNAs was performed using quantitative RT–PCR.

MAIN RESULTS AND THE ROLE OF CHANCE

Twenty-seven microRNAs were differentially expressed between women with and without endometriosis, of which six microRNAs (miR-15b-5p, miR-17-5p, miR-20a, miR-21, miR-22 and miR-26a) were selected for validation. MiR-17-5p, miR-20a and miR-22 were significantly down-regulated in women with endometriosis compared with controls (P = 0.011, 0.0020 and 0.0002, respectively), yielding an area under the receiver operator characteristics curve of 0.74 [95% confidence interval (CI): 0.58–0.90], 0.79 (95% CI: 0.65–0.93) and 0.85 (95% CI: 0.71–0.98) in discriminating endometriosis from controls, respectively.

LIMITATIONS AND REASONS FOR CAUTION

Our sample size was small and all cases were rAFS stage III–IV, which may limit generalization of plasma microRNAs for early diagnosis of endometriosis. Moreover, only six microRNAs were selected for validation.

WIDER IMPLICATIONS OF THE FINDINGS

Plasma microRNAs provide a promising opportunity for detection of endometriosis.

STUDY FUNDING/COMPETING INTEREST(S)

This research was supported by the National Natural Science Foundation of China (81170548) and Key Project for Clinical Faculty Foundation, Ministry of Health, China (2010). All authors declare no conflict of interest.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/28/2/322?rss=1

STUDY QUESTION

Is an elective single-embryo transfer (eSET) policy feasible for women aged 40 or older?

SUMMARY ANSWER

For older women (aged 40–44 years) with a good prognosis, an eSET policy can be applied with acceptable cumulative clinical pregnancy rates and live birth rates.

WHAT IS KNOWN ALREADY

Various studies have shown the effectiveness of eSET in women aged <35 years with high cumulative pregnancy rates and low rates of multiple births.

STUDY DESIGN, SIZE, DURATION

This retrospective cohort study included 628 women treated between 2000 and 2009.

PARTICIPANTS, SETTING, METHODS

Women aged 40–44 years underwent a fresh cycle of IVF or ICSI treatment with eSET (n = 264) or double-embryo transfer (DET) (n = 364). In the subsequent frozen-thawed embryo transfer cycles, SET/DET was performed in both groups according to the number of embryos available and the opinion of the couple. The study was performed at the Family Federation of Finland Helsinki Fertility Clinic.

MAIN RESULTS AND THE ROLE OF CHANCE

In the fresh cycles, the clinical pregnancy rates were 23.5 and 19.5% in the eSET and DET groups, respectively, and live birth rates were 13.6 and 11.0%, respectively. In the fresh cycles with eSET, there were no twin pregnancies, but in the DET group, there were three sets of twins (7.5%). The cumulative clinical pregnancy rates per oocyte retrieval were 37.1 and 24.2% in the eSET and DET groups, respectively (P < 0.001), and the cumulative live birth rates were 22.7 and 13.2%, respectively (P = 0.002). Cumulative twin rates were 6.7% (n = 4) in the eSET group and 8.3% (n = 4) in the DET group (P = 0.726). All of the twin pregnancies in the eSET group resulted from frozen and thawed DET embryo transfer cycles.

LIMITATIONS

The characteristics of the two patients groups are not comparable because the suitability of eSET was individually assessed by a clinician based on both clinical prognostic factors and the outcome of IVF or ICSI, i.e. the number and quality of embryos.

WIDER IMPLICATIONS OF THE FINDINGS

This study may be generalized to IVF units having experience in eSET and cryopreservation.

STUDY FUNDING/COMPETING INTEREST(S)

This study received no funding and there are no conflicts of interests to be declared.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/28/2/331?rss=1

STUDY QUESTION

What is the relationship between the rate of elective single-embryo transfer (eSET) and couples' exposure to different elements of a multifaceted implementation strategy?

SUMMARY ANSWER

Additional elements in a multifaceted implementation strategy do not result in an increased eSET rate.

WHAT IS KNOWN ALREADY

A multifaceted eSET implementation strategy with four different elements is effective in increasing the eSET rate by 11%. It is unclear whether every strategy element contributes equally to the strategy's effectiveness.

STUDY DESIGN AND SIZE

An observational study was performed among 222 subfertile couples included in a previously performed randomized controlled trial.

PARTICIPANTS, SETTINGS AND METHODS

Of the 222 subfertile couples included, 109 couples received the implementation strategy and 113 couples received standard IVF care. A multivariate regression analysis assessed the effectiveness of four different strategy elements on the decision about the number embryos to be transferred. Questionnaires evaluated the experiences of couples with the different elements.

MAIN RESULTS AND ROLE OF CHANCE

Of the couples who received the implementation strategy, almost 50% (52/109) were exposed to all the four elements of the strategy. The remaining 57 couples who received two or three elements of the strategy could be divided into two further classes of exposure. Our analysis demonstrated that additional elements do not result in an increased eSET rate. In addition to the physician's advice, couples rated a decision aid and a counselling session as more important for their decision to transfer one or two embryos, compared with a phone call and a reimbursement offer (P < 0.001).

LIMITATIONS AND REASONS FOR CAUTION

The differences in eSET rate between exposure groups failed to reach significance, probably because of the small numbers of couples in each exposure group.

WIDER IMPLICATIONS OF THE FINDINGS

Adding more elements to an implementation strategy does not always result in an increased effectiveness, which is in concordance with recent literature. This in-depth evaluation of a multifaceted intervention strategy could therefore help to modify strategies, by making them more effective and less expensive.

STUDY FUNDING/COMPETING INTERESTS

There are no funding sources or competing interests to be declared.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/28/2/336?rss=1

STUDY QUESTION

Was the delivery rate of ART cycles negatively affected by the enactment of the Law 40/2004 by the Italian Parliament which imposed a long list of restrictions for ART procedures?

SUMMARY ANSWER

This large and extensive comparative analysis of ART outcomes prior to and after the introduction of the Law 40 revealed a significant reduction in pregnancy and delivery rates per cycle, independent of age or other clinical variables, once the law went into effect.

WHAT IS KNOWN ALREADY

Several studies have been published on the effect of Law 40/2004 on ART outcomes, some authors demonstrating a negative impact of the Law in relation to specific etiologies of infertility, other authors showing opposite conclusions.

STUDY DESIGN, SIZE, DURATION

Retrospective clinical study of 3808 patients treated prior to the enactment of the Law, September 1996–March 2004 (Group I) and 6898 treated during the Law, March 2004–May 2009 (Group II).

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 10 706 ART cycles were analysed, 3808 performed before and 6898 after the application of the Law. An intention-to-treat statistical analysis was performed to detect pregnancy and delivery rates (pregnancies ≥24 weeks) per started cycle. A P value of <0.05 was considered statistically significant. We analysed different outcomes: differences in fertilization, pregnancy and delivery rate, multiple pregnancies and miscarriage rates between the two time periods.

MAIN RESULTS AND THE ROLE OF CHANCE

The delivery rate for started cycle was 20% before and 16.0% after the introduction of the Law representing a 25% reduction (P < 0.001). The multivariate analysis, corrected by female age of >38 years, duration of infertility, basal FSH level and number of retrieved oocytes, showed a 16% lower delivery rate (odds ratio: 0.84; confidence interval: 0.75–0.94). This statistical approach removed the risk that the observed effects were due to chance and confirmed unequivocally that the Law was an independent factor responsible for the reduced likelihood of a successful outcome.

LIMITATIONS, REASONS FOR CAUTION

This is a retrospective study. A prospective randomized study, with patients treated in the same time period and randomized to restrictions or not, would have minimized potential limitations due to differences in years of treatments.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings based on the analysis of such a large number of cycles proved clearly and unequivocally that imposing restrictions on the practice of ART penalized patients. These data represent a relevant clinical contribution for countries still debating the enactment of restrictive limitations of ART.

STUDY FUNDING/COMPETING INTEREST

This investigation has been supported by a finalized grant from Lombardy County, Italy (DGR 7255, 3 July 2008).

Source:
http://humrep.oxfordjournals.org/cgi/content/short/28/2/343?rss=1

STUDY QUESTION

What do older women understand of the relationship between age and fertility prior and subsequent to delivering their first child?

SUMMARY ANSWER

Women who were first-time parents over the age of 40 did not accurately perceive the relationship between age and fertility prior to conceiving with IVF.

WHAT IS KNOWN ALREADY

While increases in women's age at their first birth have been most pronounced in relatively older women, the rapidity of fertility decline is not appreciated by most non-infertility specialist physicians, the general public or men and women who are delaying childbearing.

STUDY DESIGN, SIZE AND DURATION

Qualitative retrospective interviews were conducted from 2009 to 2011 with 61 self-selected women who were patients in one of two fertility clinics in the USA.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All participants had delivered their first child following IVF when the woman was 40 years or older. The data include women's responses to the semi-structured and open-ended interview questions ‘What information did you have about fertility and age before you started trying to get pregnant?’ and ‘What did you learn once you proceeded with fertility treatment?’

MAIN RESULTS AND THE ROLE OF CHANCE

Of the women, 30% expected their fertility to decline gradually until menopause at around 50 years and 31% reported that they expected to get pregnant without difficulty at the age of 40. Reasons for a mistaken belief in robust fertility included recollections of persistent and ongoing messaging about pregnancy prevention starting in adolescence (23%), healthy lifestyle and family history of fertility (26%), and incorrect information from friends, physicians or misleading media reports of pregnancies in older celebrity women (28%). Participants had not anticipated the possibility that they would need IVF to conceive with 44% reporting being ‘shocked’ and ‘alarmed’ to discover that their understanding of the rapidity of age-related reproductive decline was inaccurate’. In retrospect, their belated recognition of the effect of age on fertility led 72% of the women to state that they felt ‘lucky’ or had ‘beaten the odds’ in successfully conceiving after IVF. Of the women, 28% advocated better fertility education earlier in life and 23% indicated that with more information about declining fertility, they might have attempted conception at an earlier age. Yet 46% of women acknowledged that even if they had possessed better information, their life circumstances would not have permitted them to begin childbearing earlier.

LIMITATIONS AND REASONS FOR CAUTION

Both the self-selected nature of recruitment and the retrospective design can result in biases due to memory limitations or participant assimilation and/or contrast of past events with current moods. The cohort did not reflect broad homogeneity in that the participants were much more likely to be highly educated, Caucasian and better able to pay for treatment than national population norms. As attitudes of older women who were unsuccessful after attempting IVF in their late 30s or early 40s are not represented, it is possible (if not likely) that the recollections of women who did not conceive after IVF would have been more strongly influenced by feelings of regret or efforts to deflect blame for their inability to conceive.

WIDER IMPLICATIONS OF THE FINDINGS

While the failure to appreciate the true biological relationship between aging and fertility may be common and may reflect inaccessibility or misinterpretation of information, it is not sufficient to explain the decades-long socio-demographic phenomenon of delayed childbearing.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by the US National Institute of Child and Human Development (NICHD, RO1-HD056202).

Source:
http://humrep.oxfordjournals.org/cgi/content/short/28/2/350?rss=1

STUDY QUESTION

Is optimal adherence to guideline recommendations in intrauterine insemination (IUI) care cost-effective from a societal perspective when compared with suboptimal adherence to guideline recommendations?

SUMMARY ANSWER

Optimal guideline adherence in IUI care has substantial economic benefits when compared with suboptimal guideline adherence.

WHAT IS KNOWN ALREADY

Fertility guidelines are tools to help health-care professionals, and patients make better decisions about clinically effective, safe and cost-effective care. Up to now, there has been limited published evidence about the association between guideline adherence and cost-effectiveness in fertility care.

STUDY DESIGN, SIZE, DURATION

In a retrospective cohort study involving medical record analysis and a patient survey (n = 415), interviews with staff members (n = 13) and a review of hospitals' financial department reports and literature, data were obtained about patient characteristics, process aspects and clinical outcomes of IUI care and resources consumed. In the cost-effectiveness analyses, restricted to four relevant guideline recommendations, the ongoing pregnancy rate per couple (effectiveness), the average medical and non-medical costs of IUI care, possible additional IVF treatment, pregnancy, delivery and period from birth up to 6 weeks after birth for both mother and offspring per couple (costs) and the incremental net monetary benefits were calculated to investigate if optimal guideline adherence is cost-effective from a societal perspective when compared with suboptimal guideline adherence.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Seven hundred and sixty five of 1100 randomly selected infertile couples from the databases of the fertility laboratories of 10 Dutch hospitals, including 1 large university hospital providing tertiary care and 9 public hospitals providing secondary care, were willing to participate, but 350 couples were excluded because of ovulatory disorders or the use of donated spermatozoa (n = 184), still ongoing IUI treatment (n = 143) or no access to their medical records (n = 23). As a result, 415 infertile couples who started a total of 1803 IUI cycles were eligible for the cost-effectiveness analyses.

MAIN RESULTS AND THE ROLE OF CHANCE

Optimal adherence to the guideline recommendations about sperm quality, the total number of IUI cycles and dose of human chorionic gonadotrophin was cost-effective with an incremental net monetary benefit between 645 and over 7500 per couple, depending on the recommendation and assuming a willingness to pay 20 000 for an ongoing pregnancy.

LIMITATIONS, REASONS FOR CAUTION

Because not all recommendations applied to all 415 included couples, smaller groups were left for some of the cost-effectiveness analyses, and one integrated analysis with all recommendations within one model was impossible.

WIDER IMPLICATIONS OF THE FINDINGS

Optimal guideline adherence in IUI care has substantial economic benefits when compared with suboptimal guideline adherence. For Europe, where over 144 000 IUI cycles are initiated each year to treat ~32 000 infertile couples, this could mean a possible cost saving of at least 20 million euro yearly. Therefore, it is valuable to make an effort to improve guideline development and implementation.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported financially by the Netherlands Organisation for Health Research and Development, Grant No. 945-12-012, The Hague, The Netherlands. The funding source had no involvement in the study. The authors declare that they have no conflict of interest.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/28/2/357?rss=1

STUDY QUESTION

Are the risks of hypoplastic left heart syndrome, transposition of great arteries, tetralogy of Fallot (TOF) and coarctation of the aorta increased in infants conceived by different assisted reproductive techniques (ARTs)?

STUDY ANSWER

ARTs, and particularly intracytoplasmic sperm injection (ICSI), are specifically associated with a higher risk of TOF.

WHAT IS ALREADY KNOWN

ARTs are associated with an increase in the overall risk of birth defects. The risk for congenital heart defects (CHDs) associated with ARTs has been evaluated as a whole but there is limited information on the risks for specific CHDs.

STUDY DESIGN, MATERIAL AND METHODS

We conducted a case–control study using population-based data from the Paris registry of congenital malformations for the period 1987–2009 and a cohort study of CHD (EPICARD) on 1583 cases of CHDs and 4104 malformed controls with no known associations with ARTs. ARTs included ovulation induction only, IVF and ICSI.

RESULTS

Exposure to ARTs was significantly higher for TOF than controls (6.6 versus 3.5%, P = 0.002); this was not the case for the other three CHDs. ARTs (all methods combined) were associated with a 2.4-fold higher odds of TOF after adjustment for maternal characteristics, paternal age and year of birth [adjusted odds ratios (OR): 2.4, 95% confidence interval (CI): 1.5–3.7] with the highest risk associated with ICSI (adjusted OR: 3.0, 95% CI: 1.0–8.9). No statistically significant associations were found for the other CHDs.

LIMITATIONS

Our study cannot disentangle to what extent the observed associations between the risk of TOF and ARTs are due to causal effects of ARTs and/or the underlying infertility problems of couples who conceive following ART.

IMPLICATIONS

The developmental basis of the specific association between the risk of TOF and ARTs need to be further investigated.

FUNDING

This work was supported by grants from the Agence de Biomédecine (Saint-Denis La Plaine, France) (to B.K.). The Paris Registry of Congenital Malformations received financial support from INSERM (Paris, France) and the Institut de Veille Sanitaire (Saint-Maurice, France). The EPICARD study was supported by three grants from the Ministry of Health (PHRC 2004, 2008 and 2011). Additional funding for the EPICARD study was provided by the AREMCAR Association (Association pour la Recherche et l'Etude des Maladies Cardiovasculaires).

COMPETING INTERESTS

None.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/28/2/367?rss=1

STUDY QUESTION

How do families with children conceived using donor sperm operate as the children grow up?

SUMMARY ANSWER

Families with children aged 5–13 years conceived through anonymous donor sperm function well, when compared with other family types with children of the same developmental stage.

WHAT IS KNOWN ALREADY

Previous studies on family relationships after donor sperm conception have been reassuring. However, these studies have suffered from methodological limitations due to small sample sizes, respondent biases and absence of appropriate controls.

STUDY DESIGN, SIZE, DURATION

This study was an observational study comparing 79 ‘donor insemination’ (DI) families with 987 ‘couple’ families, 364 ‘single mother’ and 112 ‘step-father’ families as part of the Australian Institute of Family Studies Children and Family Life (CFL) study. CFL involved the collection of data on family functioning and child wellbeing from all resident parents through a Family and Child Questionnaire for the ‘primary’ parent (FACQ-P1) and a Family Relationship Questionnaire (FRQ-P2) for the ‘other’ parent.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All questionnaires were coded with the identity known only to the researchers. The outcomes studied included parent psychological adjustment, family functioning, couple relationship, parenting and parent–child relationship. Family types were compared, separately for mothers' and fathers' reports. The results presented are the estimated means for each family type based on the final model for each outcome: post hoc comparisons between family types are reported with 95% confidence limits.

MAIN RESULTS AND THE ROLE OF CHANCE

With all of the outcomes considered, there was not one result where the DI families showed poorer functioning on average than the comparison groups.

LIMITATIONS, REASON FOR CAUTION

The final sample size of DI families is 79 with an excellent response rate of nearly 80%. However, there remains some scope for response bias.

WIDER IMPLICATIONS OF THE FINDINGS

This study further reassures us that families conceived with anonymous donor sperm do not function any differently from other family types.

STUDY FUNDING/COMPETING INTERESTS

The study was partly funded by a research grant from the Fertility Society of Australia, and the profits from a Serono Symposium on Polycystic Ovaries. There are no competing interests.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/28/2/375?rss=1

STUDY QUESTION

How good is fertility knowledge and what are treatment beliefs in an international sample of men and women currently trying to conceive?

SUMMARY ANSWER

The study population had a modest level of fertility knowledge and held positive and negative views of treatment.

WHAT IS KNOWN ALREADY

Few studies have examined general fertility treatment attitudes but studies of specific interventions show that attitudes are related to characteristics of the patient, doctor and context. Further, research shows that fertility knowledge is poor. However, the majority of these studies have examined the prevalence of infertility, the optimal fertile period and/or age-related infertility in women, in university students and/or people from high-resource countries making it difficult to generalize findings.

STUDY DESIGN, SIZE, DURATION

A cross-sectional sample completed the International Fertility Decision-making Study (IFDMS) over a 9-month period, online or via social research panels and in fertility clinics.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants were 10 045 people (8355 women, 1690 men) who were on average 31.8 years old, had been trying to conceive for 2.8 years with 53.9% university educated. From a total of 79 countries, sample size was >100 in 18 countries. All 79 countries were assigned to either a very high Human Development Index (VH HDI) or a not very high HDI (NVH HDI). The IFDMS was a 45-min, 64-item English survey translated into 12 languages. The inclusion criteria were the age between 18 and 50 years and currently trying to conceive for at least 6 months. Fertility knowledge was assessed using a 13-item correct/incorrect scale concerned with risk factors, misconceptions and basic fertility facts (range: 0–100% correct). Treatment beliefs were assessed with positive and negative statements about fertility treatment rated on a five-point agree/disagree response scale.

MAIN RESULTS AND THE ROLE OF CHANCE

Average correct score for Fertility Knowledge was 56.9%, with greater knowledge significantly related to female gender, university education, paid employment, VH HDI and prior medical consultation for infertility (all P < 0.001). The mean agreement scores for treatment beliefs showed that agreement for positive items (safety, efficacy) was correlated with agreement for negative items (short/long-term physical/emotional effects) (P > 0.001). People who had given birth/fathered a child, been trying to conceive for less than 12 months, who had never consulted for a fertility problem and who lived in a country with an NVH HDI agreed less with negative beliefs. HDI, duration of trying to conceive and help-seeking were also correlates of higher positive beliefs, alongside younger age, living in an urban area and having stepchildren. Greater fertility knowledge was associated with stronger agreement on negative treatment beliefs items (P < 0.001) but was unrelated to positive treatment beliefs items.

LIMITATIONS, REASONS FOR CAUTION

There was volunteer bias insofar as more women, people of higher education and people with fertility problems (i.e. met criteria for infertility, had consulted a medical doctor, had conceived with fertility treatment) participated and this was true in VH and NVH HDI countries. The bias may mean that people in this sample had better fertility knowledge and less favourable treatment beliefs than is the case in the general population.

WIDER IMPLICATIONS OF THE FINDINGS

Educational interventions should be directed at improving knowledge of fertility health. Future prospective research should be aimed at investigating how fertility knowledge and treatment beliefs affect childbearing and help-seeking decision-making.

STUDY FUNDING/COMPETING INTEREST(S)

Merck-Serono S. A. Geneva-Switzerland (an affiliate of Merck KGaA Darmstadt, Germany) and the Economic and Social Research Council (ESRC, UK) funded this project (RES-355-25-0038, ‘Fertility Pathways Network’). L.B. is funded by a postdoctoral fellowship from the Medical Research Council (MRC) and the ESRC (PTA-037-27-0192). I.T. is an employee of Merck-Serono S. A. Geneva-Switzerland (an affiliate of Merck KGaA Darmstadt, Germany).

Source:
http://humrep.oxfordjournals.org/cgi/content/short/28/2/385?rss=1

BACKGROUND

Supportive care is regularly offered to women with recurrent miscarriages (RMs). Their preferences for supportive care in their next pregnancy have been identified by qualitative research. The aim of this study was to quantify these supportive care preferences and identify women's characteristics that are associated with a higher or lower need for supportive care in women with RM.

METHODS

A questionnaire study was conducted in women with RMs (≥2 miscarriages) in three hospitals in the Netherlands. All women who received diagnostic work-up for RMs from January 2010 to December 2010 were sent a questionnaire. The questionnaire quantified supportive care options identified by a previous qualitative study. We next analysed associations between women's characteristics (age, ethnicity, education level, parity, pregnancy during questionnaire and time passed since last miscarriage) and their feelings about supportive care options to elucidate any differences between groups.

RESULTS

Two hundred and sixty-six women were asked to participate in the study. In total, 174 women responded (response rate 65%) and 171 questionnaires were analysed. Women with RM preferred the following supportive care options for their next pregnancy: a plan with one doctor who shows understanding, takes them seriously, has knowledge of their obstetric history, listens to them, gives information about RM, shows empathy, informs on progress and enquires about emotional needs. Also, an ultrasound examination during symptoms, directly after a positive pregnancy test and every 2 weeks. Finally, if a miscarriage occurred, most women would prefer to talk to a medical or psychological professional afterwards. The majority of women expressed a low preference for admission to a hospital ward at the same gestational age as previous miscarriages and for bereavement therapy. The median preference, on a scale from 1 to 10, for supportive care was 8.0. Ethnicity, parity and pregnancy at the time of the survey were associated with different preferences, but female age, education level and time passed since the last miscarriage were not.

CONCLUSIONS

Women with RM preferred a plan for the first trimester that involved one doctor, ultrasounds and the exercise of soft skills, like showing understanding, listening skills, awareness of obstetrical history and respect towards the patient and their miscarriage, by the health care professionals. In the event of a miscarriage, women prefer aftercare. Women from ethnic minorities and women who were not pregnant during the questionnaire investigation were the two patient groups who preferred the most supportive care options. Tailor-made supportive care can now be offered to women with RM.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/28/2/398?rss=1

BACKGROUND

Previous experiments have shown that granulocyte colony-stimulating factor (G-CSF), quantified in the follicular fluid (FF) of individual oocytes, correlates with the potential for an ongoing pregnancy of the corresponding fertilized oocytes among selected transferred embryos. Here we present a proof of concept study aimed at evaluating the impact of including FF G-CSF quantification in the embryo transfer decisions.

METHODS

FF G-CSF was quantified with the Luminex XMap technology in 523 individual FF samples corresponding to 116 fresh transferred embryos, 275 frozen embryos and 131 destroyed embryos from 78 patients undergoing ICSI.

RESULTS

Follicular G-CSF was highly predictive of subsequent implantation. The receiving operator characteristics curve methodology showed its higher discriminatory power to predict ongoing pregnancy in multivariate logistic regression analysis for FF G-CSF compared with embryo morphology [0.77 (0.69–0.83), P < 0.001 versus 0.66 (0.58–0.73), P = 0.01)]. Embryos were classified by their FF G-CSF concentration: Class I over 30 pg/ml (a highest positive predictive value for implantation), Class II from 30 to 18.4 pg/ml and Class III <18.4 pg/ml (a highest negative predictive value). Embryos derived from Class I follicles had a significantly higher implantation rate (IR) than those from Class II and III follicles (36 versus 16.6 and 6%, P < 0.001). Embryos derived from Class I follicles with an optimal morphology reached an IR of 54%. Frozen-thawed embryos transfer derived from Class I follicles had an IR of 37% significantly higher than those from Class II and III follicles, respectively, of 8 and 5% (P < 0.001). Thirty-five per cent of the frozen embryos but also 10% of the destroyed embryos were derived from G-CSF Class I follicles. Non-optimal embryos appear to have been transferred in 28% (22/78) of the women, and their pregnancy rate was significantly lower than that of women who received at least one optimal embryo (18 versus 36%, P = 0.04).

CONCLUSIONS

Monitoring FF G-CSF for the selection of embryos with a better potential for pregnancy might improve the effectiveness of IVF by reducing the time and cost required for obtaining a pregnancy.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/28/2/406?rss=1

STUDY QUESTION

What is the distribution of telomeric repeat-containing RNA (TERRA) and of telomerase in human fetal oocytes?

SUMMARY ANSWER

TERRA forms discrete foci at telomeres of human fetal oocytes and it co-localizes with both the shelterin component telomeric repeat-binding factor 2 (TRF2) and the catalytic subunit of human telomerase at the telomeres of meiotic chromosomes.

WHAT IS KNOWN ALREADY

TERRA is a structural element of the telomeric chromatin that has been described in somatic cells of many different eukaryote species. The telomerase enzyme is inactive in adult somatic cells but is active in germ cells, stem cells and in the majority of tumors; however, its distribution in oocytes is still unknown.

STUDY DESIGN, SIZE, DURATION

For this study, ovarian samples from four euploid fetuses of 22 gestational weeks were used. These samples were obtained with the consent of the parents and of the Ethics Committee of Hospital de la Vall d'Hebron.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We analyzed the distribution of TERRA and telomerase in cells derived from human fetal ovaries. The co-localization of TERRA, telomerase and telomeres was performed by optimizing a combination of immunofluorescence (IF) and RNA-fluorescent in situ hybridization (RNA-FISH) techniques. The synaptonemal complex protein 3 (SYCP3), TRF2 and protein component of telomerase [telomerase reverse transcriptase (TERT)] were detected by IF, whereas TERRA was revealed by RNA-FISH using a (CCCTAA)₃ oligonucleotide. SYCP3 signals allowed us to identify oocytes that had entered meiosis and classify them into the different stages of prophase I, whereas TRF2 indicated the telomeric regions of chromosomes.

MAIN RESULTS AND THE ROLE OF CHANCE

We show for the first time the presence of TERRA and the intracellular distribution of telomerase in human fetal ovarian cells. TERRA is present, forming discrete foci, in 75% of the ovarian tissue cells and most of TERRA molecules (~83%) are at telomeres (TRF2 co-localization). TERRA levels are higher in oocytes than in ovarian tissue cells (P = 0.00), and do not change along the progression of the prophase I stage (P = 0.37). TERRA is present on ~23% of the telomeres in all cell types derived from human fetal ovaries. Moreover, ~22% of TERRA foci co-localize with the protein component of telomerase (TERT).

LIMITATIONS, REASONS FOR CAUTION

We present a descriptive/qualitative study of TERRA in human fetal ovarian tissue. Given the difficult access and manipulation of fetal samples, the number of fetal ovaries used in this study was limited.

WIDER IMPLICATIONS OF THE FINDINGS

This is the first report on TERRA expression in oocytes from human fetal ovaries. The presence of TERRA at the telomeres of oocytes from the leptotene to pachytene stages and its co-localization with the telomerase protein component suggests that this RNA might participate in the maintenance of the telomere structure, at least through the processes that take place during the female meiotic prophase I. Since telomeres in oocytes have been mainly studied regarding the bouquet structure, our results introduce a new viewpoint of the telomeric structure during meiosis.

STUDY FUNDING/COMPETING INTEREST(S)

R.R.-V. is a recipient of a PIF fellowship from Universitat Autònoma de Barcelona. This work was supported by the Generalitat de Catalunya (2009SGR1107). The authors declare that no competing interests exist.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/28/2/414?rss=1

STUDY QUESTION

What factors are associated with the presence of areas unexposed to the perfusate after whole ovary perfusion?

SUMMARY ANSWER

Over half the ovaries perfused with the metabolic marker methylthiazolyl blue tetrazolium (MTT) were incompletely stained. Incomplete staining was statistically significantly associated with a small ovarian slice surface area, inexperience of the experimenter, and the presence of a corpus luteum.

WHAT IS KNOWN ALREADY

Whole ovary cryopreservation followed by vascular auto-transplantation has provided poor outcomes as an alternative way to safeguard fertility. Perfusion, commonly used to expose the ovaries to cryoprotectants, may miss areas excluded from the vascular network, explaining subsequent poor ovarian functionality.

STUDY DESIGN, SIZE, DURATION

An observational study of 360 ewe ovaries stained by in vitro perfusion with MTT as a qualitative marker of tissue blood supply was performed. A logistic regression model was built to identify factors associated with incomplete ovary staining.

MATERIALS, SETTING, METHODS

Whole ewe ovaries with their vascular pedicles were perfused at 0.35 ml/min with 1 g/l MTT for 2 h at 39°C under 19 experimental conditions. The pedicles were removed and the ovaries cut in half sagittally and photographed. The unstained area of the slice surface was measured. Times from ovary collection to ovary rinsing and to MTT perfusion initiation, ovary weight and slice surface area, presence of a corpus luteum and operator experience (number of ovaries previously perfused) were recorded. Pedicle MTT staining was quantified at 564 nm after solubilization in alcohol.

MAIN RESULTS AND THE ROLE OF CHANCE

Unstained areas were observed in 64.4% of the ovaries. Multivariate analysis found that incomplete ovary staining was independently associated with lower experimenter experience (P < 0.02), smaller ovary slice surface area (P < 0.0001) and presence of a corpus luteum (P < 0.01). The presence of unstained areas was independent from experimental conditions. The rate of incomplete ovary staining decreased from 83 to 60% beyond the 80th perfused ovary (P < 0.0001).

LIMITATIONS, REASONS FOR CAUTION

Descriptive study.

WIDER IMPLICATIONS OF THE FINDINGS

Blood-supply impairments that result in incomplete perfusion might adversely affect outcomes after whole ovary cryopreservation. Improved perfusion techniques should enhance success.

STUDY FUNDING/COMPETING INTEREST(S)

Agence de la Biomédecine (Paris, France), Fondation de l'AVENIR (Paris, France)/no competing interest declared.

Source:
http://humrep.oxfordjournals.org/cgi/content/short/28/2/423?rss=1

Mr. Brown #39;s Biology Human Reproduction Notes

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human reproduction female reg 61614

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[Thai Hard-subbed] Human Reproduction
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[Thai Hard-subbed] Human Reproduction - Video