This paper concerns the requirements of the EU Tissue and Cells Directives with regard to the biological screening of donors of reproductive cells which are to be used for partner donation.
METHODS
We review the evidence regarding the risks of transmission of blood-borne viruses [hepatitis B (HBV), hepatitis C (HCV) and human immunodeficiency virus (HIV)] in the assisted reproductive technology (ART) setting. We document the experience in seven Irish ART clinics since the introduction of the legislation.
RESULTS
Even among those known to be HBV-, HCV- or HIV-positive, when current best practice ART procedures are employed for gamete and embryo processing, cross-contamination in the ART facility or horizontal or vertical transmission to a partner or neonate has never been documented. When samples are processed and high-security straws are used for cryopreservation, transmission of virus and cross-contamination in storage have not been reported.
CONCLUSIONS
While initial screening of those about to embark on ART treatment is good practice, we can find no medical or scientific evidence to support re-screening prior to each treatment cycle for individuals undergoing partner donation in ART. It would seem more appropriate to focus on risk reduction using a combination of initial baseline screening (with a reduced frequency of re-testing), appropriate sample processing and best possible containment systems for cryostorage.
Currently, no standard post-operative medical therapy has been shown to be superior in reducing the recurrence of endometrioma. This retrospective study was performed to evaluate the efficacy of post-operative cyclic oral contraceptive (OC) use after GnRH agonist (GnRHa) treatment for the prevention of endometrioma recurrence.
METHODS
This retrospective study included 362 reproductive-aged patients who had undergone pelviscopic surgery for endometrioma. Patients were divided into two groups: a group that received cyclic, low-dose, monophasic OCs after GnRHa treatment (n = 175) and a group that received only GnRHa treatment (n = 187). Endometrioma recurrence was evaluated by an ultrasound.
RESULTS
During the follow-up period (median, 35 months; range, 12–114 months), recurrent endometriomas were detected in 67 patients (18.5%). Patients receiving cyclic OCs after GnRHa treatment showed a significantly reduced recurrence risk of endometrioma, when compared with patients receiving GnRHa alone (odds ratio = 0.20; 95% confidence interval, 0.10–0.38). The cumulative proportion of recurrent endometrioma after 60 months was significantly lower in OC users than in non-users (6.1 versus 43.3%; P < 0.001), and a statistically significant difference was first detected at 30 months of follow-up (5.1 versus 17.1%; P = 0.018). The number of GnRHa injections (3 versus 6) did not affect the recurrence rate for up to 60 months in OC non-users or users.
CONCLUSIONS
Post-operative cyclic OC use after GnRHa treatment effectively reduces the recurrence of endometrioma.
Non-steroidal anti-inflammatory drug (NSAID)-activated gene-1 (NAG-1) is involved in cellular processes such as inflammation, apoptosis and tumorigenesis. However, little is known about the expression and function of NAG-1 in the endometrium. This study aimed to evaluate the expression of NAG-1 in the endometrium and in the absence or presence of endometriosis and to investigate the effect of celecoxib, a selective cyclooxygenase (COX)-2 inhibitor, on NAG-1 mRNA levels and apoptosis in human endometrial stromal cells (HESCs).
METHODS
Eutopic endometrial samples were obtained during surgery from 40 patients with, and 40 patients without, endometriosis. Real-time PCR was used to quantify NAG-1 mRNA levels and immunohistochemistry was used to localize NAG-1 protein in the endometrium. To investigate the effects of celecoxib, HESCs were isolated and cultured with different concentrations of celecoxib or with 100 µM celecoxib at different times. Apoptosis was assessed by flow cytometry.
RESULTS
NAG-1 mRNA levels and immunoreactivity showed cyclical changes through the menstrual cycle, increasing during the late secretory and menstrual phases. NAG-1 mRNA and protein levels were significantly lower in patients with endometriosis, compared with the control group. Celecoxib induced NAG-1 mRNA levels and apoptosis in cultured HESCs, with the effects dependent on drug concentrations and duration of treatment. Celecoxib treatment had no effect on prostaglandin E2 levels in the culture supernatants.
CONCLUSIONS
NAG-1 may be important in maintaining homeostasis in the normal endometrium and alterations in NAG-1 expression may be associated with the establishment of endometriosis. NAG-1 might be a therapeutic target for endometriosis.
Protamine content is necessary for proper sperm chromatin condensation and subsequent male fertility. The exact effect of smoking on male fertility remains controversial. The objective of this study was to evaluate the effect of smoking on protamine content of sperm in smoker and non-smoker patients.
METHODS
Protamines 1 (P1) and 2 (P2) were quantified by gel electrophoresis in the sperm of 53 smokers and 63 non-smokers. Sperm DNA fragmentation was analyzed employing the terminal deoxynucleotidyltransferase-mediated dUTP nick-end labelling (TUNEL) assay and non-condensed chromatin was evaluated using chromomycin A3 (CMA3). Levels of smoking and oxidative stress markers were determined in seminal plasma using an enzyme linked immunosorbant assay (ELISA) and chemical reactions.
RESULTS
Protamine 2 concentrations were significantly lower (P < 0.050) in smokers than in non-smokers. In contrast P1/P2 ratios were significantly higher (P < 0.010) in smokers (1.34 ± 0.46 ng/106 sperm) than in non-smokers (1.11 ± 0.20 ng/106 sperm). The oxidative stress and smoking markers, reactive oxygen species (ROS), malondialdehyde, 8-Hydroxyguanosine (8-OHdG) and cotinine were significantly higher (P < 0.010) in smokers than in non-smokers, and correlated significantly (P < 0.050) with P1/P2 ratios. P2 showed significant negative (P < 0.050) correlations with ROS, 8-OHdG and cotinine. CMA3 and TUNEL were also significantly higher (P < 0.010) in smokers (36.4 ± 8.1 and 17.4 ± 5.3%) than in non-smokers (29.8 ± 7.1 and 11.3 ± 4.2%).
CONCLUSIONS
This is the first study to evaluate the effect of smoking on protamines. Abnormal elevation of the P1/P2 ratio appears to be associated with aberrant P2 expression in smokers. These results suggest that induced oxidative stress by cigarette smoking may have significant inverse effect on the protamination process by disrupting P2.
So far, research on the patients’ perspective on fertility care has mainly focused on women. Our primary aim was to explore what is important to men with respect to care related to testicular sperm extraction (TESE) and to identify strengths and weaknesses of that care.
METHODS
This was a mixed-method study including phenomenology on interviews with 17 ‘interview participants’ (a purposive sample with diversification for the TESE result) who received a TESE treatment at a tertiary university clinic. Strengths and weaknesses of our TESE-related quality of care were identified. Additionally, a telephone questionnaire was answered by 15 ‘rating participants’ not willing to be interviewed and the questionnaire was analyzed quantitatively.
RESULTS
Interview participants wanted more than effective treatment and attached importance to the attitude of fertility clinic staff, information, time flow, personalized care, ‘all that is necessary’, coaching, a homely atmosphere, continuity, privacy and separate accommodation. The satisfaction of rating participants (independent of the TESE result) was problematic for ‘overall experience’, ‘physician at the day clinic’ and ‘gynecologist at discussion of the result’. The attitude of fertility clinic staff and information were the most obvious strengths of our TESE-related care. Weaknesses were lack of practical information on post-surgical recovery and waiting times in the waiting room.
CONCLUSIONS
TESE patients focus not only on clinical effectiveness but also on patient-centeredness of care, and this has led to organizational changes and a new patient information brochure in our center. Qualitative research is useful to examine, understand and improve the patient-centeredness of care.
Monitoring assisted reproductive technology (ART) is essential to evaluate the performance of fertility treatment and its impact on birth rates. In Europe, there are two kinds of ART registers: voluntary and mandatory. The validity of register data is very important with respect to the quality of register-based observational studies. The aim of this paper is to determine the degree of agreement between voluntary and mandatory ART registers.
METHODS
The two sources for the data compared in this study (referring to 2005 and 2006) were FIVCAT.NET (an official compulsory Assisted Reproduction Registry within the Health Ministry of the Regional Government of Catalonia, to which all authorized clinics, both public and private, performing assisted reproduction in the region are obliged to report) and the register of the Spanish Fertility Society (SEF), to which data are provided on a voluntary basis. The SEF register data were divided into two groups: (i) data from clinics in Catalonia (SEF-CAT); (ii) data from the rest of Spain, excluding Catalonia (SEF-wCAT). The techniques compared were IVF cycle using patients’ own eggs (IVF cycle) versus donor egg cycles.
RESULTS
For IVF cycles, the voluntary ART register reflected 77.2% of those on the official one, but the corresponding figure was only 34.4% with respect to donated eggs. The variables analysed in the IVF cycle (insemination technique used, patients’ age, number of embryos transferred, pregnancy rates, multiple pregnancies and deliveries) were similar in the three groups studied. However, we observed significant differences in donor egg cycles with regard to the insemination technique used, pregnancy rates and multiple pregnancies between the voluntary and the official register.
CONCLUSIONS
Data from the voluntary ART register for IVF cycles are valid, but those for donor egg cycles are not. Further study is necessary to determine the reasons for this difference.
The birth of a boy is significantly more common than a girl prior to secondary recurrent miscarriage (SRM) and is associated with a poorer chance of a subsequent live birth. Children born after SRM are more likely to be girls. High-titer antisera specific for male antigens (H-Y) have been shown to arrest development of male bovine embryos efficiently. We consequently questioned the role of H-Y antibodies in women with SRM.
METHODS
Serum samples from patients with unexplained SRM (n = 84), unexplained primary recurrent miscarriage (PRM) (n = 12) and healthy women (n = 37) were obtained. The samples were taken during pregnancy (gestational weeks 4–5) for 77 (80%) of the patients. Enzyme-linked immunosorbent assay was used to detect immunoglobulin G antibodies that specifically recognized any of the five recombinant H-Y proteins (EIF1AY, RPS4Y1, ZFY, DDX3Y and UTY) and their H-X homologs.
RESULTS
H-Y-specific antibodies were more frequent in SRM patients (46%) compared with female controls (19%, P = 0.004) and PRM patients (8%, P = 0.01). The presence of H-Y antibodies in early pregnancy was associated with a low male: female birth ratio among the subsequent live births, as only 12% of children born to H-Y antibody-positive patients were boys compared with 44% boys born to H-Y antibody negative patients (P = 0.03).
CONCLUSIONS
The high frequency of H-Y antibody-positive SRM patients and the association between the presence of these antibodies in early pregnancy and the low number of male offspring, suggest that maternal immune responses against H-Y antigens can cause pregnancy losses. Further exploring these mechanisms may increase our understanding of unexplained SRM.
Recently we reported that an oocyte activation ability in human and mouse sperm is associated with head flatness or the presence of perinuclear theca (PT) substance, MN13, which is an oocyte activation-related protein localized on the post-acrosomal sheath (PAS). As such, we hypothesize that the appearance of oocyte activation ability is stage-specifically regulated and depends on the formation of the acrosome or PAS/PT in spermatids.
METHODS
We monitored the appearance and movement of MN13 as a PT-specific molecule during spermatogenesis and analysed how the MN13 localization is affected in mouse and human globozoospermic acrosomeless sperm.
RESULTS
MN13 was first detected on the surface of acrosomic vesicles, i.e. on the nascent outer acrosomal membrane of step 5–6 round spermatids (Sb1 spermatids in human), and it was then translocated via the outer acrosomal membrane surface to the most distal region of the acrosome in step 7 round spermatids (Sb2 spermatids). As spermatids elongated, MN13 was translocated via the cytoplasmic space between the nuclear envelope and the overlying plasma membrane towards the post-acrosomal region, and it was organized on the top of the nascent PAS that was typically found in step 14 elongated spermatids (Sd1 spermatids). In contrast, MN13 was not found in any GOPC-deficient spermatids, which completely lack the acrosome but have manchettes (microtubule bundles), nor in mouse and human acrosomeless sperm.
CONCLUSIONS
The MN13 appearance or the MN13-related PAS/PT formation is highly dependant on acrosome formation; the MN13-related oocyte activation factor/ability is stage-specifically acquired in elongating/elongated spermatids.
Glycodelin-A interacts with spermatozoa before fertilization, but its role in modulating sperm functions is not known. Zona pellucida-induced acrosome reaction is crucial to fertilization and its dysfunction is a cause of male infertility. We hypothesized that glycodelin-A, a glycoprotein found in the female reproductive tract, potentiates human spermatozoa for zona pellucida-induced acrosome reaction.
METHODS
Glycodelin isoforms were immunoaffinity purified. The sperm intracellular cAMP concentration, protein kinase-A (PKA) and extracellular signal-regulated kinase (ERK) activities, and intracellular calcium were measured by ELISA, kinase activity assay kits and Fluo-4AM technique, respectively. The phosphorylation of inositol 1,4,5-trisphosphate type-1 receptor (IP3R1) mediated by ERK was determined by western blotting. Zona pellucida-induced acrosome reaction was detected by Pisum sativum staining.
RESULTS
Pretreatment of spermatozoa with glycodelin-A significantly up-regulated adenylyl cyclase/PKA activity and down-regulated the activity of ERK and its phosphorylation of IP3R1, thereby enhancing zona pellucida-induced calcium influx and zona pellucida-induced acrosome reaction. Glycodelin-F or deglycosylated glycodelin-A did not have these actions. Treatment of spermatozoa with a protein kinase inhibitor abolished the priming activity of glycodelin-A, whilst ERK pathway inhibitors mimic the stimulatory effect of glycodelin-A on zona pellucida-induced acrosome reaction.
CONCLUSIONS
Glycodelin-A in the female reproductive tract sensitizes spermatozoa for zona pellucida-induced acrosome reaction in a glycosylation-specific manner through activation of the adenylyl cyclase/PKA pathway, suppression of extracellular signal-regulated kinase activation and up-regulation of zona pellucida-induced calcium influx. The action of glycodelin-A may be important in vivo to ensure full responsiveness of human spermatozoa to the zona pellucida.
ATP-sensitive K+ (KATP) channels link intracellular metabolism with membrane excitability and play crucial roles in cellular physiology and protection. The KATP channel protein complex is composed of pore forming, Kir6.x (Kir6.1 or Kir6.2) and regulatory, SURx (SUR2A, SUR2B or SUR1), subunits that associate in different combinations. The objective of this study was to determine whether mammalian oocytes (human, bovine, porcine) express KATP channels.
METHODS
Supernumerary human oocytes at different stages of maturation were obtained from patients undergoing assisted conception treatments. Bovine and porcine oocytes in the germinal vesicle (GV) stage were obtained by aspirating antral follicles from abattoir-derived ovaries. The presence of mRNA for KATP channel subunits was determined using real-time RT–PCR with primers specific for Kir6.2, Kir6.1, SUR1, SUR2A and SUR2B. To assess whether functional KATP channels are present in human oocytes, traditional and perforated patch whole cell electrophysiology and immunoprecipitation/western blotting were used.
RESULTS
Real-time PCR revealed that mRNA for Kir6.1, Kir6.2, SUR2A and SUR2B, but not SUR1, were present in human oocytes of different stages. Only SUR2B and Kir6.2 mRNAs were detected in GV stage bovine and porcine oocytes. Immunoprecipitation with SUR2 antibody and western blotting with Kir6.1 antibody identified bands corresponding to these subunits in human oocytes. In human oocytes, 2,4-dinitrophenol (400 µM), a metabolic inhibitor known to decrease intracellular ATP and activate KATP channels, increased whole cell K+ current. On the other hand, K+ current induced by low intracellular ATP was inhibited by extracellular glibenclamide (30 µM), an oral antidiabetic known to block the opening of KATP channels.
CONCLUSIONS
In conclusion, mammalian oocytes express KATP channels. This opens a new avenue of research into the complex relationship between metabolism and membrane excitability in oocytes under different conditions, including conception.
Oxygen consumption is a key indicator of metabolic activity within embryos. Increased oxidative activity and REDOX changes at the time of fertilization have been suggested to signal Ca2+ oscillations after sperm penetration. The objective of the present study was to determine the oxygen consumption and the REDOX status of zygotes and early embryos at the time of sperm penetration and cell cleavage and to investigate how metabolism relates to key temporal events and developmental competence.
METHODS
Individual oxygen-consumption rates of bovine in vitro matured oocytes and presumptive zygotes (n = 101) were measured using the Nanorespirometer at 0, 7, 12, 17 and 24 h after IVF. Using the Embryoscope, oxygen-consumption profiles of individual oocytes and embryos (n = 75) were recorded repeatedly from 6 h until 30 h after IVF and time-lapse images were acquired, at intervals of ~36 min. Oocytes and embryos were stained with Hoechst 33342 and visualization of nuclear stage was performed by fluorescence microscopy. To determine the REDOX status, cohorts of oocytes and zygotes (n = 55) were individually stained with REDOX-Sensor Red CC-1 and Hoechst 33342 at 0, 7, 12, 17 and 24 h after IVF and subsequently imaged by confocal microscopy.
RESULTS
A peak of oxygen consumption was observed at the time of fertilization and a smaller rise and fall in oxygen consumption could be detected prior to the first cell cleavage. Increased reactive oxygen species production was also observed at 7 h and then at 24 h after IVF, just preceding the first embryonic cleavage.
CONCLUSIONS
There are specific events during embryo development that appear to be associated with a change in oxygen consumption and REDOX state, indicating that both have a role in sperm-mediated oocyte activation and cell cleavage in bovine embryos.
Cigarette smoking during pregnancy is associated with negative reproductive consequences for male fetuses in adult life such as reduced testicular volume and sperm concentration. The present study evaluates the number of germ and somatic cells present in human embryonic first-trimester gonads in relation to maternal smoking.
METHODS
The study includes 24 human first-trimester testes, aged 37–68 days post-conception, obtained from women undergoing legal termination of pregnancy. A questionnaire was used to obtain information about smoking and drinking habits during pregnancy. Validated stereological methods were used to estimate gonadal cell numbers in histological sections. Results were also evaluated in the context of previously published data on ovaries from our laboratory.
RESULTS
A significant reduction in the number of germ cells by 55% [95% confidence interval (CI) 74–21% reduction, P = 0.004] and somatic cells by 37% (95% CI 59–3%, P = 0.023) was observed in testes prenatally exposed to maternal cigarette smoking, compared with unexposed. The effect of maternal smoking was dose-dependent being higher in the heavy smokers and remained consistent after adjusting for possible confounders such as alcohol and coffee consumption (P = 0.002). The number of germ cells in embryonic gonads, irrespective of gender, was also significantly reduced by 41% (95% CI 58–19%, P = 0.001) in exposed versus non-exposed embryonic gonads.
CONCLUSIONS
Prenatal exposure to maternal cigarette smoke reduces the number of germ and somatic cells in embryonic male and female gonads. This effect may have long-term consequences on the future fertility of exposed offspring. These findings may provide one potential cause of the reduced fertility observed during recent years.
In order to optimize IVF strategies, particularly with the use of single embryo transfer, good predictive models are required. Here, we develop a model to allow such prediction, and the structure of the models point to more general conclusions about the mode of action of prognostic factors.
METHODS
Anonymized data from consecutive embryo transfers in five IVF centres in the UK for the 2000–2005 period were extracted and the morphological grade based on common scoring criteria was included. There were 16 096 (12 487 fresh and 3609 frozen) transfers, for 8775 couples, available for analysis. Live birth data were fitted to a model with separate sub-models for embryo and recipient effects [the ‘Embryo-Uterus’ (EU) model]. All covariates were included, with sub-model selection using Akaike's information criterion.
RESULTS
Age, number of embryos created, attempt number, previous history of pregnancy, duration of infertility, day of transfer and tubal diagnosis were all identified as significant prognostic factors, along with embryo grade and growth rate. Frozen transfers were substantially less likely to lead to a live birth with odds ratios of 1/3 to 1/2 compared with fresh transfers, with no evidence of differential loss for any particular patient group. Age acts predominantly through the embryo component with only a weak effect on the uterus. The embryo number, attempt number, previous pregnancies and duration of infertility act predominantly through the uterine environment. Both sub-models show significant heterogeneity between centres.
CONCLUSIONS
The EU modelling framework has generated a model for predicting outcomes of embryo-transfer procedures, subject to the limitations of routinely collected data. With this large data set, the model allows identification of factors that act specifically on embryo viability or maternal receptivity. Variability in the two components between centres with similar overall outcomes suggests scope for further optimization of IVF treatment.
Clomiphene citrate (CC) is the first-line therapy for the induction of ovulation in infertile women with polycystic ovary syndrome (PCOS), but ~20% of patients are unresponsive. The aim of the current study was to test the hypothesis that a 6-week intervention that consisted of structured exercise training (SET) and hypocaloric diet increases the probability of ovulation after CC in overweight and obese CC-resistant PCOS patients.
METHODS
A cohort of 96 overweight and obese CC-resistant PCOS patients was enrolled consecutively in a three-arm randomized, parallel, controlled, assessor-blinded clinical trial. The three interventions were: SET plus hypocaloric diet for 6 weeks (Group A); 2 weeks of observation followed by one cycle of CC therapy (Group B); and SET plus hypocaloric diet for 6 weeks, with one cycle of CC after the first 2 weeks (Group C). The primary end-point was the ovulation rate. Other reproductive data, as well as anthropometric, hormonal and metabolic data, were also collected and considered as secondary end points.
RESULTS
After 6 weeks of SET plus hypocaloric diet, the ovulation rate was significantly (P =0.008) higher in Group C [12/32 (37.5%)] than in Groups A [4/32 (12.5%)] and B [3/32 (9.4%)] with relative risks of 3.9 [95% confidence interval (CI) 1.1–8.3; P = 0.035] and 4.0 (95% CI 1.2–12.8; P = 0.020) compared with Groups A and B, respectively. Compared with baseline, in Groups A and C, a significant improvement in clinical and biochemical androgen and insulin sensitivity indexes was observed. In the same two groups, the insulin sensitivity index was significantly (P < 0.05) better than that in Group B.
CONCLUSIONS
In overweight and obese CC-resistant PCOS patients, a 6-week intervention of SET and a hypocaloric diet was effective in increasing the probability of ovulation under CC treatment.
The study was registered at Clinicaltrials.gov: NCT0100468.
The aim of this study was to describe the perceptions of infertile men regarding the impact of infertility on their intimate relationships, their experience of treatment and their sources of information and support.
METHODS
A cross-sectional survey of a consecutive cohort of men diagnosed 5 years earlier as infertile at Melbourne IVF and the Royal Women's Hospital Reproductive Services, Melbourne was conducted. Study-specific questions assessed the impact of male factor infertility on the intimate relationships, their perceived quality of infertility-related health care and their preferred sources of infertility-related information and personal support and the effectiveness of these.
RESULTS
The response rate was 41% (112/276). Male factor infertility was reported to have had a negative impact on the intimate partner relationship by 25% of men, and 32% reported a negative effect on their sexual satisfaction. Satisfaction with medical care and clinic information was high and not influenced by the outcome of the treatment. Clinic-provided information and discussion with clinic staff were the most strongly preferred sources of information, and the partner and clinic staff were the most valued sources of personal support. Very few men found support groups useful and less than half confided in friends.
CONCLUSIONS
The findings suggest that for a significant subgroup of men, male factor infertility affects their intimate relationship negatively. Wider sources of social support are not used by infertile men as they rely predominantly on clinic-provided information and support. This indicates that psychologically informed supportive clinical care is particularly important for men diagnosed as infertile.
Currently, no published data exist about the gonadal function of children born after ICSI. To evaluate potential risk of testicular seminal dysfunction in boys born to fathers with compromised spermatogenesis, serum inhibin B (as a marker for spermatogenesis) was assessed.
METHODS
We recruited 50 pubertal adolescents from the oldest cohort of infants born following ICSI. Cross-sectional serum inhibin B levels of all 50 ICSI adolescents, and longitudinal serum inhibin B (assessed at 8 and 14 years) in 25 boys, are reported.
RESULTS
A statistically significant increase in inhibin B levels was observed between 8 (mean 69 ng/l, SD ± 35) and 14 years (mean 145 ng/l, SD ± 41; P < 0.001). In three quarters of the ICSI boys an increase in serum inhibin B levels of at least 30% between 8 and 14 years was observed. In all but 4 of the 14-year-old ICSI boys serum inhibin B was normal. Serum inhibin B levels in boys from fathers with severe oligozoospermia did not differ from concentrations in boys from fathers without severe oligozoospermia (154 ± 51 and 142 ± 47 ng/l, respectively; P = 0.4).
CONCLUSIONS
The majority of ICSI boys have a significant increase in serum inhibin B, attaining normal values for pubertal status at the age of 14 years. ICSI adolescents from fathers with severely compromised spermatogenesis do not have lower inhibin B levels than those with fathers with normal spermatograms. Further follow-up of the spermatogenic potential of ICSI teenagers up to young adulthood is mandatory to confirm a normal reproductive capacity.
The aim of this study was to estimate the fertility and pregnancy outcomes after successful conservative treatment for placenta accreta.
METHODS
This retrospective national multicenter study included women with a history of conservative management for placenta accreta in French university hospitals from 1993 through 2007. Success of conservative treatment was defined by uterine preservation. Data were retrieved from medical files and telephone interviews.
RESULTS
Follow-up data were available for 96 (73.3%) of the 131 women included in the study. There were eight women who had severe intrauterine synechiae and were amenorrheic. Of the 27 women who wanted more children, 3 women were attempting to become pregnant (mean duration: 11.7 months, range: 7–14 months), and 24 (88.9% [95% confidence interval (CI), 70.8–97.6%]) women had had 34 pregnancies (21 third-trimester deliveries, 1 ectopic pregnancy, 2 elective abortions and 10 miscarriages) with a mean time to conception of 17.3 months (range, 2–48 months). All 21 deliveries had resulted in healthy babies born after 34 weeks of gestation. Placenta accreta recurred in 6 of 21 cases [28.6% (95% CI, 11.3–52.2%)] and was associated with placenta previa in 4 cases. Post-partum hemorrhage occurred in four [19.0% (95% CI, 5.4–41.9%)] cases, related to placenta accreta in three and to uterine atony in one.
CONCLUSIONS
Successful conservative treatment for placenta accreta does not appear to compromise the patients' subsequent fertility or obstetrical outcome. Nevertheless, patients should be advised of the high risk that placenta accreta may recur during future pregnancies.
Systematic reviews and accompanying meta-analyses are the cornerstones of evidence-based medicine. Systematic reviews summarize clinical evidence; meta-analyses provide summary estimates of the treatment effect or the diagnostic test accuracy. Although deemed to provide the highest level of evidence, their clinical value is limited as they can only summarize aggregated data. In these meta-analyses the true variability of the treatment effects cannot be explored to the desired extent, because the meta-analyses cannot distinguish between patients with different clinical profiles. Systematic reviews and meta-analyses based on individual patient data (IPD), described as the ‘gold standard’ for systematic reviews are a promising approach that might overcome these limitations. IPD meta-analyses allow treatment effects and diagnostic accuracy to be estimated at the level of relevant patient subgroups. This enables researchers to investigate the effectiveness of treatment in patients with different profiles. In this article, we address the opportunities of systematic reviews and meta-analyses using IPD in reproductive medicine. We discuss its potential based on three clinical examples: single versus double embryo transfer in IVF, the diagnosis of tubal pathology and the prognostic value of ovarian reserve tests. We propose to show potential advantages of IPD systematic reviews and meta-analyses in providing stratified clinical evidence, which could improve medical care.
We have recently shown that women with endometriosis express an increased amount of telomerase and nucleolin, with concomitant loss of -H2AX in eutopic endometrium. To further examine these selected factors that regulate cell fate, in the pathogenesis of endometriosis, we studied the expression of telomerase, nucleolin, proliferating cell nuclear antigen and -H2AX in ectopic endometriotic deposits from women, and in matched eutopic and ectopic endometrial tissue from a baboon model of endometriosis.
METHODS
Ectopic active peritoneal endometriotic lesions were collected from seven symptomatic women. Endometriosis was induced in six baboons by intra-peritoneal autologous inoculation of menstrual endometrium. Eutopic and matched ectopic endometrial tissues were collected prior to and 6, 12 and 15 months after the induction of endometriosis as previously described. Eutopic endometrium was also obtained from eight healthy fertile control baboons. Immunohistochemistry was performed as previously described, and telomerase activity was confirmed using the telomeric repeat amplification protocol assay.
RESULTS
All active human endometriotic lesions expressed the proliferative markers but showed weak or absent staining for -H2AX. A similar expression pattern of these markers was seen in the ectopic lesions of the baboons with induced disease. In these baboons, the eutopic endometrium also showed intense immunoreactivity for all proliferative markers 6–12 months after induction with a parallel loss of -H2AX. The opposite staining pattern was seen in eutopic endometrium of healthy animals and in pre-induction endometrium of animals with induced disease.
CONCLUSIONS
Endometriotic lesions have excess proliferative potential; in baboons, these were present within 12 months of the initiation of the disease. In eutopic tissue, these changes appear to be induced by the development of endometriosis.
Pre-eclampsia, a syndrome usually accompanied by incomplete spiral arterial modification, occurs at an increased frequency in diabetic women. Hyperglycemia in non-obese type 1 diabetic (NOD) mice impairs gestational spiral arterial remodeling despite high local levels of interferon gamma (Ifng), the triggering cytokine in mice. Pregnancies in NOD.Ifng–/– mice were assessed to investigate this issue.
METHODS
Fecundity was assessed using the breeding history, flushing of preimplantation embryos and histological and morphometric studies of implantation sites in normoglycemic (n-) and hyperglycemic (d-) females of NOD.Ifng–/– and NOD genotypes.
RESULTS
NOD.Ifng–/– but not NOD mice are mostly infertile. In NOD.Ifng–/–, copulation often does not result in a post-implantation pregnancy. Defective fertilization and delayed preimplantation development limit n-NOD.Ifng–/– fertility, and both mechanisms are exacerbated by hyperglycemia. At mid-gestation, implantation sites in n-NOD.Ifng–/– and n-NOD mice are histologically similar. However, in d-NOD.Ifng–/–, there is minimal development of spiral arteries, hypertrophy of the myometrial region containing uterine Natural Killer (uNK) cells and a deficit in cytoplasmic granule formation in the uNK cells.
CONCLUSIONS
Ifng contributes to the success of fertilization and to the rate of preimplantation mouse embryo development in normogylcemic and hyperglycemic pregnancies. A physiological role for this cytokine in human preimplantation development merits investigation.
