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PubMed2005

Advantage of combining magnetic cell separation with sperm preparation techniques.

The selection of vital, non-apoptotic spermatozoa is a prerequisite for achieving optimal conception rates in assisted reproductive techniques. Magnetic cell sorting using annexin-V microbeads can effectively separate apoptotic and non-apoptotic spermatozoa. The objective of the present study was to optimize the integration of magnetic cell sorting in standard sperm preparations and to correlate the effect of different sperm preparation procedures on apoptotic markers. Semen specimens collected from 15 healthy donors were prepared by either density gradient centrifugation or by one-step sperm wash technique separately and in combination with magnetic cell sorting. The preparation methods were evaluated by assessment of semen parameters (motility, viability and morphology) as well as markers of apoptosis (levels of active caspase-3, integrity of membrane mitochondrial potential and externalization of phosphatidylserine). The apoptotic markers were measured using fluorochrome dyes coupled with flow cytometry. The results showed that the combination of density gradient centrifugation and annexin-V magnetic cell sorting was superior to all other sperm preparation methods in terms of providing motile, viable and non-apoptotic spermatozoa. This study clearly shows the advantage of integrating magnetic cell sorting as a part of sperm preparation, which in turn may positively affect the success rates of assisted reproductive techniques.

Adult↗

PubMed2006

Comparative study of perinatal outcome of dichorionic and trichorionic iatrogenic triplets.

OBJECTIVE: The purpose of this study was to compare the perinatal outcome of dichorionic and trichorionic triplets who were conceived by assisted reproductive techniques. STUDY DESIGN: In this retrospective study, the maternal, neonatal, and chorionicity data were collected from 106 sets of trichorionic triamniotic and 34 sets of dichorionic triamniotic triplet pregnancies who were conceived by assisted reproductive techniques between January 1986 and December 2000. Perinatal and neonatal data were evaluated in relation to chorionicity and intertriplet birth weight discordance. RESULTS: The dichorionic triamniotic triplets have an 8-fold higher risk of perinatal death than trichorionic triamniotic gestations (odds ratio, 7.9; 95% CI, 4.4-14.0; P < .001). This is attributed to a higher risk of very low birth weight (P < .01), delivery at < 30 weeks of gestation (P < .001), and premature rupture of membrane (P < .001) in dichorionic triamniotic triplets compared with trichorionic triamniotic pregnancies. Twin-twin transfusion syndrome (odds ratio, 11.5; 95% CI, 4.8-27.7; P < .001), delivery at < 30 weeks of gestation (odds ratio, 40.5; 95% CI, 16.9-97; P < .01), premature rupture of membrane (odds ratio, 6.7; 95% CI, 3.8-11.9; P < .01), and nulliparity (odds ratio, 3.1; 95% CI, 1.6-6.1; P < .05) had independent effects on perinatal loss rate. CONCLUSION: The dichorionic triplets have an 8 times higher perinatal mortality rate than trichorionic triamniotic pregnancies.

Adult↗

PubMed2004

Genomic imprinting and assisted reproduction.

Imprinted genes exhibit a parent-of-origin specific pattern of expression. Such genes have been shown to be targets of molecular defects in particular genetic syndromes such as Beckwith-Wiedemann and Angelman syndromes. Recent reports have raised concern about the possibility that assisted reproduction techniques, such as in vitro fertilization or intracytoplasmic sperm injection, might cause genomic imprinting disorders. The number of reported cases of those disorders is still too small to draw firm conclusions and the safety of these widely used assisted reproduction techniques needs to be further evaluated.

Journal Article↗

PubMed2002

Management strategies for male factor infertility.

Although modern assisted reproduction techniques contribute a lot to overcoming severe male factor infertility, application of these methods in every infertile couple would represent an over-treatment. Therefore, conventional treatment modalities are still the first approach to male fertility disorders. Apart from assisted reproduction techniques, these include surgical procedures and the administration of drugs. Causal treatment regimens of proven effectiveness are only available for patients with infertility resulting from hypogonadotrophic hypogonadism. Drug treatment of retrograde ejaculation is also effective. Inconsistent results have been obtained with empirical treatment including antiestrogens, androgens, aromatase-inhibitors, mast cell blockers, zinc and pentoxifylline. Anti-inflammatory and immunosuppressive therapy as well as treatment with antioxidants in the presence of reactive oxygen species has not yet been demonstrated to be effective by controlled studies but represent at least a rational approach which should be investigated more thoroughly. High dosage administration of follicle stimulating hormone aimed particularly at improving disturbed sperm structures, and the combination of tamoxifen with androgens, may be promising developments. A careful diagnostic work-up is necessary before any andrological treatment is commenced so that adequate treatment options can be selected for individual patients.

Adrenal Cortex Hormones↗

PubMed1999

The role of luteinizing hormone in folliculogenesis and ovulation induction.

OBJECTIVE: To review the physiologic, pathophysiologic, and clinical roles of LH in follicle and oocyte development and maturation and to assess the effects of LH content in exogenous gonadotropin preparations used for ovulation induction. DESIGN: Critical review of the scientific literature devoted to folliculogenesis. Evaluation of comparison studies that used different gonadotropin preparations for ovulation induction. CONCLUSION(S): Folliculogenesis and oocyte maturation are complex processes that require the action of both LH and FSH. Luteinizing hormone is essential to provide the androgen substrate for estrogen synthesis, which in turn contributes to oocyte maturation and may play a relevant role in optimizing fertilization and embryo quality. Although the excessive LH secretion that is present in some disorders is detrimental to reproductive function, this is not applicable to ovulation induction with hMG because this menotropin does not increase daily plasma LH levels. The results of ovulation induction with hMG or FSH-only regimens did not differ in studies conducted in patients with polycystic ovary syndrome and in most studies conducted in ovulatory women undergoing assisted reproductive techniques; conversely, hMG was clearly superior to purified FSH for the treatment of hypogonadotropic hypogonadism. Miscarriage rates were not affected by the use of hMG. Thus, low but detectable LH concentrations positively influence the outcome of ovulation induction in patients with ovulatory disorders and women undergoing assisted reproductive techniques.

Estrogens↗

PubMedDate not supplied

Clinical practice of embryo transfer.

In this review, several embryo transfer methods are considered, together with factors involved in achieving an effective transfer. The approach most used is transcervical intrauterine transfer. This is described in detail, together with the many variables influencing success, e.g. technical ability and training of personnel, catheter choice, value of a previous 'dummy transfer' and the need to minimize trauma during transfer and so prevent damage to the uterine lining, bleeding and uterine contractions. These factors can each negatively impact on pregnancy rates. Emphasis is put on quality, developmental stage and number of embryos to be transferred to limit multiple pregnancies and their unwanted side-effects. Culture to blastocyst stages and single embryo transfer when optimal quality embryos are available are discussed as means of avoiding multiple pregnancies. Reference is made to embryo cryopreservation and fertility following frozen embryo transfer. Other techniques, such as ultrasound-controlled transcervical intrauterine transfer, and ultrasound-controlled transmyometrial transfer, are reviewed. More invasive procedures, generically grouped as surgical embryo transfer, including gamete intra-Fallopian transfer (GIFT), zygote intra-Fallopian transfer (ZIFT), pronuclear stage transfer and embryo intra-Fallopian transfer (EIFT), are also described. These techniques had a place in IVF when the need to apply assisted reproductive techniques exceeded the capacity of most laboratories, but not today thanks to refined laboratory technology and improved understanding of implantation. Alternative assisted reproductive technologies, such as direct intra-follicular insemination (DIFI), Fallopian spermatic perfusion (FSP), peritoneal oocyte stage and sperm transfer and intra-vaginal culture (IVC), are mentioned briefly.

Cryopreservation↗

PubMed2003

Cause and risk of stillbirth in twin pregnancies: a retrospective audit.

BACKGROUND: The epidemiology of twin pregnancies complicated by stillbirth of one or both fetuses is a scarcely examined area. The risk of perinatal death in twin pregnancies is increased 2-5 times compared to singletons, and the identification of preventable risk factors becomes increasingly important as the number of multiple pregnancies is rising. We report the causes of death in twin pregnancies and their respective risk factors. METHODS: Twin pregnancies (n = 54) complicated by antepartum or intrapartum stillbirth of one or both twins (n = 68) and twin pregnancies with normal outcome (n = 103) in the counties of Oslo and Akershus, Norway, from 1986 to 1995 were included. The cases were classified and compared to the controls in multiple logistic regression analyses with regard to risk factors. RESULTS: The risk of stillbirth increased with monochorionicity, non-Western origin and assisted reproduction techniques (ART). The cases could be divided into eight different groups according to the primary diagnosis. The groups did not fit any of the existing cause-of-death classifications used on singleton stillbirths. CONCLUSIONS: The identification of monochorionic gestation should be made early in pregnancy to designate the level of risk. Assisted reproduction techniques leading to a high incidence of twins should be avoided. Health care professionals in the immigrant population should address the detrimental effects of consanguinity on reproductive outcome. We emphasize the need of a new cause-of-death classification for twin stillbirths.

Case-Control Studies↗

PubMed1995

Appraisal of gamete intrafallopian transfer.

OBJECTIVE: To collect results of gamete intrafallopian transfer on a large scale in order to compare treatment indications, results, and factors which influence the success rates; to evaluate whether gamete intrafallopian transfer is well-established and what the real place of this procedure is among other assisted reproduction techniques. DESIGN: Data relating to gamete intrafallopian transfer were collected from World Reports, national registries of different countries and meta-analysis of medical publications during the years 1986-1991. SUBJECT: Official registries reported 47,200 treatment cycles and 18,759 treatment cycles were analysed from ten medical publications. RESULTS: The procedure accounts for 13.5% of all assisted reproduction techniques but its popularity varies significantly among countries. The same indications for gamete intrafallopian transfer are followed by all countries, but great differences exist with regard to the proportional share of each etiology. Also, the share has changed considerably over the years. TREATMENT OUTCOME: 10,667 clinical pregnancies were reported which represent 24% of treatment cycles and 29% of ovum pick-up. The live birth rate was 23.3%; abortion rate, 22%; and ectopic pregnancy rate, 5.5%. The stillbirth rate was 2.3% and the malformation rate was 2.8%, not confined to specific organs or systems. There were 19.5% twins, 4.6% triplets and 0.3% quadruplets or more. The number of transferred oocytes influenced pregnancy rates: 28% for transfer of four oocytes and only 10% following transfer of one oocyte. The cause of infertility might influence the results and the poorest results are obtained for male factor infertility. In most cases correlation of success rates reported by leading units through medical publications closely resembles the overall national registries results. Indications for this treatment were broadened over the years, but its role among other assisted reproduction technologies is not agreed upon, especially for male factor and unexplained infertility. CONCLUSIONS: Gamete intrafallopian transfer carries an overall higher pregnancy rate than in vitro fertilization. Quality control by professional or public associations should be established and more research employed over indications for treatment and results in order to establish when GIFT is the treatment of choice and when other modes of treatment should be preferred.

Australia↗

PubMed2004

[Twin pregnancies and their outcome at the Department of Obstetrics and Gynecology, Institute of Mother and Child in Warsaw, in the period of 1993-2000].

OBJECTIVE: The aim of this study was to analyse the course of twin pregnancies delivered at the Department of Obstetrics and Gynaecology, Institute of Mother and Child in Warsaw, from 1993 to 2000. MATERIALS AND METHODS: The medical documentation of women with twin pregnancy was looked into. Such parameters as mode of conception, maternal age and parity were taken into account. The data concerning the duration of pregnancy, mode of delivery, birth weight and condition of newly born infants were retrospectively reviewed. RESULTS: There a total of 232 (1.46%) twin pregnancies out of 15,869 births. A gradual increase in absolute number of twin deliveries and a relative increase of multiple pregnancies due to the use of assisted reproduction techniques was observed. The tendency to end twin pregnancies by caesarean section was detected. Although the perinatal care improved over the years, a small decrease of mean gestational age at delivery was observed. No significant difference in neonatal outcome in relation to the mode of delivery in researched material was noticed. CONCLUSIONS: The number of twin pregnancies due to the use of assisted reproduction techniques is on the increase. A percentage of women delivering for the first time has risen among women with twin pregnancy. Twin pregnancies are often ended by caesarean section and the frequency of caesarean sections has increased over time.

Academies and Institutes↗

PubMedDate not supplied

Sperm aneuploidy in infertile men.

A recent line of research has shown that infertile male patients produce cytogenetically abnormal spermatozoa, despite a normal somatic karyotype, as a result of an altered intra-testicular environment that affects negatively the mechanisms controlling chromosome segregation during cell division. The rate of aneuploid spermatozoa production is significantly higher in patients with abnormal sperm parameters compared with those of normozoospermic subjects or infertile patients with normal sperm parameters. All chromosomes are subject to aneuploidy, although at a different rate; the heterochromosomes are more often altered than are the autosomes. A negative correlation has been reported to exist between aneuploidy and the main sperm parameters, suggesting that greater testicular damage is associated with a greater chance of chromosome malsegregation events. Abnormally-shaped spermatozoa are more likely to have chromosome abnormalities, particularly those with an enlarged head. More studies are necessary, however, to evaluate whether other types of sperm head abnormalities are also associated with an abnormal sperm chromosome complement. The possibility of retrieving testicular or epididymal spermatozoa in patients with azoospermia and using them in assisted reproduction techniques has prompted the evaluation of their chromosomal status. Studies have shown that testicular and epididymal spermatozoa have a greater rate of aneuploidy compared with that of ejaculated spermatozoa. Some authors have also shown that patients with non-obstructive azoospermia have a significantly higher sperm aneuploidy rate compared with that of patients with obstructive azoospermia. Sperm aneuploidy seems to have a negative impact on assisted reproduction technique outcome. Although it does not affect the fertilization rate, an elevated sperm aneuploidy rate is associated with a greater rate of pregnancy failure. Nevertheless, some patients with elevated sperm aneuploidy rate can still achieve a pregnancy, but with an increased risk of generating an aneuploid offspring. Thus, sperm aneuploidy evaluation is recommended in infertile patients with abnormal semen parameters, particularly if they undergo IVF programmes.

Aneuploidy↗

PubMed2005

Single, transcervical insemination using frozen-thawed semen in the Greyhound: a case series study.

Transcervical insemination (TCI) has generated recent interest as an assisted reproductive technique in the dog. A case series study was performed to determine if TCI using frozen-thawed semen was a viable technique to offer in a general veterinary practice setting. Over a period exceeding 28 months, 137 Greyhound bitches were presented for assisted breeding. A single, timed insemination using a rigid cystoscope to aid in transcervical deposition of a frozen-thawed semen dose was given within 72 h after the behaviorally estrual bitch had a > 4 ng/mL serum progesterone concentration and estrus-categorized vaginal cytology. Litter size, pregnancy and whelping rate were collected; their association to semen center and stud dog were quantified. Of the 137 bitches, 117 were bred for one cycle and 20 were bred for two or more cycles, giving a total of 161 single, timed inseminations. Pregnancy rate was 89.4%, with 141 (87.5%) whelping. Litter size was 6.9+/-2.7 (mean+/-S.D.) pups. Semen center (P=0.84) and stud (P=0.79) had no effect on pregnancy. These results were quite favorable when compared to prior TCI studies, and are possibly due to the use of a single breed (i.e., Greyhound) with good fertility. This study supported the application of TCI, in Greyhounds, as a successful and viable service to offer in private practice. Additionally, these results have value in their use for benchmarking future breed-specific and TCI research. Serendipitously, the apparent fecundity results obtained in this observational study suggests a possible greater appreciation be given to breed composition and choice in assisted reproductive technique studies.

Animals↗

PubMed1996

Current and future issues in assisted reproduction.

The last quarter of the twentieth century has given rise to reproductive technologies and arrangements that in the earlier part of the century could only be dreamed of by the authors of science fiction. We stand in the middle of this reproductive revolution, trying to cope with the developments that have already occurred but with an uneasy sense that the future may be even more complicated ethically than the past and the present. In this brief essay, I will survey recent ethical and public-policy discussions of two reproductive techniques (assisted insemination and in vitro fertilization) and one reproductive arrangement (surrogate motherhood). After distinguishing three phases in the normative debate, I will briefly comment on some of the characteristics of, and continuing ambiguities in, the ethical debate of the past 25 years. At the conclusion of the essay, I will attempt to anticipate three future issues in ethics and reproduction.

Advisory Committees↗

PubMed1996

Beyond recanalizing proximal tube occlusion: the argument for further diagnosis and classification.

Proximal tube occlusion (PTO) accounts for 20% of tubal factor cases. The classification into nodular (salpingitis isthmica nodosa or endometriosis), non-nodular (true fibrotic occlusion) and so-called pseudo occlusion (detritus, polyps, hypoplastic tubes) is essential. Using falloposcopy, PTO that is already diagnosed by laparoscopy and hysterosalpingography (HSG) can be confirmed or bypassed (false PTO); patients with false PTO were placed on a temporary waiting period. Nodular and pseudo occlusion patients were pre-treated with gonadotrophin-releasing hormone analogue (GnRH-a) for at least 6 weeks to shrink the underlying pathology, after which tubal re-catheterization was performed. In a prospective study starting in July 1993, 53 patients prediagnosed as having PTO were examined by falloposcopy. Three of these patients had non-nodular occlusion and were directed to microsurgical repair (conservative treatment not possible). A total of 19 cases revealed patent tubes with healthy mucosa and no underlying pathology (false PTO). Of the remaining 31 patients, 18 were classified as nodular and 13 as pseudo occlusion. In all of these patients at least one tube was patent after GnRH-a treatment. After a 6 month period, 37% of the false PTO patients achieved a spontaneous pregnancy (6% per cycle). The spontaneous pregnancy rate in the true PTO group was significantly lower (10% per patient, 1.6% per month; P < 0.05). Using assisted reproduction techniques, in particular gamete intra-Fallopian transfer (GIFT), as a subsequent treatment for the true PTO group, a pregnancy rate of 50% per cycle was achieved. A retrospective analysis of our entire PTO population (n = 109) showed a spontaneous pregnancy rate after achieving tubal patency (using falloposcopy and GnRH-a) that was dramatically low (1.8%), with no difference between the nodular and pseudo groups. The chance for pregnancy can be enhanced significantly (P < 0.001) using assisted reproduction techniques (GIFT) following tubal re-catheterization and GnRH-a treatment.

Buserelin↗

PubMed2002

The place of gonadotrophin-releasing hormone antagonists in reproductive medicine.

Gonadotrophin-releasing hormone (GnRH) antagonists have recently been introduced into clinical practice. They appear to offer a promising alternative to the long-established GnRH agonist regimens for prevention of a premature LH surge during ovarian stimulation for assisted reproductive techniques. Clinical outcomes achieved with antagonists are comparable with those of a long GnRH agonist protocol, while treatment times and gonadotrophin requirements are reduced and safety is improved. In particular, the antagonists appear to be associated with a lower risk of ovarian hyperstimulation syndrome (OHSS) than do agonists. Patient surveys suggest a preference for antagonist over agonist treatment cycles. These benefits suggest that GnRH antagonists have the potential to replace agonists as the treatment of choice in ovarian stimulation for assisted reproductive techniques. Two agents, cetrorelix and ganirelix, are currently in clinical use. Cetrorelix is available in single- and multiple-dose formulations, offering increased flexibility compared with ganirelix.

Amino Acid Sequence↗

PubMed2003

Invasive procedures in multiple gestations.

PURPOSE OF REVIEW: The incidence of multiple gestations has increased significantly with advances in assisted reproductive techniques resulting in a concomitant increase in invasive procedures in these pregnancies. Commonly performed invasive procedures include amniocentesis, chorionic villus sampling, multifetal pregnancy reduction, and selective termination. Amniocentesis and chorionic villus sampling are also performed in singleton pregnancies, while multifetal pregnancy reduction and selective termination are procedures that are unique to multiple gestations. RECENT FINDINGS: With increased operator experience, pregnancy loss rates after chorionic villus sampling, multifetal pregnancy reduction, and selective termination have decreased to acceptably low levels. Amniocentesis and chorionic villus sampling continue to have similar loss rates in experienced hands. A recent study suggests that amniocentesis in twins may have a higher post-procedural loss rate than in singletons; this may be due to the higher background loss rate of twins. There has been a recent increase in multifetal pregnancy reduction to a singleton with a trend towards improved outcomes over reduction to twins; future studies should focus on whether this confers a definitive advantage. Newer data suggests that selective termination after 20 weeks gestation in experienced hands does not increase loss rates over those procedures performed before 20 weeks. Newer techniques, such as cord coagulation, continue to be developed for selective termination in monochorionic pregnancies, though still with considerable morbidity and mortality. SUMMARY: In summary, invasive procedures in multiple gestations are now commonly performed with. It is our hope that primary prevention of high order multiple pregnancies by optimization of assisted reproductive techniques will decrease the need for these procedures.

Abortion, Eugenic↗

PubMed2005

Does human sperm nuclear DNA integrity affect embryo quality?

Abnormalities in the male genome are a clear potential reason for post fertilization failure. Male infertility may arise due to high levels of loosely packaged chromatin and damaged DNA. The achievement of a correct chromatin packaging level is essential for successful fertilization. The chromatin contained in the nuclei of mammalian spermatozoa is an extremely compact and stable structure. The reports on mammalian spermatozoa indicate that available volume is insufficient to contain sperm chromatin packed in nucleosome like structure and thus is organized in a special way. Different unique properties of sperm DNA like high degree of inertness and stability, absence of transcription, replacement of somatic histone by protamine etc have made the study of sperm chromatin more interesting. Increased levels of sperm nuclear DNA damage exist in infertile men with abnormal sperm parameters (i.e. concentration, motility and morphology), and various assay techniques have been developed to evaluate sperm chromatin maturity/DNA integrity. These assays are based on the facts that defects in chromatin structure have been shown to lead to increased DNA instability and sensitivity to denaturing stress. DNA integrity in the sperm is essential for the accurate and successful transmission of genetic information. Importance of sperm DNA has also become more obvious in the context of assisted reproductive techniques. While recent advances in assisted reproductive technologies have made possible and practical for many infertile men to become father, the risk of transmission of genetic mutation to the offspring, however, still remains. Further research is necessary to devise techniques for identification and selection of sperm with undamaged DNA for ICSI or to remove sperm with damaged DNA from the semen sample to improve the pregnancy outcome in ICSI.

Animals↗

PubMed2002

[Legal and ethical problems in assisted reproduction--case report].

OBJECTIVE: The objective of the study is to evaluate legal and ethical aspects of the assisted reproduction in the Czech Republic. These aspects are described in the context of the concrete case. DESIGN: Case report. SETTING: Department of Social Medicine, Medical and Health Care Administration Faculty of the Masaryk University, Brno and Centre of the Reproductive Medicine Zlín. SUBJECT AND METHOD: The description of the concrete case that happened in the Czech Republic. A widow asked for the artificial insemination using the sperm of her deceased husband. CONCLUSION: It was concluded that there is absolutely insufficient legal regulation of the assisted reproduction techniques, it does not respond to the development of the medical knowledge and it responds insufficiently to the ethical dilemmas concerning the assisted reproduction.

Bioethical Issues↗

PubMed1997

Cost-effectiveness of infertility treatments: a cohort study.

OBJECTIVE: To determine the cost-effectiveness of infertility treatments. DESIGN: Retrospective cohort study. SETTING: Academic medical center infertility practice. PATIENT(S): All patients treated for infertility in a 1-year time span. INTERVENTION(S): Intrauterine inseminations, clomiphene citrate and IUI (CC-IUI), hMG and IUI (hMG-IUI), assisted reproductive techniques (ART), and neosalpingostomy by laparotomy. MAIN OUTCOME MEASURE(S): All medical charges and pregnancy outcomes associated with the treatments were obtained. Cost-effectiveness ratios defined as cost per delivery were determined for each procedure. The effects of a woman's age and the number of spermatozoa inseminated on cost-effectiveness of the procedures was also determined. RESULT(S): Intrauterine inseminations, CC-IUI, and hMG-IUI have a similar cost per delivery of between $7,800 and $10,300. All of these were more cost-effective than ART, which had a cost per delivery of $37,000. Assisted reproductive techniques in women with blocked fallopian tubes was more cost-effective than tubal surgery performed by laparotomy, which had a cost per delivery of $76,000. Increasing age in women and lower numbers of spermatozoa inseminated were factors leading to higher costs per delivery for IUI, CC-IUI, hMG-IUI, and ART. Use of donor oocytes reduced the cost per delivery of older women to the range seen in younger women with ART. CONCLUSION(S): Our analysis supports, in general, the use of IUI, CC-IUI, and hMG-IUI before ART in women with open fallopian tubes. For women with blocked fallopian tubes, IVF-ET appears to be the best treatment from a cost-effectiveness standpoint.

Clomiphene↗