Heterochronic bilateral ectopic pregnancy after ovulation induction

Ectopic pregnancy is identified with the widely-applied assisted reproductive technology (ART). Bilateral ectopic pregnancy is a rare form of ectopic pregnancy which is difficult to be diagnosed at the pre-operation stage. In this paper, we presented an unusual case of heterochronic bilateral ectopic pregnancy after stimulated intrauterine insemination (IUI), where there has been a delay of 22 d between the diagnoses of the two ectopic pregnancies. Literature was reviewed on the occurrence of bilateral ectopic pregnancy during the past four years in the MEDLINE database. We found 16 cases of bilateral ectopic pregnancy reported since 2008, and analyzed the characteristics of those cases of bilateral ectopic pregnancy. We emphasize that ovulation induction and other ARTs may increase the risk of bilateral ectopic pregnancy. Because of the difficulty in identification of bilateral ectopic pregnancy by ultrasonography, the clinician should be aware that the treatment of one ectopic pregnancy does not preclude the occurrence of a second ectopic pregnancy in the same patient and should pay attention to the intra-operation inspection of both side fallopian tubes in any ectopic pregnancy case.

The risk of neurodisability and other long-term outcomes for infants born following ART

Children born after assisted reproductive technologies (ART) have an increased morbidity. The risk of developing cerebral palsy is nearly doubled and the risk of developing epilepsy is also higher. Behavioural problems including attention deficit/hyperactivity disorder may be more common in children born following ART than among naturally conceived children but the finding is uncertain. Data on autism are difficult to interpret. There may exist a small increase in the incidence of childhood cancer and there is greater evidence of an elevated risk of asthma. To some extent, these risks are mediated by neonatal complications including prematurity and low birth weight but some effects such as cerebral palsy are likely to be linked to the increased rate of multiple births after ART. Many of the neonatal complications after ART are most likely linked to parental subfertility and are less an effect of the ART technology. The possibility exists that imprinting errors, associated with subfertility and/or ART, may result in long-term morbidity.

The economic implications of multiple pregnancy following ART

The clinical risks to mothers and babies associated with assisted reproductive technology (ART) multiple birth pregnancies are well described and widely recognized. In contrast, the long-term economic consequences that follow are less appreciated. The few economic analyses that do exist consistently demonstrate the greater patient, healthcare and societal costs associated with twins and higher-order multiples when compared with singleton infants, and convincingly add to the argument that single embryo transfer should be standard practice in most patient groups. Several recent studies have shown that the relative price paid by patients for ART treatment not only has implications for who can afford to access treatment, but also plays an important role in incentivizing embryo transfer practices and thus ART multiple birth rates. This review summarizes the current literature on the costs and consequences of ART multiple births, the contribution of ART multiple births to the economic burden associated with preterm birth, the evidence for the cost-effectiveness of single embryo transfer, and the association between the cost of treatment and the downstream costs associated with multiple births.

In vitro fertilization-embryo transfer pregnancy was a risk factor for hemorrhagic shock in women with placental polyp

OBJECTIVE

The aim of this study was to determine the risk factors for hemorrhagic shock in women with placental polyp.

MATERIALS AND METHODS

Twelve women (group A) developed hemorrhagic shock (shock index<1.5) and received uterine artery embolization (UAE). The other 25 women (group B) had shock index<1.5 and did not receive UAE. All women underwent transcervical resection (TCR). The risk factors for the development of hemorrhagic shock, including the age, conception mode, numbers of previous abortion, gestational weeks at termination of pregnancy (TOP), blood loss weights at TOP and at TCR, were analyzed.

RESULTS

When compared with group B, group A had higher in vitro fertilization-embryo transfer (IVF-ET) pregnancy rate (58.3 versus 12.0%, p<0.01), number of previous abortion (median 1.58 versus 0.68, p<0.05), gestational weeks at TOP (median 36.5 versus 17.0 weeks, p<0.05), and blood loss weight at TOP (median 2151 versus 40 g, p<0.05). A logistic regression analysis reveled that IVF-ET (OR 41, 95% CI 1.3-1264) and blood loss weight at TOP (1.0025, 1.0006-1.0044) were independent risk factors for hemorrhagic shock.

CONCLUSIONS

For the first time, IVF-ET pregnancy was found to be a risk factor for the development of hemorrhagic shock in women with placental polyp.

A prediction model for live birth and multiple births within the first three cycles of assisted reproductive technology

OBJECTIVE

To develop a model predictive of live-birth rates (LBR) and multiple birth rates (MBR) for an individual considering assisted reproduction technology (ART) using linked cycles from Society for Assisted Reproductive Technology Clinic Outcome Reporting System (SART CORS) for 2004-2011.

DESIGN

Longitudinal cohort.

SETTING

Clinic-based data.

PATIENT(S)

288,161 women with an initial autologous cycle, of whom 89,855 did not become pregnant and had a second autologous cycle and 39,334 did not become pregnant in the first and second cycles and had a third autologous cycle, with an additional 33,598 women who had a cycle using donor oocytes (first donor cycle).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

LBRs and MBRs modeled by woman's age, body mass index, gravidity, prior full-term births, infertility diagnoses by oocyte source, fresh embryos transferred, and cycle, using backward-stepping logistic regression with results presented as adjusted odds ratios (AORs) and 95% confidence intervals.

RESULT(S)

The LBRs increased in all models with prior full-term births, number of embryos transferred; in autologous cycles also with gravidity, diagnoses of male factor, and ovulation disorders; and in donor cycles also with the diagnosis of diminished ovarian reserve. The MBR increased in all models with number of embryos transferred and in donor cycles also with prior full-term births. For both autologous and donor cycles, transferring two versus one embryo greatly increased the probability of a multiple birth (AOR 27.25 and 38.90, respectively).

CONCLUSION(S)

This validated predictive model will be implemented on the Society for Assisted Reproductive Technology Web site (www.sart.org) so that patients considering initiating a course of ART can input their data on the Web site to generate their expected outcomes.

A comparative analysis of postpartum maternal mental health in women following spontaneous or ART conception

OBJECTIVE

To determine whether conception following assisted reproductive technology (ART) predisposes women to increased risk of postnatal depression (PND), compared to women who conceived naturally, when controlling for such factors as: multiple birth, previous maternal psychiatric history and sociodemographic status.

PARTICIPANTS

A total of 200 women who attended the private antenatal and fertility clinics of a fertility specialist in a large Australian city between January 2009 and December 2011 were contacted via telephone.

RESULTS

There was no difference in the rate of PND between the two groups (7.5% versus 7.4%, p = ns). Aside from the slightly older maternal age in the ART group (35.4 versus 33, p < 0.05), baseline socio-demographics were similar. There was a significantly higher rate of previous maternal clinical depression in the ART group compared to the controls (17% versus 5%, p < 0.05); however, other known risk factors for PND, including previous PND (10.6% versus 13.7%, p = ns), multiple births (2.1% versus 4.2%, p = ns) and low infant birth weight (3.3 kg versus 3.4 kg, p = ns), were not different in the two cohorts. Women who conceived naturally were also more likely to breastfeed for a longer duration (78% versus 89%, p < 0.05).

CONCLUSION

Our study demonstrates that when accounting for well-known risk and protective factors for postpartum depression, women who conceive using ART are not at an increased risk PND. In addition, the low rate of multiple births in the ART group further validates the practice of single embryo transfer.

Anti-Müllerian hormone (AMH) is a strong predictor of live birth in women undergoing assisted reproductive technology

In the present study, we evaluated the clinical value of the following parameters: basal anti-Müllerian hormone (AMH), follicle-stimulating hormone (FSH), inhibin B and antral follicle count (AFC) in predicting live birth outcomes. The study involved 603 women undergoing in vitro fertilization (IVF) using the long protocol for controlled ovarian hyperstimulation (COH). Serum levels of AMH, FSH and inhibin B as well as AFC were measured on the first three days of the menstrual cycle prior to the beginning of stimulation. AMH was the only independent parameter that correlated with the chance of live birth. We found that live birth rates of 46.2% (patient age <35 years), 44.7% (35-37 years), 32.1% (38-39) and 15.3% (>39) were associated with concentrations of AMH>1.4 ng/ml. For the AMH range 0.6-1.4 ng/ml, the live birth rates were 29.3%, 12.5%, 5.6% and 2.7%, respectively, and for AMH concentrations below 0.6 ng/ml the rates were 7.1%, 8.3%, 0% and 5.8%, respectively. Independently of other parameters affecting the chance of live birth, the success rate was the highest when the AMH level was >2 ng/ml, significantly lower when the AMH concentration was about 1 ng/ml, and 0% when the AMH concentration was ∼0.1 ng/ml. In conclusion, this is the first report to demonstrate that AMH level correlated better than age, FSH or inhibin B concentrations or AFC with live birth outcome. Therefore, the basal serum concentration of AMH may become a new, substantial prognostic factor regarding live birth above and beyond other currently available predictors of IVF outcome.

Management of infertility in women over 40

Women's fertility potential is declining with age because of multiples intrinsic and extrinsic factors such as life style, oxidative stress and/or endocrine disruptors and is affecting the ability of these women to conceive naturally. This declining fertility potential and the late age of motherhood is increasing significantly the number of patients consulting infertility specialists. Different strategies of investigation and management are proposed to patients over 40 in order to overcome their infertility and improve the live birth rate in these patients. Intra Uterine Insemination (IUI) in women over 40 is associated with a low rate of ongoing pregnancy and IUI should not therefore be offered always as the first line of treatment. When the predictive factors are positive IVF/ICSI seem to be good alternatives until 43 years of age. Customized ovarian stimulation and flexible laboratory methods such as in vitro maturation (IVM), preimplantation genetic diagnosis (PGD), embryo vitrification and transfer after thawing in subsequent natural or artificial cycles can improve the success rate of ART in patients over 40. Meanwhile, oocyte and embryos donation remain good options for patient over 40 with a bad prognosis and can lead to successful ongoing pregnancies until 45 years of age. Ovarian tissue cryopreservation, oocyte vitrification at the germinal vesicle (GV) stage or metaphase II stage present a breakthrough for fertility preservation but the ideal age for starting fertility preservation is still debated as well as the minimum number of oocytes to be vitrified in order to optimize the chances of pregnancy when needed at an older age. This manuscript reports the results of our own experience from patients older than 40 in the light of the published data and discusses the different therapeutic alternatives which can be proposed to patients over 40 consulting ART centres.

Results from adding recombinant LH for assisted reproductive technology treatment: A randomized control trial

BACKGROUND

Based on classical two-cell, two-gonadotropin theory, in the follicle, follicle-stimulating hormone (FSH) and luteinizing hormone (LH) put on their main effects on the granulosa and theca cells. LH is essential for androgens production. Androgens are used for estradiol production by granulosa cells. Profound suppression of LH concentrations in some normogonadotropic patients can cause several adverse effects.

OBJECTIVE

The main clinical purpose of this study was that normoresponder women treated with controlled ovarian super ovulation for IVF or ICSI may benefit from co-administration of rLH.

MATERIALS AND METHODS

40 patients who were candidates for assisted reproductive technology (ART) were randomly selected. In all patients long luteal protocol was used for ovulation induction. Patients were randomly divided into two groups: Group 1 (n=20) with standard long protocol (GnRH agonist) and r-FSH alone, Group 2 (n=20) with standard long protocol (GnRH agonist) and r-FSH with r-LH. RESULTS were statistically analyzed and compared in two groups.

RESULTS

The number of retrieved oocytes, mature oocytes, cleaved embryos, transferred embryos, estradiol levels in Human chorionic gonadotropin (hCG) administration day, implantation rate and clinical pregnancy rate in group 2 were higher but not significantly different.

CONCLUSION

Administration of rLH in late follicular phase had no beneficial effect on outcomes in young women with mean age of 31 years. Maybe a greater sample size should be used to see the effects more accurately; also it is possible that rLH will be useful in older patients. Registration ID in IRCT: IRCT201304302575N4.

Increasing and decreasing factors of hope in infertile women with failure in infertility treatment: A phenomenology study

BACKGROUND

Assisted reproductive technology (ART) provide the hope of pregnancy for infertile women, but do not always turn this hope into reality.

OBJECTIVE

The purpose of this study was to explore the lived experience of infertile women from increasing and decreasing factors of hope in infertile women with failure in infertility treatment.

MATERIALS AND METHODS

Using a qualitative research design (Phenomenology study), 23 subjects were selected who had experienced infertility failure visited by gynecologist (Rasekh Infertility center) in 2012. The data were collected through semi structured interviews and analyzed using interpretive research strategies of phenomenology by Collizi's seven-stage method.

RESULTS

Totally 96 codes were identified. The data arranged in two categories. The factors decreasing and increasing hope in infertility treatments. Totally 5 themes and 20 sub themes were extracted. The increasing factors which emerged from the data contain "spiritual source", "family interaction and support" and "information through the media", and decreasing factors contain "nature of treatments" and "negatively oriented mind".

Improved cycle outcomes after laparoscopic ovarian diathermy in hyper-responder patients with previous ART failure

Excessive response to ovarian stimulation is common among hyper-responder patients undergoing assisted reproductive technology (ART). Cycle cancellations and severe ovarian hyperstimulation syndrome (OHSS) are all detrimental consequences observed within this cohort and several approaches have been proposed to enhance outcomes. The current study is designed to evaluate whether laparoscopic ovarian diathermy (LOD) improves ART outcomes and pregnancy rates by reducing Anti-mullerian hormone (AMH) levels in a group of patients who had a history of recurrent ART failure and high response. A total of 40 hyper-responder patients with history of previous ART failure were included. Group I consisted of 22 patients that underwent LOD prior to ART. Group II consisted of 18 patients that underwent only ART. Cycle outcomes of groups were compared. Following LOD, significant reduction in AMH levels were detected in group I (4.75 ng/mL to 2.25 ng/mL). Clinical pregnancies were similar among groups (40% versus 27.8% p = 0.65). There was no cycle cancellation in Group I, whereas there were three cycle cancellations observed due to OHSS in Group II. Our results indicate that LOD might offer enhanced fertility outcomes and may reduce the likelihood of cycle cancellations in hyper-responders with previous ART failures.

Current Jewish perspectives on maternal identity

Infertility counseling is a specialized field that will continue to grow in coming years as the impact of infertility and its treatment is documented more in terms of emotional, physical, social and life consequences. We report here on more recent developments in halakha (Jewish law and ethics) that are of importance to Orthodox Jewish infertile couple considering donor gametes or surrogacy. Counselors should anticipate issues that may arise in the future and assist couples in their efforts to address them. Good medical practice values the importance of understanding the patient's individual concerns and values, including the complex psychological, sociological and cultural context in which they experience their infertility. Good counseling anticipates and addresses future problems about which patients might not currently be aware, and requires up-to-date authoritative information.

The impact of exposure to serum lipids during in vitro culture on the transcriptome of bovine blastocysts

In vitro culture has a detrimental impact on early embryonic development, and serum addition to IVC is recognized to compromise blastocyst quality. Particularly, serum fatty acids affect embryonic lipid composition and reduce cryopreservation survival. To understand the molecular pathways of serum-induced embryonic stress, this study examined the early development of bovine embryos produced in different protein- or lipid-supplemented culture media: BSA alone (control), BSA + serum lipid fraction (SELF), delipidated serum and total serum. These protein-lipid treatments were applied from the eight to 16 cell stages to the blastocyst stage. As planned, SELF treatment increased the fatty acid concentration in the medium compared with control medium but did not induce embryo toxicity. However, microarray comparison between blastocysts cultured in BSA without or with SELF revealed differential transcriptomic profile associated with ceramide-induced oxidative stress and inflammation. Moreover, the SELF treatment had a significant impact on genes involved in cholesterol metabolism (LDLR, HMGCS1), with the potential upstream control of the transcription factors SREBP and PPARA, two major regulators of cholesterol metabolism. In addition, the expression of pluripotence-related genes (APEX, CLDN6) was downregulated in blastocysts subjected to either SELF or total serum. Taken together, these results illustrate how the early embryonic transcriptome responds to increased lipid exposure through an inflammatory and metabolic signature.

Outcomes with intracytoplasmic sperm injection of cryopreserved sperm from men with spinal cord injury

BACKGROUND

Erectile dysfunction, ejaculatory dysfunction and poor semen quality are the main causes of infertility in men with spinal cord injury (SCI). Different sperm retrieval techniques such as penile vibratory stimulation (PVS), electro-ejaculation (EEJ) or surgical sperm retrieval (SSR) associated or not with sperm cryopreservation can be offered to these patients to preserve their fertility. If fatherhood cannot be achieved naturally, assisted reproductive techniques can be offered to these patients using either fresh or frozen/thawed sperm. The aim of the study was to report in SCI patients from Dijon (Burgundy) and in the literature, intracytoplasmic sperm injection (ICSI) outcomes using frozen sperm obtained either by antegrade ejaculation (PVS or sexual intercourse) or by SSR.

METHODS

A retrospective analysis was performed in Dijon, Burgundy over a 17 year period (1995-2011) on a cohort of 19 SCI men (6 quadriplegics and 13 paraplegics, mean age: 25.2 ± 5.6 years) who underwent a sperm cryopreservation followed or not by intracytoplasmic sperm injection (ICSI). Patients were divided into two groups according to the sperm retrieval method used (antegrade ejaculation group (n=10): penile vibratory stimulation (PVS) for 9 patients and sexual intercourse for 1 patient and surgical sperm retrieval (SSR) group: n=9). The sperm parameters in both groups were analyzed. Pregnancy outcomes in the 8 couples who underwent ICSI were evaluated.

RESULTS

The fertilization rates were 57 and 55%, the embryo's cleavage rates were 90 and 93% in the antegrade ejaculation and SSR groups respectively. Among the 8 couples who underwent ICSI, 5 couples achieved pregnancy. The pregnancy rates per couple were 50% and 75% in the antegrade and SSR groups respectively.

CONCLUSIONS

Although some studies don't recommend freezing sperm in SCI patients, the pregnancy rates presented in this study are encouraging and warrant the use of frozen/thawed sperm in very specific situations.

Sperm-egg interaction and functional assessment of springbok, impala and blesbok cauda epididymal spermatozoa using a domestic cattle in vitro fertilization system

The study assesses the possibility to estimate the potential fertility of post-thawed antelope (Antidorcas marsupialis), impala (Aepyceros melampus) and blesbok (Damaliscus dorcus phillipsi) epididymal sperm using homologous and heterologous IVF and the functioning of cattle IVF system to produce antelope embryos. Cauda epididymal sperm were collected from the antelope and cryopreserved under field conditions. In vitro matured domestic cow, blesbok and springbok oocytes were co-incubated in modified-Tyrode Lactate (m-TL) IVF media with springbok, impala and blesbok sperm for heterologous IVF and springbok and blesbok sperm for homologous IVF. A group of presumptive zygotes from each treatment were examined for sperm penetration and male pronuclear formation after 18h and the remainder were cultured and evaluated for embryo cleavage 22h later. The study shows that Modified Tyrode Lactate in vitro fertilization media supports survivability, capacitation and hyperactivation of springbok, impala and blesbok sperm. Springbok, impala and blesbok post-thawed epididymal spermatozoa are capable of fertilizing domestic cow oocytes under conditions that support domestic cattle IVF. Penetration, male pronuclear formation and embryo cleavage did not differ (p>0.05) between cow oocytes inseminated with sperm from springbok, impala or blesbok however these parameters were higher (p<0.05) for oocytes inseminated with bull sperm. Modified Tyrode Lactate IVF media supported homologous fertilization and embryo development in springbok and blesbok however did not support blastocyst development. These findings suggest that cattle provide a useful model for evaluating springbok, impala and blesbok post-thawed cauda epididymal sperm functionality. Domestic cattle embryo culture conditions need to be modified to promote blastosyst development in these antelope species. Such research provides an important tool in assisted reproductive technology development when high biological value material is utilized for wild species recovery plans.

Acceptable cost for the patient and society

Alongside the debate around clinical, scientific, and ethical aspects of assisted reproductive technology (ART), there exists a parallel debate around the economics of ART treatment and what is the most appropriate funding framework for providing safe, equitable, and cost-effective treatment. The cost of ART treatment from a patient perspective exhibits striking differences worldwide due to the costliness of underlying health care systems and the level of public and third-party subsidization. These relative cost differences affect not only who can afford to access ART treatment but how ART is practiced in terms of embryo transfer practices; in turn significantly impacting the health outcomes and costs of caring for ART conceived children. Although empirical evidence indicates that ART treatment is "good value money" from a societal and patient perspective, the challenge remains to communicate this to policy makers, primarily because fertility treatments are not easily accommodated by traditional health economic methods. Furthermore, with global demand for ART treatment likely to increase, it is important that future funding decisions are informed by what has been learned about how costs and economic incentives influence equity of access and clinical practice. In this review we provide an international perspective on the costs and consequences of ART and summarize key economic considerations from the perspective of ART patients, providers, and society as a whole in the coming decade.

Harlequin ichthyosis in a neonate born with assisted reproductive technology: a case report

Harlequin ichthyosis is a rare and the most severe form of congenital ichthyosis. Although prenatal diagnosis isdifficult for this disorder, recently, this obstacle has markedly improved with the use of DNA-based prenataldiagnosis. Here in, we presented a neonate with harlequin ichthyosis born by assisted reproductive technology(ART). In this case, the diagnosis of harlequin ichthyosis was not established by conventional prenatal screening.

The control of mtDNA replication during differentiation and development

BACKGROUND

Mitochondrial DNA (mtDNA) is important for energy production as it encodes some of the key genes of electron transfer chain, where the majority of cellular energy is generated through oxidative phosphorylation (OXPHOS). MtDNA replication is mediated by nuclear DNA-encoded proteins or enzymes, which translocate to the mitochondria, and is strictly regulated throughout development. It starts with approximately 200 copies in each primordial germ cell and these copies undergo expansion and restriction events at various stages of development.

SCOPE OF REVIEW

I describe the patterns of mtDNA replication at key stages of development. I explain that it is essential to regulate mtDNA copy number and to establish the mtDNA set point in order that the mature, specialised cell acquires the appropriate numbers of mtDNA copy to generate sufficient adenosine triphosphate (ATP) through OXPHOS to undertake its specialised function. I discuss how these processes are dependent on the controlled expression of the nuclear-encoded mtDNA-specific replication factors and that this can be modulated by mtDNA haplotypes. I discuss how these events are altered by certain assisted reproductive technologies, some of which have been proposed to prevent the transmission of mutant mtDNA and others to overcome infertility. Furthermore, some of these technologies are predisposed to transmitting two or more populations of mtDNA, which can be extremely harmful.

MAJOR CONCLUSIONS

The failure to regulate mtDNA replication and mtDNA transmission during development is disadvantageous.

GENERAL SIGNIFICANCE

Manipulation of oocytes and embryos can lead to significant implications for the maternal-only transmission of mtDNA. This article is part of a Special Issue entitled Frontiers of mitochondrial research.

The impact of consumer affordability on access to assisted reproductive technologies and embryo transfer practices: an international analysis

OBJECTIVE

To systematically quantify the impact of consumer cost on assisted reproduction technology (ART) utilization and numbers of embryos transferred.

DESIGN

Ordinary least squared (OLS) regression models were constructed to measure the independent impact of ART affordability-measured as consumer cost relative to average disposable income-on ART utilization and embryo transfer practices.

SETTING

Not applicable.

PATIENT(S)

Women undergoing ART treatment.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

OLS regression coefficient for ART affordability, which estimates the independent effect of consumer cost relative to income on utilization and number of embryos transferred.

RESULT(S)

ART affordability was independently and positively associated with ART utilization with a mean OLS coefficient of 0.032. This indicates that, on average, a decrease in the cost of a cycle of 1 percentage point of disposable income predicts a 3.2% increase in utilization. ART affordability was independently and negatively associated with the number of embryos transferred, indicating that a decrease in the cost of a cycle of 10 percentage points of disposable income predicts a 5.1% increase in single-embryo transfer cycles.

CONCLUSION(S)

The relative cost that consumers pay for ART treatment predicts the level of access and number of embryos transferred. Policies that affect ART funding should be informed by these findings to ensure equitable access to treatment and clinically responsible embryo transfer practices.

The office visit

This article summarizes the current office-based evaluation of male infertility and offers speculation, based on current research, on the future evolution of this encounter. A comprehensive history, physical examination, and semen analysis remain paramount to directing the evaluation; however, new advances continue to refine diagnostic and treatment algorithms. Interpretation of the routine semen analysis as well as adjunctive assessments, including reactive oxygen species, DNA fragmentation, and fluorescent in situ hybridization (FISH) are discussed. The analysis of genetic and endocrine abnormalities is reviewed.

Efficacy of 17α- hydroxy progestrone on decreasing preterm labor in ART pregnancies: A randomized clinical trial

BACKGROUND

Preterm labor (PTL) is one of the most important causes in neonatal mortality and morbidity. Late preterm labor (34-36w) includes 75% of such birth. Assisted reproductive technology (ART) pregnant women are at increased risk of PTL.

OBJECTIVE

The study has been undertaken to determine whether beginning and continuing 17-α hydroxy progesterone caproate can reduce risk of PTL or change neonatal mortality.

MATERIALS AND METHODS

In a double-blind clinical randomized control trial, 106 women were treated by ART technique for their infertility and in gestational age at 16 weeks entered in our study. In one group, 17-α hydroxy progesterone caproate (Femolife) was injected intramuscularly every week until 36 weeks of gestation and in another group; placebo was injected from 16 until 36 weeks of gestetion. Data collected from pregnancy outcomes, infancy, and subsidiary problems were statistically analyzed by a questionnaire.

RESULTS

The risk of PTL in placebo group was 2.48 higher than control group that was not significant (Cl: 0.81-9.94). Femolife side effect in case group was gestational diabetes and local complication was not frequent. NICU admission was not significantly different between groups.

CONCLUSION

Although it seems that 17-α hydroxy progesterone caproate does not cause significantly decrease in PTL in singleton ART gestations but any reduction of PTL in such high risk pregnancies may improve final gestational outcome. There is critical need for larger clinical trials to better understanding causes of PTL, specifically late preterm labor, to prevent mortality and morbidity in ART gestation. This article extracted from Residential thesis. (Hoora Amouzegar)

REGISTRATION ID IN IRCT

IRCT2012101611132N1.

[PROK1, prognostic marker of embryo implantation?]

In spite of improvements in assisted reproductive technology (ART) during the last 30 years, the rate of pregnancy remains constrained, as only about 25 % of embryo transfer lead to successful pregnancies, even with an average of two embryos replaced. Embryo selection is currently based on the establishment of morphokinetic scores, a method that obviously exhibits limitations. Therefore, the assessment of embryo development potency by criteria of higher predictive value is mandatory in order to increase the rates of pregnancy. Nowadays, there is increasing evidence that angiogenic factors might contribute to the success of the implantation and to the pregnancy outcome. Among these factors, prokineticin 1 (PROK1) and its receptors (PROKRs) constitute new targets that showed over the last ten years strong biological features directly linked to ovarian physiology, endometrial receptivity, embryo implantation and thus successful pregnancies. In ART, the rates of circulating PROK1 were reported in 2012 as significantly linked to the quality of embryonic cohort, as well as to the rates of pregnancy. Our preliminary data suggest a high potential of this cytokine in the success of implantation and pregnancy, and strongly overtones the emergency to investigate the value of its measurement in conditioned media of oocytes and embryo cultures in ART.

From laboratories to chambers of parliament and beyond: producing bioethics in France and Romania

In a European context marked by heterogeneous Assisted Reproductive Technology (ART) practices, this article will elucidate and compare the norm elaboration processes pertaining to ART in France and Romania. Using an experimental five-phase model encompassing experimentation, excesses, social mobilization, legislation and contestation, I will examine the processes linking micro (everyday medical practices), meso (institutional regulation) and macro (legislation) levels of ART bioethics in the two countries since the 1980s. ART has developed in France and Romania on different time frames, and Romania's management of ART is decisively influenced by Ceauşescu's pro-natalist policy. However, I will show how the two countries share similar trajectories along the proposed model's first three phases of norm elaboration, and, in recent years, how both have witnessed the emergence of social actors' claims for a more liberal and state-sponsored access to ART, requiring a redefinition of bioethics in line with reproductive social justice at national levels. This is fed by contemporary medical practices and social values, and an increasing transnational interconnectedness between social actors.

The multiple birth epidemic: revisited

The modern era of infertility treatment was heralded over half a century ago with the introduction of new hormonal drugs that could effectively induce ovarian ovulation. However, it was quickly recognized that the birth of these new "miracle drugs" was associated with a remarkable increase in the incidence of high-order multiple births. Despite the fantastic improvement in our ability to monitor ovarian response during ovulation induction, and our power to control the number of embryos introduced into the womb through IVF, multiple births remain a leading cause of long-term child morbidity among infertility patients. Efforts to prevent what was coined in the 1960s as the "multiple birth epidemic" remain an urgent concern. A new body of research clearly points at our capacity to reduce the risk of multiple births and their associated long term morbidity without diminishing current high success rates of infertility treatment.

Infertility and Immunocontraception based on zona pellucida

The zona pellucida (ZP) is an extracellular matrix surrounding ovarian oocytes, ovulated eggs and preimplantation embryos. It plays several important roles at different stages of reproduction. Its constituent glycoproteins are expressed specifically in the ovary. It is thus possible to produce autoantibodies to ZP proteins that interfere with reproductive functions including folliculogenesis, fertilization and implantation. First, this article describes the history of anti-ZP antibodies detected in women with idiopathic infertility. Second, the current relationship between anti-ZP antibodies and infertility is discussed in relation to assisted reproductive medicine. Third, we introduce the latest studies of animal experiments involving the ZP. Finally, immunocontraceptive vaccine development using various ZP antigens is reviewed.

Biochemical pregnancy during assisted conception: a little bit pregnant

Assisted reproductive technology (ART) has revolutionized the management of subfertility as many couples who previously had no hope of achieving a pregnancy are able to do so. Several factors contribute to the successful outcome of assisted conception. The period of waiting for the pregnancy test after assisted conception could be very crucial to the patient. One outcome of assisted conception could be a positive pregnancy test which could lead to a clinical pregnancy resulting in a live birth, clinical pregnancy resulting in a miscarriage or a biochemical pregnancy. A negative pregnancy test, failure to fertilise and failure to respond to stimulation usually lead to a big blow to the couple. As far as biochemical pregnancy is concerned, its exact aetiology remains unknown. There are no definite predictive factors for its occurrence that can be remedied in subsequent cycles. Several associated aetiologies have been suggested in the literature. This review aims at addressing the issue of biochemical pregnancy after assisted conception as a prelude to conducting further studies to assess if there are any predictive factors for its occurrence.

Congenital malformations associated with assisted reproductive technology: a California statewide analysis

BACKGROUND

Management of congenital malformations comprises a large part of pediatric surgical care. Despite increasing utilization of assisted reproductive technology (ART) and fertility-related services (FRS), associations with birth defects are poorly understood.

METHODS

Infants born after ART or FRS were identified from the California Linked Birth Cohort Dataset from 2006 to 2007 and compared to propensity matched infants conceived naturally. Factors associated with major congenital malformations were evaluated using Firth logistic regression.

RESULTS

With a cohort of 4,795 infants born after ART and 46,025 naturally conceived matched controls, major congenital malformations were identified in 3,463 infants. Malformations were increased for ART infants (9.0% vs. 6.6%, p<0.001). After adjusting for infant and maternal factors, ART infants exhibited increased odds of major malformations overall (OR 1.25, 95% CI 1.12-1.39), specifically defects of the eye (OR 1.81, 95% CI 1.04-3.16), head and neck (OR 1.37, 95% CI 1.00-1.86), heart (OR 1.41, 95% CI 1.22-1.64), and genitourinary system (OR 1.40, 95% CI 1.09-1.82). The likelihood of birth defects was increased for multiples (OR 1.35, 95% CI 1.18-1.54) and not singletons. Odds of congenital malformation after FRS alone (n=1,749) were non-significant.

CONCLUSION

ART contributes a significant risk of congenital malformation and may be more pronounced for multiples. Accurate counseling for parents considering ART and multidisciplinary coordination of care prior to delivery are warranted.

Student midwives' responses to reproductive ethics: a qualitative focus group approach using case scenarios

OBJECTIVE

the aim of this study was to gain an understanding of how midwifery students respond to a range of ethical dilemmas which they may encounter in clinical practice in relation to the use of reproductive technologies.

DESIGN

during a series of focus groups, student midwives were asked to consider four novel scenarios, which highlighted some of the most controversial issues in contemporary reproductive ethics. These included assisted reproduction for older women, surrogacy and mental health, sex selection and reproductive cloning.

SETTING

a University in the East Midlands, England.

PARTICIPANTS

purposeful sampling was adopted which resulted in four focus groups with a total of 16 student midwives.

FINDINGS

a process of thematic analysis generated four key themes: choice and expectation, consumer society; distributive justice; parental rights and welfare of the child.

CONCLUSIONS

our results suggest that student midwives are sensitive to the range of ethical dilemmas associated with the increased use of technology in human reproduction, and construct distinct boundaries in relation to what is considered of benefit or good to the mother, parents, the child and to society and what is considered harmful to the individual, the child and society. They also expressed their opposition to the excessive use of technological intervention, preferring instead to maintain a more naturalistic approach to reproduction. This is especially significant where concerns about the welfare of the child are articulated.

Assisted reproductive technology after the birth of louise brown

BACKGROUND

Public interest in Assisted Reproductive Technology (ART) has remained high since the birth of the world's first in vitro fertilization baby, Louise Brown, in the United Kingdom. ART allows scientists to manipulate the fertilization process in order to bypass some pathological obstacles such as blocked fallopian tubes and non-functioning ovaries in the females, and blocked vas deferens and low sperm count in the males. The purpose was to provide a historical outline and identify the researches that most contributed to ART.

METHODS

A review of published experimental and clinical studies of assisted reproduction carried out at the University of Bristol library website (MetaLib(®)). A cross-search of seven different medical databases (AMED-Allied and Complementary Medicine Database, BIOSIS Previews on Web of Knowledge, Cochrane Library, Embase, and the Medline on Web of Knowledge, OvidSP and PubMed) was completed by using the key words to explore the major milestones and progress in the development and implementation of ART.

RESULTS

A speedy advancement in the development of different assisted reproductive techniques makes infertility problem more treatable than it ever had been.

CONCLUSION

Although no other field in the medicine has integrated new knowledge into the daily practice more quickly than ART yet, there is a need for social research to counterbalance the dominance of biomedical one, in particular the people's actual experiences and expectations of ART.

The correlation between follicular fluid pregnancy-associated plasma protein A levels, fertilization, and embryo quality in GnRH agonist and GnRH antagonist protocols in ART cycles

BACKGROUND

Determination of oocyte fertilization and embryo quality are one of the most important purposes in ART cycles. Follicular fluid provides an important microenvironment for development of oocytes and some biochemical characteristics of the follicular fluid, such as pregnancy-associated plasma protein-A (PAPP-A), may play an important role in prediction of success rate of ART.

OBJECTIVE

This study was performed to evaluate whether there was any difference in follicular fluid PAPP-A, fertilization, and embryo quality between GnRH agonist long protocol and flexible GnRH antagonist multiple-dose protocol in ART cycles.

MATERIALS AND METHODS

A total of 100 women who were candidates for ART were enrolled the study and were divided into two groups, GnRH agonist (GnRHa) long protocol (n=51) and flexible GnRH antagonist (GnRHant) multiple-dose protocol (n=49). Follicular fluid sample was obtained from a single mature follicle and follicular fluid PAPP-A level, fertilization and embryo quality of the same oocyte were evaluated in both groups.

RESULTS

There was no significant difference in the mean levels of follicular fluid PAPP-A between the GnRHa protocol and GnRHant protocol (3.5±1.4 vs. 3.8±1.9, respectively). The mean levels of follicular fluid PAPP-A in fertilized oocyte and good quality embryo were comparable in GnRHa and GnRHant protocols.

CONCLUSION

Our data indicated that no differences of follicular fluid PAPP-A levels were observed between cycles using GnRHa long protocol and those of using flexible GnRHant multiple-dose protocol.

A meta-analysis of the relationship between endometrial thickness and outcome of in vitro fertilization cycles

OBJECTIVE:

The objective was to evaluate the relationship between endometrial thickness on the day of human chorionic gonadotropin administration and pregnancy outcome in in vitro fertilization cycles.

DESIGN:

This was a systematic review and meta-analysis.

MATERIALS AND METHODS:

We identified 484 articles using Cochrane library, PubMed, Web of Science, and Embase searches with various key words including endometrial thickness, pregnancy, assisted reproductive technology, endometrial pattern, and in vitro fertilization. A total of 14 studies with data on endometrial thickness and outcome were selected, representing 4922 cycles (2204 pregnant and 2718 nonpregnant). The meta-analysis with a random effects model was performed using comprehensive meta-analysis software. We calculated the standardized mean difference, odds ratio (OR), and 95% confidence intervals (CIs).

RESULTS:

There was a significant difference in the mean endometrial thickness between pregnant and nonpregnant groups (P<0.001), with a standardized mean difference of 0.4 mm (95% CI 0.22–0.58). The OR for pregnancy was 1.40 (95% CI 1.24–1.58).

CONCLUSIONS:

The mean endometrial thickness was significantly higher in pregnant women compared to nonpregnant. The mean difference between two groups was <1 mm which may not be clinically meaningful. Although there may be a relationship between endometrial thickness and pregnancy, implantation potential is probably more complex than a single ultrasound measurement can determine.

Successful management of heterotopic pregnancy after fetal reduction using potassium chloride and methotrexate

Heterotopic pregnancy, the presence of two gestational sacs simultaneously, is a rare event but with the advent of Assisted Reproductive Technology, it is now an increasingly common complication. The reported incidence of a heterotopic pregnancy in a spontaneous cycle is quoted as 1 in 30,000. We report the case of a 38-year-old primigravida who was referred to our center at 11 + 2 weeks gestation with a diagnosis of heterotopic pregnancy for further management. A non-surgical intervention comprising of transvaginal ultrasound-guided potassium chloride and methotrexate into the cervical pregnancy resulted in a successful outcome. As an obstetrician, a high index of clinical suspicion and an early scan is mandatory to make a diagnosis of a heterotopic pregnancy and manage accordingly.

Singleton pregnancy outcomes after assisted and non-assisted reproductive technology in infertile patients

Purpose

Singleton pregnancy after assisted reproductive technology (ART) has been associated with higher risks of adverse pregnancy outcome than naturally conceived singleton pregnancy. This study was to elucidate whether the ART procedure is responsible for abnormal pregnancy outcome comparing those after ART and non-ART in infertile patients.

Methods

We compare the singleton pregnancy outcome of infertile patients in our university hospital between 2000 and 2008 following ART (351 pregnancies) and non-ART (213 pregnancies) procedures. Pregnancy outcome parameters were incidence of pregnancy induced hypertension, placenta previa, placental abruption, cesarean delivery, preterm birth, very preterm birth, stillbirth, low birth weight and very low birth weight.

Results

Most of the pregnancy outcome parameters were not significantly different between the ART group and the non-ART group. Only placenta previa was significantly higher in the ART group than in the non-ART group (odds ratio 4.0; 95 % CI 1.2-13.7).

Conclusions

ART procedure may itself be a risk factor for the development of placenta previa. Some of the abnormal perinatal outcomes that had been previously attributed to ART, however, may be due to the baseline characteristics of infertile patients.

Gestational surrogacy: Viewpoint of Iranian infertile women

BACKGROUND

Surrogacy is a popular form of assisted reproductive technology of which only gestational form is approved by most of the religious scholars in Iran. Little evidence exists about the Iranian infertile women's viewpoint regarding gestational surrogacy.

AIM

To assess the viewpoint of Iranian infertile women toward gestational surrogacy.

SETTING AND DESIGN

This descriptive study was conducted at the infertility clinic of Tabriz University of Medical Sciences, Iran.

MATERIALS AND METHODS

The study sample consisted of 238 infertile women who were selected using the eligible sampling method. Data were collected by using a researcher developed questionnaire that included 25 items based on a five-point Likert scale.

STATISTICAL ANALYSIS

Data analysis was conducted by SPSS statistical software using descriptive statistics.

RESULTS

Viewpoint of 214 women (89.9%) was positive. 36 (15.1%) women considered gestational surrogacy against their religious beliefs; 170 women (71.4%) did not assume the commissioning couple as owners of the baby; 160 women (67.2%) said that children who were born through surrogacy would better not know about it; and 174 women (73.1%) believed that children born through surrogacy will face mental problems.

CONCLUSION

Iranian infertile women have positive viewpoint regarding the surrogacy. However, to increase the acceptability of surrogacy among infertile women, further efforts are needed.

In vitro fertilization/intracytoplasmic sperm injection for male infertility

Progress in the field of assisted reproduction, and particularly micromanipulation, now heralds a new era in the management of severe male factor infertility, not amenable to medical or surgical correction. By overcoming natural barriers to conception, in vitro fertilization and embryo transfer (IVF-ET), subzonal sperm insemination, partial zona dissection, and intracytoplasmatic injection of sperm (ICSI) now offer couples considered irreversibly infertile, the option of parenting a genetically related child. However, unlike IVF, which necessitates an optimal sperm number and function to successfully complete the sequence of events leading to fertilization, micromanipulation techniques, such as ICSI, involving the direct injection of a spermatozoon into the oocyte, obviate all these requirements and may be used to alleviate severe male factor infertility due to the lack of sperm in the ejaculate due to severely impaired spermatogenesis (non-obstructive azoospermia) or non-reconstructable reproductive tract obstruction (obstructive azoospermia). ICSI may be performed with fresh or cryopreserved ejaculate sperm where available, microsurgically extracted epididymal or testicular sperm with satisfactory fertilization, clinical pregnancy, and ongoing pregnancy rates. However, despite a lack of consensus regarding the genetic implications of ICSI or the application and efficacy of preimplantation genetic diagnosis prior to assisted reproductive technology (ART), the widespread use of ICSI, increasing evidence of the involvement of genetic factors in male infertility and the potential risk of transmission of genetic disorders to the offspring, generate major concerns with regard to the safety of the technique, necessitating a thorough genetic evaluation of the couple, classification of infertility and adequate counseling of the implications and associated risks prior to embarking on the procedure. The objective of this review is to highlight the indications, advantages, limitations, outcomes, implications and safety of using IVF/ICSI for male factor infertility to enable a more judicious use of these techniques and maximize their potential benefits while minimizing foreseen complications.

Outcome of assisted reproductive technology in women aged 40 years and older

BACKGROUND

Human fertility has been declined all over the world. Advanced women's age is one of the most important factors in determining the success of reproduction and ageing has negative impact on ART outcome and advanced female age decreases the chance of live birth rates achieved using ART, especially after 40 years of age.

OBJECTIVE

To evaluate ART outcomes regarding to pregnancy, abortion, cycle cancellation and live birth rates in women 40 years and older.

MATERIALS AND METHODS

A retrospective study was performed on three hundred-thirteen women undergoing ART cycles in the Madar Hospital in Yazd. Women with age ≥ 40 years who indicated for ART enrolled the study regardless of the infertility type or etiology. In this study, we used data from IVF or ICSI cycles using fresh embryo transfer. Follow up was performed in regard to pregnancy, abortion, cycle cancellation and live birth rates.

RESULTS

The mean age of women was 41.87±1.97 years. Chemical pregnancy rate was 8.6% (27/313) per cycle. Clinical pregnancy rate was 3.8% (12/313) per cycle. Spontaneous abortion was observed in 63% (17/27) of patients with positive pregnancy test. The overall cancellation rate was 23.3% per oocytes retrieval. The overall live birth rate per cycle for all women who initiated an ART cycle at age ≥40 years was 3.2% (10/313) that eight of those women were under 42 years old.

CONCLUSION

Based on our results, we suggest that women with age 42 years and above should be advised to use other options, including oocyte donation or adoption.

Evaluation of possible criteria for elective single embryo transfer

Purpose

A major problem of assisted reproductive technology (ART) is multiple gestation, which impacts neonatal and perinatal medicine. The literature contains a number of reports that elective single embryo transfer (eSET) is effective for the control of multiple pregnancies; however, to date, uniform criteria have not been established.

Methods

Using logistic regression analysis based on the results of ART in our department from January 2005 to July 2006, our eSET criteria were established. We conducted a comparative study of the clinical pregnancy rate, multiple gestation rate, and delivery rate before and after eSET (before-eSET and after-eSET groups, respectively).

Results

As a result of the analysis, our eSET criteria included all three of the following: (A) patient age ≤37, (B) previous IVF/ICSI trials ≤5, and (C) acquisition of two or more good-quality embryos. Based on our criteria, the after-eSET group was not found to have a decrease in the pregnancy rate; however, the multiple gestation rate decreased as compared to the before-eSET group. In addition, as a result of various evaluations of the eSET group, interesting findings were revealed.

Conclusions

In the after-eSET group, our eSET criteria achieved a decrease in the multiple pregnancy rate without a decrease in the pregnancy rate.

Luteal phase bleeding after IVF cycles: comparison between progesterone vaginal gel and intramuscular progesterone and correlation with pregnancy outcomes

BACKGROUND

To compare luteal phase bleeding and pregnancy outcomes in normogonadotropic patients receiving progesterone vaginal gel (PVG) or intramuscular progesterone (IMP) injections.

METHODS

In this retrospective cohort study, data from 270 patients (292 cycles) undergoing day-3 fresh embryo transfer were analyzed. PVG, 90 mg daily (170 cycles) or IMP, 50 mg daily (122 cycles) began at egg retrieval.

RESULTS

Luteal phase bleeding was significantly more common in the PVG than the IMP group. No significant differences were observed in biochemical pregnancy or spontaneous abortion rates between the two groups. Patients who bled before the pregnancy test had significantly lower total and clinical pregnancy rates than non-bleeders. Total and ongoing pregnancy/delivery rates were higher in the PVG than IMP group, but did not achieve statistical significance.

CONCLUSION

Luteal phase bleeding was more common in the PVG group than the IMP group, but pregnancy was successful in more patients in the PVG group. Luteal phase bleeding is prevented or delayed during IMP treatment, but patients who bled before the pregnancy test, whether using the gel or injected progesterone, had significantly reduced pregnancy rates compared with non-bleeders.

The impact of endometriosis, endometrioma and ovarian cystectomy on assisted reproductive technology

Purpose

To assess outcomes in assisted reproductive technology (ART) in infertile women with endometriosis with respect to their concomitant endometrioma status and surgical history in our department.

Methods

This is a retrospective case control study which analyzes informational data obtained at a university hospital. The study drew from a patient pool of 332 cases (877 cIVF/ICSI cycles) that took place in our department from 2006 to 2008. Sixty-one cases (97 cycles) had major indications for cIVF/ICSI with endometriosis. We classified groups from these 61 cases as follows: an unoperated endometrioma group (A) with 31 cycles, a postoperative endometrioma group (B) with 51 cycles, and a no endometrioma group (C) with 15 cycles. We analyzed and compared these three groups and also included a non-endometriosis tubal infertility group (D) with 27 cycles.

Results

In the control group (D), serum FSH levels and the cancellation rates were significantly lower than those of other groups, and the number of developing follicles was higher. E2 levels before oocyte aspiration in the postoperative endometrioma group (B) was lower. Implantation, pregnancy, delivery and miscarriage rates were not significantly different among the four groups.

Conclusion

The results suggest that endometriosis causes a decrease in endocrinologic ovarian function whether or not an endometrioma is also present. As for E2 level before oocyte aspiration, our results suggest that ovarian reserves might be reduced by endometrioma excision, but this is difficult to evaluate. In the endometriosis groups, cancellation rates were significantly higher, although when embryos were transferred the pregnancy rates were not significantly different when compared with the non-endometriosis group. As for infertile women with endometriomas, our results suggest that preexisting ovarian reserve is reduced by the presence of endometriosis, and ovarian reserve might also be reduced by excision of endometriomas.

Is surgical repair of the fallopian tubes ever appropriate?

The overall median prevalence of infertility, defined as no conception after more than 12 months of unprotected intercourse with the husband or cohabiting partner in women aged 15 to 44 years, is approximately 9%. About 25% to 33% of female infertility is the result of tubal disease and endometriosis. In view of very successful alternative treatment of tubal factor infertility, the surgical repair of the fallopian tubes is all but obsolete and has been replaced with assisted reproductive technology. This article reviews situations in which surgical repair of the fallopian tubes may facilitate conception.