Two new prediction rules for spontaneous pregnancy leading to live birth among subfertile couples, based on the synthesis of three previous models

BACKGROUND

Several models have been published for the prediction of spontaneous pregnancy among subfertile patients. The aim of this study was to broaden the empirical basis for these predictions by making a synthesis of three previously published models.

METHODS

We used the original data from the studies of Eimers et al. (1994), Collins et al. (1995) and Snick et al. (1997) on couples consulting for various forms of subfertility. We developed a so-called three-sample synthesis model for predicting spontaneous conception leading to live birth within 1 year after intake based on the three data sets. The predictors used are duration of subfertility, women's age, primary or secondary infertility, percentage of motile sperm, and whether the couple was referred by a general practitioner or by a gynaecologist (referral status). The performance of this model was assessed according to a 'jack-knife' analysis. Because the post-coital test (PCT) was not assessed in one of the samples, a synthesis model including the PCT was based on two samples only.

RESULTS

The ability of the synthesis models to distinguish between women who became pregnant and those who did not was comparable to the ability of the one-sample models when applied in the other samples. The reliability of the predictions by the three-sample synthesis model was somewhat better. Predictions improved considerably by including the PCT.

CONCLUSIONS

The synthesis models performed better and had a broader empirical basis than the original models. They are therefore better suitable for application in other centres.

A comparison of ovulation suppression and ovulation stimulation in the treatment of endometriosis-associated infertility

This study compares ovulation stimulation or suppression with the pregnancy rate among infertile couples with endometriosis. The design is a nonrandomized, prospective, multicentered cohort analytic study. Two hundred and ninety-seven couples with laparoscopy-proven endometriosis were analyzed: 68 received no therapy, 42 received clomiphene and 74 received danazol. Forty patients (22%) conceived and pregnancy rates were similar in each treatment group. The relative likelihood of pregnancy associated with clomiphene was 2.9 (95% confidence limits 1.2-7.1); the relative likelihood of pregnancy with danazol was 1.02 (95% confidence limits 0.5-2.3). This study suggests that pregnancy rates during clomiphene treatment could be superior to expectant therapy, while pregnancy rate after danazol is similar to no treatment.

Unexplained infertility: a review of diagnosis, prognosis, treatment efficacy and management

The dilemma of unexplained infertility posed by Southam in 1960 remains today: despite advances in the diagnostic assessment of infertility, many couples still have no explanation for their infertility. Even the most sophisticated evaluation of semen, ovulation and genital tract competence cannot reveal all of the possible defects in the complex process leading to conception. Because it arises from these shortcomings in our knowledge of fertilization and from our inability to utilize all of the current knowledge, unexplained infertility is a challenge for both biological and clinical research. This paper attempts to summarize some clinical issues in the management of unexplained infertility: the prevalence of the disorder, problems in the definition and possible explanations for the existence of this diagnostic category. It reviews outcome-based clinical publications as a guide to decision-making on what diagnostic tests to use, provides a summary of the untreated prognosis and evaluates study results that may serve as a basis for treatment decisions in this puzzling diagnostic category of infertility.

Surgery or embolisation for varicocele in subfertile men

BACKGROUND

A varicocele is a meshwork of distended blood vessels in the scrotum, usually left-sided, due to dilatation of the spermatic vein. Although the concept that varicocele causes, and varicocelectomy cures, male subfertility has been around for almost fifty years, the mechanisms by which varicocele would affect fertility have not yet been satisfactorily explained, and neither have the mechanisms by which varicocelectomy would restore fertility. Furthermore, it has been questioned whether a causal relation exists at all between the distension of the pampiniform plexus and impairment of fertility.

OBJECTIVES

To evaluate the effect of varicocele treatment on pregnancy rate in subfertile couples.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group trials register (searched 12 Sept 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2004), MEDLINE (January 1966 to May 2004), EMBASE (January 1985 to May 2004) and reference lists of articles. In addition, we hand searched 22 specialist journals in the field from their first issue until 2004. We also checked cross references, references from review articles, and contacted researchers in the field.

SELECTION CRITERIA

RCTs were included if they were relevant to the clinical question posed, if they reported pregnancy rates as an outcome measure, and if they reported data in treated (surgical ligation or radiological embolization of the internal spermatic vein) and untreated groups.

DATA COLLECTION AND ANALYSIS

Nine studies met the inclusion criteria for this review. One was an extension of a previously published study (Nieschlag 1995/1998), which left eight studies for analysis (Nilsson 1979; Breznik 1993; Madgar 1995; Yamamoto 1996; Nieschlag 1995/1998; Grasso 2000; Unal 2001; Krause 2002). All eight only included men from couples with subfertility problems, one (Madgar 1995) excluded men with sperm counts <5 mill/mL, one (Krause 2002) men with sperm counts <2 mill/mL and/or progressive motility <10%, two trials involving clinical varicoceles included some men with normal semen analysis (Nilsson 1979; Breznik 1993). Three studies (Yamamoto 1996; Grasso 2000; Unal 2001) specifically addressed only men with subclinical varicoceles. Two authors independently screened potentially relevant trials. Any differences of opinion were resolved by consensus (none occurred for this review). Studies were excluded from meta-analysis if they made comparisons other than those specified above.

MAIN RESULTS

The combined Peto odds ratio (OR) of the eight studies is 1.10 (95%CI 0.73 to 1.68), indicating no benefit of varicocele treatment over expectant management in subfertility couples in whom varicocele in the man is the only abnormal finding.

REVIEWERS' CONCLUSIONS

There is no evidence that treatment of varicocele in men from couples with otherwise unexplained subfertility improves the couple's chance of conception.

Current perspectives on oral contraceptive use

Oral contraceptives are one of the most highly effective forms of contraception and provide many short- and long-term noncontraceptive health benefits. They control menstrual cycle irregularities, such as breakthrough bleeding and amenorrhea, and are effective in treating dysfunctional uterine bleeding. In addition, for decades after oral contraceptive use is discontinued they are associated with substantial decreases in the risk of ovarian cancer (up to 80%) and of endometrial cancer (40%-50%), and nearly eliminate benign functional ovarian cysts. Long-term oral contraceptive use confers protection against benign breast disease and colorectal cancer, may help prevent rheumatoid arthritis, decreases ectopic pregnancy and hospitalizations for pelvic inflammatory disease, and helps preserve bone mineral density to reduce risk of fractures. Large bodies of evidence from extensive research have clarified the perceived association of oral contraceptive use with cardiovascular disease and with breast cancer. Findings indicate that there is no increased risk of myocardial infarction or stroke associated with oral contraceptive use in healthy, nonsmoking, normotensive women. Although there is a 3- to 4-fold increased risk of venous thromboembolism with current oral contraceptive use, the absolute risk is very small and is half that associated with pregnancy. Women of all reproductive ages, including perimenopausal women, can realize many health benefits through oral contraceptive use, including improved health status later in life.

Current perspectives on benefits and risks of hormone replacement therapy

Hormone replacement therapy with estrogen alone or with added progestin relieves menopausal symptoms and physical changes associated with depleted endogenous estrogen levels. Estrogen replacement has also demonstrated a clear benefit in the prevention of osteoporosis. Hormone replacement therapy with added progestin maintains spinal bone density, protects against postmenopausal hip fractures, and provides these benefits even when therapy is started after age 60. More recently, additional benefits have emerged. Current estrogen and hormone replacement therapy users have a 34% reduction in the risk of colorectal cancer and a 20% to 60% reduction in the risk of Alzheimer's disease. Until recently, the body of evidence indicated that hormone replacement therapy with estrogen only reduced cardiovascular disease risk by 40% to 50% in healthy patients; whether the findings of 3 ongoing trials will change this conclusion is pending availability of the final results. The many benefits of estrogen and hormone replacement therapy must be weighed against a slight increase in the risk of breast cancer diagnosis with use for 5 or more years, but which disappears following cessation of therapy. Overall, estrogen and hormone replacement therapy improves the quality of life and increases life expectancy for most menopausal women.

Cost-effectiveness of hysterosalpingography, laparoscopy, and Chlamydia antibody testing in subfertile couples

OBJECTIVE

To evaluate the cost-effectiveness analysis of hysterosalpingography (HSG), laparoscopy, and Chlamydia antibody testing (CAT) in subfertile couples.

DESIGN

Cost-effectiveness analysis.

SETTING

Decision analytic framework.

PATIENT(S)

Data of >2,000 subfertile couples in the Canadian Infertility Treatment Evaluation Study. Results of CA-125 measurement and CAT were simulated from baseline characteristics.

INTERVENTION(S)

Expectant management was considered to be the reference strategy (strategy 1). In strategy 2 and 3, IVF was offered either immediately or after 2.5 years. In strategy 4, the decision to offer or delay treatment was based on the couple's chance of spontaneous conception. Nine strategies incorporated combinations of CAT, CA-125 measurement, HSG, and laparoscopy.

MAIN OUTCOME MEASURE(S)

Expected live birth rates, expected number of IVF cycles, and expected total costs.

RESULT(S)

The strategy starting with CAT was the most cost-effective in couples whose 3-year chance of conception was >14%, whereas the strategy starting with HSG was the most cost-effective in couples with worse fertility prospects.

CONCLUSION(S)

The diagnostic work-up to detect tubal pathology in subfertile couples should start with CAT in couples with relatively good fertility prospects and immediate HSG in couples with relatively poor fertility prospects.

Surgery or embolisation for varicocele in subfertile men

BACKGROUND

A varicocele is an, almost exclusively left-sided, varicosity of the pampiniform plexus of the spermatic cord, forming a tangle of distended blood vessels in the scrotum. Although the concept that varicocele causes male subfertility and therefore varicocelectomy cures male subfertility has been around for almost fifty years now, the mechanisms by which varicocele would affect fertility have not yet been satisfactorily explained, and neither have the mechanisms by which varicocelectomy would resolve subfertility. Furthermore, it has been questioned whether a causal relation exists at all between the distension of the pampiniform plexus and impairment of fertility.

OBJECTIVES

To evaluate the effect of varicocele treatment on pregnancy rate in subfertile couples.

SEARCH STRATEGY

Relevant trials were identified in the Cochrane Menstrual Disorders and Subfertility Group's specialised register of controlled trials. A MEDLINE search, using the group's search strategy, was performed for the period 1966-2000. Also, hand searching was performed of 22 specialist journals in the field from their first issue till 2000. Cross references and references from review articles were checked.

SELECTION CRITERIA

RCTs were included if they were relevant to the clinical question posed, if they reported pregnancy rates as an outcome measure, and if they reported data in treated (surgical ligation or radiological embolization of the internal spermatic vein) and untreated groups.

DATA COLLECTION AND ANALYSIS

Six studies met the inclusion criteria for this review. One (Nieschlag 1995/1998) was an extension of a previously published study (Nieschlag 1995/1998), which left five studies for analysis (Nilsson 1979; Breznik 1993; Madgar 1995; Yamamoto 1996; Nieschlag 1995/1998). The results of a WHO megatrial are awaited but as yet are unavailable. The WHO data will be added if and when they will have become available. All five only included men from couples with subfertility problems, one (Madgar 1995) excluded men with sperm counts <5 mill/mL, three (Nilsson 1979; Breznik 1993; Yamamoto 1996) also included men with normal semen analysis. One study (Yamamoto 1996) specifically addressed only men with subclinical varicoceles as diagnosed by thermography. Potentially relevant trials were screened independently by two authors (JE and JC). Any differences of opinion were resolved by consensus meeting (none occurred for this review). Studies were excluded from meta-analysis if they made comparisons other than those specified above.

MAIN RESULTS

One trial (Madgar 1995) reported a statistically significant improvement in pregnancy rate following high ligation of the left spermatic vein. None of the other four studies showed individually a significant effect on pregnancy rates of varicocele treatment over no-treatment (Nilsson 1979; Breznik 1993; Yamamoto 1996), or over counseling only (Nieschlag 1995/1998). The combined RR (Relative Risk; random effects method) of the five studies is 1.06 (95%CI 0.57-1.94), the Peto OR (Odds Ratio) is 1.15 (95%CI 0.73-1.83).

REVIEWER'S CONCLUSIONS

Insufficient evidence exists that treatment of varicocele in men from couples with otherwise unexplained subfertility does improve the couple's spontaneous pregnancy chances.

Age and residual cholesterol efflux affect HDL cholesterol levels and coronary artery disease in ABCA1 heterozygotes

We and others have recently identified mutations in the ABCA1 gene as the underlying cause of Tangier disease (TD) and of a dominantly inherited form of familial hypoalphalipoproteinemia (FHA) associated with reduced cholesterol efflux. We have now identified 13 ABCA1 mutations in 11 families (five TD, six FHA) and have examined the phenotypes of 77 individuals heterozygous for mutations in the ABCA1 gene. ABCA1 heterozygotes have decreased HDL cholesterol (HDL-C) and increased triglycerides. Age is an important modifier of the phenotype in heterozygotes, with a higher proportion of heterozygotes aged 30-70 years having HDL-C greater than the fifth percentile for age and sex compared with carriers less than 30 years of age. Levels of cholesterol efflux are highly correlated with HDL-C levels, accounting for 82% of its variation. Each 8% change in ABCA1-mediated efflux is predicted to be associated with a 0.1 mmol/l change in HDL-C. ABCA1 heterozygotes display a greater than threefold increase in the frequency of coronary artery disease (CAD), with earlier onset than unaffected family members. CAD is more frequent in those heterozygotes with lower cholesterol efflux values. These data provide direct evidence that impairment of cholesterol efflux and consequently reverse cholesterol transport is associated with reduced plasma HDL-C levels and increased risk of CAD.

tRNA determinants for transcription antitermination of the Bacillus subtilis tyrS gene

Transcriptional regulation of the T box family of aminoacyl-tRNA synthetase and amino acid biosynthesis genes in Gram-positive bacteria is mediated by a conserved transcription antitermination system, in which readthrough of a termination site in the leader region of the mRNA is directed by a specific interaction with the cognate uncharged tRNA. The specificity of this interaction is determined in part by pairing of the anticodon of the tRNA with a "specifier sequence" in the leader, a codon representing the appropriate amino acid, as well as by pairing of the acceptor end of the tRNA with an unpaired region of the antiterminator. Previous studies have indicated that although these interactions are necessary for antitermination, they are unlikely to be sufficient. In the current study, the effect of multiple mutations in tRNA(Tyr) on readthrough of the tyrS leader region terminator, independent of other tRNA functions, was assessed using a system for in vivo expression of pools of tRNA variants; this system may be generally useful for in vivo expression of RNAs with defined end points. Although alterations in helical regions of tRNA(Tyr) that did not perturb base pairing were generally permitted, substitutions affecting conserved features of tRNAs were not. The long variable arm of tRNA(Tyr) could be replaced by either a short variable arm or a long insertion of a stable stem-loop structure. These results indicate that the tRNA-leader RNA interaction is highly constrained, and is likely to involve recognition of the overall tertiary structure of the tRNA.

Cost-effectiveness of in vitro fertilization and embryo transfer

OBJECTIVE

Economic analyses in reproductive medicine often fail to take into account the chances of treatment-independent conception. We compared the cost-effectiveness of several realistic strategies involving IVF using no treatment as the reference strategy.

DESIGN

A decision tree was constructed for a subfertile couple in which the clinician had to decide whether to offer treatment with IVF. No treatment at all was used as the reference strategy.

SETTING

An analytic decision-making framework.

PATIENT(S)

Hypothetical subfertile couples.

INTERVENTION(S)

Two potential treatment approaches: three IVF cycles performed as soon as possible, or no treatment performed initially and then three or four IVF cycles performed if a pregnancy resulting in a live birth does not occur naturally after 212 years.

MAIN OUTCOME MEASURE(S)

The cost of establishing one pregnancy that results in a live birth.

RESULT(S)

The cost-effectiveness of IVF depended not only on the costs and expected success rates of IVF itself but also on the couple-specific chances of treatment-independent conception. Consequently, the cost-effectiveness of IVF is strongly dependent on the age of the female partner. This finding corresponds with everyday clinical experience.

CONCLUSION(S)

Economic analyses in reproductive medicine should take into account the option of providing no treatment.

Antiphospholipid antibodies and in vitro fertilization success: a meta-analysis

OBJECTIVE

To evaluate whether the presence of antiphospholipid antibodies among women undergoing IVF affects the likelihood of IVF success.

DESIGN

A meta-analysis of seven eligible studies on antiphospholipid antibodies and IVF outcome.

MAIN OUTCOME MEASURE(S)

Odds ratios (ORs) and 95% confidence intervals (CIs) of an association between the presence of antiphospholipid antibodies and both clinical pregnancy and live birth from IVF.

RESULT(S)

There was no significant association between antiphospholipid abnormalities and either clinical pregnancy (OR 0.99; 95% CI 0.64-1.53) or live birth (OR 1.07; 95% CI 0.66-1.75) in IVF patients.

CONCLUSION(S)

The measurement of antiphospholipid antibodies is not warranted in patients undergoing IVF.

Mutations in the ABC1 gene in familial HDL deficiency with defective cholesterol efflux

BACKGROUND

A low concentration of HDL cholesterol is the most common lipoprotein abnormality in patients with premature atherosclerosis. We have shown that Tangier disease, a rare and severe form of HDL deficiency characterised by a biochemical defect in cellular cholesterol efflux, is caused by mutations in the ATP-binding-cassette (ABC1) gene. This gene codes for the cholesterol-efflux regulatory protein (CERP). We investigated the presence of mutations in this gene in patients with familial HDL deficiency.

METHODS

Three French-Canadian families and one Dutch family with familial HDL deficiency were studied. Fibroblasts from the proband of each family were defective in cellular cholesterol efflux. Genomic DNA of each proband was used for mutation detection with primers flanking each exon of the ABC1 gene, and for sequencing of the entire coding region of the gene. PCR and restriction-fragment length polymorphism assays specific to each mutation were used to investigate segregation of the mutation in each family, and to test for absence of the mutation in DNA from normal controls.

FINDINGS

A different mutation was detected in ABC1 in each family studied. Each mutation either created a stop codon predicted to result in truncation of CERP, or altered a conserved aminoacid residue. Each mutation segregated with low concentrations of HDL-cholesterol in the family, and was not observed in more than 500 control chromosomes tested.

INTERPRETATION

These data show that mutations in ABC1 are the major cause of familial HDL deficiency associated with defective cholesterol efflux, and that CERP has an essential role in the formation of HDL. Our findings highlight the potential of modulation of ABC1 as a new route for increasing HDL concentrations.

Mutations in ABC1 in Tangier disease and familial high-density lipoprotein deficiency

Genes have a major role in the control of high-density lipoprotein (HDL) cholesterol (HDL-C) levels. Here we have identified two Tangier disease (TD) families, confirmed 9q31 linkage and refined the disease locus to a limited genomic region containing the gene encoding the ATP-binding cassette transporter (ABC1). Familial HDL deficiency (FHA) is a more frequent cause of low HDL levels. On the basis of independent linkage and meiotic recombinants, we localized the FHA locus to the same genomic region as the TD locus. Mutations in ABC1 were detected in both TD and FHA, indicating that TD and FHA are allelic. This indicates that the protein encoded by ABC1 is a key gatekeeper influencing intracellular cholesterol transport, hence we have named it cholesterol efflux regulatory protein (CERP).

Comparison of hysterosalpingography and laparoscopy in predicting fertility outcome

In this study, we compare the prognostic significance of hysterosalpingography (HSG) and laparoscopy for fertility outcome. In a prospective cohort study in 11 clinics participating in the Canadian Infertility Treatment Evaluation Study (CITES), consecutive couples who registered between 1 April 1984 and 31 March 1987 for the evaluation of subfertility and who underwent HSG and laparoscopy were included. Unilateral and bilateral tubal occlusion at HSG and laparoscopy were related to treatment-independent pregnancy. Cox regression was used to calculate fecundity rate ratios (FRR). Of the 794 patients who were included, 114 (14%) showed one-sided tubal occlusion and 194 (24%) showed two-sided tubal occlusion on HSG. At laparoscopy, 94 (12%) showed one-sided tubal occlusion and 96 (12%) showed two-sided tubal occlusion. Occlusion detected on HSG and laparoscopy showed a moderate agreement beyond chance (weighted kappa-statistic 0.42). The adjusted FRR of one-sided tubal occlusion at HSG was 0.80, whereas two-sided tubal occlusion showed an FRR of 0.49. For laparoscopy, the FRR were 0.51 and 0.15 respectively. After a normal or one-sided occluded HSG, laparoscopy showed two-sided occlusion in 5% of the patients, and fertility prospects in these patients were virtually zero. If two-sided tubal occlusion was detected on HSG but not during laparoscopy, fertility prospects were slightly impaired. Fertility prospects after a two-sided occluded HSG were strongly impaired in cases where laparoscopy showed one-sided and two-sided occlusion, with FRR of 0.38 and 0.19 respectively. Although laparoscopy performed better than HSG as a predictor of future fertility, it should not be considered as the perfect test in the diagnosis of tubal pathology. For clinical practice, laparoscopy can be delayed after normal HSG for at least 10 months, since the probability that laparoscopy will show tubal occlusion after a normal HSG is very low.

Canadian semen quality: an analysis of sperm density among eleven academic fertility centers

OBJECTIVE

To determine whether sperm quality has declined among Canadian men during the past 13 years and whether there are regional differences in sperm quality.

DESIGN

Retrospective temporal series of cross-sectional studies.

SETTING

University fertility centers across Canada.

PATIENT(S)

Men being investigated as part of the normal infertility work-up.

MAIN OUTCOME MEASURE(S)

Sperm concentrations among all the samples were compared on an annual basis to assess any changes over 13 years from 1984 through 1996.

RESULT(S)

There were regional differences and trends in both up and down directions. Linear regression analysis of the means of each center for each year showed no significant trend. However, when all the samples were analyzed by regression analysis there was a significant downward trend.

CONCLUSION(S)

Linear regression analysis showed a significant downward trend in sperm concentration among 48,968 samples from Canadian men obtained from 1984 through 1996. A significant difference was seen in the mean concentrations between centers, ranging from 48.6 to 104.5 X 10(6)/mL. Secular trends in sperm density are dependent on the statistical method used for analysis.

A randomized controlled trial of three low-dose gonadotrophin protocols for unexplained infertility

This randomized controlled trial assessed which of three low-intensity ovulation induction protocols was associated with the highest rate of cycle completion among infertile women undergoing intrauterine insemination (IUI) with their husband's spermatozoa. Sixty-three women aged < or = 42 years with normospermic partners participated in the study. The primary diagnosis of infertility was unexplained in 89% of subjects, endometriosis in 6% and tubal factor in 5%. Women were assigned to three groups according to recombinant FSH dosage: group A received two ampoules (75 IU FSH per ampoule) on cycle day 4, and one ampoule on days 6 and 8 (total four ampoules); group B received two ampoules on days 4, 6 and 8 (total six ampoules); group C received two ampoules on days 4, 6, 8 and 10 (total eight ampoules). Daily ultrasound investigations began on cycle day 9-12 and human chorionic gonadotrophin (HCG) 5000 IU was administered when one or two follicles > or = 18 mm were seen. IUI was scheduled for the next day. HCG was given and/or ovulation shown to have occurred in 88 of 109 cycles attempted (81%) with no differences among the three dose groups. Two singleton pregnancies occurred (2.3% per ovulatory cycle and 1.8% per cycle start). There were no significant differences among the three regimes in terms of cycle parameters, suggesting that an individualized and more intensive approach to ovarian stimulation is necessary for many women with unexplained infertility.

Failure of chest X-rays to diagnose pneumothoraces after blunt trauma

We report four cases of occult pneumothorax in patients who had suffered blunt trauma. In each case supine chest X-rays failed to diagnose an anterior pneumothorax. Subsequent spiral computerised tomography scans of the chest showed anterior pneumothoraces in all cases. In two of the cases anterior pneumothoraces were present in spite of a chest drain having been placed in the pleural cavity. We recommend the insertion of anteriorly positioned chest drains to relieve pneumothoraces in severely injured trauma patients.

Clinical research evidence and clinical practice

An informal survey among colleagues turns up the far-from surprising information that the average patient contact involves at least three or four judgements and decisions: judgements about aetiology and prognosis, decisions about diagnosis and therapy, and sometimes discussions about costs and side-effects. And so it goes: 20 patients a day, 60 decisions; 100 patients a week, 300 decisions. Who makes these decisions, the doctor or the patient? What factors govern the final choice in each case? Evidence-based medicine (EBM) is the factor getting a lot of attention these days, but clinical decisions depend on many different elements. Good doctors have always made use of experience and judgement as well as the best available evidence.

The spontaneous pregnancy prognosis in untreated subfertile couples: the Walcheren primary care study

The spontaneous pregnancy prognosis of couples in a primary care situation has never been studied. Prognostic models have been developed for referral populations only. We wished to develop a prognostic model to estimate the likelihood of live birth and the impact of prognostic factors among untreated subfertile couples in a primary care situation. With this aim, we conducted a cohort follow-up study of 726 couples in the peninsula of Walcheren, a geographically isolated, but demographically and socio-economically representative area of an industrialized Western society, The Netherlands. Of the Walcheren population, 9.9% exhibit subfertility complaints at least once during their lifetime. There were 201 live birth conceptions during 9915 months of untreated observation. The cumulative rate of conceptions leading to live births was 52.5% when all of the untreated observations were considered, and 72.0% in the subgroup of 342 couples who remained untreated throughout their follow-up. The relevant prognostic factors in this primary care subfertility population were: abnormal post-coital test, tubal defect, ovulation defect, and duration of subfertility. A prediction score based on these factors would be accurate in approximately 76-79% of cases. Live birth prognosis can be estimated with sufficient accuracy to be useful in counselling subfertility patients, and in planning clinical management.

Major DNA fragmentation is a late event in apoptosis

Apoptosis, the terminal morphological and biochemical events of programmed cell death, is characterized by specific changes in cell surface and nuclear morphology. In addition, DNA fragmentation in an internucleosomal pattern is detectable in mass cultures of apoptotic cells. However, DNA fragmentation and nuclear morphological changes may not necessarily be associated events. In this study, we examined OVCAR-3 and KB human carcinoma cells using time-lapse video phase-contrast microscopy to characterize the surface and nuclear morphological features of apoptosis in response to treatment with either taxol or ricin. The surface morphological features of apoptosis were the same in both cell types and with both drugs. Using an in situ nick-translation histochemical assay, these single cells were also examined for DNA strand breaks during apoptosis. Surface morphological changes demonstrated discrete stages of cell rounding, surface blebbing, followed by cessation of movement and the extension of thin surface microspikes, followed much later by surface blistering and cell lysis. Nuclear features examined by DAPI cytochemistry demonstrated apoptotic nuclear condensation very early in this sequence, usually at the time of initial surface blebbing. The nick-translation assay, however, demonstrated DNA strand breaks at a much later time, only after the formation of separated apoptotic bodies or after final cell lysis. This study points out the differences between surface and nuclear morphological changes in apoptosis, and the large temporal separation between nuclear morphological changes and major DNA fragmentation detectable by this in situ technique. This result suggests caution in using in situ nick-translation as a direct correlate of internucleosomal DNA fragmentation in apoptosis.