Embryo morphology, developmental rates, and maternal age are correlated with chromosome abnormalities

OBJECTIVE

To determine some of the unresolved questions related to chromosome anomalies in early human embryos, such are the detection of any advanced maternal age effect; the complete assessment of mosaicism, which requires analysis of all cells; and the relationship with embryonic dysmorphism. Fluorescence in situ hybridization has been used in this study to answer these issues.

DESIGN

Fluorescence in situ hybridization analysis of human embryos using simultaneously probes for three or five chromosomes. Five hundred twenty-four cleavage-stage human embryos obtained by IVF were analyzed by fluorescence in situ hybridization. Embryos were allocated into three groups according to morphological and developmental characteristics (arrested; slow and/or fragmented; morphologically and developmentally normal). The embryos also were analyzed according to maternal age.

RESULTS

Dysmorphic embryos had higher rates of polyploidy and diploid mosaicism. Aneuploidy increased with maternal age in nonarrested embryos. Preimplantation genetic diagnosis successfully detected these abnormalities.

CONCLUSION

This study demonstrates that, in morphologically and developmentally normal human embryos, cleavage-stage aneuploidy significantly increases with maternal age. The results suggest that implantation failure in older women largely could be due to aneuploidy.

Micropuncture retrieval of epididymal sperm with in vitro fertilization: importance of in vitro micromanipulation techniques

OBJECTIVES

To evaluate the importance of in vitro micromanipulation techniques, specifically intracytoplasmic sperm injection (ICSI), for the fertility treatment of men with congenital absence of the vas deferens (CAV) or other unreconstructable male reproductive tract obstruction.

METHODS

Results using ICSI during in vitro fertilization (IVF) were compared to previously published results of IVF alone and IVF with other micromanipulation techniques at the same infertility center. Main outcome parameters evaluated were: fertilization rate per oocyte, clinical pregnancy rate, and ongoing pregnancies and deliveries.

RESULTS

IVF with ICSI yielded a fertilization rate per oocyte of 140 of 312 (45%) and a clinical pregnancy rate of 14 of 27 (52%) per cycle of sperm and egg retrieval. Ongoing pregnancies or deliveries have occurred for 13 of 27 (48%) cycles with ICSI. These results were better than our previously published results of IVF alone or in conjunction with the micromanipulation techniques of subzonal insertion (SuZI) or partial zona dissection (PZD) that yielded a 119 of 631 (19%; P < 0.0001) fertilization rate, clinical pregnancy rate of 14 of 51 (27%; P < 0.001) and ongoing pregnancy or delivery for 12 of 51 cycles (24%; P < 0.001).

CONCLUSIONS

Epididymal sperm retrieval should be performed only when micromanipulation is available in conjunction with IVF to maximize chances of fertilization and subsequent pregnancies. The use of ICSI for epididymal sperm appears to maximize chances of pregnancy for couples with surgically unreconstructable obstructive male infertility.

Cystic fibrosis gene mutations do not affect sperm function during in vitro fertilization with micromanipulation for men with bilateral congenital absence of vas deferens

OBJECTIVE

To assess the effects of cystic fibrosis transmembrane-conductance regulator (CFTR) gene mutations on sperm function and fertility in men with bilateral congenital absence of the vas deferens.

DESIGN

Prospective.

SETTING

Division of urologic microsurgery and associated hospital-based IVF unit.

MAIN OUTCOME MEASURES

Fertilization and pregnancy rates.

PATIENTS

Men referred to our fertility unit for treatment of bilateral congenital absence of the vas deferens, using sperm surgically retrieved from the epididymis with IVF and micromanipulation.

RESULTS

Of 45 men with bilateral congenital absence of the vas, 54% (19/35) tested were found to be carriers of CFTR gene mutations, with one compound heterozygote. Epididymal sperm from men affected with CFTR mutations fertilized 19% (29/152) of oocytes, whereas men without mutations fertilized 22% (44/204) of oocytes. Pregnancy rates (PRs) were 36% (5/14) for cycles involving men with CFTR mutations and 33% (5/15) for other patients with congenital absence of the vas deferens but without detectable CFTR mutations.

CONCLUSIONS

The presence of detectable CFTR mutations does not affect fertilization rates or PRs for men with bilateral congenital absence of the vas deferens when IVF and micromanipulation are applied.

Endometriosis: a stage by stage analysis--the role of in vitro fertilization

OBJECTIVE

To investigate the impact of endometriosis stage on IVF.

PATIENTS

A retrospective study of 214 patients diagnosed with endometriosis who underwent 360 cycles of IVF at The New York Hospital-Cornell Medical Center. Meanwhile, 111 pure mechanical (tubal) infertility patients treated in 160 cycles at the same time were designated as the control group for comparison.

MAIN OUTCOME MEASURES

Patient's hormone and semen profiles, hormonal response and outcome to stimulation, as well as the outcome of pregnancy, abortion, and delivery rate were analyzed.

RESULTS

No differences in the pregnancy outcome between the endometriosis and control groups were noted when compared among the subgroups of pure endometriosis, endometriosis plus tubal factor, endometriosis plus others (primarily endometriosis plus male factor), and control. Comparing the outcomes in pure endometriosis cases by staging, we could not find any discrepancies in terms of pregnancy rates (PRs) according to the severity of the disease. The addition of GnRH analogur down-regulation to gonadotropin stimulation resulted in an increase in PR. A relatively high delivery rate (38.9% per cycle, 41.9% per retrieval, and 43.2% per transfer) was achieved when the pure endometriosis patients were treated with concomitant leuprolide acetate down-regulation and gonadotropin.

CONCLUSION

We have observed that pregnancy outcome in patients with endometriosis was not different than the outcome for patients with mechanical (tubal) infertility. There were no differences in PRs by stage of endometriosis.

[Indications for intracytoplasmic sperm injection: possible influence of oocyte quality on the results]

Intracytoplasmic sperm injection is theoretically the first line treatment of many forms of severe male infertility, but the prognostic factors are to be determined according to the indications. Thus the results of two clinical teams working with the same biological Unit show statistically different pregnancy rates per oocyte pick-up (15.9% versus 35.7% - p < 0.02) and per transfer (16.9% versus 34.9% - p < 0.03). They could by explained by female factors such as age and ovarian response to stimulation, which probably have influence on embryonic quality.

[Oocyte maturity and quality: value of intracytoplasmic sperm injection. Fertility of microinjected oocytes after in vitro maturation]

Many studies in IVF practice, have tried to assess the maturity and quality of oocytes prior to insemination and relate it to IVF efficiency and to the pattern of ovarian stimulation. They were based on the indirect evaluation of the aspect of the cumulus-corona-cell complex (CCC) which was rapidly shown to be poorly correlated to the oocyte nuclear and cytoplasmic maturity in stimulated cycles. For sperm microinjection procedures, oocytes need to be peeled off from any follicular cell through hyaluronidase action in order to gain an easy access to the zona pellucida and the ooplasm. If therefore becomes possible to precisely known at recovery the nuclear status of the oocyte cohort as well as the rate of degenerative gametes. Immature oocytes can be further matured in vitro. Moreover, the ICSI procedure (intracytoplasmic sperm injection) allows a direct assessment of the cytoplasmic maturation, whatever the maturity of the ZP and its receptors and of the plasma membrane. On a preliminary evaluation of 70 ICSI cycles performed in our collaborative group from september to november 1994 and leading to a 24 % pregnancy rate per oocyte pick-up we focused on the true maturation of the oocyte cohort, its outcome and correlation with ICSI efficiency and stimulation protocol. On the 760 oocytes, 13.9% were atretic, 9% at the germinal vesicle stage (GV), 3.4% in metaphase 1 and 73.7% in metaphase 2 at recovery.(ABSTRACT TRUNCATED AT 250 WORDS)

Formation of male pronuclei in partitioned human oocytes

Ninety-five metaphase II human oocytes, aged in vitro for either one day or for two days, and five fresh immature oocytes with no visible germinal vesicle nucleus were partitioned into small cytoplasts after removal of the zona pellucida and exposure to cytochalasin B. Seventy-one metaphase II and four immature oocytes were used as intact zona-free controls. The cytoplasts derived from each partitioned oocyte and all the zona-free whole oocytes were exposed to normal or subfertile donor sperm and later assessed for signs of male pronucleus development. A total of 711 fragments (an average of 8 fragments per partitioned egg) with a mean diameter of about 50 microns were produced from the 100 partitioned oocytes. When exposed to normal sperm, 76% of the 1-day-old metaphase II fragments, 67% of the 2-day-old metaphase II fragments, and 83% of the immature oocyte fragments were fertilized. The mean number of decondensing nuclei per partitioned oocyte was 11.9 for the 1-day-old metaphase II oocytes, 6.4 for the 2-day-old metaphase II oocytes, and 13 for the immature oocytes. The mean number of decondensing nuclei per a whole zona-free oocyte was 5.6 for the 1-day-old metaphase II oocytes (p < 0.05), 6.7 for the 2-day-old metaphase II oocytes (NS), and 13 for the immature oocytes. When exposed to subfertile sperm, 54% of the 1-day-old metaphase II fragments and 28% of the 2-day-old metaphase II fragments were fertilized.(ABSTRACT TRUNCATED AT 250 WORDS)

The culture of credit

Scientific ideals call for collaboration and sharing. But in today's competitive scientific enterprise, a tremendous premium is placed on individual credit, setting the stage for conflict.

[The use of amphotericin B in a general hospital]

BACKGROUND

Amphotericin B (AmB) remains the standard treatment for most systemic mycosis. In addition to the ordinary deoxycholate formulation (AmB-DC), liposomal AmB (AmB-LP) is available in the United Kingdom. The aim of this study was to determine the patterns of usage of AmB in the present situation.

METHODS

A 3 month prospective audit (August-October 1992) and a 3 year retrospective analysis of usage and expenditure in a United Kingdom University Hospital were carried out.

RESULTS

A total of 42 courses and 564 days of treatment with AmB were analysed during the prospective audit. The total cost of AmB was 38,000 pounds (roughly 7,600,000 pesetas). AmB-LP accounted for 92% of the expenditure on AmB and 72% of the total expenditure on antifungals during the survey period. In 60% of the courses AmB was given as an empiric treatment. Only 65% of the days of treatment with AmB-LP were used according to the institution guidelines. The estimated cost of the days of treatment with AmB-LP that did not follow the institution guidelines was 9,500 pounds (roughly 1,800,000 pesetas). The retrospective analysis revealed a striking increase in the expenditure on AmB since the release of AmB-LP. There was an steady growth in the usage of both AmB-DC and AmB-LP over the 3 year period analysed.

CONCLUSIONS

AmB is being increasingly used, mainly as an empiric treatment. The release of AmB-LP has had a great impact on the AmB budget. The current prescriptions habits of AmB-LP could be improved. To ensure an appropriate usage a direct control of AmB-LP might be advisable.

[Milk feeding of infants and cow's milk protein hypersensitivity]

BACKGROUND

Cow milk protein intolerance (CMPI) is characterized by a wide range of symptoms and signs affecting the gastro-intestinal tract, the respiratory system and the skin. A better definition, a stricter application of diagnostic criteria and critical evaluation of certain immunologic correlates can contribute to a better understanding and preventive treatment of this entity.

POPULATION AND METHODS

Two hundred-seventeen infants with CMPI seen between January 1980 and December 1993 were included in the study. They were classified into two groups: 1) acute reaginic CMPI (type I): 125 infants and 2) CMP enteropathy or colitis (type III or IV): 92 infants, according to classical diagnostic criteria. Careful investigation concerning the type of milk feeding (breast or artificial) proposed prior to clinical manifestations was performed.

RESULTS

Among the 125 infants (aged 3 to 20 weeks) with acute reaginic CMPI, 121 (97%) had been breast-fed with a sudden weaning; 30 of these infants had also received one to three formula bottles during the first 3 days of life and 14 certainly had not received such formula bottles. Among the 92 infants with CMPI, type III or IV, 33 (38%) had been exclusively breast-fed, a figure quite similar to the breast feeding incidence in our region.

CONCLUSIONS

These results clearly show the importance of breast-feeding in the personal history of CMPI. Acute reaginic type of CMPI is favored by early ingestion of formula bottles in breast-fed infants and by early sudden weaning. Hypoallergenic formula in five cases was unable to protect infants against further allergic manifestation.

Viridans streptococcal bacteraemia: a clinical survey

The occurrence of viridans streptococcal bacteraemia (VSB) in a London postgraduate teaching hospital was analysed retrospectively. Over a 30-month period, 39 patients with VSB were identified, and the clinical significance of VSB was assessed for each, based upon clinical and laboratory information. Endocarditis accounted for only 13% of the total patients with apparent VSB. A greater proportion of patients with VSB originated from the haematology unit (21%) and in particular, the bone-marrow transplantation unit (15%). VSB also occurred in patients with solid epithelial malignancies and in children aged < 12 months. Mortality associated with VSB was 7%. Viridans streptococci are emerging as important pathogens in previously unrecognized clinical settings, particularly hospitalized, immunocompromised patients.

Induction of Plasmodium falciparum sporozoite-neutralizing antibodies upon vaccination with recombinant Pfs16 vaccinia virus and/or recombinant Pfs16 protein produced in yeast

Pfs16 is a sexual stage/sporozoite-specific antigen of Plasmodium falciparum and is a potential candidate for a sporozoite-neutralizing vaccine. To obtain more information on the function of Pfs16 and to investigate its role during transmission and hepatocyte invasion, immunization experiments were performed with both a Pfs16-specific recombinant vaccinia virus and virus-like particles produced in yeast composed of the hepatitis B surface antigen (HBsAg) and antigen Pfs16 fused to HBsAg. Upon transformation of yeast cells, harbouring a genomic copy of the HBsAg gene, with a plasmid carrying the fusion gene Pfs16-HBsAg (Pfs16-S) virus-like hybrid particles composed of HBsAg and Pfs16-S were formed of a size similar to those present in human sera after infection with the hepatitis B virus. Cells infected with recombinant Pfs16 vaccinia virus synthesized a polypeptide of approx. 16 kDa that reacted with a Pfs16-specific polyclonal antibody. Animals vaccinated with the yeast hybrid particles and/or recombinant vaccinia virus both produced Pfs16-specific antibodies. These antibodies showed no transmission-blocking activity, but they efficiently diminished or abolished in vitro invasion of sporozoites into human hepatoma cells (HepG2-A16) and primary human hepatocytes.

The effects of antireflux therapy on pulmonary function in patients with severe gastroesophageal reflux disease. Department of Veterans Affairs Gastroesophageal Reflux Disease Study Group

OBJECTIVES

Gastroesophageal reflux can induce bronchospasm, and antireflux therapy has been shown to improve pulmonary function in patients who have gastroesophageal reflux disease (GERD) associated with asthma. Our objective was to study the pulmonary effects of antireflux therapy in patients who had severe GERD without clinically apparent lung disease.

METHODS

In a Department of Veterans Affairs Cooperative Study, patients who had complicated GERD without important lung disease were randomly assigned to receive one of three types of antireflux treatment, including two kinds of medical therapy and a surgical therapy. Patients had pulmonary function tests (PFTs), including total lung capacity, residual volume, forced vital capacity, forced expiratory volume in 1 s, maximal midexpiratory flow, and diffusing capacity for carbon monoxide.

RESULTS

Two hundred forty-seven patients (243 men, four women; mean age 58 yr) entered the randomized trial, and 151 returned for PFTs at 1 yr. For the entire study group and for all three treatment groups, mean values for PFTs at 1 yr did not differ significantly from those at baseline. Even in subgroups of patients whose baseline PFTs were abnormal and whose esophagitis had healed completely, there were no significant changes in results of PFTs.

CONCLUSIONS

For veteran patients with severe GERD and no obvious lung disease, 1 yr of antireflux therapy had no important effect on pulmonary function. These findings suggest that GERD is not commonly associated with inapparent, reversible pulmonary dysfunction.

Enhancement of fertilization by micromanipulation

Micromanipulation techniques have been successfully applied to human gametes to assist fertilization when normal function is impaired. The past few years have witnessed the rapid evolution and clinical incorporation of this technology. The unprecedented efficiency of intracytoplasmic sperm injection far surpasses all previous methods. This method has thus become the best treatment option for many forms of male infertility.