Effect of coasting on the implantation potential of embryos transferred after cryopreservation and thawing

OBJECTIVE

To examine the effect of withholding gonadotropins on the outcome of embryos after cryopreservation and thawing.

DESIGN

Retrospective clinical evaluation of patients having cryopreserved-thawed ET trials with coasting during the corresponding ovarian stimulation cycle.

SETTING

Academic tertiary clinical care unit.

PATIENT(S)

Patients with cryopreserved embryos having coasting in their fresh IVF cycle and age-matched controls without coasting, both groups receiving the same stimulation protocol (long GnRH agonist plus recombinant FSH).

INTERVENTION(S)

All patients had a cycle in which embryos were transferred fresh and a cycle of thawing of cryopreserved embryos with the aim of transferring in a steroid-supplemented cycle.

MAIN OUTCOME MEASURE(S)

Embryo survival, implantation, and clinical pregnancy rates.

RESULT(S)

Post-thawing embryo survival (66.4% vs. 73%), implantation (12.3% vs. 13.0%), and clinical pregnancy rates (31.5% vs. 38.0%) were similar in study and control groups, respectively. Patients with coasting for > or =3 days had significantly lower post-thawing embryo survival rates compared with patients having shorter duration of coasting (<3 days) and controls. Implantation and pregnancy rates, however, were similar in the three groups.

CONCLUSION(S)

Coasting did not seem to have a detrimental effect on oocyte and embryo quality because the implantation competence of transferred concept after cryopreservation and thawing was similar to that of controls. However, prolonged coasting (> or =3 days) had a subtle negative impact on the post-thaw survival rate.

Controlled ovarian hyperstimulation protocols for in vitro fertilization: two decades of experience after the birth of Elizabeth Carr

OBJECTIVE

To critically discuss the current protocols for the management of controlled ovarian hyperstimulation in assisted reproduction technology.

DESIGN

Review of the literature and presentation of our experience.

MAIN OUTCOME MEASURE(S)

Ovarian response (peak serum estrogen levels, number of oocytes retrieved, quality of oocytes and embryos) and pregnancy outcome (clinical, delivery, and multiple pregnancy rates).

RESULT(S)

Controversies still exist regarding selection of gonadotropin preparation, choice of adjuvant therapy with GnRH analogues, and use of oral contraceptive pills. Patients identified as intermediate responders have an excellent outcome with adjuvant therapy with either a GnRH agonist (long protocol) or a GnRH antagonist, but tailoring of gonadotropin dose must be performed to achieve optimized results. High responders perform favorably with gentler gonadotropin stimulation that minimizes the occurrence of ovarian hyperstimulation syndrome. On the other hand, results in low responders remain suboptimal both in terms of ovarian response and oocyte/embryo quality in spite of a variety of stimulation regimens used.

CONCLUSION(S)

Ovarian stimulation is a critical step in in vitro fertilization therapy. A variety of controlled ovarian hyperstimulation regimens are available and efficacious, but individualization of management is essential and depends on assessment of the ovarian reserve. Identification of the etiologies of poor ovarian response constitutes a formidable challenge facing reproductive endocrinologists.

Pseudomyxoma peritonei: a rare differential diagnosis of hydrosalpinx

OBJECTIVE

To establish the diagnosis of a right hydrosalpinx in a woman with primary infertility.

DESIGN

Case report.

SETTING

Departments of Obstetrics and Gynecology and Surgery, academic medical center and teaching hospital.

PATIENT(S)

A healthy 41-year-old woman with a history of primary infertility and a possible right hydrosalpinx.

INTERVENTION(S)

Operative laparoscopy, disconnection of right hydrosalpinx, peritoneal biopsies.

MAIN OUTCOME MEASURE(S)

Establishment of diagnosis with peritoneal biopsies.

RESULT(S)

The patient was diagnosed with peritoneal pseudomyxoma peritonei, which required further treatment.

CONCLUSION(S)

Malignancies, although rare, should always be part of the differential diagnosis of external causes of tubal disease.

In search of candidate genes critically expressed in the human endometrium during the window of implantation

BACKGROUND

In this prospective randomized blinded clinical trial, we examined gene expression profiles of the human endometrium during the early and mid-luteal phases of the natural cycle.

METHODS

An endometrial biopsy was performed on day 16 (LH +3) or on day 21 (LH +8), followed by RNA extraction and microarray analysis using an Affymetrix HG-U95A microchip. Data analysis was carried out using pairwise multiple group comparison with the significance analysis of microarrays (SAM) software.

RESULTS

With a false discovery rate of 0, the analysis revealed that 107 genes were significantly and differently expressed (> or =2-fold) during the early versus the mid-luteal phase of the cycle. Forty-five of these genes have not been previously linked to endometrial receptivity. Validation of the microarray data was accomplished using semiquantitative RT-PCR. We demonstrated the presence of estrogen and progesterone response elements (ERE and PRE) by analysis of the 5'-flanking regions of a subset of differentially regulated genes.

CONCLUSIONS

Using a strict bioinformatics approach of microarray data, we demonstrated significant changes in candidate genes during the transition of the early to the mid-luteal phase of the human endometrium that may have functional significance for the opening and maintenance of the window of implantation.

A synthetic decapeptide from a conserved ZP3 protein domain induces the G protein-regulated acrosome reaction in bovine spermatozoa

In some animal species, the zona pellucida protein 3 (ZP3) plays a central role during fertilization, functioning as a specific receptor for sperm and as an inducer of the acrosome reaction. On the other hand, the zona pellucida protein 2 (ZP2) acts as a secondary receptor, binding to acrosome-reacted sperm. The objective of these studies was to identify ZP2 and ZP3 domains that may be of importance for the induction of the acrosome reaction. For this purpose, we synthesized a number of ZP2 and ZP3 peptides that were either conserved among species or that were species-specific according to their respective primary structures. We identified a defined, conserved ZP3 decapeptide (ZP3-6 peptide) that bound to the surface of the acrosomal region and induced the acrosome reaction in a concentration-dependent manner in capacitated bovine sperm; this effect was significant in the nanomolar range. Pertussis toxin inhibited the ZP3-6 peptide-induced acrosome reaction but had no effect on the progesterone-induced exocytotic event. Our data are in accordance with previous studies showing that progesterone induces acrosomal exocytosis via a different pathway than ZP3 and strengthen the hypothesis that the effect of ZP3-6 peptide upon acrosomal exocytosis is G protein regulated. Despite the commonly accepted idea that glycosylation of ZP proteins is required for successful sperm-oocyte interaction, we found that acrosomal exocytosis can be induced by a synthetic ZP3 peptide that is not glycosylated. The results presented in this study may be useful for the investigation of the molecular mechanisms of sperm-egg interaction in bovine and other species.

Follicular phase serum levels of luteinizing hormone do not influence delivery rates in in vitro fertilization cycles down-regulated with a gonadotropin-releasing hormone agonist and stimulated with recombinant follicle-stimulating hormone

OBJECTIVE

To assess the value of serum LH measurements in early and late follicular phase as predictors of ovarian response and IVF outcome in patients treated with recombinant FSH with GnRH agonist (GnRH-a) pituitary down-regulation.

DESIGN

Retrospective cohort analysis.

SETTING

Institutional.

PATIENT(S)

Women undergoing 157 consecutive IVF cycles suppressed with leuprolide acetate (LA) started in the midluteal phase and stimulated with recombinant FSH. Only women <40 years of age and with a basal cycle day 3 serum FSH </=9 IU/L were included.

INTERVENTION(S)

Serum LH levels were measured on cycle days 3 (D3) and 10 (D10).

MAIN OUTCOME MEASURE(S)

Delivery rates. Other secondary outcome measures included fertilization rate, clinical pregnancy rate, and parameters of ovarian response (peak E(2), number of metaphase II oocytes, and number of ampules of recombinant FSH).

RESULTS

No significant differences were found with respect to ovarian response, fertilization rate, and outcome of pregnancy, when three threshold values of D3 and D10 serum LH (1, 1.5, and 2 mIU/mL) were analyzed. In addition, no significant differences were found between conception (n = 87) and no conception (n = 71) groups with respect to D3 or D10 LH. Receiver operator characteristic (ROC) analysis showed that neither the serum LH concentration on D3 nor on D10 was able to discriminate between conception and nonconception cycles (area under the curve [AUC](ROC)= 0.54, AUC(ROC)= 0.56), or between delivered pregnancies and first trimester pregnancy loss (AUC(ROC)= 0.53, AUC(ROC) = 0.61).

CONCLUSIONS

The suppressed levels of early and late follicular serum LH in women <40 years of age with normal ovarian function desensitized with a GnRH-a and treated with recombinant FSH are not predictive of ovarian response, pregnancy, or delivery. These data do not support the use of exogenous LH supplementation in this clinical scenario.

Management of Infertility in Women with Polycystic Ovary Syndrome

The management of infertility in women with polycystic ovary syndrome (PCOS) centers around options for inducing ovulation. This is an evidence-based review of the management of PCOS, which includes a MEDLINE search of publications between 1986 and May 2005 and a search of the Cochrane Database. Weight loss, exercise, and metformin will induce ovulation in many insulin-resistant women and obese women with PCOS, and should always be the first-line treatment. Ovulation induction has been performed with clomiphene citrate (clomifene) as the first-line treatment, but the use of aromatase inhibitors has been shown to be as successful. The strategies for reducing the risks of gonadotropin therapy such as low-dose follicle-stimulating hormone (FSH) stimulation and the addition of metformin are discussed. Both gonadotropin releasing-hormone agonists and antagonists are equally effective in in vitro fertilization stimulation in conjunction with FSH therapy. Metformin may have a benefit in pregnancy in reducing the risks of miscarriage and diabetes mellitus; however, prospective trials are still lacking.

Gene expression profiles and structural/functional features of the peri-implantation endometrium in natural and gonadotropin-stimulated cycles

It has been speculated that controlled ovarian hyperstimulation (COH), as performed during in vitro fertilization therapy, may negatively affect embryo implantation. The objective of this prospective and randomized study was to investigate gene expression profiles of the human endometrium during the window of implantation of gonadotropin-stimulated COH cycles compared with temporally matched natural cycles (d 21). Analysis was performed with high-density oligonucleotide microarrays. In addition, other structural and functional features of the endometrium were investigated. Results corroborated that COH cycles depicted advancement of pinopodes appearance, histological features, and steroid receptor down-regulation when compared with natural cycles. These changes were associated with significant, albeit small, variations in gene expression (18 genes/expressed sequence tags and -1.55- to +3.40-fold changes). Second, there were significant changes in gene expression when comparing cycles using a GnRH agonist vs. a GnRH antagonist (13 genes/expressed sequence tags and +1.42- to +2.10-fold changes). This is the first attempt to elucidate gene expression profiles of the endometrium during COH cycles. The observed differences in gene expression in COH cycles using state-of-the-art protocols may not have a major functional impact on embryo implantation.

Somatic cell apoptosis markers and pathways in human ejaculated sperm: potential utility as indicators of sperm quality

In this study we extended earlier work to determine whether sperm respond to somatic cell apoptotic stimuli and whether apoptotic phenotypes are significant indicators of human sperm quality. We evaluated ejaculated sperm from fertile donors and subfertile patients following purification of fractions of high and low motility. In unstimulated conditions, caspase enzymatic activity was higher in motile fractions from subfertile patients than in donors, and was higher in low motility fractions from both groups. Staurosporine, but not a Fas ligand or H2O2, significantly increased caspase activity, but only in high motility fractions. Procaspase-3, -7 and -9 and low levels of active caspase-3, -7 and -9 were identified by immunoblot analysis. Apoptosis-inducing factor (AIF) was present in all samples but poly ADP-ribose polymerase-1 (PARP-1) was not detected. Phosphatidylserine translocation was significantly increased only with H2O2 treatment. In ejaculates of both subfertile and fertile men, we demonstrated the presence and activation of several proteins that are key constituents of apoptosis-related pathways in somatic cells, which may serve as markers for sperm quality.

Results of in vitro fertilization in patients with endometriomas: is surgical removal beneficial?

OBJECTIVE

The purpose of this study was to investigate the effect of endometriomas on clinical pregnancy rates of in vitro fertilization-embryo transfer.

STUDY DESIGN

Infertile patients with endometriosis who underwent in vitro fertilization-embryo transfer were divided into group 1 patients who had a history of ovarian endometriomas and group 2 patients who did not. The patients in group 1 were further divided into group 1A who had their endometriomas removed by laparoscopic ovarian cystectomy before the start of in vitro fertilization-embryo transfer and group 1B who underwent in vitro fertilization-embryo transfer with the presence of endometriomas. The clinical pregnancy rates of these groups were compared.

RESULTS

Clinical pregnancy rates per transfer were similar in group 1 and group 2 (40% vs 47%; P =.38) and similar in patients in group 1A and group 1B (47% vs 34%; P =.28), although the direction was toward improved pregnancy rates in the groups of patients without endometriomas present at the time of in vitro fertilization stimulation. When patients >39 years of age were excluded, the overall pregnancy rate was higher in those patients who had no current endometriomas than in those patients who had endometriomas present at the time of stimulation (65% vs 39%; P =.05). For patients with unilateral endometriomas, similar numbers of mature oocytes were aspirated between the affected and unaffected ovaries.

CONCLUSION

Although the history of endometriomas does not appear to affect in vitro fertilization-embryo transfer outcomes adversely, there may be a benefit in the removal of endometriomas before in vitro fertilization.

Presence and significance of somatic cell apoptosis markers in human ejaculated spermatozoa

Ejaculated spermatozoa, particularly in infertile men, have been shown to display morphological and biochemical features that are typical of an apoptotic phenotype in somatic cells. Deregulation of apoptosis is known to play roles in a number of disease processes, but roles for apoptosis in ejaculated spermatozoa and male infertility are poorly defined or have not been studied. Preliminary data demonstrated that populations of ejaculated spermatozoa express: (i) various degrees of plasma membrane translocation of phosphatidylserine and DNA fragmentation; and (ii) active caspase-3, the main executor of apoptosis in somatic cells, with an apparent exclusive cellular location to the mid-piece. Tests are currently being carried out on the effects of well-known apoptosis agonists and caspase inhibitors on such markers using purified populations of leukocyte-free ejaculated human spermatozoa. The main objective is to determine if somatic cell apoptosis markers are relevant indicators and/or causative factors of male infertility.

Estrogen down-regulates GnRH gene expression in human placental cytotrophoblast cells

This study aims at investigating and characterizing GnRH gene expression and regulation in human placental cytotrophoblasts by estradiol. RT-PCR analysis demonstrates that the cytotrophoblasts expressed the pro-GnRH gene. PCR with two pairs of oligonucleotide primers generated doublets 870 bases apart at the expected molecular weights, indicating that the upstream and downstream transcriptional start sites of the GnRH gene were utilized and that transcripts with and without intron I were both produced. In human placental cytotrophoblasts, the upstream transcription start site of GnRH gene was the major one and gave rise to an mRNA level three times higher than the downstream start site. RT-PCR assay also revealed that estradiol downregulated the expression of GnRH gene in human cytotrophoblasts. Estradiol at the concentration of 10nM led to a significant (50%) reduction in the mRNA from the upstream transcription start site. Such downregulation was dose-dependent and abolished by the addition of an estrogen antagonist, ICI, indicating that the gene expression was mediated by estrogen receptors. Furthermore, downregulation of GnRH gene expression by estradiol has also been confirmed by luciferase assay.

Localization and functional importance of a conserved zona pellucida 2 protein domain in the human and bovine ovary using monoclonal anti-ZP2 peptide antibodies

In mammals, gamete recognition and sperm binding to the oocyte are mediated by the zona pellucida (ZP), an acellular coat surrounding the plasma membrane of the oocyte that consists of particular ZP proteins. The ZP2 protein mediates secondary sperm binding to the ZP. Its primary structures are highly conserved as revealed by cDNA cloning. In the present study, we investigated the localization of ZP2 in human and bovine ovaries and oocytes and the influence of monoclonal anti-ZP2 peptide antibodies upon bovine sperm-egg interactions. We generated a monoclonal anti-ZP2 synthetic peptide antibody, mAb ZP2-20, against a sequence that is strongly conserved in the mammalian ZP2 amino acid sequence. Specificity of mAb ZP2-20 was determined by ELISA and immunoblotting, respectively. Our results show that mAb ZP2-20 specifically detected the peptide used as an antigen and reacted with its corresponding protein antigen in human and bovine ovaries. In order to elucidate effects of mAb ZP2-20 upon bovine sperm-ZP binding, we used the competitive hemizona assay (cHZA) and found that the antibodies clearly inhibit sperm binding to the ZP. We conclude that (i). monoclonal antibodies against ZP2 peptides react with ZP proteins present in bovine and human ovaries and can be used as a specific marker for ZP2; and that (ii). mAb ZP2-20 detects a ZP2 epitope that is of functional relevance for sperm-ZP interactions.

Factors associated with an optimal pregnancy outcome in an oocyte donation program

PURPOSE

To identify donor and recipient variables that may have a significant impact on pregnancy outcome in order to optimize results of an oocyte donation program.

METHOD

Retrospective analysis through a Generalized Estimating Equation (GEE) approach to clustered and binary clustered data, linear mixed effects model, scatter plot smoothing functions, and receiving operator characteristics (ROC) curves.

SETTING

University-based center.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURES

Pregnancy and implantation rates.

PATIENTS

257 donation and transfer cycles.

RESULT(S)

Overall results were as follows: clinical pregnancy rate, 47%; implantation rate, 22%; abortion rate, 19%; and overall multiple pregnancy rate, 35%. The total reproductive potential was 60%. Implantation and pregnancy rates were not significantly related to any variable from donors or recipients. Abortion rate increased significantly with donors' increased basal serum LH. Pregnancy rate was significantly enhanced with improved embryo quality. In donors stimulated more than once, the pregnancy rate was 84%.

CONCLUSION(S)

Although no single or combined donor or recipient variable(s) could be identified as predictor(s) of pregnancy, the data suggest that donors < or = 33 years of age with basal cycle day 3 serum levels of FSH 4-8 IU/L, LH < 8 IU/L, and E2 < 70 pg/mL had an optimal outcome. Transfer of two selected embryos on day 3 yields a favorable pregnancy outcome while significantly decreasing the occurrence of multiple pregnancies. These policies, in addition to embryo cryopreservation, were associated with optimal pregnancy outcome in oocyte donation.

Impact of transabdominal ultrasound guidance on performance and outcome of transcervical uterine embryo transfer

PURPOSE

To determine the impact of transabdominal ultrasound guidance on embryo transfer during IVF therapy.

METHODS

Retrospective analysis of 823 consecutive embryo transfers. Three hundred and sixty-seven procedures performed with transabdominal ultrasound guidance were compared to 456 cases performed with the "clinical touch" method.

RESULTS

Ultrasound-guided embryo transfer yielded higher, but not statistically significant, clinical pregnancy (48% vs. 44%) and implantation rates (22% vs. 20%). The incidence of multiple pregnancies, ectopic and multiple pregnancy rates were similar. The frequency of negative factors typically associated with difficult transfers, such as requirement of use of tenaculum, and presence of blood or mucus in the catheter tip, were significantly lower in the ultrasound-guided group in comparison with the clinical touch group. Ultrasound-guided embryo transfer was associated with a significantly increased easiness of transfer performance; 95% of the transfers were rated as very easy in the ultrasound-guidance group compared to 87% in the clinical touch group. The use of a soft pass catheter was the only variable independently and significantly associated with pregnancy success (odds ratio = 2.74).

CONCLUSION(S)

Ultrasound-guidance facilitates embryo transfer and in combination with the use of a soft catheter should be implemented to optimize embryo transfer results.