HLA-matched embryos selected for siblings requiring haematopoietic stem cell transplantation: a psychological perspective

Allogeneic haematopoietic stem cell transplantation (HSCT) is a treatment for a number of acquired and congenital diseases. An important factor in the outcome of the treatment is the degree of human leukocyte antigen (HLA) compatibility between patient and donor. HLA identical siblings therefore provide the best chance for the recipient. Preimplantation genetic diagnosis (PGD) can be used to select HLA identical embryos if there is no HLA compatible sibling in the family. The Centre for Reproductive Medicine considered it morally justified to give medical assistance to couples in need of an HLA matched sibling. Two considerations played an important role in this respect: (i) the use as a donor should not be the only parents' motive for having the child and (ii) IVF and HLA typing on the embryos would be less of a burden for the parents than other alternatives. Since the first request in 2000, 12 couples have been referred for psychological counselling. The motivation of four couples will be discussed in depth. The validity of the arguments will be checked against the experience of the actual cases. The consequences of the treatment on the welfare of the future donor child will be discussed.

Profound LH suppression after GnRH antagonist administration is associated with a significantly higher ongoing pregnancy rate in IVF

BACKGROUND

The significance of suppressed LH levels in GnRH antagonist cycles for IVF outcome is currently unknown. The purpose of this study was to evaluate prospectively the association between LH levels and ongoing pregnancy achievement after GnRH antagonist initiation in IVF cycles.

METHODS

Ovarian stimulation with a fixed dose of 200 IU recombinant FSH and daily GnRH antagonist (ganirelix) 0.25 mg from day 6 of stimulation was initiated in 116 women. Patients were not pretreated with an oral contraceptive. Induction of final oocyte maturation was performed with HCG 10,000 IU as soon as three follicles of > or =17 mm were present in ultrasound, and was followed by oocyte pick-up, conventional IVF or ICSI, and embryo transfer. The luteal phase was supplemented with vaginal progesterone.

RESULTS

A significant decrease of both ongoing pregnancy rate and implantation rate was present across groups of patients with increasing LH levels. The highest implantation rate and ongoing pregnancy rate was present in those patients with LH levels on day 8 of stimulation < or =0.5 IU/l.

CONCLUSIONS

Profound suppression of LH on day 8 of stimulation is associated with a significantly higher chance of achieving an ongoing pregnancy. More studies are necessary to evaluate this phenomenon further.

Should we advise patients undergoing IVF to start a cycle leading to a day 3 or a day 5 transfer?

BACKGROUND

The aim of this study was to compare ongoing pregnancy rates per started cycle between patients randomized at consultation to have embryo transfer either on day 3 or on day 5 of in-vitro culture.

METHODS

All patients <43 years of age for whom IVF was indicated were allowed to participate in the study (day 3 group, 234 patients; day 5 group, 226 patients). Ovarian stimulation was performed either using GnRH antagonists/recombinant FSH (rFSH) (day 3, 70.1% of patients; day 5, 72.6% of patients) or using the long GnRH agonist protocol/urinary gonadotropins (day 3, 29.9% of patients; day 5 27.4% of patients).

RESULTS

The random decision to initiate a cycle leading to day 5 as compared with a day 3 transfer was associated with a significantly lower chance of embryo cryopreservation (day 3, 61.5%; day 5, 50.4%; P<0.02). Ongoing pregnancy rate per started cycle did not differ between the two groups compared [day 3, 32.1%, 95% confidence interval (CI) 26.4-38.2%; day 5, 33.2%, 95% CI 27.3-39.5%].

CONCLUSIONS

Advising patients at consultation to initiate an IVF cycle leading to a day 5 as compared with a day 3 transfer does not appear to increase the probability of ongoing pregnancy, and is associated with a significantly lower probability of obtaining cryopreserved embryos.

Elevated progesterone at initiation of stimulation is associated with a lower ongoing pregnancy rate after IVF using GnRH antagonists

BACKGROUND

The objective of this prospective study was to assess the impact of elevated serum progesterone levels on day 2 of the cycle on pregnancy rates in patients treated by IVF using GnRH antagonists.

METHODS

Ovarian stimulation was started on day 2 of the cycle if progesterone levels were normal (normal-P group, n = 390). In the presence of elevated progesterone, initiation of stimulation was postponed for 1 or 2 days (high-P group, n = 20) and was started if repeat progesterone levels returned to normal range (n = 16). Stimulation was performed with recombinant FSH (rFSH) and GnRH antagonist was always started on day 6 of stimulation.

RESULTS

A significantly higher exposure to progesterone and a significantly lower exposure to estradiol was present in the high-P as compared with the normal-P group from day 1 to day 8 of stimulation. In addition, a significantly lower ongoing pregnancy rate both per started cycle (5.0% versus 31.8%; P = 0.01) and per embryo transfer (6.3% versus 36.9%; P = 0.01) was present in the high-P compared with the normal-P group, respectively.

CONCLUSIONS

The presence of elevated serum progesterone on day 2 of the cycle is associated with a decreased chance of pregnancy in patients treated with rFSH and GnRH antagonists.

Pregnancy outcome and neonatal data of children born after ICSI using testicular sperm in obstructive and non-obstructive azoospermia

BACKGROUND

Registries on outcome of ICSI pregnancies obtained with testicular sperm do not differentiate between obstructive (OA) and non-obstructive azoospermia (NOA). We evaluated the pregnancy outcome and neonatal data on children born after ICSI using testicular sperm of men with histologically proven OA or NOA.

METHODS

Pregnancies obtained after ICSI using testicular sperm of men with defined NOA (n = 70) were compared with those of men with OA (n = 204).

RESULTS

Multiple birth rates in NOA and OA couples, respectively, were 21 versus 27% (P = NS), overall preterm delivery rates were 38 versus 26% (NS), and prematurity rates were 24 versus 13% for singletons (NS) and 86 versus 54% for twins (relative risk 1.59, 95% confidence interval 1.04-2.42). Median gestational age for singletons was 38.3 versus 39.3 weeks, respectively (P < 0.05). The low birth weight rates were 34 versus 31%, respectively (NS). The early perinatal mortality rate was 66 versus 15 per 1000 births, respectively, (NS). Major congenital malformations were observed in 4 versus 3%, respectively, of the live born babies (NS). Prenatal karyotypes showed 7% de-novo abnormalities in the NOA group versus 1% in the OA group (NS).

CONCLUSIONS

Our data do not show differences between NOA and OA pregnancies except for a strong tendency towards a lower gestational age in singletons and a higher percentage of premature twins in the NOA group. Although our data are based on a limited sample, the differences observed call for further analysis. Given the low pregnancy rates after ICSI with NOA, a multicentre study, differentiating NOA and OA patients, would be recommended.

Clomiphene citrate versus letrozole for ovarian stimulation: a pilot study

The purpose of this pilot study was to compare the endocrinological environment of cycles stimulated with clomiphene citrate (CC) or letrozole. Fifteen patients undergoing intrauterine insemination (IUI) received from day 3 to day 7 of the cycle either letrozole 2.5 mg/day (n = 7) or clomiphene citrate 100 mg/day (n = 8). IUI was performed one day after the detection of LH peak. No luteal support was administered. Significantly lower serum oestradiol concentrations were present in the follicular phase on days 9, 13 and 15 of the cycle and in the luteal phase on days 3 and 6 post-IUI in the letrozole group compared with those in the CC group. Progesterone concentrations and oestradiol concentrations were significantly lower in the letrozole group than in the CC group on the day of LH peak. Significantly more follicles developed in patients in the CC group compared with those in the letrozole group. In conclusion, significantly lower oestradiol concentrations and fewer follicles are observed in cycles stimulated with 2.5 mg letrozole compared with cycles stimulated with 100 mg CC from day 3 to day 7 of the cycle.

Comparison of lithium concentrations in red blood cells and plasma in samples collected for TDM, acute toxicity, or acute-on-chronic toxicity

BACKGROUND

Lithium salts (Li+) are still one of the most appropriate treatments in manic-depressive disorders. Since Li+ has a narrow therapeutic index, plasma levels must be closely monitored to verify maintenance pharmacotherapy, to prevent side effects, to evaluate compliance and to avoid increasing rates of relapse. Although it has been reported that Li+ concentrations in red blood cells (RBC) should be a better indicator of brain levels, therapeutic drug monitoring (TDM) of Li+ is not based on its routine assessment.

OBJECTIVE

The aim of this retrospective study was to compare Li+ concentrations in RBC and plasma and the calculated ratio (LiR= RBC/plasma concentrations) in the three groups of patients.

METHODS

During the past 3 years, 309 Li+ measures were collected corresponding to 165 patients classified into three subgroups (TDM, acute or acute-on-chronic intoxication). Li+ plasma (Cplasma) and RBC (CRBC) concentrations were determined by atomic absorption spectrophotometry.

RESULTS

Results showed that Li+ concentrations in plasma are significantly correlated to Li+ concentration in RBC (r=0.81, P<0.0001). Although a wide inter- and intra-variability was found, Cplasma, CRBC and LiR were statistically different in the three groups. Compared with TDM, Cplasma was more elevated in cases of acute intoxication whereas Li+ accumulated preferentially in RBC in cases of acute-on-chronic intoxication.

CONCLUSION

This study shows the interest of determining Li+ in RBC and plasma for TDM, and that LiR could be a sensitive marker of intoxication and of Li+ impregnation.

Should requests for donor insemination on social grounds be expanded to transsexuals?

Donor insemination may provide an answer to transsexuals with female partners who have a wish for a child. Although the follow-up on children born in the context of these families is non-existent and the follow-up on transsexuals after sex reassignment surgery (SRS) is limited, fertility centres might consider accepting the requests of transsexuals with a female partner. Between 1997 and 2001, nine couples presented themselves at the Centre for Reproductive Medicine of the Dutch-speaking Brussels Free University, of whom five couples were accepted. Nevertheless, some caution is called for because transsexualism is socially not accepted. Moreover, transsexualism is still considered to be psychiatric condition. The following recommendations should be taken in consideration. Treatment should be limited to female-to-male transsexuals with a female partner. A multidisciplinary team of specialists should carry out the diagnosis for gender identity. Developmental problems of the gender-disordered child might interfere with socio-economic, psychological and emotional stability in adulthood. The period of sex reassignment should be nearly completed.

Counselling lesbian couples: requests for donor insemination on social grounds

Fertility centres are increasingly involved in dealing with requests from lesbian couples for donor insemination (DI). Data were collected on 95 Belgian lesbian couples who applied for DI. The majority of couples were well integrated in a social environment (family, friends and work) that consisted mainly of heterosexuals. They tended to be open about their homosexuality and most couples considered the social environment to be tolerant towards their homosexual orientation. Couples who considered alternatives to DI would have liked to have had more information on the donor and were more inclined to introduce a 'godfather' who would take special interest in the child. Couples who considered DI to be the best solution considered the absence of a father to be less of a problem for the child and wished to have no information at all as regards the donor. Approximately half the couples considered their family a two-mother unit. For the other couples, the family unit consisted of a mother and her partner who shared parental responsibility for the child equally. The issues that are considered important to cope with and on which lesbian couples should be counselled are presented in the discussion.

Adnexal torsion after gonadotrophin ovulation induction for IVF or ICSI and its conservative treatment

This study was designed to find out the incidence of ovarian torsion in the patients who were in ovulation induction treatment for either In vitro fertilization (IVF) or Intracytoplasmic sperm injection (ICSI). Also operative laparoscopic conservative treatment (detorsion or unwinding the twisted adnex) was tried to perform to all the patients. Among 10,583 cycles 9 ovarian torsion cases had been diagnosed laparoscopically between January 1994 and October 1998. 104 ovarian hyperstimulation syndrome (OHSS) patients were evaluated during that time. From 104 hyperstimulated cases three had torsion of the adnex and two of them were pregnant. Five of the patients were clinically and one was chemically pregnant. First, laparoscopy was done to all the patients and 8 of them could be detorsioned, in one case unwinding performed by laparotomy because of the large size of the ovary. No complications were observed after conservative surgery. These results demonstrate that, in the IVF or ICSI clinics ovarian torsion has to be regarded as one of the major complications especially if the patients are hyperstimulated or pregnant or both. Immediate manipulation is needed conservatively, preserving the ovaries which were very important for those infertile patients.

Neonatal data on a cohort of 2889 infants born after ICSI (1991-1999) and of 2995 infants born after IVF (1983-1999)

BACKGROUND

To evaluate the safety of ICSI, this study compared data of IVF and ICSI children by collecting data on neonatal outcome and congenital malformations during pregnancy and at birth.

METHODS

The follow-up study included agreement to genetic counselling and eventual prenatal diagnosis, followed by a physical examination of the children after 2 months, after 1 year and after 2 years. 2840 ICSI children (1991-1999) and 2955 IVF children (1983-1999) were liveborn after replacement of fresh embryos. ICSI was carried out using ejaculated, epididymal or testicular sperm.

RESULTS

In the two cohorts, similar rates of multiple pregnancies were observed. ICSI and IVF maternal characteristics were comparable for medication taken during pregnancy, pregnancy duration and maternal educational level, whereas maternal age was higher in ICSI and a higher percentage of first pregnancies and first children born was observed in the ICSI mothers. Birthweight, number of neonatal complications, low birthweight, stillbirth rate and perinatal death rate were compared between the ICSI and the IVF groups and were similar for ICSI and IVF. Prematurity was slightly higher in the ICSI children (31.8%) than in the IVF children (29.3%). Very low birthweight was higher in the IVF pregnancies (5.7%) compared with ICSI pregnancies (4.4%). Major malformations (defined as those causing functional impairment or requiring surgical correction), were observed at birth in 3.4% of the ICSI liveborn children and in 3.8% of the IVF children (P = 0.538). Malformation rate in ICSI was not related to sperm origin or sperm quality. The number of stillbirths (born > or =20 weeks of pregnancy) was 1.69% in the ICSI group and 1.31% in the IVF group. Total malformation rate taking into account major malformations in stillborns, in terminations and in liveborns was 4.2% in ICSI and 4.6% in IVF (P = 0.482).

CONCLUSIONS

The comparison of ICSI and IVF children taking part in an identical follow-up study did not show any increased risk of major malformations and neonatal complications in the ICSI group.

[Research activities of interns in pharmacy]

During their hospital internship, French pharmacists have many opportunities to participate in research activities, especially in post-doctoral work (DEA). We conducted a national survey among pharmacy residents and interns to ascertain their motivations before completing their diploma. Many (about 50%) considered their post-doctorate work as an initiation before starting their scientific profession. Other motivations were also noted. This study provides data for future comparisons.

Clinical implications of uterine malformations and hysteroscopic treatment results

Uterine malformations consist of a group of miscellaneous congenital anomalies of the female genital system. Their mean prevalence in the general population and in the population of fertile women is approximately 4.3%, in infertile patients approximately 3.5% and in patients with recurrent pregnancy losses approximately 13%. Septate uterus is the commonest uterine anomaly with a mean incidence of approximately 35% followed by bicornuate uterus (approximately 25%) and arcuate uterus (approximately 20%). It seems that malformed uterus and especially septate uterus is not an infertility factor in itself. However, it may have a part in the delayed natural conception of women with mainly secondary infertility. On the other hand, patients with uterine malformations seem to have an impaired pregnancy outcome even as early as their first pregnancy. Overall term delivery rates in patients with untreated uterine malformations are only approximately 50% and obstetric complications are more frequent. Unicornuate and didelphys uterus have term delivery rates of approximately 45%, and the pregnancy outcome of patients with untreated bicornuate and septate uterus is also poor with term delivery rates of only approximately 40%. Arcuate uterus is associated with a slightly better but still impaired pregnancy outcome with term delivery rates of approximately 65%. Women who have undergone hysteroscopic septum resection and have been reported in the different series comprise a highly selected group of symptomatic patients with term delivery and live birth rates of only approximately 5%. Hysteroscopic treatment seems to restore an almost normal prognosis for the outcome of their pregnancies with term delivery rates of approximately 75% and live birth rates of approximately 85%. It seems, therefore, that hysteroscopic septum resection can be applied as a therapeutic procedure in cases of symptomatic patients but also as a prophylactic procedure in asymptomatic patients in order to improve their chances for a successful delivery.

Embryo freezing after intracytoplasmic sperm injection

This study reports on the safety and efficiency of the cryopreservation of human embryos obtained after intracytoplasmic sperm injection. For this, we evaluated the morphological survival, the capacity of the surviving embryo to develop further in vitro and in vivo. After freezing-thawing embryos obtained after ICSI, 40% of the embryos do not survive the cryopreservation procedure. After selective transfer of further cleaving frozen-thawed embryos, pregnancy loss was 31% (subclinical pregnancy rate of 13% and miscarriage rate of 18%). As a result the livebirth rate per transferred embryos and per thawed embryo was 7 and 3% respectively. Obstetric outcome as well as further follow-up of the children born indicate that cryopreservation of ICSI embryos is a safe procedure, long term follow-up of the children born however is still warranted.

Study of DNA-methylation patterns at chromosome 15q11-q13 in children born after ICSI reveals no imprinting defects

The introduction of intracytoplasmic sperm injection (ICSI) has raised concern about safety in terms of a possible increase in the incidence of major congenital malformations, chromosomal aberrations or developmental problems. The possible influence of genetic imprinting on an ICSI procedure has not yet been investigated. We therefore studied the DNA-methylation status at a defined region in chromosome 15q11-q13 in 92 children born after an ICSI procedure. Imprinting defects in this region are associated with neurogenetic disorders, e.g. Angelman syndrome (AS) and Prader-Willi syndrome (PWS). Blood samples were taken directly after birth and stored at -80 degrees C. Genomic DNA purification was performed from 3-7 ml EDTA-blood. Sodium bisulphite treatment was carried out in order to distinguish methylated from unmethylated DNA by transferring the unmethylated nucleic acid cytosine into uracil and leaving the methylated cytosine unchanged. Subsequently, a methylation-specific polymerase chain reaction (M-PCR) was performed. In all 92 children (83 from ICSI with ejaculated spermatozoa and nine from ICSI with non-ejaculated spermatozoa), a regular DNA-methylation pattern was found in the PWS/AS region. In none of the children were clinical symptoms of PWS or AS present. In conclusion, the results of this study do not indicate a higher risk of DNA-methylation defects in children born after ICSI.

Lymphocyte P-glycoprotein expression and activity before and after rifampicin in man

It has recently been shown that P-glycoprotein (P-gp) is inducible by rifampicin in the human gut as shown in intestinal biopsies. The present study was performed in order to test the hypothesis that human peripheral lymphocytes can be used to assess such an inducibility. We also assessed inter- and intra-individual variability of P-gp expression and activity in peripheral lymphocytes. Blood samples from 13 healthy volunteers were collected 1.7, 14 and 19 days after inclusion. Rifampicin treatment (600 mg/day) was administered from day 15 to day 18. Lymphocyte P-gp expression was measured at the messenger RNA level by semi-quantitative RT-PCR and at the protein level by immunostaining flow cytometry. P-gp activity was determined by flow cytometry with rhodamine 123 efflux. Cytochrome P4503A4 (CYP3A4) inducibility was measured by comparing the urinary metabolic ratio of 6beta-hydroxycortisol/cortisol on day 14 and 19, Lymphocyte P-gp expression and activity was not induced by rifampicin, while it increased CYP3A4 activity from 5.0 +/- 4.0 to 22.9 +/- 16.6 (P < 0.001). There was a 3 - 4-fold inter-individual variability and a 3 - 44 % intra-individual variability of lymphocyte P-gp expression and activity. Peripheral lymphocytes are not an appropriate material to assess P-gp inducibility in humans. P-gp shows significant inter- and intra-individual variability in human lymphocytes.

Analysis of the bleeding pattern in assisted reproduction cycles with luteal phase supplementation using vaginal micronized progesterone

This study was designed to determine the effects of a vaginal micronized progesterone preparation on bleeding patterns and pregnancy outcomes after in-vitro fertilization and intracytoplasmic sperm injection (IVF-ICSI). The study population consisted of 149 consecutive women who had undergone IVF-ICSI using 'long-protocol' stimulation with buserelin-human menopausal gonadotrophin (HMG). A retrospective chart analysis of computerized medical records was undertaken. Vaginal progesterone (200 mg three times daily) was begun the day before oocyte retrieval and continued for a minimum of 16-19 days following human chorionic gonadotrophin (HCG) administration. Occurrence of bleeding following HCG injection, pregnancy rate and outcomes, and serum concentrations of oestradiol were measured. Women undergoing IVF and embryo transfer with ICSI and using vaginal progesterone for luteal support had normal luteal phase lengths (day of HCG minus day of onset of bleeding). In the absence of pregnancy, bleeding occurred after 19.2 +/- 3.9 days (mean +/- SD). Out of the pregnant group only three women bled within 19 days of HCG administration: two had biochemical pregnancies which spontaneously vanished and one evolved to term. The results reflect the normal bleeding pattern to be expected when vaginal progesterone is used for luteal support in IVF and embryo transfer, an approach whose efficacy has been amply proven. No shortened luteal phases were observed using vaginally administered progesterone.

Progesterone for the luteal support of assisted reproductive technologies: clinical options

The role of progesterone in luteal support in assisted reproductive technologies (ART) is reviewed. There is insufficient data in ART treatment without gonadotrophin-releasing hormone (GnRH) analogues, to prove the necessity for luteal phase support using progesterone. Prospective studies have shown that ART cycles using GnRH analogues need to be supplemented. GnRH antagonists could have some adverse effects on the luteal phase. So far, no prospective randomized comparative study has been performed to investigate the necessity for luteal phase support when antagonists are used in ART cycles. Clinical outcome data (pregnancy and abortion rates) show similar success rates for human chorionic gonadotrophin (HCG) or progesterone supplementation. A major disadvantage of using HCG is the risk of maintaining or enhancing ovarian hyperstimulation syndrome. Of the several routes of administration of progesterone, the vaginal route is preferred because of its ease of use, reduced side-effects and, most importantly, the first uterine pass effect.