Role of Antioxidants in Assisted Reproductive Techniques

Oxidative stress (OS) has been recognized as a significant cause of suboptimal assisted reproductive outcome. Many of the sperm preparation and manipulation procedures that are necessary in the in vitro environment can result in excessive production of reactive oxygen species (ROS) thereby exposing the gametes and growing embryos to significant oxidative damage. Antioxidants have long been utilized in the management of male subfertility as they can counterbalance the elevated levels of ROS inducing a high state of OS. Few studies have looked into the clinical effectiveness of antioxidants in patients undergoing assisted reproduction. While an overall favorable outcome has been perceived, the specific clinical indication and optimal antioxidant regimen remain unknown. The goal of our review is to explore the sources of ROS in the in vitro environment and provide a clinical scenario-based approach to identify the circumstances where antioxidant supplementation is most beneficial to enhance the outcome of assisted reproduction.

The Consequences of Maternal-Embryonic Cross Talk During the Periconception Period on Subsequent Embryonic Development

The periconception period comprises the final maturation of sperm and the processes of fertilization and early embryonic development, which take place in the oviduct. The final goal of these important events is to lead to establishment of pregnancy leading to the birth of healthy offspring. Studies in rodents and domestic animals have demonstrated that environmental conditions experienced during early development affect critical aspects of future growth, metabolism, gene expression, and physiology. Similarly, in vitro culture of embryos can be associated with changes in fetal growth, gene expression and regulation, and postnatal behavior.In the oviduct, the cross talk between the mother and gametes/embryo begins after ovulation, between the oocyte and the female reproductive tract, and continues with the sperm and the early embryo after successful fertilization. These signals are mainly the result of direct interaction of gametes and embryos with oviductal and endometrial cells, influencing the microenvironment at the specific location. Identifying and understanding the mechanisms involved in this cross talk during the critical period of early reproductive events leading to pregnancy establishment could potentially lead to improvements in current in vitro embryo production systems in domestic mammals and humans. In this review, we discuss current knowledge of the short- and long-term consequences of in vitro embryo production on embryo development.

The effects of different levels of superoxide dismutase in Modena on boar semen quality during liquid preservation at 17°C

This study was conducted to investigate the influence of superoxide dismutase (SOD) on the quality of boar semen during liquid preservation at 17°C. Semen samples from 10 Duroc boars were collected and pooled, divided into five equal parts and diluted with Modena containing different concentrations (0, 100, 200, 300 and 400 U/mL) of SOD. During the process of liquid preservation at 17°C, sperm motility, acrosome integrity, membrane integrity, total antioxidant capacity (T-AOC) activity, malondialdehyde (MDA) content and hydrogen peroxide (H₂ O₂ ) content were measured and analyzed every 24 h. Meanwhile, effective survival time of boar semen during preservation was evaluated and analyzed. The results indicated that different concentrations of SOD in Modena showed different protective effects on boar sperm quality. Modena supplemented with SOD decreased the effects on reactive oxygen species on boar sperm quality during liquid preservation compared with that of the control group. The added 200 U/mL SOD group showed higher sperm motility, membrane integrity, acrosome integrity, effective survival time and T-AOC activity. Meanwhile, the added 200 U/mL SOD group showed lower MDA content and H₂ O₂ content. In conclusion, addition of SOD to Modena improved the boar sperm quality by reducing oxidative stress during liquid preservation at 17°C and the optimum concentration was 200 U/mL.

Diagnostic application of total antioxidant capacity in seminal plasma to assess oxidative stress in male factor infertility

PURPOSE

This study was undertaken in order to establish a new reference value for the total antioxidant capacity (TAC) in seminal plasma as a predictor of fertility. This study also aims to propose a detailed protocol for the TAC assay including calculation of assay results and assessment of sensitivity and specificity over possible cutoff values in infertile men and controls with proven and unproven fertility.

METHODS

Seminal plasma from 279 infertile patients and 46 normal healthy men referred to a male infertility testing laboratory were tested to measure TAC by a colorimetric assay kit. Receiver operating characteristics (ROC) curves were generated to establish cutoff values, sensitivity, and specificity, and the distribution of cutoff values in controls and infertile patients was calculated.

RESULTS

Infertile patients showed significantly lower levels (mean ± SEM) of total antioxidants (micromolar Trolox equivalents) in their seminal plasma (1863.84 ± 27.16 μM) compared to those from fertile men (2013 ± 56.04 μM, P = 0.019). A preferred cutoff TAC value of 1947 μM could facilitate better diagnosis of oxidative stress (OS) in men with male factor infertility. At this threshold, the specificity of TAC assay was 63.0 % and the sensitivity 59.5 % with a positive predictive value of 90.7 % and a negative predictive value of 20.4 %.

CONCLUSIONS

Our results establish a new diagnostic cutoff TAC value of 1947 μM in seminal plasma to distinguish prevalence of OS in infertile patients compared to healthy men. This study provides a robust reference value of seminal plasma TAC that may provide an important diagnostic tool to the physicians for managing OS and male factor infertility in such patients.

Efficacy of psychosocial interventions for psychological and pregnancy outcomes in infertile women and men: a systematic review and meta-analysis

OBJECTIVE

To evaluate the evidence on the efficacy of psychosocial interventions for improving pregnancy rates and reducing distress for couples in treatment with assisted reproductive technology (ART).

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PsycINFO, PubMed, EMBASE, CINAHL, Web of Science and The Cochrane Library between 1978 and April 2014.

STUDY SELECTION

Studies were considered eligible if they evaluated the effect of any psychosocial intervention on clinical pregnancy and/or distress in infertile participants, used a quantitative approach and were published in English.

DATA EXTRACTION

Study characteristics and results were extracted and the methodological quality was assessed. Effect sizes (ES; Hedges g) were pooled using a random effects model. Heterogeneity was assessed using the Q statistic and I(2), and publication bias was evaluated using Egger's method. Possible moderators and mediators were explored with meta-analyses of variances (ANOVAs) and meta-regression.

RESULTS

We identified 39 eligible studies (total N=2746 men and women) assessing the effects of psychological treatment on pregnancy rates and/or adverse psychological outcomes, including depressive symptoms, anxiety, infertility stress and marital function. Statistically significant and robust overall effects of psychosocial intervention were found for both clinical pregnancy (risk ratio=2.01; CI 1.48 to 2.73; p<0.001) and combined psychological outcomes (Hedges g=0.59; CI 0.38 to 0.80; p=0.001). The pooled ES for psychological outcomes were generally larger for women (g: 0.51 to 0.73) than men (0.13 to 0.34), but the difference only reached statistical significance for depressive symptoms (p=0.004). Meta-regression indicated that larger reductions in anxiety were associated with greater improvement in pregnancy rates (Slope 0.19; p=0.004). No clear-cut differences were found between effects of cognitive-behavioural therapy (CBT; g=0.84), mind-body interventions (0.61) and other intervention types (0.50).

CONCLUSIONS

The present meta-analysis suggests that psychosocial interventions for couples in treatment for infertility, in particular CBT, could be efficacious, both in reducing psychological distress and in improving clinical pregnancy rates.

Melatonin: shedding light on infertility?--A review of the recent literature

In recent years, the negative impact of oxidative stress on fertility has become widely recognised. Several studies have demonstrated its negative effect on the number and quality of retrieved oocytes and embryos following in-vitro fertilisation (IVF). Melatonin, a pineal hormone that regulates circadian rhythms, has also been shown to exhibit unique oxygen scavenging abilities. Some studies have suggested a role for melatonin in gamete biology. Clinical studies also suggest that melatonin supplementation in IVF may lead to better pregnancy rates. Here we present a critical review and summary of the current literature and provide suggestions for future well designed clinical trials.

Oral antioxidants supplementation for women with unexplained infertility undergoing ICSI/IVF: randomized controlled trial

OBJECTIVE

Good oocyte quality and maturity are important prerequisites for high fertilization and implantation rates in IVF/ICSI treatment cycles. Reactive oxygen species (ROS) are produced within ovarian follicles, especially during the ovulation process, and increased ROS activity may be a cause of impaired oocyte maturation and higher rate of failure of IVF/ICSI cycles.

STUDY DESIGN

RCT evaluating the effect of antioxidant supplementation on ICSI/IVF outcomes. Two hundred and eighteen women with unexplained subfertility undergoing IVF/ICSI were randomized into two groups. The study group (n = 112) received daily oral antioxidants in the form of multivitamins and minerals (amino acid chelated) while the control group (n = 106) did not. Main outcomes were number of mature metaphase II (MII) oocytes and clinical pregnancy rate.

RESULTS

There were no significant changes between the groups as regards age, BMI, basal FSH, number of mature (MII) oocytes (12.7 ± 9.4 vs. 13.2 ± 8.6, P = 0.7) and clinical pregnancy rate per woman randomized (38% vs. 34%; [OR = 1.2; 95% CI, 0.70-2.11].

CONCLUSION

Oral antioxidants in the form of a combination of multivitamins and minerals (amino acid chelated) did not improve oocyte quality and pregnancy rates in women with unexplained infertility undergoing IVF/ICSI treatment.

Differences in cumulus cells gene expression between modified natural and stimulated in vitro fertilization cycles

PURPOSE

The aim of our study was to determine whether there are any differences in the cumulus cell gene expression profile of mature oocytes derived from modified natural IVF and controlled ovarian hyperstimulation cycles and if these changes could help us understand why modified natural IVF has lower success rates.

METHODS

Cumulus cells surrounding mature oocytes that developed to morulae or blastocysts on day 5 after oocyte retrieval were submitted to microarray analysis. The obtained data were then validated using quantitative real-time PCR.

RESULTS

There were 66 differentially expressed genes between cumulus cells of modified natural IVF and controlled ovarian hyperstimulation cycles. Gene ontology analysis revealed the oxidation-reduction process, glutathione metabolic process, xenobiotic metabolic process and gene expression were significantly enriched biological processes in MNIVF cycles. Among differentially expressed genes we observed a large group of small nucleolar RNA's whose role in folliculogenesis has not yet been established.

CONCLUSION

The increased expression of genes involved in the oxidation-reduction process probably points to hypoxic conditions in modified natural IVF cycles. This finding opens up new perspectives for the establishment of the potential role that oxidation-reduction processes have in determining success rates of modified natural IVF.

Brief co-incubation of sperm and oocytes for in vitro fertilization techniques

BACKGROUND

The in vitro fertilization (IVF) technique is commonly used and is the only treatment option for a proportion of infertile couples. To obtain better outcomes of IVF, it is important to enhance embryo quality by optimizing IVF techniques. In IVF procedures, oocytes and sperm are routinely co-incubated overnight, which may expose oocytes and zygotes to suboptimal culture conditions with increased reactive oxygen species (ROS) produced by sperm in this long term culture. As an attempt to avoid possible detrimental effects on the oocytes from long exposure to sperm, the brief co-incubation insemination protocol was developed. However, despite a number of studies in this area, it is unclear whether brief co-incubation improves the IVF outcomes compared with the standard overnight insemination protocol.

OBJECTIVES

This Cochrane review aimed to determine whether brief co-incubation of sperm and oocytes improves outcomes compared with the standard overnight insemination protocol for women undergoing IVF.

SEARCH METHODS

We searched the Cochrane Menstrual Disorders and Subfertility Group Register (14 June 2012), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, 1st quarter), MEDLINE (1948 to 14 June 2012), EMBASE (1989 to 14 June 2012), PsycINFO (1806 to 14 June 2012) and CINAHL (1980 to 26 July 2012). In addition, we searched trials registers, reference lists of articles, conference proceedings (American Society for Reproductive Medicine (ASRM), European Society of Human Reproduction and Embryology (ESHRE)) and contacted experts in the field.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing brief co-incubation of gametes with the standard overnight insemination protocol.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and trial quality, and extracted data. Disagreements were resolved by discussion with a third author. Statistical analysis was performed using RevMan software.

MAIN RESULTS

Eight RCTs with 733 women in total that compared brief co-incubation and the standard insemination protocol were included. Live birth was not reported in the included studies. For ongoing pregnancy rate, there were 127 ongoing pregnancies in two trials including 426 women. The low quality evidence showed that brief co-incubation was associated with an increased ongoing pregnancy rate compared to the standard insemination protocol (pooled odds ratio (OR) 2.42, 95% confidence interval (CI) 1.55 to 3.77; P < 0.0001, I(2) = 0%). Measuring clinical pregnancy rate, there were 93 clinical pregnancies in three trials including 372 women. The low quality evidence showed that brief co-incubation was associated with a significantly higher clinical pregnancy rate than the overnight insemination protocol (pooled OR 2.36, 95% CI 1.45 to 3.85; P = 0.0006, I(2) = 0%). For the miscarriage rate, there were six miscarriages in one trial including 167 women. This low quality evidence suggested no significant difference in the odds of miscarriage between brief co-incubation and standard insemination (OR 1.98, 95% CI 0.35 to 11.09; P = 0.44).

AUTHORS' CONCLUSIONS

This review has provided evidence that brief co-incubation of sperm and oocytes may improve the ongoing pregnancy and clinical pregnancy rates for infertile women undergoing IVF cycles. More RCTs are required to assess whether brief co-incubation would contribute to a higher live birth rate and a lower miscarriage rate compared to the standard overnight insemination protocol.

Analysis of follicular fluid and serum markers of oxidative stress in women with infertility related to endometriosis

OBJECTIVE

To study the levels of four markers of oxidative stress in follicular fluid (FF) and plasma of patients with infertility related to endometriosis and controls.

DESIGN

Experimental study.

SETTING

University-affiliated hospital and infertility center.

PATIENT(S)

Ninety-one infertile women were included in the study (23 infertile women with endometriosis and 68 controls including infertile women due to tubal factor, male factor, or healthy egg donors).

INTERVENTION(S)

Blood was obtained at the time of egg retrieval, and FF from the mature follicles of each ovary was centrifuged and frozen until analysis.

MAIN OUTCOME MEASURE(S)

Vitamin C and E, malondialdehyde, and superoxide dismutase concentrations in plasma and follicular fluid.

RESULT(S)

Women with endometriosis showed a lower vitamin C concentration in FF (12.7 ± 5.9 vs. 9.7 ± 6.9 μg/mL) and lower superoxide dismutase concentration in plasma (0.9 ± 1.4 vs. 0.5 ± 0.7 U/mL) compared with controls. Vitamin E plasma levels were significantly higher in women with endometriosis (8.1 ± 3.8 vs. 5.2 ± 3.2 μg/mL). A nonsignificant trend toward a lower plasma concentration of malondialdehyde was found in women with endometriosis.

CONCLUSION(S)

These findings suggest a lower antioxidant capacity in infertile women with endometriosis. Although a certain level of reactive oxygen species is required under physiological conditions, an altered balance between pro-oxidant and antioxidant activities may have an impact on folliculogenesis and adequate embryo development.

Impacts of oxidative stress and antioxidants on semen functions

Oxidative stress (OS) has been considered a major contributory factor to the infertility. Oxidative stress is the result of imbalance between the reactive oxygen species (ROS) and antioxidants in the body which can lead to sperm damage, deformity, and eventually male infertility. Although high concentrations of the ROS cause sperm pathology (ATP depletion) leading to insufficient axonemal phosphorylation, lipid peroxidation, and loss of motility and viability but, many evidences demonstrate that low and controlled concentrations of these ROS play an important role in sperm physiological processes such as capacitation, acrosome reaction, and signaling processes to ensure fertilization. The supplementation of a cryopreservation extender with antioxidant has been shown to provide a cryoprotective effect on mammalian sperm quality. This paper reviews the impacts of oxidative stress and reactive oxygen species on spermatozoa functions, causes of ROS generation, and antioxidative strategies to reduce OS. In addition, we also highlight the emerging concept of utilizing OS as a tool of contraception.

Review: Toxicants in reproductive fluid and in vitro fertilization (IVF) outcome

Some of the physical, chemical, dietary, occupational and environmental factors are having adverse effect on human reproduction. Increasing trend in reproductive disorders in recent years at least in part might be associated with these factors. The data available suggests less success rate of in vitro fertilization (IVF) outcome of parents exposed to some of the reproductive toxic chemicals as compared to parents who were not exposed to such chemicals. However, data are very meager and require more studies as some debatable data also exists. But existing positive findings encourage in advising that sub-fertile subjects, who are planning to go for the IVF, should reduce toxic exposure well in advance by adopting positive life style and work environment. Further, clinician ought to be aware of occupational and environmental exposure history of the participating couple.