Nuchal translucency in twins according to mode of assisted conception and chorionicity

OBJECTIVES

The impact of nuchal translucency (NT) screening in twins conceived after use of assisted reproduction technology (ART) has not been addressed properly in the literature. The aim of the current study was to assess, in a large cohort from a single center, NT in twins following various modes of ART as compared with NT in spontaneously-conceived twins and to differentiate results with regard to chorionicity.

METHODS

Retrospective data from 825 twin pregnancies were available for this study. All pregnant women underwent NT screening and chorionicity determination between 11 + 0 and 13 + 6 weeks' gestation in our center. Information about mode of conception and pregnancy outcome was obtained from hospital records and by telephone interviews. Twins were classified as having been conceived after in-vitro fertilization (IVF) with the woman's own or a donated embryo, after non-IVF ART or spontaneously. NT distribution in subgroups of fetuses was compared on the basis of the multiple of the normal median (MoM), SD of log10 MoM estimated by the 90(th) -10(th) centile range divided by 2.563 and the proportion of NT values exceeding the normal 95(th) centile which was 1.641 MoM in the singletons.

RESULTS

NT values were statistically significantly higher in ART pregnancies as compared with spontaneously-conceived pregnancies (Wilcoxon rank-sum test, P < 0.05) with medians of 1.073 and 1.038 MoM, respectively, but the proportion with values above the normal 95(th) percentile did not differ (chi-square test, P = 0.89). Among the ART twins, NT values were significantly higher for those conceived using IVF methods (P < 0.005), with a median of 1.082 MoM, compared with a median of 1.022 MoM using other methods. However, although a greater proportion exceeded the 95(th) centile (7.3% compared with 4.8%) this difference did not reach statistical significance (P = 0.17). There were no differences in NT values according to chorionicity (Wilcoxon rank-sum test, P = 0.75). The standard deviation of log10 NT was similar for all subgroups of twins. The correlation coefficient between fetuses in ART pregnancies was statistically significantly lower than that in spontaneously-conceived pregnancies (P < 0.05) but no significant differences were found between types of ART or according to chorionicity.

CONCLUSIONS

There was a small but significant increase in NT levels among ART pregnancies, which appeared to be confined to those conceived using IVF, and a small reduction in the correlation between fetuses. These effects probably have little impact on the estimated risk based on algorithms in use today.

Assisted reproductive technology in India: A 3 year retrospective data analysis

Assisted reproductive technology (ART) has grown by leaps and bounds in the last few years. India has one of the highest growths in the ART centers and the number of ART cycles performed every year. Very soon India will be the leader in the world of ART in terms of a number of cycles. With the advances of technology and availability of techniques even in tier II and tier III cities our country, the results still vary dramatically. There is no standardization of protocols and reporting is very inadequate. Furthermore, there are only ART guidelines and no law still exists. Our first and the biggest challenge is to document the tremendous work being done in India and on the basis of analysis of this work, a proper registry can be made and guidance given to all on standardization and improvement. This is the 8^th edition of National ART Registry of India being presented and analyzed.

Demographic relevancy of increased use of assisted reproduction in European countries

BACKGROUND

Delayed childbearing in European countries has resulted in an increase in the number of women having children later in life. Thus more women face the problem of age-related infertility and cannot achieve their desired number of children. Childbearing postponement is one of the main reasons for the increasing use of assisted reproductive technology (ART) and conversely, the latter may be one of the factors contributing to the rise in female childbearing age. The research goal of our article is to evaluate the demographic importance of ART increased use and to examine its impact on both the fertility rate and birth timing.

METHODS

Comparative analysis based on demographic and ART data collected by the European IVF-monitoring (EIM) Consortium for the European Society of Human Reproduction and Embryology (ESHRE).

RESULTS

Most countries with a higher total fertility rate (TFR) also registered a higher number of treatment cycles per 1 million women of reproductive age. Despite the positive relationship between the postponement rate and the demand for ART among women aged 35 and older, the highest share of children born after ART was not found in countries characterized by a "delayed" fertility schedule. Instead, the highest proportion of ART births was found in countries with fertility schedules concentrated on women aged between 25 and 34. Accordingly, the effective use of ART can be expected in populations with a less advanced postponement rate.

CONCLUSIONS

ART can have a demographic relevancy when women take advantage of it earlier rather than later in life. Furthermore it is suggested that the use of ART at a younger age increases women's chance of achieving their reproductive goals and reduces the risk of age-related infertility and failed ART. Based on a demographic approach, reproductive health policy may become an integral part of policies supporting early childbearing: it may keep women from delaying too long having children and increase the chance of diagnosing potential reproductive health problems requiring a timely ART application.

Pregnancy outcomes in a university hospital after legal requirement for single-embryo transfer

OBJECTIVE

To present our in vitro fertilization outcomes after implementation of the Turkish government policy limiting the number of transferred embryos to one, in women under the age of 35, and two, in women over age 35; and to demonstrate the feasibility of this policy.

STUDY DESIGN

We retrospectively reviewed the records of 423 patients who underwent ovarian stimulation, oocyte pick-up, intracytoplasmic sperm injection and embryo transfer due to primary or secondary infertility over a 22-month time interval. Clinical pregnancy was defined as a fetal heartbeat in the seventh gestational week. Embryo transfers were carried out on day 3 or 5. Descriptive statistics are given as the number of subjects and percentages.

RESULTS

A total of 353 embryo transfers were performed: 261 (73.9%) were single-embryo transfer (244 (69.1%) elective and 17 (4.8%) non-elective) and 92 (26.1%) were double-embryo transfer. Of the 244 elective single-embryo transfers, 6.6% (n=16) were performed using frozen-thawed embryos. The average patient age was 29.6±4.5 years in the single-embryo group and 36.5±2.4 years in the double-embryo group. The cumulative pregnancy rates per oocyte pick-up were similar in both groups: 41% (n=107) in the single-embryo group and 43.4% (n=40) in the double-embryo group (p=0.678). The cumulative live birth rate of the single-embryo group (32.1%) was not statistically different from the double-embryo group (35.8%) (p=0.518). The twin pregnancy rate after single-embro transfer was significantly lower than with double-embryo transfer (2.8% (n=3) vs. 32.5% (n=13); p<0.001) and 62.5% of the twin pregnancies occurred in women 35 years or older who underwent double-embryo transfer. No significant difference in the spontaneous abortion rates was recorded between the single- and double-embryo transfer groups (16 (6.1%) vs. 6 (6.5%); p=0.894).

CONCLUSION

Single-embryo transfer results in a pregnancy rate comparable to double-embryo transfer, with a significantly reduced multiple pregnancy rate. Double-embryo transfer in patients over age 35 should be reconsidered because of the resulting high rate of multiple pregnancy.

Embryo selection using metabolomics

Faced with an increasing demand to select one embryo to transfer back to patients, a number of techniques are being developed to assist in discriminating differences within the cohort of a patient's embryos. A new and emerging technology which allows us to measure the profile of different metabolites in embryo culture media and formulate a viability score correlated to implantation potential is metabolomics.

Maternal and perinatal outcomes in spontaneous versus assisted conception twin pregnancies

OBJECTIVE

To compare maternal and perinatal outcomes in twin pregnancies conceived via assisted reproductive techniques (ART) compared with spontaneous twin pregnancies.

STUDY DESIGN

This retrospective study examined 345 dichorionic, di-amniotic twin pregnancies (207 conceived spontaneously and 138 conceived via ART), delivered between January 2007 and June 2011 at the San Pietro Fatebenefratelli Hospital, Rome, a tertiary medical centre. Maternal and perinatal outcomes were compared. A multiple logistic regression analysis was performed to calculate risk estimates as odds ratios (OR) adjusted for maternal age, parity and systemic diseases. Patient data were obtained from a computerized database and analyzed using Statistical Package for the Social Sciences Version 17.

RESULTS

Gestational age and birth weight were lower in the ART group, and preterm delivery, gestational diabetes and placental abruption were higher in the ART group compared with the spontaneous conception group. The incidence rates of respiratory complications, patent ductus arteriosus and admission to the neonatal intensive care unit were higher among ART newborns. Length of hospital stay for mothers and newborns was longer in the ART group. No differences in mode of delivery, Apgar score at 5min, congenital anomalies, perinatal mortality, and other considered pregnancy and neonatal complications were found between the two groups. Multivariate analysis adjusted for maternal age, parity and systemic diseases revealed that only the rates of placental abruption [OR 7.45, 95% confidence interval (CI) 2.05-26.98] and patent ductus arteriosus (OR 3.39, 95% CI 1.01-11.46) were significantly higher for the ART group.

CONCLUSIONS

Twin pregnancies conceived via ART are at greater risk of poorer outcomes than spontaneous twin pregnancies. This may be related to the type of conception and specific negative features of subfertile patients undergoing infertility treatment.

Association of TSH concentrations and thyroid autoimmunity with IVF outcome in women with TSH concentrations within normal adult range

BACKGROUND/AIMS

This study aimed to evaluate the association of thyroid-stimulating hormone (TSH) concentrations and presence of thyroid autoimmunity (TAI) with the live birth rate in euthyroid women undergoing in vitro fertilization (IVF).

METHODS

This study of retrospective design included 158 euthyroid women (TSH 0.5-4.5 µIU/ml) who underwent IVF from January 2006 to December 2010. Thyroid parameters were measured on day 3 of the previous nontreatment cycle. Women were subgrouped and analyzed according to their TSH concentrations (low: 0.5-2.5 vs. high: 2.6-4.5 µIU/ml) and TAI (present vs. absent).

RESULTS

No difference in the live birth rate was found between the TSH (low: 34.2% vs. high: 36.8%, p = 0.763) or TAI (present: 26.7% vs. absent: 34.3%, p = 0.568) subgroups.

CONCLUSION

This study found no evidence that increased TSH concentrations or the presence of TAI determined before IVF affect the live birth rate in euthyroid women. A better insight into the role of thyroid function during application of IVF is needed.

Blood pressure and anthropometrics of 4-y-old children born after preimplantation genetic screening: follow-up of a unique, moderately sized, randomized controlled trial

BACKGROUND

Recent studies suggest that in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) are associated with suboptimal cardiometabolic outcome in offspring. It is unknown whether preimplantation genetic screening (PGS), which involves embryo biopsy, affects blood pressure (BP), anthropometrics, and the frequency of received medical care.

METHODS

In this prospective multicenter follow-up study, we assessed BP, anthropometrics, and received medical care of 4-y-old children born to women who were randomly assigned to IVF/ICSI with PGS (n = 49) or without PGS (controls; n = 64). We applied linear and generalized linear mixed-effects models to investigate possible effects of PGS.

RESULTS

BP in the PGS and control groups was similar: 102/64 and 100/64 mm Hg, respectively. Main anthropometric outcomes in the PGS vs. control group were: BMI: 16.1 vs. 15.8; triceps skinfold: 108 vs. 98 mm; and subscapular skinfold: 54 vs. 53 mm (all P values > 0.05). More PGS children than controls had received paramedical care (speech, physical, or occupational therapy: 14 (29%) vs. 9 (14%); P = 0.03 in multivariable analysis). The frequency of medicial treatment was comparable.

CONCLUSION

PGS does not seem to affect BP or anthropometrics in 4-y-old children. The higher frequency of received paramedical care after PGS may suggest an effect of PGS on subtle developmental parameters.

Health outcomes of children born after IVF/ICSI: a review of current expert opinion and literature

The Sixth Evian Annual Reproduction (EVAR) Workshop Group Meeting was held to evaluate the impact of IVF/intracytoplasmic sperm injection on the health of assisted-conception children. Epidemiologists, reproductive endocrinologists, embryologists and geneticists presented data from published literature and ongoing research on the incidence of genetic and epigenetic abnormalities and congenital malformations in assisted-conception versus naturally conceived children to reach a consensus on the reasons for potential differences in outcomes between these two groups. IVF-conceived children have lower birthweights and higher peripheral fat, blood pressure and fasting glucose concentrations than controls. Growth, development and cognitive function in assisted-conception children are similar to controls. The absolute risk of imprinting disorders after assisted reproduction is less than 1%. A direct link between assisted reproduction and health-related outcomes in assisted-conception children could not be established. Women undergoing assisted reproduction are often older, increasing the chances of obtaining abnormal gametes that may cause deviations in outcomes between assisted-conception and naturally conceived children. However, after taking into account these factors, it is not clear to what extent poorer outcomes are due to the assisted reproduction procedures themselves. Large-scale, multicentre, prospective epidemiological studies are needed to investigate this further and to confirm long-term health consequences in assisted-conception children. Assisted reproduction treatment is a general term used to describe methods of achieving pregnancy by artificial means and includes IVF and sperm implantation. The effect of assisted reproduction treatment on the health of children born using these artificial methods is not fully understood. In April 2011, fertility research experts met to give presentations based on research in this area and to look carefully at the evidence for the effects of assisted reproduction treatment on children's health. The purpose of this review was to reach an agreement on whether there are differences in the health of assisted-conception children with naturally conceived children. The researchers discovered no increased risk in birth defects in assisted-conception children compared with naturally conceived children. They found that IVF-conceived children have lower birth weights and higher fat under the skin, higher blood pressure and higher fasting glucose concentrations than naturally conceived children; however, growth, development and cognitive function are similar between groups. A very low risk of disorders of genetic control was observed in assisted-conception children. Overall, there did not appear to be a direct link between assisted reproduction treatment and children's health. The researchers concluded that the cause of some differences in the health of children conceived using assisted reproduction treatment may be due to the age of the woman receiving treatment. Large-scale, research studies are needed to study the long-term health of children conceived using assisted reproduction treatment.

Anatomical causes of female infertility and their management

The main female anatomical causes of infertility include post-infectious tubal damage, endometriosis, and congenital/acquired uterine anomalies. Congenital (septate uterus) and acquired (myomas and synechiae) diseases of the uterus may lead to infertility, pregnancy loss, and other obstetric complications. Pelvic inflammatory disease represents the most common cause of tubal damage. Surgery still remains an important option for tubal factor infertility, with results in terms of reproductive outcome that compare favorably with those of in vitro fertilization. Endometriosis is a common gynecologic condition affecting women of reproductive age, which can cause pain and infertility. The cause of infertility associated with endometriosis remains elusive, suggesting a multifactorial mechanism involving immunologic, genetic, and environmental factors. Despite the high prevalence of endometriosis, the exact mechanisms of its pathogenesis are unknown. Specific combinations of medical, surgical, and psychological treatments can ameliorate the quality of life of women with endometriosis. In the majority of cases, surgical treatment of endometriosis has promoted significant increases in fertilization rates. There are obvious associations between endometriosis and the immune system, and future strategies to treat endometriosis might be based on immunologic concepts.

New molecular markers for the evaluation of gamete quality

PURPOSE

Only 30 % of IVF cycles result in a pregnancy, so that multiple embryos need to be replaced, per treatment cycle, to increase pregnancy rates, resulting in a multiple gestation rate of 25 %. The use of new markers in the gamete selection, could reduce the number of the oocytes to be fertilized and embryos to be produced, but the tools to evidence the gamete competence remain unavailable and more studies are needed to identify bio-markers to select the best oocyte and sperm to produce embryos with higher implantation potentiality.

METHODS

To define oocyte competence, the apoptosis of the surrounding cumulus cells and the oxygen consumption rates for individual oocytes before fertilization seems to provide a non-invasive marker of oocyte competence and hence a quantitative assessment of the reproductive potential for the oocyte. The chromatin integrity seems to be used also as biological marker of sperm competence, together with the morphological evaluation of large vacuoles in the head.

RESULTS

The apoptosis rate of cumulus cells lower than 25 % and an higher oxygen consumption could be an evidence of an overall metabolic activity, related to a better fertilization ability and embryo cleavage quality. The apoptosis rate of the sperm chromatin, evaluated by direct Tunel in situ analysis, seems to be, also for the male gamete, a marker of competence and implantation potentiality, in particular when it is lower than 20 %. The evaluation of the presence of large vacuoles in the sperm head prior to perform ICSI seems to increase the implantation rate, but it is not associated to chromatin integrity.

CONCLUSIONS

The biological concept of competence appears unrelated to any morphological parameters, so that it is necessary to investigate new molecular markers in the gamete selection. Apoptosis of cumulus cells in the oocytes and spermatozoa, revealing the presence of large vacuoles, could help to determine the competence of the gamete to be fertilize.

Pregnancy outcome using general anesthesia versus spinal anesthesia for in vitro fertilization

Background

There is a considerable rate of fertility failure and this causes a great burden of untoward effects for patients. Usually a considerable number of these patients undergo anesthesia for their treatment.

Objectives

This study was designed to compare the effects of general and spinal anesthesia on these patients.

Patients and Methods

In a randomized clinical trial, after taking informed written consent from the patients, 200 patients entered the study; 100 in each. During a 2 year period, women aged 20 to 40 years entered the study (one group receiving spinal anesthesia and the other, receiving general anesthesia). Ovum retrieval protocols were the same. Nonparametric and parametric analyses were used for data analysis. P value less than 0.05 was considered significant.

Results

There was no difference between the two groups regarding demographic variables. 15 of 100 patients (15%) in the general anesthesia group and 27 of 100 patients (27%) in the spinal anesthesia group had successful pregnancy after IVF; so, spinal anesthesia increased significantly the chance of IVF success (P value < 0.001; Chi Square).

Conclusions

The results of this study demonstrated that spinal anesthesia increased the chance of fertilization success.

Success Rate of Inseminations Dependent on Maternal Age? An Analysis of 4246 Insemination Cycles

Intrauterine insemination (IUI) has latterly become less important in reproductive medicine. The aim of this retrospective analysis was to identify and evaluate the success rates of repeated insemination cycles in women of different ages. All women who underwent intrauterine insemination in the Wiesbaden Fertility Clinic between 1998 and 2010 were included in the analysis. Additional inclusion criteria were: not more than 45 years old, previous FSH stimulation and slight to moderate subfertility of the male partner. A total of 4246 insemination cycles in 1612 patients were included in the analysis. The average number of IUI cycles per patient was 2.24 (1-14). Patient age ranged from 19 to 45 years (mean: 33.9 years). Logistic regression analysis showed a drop in pregnancy rates with increasing age (p = 0.000). However, for the first three cycles the pregnancy rates for women aged 40 and 41 did not differ from those of women aged between 35 and 39 years. Overall pregnancy rates were stable in women up to the age of 40, even after several insemination cycles (7.5 and 10 %). Insemination is therefore still an effective procedure in selected patients. Stable pregnancy rates were recorded even after more than 3 cycles. After 3 cycles, the success rates for women aged 40 and 41 did not differ from those of women below the age of 40.

Metabolic profiling of human follicular fluid identifies potential biomarkers of oocyte developmental competence

The use of metabolomic based techniques to aid oocyte and embryo selection has gained attention in recent years. Previous work from our laboratory has demonstrated that the (1)H NMR-based metabolic profile of follicular fluid correlates with oocyte developmental potential. Patients undergoing IVF at the Merrion Fertility Clinic had follicular fluid collected at the time of oocyte retrieval. The fatty acid composition of follicular fluid from follicles where oocytes fertilised and developed into multi-cell embryos (n=15) and from oocytes that fertilised normally but failed to cleave (n=9) (cleaved vs non-cleaved) was compared. Statistical analysis was performed on the data using univariate and multivariate techniques. Analysis of the fatty acid composition revealed that there were nine fatty acids significantly different between follicular fluid from the cleaved and the non-cleaved sample groups. Of particular interest were the higher concentration of total saturated (P=0.03) and the lower concentration of total polyunsaturated fatty acids in the non-cleaved sample group (P=0.001). Random forest classification models were used to predict successful cleavage in follicular fluid samples producing models with errors rates of <10%. Receiver operating characteristic analysis demonstrated that the model had good predictability with an area under the curve of 0.96. The panel of fatty acid biomarkers identified in this study indicates that the fatty acid composition of follicular fluid may be more predictive in comparison to other previously identified biomarkers. Following validation in a larger cohort, these biomarkers may have the potential to be used in fertility clinics to aid the selection of oocytes in the future.

Risk disparities in the globalisation of assisted reproductive technology: the case of Asia

This paper analyses the disparities in risks associated with biomedical technology focusing on the results of assisted reproductive technology (ART). ART among biomedical technologies transferred to Asia is a representative case that reveals in its clinical use and related scientific research the global politics of technology. This study notes the global politics at work in the recognition of and reaction to such risks. While many Asian countries aggressively pursue technological development, weak legislative and administrative regulations have created various problems and controversial cases. This study asserts that risks associated with technology are characterised as social facts not natural ones or mere 'side effects', since technological development and risk are closely intertwined.

Economic evaluation of highly purified human menopausal gonadotropin versus recombinant human follicle-stimulating hormone in fresh and frozen in vitro fertilization/intracytoplasmic sperm-injection cycles in Sweden

Gonadotropin-releasing hormone-analog type, fertilization method, and number of embryos available for cryopreservation should be incorporated into economic evaluations of highly purified human menopausal gonadotropin (HP-hMG) and recombinant human follicle-stimulating hormone (r-hFSH), as they may affect treatment costs. We searched for randomized trials and meta-analyses comparing HP-hMG and r-hFSH. Meta-analysis showed no significant difference in live births (odds ratio 0.82, 95% confidence interval [CI] 0.66–1.01), but a greater number of oocytes with r-hFSH (mean difference [MD] 1.96, 95% CI 1.02–2.90). Using a cost-minimization model for Sweden, accounting for embryo availability, survival following thawing, and patient dropout, we simulated patients individually for up to three cycles. R-hFSH was found to be cost-saving, at 2,767 kr (95% CI 1,580–4,057) per patient (€315 or $411); baseline savings were 6.43% of the total HP-hMG cost. In fresh cycles only, the savings for r-hFSH were 1,752 kr (95% CI 48–3,658) per patient (€200 or $260). In univariate sensitivity analyses, savings were obtained until the price of r-hFSH increased by 30% or the dosage of HP-hMG decreased by 38%–62% of baseline value. In probabilistic sensitivity analysis, r-hFSH was cost-saving in 100% of the simulated cohort per patient and in 85% per live birth; the respective percentages for fresh cycles only were 97.3% and 73.1%. In conclusion, a greater number of oocytes with r-hFSH allows for more frozen embryo transfers, thereby reducing overall treatment cost.

Selection of euploid blastocysts for cryopreservation with array comparative genomic hybridization (aCGH) results in increased implantation rates in subsequent frozen and thawed embryo transfer cycles

BACKGROUND

In assisted reproductive treatments, embryos remaining after fresh embryo transfer are usually selected for cryopreservation based on traditional morphology assessment. Our previous report has demonstrated that array comparative genomic hybridization (aCGH) screening for IVF patients with good prognosis significantly improves clinical and ongoing pregnancy rates in fresh embryo transfer cycles. The current study further investigates the efficiency of applying aCGH in the selection of euploid embryos for cryopreservation as related to pregnancy and implantation outcomes in subsequent frozen embryo transfer (FET) cycles.

METHODS

First-time IVF patients with good prognosis undergoing fresh single embryo transfer and having at least one remaining blastocyst for cryopreservation were prospectively randomized into two groups: 1) Group A patients had embryos assessed by morphology first and then by aCGH screening of trophectoderm cells and 2) Group B patients had embryos evaluated by morphology alone. All patients had at least one blastocyst available for cryopreservation after fresh embryo transfer. There were 15 patients in Group A and 23 patients in Group B who failed to conceive after fresh embryo transfer and completed the FET cycles. Blastocyst survival and implantation rates were compared between the two groups.

RESULTS

There were no significant differences in blastocyst survival rates between Group A and Group B (90.9% vs. 91.3%, respectively; p >0.05). However, a significantly higher implantation rate was observed in the morphology assessment plus aCGH screening group compared to the morphology assessment alone group (65.0% vs. 33.3%, respectively; p = 0.038). There was no miscarriage observed in Group A while a 16.7% miscarriage rate was recorded in Group B (0% vs. 16.7%, respectively; p >0.05).

CONCLUSIONS

While aCGH screening has been recently applied to select euploid blastocysts for fresh transfer in young, low-risk IVF patients, this is the first prospective study on the impact of aCGH specifically on blastocyst survival and implantation outcomes in the subsequent FET cycles of IVF patients with good prognosis. The present study demonstrates that aCGH screening of blastocysts prior to cryopreservation significantly improves implantation rates and may reduce the risk of miscarriage in subsequent FET cycles. Further randomized clinical studies with a larger sample size are needed to validate these preliminary findings.

Tumor necrosis factor-308 polymorphism increases the embryo implantation rate in women undergoing in vitro fertilization

STUDY QUESTION

Do TNF-308 and -238 polymorphisms impact the embryo implantation rate after in vitro fertilization (IVF) in women without female infertility factor?

SUMMARY ANSWER

The presence of the TNF-308A allele is associated with high implantation and multiple pregnancy rates in women without known infertility factors after ovarian hyperstimulation with exogenous FSH.

WHAT IS ALREADY KNOWN

Multiple pregnancies are frequent after the use of Assisted Reproductive Technologies. Single embryo transfer (SET) has been proposed as a simple way to prevent these risks. However, the extension of SET indications to patients not selected based on specific criteria is controversial because of reduced pregnancy rates. To date, the predictive value of the parameters used for SET (age, gynecological history of the patient and uterine characteristics) allows a pregnancy rate of ~30%.

STUDY DESIGN, SIZE, DURATION

The potential predictive value of TNF polymorphisms (-308, rs1800629 and -238, rs361525) on implantation rate was evaluated in 424 women requiring IVF due to male fertility factors. This cohort retrospective study was conducted over 4 years in University-affiliated hospitals.

PARTICIPANTS, SETTING, METHODS

The entire patient group included 424 women undergoing intracytoplasmic sperm injection (ICSI) due to male fertility factors without the contribution of any female factor. From among this group, a selected patient group included 120 women with a normal karyotype, age under 38 years, serum follicle-stimulating hormone (Day-3 FSH) levels below 10 IU/l, a long agonist desensitization protocol associated with recombinant FSH treatment and a Caucasian background.

MAIN RESULTS AND THE ROLE OF CHANCE

The TNF-238 polymorphism was not associated with implantation rate. In contrast, the presence of the TNF-308A allele was associated with increased Day 3-E2 levels as well as higher implantation and multiple pregnancy rates after fresh embryo transfer in women from the entire and selected patient groups. Moreover, in the selected patient group, the presence of the TNF-308A allele was also associated with a decrease in the miscarriage rate. The benefit of the TNF-308A allele in predicting implantation rates was not observed after the use of frozen embryos.

LIMITATIONS, REASONS FOR CAUTION

Future studies are needed to evaluate whether the TNF-308A allele might also be a biomarker in women with infertility factors.

WIDER IMPLICATIONS OF THE FINDING

The TNF-308A allele may represent a good candidate for a potential predictive, non-invasive biomarker in the SET strategy. However, its impact should be evaluated in prospective studies.

STUDY FUNDING/COMPETING INTEREST

This study was conducted with financial support from the French Institute for Health and Medical Research (INSERM), Organon France for a FARO (Fond d'Aide à la Recherche Organon) fellowship (to V.T.) and CHU Nice PHRC (PHRC 09-279).There are no competing interests.

Number of embryos for transfer following in vitro fertilisation or intra-cytoplasmic sperm injection

BACKGROUND

Multiple embryo transfer during in vitro fertilisation (IVF) increases multiple pregnancy rates causing maternal and perinatal morbidity. Single embryo transfer is now being seriously considered as a means of minimising the risk of multiple pregnancy. However, this needs to be balanced against the risk of jeopardising the overall live birth rate.

OBJECTIVES

To evaluate the effectiveness and safety of different policies for the number of embryos transferred in couples who undergo assisted reproductive technology (ART).

SEARCH METHODS

We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE, from inception to July 2013. We handsearched reference lists of articles, trial registers and relevant conference proceedings and contacted researchers in the field.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing different policies for the number of embryos transferred following IVF or intra-cytoplasmic sperm injection (ICSI) in subfertile women. Studies of fresh or frozen and thawed transfer of one, two, three or four embryos at cleavage or blastocyst stage were eligible.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial eligibility and risk of bias and extracted the data. The overall quality of the evidence was graded in a summary of findings table.

MAIN RESULTS

Fourteen RCTs were included in the review (2165 women). Thirteen compared cleavage-stage transfers (2017 women) and two compared blastocyst transfers (148 women): one study compared both. No studies compared repeated multiple versus repeated single embryo transfer (SET). DET versus repeated SETDET was compared with repeated SET in three studies of cleavage-stage transfer. In these studies the SET group received either two cycles of fresh SET (one study) or one cycle of fresh SET followed by one frozen SET in a natural or hormone-stimulated cycle (two studies). When these three studies were pooled, the cumulative live birth rate after one cycle of DET was not significantly different from the rate after repeated SET (OR 1.22, 95% CI 0.92 to 1.62, three studies, n=811, I(2)=0%, low quality evidence). This suggests that for a woman with a 40% chance of live birth following a single cycle of DET, the chance following repeated SET would be between 30% and 42%. The multiple pregnancy rate was significantly higher in the DET group (OR 30.54, 95% CI 7.46 to 124.95, three RCTs, n = 811, I(2) = 23%, low quality evidence), suggesting that for a woman with a 15% risk of multiple pregnancy following a single cycle of DET, the risk following repeated SET would be between 0% and 2%. Single-cycle DET versus single-cycle SETA single cycle of DET was compared with a single cycle of SET in 10 studies, nine comparing cleavage-stage transfers and two comparing blastocyst-stage transfers. When all studies were pooled the live birth rate was significantly higher in the DET group (OR 2.07, 95% CI 1.68 to 2.57, nine studies, n = 1564, I(2) = 0%, high quality evidence). This suggests that for a woman with a 40% chance of live birth following a single cycle of DET, the chance following a single cycle of SET would be between 22% and 30%. The multiple pregnancy rate was also significantly higher in the DET group (OR 8.47, 95% CI 4.97 to 14.43, 10 studies, n = 1612, I(2) = 45%, high quality evidence), suggesting that for a woman with a 15% risk of multiple pregnancy following a single cycle of DET, the risk following a single cycle of SET would be between 1% and 4%. The heterogeneity for this analysis was attributable to a study with a high rate of cross-over between treatment arms. Other comparisons Other fresh cycle comparisons were evaluated in three studies which compared DET versus transfer of three or four embryos. Live birth rates did not differ significantly between the groups for any comparison, but there was a significantly lower multiple pregnancy rate in the DET group than in the three embryo transfer (TET) group (OR 0.36, 95% CI 0.13 to 0.99, two studies, n = 343, I(2) = 0%).

AUTHORS' CONCLUSIONS

In a single fresh IVF cycle, single embryo transfer is associated with a lower live birth rate than double embryo transfer. However, there is no evidence of a significant difference in the cumulative live birth rate when a single cycle of double embryo transfer is compared with repeated SET (either two cycles of fresh SET or one cycle of fresh SET followed by one frozen SET in a natural or hormone-stimulated cycle). Single embryo transfer is associated with much lower rates of multiple pregnancy than other embryo transfer policies. A policy of repeated SET may minimise the risk of multiple pregnancy in couples undergoing ART without substantially reducing the likelihood of achieving a live birth. Most of the evidence currently available concerns younger women with a good prognosis.

Comparison of embryo transfer strategies and assisted reproduction outcome in Slovenian and cross-border patients

A reduction in the number of embryos transferred is the most important step in decreasing multiple gestation rates after medically assisted reproduction. Slovenia has implemented insurance company regulations that regulate single-embryo transfer in selected good-prognosis couples. The aim of the present study was to evaluate its effects on the Slovenian population compared with cross-border patients, who are not affected by the insurance company policy. Ultimately, 2403 couples undergoing IVF or intracytoplasmic sperm injection were included in the retrospective analysis. Patients were classified according to their origin. The decision about the number of embryos transferred and the treatment success were evaluated. The implementation of the policy favouring single-embryo transfer resulted in a significant decrease in the twin birth rate in Slovenian patients (24.4% before policy versus 6.7% after policy implementation, P<0.001). Although in cross-border patients twin birth rates have declined through the study period, they remained significantly higher compared with Slovenian patients (23.1% versus 6.7%, P<0.001). The data demonstrate that insurance company policies favouring single-embryo transfer are an effective tool in decreasing multiple gestation rates. Similar mechanisms should be implemented in the cross-border patient population.

A Rasch-based dimension of delivery experience: spontaneous vs. medically assisted conception

AIMS AND OBJECTIVES

To devise a set of indices representative of a latent dimension of delivery perception, aimed at the assessment of birth experience after both spontaneous and medically assisted conception.

BACKGROUND

Birth experience is of great importance for its prognostic value for the woman and newborn's psychophysical well-being, especially after the experience of assisted reproduction technology. Up to date, a delivery perception assessment measure targeted to both spontaneously and medically assisted conceiving women does not exist yet.

DESIGN

Measure development and psychometric analysis; quantitative and qualitative analysis of women's delivery experience measures.

METHODS

Thirty-one indices characterising seven relevant aspects of birth perception were devised from the literature and evaluated on a 4-point Likert-type scale by 98 childbearing women (54 spontaneously and 44 medically assisted conceiving) in the 24-48 hours postpartum time frame. Women's obstetric history information was also collected. The dimension psychometric definition was pursued within a latent trait perspective, by applying the many-facet Rasch measurement model.

RESULTS

A latent delivery perception dimension composed of 18 valid and reliable indices, qualifying six labour and delivery perception clinical aspects, was identified. Medically assisted conceiving women evidenced a more positive birth perception, but when analysing each index, they showed peculiar intense worries about themselves and their baby's health, even if they felt more satisfied, safer and stronger in almost every labour and birth aspect.

CONCLUSIONS

The delivery perception dimension integrates all relevant birth experience aspects in 18 easy-to-administer indices and provides a valid, reliable and feasible assessment tool for both the clinical practice and research purposes.

RELEVANCE TO CLINICAL PRACTICE

The delivery perception dimension clearly discriminates between women's types of conception and identifies relevant differences in their birth experience, which are interesting for their clinical implications within a prognostic and intervention perspective of support provision in the early postpartum period.

Prediction models in in vitro fertilization; where are we? A mini review

Since the introduction of in vitro fertilization (IVF) in 1978, over five million babies have been born worldwide using IVF. Contrary to the perception of many, IVF does not guarantee success. Almost 50% of couples that start IVF will remain childless, even if they undergo multiple IVF cycles. The decision to start or pursue with IVF is challenging due to the high cost, the burden of the treatment, and the uncertain outcome. In optimal counseling on chances of a pregnancy with IVF, prediction models may play a role, since doctors are not able to correctly predict pregnancy chances. There are three phases of prediction model development: model derivation, model validation, and impact analysis. This review provides an overview on predictive factors in IVF, the available prediction models in IVF and provides key principles that can be used to critically appraise the literature on prediction models in IVF. We will address these points by the three phases of model development.

Long-term follow-up of children conceived through assisted reproductive technology

Children conceived via assisted reproductive technologies (ART) are nowadays a substantial proportion of the population. It is important to follow up these children and evaluate whether they have elevated health risks compared to naturally conceived (NC) children. In recent years there has been a lot of work in this field. This review will summarize what is known about the health of ART-conceived children, encompassing neonatal outcomes, birth defects, growth and gonadal developments, physical health, neurological and neurodevelopmental outcomes, psychosocial developments, risk for cancer, and epigenetic abnormalities. Most of the children conceived after ART are normal. However, there is increasing evidence that ART-conceived children are at higher risk of poor perinatal outcome, birth defects, and epigenetic disorders, and the mechanism(s) leading to these changes have not been elucidated. Continuous follow-up of children after ART is of great importance as they progress through adolescence into adulthood, and new ART techniques are constantly being introduced.

Bisphenol a exposure disrupts genomic imprinting in the mouse

Exposure to endocrine disruptors is associated with developmental defects. One compound of concern, to which humans are widely exposed, is bisphenol A (BPA). In model organisms, BPA exposure is linked to metabolic disorders, infertility, cancer, and behavior anomalies. Recently, BPA exposure has been linked to DNA methylation changes, indicating that epigenetic mechanisms may be relevant. We investigated effects of exposure on genomic imprinting in the mouse as imprinted genes are regulated by differential DNA methylation and aberrant imprinting disrupts fetal, placental, and postnatal development. Through allele-specific and quantitative real-time PCR analysis, we demonstrated that maternal BPA exposure during late stages of oocyte development and early stages of embryonic development significantly disrupted imprinted gene expression in embryonic day (E) 9.5 and 12.5 embryos and placentas. The affected genes included Snrpn, Ube3a, Igf2, Kcnq1ot1, Cdkn1c, and Ascl2; mutations and aberrant regulation of these genes are associated with imprinting disorders in humans. Furthermore, the majority of affected genes were expressed abnormally in the placenta. DNA methylation studies showed that BPA exposure significantly altered the methylation levels of differentially methylated regions (DMRs) including the Snrpn imprinting control region (ICR) and Igf2 DMR1. Moreover, exposure significantly reduced genome-wide methylation levels in the placenta, but not the embryo. Histological and immunohistochemical examinations revealed that these epigenetic defects were associated with abnormal placental development. In contrast to this early exposure paradigm, exposure outside of the epigenetic reprogramming window did not cause significant imprinting perturbations. Our data suggest that early exposure to common environmental compounds has the potential to disrupt fetal and postnatal health through epigenetic changes in the embryo and abnormal development of the placenta.

BPA is a widely used compound to which humans are exposed, and recent studies have demonstrated the association between exposure and adverse developmental outcomes in both animal models and humans. Unfortunately, exact mechanisms of BPA–induced health abnormalities are unclear, and elucidation of these relevant biological pathways is critical for understanding the public health implication of exposure. Recently, increasing data have demonstrated the ability of BPA to induce changes in DNA methylation, suggesting that epigenetic mechanisms are relevant. In this work, we study effects of BPA exposure on expression and regulation of imprinted genes in the mouse. Imprinted genes are regulated by differential DNA methylation, and they play critical roles during fetal, placental, and postnatal development. We have found that fetal exposure to BPA at physiologically relevant doses alters expression and methylation status of imprinted genes in the mouse embryo and placenta, with the latter tissue exhibiting the more significant changes. Additionally, abnormal imprinting is associated with defective placental development. Our data demonstrate that BPA exposure may perturb fetal and postnatal health through epigenetic changes in the embryo as well as through alterations in placental development.

The effect of preimplantation genetic screening on neurological, cognitive and behavioural development in 4-year-old children: follow-up of a RCT

STUDY QUESTION

Does embryo biopsy inherent to preimplantation genetic screening (PGS) affect neurological, cognitive and behavioural development of 4-year-old children?

SUMMARY ANSWER

PGS does not seem to affect neurological, cognitive and behavioural development of 4-year-old singletons; however, our data suggest that it may be associated with altered neurodevelopment in twins.

WHAT IS KNOWN ALREADY

Evidence concerning the safety of PGS on neurodevelopmental outcome in offspring is scarce. The present study provides information on neurodevelopmental, cognitive and behavioural outcome of 4-year-old PGS offspring.

STUDY DESIGN, SIZE, DURATION

A prospective, assessor-blinded follow-up study of children born to women who participated in a multi-centre RCT on the effect of IVF with or without PGS.

PARTICIPANTS/MATERIALS, SETTING, METHODS

At 4 years, 49 children (31 singletons, 9 sets of twins) born following IVF with PGS and 64 children (42 singletons, 11 sets of twins) born following IVF without PGS (controls) were assessed (post-natal attrition 18%). Neurological development was evaluated with the standardized, age-specific and sensitive neurological examination according to Hempel, resulting in a neurological optimality score (NOS), a fluency score and the rate of adverse neurological outcome. Primary outcome was the fluency score, as fluency of movements is easily reduced by subtle dysfunction of the brain. Cognitive development was evaluated with the Kaufman Assessment Battery for Children; behavioural development was evaluated with the Child Behavior Checklist. The effect of PGS was analysed with a mixed effects model.

MAIN RESULTS AND THE ROLE OF CHANCE

Based on the intention to treat analysis, neurodevelopmental outcome of PGS children was similar to that of controls. However, additional analyses indicated that PGS affected neurodevelopmental outcome of twins in a different way than that of singletons. The fluency score of singletons born following PGS was similar to that of control singletons [mean values, 95% confidence intervals (CIs): 12.2 (11.5;12.8) and 12.2 (11.6;12.8)], respectively, P = 0.977) that was also true for the other neurodevelopmental parameters. The fluency score of PGS twins was significantly lower than that of control twins [mean values, 95% CIs: 10.6 (9.8;11.3) and 12.3 (11.5;13.1)], respectively, P = 0.001); the same was true for the NOS. In addition, PGS in twins was associated with a higher sequential intelligence quotient score. On the other hand, other neurodevelopmental parameters were similar for PGS twins and control twins. Post hoc sample size calculation for the primary outcome parameter, the fluency score, indicated that the study groups, including the subgroups of singletons and twins, were adequately powered.

LIMITATIONS, REASONS FOR CAUTION

We assessed singletons and twins who contributed to the generalizability of the study. A limitation of our study is the relative small size of our study groups and the selective dropout in both groups (dropouts PGS group: higher gestational age; control group: less well-educated parents). These preclude the conclusion that PGS per se is not associated with neurodevelopmental, cognitive and behavioural problems in singletons and the conclusion that PGS is associated with altered neurodevelopmental outcome in twins.

WIDER IMPLICATIONS OF THE FINDINGS

The need for careful long-term monitoring of children born following embryo biopsy remains, as it is still applied in the form of PGD and it is still unknown whether embryo biopsy affects long-term neurodevelopmental outcome.

Increased risk for cancer among offspring of women with fertility problems

Some studies have indicated that children born after fertility treatment have a potential risk for cancer, but the results are inconsistent. Furthermore, any negative effects of fertility treatment might be due to the underlying infertility rather than to the procedure itself. In the largest cohort study to date with information on fertility, we examined whether the offspring of women with fertility problems had a higher risk for cancer than offspring of women without fertility problems. The study cohort consisted of 2,830,054 offspring born in Denmark between 1964 and 2006. Of these, 125,844 were offspring of women evaluated for infertility. Cox regression models were used to estimate the possible effect of being the offspring of a woman evaluated for infertility on the risk for cancer. Analyses were performed separately for cancer during childhood (0-19 years) and cancer in young adulthood (>20 years). We found that offspring born to women with fertility problems had higher overall risks for cancer in childhood (hazard ratio (HR), 1.18; 95% confidence interval (CI), 1.05-1.32) and in young adulthood (HR, 1.22; 95% CI, 1.04-1.43) than offspring of women without fertility problems. Offspring of women with fertility problems had significantly increased risks for leukemia in childhood (HR, 1.30; 95% CI, 1.06-1.60) and for cancer of the endocrine glands in young adulthood (HR, 2.67; 95% CI, 1.35-5.29). These findings suggest that offspring born to mothers with fertility problems are at increased risk for cancer in both childhood and young adulthood. If real, our findings of an ∼18% overall increase in risk for cancer in childhood and an ∼22% overall increase in risk for cancer in young adulthood would mean about four additional cases of childhood cancer and about nine additional cases of cancer in young adults per 100,000 exposed offspring.

Phenotypic differences in children conceived from fresh and thawed embryos in in vitro fertilization compared with naturally conceived children

OBJECTIVE

To determine whether anthropometric and biochemical features differ in in vitro fertilization (IVF) children conceived via fresh (IVFF) or thawed (IVFT) embryo transfer compared with naturally conceived controls.

DESIGN

A cross-sectional controlled study.

SETTING

University clinical research unit.

PATIENT(S)

Healthy prepubertal children (3.5-11.0 years), singletons, born at term (>37 weeks), who were either naturally conceived (controls; n = 94) or IVF children conceived via the transfer of a fresh (IVFF; n = 72) or thawed (IVFT; n = 43) embryo.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Assessments of anthropometry (adjusted for parental variables), dual-energy X-ray absorptiometry-derived body composition, fasting plasma growth factors, lipids, and parameters of glucose regulation.

RESULT(S)

The IVFF but not the IVFT children weighed less at birth than the control children. The IVFF children were taller than both the controls and IVFT children. Sex-specific analyses showed height differences among girls, with IVFF girls being taller than their control and IVFT counterparts. Taller stature in IVFF children was associated with increased insulin-like growth factor I (IGF-I) concentrations compared with controls, whereas the IVFT children displayed increased IGF-II and decreased insulin-like growth factor binding protein 3 (IGFBP-3) concentrations compared with the controls. More favorable lipid profiles were also evident in IVFF but not IVFT children compared with the control children.

CONCLUSION(S)

These preliminary findings highlight that the transfer of a fresh versus a thawed IVF embryo affects height, plasma growth factor, and lipid profiles in childhood. Therefore, embryo derivation should be considered when assessing physical and biochemical phenotype of IVF children.

Is ICSI Risky?

As assisted reproductive technology (ART) methods become the mainstream of infertility treatment, it has become even more critical to reassess its safety. Following the results of a study published by the Robinson Institute in the New England Journal of Medicine, the risk of ART, especially intracytoplasmic sperm injection (ICSI), has never been so closely scrutinized. This paper traces the origins and development of ICSI, assesses the risks documented in the literature, and finally interprets the implications of the study for couples contemplating therapy. We support the need for continued vigilance towards ICSI and the importance in investigating male-factor infertility as a prequel to its use.

Embryo culture media and IVF/ICSI success rates: a systematic review

BACKGROUND The media that are used to culture human preimplantation embryos are considered to be an important factor for the success rates of IVF/ICSI. Here, we present a systematic review of randomized controlled trials (RCTs) on the effect of culture media on IVF/ICSI success rates. METHODS RCTs published between January 1985 and July 2012 were eligible for inclusion. The primary outcome was live birth. Secondary outcomes were health of babies born, ongoing pregnancies, clinical pregnancies, miscarriages, multiple pregnancies, implantation rate, cryopreservation rate, embryo quality and fertilization rate. For those media that were evaluated in more than one comparison, an unconventional meta-analysis was performed by pooling the data of the media they were compared to. RESULTS Twenty-two RCTs were included that evaluated 31 different comparisons. Conventional meta-analysis was not possible for any of the outcomes as nearly all trials compared different culture media. Only four trials reported on live birth, and one of them reported a significant difference. Nine trials reported on ongoing and/or clinical pregnancy rates, of which four showed a significant difference. Pooling the data did not reveal a superior culture medium. CONCLUSIONS It is yet unknown what culture medium leads to the best success rates in IVF/ICSI. Given the potential importance of culture media for treatment outcome, rigorously designed RCTs are needed for currently available, as well as newly introduced culture media.

Fertility in Advanced Societies: A Review of Research: La fécondité dans les sociétés avancées: un examen des recherches

This paper provides a review of fertility research in advanced societies, societies in which birth control is the default option. The central aim is to provide a comprehensive review that summarizes how contemporary research has explained ongoing and expected fertility changes across time and space (i.e., cross- and within-country heterogeneity). A secondary aim is to provide an analytical synthesis of the core determinants of fertility, grouping them within the analytical level in which they operate. Determinants are positioned at the individual and/or couple level (micro-level), social relationships and social networks (meso-level); and, by cultural and institutional settings (macro-level). The focus is both on the quantum and on the tempo of fertility, with a particular focus on the postponement of childbearing. The review incorporates both theoretical and empirical contributions, with attention placed on empirically tested research and whether results support or falsify existing theoretical expectations. Attention is also devoted to causality and endogeneity issues. The paper concludes with an outline of the current challenges and opportunities for future research.

Impaired mitochondrial function in murine oocytes is associated with controlled ovarian hyperstimulation and in vitro maturation

The present study was designed to determine whether controlled ovarian hyperstimulation (COH) and in vitro maturation (IVM), two common clinical procedures in human IVF treatment, have an impact on mitochondrial DNA (mtDNA) copy number and mitochondrial function in oocytes. Matured mouse oocytes recovered following COH, IVM and natural cycles (NC), which simulated those treatments in human clinic IVF treatment. The copies of mtDNA, the activity of mitochondria as determined by inner mitochondrial membrane potential and oocyte adenosine trisphosphate (ATP) content, pattern of mitochondrial distribution, reactive oxygen species (ROS) levels and the integrity of the cytoskeleton were evaluated in oocytes. Significant differences were detected between COH and NC groups in all measures, except the pattern of mitochondrial distribution and ROS levels. There were also significant differences detected between IVM and NC treatment groups in the copies of mitochondrial DNA, the level of ROS and the integrity of the cytoskeleton in oocytes. In conclusion, the results of this investigation indicate that non-physiological COH and IVM treatments inhibit mtDNA replication, alter mitochondrial function and increase the percentage of abnormal cytoskeleton and ROS production. Damage related to the mitochondria may partly explain the low efficiency of IVF and high rate of embryonic loss associated with these clinical procedures.

Amino acid turnover by human oocytes is influenced by gamete developmental competence, patient characteristics and gonadotrophin treatment

STUDY QUESTION

Can amino acid profiling differentiate between human oocytes with differing competence to mature to metaphase II (MII) in vitro?

SUMMARY ANSWER

Oocytes which remained arrested at the germinal vesicle (GV) stage after 24 h of in vitro maturation (IVM) displayed differences in the depletion/appearance of amino acids compared with oocytes which progressed to MII and patient age, infertile diagnosis and ovarian stimulation regime significantly affected oocyte amino acid turnover during IVM.

WHAT IS KNOWN ALREADY

Amino acid profiling has been proposed as a technique which can distinguish between human pronucleate zygotes and cleavage stage embryos with the potential to develop to the blastocyst stage and implant to produce a pregnancy and those that arrest. Most recently, the amino acid turnover by individual bovine oocytes has been shown to be predictive of oocyte developmental competence as indicated by the gamete's capacity to undergo fertilization and early cleavage divisions in vitro.

STUDY DESIGN, SIZE, DURATION

The study was conducted between March 2005 and March 2010. A total of 216 oocytes which were at the GV or metaphase I (MI) stages at the time of ICSI were donated by 67 patients.

PARTICIPANTS/MATERIALS, SETTINGS, METHODS

The research was conducted in university research laboratories affiliated to a hospital-based infertility clinic. Oocytes were cultured for 24 h and the depletion/appearance of amino acids was measured during the final 6 h of IVM. Amino acid turnover was analysed in relation to oocyte meiotic progression, patient age, disease aetiology and controlled ovarian stimulation regime.

MAIN RESULTS AND THE ROLE OF CHANCE

The depletion/appearance of key amino acids was linked to the maturation potential of human oocytes in vitro. Oocytes which arrested at the GV stage (n = 9) depleted significantly more valine and isoleucine than those which progressed to MI (n = 32) or MII (n = 107) (P < 0.05). Glutamate, glutamine, arginine and valine depletion or appearance differed in MII versus degenerating oocytes (n = 20) (P < 0.05). Glutamine, arginine, methionine, phenylalanine, total depletion and total turnover all differed in oocytes from patients aged < 35 years versus patients ≥35 years (P < 0.05). MII oocytes obtained following ovarian stimulation with recombinant FSH depleted more isoleucine (P < 0.05) and more alanine and lysine (P < 0.05) appeared than oocytes from hMG-stimulated cycles. MII oocytes from patients with a polycystic ovary (PCO) morphology (n = 33) depleted more serine (P < 0.05) than oocytes from women with normal ovaries (n = 61).

LIMITATIONS, REASONS FOR CAUTION

Immature oocytes collected at the time of ICSI were used as the model for human oocyte maturation. These oocytes have therefore failed to respond to the ovulatory hCG trigger in vivo (they are meiotically incompetent), and have limited capacity to support embryo development in vitro. The lack of cumulus cells and stress of the conditions in vitro may have influenced turnover of amino acids, and owing to the small sample sizes further studies are required to confirm these findings.

WIDER IMPLICATIONS OF THE FINDINGS

The findings provide support for the hypothesis that oocyte metabolism reflects oocyte quality. Longitudinal studies are required to link these functional metabolic indices of human oocyte quality with embryo developmental competence. Oocyte amino acid profiling may be a useful tool to quantify the impact of new assisted reproduction technologies (ART) on oocyte quality.

STUDY FUNDING/COMPETING INTERESTS

This project was funded by the UK Biology and Biotechnology Research Council (BB/C007395/1) and the Medical Research Council (G 0800250). K.E.H was in receipt of a British Fertility Society/Merck Serono studentship. H.J.L. is a shareholder in Novocellus Ltd, a company which seeks to devise a non-invasive biochemical test of embryo health.

Are sperm DNA fragmentation, hyperactivation, and hyaluronan-binding ability predictive for fertilization and embryo development in in vitro fertilization and intracytoplasmic sperm injection?

OBJECTIVE

To determine the diagnostic value of the following sperm function tests in predicting the fertilizing ability of spermatozoa in conventional in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI): hyaluronan-binding assay (HBA), DNA fragmentation (Halosperm), and hyperactivity.

DESIGN

Prospective study.

SETTING

University medical center.

PATIENT(S)

133 couples undergoing infertility treatment with IVF/ICSI.

INTERVENTION(S)

Analysis of sperm DNA fragmentation, hyaluronan-binding ability, and hyperactivation on washed semen samples used for the insemination of oocytes.

MAIN OUTCOME MEASURE(S)

Correlation between the results of sperm function tests and the fertilization rate (FR) or embryo quality (EQ) after IVF and ICSI. Comparison of the sperm DNA fragmentation, hyperactivation, and hyaluronan binding ability between cycles with less than 50% (group 1) and more than 50% (group 2) of oocytes fertilized after IVF.

RESULT(S)

Both FR and EQ in IVF cycles negatively correlated with sperm DNA fragmentation. Furthermore, a positive correlation was observed between FR and hyaluronan-binding ability or induced hyperactivity. The semen samples from the IVF cycles with low FR (group 1) were characterized by statistically significantly higher sperm DNA fragmentation and lower hyaluronan-binding ability in comparison with semen samples from the group with high levels of fertilization (group 2). In ICSI cycles, no relationship was found between sperm function tests and FR or EQ.

CONCLUSION(S)

The Halosperm test, the HBA test, and induced hyperactivity are useful in predicting the ability of spermatozoa to fertilize oocytes in IVF and are helpful in distinguishing semen samples suitable for IVF or ICSI.