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.

Why do singletons conceived after assisted reproduction technology have adverse perinatal outcome? Systematic review and meta-analysis

BACKGROUND

Assisted reproduction technology (ART) is used worldwide, at increasing rates, and data show that some adverse outcomes occur more frequently than following spontaneous conception (SC). Possible explanatory factors for the well-known adverse perinatal outcome in ART singletons were evaluated.

METHODS

PubMed and Cochrane databases from 1982 to 2012 were searched. Studies using donor or frozen oocytes were excluded, as well as those with no control group or including <100 children. The main outcome measure was preterm birth (PTB defined as delivery <37 weeks of gestation), and a random effects model was used for meta-analyses of PTB. Other outcomes were very PTB, low-birthweight (LBW), very LBW, small for gestational age and perinatal mortality.

RESULTS

The search returned 1255 articles and 65 of these met the inclusion criteria. The following were identified as predictors for PTB in singletons: SC in couples with time to pregnancy (TTP) > 1 year versus SC singletons in couples with TTP ≤ 1 year [adjusted odds ratio (AOR) 1.35, 95% confidence interval (CI) 1.22, 1.50]; IVF/ICSI versus SC singletons from subfertile couples (TTP > 1 year; AOR 1.55, 95% CI 1.30, 1.85); conception after ovulation induction and/or intrauterine insemination versus SC singletons where TTP ≤ 1 year (AOR 1.45, 95% CI 1.21, 1.74); IVF/ICSI singletons versus their non-ART singleton siblings (AOR 1.27, 95% CI 1.08, 1.49). The risk of PTB in singletons with a 'vanishing co-twin' versus from a single gestation was AOR of 1.73 (95% CI 1.54, 1.94) in the narrative data. ICSI versus IVF (AOR 0.80, 95% CI 0.69-0.93), and frozen embryo transfer versus fresh embryo transfer (AOR 0.85, 95% CI 0.76, 0.94) were associated with a lower risk of PTB.

CONCLUSIONS

Subfertility is a major risk factor for adverse perinatal outcome in ART singletons, however, even in the same mother an ART singleton has a poorer outcome than the non-ART sibling; hence, factors related to the hormone stimulation and/or IVF methods per se also may play a part. Further research is required into mechanisms of epigenetic modification in human embryos and the effects of cryopreservation on this, whether milder ovarian stimulation regimens can improve embryo quality and endometrial conditions, and whether longer culture times for embryos has a negative influence on the perinatal outcome.

In vitro fertilisation treatment and factors affecting success

The efficacy of assisted reproductive technologies has improved significantly over the past decades. The main indications for in vitro fertilisation include tubal obstruction, severe male-factor infertility, severe endometriosis, ovulatory dysfunction, diminished ovarian reserve, and infertility of unexplained cause. In vitro fertilisation has also become an effective treatment option for couples wishing to undergo pre-implantation genetic diagnosis or screening, and for those wishing to cryopreserve their oocytes or embryos for preservation of fertility. The management of women in late reproductive age poses a major challenge; the optimum in vitro fertilisation treatment for poor responders remains elusive. The success of in vitro fertilisation treatment can be optimised by taking an individualised, patient-centered approach to controlled ovarian hyperstimulation. Key components involve selection of an appropriate controlled ovarian protocol, close-cycle monitoring, adjustment of gonadotropin dosage to avoid hyper-response, and individualised timing of human chorionic gonadotropin injection. Future directions of assisted reproductive technologies include development of non-invasive embryo selection methods, use of transcriptomics, proteomics, metabolomics, and time-lapse imaging technologies.

Effect of polyvinylpyrrolidone on sperm function and early embryonic development following intracytoplasmic sperm injection in human assisted reproduction

The objective here was to review the effects of polyvinylpyrrolidone (PVP) upon sperm function and embryonic development in humans. PVP has been used successfully in intracytoplasmic sperm injection (ICSI) to facilitate the handling and immobilization of sperm for both domestic animals and humans. In our previous reports, PVP solution exists locally in embryos injected during the early developmental period, and also exerts influence over the developmental capacity of such embryos. In other reports, PVP causes significant damage to sperm membranes that can be detected by transmission electron microscopy, and has been associated with chromosomal abnormalities in pregnancy derived from ICSI embryos. In some Japanese clinics, PVP-free media has been used for sperm immobilization in order to optimise safety. Consequently, it is strongly suggested that the success rate of fertilization and clinical pregnancy could be improved by using PVP-free solution for human ICSI. In conclusion, our interpretation of the available data is to perform ICSI without PVP or select a lower concentration of PVP solution in order to reduce safety for pregnancy and children born via ICSI.

Medical successes and couples' psychological problems in assisted reproduction treatment: a narrative based medicine approach

OBJECTIVE

1) To explore the psychological processes that develop in women and men during their first pregnancy obtained with assisted reproduction treatment; 2) to individuate the main plot that women and men use to recount their transition to parenthood.

METHODS

A face-to-face semi-structured autobiographical interview was administered. The interview was aimed to investigate the story of pregnancy. Interviews were transcribed verbatim and analyzed in order to merge principal themes.

PARTICIPANTS

15 Italian couples waiting for the first child after a conception with assisted reproductive technologies.

RESULTS

Medically assisted pregnancy constitutes an extremely stressful, highly medicalised experience, that the couple, however, narrated according to a basic plot consisting in four phases: doubt, final sentence, victory, monitoring.

CONCLUSIONS

Results suggest that physicians can benefit from knowing the phases that infertile couples experience during pregnancy because these can serve as a framework to use in monitoring their transition to parenthood and in planning psychological support and health interventions for them.

Administration of calcitonin promotes blastocyst implantation in mice by up-regulating integrin β3 expression in endometrial epithelial cells

STUDY QUESTION

Does exogenous calcitonin improve the efficiency of implantation in mice by increasing uterine receptivity?

SUMMARY ANSWER

The administration of calcitonin could improve the efficiency of implantation by increasing the expression of several receptivity-related genes in endometrial epithelial cells (EECs).

WHAT IS KNOWN ALREADY

Calcitonin is one of the biomarkers of uterine receptivity, which is transiently produced in the uterine epithelia during the period of implantation both in humans and mouse.

STUDY DESIGN, SIZE, DURATION

Hormone-replaced mice were used for in vivo experiments. To evaluate the effect of calcitonin on uterine receptivity, the expression of endometrial genes was analyzed 36 h after i.p. injection of 0.5 IU calcitonin in a treatment group versus saline in the control. To evaluate the effect of calcitonin on implantation efficiency in vivo, two groups received 0.5 IU or 2 IU calcitonin (i.p.) 24 h before embryo transfer, and a control group received saline (i.p.) (n = 18 mice per group). Implantation sites were counted 7 days after embryo transfer. The RL95-2 human endometrial carcinoma cell line was used to study the mechanisms underlying the effect of calcitonin on gene expression in the endometria. Using an in vitro model of endometrium-trophoblast interaction, established with RL95-2 cells and JAR (human choriocarcinoma cell line) trophoblast, endometrial receptivity was evaluated by comparing attachment and outgrowth of JAR spheroids in control and treatment groups.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Uterine receptivity in ovariectomized mice was induced by injection of estradiol and progesterone. Expression of eight genes in murine endometrium and RL95-2 cells was analyzed by real-time RT-PCR, western blot, immunohistochemical analysis, flow cytometry and enzyme-linked immunosorbent assay. We tested the effects of a protein kinase C inhibitor, matrigel and an antibody against integrin αvβ3 using RL95-2 cells and performed attachment and outgrowth assays using the in vitro model of endometrium-trophoblast interaction. Implantation efficiency was evaluated by counting the implantation sites after embryo transfer.

MAIN RESULTS AND THE ROLE OF CHANCE

Calcitonin up-regulated αvβ3 in RL95 cells, which in turn resulted in increased levels of the leukemia inhibitory factor (LIF) and heparin binding-epidermal growth factor (HB-EGF) mRNA (both P < 0.01 versus control) and protein (both P < 0.05 versus control). The attachment and expansion of JAR spheroids was promoted by pretreatment of EECs with calcitonin (P < 0.05 versus control) together with significantly increased expression of αvβ3, LIF and HB-EGF. Moreover, the injection of calcitonin in the preimplantation phase increased the total number of implantation sites in treatment groups (55 in control versus 78 and 85 in 0.5 and 2 IU groups, respectively). Compared with the control group (3.11 ± 2.14), the average number of implantation sites in the 2 IU calcitonin treatment group increased (4.72 ± 1.87, P = 0.022).

LIMITATIONS, REASONS FOR CAUTION

Experiments were performed in mice and human cell lines but not in primary cultures of human endometrial cells.

WIDER IMPLICATIONS OF THE FINDINGS

The findings presented here have important implications, in that calcitonin administration (currently used for treatment of hypercalcemia or osteoporosis) may have clinical benefits in assisted reproduction programs, by facilitating endometrial receptivity and embryo implantation. However, further studies are required to confirm these findings.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by National Science Foundation of China (No. 81170619). There are no financial or commercial conflicts in this study.

Single embryo transfer reduces the risk of perinatal mortality, a population study

STUDY QUESTION

Do births following single embryo transfers (SET) have a reduced risk of perinatal mortality compared with those following double embryo transfers (DET)?

SUMMARY ANSWER

SET is associated with reduced risk of perinatal mortality compared with DET.

WHAT IS KNOWN ALREADY

Fetal, neonatal and perinatal mortality are important indicators for monitoring pregnancy and childbirth, particularly for births following assisted reproductive technology (ART) treatments. Following the introduction of SET, there has been a decline in the perinatal mortality rate (PMR) among babies born after ART in Australia and New Zealand.

STUDY DESIGN, SIZE, DURATION

This population study (census) included 50,258 births of ≥ 20 weeks gestation and/or ≥ 400 g of birthweight following embryos transfer cycles in Australia and New Zealand during the period 2004-2008.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The PMR was calculated according to the number of embryos transferred and other demographic and treatment-related factors. Perinatal deaths were defined as the number of fetal deaths (stillbirths) plus the number of neonatal deaths (deaths that occur before 28 days after birth).

MAIN RESULTS AND THE ROLE OF CHANCE

The PMR was 16.2 per 1000 births (n= 813). Of the 813 perinatal deaths, 630 were fetal deaths and 183 neonatal deaths. Twins had a significantly higher PMR (27.8 per 1000 births) than singletons (12.4 per 1000 births). The risk of perinatal mortality for all births following DET was 53% higher than for all births following SET (adjusted risk ratio 1.53, 95% confidence interval (95% CI): 1.29-1.80). Births following fresh DET had a 58% increased risk of perinatal mortality compared with births following fresh SET (risk ratio 1.58, 95% CI: 1.32-1.90).

LIMITATIONS, REASONS FOR CAUTION

Information on outcomes was missing from <1% of clinical pregnancies recorded in Australian and New Zealand Assisted Reproduction Database for the study period. There are no data on the timing of fetal death, the cause of perinatal death or on late termination of pregnancy at ≥ 20 weeks' gestation.

WIDER IMPLICATIONS OF THE FINDINGS

Double and higher order embryo transfer is associated with a higher risk of perinatal mortality when compared with SET. The number of embryos transferred is determined by the clinician with consent of the patient and is a modifiable treatment factor. SET should be advocated as the first-line management in ART as it is the single most effective public health intervention for preventing excess perinatal mortality among ART pregnancies.

STUDY FUNDING/COMPETING INTEREST(S)

Nil.

Assisted reproductive techniques and the risk of anorectal malformations: a German case-control study

BACKGROUND

The use of assisted reproductive techniques (ART) for treatment of infertility is increasing rapidly worldwide. However, various health effects have been reported including a higher risk of congenital malformations. Therefore, we assessed the risk of anorectal malformations (ARM) after in-vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI).

METHODS

Data of the German Network for Congenital Uro-REctal malformations (CURE-Net) were compared to nationwide data of the German IVF register and the Federal Statistical Office (DESTATIS). Odds ratios (95% confidence intervals) were determined to quantify associations using multivariable logistic regression accounting for potential confounding or interaction by plurality of births.

RESULTS

In total, 295 ARM patients born between 1997 and 2011 in Germany, who were recruited through participating pediatric surgeries from all over Germany and the German self-help organisation SoMA, were included. Controls were all German live-births (n = 10,069,986) born between 1997 and 2010. Overall, 30 cases (10%) and 129,982 controls (1%) were born after IVF or ICSI, which translates to an odds ratio (95% confidence interval) of 8.7 (5.9-12.6) between ART and ARM in bivariate analyses. Separate analyses showed a significantly increased risk for ARM after IVF (OR, 10.9; 95% CI, 6.2-19.0; P < 0.0001) as well as after ICSI (OR, 7.5; 95% CI, 4.6-12.2; P < 0.0001). Furthermore, separate analyses of patients with isolated ARM, ARM with associated anomalies and those with a VATER/VACTERL association showed strong associations with ART (ORs 4.9, 11.9 and 7.9, respectively). After stratification for plurality of birth, the corresponding odds ratios (95% confidence intervals) were 7.7 (4.6-12.7) for singletons and 4.9 (2.4-10.1) for multiple births.

CONCLUSIONS

There is a strongly increased risk for ARM among children born after ART. Elevations of risk were seen after both IVF and ICSI. Further, separate analyses of patients with isolated ARM, ARM with associated anomalies and those with a VATER/VACTERL association showed increased risks in each group. An increased risk of ARM was also seen among both singletons and multiple births.

When no choice of embryos exists, the multiple pregnancy risk is still high

Multiple pregnancies arising from assisted reproduction are known to be associated with increased medical, psychological, economical and social risks. If only two embryos develop after culture, how should the couple be counselled in relation to the risk of multiple pregnancy? We performed a retrospective review of all IVF/ICSI treatments performed between 1 January 2005 and 31 December 2007, that resulted in double embryos transfer (DET). We identified 623 cycles with a fortuitous DET (Group I) and 635 cycles with an elective DET (Group II). Group II were significantly more likely to have twins when compared with Group I, irrespective of age. Twin rates in Group I were higher in IVF compared with ICSI; 33.3% vs 16.6% in < 35 years old and 16.2% vs 7.6% in 35-40 years old. Therefore, single embryo transfer should be considered for IVF patients below 35 years old, even if only two good quality embryos are available.

Motile sperm organelle morphology evaluation-selected globozoospermic human sperm with an acrosomal bud exhibits novel patterns and higher levels of phospholipase C zeta

STUDY QUESTION

Does motile sperm organelle morphology examination (MSOME) affect levels and localization patterns of the oocyte activation factor phospholipase C zeta (PLCζ) in globozoospermic sperm with and without an acrosomal bud?

SUMMARY ANSWER

MSOME identified round-headed globozoospermic sperm with increased levels of PLCζ relative to sperm from the same sample that did not undergo MSOME, and identified novel patterns of PLCζ localization in sperm exhibiting an acrosomal bud.

WHAT IS KNOWN ALREADY

Absence or reduction in the level of PLCζ in the sperm head, abnormal localization patterning, or defective functional ability as a result of PLCζ gene mutation, have been linked to certain types of human male factor infertility in which oocyte activation is deficient. It has been determined that a subpopulation of sperm (1%) from a patient exhibiting 100% globozoospermia presented with an acrosome bud upon MSOME. A cycle of intracytoplasmic morphologically selected sperm injection, carried out with sperm exhibiting an acrosomal bud led to pregnancy and birth of a healthy baby boy, without the use of assisted oocyte activation (AOA).

STUDY DESIGN, SIZE, DURATION

Immunofluorescent analysis of PLCζ in globozoospermic sperm from three patients, before and after MSOME.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Quantitative immunofluorescence was used to investigate PLCζ levels and localization patterns in individual sperm (n = 1 patient) identified by MSOME and isolated by micromanipulation, and presenting with and without the acrosomal bud. A secondary aim was to investigate levels and localization patterns of PLCζ in sperm before and after MSOME from two other globozoospermic men.

MAIN RESULTS AND THE ROLE OF CHANCE

Non-globozoospermic control sperm exhibited characteristic localization patterns of PLCζ immunofluorescence. Completely round-headed globozoospermic sperm from patients 1-3 were either devoid of PLCζ immunofluorescence, or exhibited an abnormal, punctate, pattern of PLCζ localization. PLCζ immunofluorescence in sperm exhibiting an acrosomal bud was observed in the midpiece with varying fluorescent intensity and was detected in 28.5% of such sperm. The majority of sperm with an acrosomal bud (43.0%) exhibited punctate patterns of PLCζ localization within the sperm head. A further 28.5% of sperm exhibited PLCζ in both the head and the midpiece. Total levels of PLCζ, and the proportions of sperm exhibiting PLCζ immunoreactivity, showed significant variance (P ≤ 0.05) amongst control [45.8 arbitrary units (a.u.) and 95.7%, respectively], non-MSOME-selected (25.9 a.u. and 46.1%, respectively) and MSOME-selected globozoospermic sperm (33.4 a.u. and 65.0%, respectively). Total levels of PLCζ immunofluorescence, and proportions of sperm exhibiting PLCζ immunoreactivity, in control sperm was significantly higher (P≤ 0.05) compared with non-MSOME-selected sperm, but not significantly different from MSOME-selected sperm.

LIMITATIONS, REASONS FOR CAUTION

The low numbers of sperm analysed may not be ideal for conclusive statistical analysis. Evaluation of the effects of MSOME on morphologically normal sperm would confirm conclusions.

WIDER IMPLICATIONS OF THE FINDINGS

The present findings provide hope for the future treatment of globozoospermia without the need for AOA, and provide further evidence for the clinical application of PLCζ as a therapeutic and prognostic tool.

STUDY FUNDING/COMPETING INTEREST(S)

The research described herein was funded by the Nuffield Department of Obstetrics and Gynaecology, University of Oxford. The authors report no conflict of interest.

Effect of maternal age on the outcomes of in vitro fertilization and embryo transfer (IVF-ET)

This is a retrospective, observational study to evaluate the effect of maternal age on the outcomes of in vitro fertilization and embryo transfer (IVF-ET). 11830 IVF-ET cycles from 10268 women were included. Four groups of different maternal age periods were compared. The groups were 21-30 years old group (4549 cycles), 31-35 years old group (4424 cycles), 36-40 years old group (2429 cycles), and over 40 years old group (428 cycles). The mean starting dose of Gn and mean total dose of Gn in each cycle were significantly higher (P<0.01), while the mean retrieved oocyte number was significantly lower (P<0.01) in groups of higher maternal age period than those in each of the lower groups. The biochemical pregnancy rate and the clinical pregnancy rate were significantly lower (P<0.01), while the miscarriage rate was significantly higher (P<0.01) in groups of higher maternal age period than those in the lower groups. No difference was found in two-pronuclear zygotes (2PN) rate and good quality embryo rate among different groups. Birth defect rate was also comparable in the born babies in different groups. In the group with patients' age over 40 years old, the pregnancy rate was 26.87%, the clinical pregnancy rate was 19.39%, while the miscarriage rate after clinical pregnancy was 36.14%. To draw the conclusion, patients with higher maternal age had worse IVF outcomes. In women of fertile age, patients between 20 and 30 years old have the best IVF outcomes. Patients over 40 years old have poor IVF outcome and high miscarriage rate, which suggested the necessity of preimplantation genetic screening (PGS).

Assisted reproductive technology in Europe, 2008: results generated from European registers by ESHRE

BACKGROUND

This 12th European IVF-monitoring (EIM) report presents the results of treatments involving assisted reproductive technology (ART) initiated in Europe during 2008.

METHODS

From 36 countries (3 more compared with 2007), 1051 clinics reported 532 260 treatment cycles including: IVF (124 539), ICSI (280 552), frozen embryo replacements (FER, 97 120), egg donation (ED, 13 609), in vitro maturation (IVM, 562), preimplantation genetic diagnosis/screening (PGD/PGS, 2875) and frozen oocyte replacements (FOR, 4080). Overall, this represents a 7.9% increase in the activity since 2007, which is mainly related to an increase in cycles from almost all registers and only partially to the new countries entering EIM (Estonia, Kazakhstan, Moldova and Romania, 5480 cycles in total). European data on intrauterine insemination using husband/partner's (IUI-H) and donor (IUI-D) semen were reported from 27 and 21 countries, respectively. A total of 144 509 IUI-H (+1.5%) and 24 960 IUI-D (-4.3%) cycles were included.

RESULTS

In 19 countries where all clinics reported to the ART register, a total of 350 143 ART cycles were performed in a population of 369.8 million, corresponding to 947 cycles per million inhabitants. For IVF, the clinical pregnancy rates per aspiration and per transfer were 28.5 and 32.5%, respectively, and for ICSI the corresponding rates were 28.7 and 31.9%. In FER cycles, the pregnancy rate per thawing was 19.3%. The delivery rate after IUI was 9.1% for IUI-H and 13.8% for IUI-D. In IVF and ICSI cycles, one, two, three and four or more embryos were transferred in 22.4, 53.2, 22.3 and 2.1%, respectively. The proportions of singleton, twin and triplet deliveries after IVF and ICSI (combined) were 78.3, 20.7 and 1.0%, respectively, resulting in a total multiple delivery rate of 21.7%, compared with 22.3% in 2007, 20.8% in 2006 and 21.8% in 2005. In FER cycles, the multiple delivery rate was 13.7% (13.4% twins and 0.3% triplets). In women undergoing IUI, twin and triplet deliveries occurred in 10.6% and 0.7% with IUI-H and in 9.4 and 0.3% with IUI-D, respectively.

CONCLUSIONS

In comparison with previous years, there was an increase in the reported number of ART cycles in Europe. For the first time in 5 years, the pregnancy rates failed to show a year-on-year increase. Compared with 2007, the number of transfers of multiple embryos (3+) and a multiple delivery rate showed a marginal decline.

A Review of Outcome Data concerning Children Born following Assisted Reproductive Technologies

Assisted reproductive technologies (ARTS) are used for more than 30 years to help infertile couples. Concerns about long-term health of children conceived following ART have led to start follow-up studies. Despite methodological limitations and discrepant results, many of the studies and meta-analyses have reported an increased risk of birth defects after ART. Etiologies may be multiple births, a major drawback of ART, parents' subfertility, or technologies themselves. Prematurity and intrauterine growth retardation (IUGR) seem to cause most of the pathologies reported in ART children. Nevertheless, epigenetic disorders need to be followed up since increases of imprinting diseases were reported. Consequently, alteration of gametes and early embryo development with ART may have consequences on children health since periconceptional period is critical for long-term development. Yet general condition of most of children conceived with ART is reassuring, but long-term followup is still strongly needed.

Obstetric and perinatal outcomes in singleton pregnancies resulting from the transfer of frozen thawed versus fresh embryos generated through in vitro fertilization treatment: a systematic review and meta-analysis

OBJECTIVE

To perform a systematic review and meta-analysis of obstetric and perinatal complications in singleton pregnancies after the transfer of frozen thawed and fresh embryos generated through IVF.

DESIGN

Systematic review.

SETTING

Observational studies, comparing obstetric and perinatal outcomes in singleton pregnancies subsequent to frozen thawed ET versus fresh embryo transfer, were included from Medline, EMBASE, Cochrane Central Register of Clinical Trials, DARE, and CINAHL (1984-2012).

PATIENT(S)

Women undergoing IVF/intracytoplasmic sperm injection (ICSI).

INTERVENTION(S)

Two independent reviewers extracted data and assessed the methodological quality of the relevant studies using critical appraisal skills program scoring. Risk ratios and risk differences were calculated in Rev Man 5.1. Subgroup analysis was performed on matched cohort studies.

MAIN OUTCOME MEASURE(S)

Antepartum hemorrhage, very preterm birth, preterm birth, small for gestational age, low birth weight, very low birth weight, cesarean section, congenital anomalies, perinatal mortality, and admission to neonatal intensive care unit.

RESULT(S)

Eleven studies met the inclusion criteria. Singleton pregnancies after the transfer of frozen thawed embryos were associated with better perinatal outcomes compared with those after fresh IVF embryos. The relative risks (RR) and 95% confidence intervals (CI) of antepartum hemorrhage (RR = 0.67, 95% CI 0.55-0.81), preterm birth (RR = 0.84, 95% CI 0.78-0.90), small for gestational age (RR = 0.45, 95% CI 0.30-0.66), low birth weight (RR = 0.69, 95% CI 0.62-0.76), and perinatal mortality (RR = 0.68, 95% CI 0.48-0.96) were lower in women who received frozen embryos.

CONCLUSION(S)

Although fresh ET is the norm in IVF, results of this systematic review of observational studies suggest that pregnancies arising from the transfer of frozen thawed IVF embryos seem to have better obstetric and perinatal outcomes.

A reduction in public funding for fertility treatment--an econometric analysis of access to treatment and savings to government

BACKGROUND

Almost all assisted reproductive technology (ART) and intrauterine insemination (IUI) treatments performed in Australia are subsidized through the Australian Government's universal insurance scheme, Medicare. In 2010 restrictions on the amount Medicare paid in benefits for these treatments were introduced, increasing patient out-of-pocket payments for fresh and frozen embryo ART cycles and IUI. The aim of this study was to evaluate the impact of the policy on access to treatment, savings in Medicare benefits and the number of ART conceived children not born.

METHODS

Pooled quarterly cross-sectional Medicare data from 2007 and 2011 where used to construct a series of Ordinary Least Squares (OLS) regression models to evaluate the impact of the policy on access to treatment by women of different ages. Government savings in the 12 months after the policy was calculated as the difference between the predicted and observed Medicare benefits paid.

RESULTS

After controlling for underlying time trends and unobserved factors the policy change reduced the number of fresh embryo cycles by almost 8600 cycles over 12 months (a 16% reduction in cycles, p < 0.001). The policy effect was greatest on women aged 40 years and older (38% reduction in cycles, p < 0.001). Younger women engaged in relatively more anticipatory behaviour by bringing forward their fresh cycles to 2009. Frozen embryo cycles, which are approximately one quarter of the cost of a fresh cycle, were only marginally impacted by the policy. Utilisation of IUI cycles were not impacted by the policy. After adjusting for anticipatory behaviour, $76 million in Medicare benefits was saved in the 12 months after the policy change (0.47% of annual Medicare benefits). Between 1200 and 1500 ART conceived children were not born in 2010 as a consequence of the policy.

CONCLUSIONS

The introduction of the policy resulted in a significant reduction in fresh ART cycles in the first 15 months after its introduction. Further evaluation on the long-term impact of the policy with regard access to treatment and on clinical practice, particularly the number of embryos transferred, is crucial to ensuring equitable access to fertility treatment and the health and welfare of ART children.

Obstetric outcome and long-term follow up of children conceived through assisted reproduction

Most children born after assisted reproduction techniques are healthy. The most important risk associated with in-vitro fertilisation is the higher multiple birth rate, which may result in increased child morbidity because several embryos are transferred at each cycle. Single-embryo transfer reduces this risk dramatically. Large registry studies and meta-analyses have indicated a small but statistically significantly increased risk of congenital malformations among children born after in-vitro fertilisation. Other risks, such as preterm birth and low birth weight seem to be associated more with parental characteristics than the in-vitro fertilisation technique. All knowledge about children conceived through in-vitro fertilisation is based on observational studies, with risks of bias and confounders. It is possible that pregnancies and children resulting from in-vitro fertilisation are more carefully monitored and seek health care more frequently, resulting in more health problems being discovered. Continuous follow up of children after in-vitro fertilisation is of great importance, particularly as new techniques are constantly being introduced.

Preterm birth and Assisted Reproductive Technology/ART: maternal emotional wellbeing and quality of mother-newborn interaction during the first three months of life

OBJECTIVE

Assisted Reproductive Technology (ART) and premature birth are stressful and difficult experiences for women. No research to date has examined the impact of ART on mother-child relationship in instances of preterm delivery. This study explored the psychological status of preterm infants' ART-mothers and the quality of mother-infant dyadic interaction, up to child age of three months (Corrected Age = CA).

METHOD

Forty-one ART-dyads and 53 Spontaneous Pregnancy (SP) dyads were enrolled. Mother and child were assessed at 5 to 7 days after birth (T1), at child discharge from hospital (T2), at one month after discharge (T3); and at 3 months CA (T4). The following measures were administered to the mothers: the Gordon Personal Profile Inventory, the Beck Anxiety Inventory, the Beck Depression Inventory, and the Parenting Stress Index S-F. Mother-child interaction was coded by using the Nursing Child Assessment Feeding Scale.

RESULTS

At childbirth, the control group mothers showed a higher level of anxiety than the ART-mothers did, but at T2, T3, T4, both groups' parenting stress levels were below threshold. Conversely, ART mothers more frequently provided suitable stimulation for their child's socio-emotional and cognitive development than the control group did. No significant between-group differences were observed in the mothers' capacity to respond to their children's distress, nor in sensitivity to child cues. Both infant groups showed equal ability to send clear signals and to respond to parent-provided care.

CONCLUSIONS

ART and SP mothers with premature infants showed no differences in degree of emotional burden experienced during the neonatal period. Yet, dyadic interaction was qualitatively better in ART dyads than in SP dyads.

Elective single embryo transfer and cumulative pregnancy rate: five-year experience in a Southern European Country

To compare cumulative pregnancy and live birth rates of single embryo transfer (SET) vs. double embryo transfer (DET) in women <35 years old with good-quality embryos, we designed an observational prospective study carried out between October 2002 and December 2006. Patients who accepted SET were compared with those who decided DET. A total of 628 couples who underwent embryo transfers met the criteria for SET: 52% accepted it, while 47.8% asked for DET. Implantation rate was higher in SET, 46.6% (p < 0.05), whereas pregnancy rate (PR) per transfer was higher in DET, 38.3% (p < 0.05). Twin PR in DET was 26.4% compared with 0.7% in SET (p < 0.05). SET group performed 278 frozen embryo transfer and DET 128. The mean of embryos transferred was the same, resulting in similar pregnancy and twin PR (SET: 24.8% and 21.7% vs. DET: 25.0% and 28.1%). Cumulative PR was 66.2% in SET and 69.7% in DET, not showing significant differences (NS). Likewise, cumulative live birth rates did not show differences. Cumulative twin PR in SET was 7.2% and in DET 26.6%, (p < 0.05). Cumulative PR over time leveled at 15-18 months follow-up in both groups. In Conclusion, in order to reduce twins we support the promotion of SET.

Ovarian stimulation and intrauterine insemination at the quarter centennial: implications for the multiple births epidemic

Ovarian stimulation and intrauterine insemination (OS/IUI), a mainstay of current infertility therapy and a common antecedent to IVF, is a significant driver of the multiple births epidemic. Redress of this challenge, now marking its quarter centennial, will require a rethinking of current practice patterns. Herein we explore prospects for prevention, mitigation, and eventual resolution. We conclude that the multiple births attributable to OS/IUI may not be entirely preventable but that the outlook for their mitigation is promising, if in need of solidification. Specifically, we observe that low-dose (≤ 75 IU) gondotropin, clomiphene, and especially off-label letrozole regimens outperform high-dose (≥ 150 IU) gonadotropin counterparts in the gestational plurality category while maintaining comparable per-cycle pregnancy rates. Accordingly we recommend that, subject to appropriate exceptions, high-dose gonadotropin regimens be used sparingly and that whenever possible they be replaced with emerging alternatives. Finally, we posit that OS/IUI is not likely to be superseded by IVF absent further commoditization and thus greater affordability.

Recommendations for fertility preservation in patients with lymphomas

PURPOSE

This guideline aims to serve as a reference for fertility specialists and other specialists working with young patients at risk of premature ovarian insufficiency (POI) or testicular dysfunction (TD) due to treatment of Hodgkin or Non-Hodgkin lymphoma.

METHODS

PubMed search of articles addressing risk of POI and TD according to different treatment protocols used in lymphoma patients. PubMed search of articles presenting different options for fertility treatment in cancer patients.

RESULTS

The risk of POI/TD depends on the protocol used with the highest risk in patients treated with haematopoietic stem cell transplantation/bone marrow transplantation (HSCT/BMT) and the lowest risk in patients treated with ABVD (Adriamycin, Bleomycin, Vincristine and Decarbazine). The different options of fertility preservation are discussed and their relevance according to treatment protocol, age of the patient and urgency to start treatment.

CONCLUSION

Fertility issues should be discussed with all women of fertile age. Fertility preservation should be offered to young women when relevant. Children should be informed together with their parents. All men should be offered semen cryopreservation regardless of protocol used. At present, there are no established methods of fertility preservation in pre-pubertal boys. This guideline offers suggestions to the most preferred methods of fertility preservation according to treatment protocol, age of the patient, and urgency to start treatment.

Predicting and preventing ovarian hyperstimulation syndrome (OHSS): the need for individualized not standardized treatment

Ovarian hyperstimulation syndrome (OHSS) is the most serious complication of controlled ovarian stimulation (COS) as part of assisted reproductive technologies (ART). While the safety and efficacy of ART is well established, physicians should always be aware of the risk of OHSS in patients undergoing COS, as it can be fatal. This article will briefly present the pathophysiology of OHSS, including the key role of vascular endothelial growth factor (VEGF), to provide the foundation for an overview of current techniques for the prevention of OHSS. Risk factors and predictive factors for OHSS will be presented, as recognizing these risk factors and individualizing the COS protocol appropriately is the key to the primary prevention of OHSS, as the benefits and risks of each COS strategy vary among individuals. Individualized COS (iCOS) could effectively eradicate OHSS, and the identification of hormonal, functional and genetic markers of ovarian response will facilitate iCOS. However, if iCOS is not properly applied, various preventive measures can be instituted once COS has begun, including cancelling the cycle, coasting, individualizing the human chorionic gonadotropin trigger dose or using a gonadotropin-releasing hormone (GnRH) agonist (for those using a GnRH antagonist protocol), the use of intravenous fluids at the time of oocyte retrieval, and cryopreserving/vitrifying all embryos for subsequent transfer in an unstimulated cycle. Some of these techniques have been widely adopted, despite the scarcity of data from randomized clinical trials to support their use.

Patterns of globalized reproduction: Egg cells regulation in Israel and Austria

Since the successful introduction of in vitro fertilization in 1978, medically assisted reproduction (MAR) has proliferated in multiple clinical innovations. Consequently, egg cells have become an object of demand for both infertility treatment and stem cell research, and this raises complex legal, ethical, social and economic issues.In this paper we compare how the procurement and use of human egg cells is regulated in two countries: Israel and Austria. Israel is known for its scientific leadership, generous public funding, high utilization and liberal regulation of assisted reproductive technology (ART). Austria lies at the other extreme of the regulatory spectrum in terms of restrictions on reproductive interventions.In both countries, however, there is a constant increase in the use of the technology, and recent legal developments make egg cells more accessible. Also, in both countries the scarcity of egg cells in concert with the rising demand for donations has led to the emergence of cross-border markets and global 'reproductive tourism' practices. In Israel, in particular, a scandal known as the 'eggs affair' was followed by regulation that allowed egg cell donations from outside the country under certain conditions.Cross-border markets are developed by medical entrepreneurs, driven by global economic gaps, made possible by trans-national regulatory lacunae and find expression as consumer demand. The transnational practice of egg cell donations indicates the emergence of a global public health issue, but there is a general lack of medical and epidemiological data on its efficacy and safety. We conclude that there is need for harmonisation of domestic laws and formulation of new instruments for international governance.

In vitro fertilisation for unexplained subfertility

BACKGROUND

In vitro fertilisation (IVF) is a widely accepted treatment for unexplained infertility (NICE 2004), which affects up to a third of all infertile couples. With estimated live birth rates (LBRs) per cycle varying from 33.1% in women aged under 35 years down to 12.5% in women aged between 40 and 42 years (HFEA 2011), its effectiveness has not been rigorously evaluated in comparison with other treatments. With increasing awareness of the role of expectant management, less-invasive procedures such as intrauterine insemination (IUI), and concerns about multiple pregnancies and costs associated with IVF, it is important to evaluate the effectiveness of IVF against other treatment options in couples with unexplained infertility.

OBJECTIVES

To evaluate the effectiveness and safety of IVF compared to expectant management, clomiphene citrate, IUI alone and intrauterine insemination plus controlled ovarian stimulation (IUI+SO).

SEARCH METHODS

Cochrane Menstrual Disorders and Subfertility Group Trials Register (searched July 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, first quarter), MEDLINE (1970 to July 2011), EMBASE (1985 to July 2011) and reference lists of articles were searched. Relevant conference proceedings were handsearched. Authors were contacted.

SELECTION CRITERIA

Randomised controlled trials (RCTs) were included. LBR per woman was the primary outcome.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility and quality of trials.

MAIN RESULTS

Six RCTs were included in the final analysis. LBR per woman was significantly higher with IVF (45.8%) than expectant management (3.7%) (odds ratio (OR) 22.00, 95% confidence interval (CI) 2.56 to 189.37, 1 RCT, 51 women). There were no comparative data for clomiphene citrate. There was no evidence of a significant difference in LBR between IVF and IUI alone (OR 1.96, 95% CI 0.88 to 4.36, 1 RCT, 113 women), 40.7% with IVF versus 25.9% with IUI. In studies comparing IVF versus IUI+SO, LBR per woman did not differ significantly between the groups among treatment-naive women (OR 1.09, 95% CI 0.74 to 1.59, 2 RCTs, 234 women) but was significantly higher in a large RCT of women pretreated with IUI + clomiphene citrate (OR 2.66, 95% CI 1.94 to 3.63, 1 RCT, 341 women). These three studies could not be pooled due to high heterogeneity (I(2) = 84%). There was no evidence of a significant difference in multiple pregnancy rate (MPR) or ovarian hyperstimulation syndrome (OHSS) between the two treatments (OR 0.64, 95% CI 0.31 to 1.29, 3 RCTs, 351 women; OR 1.53, 95% CI 0.25 to 9.49, 1 RCT, 118 women, respectively).

AUTHORS' CONCLUSIONS

IVF may be more effective than IUI+SO. Due to paucity of data from RCTs the effectiveness of IVF for unexplained infertility relative to expectant management, clomiphene citrate and IUI alone remains unproven. Adverse events and the costs associated with these interventions have not been adequately assessed.

Guidelines for infertility counselling in different countries: is there an emerging trend?

BACKGROUND

It is widely accepted that infertility and involuntary childlessness, and the decision to engage with assisted reproduction technology (ART) services as a patient, donor or surrogate can entail wide-ranging psychosocial issues. Psychosocial counselling has, therefore, become valued as an integral element of ART services. The objective of this study was to begin to map out what exists globally by the way of guidelines for infertility counselling.

METHODS

Data were analysed from formal guidelines produced by seven national infertility counselling bodies, onetransnational infertility counselling organization, reports of the American Society for Reproductive Medicine Ethics Committee and Practice Committee and the ESHRE Task Force on Ethics and Law. Additional sources of data were the International Infertility Counseling Organization and counselling colleagues internationally.

RESULTS

Four broad areas concerning contemporary practice in infertility counselling are identified: (i) the legal mandate for counselling; (ii) eligibility credentials for individuals carrying out professional counselling activities; (iii) different forms of counselling and (iv) counselling practice in relation to specific elements of assisted reproduction treatment.

CONCLUSIONS

Internationally, the development of infertility guidelines is best described as a 'work in progress', although key trends are evident.

Full in vitro fertilization laboratory mechanization: toward robotic assisted reproduction?

OBJECTIVE

To describe the current efforts made to standardize different steps of assisted reproductive technology processes by the introduction of new technologies for the nonsubjective sperm selection process, oocyte denudation by mechanical removal of cumulus cells, oocyte positioning, sperm motility screening, fertilization, embryo culture, media replacement by microfluidics, and monitoring of embryo development by time-lapse photography, embryo secretions, and/or O(2) consumption. These technologies could be integrated in a unique and fully automated device.

DESIGN

Pubmed database and research and development data from authors.

SETTING

University-affiliated private center.

PATIENT(S)

None.

INTERVENTION(S)

None.

MAIN OUTCOME MEASUREMENT(S)

None.

RESULT(S)

Several technologies would be useful for: 1) selection of sperm based on viability; 2) manipulation and removal of the cumulus cells' narrow channel regions combined with microfluidics; 3) advances in oocyte positioning precision through the use of joystick-controlled micromanipulators; 4) microfluidics allowing the gradual change of a culture medium, which might result in better embryo development as well as reduce the amount of embryo manipulation; 5) time-lapse, proteomic, and metabolic scoring of the developing embryo, allowing multiple and optimized selection of the embryos. The technologies described in this review have not yet reported reliable clinical proofs.

CONCLUSION(S)

We already have available some of the technologies described, but we envisage an integrated device, i.e., an IVF lab-on-a-chip, by which oocyte and sperm would be processed to achieve a perfect embryo ready to be delivered into the uterus. With such a device, sample preparation, chemical or biologic reactions, and data collection would be integrated.

Assisted reproductive technology in Europe, 2007: results generated from European registers by ESHRE

BACKGROUND

This 11th European IVF-monitoring report presents the results of assisted reproductive technology (ART) treatments initiated in Europe during 2007.

METHODS

From 33 countries, 1029 clinics reported 493 184 treatment cycles: IVF (120 761), ICSI (256 642), frozen embryo replacement (91 145), egg donation (15 731), preimplantation genetic diagnosis/preimplantation genetic screening (4638), in vitro maturation (660) and frozen oocytes replacements (3607). Overall, this represents a 7.6% increase since 2006, mostly related to an increase in all registers. IUI using husband/partner's (IUI-H) and donor (IUI-D) semen was reported from 23 countries: 142 609 IUI-H (+6.2%) and 26 088 IUI-D (+7.2%).

RESULTS

In 18 countries where all clinics reported, 376 971 ART cycles were performed in a population of 425.6 million (886 cycles per million). The clinical pregnancy rates per aspiration and per transfer were 29.1 and 32.8% for IVF, and 28.6 and 33.0% for ICSI. Delivery rate after IUI-H was 10.2% in women aged < 40 years. In IVF/ICSI cycles, 1, 2, 3 and ≥4 embryos were transferred in 21.4, 53.4, 22.7 and 2.5% of cycles, with no decline in the number of embryos per transfer since 2006. The proportion of multiple deliveries (22.3: 21.3% twin and 1.0% triplet), did not decrease compared with 2006 (20.8%) and 2005 (21.8%). In women < 40 years undergoing IUI-H, twin deliveries occurred in 11.7% and triplets in 0.5%.

CONCLUSIONS

In comparison with previous years, the reported number of ART cycles in Europe increased in 2007; pregnancy rates increased marginally, but the earlier decline in the number of embryos transferred and multiple births did not continue.

Cross-border reproductive services--suggestions for ethically based minimum standards of care in Europe

Cross-border reproductive services (CBRS) is a phenomenon discussed worldwide. The major challenges associated with CBRS are the lack of data on the number of patients travelling for treatment and lack of transparency regarding the quality and safety of treatment procedures, especially in countries that have not yet introduced legislation or binding professional guidelines. This has given rise to practices that range from dubious to irresponsible treatment. Given that pan-European (let alone globally encompassing) legislation or guidelines are unlikely to appear quickly if at all, the authors suggest the implementation of ethically based minimum standards of care to which clinics and service providers can adhere on a voluntary basis. Such minimum standards of care can result in providing infertility treatment that is transparent, accountable and carried out responsibly for all parties involved.

Obstetric outcome in singletons after in vitro fertilization with cryopreserved/thawed embryos

BACKGROUND

There is increasing use of cryopreservation in IVF. This study compared singletons born after cryopreservation with singletons born after fresh IVF cycles and singletons born to women in the general population.

METHODS

Data were collected for Swedish IVF treatments during the years 2002-2006. All singletons from single embryo transfer (SET) and double embryo transfer (DET) after cryopreserved (n = 2348) and fresh cycles (n = 8944) were included and cross-linked with the Swedish Medical Birth Registry and compared with all singletons born after spontaneous conception (n = 571 914). Main outcomes were preterm and very preterm birth and low and very low birthweight (VLBW). Other outcomes were small for gestational age, large for gestational age (LGA), perinatal mortality and maternal outcomes.

RESULTS

Singletons from cryopreserved SET/DET or cryopreserved SET had increased rates of extreme preterm birth compared with singletons from the general population. A lower rate of LBW was found for cryopreserved SET/DET singletons compared with singletons from fresh cycles; however, a higher rate of perinatal mortality was detected. The rates of LGA and macrosomia were increased for cryopreserved SET/DET singletons when compared with those from fresh cycles and the general population. For maternal outcomes, a higher rate of pre-eclampsia was noted for pregnancies from cryopreserved cycles compared with those from fresh cycles or the general population, but the rate of placenta praevia was lower in pregnancies from cryopreserved cycles compared with those from fresh cycles.

CONCLUSIONS

The obstetric outcome of singletons after cryopreservation was slightly poorer when compared with the general population. In comparison with fresh cycles, the outcome varied. The finding of an increased rate of LGA after cryopreservation requires further study.