Why do couples refuse or discontinue ART?

Impact of in vitro fertilization state mandates for third party insurance coverage in the United States: a review and critical assessment

The American Society for Reproductive Medicine estimates that fewer than a quarter of infertile couples have sufficient access to infertility care. Insurers in the United States (US) have long considered infertility to be a socially constructed condition, and thus in-vitro fertilization (IVF) an elective intervention. As a result, IVF is cost prohibitive for many patients in the US. State infertility insurance mandates are a crucial mechanism for expanding access to fertility care in the US in the absence of federal legislation. The first state insurance mandate for third party coverage of infertility services was passed by West Virginia in 1977, and Maryland passed the country's first IVF mandate in 1985. To date, twenty states have passed legislation requiring insurers to cover or offer coverage for the diagnosis and treatment of infertility. Ten states currently have "comprehensive" IVF mandates, meaning they require third party coverage for IVF with minimal restrictions to patient eligibility, exemptions, and lifetime limits. Several studies analyzing the impact of infertility and IVF mandates have been published in the past 20 years. In this review, we characterize and contextualize the existing evidence of the impact of state insurance mandates on access to infertility treatment, IVF practice patterns, and reproductive outcomes. Furthermore, we summarize the arguments in favor of insurance coverage for infertility care and assess the limitations of state insurance mandates as a strategy for increasing access to infertility treatment. State mandates play a key role in the promotion of evidence-based practices and represent an essential and impactful strategy for the advancement of gender equality and reproductive rights.

Restraint stress and elevation of corticotrophin-releasing hormone in female mice impair oocyte competence through activation of the tumour necrosis factor α (TNF-α) system

Studies have observed that restraint stress (RS) and the associated elevation in corticotrophin-releasing hormone (CRH) impair oocyte competence by triggering apoptosis of ovarian cells but the underlying mechanisms are largely unclear. Although one study demonstrated that RS and CRH elevation triggered apoptosis in ovarian cells and oocytes via activating Fas/FasL signalling, other studies suggested that RS might damage cells by activating other pathways as well as Fas signalling. The objective of this study was to test whether RS and CRH elevation impairs oocytes by activating tumour necrosis factor α (TNF-α) signalling. Our invivo experiments showed that RS applied during oocyte prematuration significantly increased expression of TNF-α and its receptor (TNFR1) while inducing apoptosis in both oocytes and mural granulosa cells (MGCs). Invitro treatment of MGCs with CRH significantly increased their apoptotic percentages and levels of TNF-α and TNFR1 expression. Invitro knockdown by interfering RNA, invivo knockout of the TNF-α gene or injection of TNF-α antagonist etanercept significantly relieved the adverse effects of RS and CRH on apoptosis of MGCs and/or the developmental potential and apoptosis of oocytes. The results suggest that RS and CRH elevation in females impair oocyte competence through activating TNF-α signalling and that a TNF-α antagonist might be adopted to ameliorate the adverse effects of psychological stress on oocytes.

Dropout rate and cumulative birth outcomes in couples undergoing in vitro fertilization within a funded and actively managed system of care in New Zealand

OBJECTIVE

To determine the dropout rate between the first and second in vitro fertilization (IVF) cycles in a controlled population derived from a funded and actively managed system of care in New Zealand, including the reason for dropout and associated cumulative live birth rate.

DESIGN

Retrospective cohort.

SETTING

Multicenter IVF practice.

PATIENT(S)

Couples qualifying for publicly funded IVF treatment under New Zealand's Clinical Priority Assessment Criteria. Couples (n = 974) started treatment between July 2011 and June 2013, used their own gametes, and were eligible for up to 2 IVF packages of funded care (including the transfer of surplus embryos).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

IVF dropout rate, reason for dropout, and cumulative live birth rate.

RESULT(S)

A low IVF dropout rate between the first and second IVF cycle was reported within this controlled IVF population, with 10% of couples discontinuing treatment for reasons related to stress. The cumulative live birth rate in this "low dropout" population was 59% at the end of treatment, ranging from 72% (≤30 years) to 42% (38-39 years) according to female age. Most patients who discontinued for stress had a good prognosis, and a third of patients still had embryos in cryostorage. Only 30% of those who discontinued used the funded counseling services.

CONCLUSION(S)

A low dropout rate (10%) can be achieved within an actively managed IVF population. This was lower than previously reported, suggesting that prognosis, cost, and treatment management are the significant causes of dropout within the general IVF population. Couples with many embryos also require psychological support because of treatment fatigue or repeated transfers.

A clinical counseling tool predicting supernumerary embryos after a fresh IVF cycle

PURPOSE

To identify factors predictive of having supernumerary embryos in a fresh IVF cycle and create a prediction model for clinical counseling.

METHODS

We utilized a multivariable Poisson regression to identify predictive factors and then entered these into a logistic regression model, calculating a risk index for each significant variable. The final model was tested using a receiver operating characteristic curve.

RESULTS

A total of 60,616 fresh transfer cycles were reported to the Society for Assisted Reproductive Technology in 2014. Of these, 47.17% produced supernumerary embryos. A multivariate Poisson regression identified factors predictive of having supernumerary embryos, with age and AMH being the most predictive. Clinical prediction models were developed with acceptable and excellent discrimination. 23.5% of our cohort did not achieve a live birth following their fresh transfer and had excess embryos cryopreserved for future attempts.

CONCLUSION

Our study suggests that in a minority of fresh IVF cycles in the USA, the fresh transfer is not successful, and there are excess embryos cryopreserved for future use. The likelihood of excess embryos beyond those that would be transferred can be predicted with satisfactory precision prior to initiation of the cycle and with improved precision after fresh embryo transfer. Providing patients with a realistic estimate of their chances of having excess embryos at an initial IVF consult especially those with suspected poor prognosis can be beneficial in determining whether to proceed with multiple embryo banking cycles as opposed to proceeding with a fresh transfer, and whether to opt for an enhanced embryo selection technique such as preimplantation genetic testing for aneuploidy (PGT-A).

Factors associated with early in vitro fertilization treatment discontinuation

OBJECTIVE

To investigate factors associated with early IVF treatment discontinuation.

DESIGN

Retrospective cohort study.

SETTING

Academic medical center.

PATIENT(S)

Six hundred sixty-nine first-attempt IVF patients who did not have a live birth.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Treatment discontinuation and time to return for a second IVF cycle.

RESULT(S)

Women without IVF insurance coverage were more likely to discontinue treatment than women with insurance coverage (adjusted odds ratio [aOR] = 3.12; 95% confidence interval [CI], 2.22-4.40). African-American women were more likely to discontinue treatment (aOR = 2.95; 95% CI, 1.54-5.66) and returned for treatment more slowly (adjusted hazard ratio [aHR] = 0.44; 95% CI, 0.28-0.71) than non-Hispanic white women, regardless of IVF insurance coverage or income. Women with a poor prognosis were more likely to discontinue treatment than women with a good prognosis. Older women with IVF insurance coverage or a good prognosis had a shorter time to return for a second IVF cycle than older women without IVF insurance coverage or with a poor prognosis. Estimated income, distance to clinic, fertility diagnosis, number of oocytes retrieved, and history of previous live birth were not associated with treatment discontinuation or time to return for a second IVF cycle after adjustment for covariates.

CONCLUSION(S)

IVF insurance coverage, race, age, and future treatment prognosis are associated with IVF treatment discontinuation and time to return.

Perspectives of complementary and alternative medicine (CAM) practitioners in the support and treatment of infertility

BACKGROUND

Infertility patients are increasingly using complementary and alternative medicine (CAM) to supplement or replace conventional fertility treatments. The objective of this study was to determine the roles of CAM practitioners in the support and treatment of infertility.

METHODS

Ten semi-structured interviews were conducted in Ottawa, Canada in 2011 with CAM practitioners who specialized in naturopathy, acupuncture, traditional Chinese medicine, hypnotherapy and integrated medicine.

RESULTS

CAM practitioners played an active role in both treatment and support of infertility, using a holistic, interdisciplinary and individualized approach. CAM practitioners recognized biological but also environmental and psychosomatic determinants of infertility. Participants were receptive to working with physicians, however little collaboration was described.

CONCLUSIONS

Integrated infertility patient care through both collaboration with CAM practitioners and incorporation of CAM's holistic, individualized and interdisciplinary approaches would greatly benefit infertility patients.

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.

Disinvestment policy and the public funding of assisted reproductive technologies: outcomes of deliberative engagements with three key stakeholder groups

Background

Measures to improve the quality and sustainability of healthcare practice and provision have become a policy concern. In addition, the involvement of stakeholders in health policy decision-making has been advocated, as complex questions arise around the structure of funding arrangements in a context of limited resources. Using a case study of assisted reproductive technologies (ART), deliberative engagements with a range of stakeholder groups were held on the topic of how best to structure the distribution of Australian public funding in this domain.

Methods

Deliberative engagements were carried out with groups of ART consumers, clinicians and community members. The forums were informed by a systematic review of ART treatment safety and effectiveness (focusing, in particular, on maternal age and number of treatment cycles), as well as by international policy comparisons, and ethical and cost analyses. Forum discussions were transcribed and subject to thematic analysis.

Results

Each forum demonstrated stakeholders’ capacity to understand concepts of choice under resource scarcity and disinvestment, and to countenance options for ART funding not always aligned with their interests. Deliberations in each engagement identified concerns around ‘equity’ and ‘patient responsibility’, culminating in a broad preference for (potential) ART subsidy restrictions to be based upon individual factors rather than maternal age or number of treatment cycles. Community participants were open to restrictions based upon measures of body mass index (BMI) and smoking status, while consumers and clinicians saw support to improve these factors as part of an ART treatment program, as distinct from a funding criterion. All groups advocated continued patient co-payments, with measures in place to provide treatment access to those unable to pay (namely, equity of access).

Conclusions

Deliberations yielded qualitative, socially-negotiated evidence required to inform ethical, accountable policy decisions in the specific area of ART and health care more broadly. Notably, reductionist, deterministic characterizations of stakeholder ‘self-interest’ proved unfounded as each group sought to prioritise universal values (in particular, ‘equity’ and ‘responsibility’) over specific, within-group concerns. Our results - from an emotive case study in ART - highlight that evidence-informed disinvestment decision-making is feasible, and potentially less controversial than often presumed.

Antioxidant supplementation overcomes the deleterious effects of maternal restraint stress-induced oxidative stress on mouse oocytes

In this study, using a mouse model, we tested the hypothesis that restraint stress would impair the developmental potential of oocytes by causing oxidative stress and that antioxidant supplementation could overcome the adverse effect of stress-induced oxidative stress. Female mice were subjected to restraint stress for 24 h starting 24 h after equine chorionic gonadotropin injection. At the end of stress exposure, mice were either killed to recover oocytes forin vitromaturation (IVM) or injected with human chorionic gonadotropin and caged with male mice to observein vivodevelopment. The effect of antioxidants was testedin vitroby adding them to IVM medium orin vivoby maternal injection immediately before restraint stress exposure. Assays carried out to determine total oxidant and antioxidant status, oxidative stress index, and reactive oxygen species (ROS) and glutathione levels indicated that restraint stress increased oxidative stress in mouse serum, ovaries, and oocytes. Whereas the percentage of blastocysts and number of cells per blastocyst decreased significantly in oocytes from restraint-stressed mice, addition of antioxidants to IVM medium significantly improved their blastocyst development. Supplementation of cystine and cysteamine to IVM medium reduced ROS levels and aneuploidy while increasing glutathione synthesis and improving pre- and postimplantation development of oocytes from restraint-stressed mice. Furthermore, injection of the antioxidant epigallocatechin gallate into restraint-stressed mice significantly improved the blastocyst formation and postimplantation development of their oocytes. In conclusion, restraint stress at the oocyte prematuration stage impaired the developmental potential of oocytes by increasing oxidative stress and addition of antioxidants to IVM medium or maternal antioxidant injection overcame the detrimental effect of stress-induced oxidative stress. The data reported herein are helpful when making attempts to increase the chances of a successful outcome in human IVF, because restraint was applied at a stage similar to the FSH stimulation period in a human IVF program.

Restraint stress inhibits mouse implantation: temporal window and the involvement of HB-EGF, estrogen and progesterone

It is known that psychological stress affects reproduction in women, but it is unknown whether the effect is by impairing implantation. Although studies suggest that long periods of auditory or restraint stress may inhibit implantation in rats and mice, the exact stage of pregnancy at which stress impairs implantation is unclear. Furthermore, whether stress impairs implantation by decreasing the heparin-binding epidermal growth factor-like growth factor (HB-EGF), estrogen and/or progesterone and whether by acting on embryos or on the uterus need further investigations. In this study, a 24-h restraint stress was initiated at 15:30 of day 3 (regimen 1) or at 07:30 (regimen 2) or 15:30 of day 4 (regimen 3) of pregnancy (vaginal plug  =  day 1) to observe effects of restraint stress applied at different peri-implantation stages on implantation. Among the three regimens, whereas regimens 1 and 3 affected neither term pregnancy nor litter size, regimen 2 reduced both. Further observations indicated that regimen 2 of restraint stress also delayed blastocyst hatching and the attachment reaction, decreased serum concentrations of progesterone and estradiol, and down regulated the expression of HB-EGF in both the endometrium and blastocysts. Taken together, the results suggested that restraint stress inhibited mouse implantation in a temporal window-dependent manner and by impairing blastocyst activation and hatching and uterine receptivity via down-regulating HB-EGF, estrogen and progesterone. Thus, the stress applied within the implantation window impaired implantation by acting on both embryos and the uterus.

The impact of social relations among men and women in fertility treatment on the decision to terminate treatment

STUDY QUESTION

Do social support and social strain from social relations have an impact on the decision to terminate fertility treatment among men and women after 1 year of unsuccessful treatment?

SUMMARY ANSWER

Several functional aspects of social relations show an impact on the probability to terminate treatment; social support from family significantly decreases the probability to terminate and experience of conflicts or problematic communication with the partner significantly increases the probability to terminate treatment.

WHAT IS KNOWN ALREADY

Fertility patients can experience psychological, physical and economical strain as consequences of infertility and fertility treatment, and previous studies have shown that these pressures increase the probability of deciding to terminate treatment before the treatment options are exhausted. Some studies have indicated that social relations can also have an effect.

STUDY DESIGN, SIZE, DURATION

This study is part of the prospective Infertility Cohort from the Copenhagen Multi-centre Psychosocial Infertility Research Programme. Baseline data were collected during January 2000-August 2001 among patients recruited at five Danish fertility clinics during their initial visit and follow-up data were collected after 1 year.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The study group (n = 777; 427 women, 350 men) consisted of patients who did not achieve a live birth or an ongoing pregnancy during follow-up. Social support and strain from the patients' partner, family, family-in-law, friends and colleagues were measured at baseline and the decision to terminate treatment while treatment options were not yet exhausted was measured as the outcome at the 1-year follow-up.

MAIN RESULTS AND THE ROLE OF CHANCE

At the 1-year follow-up, 23% of the study group had decided to terminate treatment. For women, low levels of family support, specifically with regard to infertility, were associated with the termination of treatment after 1 year [odds ratio (OR) 6.1, 95% confidence interval (CI) 2.2-16.8] and, for men, low levels of general family support had a similar impact (OR 2.6, 95% CI 1.0-7.0). For men, difficulties in communicating with their partner about the infertility increased the probability of terminating the treatment (OR 2.3, 95% CI 1.2-4.1) and, for women, frequent conflicts with their partner increased the probability of terminating the treatment (OR 12.4, 95% CI 2.9-54.1). For women, conflicts with friends were also a predictor of treatment termination (OR 2.2, 95% CI 1.2-4.2).

WIDER IMPLICATIONS OF THE FINDINGS

Functional aspects of social relations have an impact on the decision to terminate fertility treatment among men and women. The findings in this study provide new insights into how the close social environment can have implications for men and women going through fertility treatment.

FUNDING

This study has received support from the Danish Health Insurance Fund (J.nr. 11/097-97), the Else and Mogens Wedell-Wedellsborgs Fund, the manager E. Danielsens and Wife's Fund, the merchant L.F. Foghts Fund, the Jacob Madsen and Wife Olga Madsen's Fund, and the Engineer K.A. Rohde and Wife's Fund. The authors have no conflicts of interest to declare.

Infertility treatment: when is it time to give up? An Internet-based survey

INTRODUCTION

Many factors have been suggested that influence a couple's decision to stop infertility treatment despite not achieving their goal of having a baby. This Internet-based questionnaire study aims to shed light on these reasons by surveying patients who have received treatment from a variety of different centres.

METHODS

Registered users of an independent infertility website were invited to participate in the survey by filling in a structured questionnaire.

RESULTS

Eighty users completed the questionnaire. Fifty-eight percent of patients received treatment in just one centre. Seventy-eight percent of the patients paid for the treatment themselves. Forty-two percent of couples intended to have only one treatment cycle and 60% of couples reported undergoing more cycles than they had originally intended. Ten percent of patients regretted not stopping their treatment earlier. The most common reasons why patients opted against further treatment cycles were financial constraints (46%), emotional burden (35%), poor response to treatment (29%) and poor egg quality (19%).

CONCLUSIONS

The decision to stop treatment despite poor outcomes is a difficult one and unique to the couple. The findings of this study are consistent with the widely held belief that in vitro fertilization is a stressful, expensive process, given that almost all women cited these as reasons to stop treatment.

Assisted reproductive technologies in public and private clinics

The aim of this study was to analyse the influence of the type of service provided by assisted reproduction clinics. The activities, treatment patterns and results achieved by assisted reproduction centres in Spain were examined, comparing public and private clinics. A retrospective study was carried out using the Assisted Reproductive Technology Register of the Spanish Fertility Society for 2002-2004. The results showed that 74%, 96% and 99% of IVF/intracytoplasmic sperm injection, oocyte donation and preimplantation genetic diagnosis cycles, respectively, were carried out in the private sector. Public clinics performed proportionally more transfers of three embryos than the private clinics (48.1% versus 41.7%). More elective transfers were performed in private clinics. Pregnancy rates per cycle started, per puncture and per transfer were significantly higher among private than public clinics (29.1%, 32.7% and 35.9% versus 25.2%, 28.5% and 32.6%, respectively) (P < 0.05). Implantation rate has risen year on year in both types of clinic and was significantly higher (P < 0.05), every year, among the private clinics. The multiple-pregnancy rate was significantly higher among the private clinics (30.8% versus 26.4%) (P < 0.05). In conclusion, differences exist between public and private clinics as regards to their volume of activity, the range of services offered, clinical practice and results achieved.

Transient stress and stress enzyme responses have practical impacts on parameters of embryo development, from IVF to directed differentiation of stem cells

In this review, we discuss the expression, regulation, downstream mechanisms, and function of stress-induced stress enzymes in mammalian oocytes, peri-implantation embryos, and the stem cells derived from those embryos. Recent reports suggest that stress enzymes mediate developmental functions during early mammalian development, in addition to the homeostatic functions shared with somatic cells. Stress-induced enzymes appear to insure that necessary developmental events occur: many of these events may occur at a slower rate, although some may occur more rapidly. Developmental events induced by stress may be mediated by a single dominant enzyme, but there are examples of responses that require the integration of more than one stress enzyme. The discussion focuses on the consequences of stress as a function of duration and magnitude, and this includes an emerging understanding of the threshold levels of duration and magnitude that lead to pathology. Other topics discussed are the reversibility of the developmental as well as homeostatic consequences of stress, the further problems with readaptation after stress subsides, and the mechanisms and functions of stress enzymes during early mammalian development. The analyses are done with specific concern for their practical impact in assisted reproductive technology (ART) and stem cell technologies.

Infertility and the use of infertility treatments in Finland: Prevalence and socio-demographic determinants 1992–2004

OBJECTIVE

To examine changes in the use of infertility treatments by time, the causes of infertility, lifetime prevalence of subfertility, and the use of infertility treatments by socio-demographic factors.

STUDY DESIGN

Aggregate IVF statistics (1992-2004) and two nationally representative cross-sectional surveys (1997 and 2002).

RESULTS

Total number of IVF, ICSI and FET treatments initiated more than tripled between 1992 and 2004. The proportion of tubal injury as a cause of infertility treatment decreased over time while other female factors, male factor and multiple causes became more common. Self-reported lifetime subfertility was 16.0% in 2002 among women aged 25-64 years. Subfertility differed notably by age and education: young less educated women and older more educated women more frequently reported subfertility. Use of hormone therapy to treat subfertility (1997 and 2002) and participation in infertility treatments or medical examinations (2002) was more common among urban, highly educated and affluent women.

CONCLUSIONS

The use of infertility treatments increased and the proportions of causes of infertility have changed over time. Self-reported subfertility differed by age and education. There are socio-demographic differences in the use of infertility treatments.

Resource allocation of in vitro fertilization: a nationwide register-based cohort study

BACKGROUND

Infertility is common and in vitro fertilization (IVF) is a widely used treatment. In IVF the need increases and the effectiveness and appropriateness decrease by age. The purpose of this study was to describe allocation of resources for IVF by women's age, socioeconomic position, area of residence and treatment sector (public vs. private) and to discuss how fairly the IVF resources are allocated in Finland.

METHODS

Women who received IVF between 1996 and 1998 (N = 9175) were identified from the reimbursement records of the Social Insurance Institution (SII). Information on IVF women's background characteristics came from the Central Population Register and the SII, on treatment costs from IVF clinics and the SII, and on births from the Medical Birth Register. The main outcome measures were success of IVF by number of cycles and treated women, expenditures per IVF cycles, per women, per live-birth, and per treatment sector, and private and public expenditures. Expenditures were estimated from health care visits and costs.

RESULTS

During a mean period of 1.5 years, older women (women aged 40 or older) received 1.4 times more IVF treatment cycles than younger women (women aged below 30). The success rate decreased by age: from 22 live births per 100 cycles among younger women to 6 per 100 among older women. The mean cost of a live birth increased by age: compared to younger women, costs per born live birth of older women were 3-fold. Calculated by population, public expenditure was allocated most to young women and women from the highest socioeconomic position. Regional differences were not remarkable.

CONCLUSION

Children of older infertile women involve more expense due to the lower success rates of IVF. Socioeconomic differences suggest unfair resource allocation in Finland.

Use of hyperosmolar stress to measure stress-activated protein kinase activation and function in human HTR cells and mouse trophoblast stem cells

Embryo growth is inversely correlated with hyperosmolar stress-induced stress-activated protein kinase/jun kinase (SAPK/JNK) induction. To examine whether stress has similar effects in stem cells derived from the embryo, the authors test trophoblast stem cells. The stress response of human placental and mouse trophoblast stem cell lines are tested here. Peak phosphorylated SAPK/JNK was induced by 400 mM sorbitol at 0.5 hours. At this dose, there is an SAPK/JNK-dependent decrease in mitogenic, phosphorylated cMyc at 0.5 hours preceding an SAPK/JNK-dependent decrease in cell cycle entrance at 24 hours. At 0.5 hours, SAPK/JNK decreases terminal deoxynucleotidyltransferase dUTP nick end labeling/apoptosis at sorbitol doses from 50 mM to 400 mM and induces phosphorylated cJun prior to an SAPK/JNK-dependent, approximate 8-fold increase in apoptosis by 24 hours at 400 mM. SAPK/JNK phosphorylation peaked at 0.5 to 4 hours and largely subsided by 12 hours. Thus, total SAPK/JNK exists before stress and mediates rapid, homeostatic molecular responses that become biologic consequences after phosphorylated SAPK/JNK ends. This suggests continuity in the homeostatic mechanisms and functions of SAPK/JNK in placental lineage cells during implantation, in which SAPK/JNK is completely responsible for cell cycle arrest and largely responsible for apoptosis.

Using hyperosmolar stress to measure biologic and stress-activated protein kinase responses in preimplantation embryos

We used hyperosmolar stress to test blastocysts for their biologic and enzymatic responses to culture stress. Embryos mount dose- and time-dependent responses to hyperosmolar stress. Biological responses included slowed cavitation and cell accumulation and increased apoptosis at increasing doses. These responses were preceded by stress-activated protein kinase (SAPK) phosphorylation and nuclear translocation consistent with its causal role. For cavitation and new cell cycle initiation, 200 mM sorbitol caused stasis. Above 200 mM, sorbitol was ultimately lethal and below 200 mM, its embryos had milder effects. Phosphorylated SAPK was induced rapidly in embryos at 0.5 h in a dose-dependent manner from 0 to 600 mM sorbitol. Higher hyperosmolarity caused a biphasic peak of phosphorylated SAPK, but there was no return to baseline through 3 h. At 24 h, a dose-dependent response persisted that was linear from 0 to 200 mM sorbitol. Hyperosmolar stress rapidly induced, within 0.5 h, phosphorylated, nuclear c-Jun and decreased phosphorylated, nuclear c-Myc in a SAPK-dependent manner. The data suggest that SAPK is induced and functions on down-stream effector molecules in a temporal and quantitative manner consistent with its function in the embryonic homeostatic response to stress. The remarkable resistance of embryos to high concentrations of sorbitol suggests that part of its homeostatic response is different from that of somatic cells.

Quality management systems in ART: are they really needed? An Australian clinic's experience

As assisted reproductive technology (ART) expanded globally, several countries introduced prescribed requirements for treatment and monitoring of outcomes, as well as a licensing or accreditation requirement. While it is common for ART laboratories to be required to have an effective quality control system, the remainder of the clinic is often under less stringent regulation. Furthermore, when treatment conditions are prescribed, the standards tend to be conservative and clinics may choose to establish their own standards. Total quality management systems are now being used by an increasing number of ART clinics. In Australia and New Zealand, it is now a requirement to have a quality management system in order to be accredited and to help meet customer demand for improved delivery of ART services in these two countries.