Outcome of in vitro fertilization treatment in patients who electively inseminate a limited number of oocytes to avoid creating surplus human embryos for cryopreservation

Five years (2004-2009) of a restrictive law-regulating ART in Italy significantly reduced delivery rate: analysis of 10,706 cycles

STUDY QUESTION

Was the delivery rate of ART cycles negatively affected by the enactment of the Law 40/2004 by the Italian Parliament which imposed a long list of restrictions for ART procedures?

SUMMARY ANSWER

This large and extensive comparative analysis of ART outcomes prior to and after the introduction of the Law 40 revealed a significant reduction in pregnancy and delivery rates per cycle, independent of age or other clinical variables, once the law went into effect.

WHAT IS KNOWN ALREADY

Several studies have been published on the effect of Law 40/2004 on ART outcomes, some authors demonstrating a negative impact of the Law in relation to specific etiologies of infertility, other authors showing opposite conclusions.

STUDY DESIGN, SIZE, DURATION

Retrospective clinical study of 3808 patients treated prior to the enactment of the Law, September 1996-March 2004 (Group I) and 6898 treated during the Law, March 2004-May 2009 (Group II).

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 10 706 ART cycles were analysed, 3808 performed before and 6898 after the application of the Law. An intention-to-treat statistical analysis was performed to detect pregnancy and delivery rates (pregnancies ≥ 24 weeks) per started cycle. A P value of <0.05 was considered statistically significant. We analysed different outcomes: differences in fertilization, pregnancy and delivery rate, multiple pregnancies and miscarriage rates between the two time periods.

MAIN RESULTS AND THE ROLE OF CHANCE

The delivery rate for started cycle was 20% before and 16.0% after the introduction of the Law representing a 25% reduction (P < 0.001). The multivariate analysis, corrected by female age of >38 years, duration of infertility, basal FSH level and number of retrieved oocytes, showed a 16% lower delivery rate (odds ratio: 0.84; confidence interval: 0.75-0.94). This statistical approach removed the risk that the observed effects were due to chance and confirmed unequivocally that the Law was an independent factor responsible for the reduced likelihood of a successful outcome.

LIMITATIONS, REASONS FOR CAUTION

This is a retrospective study. A prospective randomized study, with patients treated in the same time period and randomized to restrictions or not, would have minimized potential limitations due to differences in years of treatments.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings based on the analysis of such a large number of cycles proved clearly and unequivocally that imposing restrictions on the practice of ART penalized patients. These data represent a relevant clinical contribution for countries still debating the enactment of restrictive limitations of ART.

Results of in vitro fertilization in Italy after the introduction of a new law

OBJECTIVE

To investigate the consequences of a law introduced in Italy in 2004 that forbids the fertilization or injection of more than three oocytes for assisted reproduction and does not allow any embryo selection or cryopreservation.

DESIGN

Retrospective observational analysis.

SETTING

Subfertile patients enrolled in an assisted reproduction program.

PATIENT(S)

Before the introduction of the law there were 1,179 cycles and after its enactment there were 1,860 cycles in 1,619 subfertile couples.

INTERVENTION(S)

Ovarian stimulation for IVF/intracytoplasmic sperm injection (ICSI) attempts.

MAIN OUTCOME MEASURE(S)

Pregnancy and implantation rate.

RESULT(S)

Pregnancy rates (PR) per cycle (24.34% vs. 23.11%), per retrieval (28.64% vs. 25.65%), per transfer (31.37% vs. 27.74%), and the take-home babies per started cycle (19.1% vs. 18%) was not significantly different between the two periods. After introduction of the law, the PR significantly decreased in patients whose total motile sperm count was <1 x 10(6) (40.85% vs. 23.62%) and in patients receiving two embryos (35.71% vs. 23.53%). This difference was mostly the result of a reduced PR in patients <36 years old receiving two unselected embryos (41.16% vs. 30.90%). This result was, however, obscured by the higher proportion of patients <36 years (3.9% vs. 45.12%) receiving three embryos after the enactment of the law, which lead to a significantly higher PR (28.73% vs. 37.56%) and a consequent significantly higher triplet rate (0.58% vs. 4.71%).

CONCLUSION(S)

Women in whom elective transfer of two embryos was allowed before passing the law and couples with a severe male infertility factor had significantly reduced success rates. Although the overall PR did not change after the new law, if the transfer of frozen embryos is not considered, this was mainly the result of a higher number of embryos transferred into women <36 years old. This study shows how the negative effects of the new law are obscured by the transfer of a higher number of embryos in younger patients, resulting in a higher PR at the cost of a significantly higher triplet rate.

Progesterone regulation of human granulosa/luteal cell viability by an RU486-independent mechanism

CONTEXT

Progesterone (P4) inhibits human granulosa/luteal cell apoptosis by an unknown mechanism.

OBJECTIVE

Our objective was to assess the role of the nuclear P4 receptor (PGR) and PGR membrane component 1 (PGRMC1) in mediating P4's antiapoptotic action in human granulosa/luteal cells.

DESIGN, SETTING, AND PATIENTS

In vitro laboratory studies were designed in which human granulosa/luteal cells were harvested from in vitro fertilization patients from 2004-2006.

MAIN OUTCOME MEASURE

Apoptosis was assessed by terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end-labeling assays and DNA staining. Protein expression was observed by Western blot and immunocytochemistry.

RESULTS

PGR was detected in 20% of the human granulosa/luteal cells, and 25 and 50 microM RU486 induced at least 70% of the cells to undergo apoptosis. Five micromolar RU486 neither induced apoptosis nor attenuated the antiapoptotic action of 1 microM P4. PGRMC1 and its binding partner, plasminogen activator inhibitor RNA-binding protein-1 (PAIRBP1), were detected in human granulosa/luteal cells. Antibodies to either PGRMC1 or PAIRBP1 completely attenuated P4's action.

CONCLUSIONS

PGR does not exclusively mediate P4's action because 1) 5 microM RU486 should have been able to override the antiapoptotic action of 1 microM P4 because RU486 binds to the PGR at a greater affinity than P4; 2) 25 and 50 microM RU486 induce three to four times more cells to undergo apoptosis than express PGR; 3) P4 must be continuously present to prevent apoptosis, which implies a rapid, possibly membrane-initiated mechanism of action; and 4) expression and blocking antibody studies suggest that PGRMC1 and PAIRBP1 account in part for P4's action in human granulosa/luteal cells.

Effect of oocyte morphology on embryo development and implantation

Assessment of oocyte morphology is a difficult task, since underlying mechanisms that change the appearance of the oocyte are multifactorial and complex. Significant morphological variations are known to exist among oocytes that may affect the developmental competence and implantation potential of the derived embryo. Morphological variations of the oocyte may result from intrinsic factors such as age and genetic defects or extrinsic factors such as stimulation protocols, culture conditions, and nutrition. The effect of these morphological variations of the oocyte on embryo development and implantation, however, is not conclusively defined because of methodological flaws inherent to most of the studies in the literature. This review will mainly discuss morphological markers of oocyte quality/viability in relation to the oocyte morphology and attempt to clarify whether morphological evaluation of the oocyte can be utilized for predicting the implantation potential of the derived embryo.