Subfertility: causes, treatment and outcome

Luteal phase support for women trying to conceive by intrauterine insemination or sexual intercourse

BACKGROUND

Ovulation induction may impact endometrial receptivity due to insufficient progesterone secretion. Low progesterone is associated with poor pregnancy outcomes.

OBJECTIVES

To assess the effectiveness and safety of luteal phase support (LPS) in infertile women trying to conceive by intrauterine insemination or by sexual intercourse.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Group Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, LILACS, trial registries for ongoing trials, and reference lists of articles (from inception to 25 August 2021).

SELECTION CRITERIA

Randomised controlled trials (RCTs) of LPS using progestogen, human chorionic gonadotropin (hCG), or gonadotropin-releasing hormone (GnRH) agonist supplementation in IUI or natural cycle.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Our primary outcomes were live birth rate/ongoing pregnancy rate (LBR/OPR) and miscarriage.  MAIN RESULTS: We included 25 RCTs (5111 participants). Most studies were at unclear or high risk of bias. We graded the certainty of evidence as very low to low. The main limitations of the evidence were poor reporting and imprecision. 1. Progesterone supplement versus placebo or no treatment  We are uncertain if vaginal progesterone increases LBR/OPR (risk ratio (RR) 1.10, 95% confidence interval (CI) 0.81 to 1.48; 7 RCTs; 1792 participants; low-certainty evidence) or decreases miscarriage per pregnancy compared to placebo or no treatment (RR 0.70, 95% CI 0.40 to 1.25; 5 RCTs; 261 participants). There were no data on LBR or miscarriage with oral stimulation. We are uncertain if progesterone increases LBR/OPR in women with gonadotropin stimulation (RR 1.24, 95% CI 0.80 to 1.92; 4 RCTs; 1054 participants; low-certainty evidence) and oral stimulation (clomiphene citrate or letrozole) (RR 0.97, 95% CI 0.58 to 1.64; 2 RCTs; 485 participants; low-certainty evidence). One study reported on OPR in women with gonadotropin plus oral stimulation; the evidence from this study was uncertain (RR 0.73, 95% CI 0.37 to 1.42; 1 RCT; 253 participants; low-certainty evidence). Given the low certainty of the evidence, it is unclear if progesterone reduces miscarriage per clinical pregnancy in any stimulation protocol (RR 0.68, 95% CI 0.24 to 1.91; 2 RCTs; 102 participants, with gonadotropin; RR 0.67, 95% CI 0.30 to 1.50; 2 RCTs; 123 participants, with gonadotropin plus oral stimulation; and RR 0.53, 95% CI 0.25 to 1.14; 2 RCTs; 119 participants, with oral stimulation). Low-certainty evidence suggests that progesterone in all types of ovarian stimulation may increase clinical pregnancy compared to placebo (RR 1.38, 95% CI 1.10 to 1.74; 7 RCTs; 1437 participants, with gonadotropin; RR 1.40, 95% CI 1.03 to 1.90; 4 RCTs; 733 participants, with gonadotropin plus oral stimulation (clomiphene citrate or letrozole); and RR 1.44, 95% CI 1.04 to 1.98; 6 RCTs; 1073 participants, with oral stimulation). 2. Progesterone supplementation regimen  We are uncertain if there is any difference between 300 mg and 600 mg of vaginal progesterone for OPR and multiple pregnancy (RR 1.58, 95% CI 0.81 to 3.09; 1 RCT; 200 participants; very low-certainty evidence; and RR 0.50, 95% CI 0.05 to 5.43; 1 RCT; 200 participants, very low-certainty evidence, respectively). No other outcomes were reported for this comparison. There were three different comparisons between progesterone regimens. For OPR, the evidence is very uncertain for intramuscular (IM) versus vaginal progesterone (RR 0.59, 95% CI 0.34 to 1.02; 1 RCT; 225 participants; very low-certainty evidence); we are uncertain if there is any difference between oral and vaginal progesterone (RR 1.25, 95% CI 0.70 to 2.22; 1 RCT; 150 participants; very low-certainty evidence) or between subcutaneous and vaginal progesterone (RR 1.05, 95% CI 0.54 to 2.05; 1 RCT; 246 participants; very low-certainty evidence). We are uncertain if IM or oral progesterone reduces miscarriage per clinical pregnancy compared to vaginal progesterone (RR 0.75, 95% CI 0.43 to 1.32; 1 RCT; 81 participants and RR 0.58, 95% CI 0.11 to 3.09; 1 RCT; 41 participants, respectively). Clinical pregnancy and multiple pregnancy were reported for all comparisons; the evidence for these outcomes was very uncertain. Only one RCT reported adverse effects. We are uncertain if IM route increases the risk of adverse effects when compared with the vaginal route (RR 9.25, 95% CI 2.21 to 38.78; 1 RCT; 225 participants; very low-certainty evidence). 3. GnRH agonist versus placebo or no treatment  No trials reported live birth. The evidence is very uncertain about the effect of GnRH agonist in ongoing pregnancy (RR 1.10, 95% CI 0.70 to 1.74; 1 RCT; 291 participants, very low-certainty evidence), miscarriage per clinical pregnancy (RR 0.73, 95% CI 0.26 to 2.10; 2 RCTs; 79 participants, very low-certainty evidence) and clinical pregnancy (RR 1.00, 95% CI 0.68 to 1.47; 2 RCTs; 340 participants; very low-certainty evidence), and multiple pregnancy (RR 0.28, 95% CI 0.11 to 0.70; 2 RCTs; 126 participants). 4. GnRH agonist versus vaginal progesterone  The evidence for the effect of GnRH agonist injection on clinical pregnancy is very uncertain (RR 1.00, 95% CI 0.51 to 1.95; 1 RCT; 242 participants). 5. HCG injection versus no treatment  The evidence for the effect of hCG injection on clinical pregnancy (RR 0.93, 95% CI 0.40 to 2.13; 1 RCT; 130 participants) and multiple pregnancy rates (RR 1.03, 95% CI 0.22 to 4.92; 1 RCT; 130 participants) is very uncertain. 6. Luteal support in natural cycle No study evaluated the effect of LPS in natural cycle. We could not perform sensitivity analyses, as there were no studies at low risk of selection bias and not at high risk in other domains.

AUTHORS' CONCLUSIONS

We are uncertain if vaginal progesterone supplementation during luteal phase is associated with a higher live birth/ongoing pregnancy rate. Vaginal progesterone may increase clinical pregnancy rate; however, its effect on miscarriage rate and multiple pregnancy rate is uncertain. We are uncertain if IM progesterone improves ongoing pregnancy rates or decreases miscarriage rate when compared to vaginal progesterone. Regarding the other reported comparisons, neither oral progesterone nor any other medication appears to be associated with an improvement in pregnancy outcomes (very low-certainty evidence).

Altered eutopic endometrial T-regulatory and T-helper 17 lymphocyte ratio in women with unexplained subfertility

PROBLEM

Perturbations in T-helper lymphocyte profiles have previously been associated with endometriosis related subfertility and conception failure. Hence a retrospective in vitro study was conducted to evaluate the relationship between T-regulatory (Treg) and T-helper 17 (Th17) lymphocytes in the eutopic endometrium of women with unexplained subfertility and correlate these profiles to their conception status.

METHOD OF STUDY

Eutopic endometrial biopsies were collected during the mid-secretory phase of the menstrual cycle, from women with unexplained subfertility. These samples were evaluated immunohistochemically for Treg and Th17 lymphocytes as well as the related proinflammatory cytokine, Interleukin-17 (IL-17). These eutopic endometrial T lymphocyte subpopulations were compared to the patients' conception status in subsequent cycles.

RESULTS

Though Treg cells were not indicative of conception success in subsequent cycles, patients who maintained their subfertile (no conception) status were observed to have a higher Th17 cell count in their eutopic endometrium. The ratio of Treg:Th17 cell counts was significantly correlated to patient conception status as well. These trends stayed consistent irrespective of concurrent endometriosis.

CONCLUSION

Patients with a high proinflammatory Th17 lymphocyte profile and low Treg:Th17 ratio in their eutopic endometrium during the secretory phase of their menstrual cycle are more likely to not conceive in subsequent cycles.

Mesenchymal Stem Cells in Preclinical Infertility Cytotherapy: A Retrospective Review

Infertility is a global reproductive disorder which is caused by a variety of complex diseases. Infertility affects the individual, family, and community through physical, psychological, social and economic consequences. The results from recent preclinical studies regarding stem cell-based therapies are promising. Stem cell-based therapies cast a new hope for infertility treatment as a replacement or regeneration strategy. The main features and application prospects of mesenchymal stem cells in the future of infertility should be understood by clinicians. Mesenchymal stem cells (MSCs) are multipotent stem cells with abundant source, active proliferation, and multidirectional differentiation potential. MSCs play a role through cell homing, secretion of active factors, and participation in immune regulation. Another advantage is that, compared with embryonic stem cells, there are fewer ethical factors involved in the application of MSCs. However, a number of questions remain to be answered prior to safe and effective clinical application. In this review, we summarized the recent status of MSCs in the application of the diseases related to or may cause to infertility and suggest a possible direction for future cytotherapy to infertility.

Iodine and fertility: do we know enough?

Iodine is a vital micronutrient and its importance in thyroid function is well established. However, abnormalities in iodine intake may also have other effects. In particular, iodine is taken up avidly by the ovary and endometrium. Iodine deficiency is associated with reduced fertility. The use of high iodine concentration contrast media has recently been shown to improve conception rates in couples with unexplained infertility (UI). We hypothesize that this improvement could be related to the iodine excess and mechanisms independent of its action on thyroid. In this article, the metabolism of iodine and its potential role in fertility will be discussed, including the impact of both iodine deficiency and excess states and the importance of iodine in normal fetal development. This will include insights from animal studies on the effect of iodine in the uterine and ovarian structural environment, hormonal milieu and immunological factors affecting implantation. We speculate that iodine may well have a role as a potential therapy for UI.

Postnatal exposure to endosulfan affects uterine development and fertility

Endosulfan is an organochlorine pesticide (OCP) used in large-scale agriculture for controlling a variety of insects and mites that attack food and non-food crops. Although endosulfan has been listed in the Stockholm Convention as a persistent organic pollutant to be worldwide banned, it is still in use in some countries. Like other OCPs, endosulfan is bioaccumulative, toxic and persistent in the environment. Human unintentional exposure may occur through air inhalation, dietary, skin contact, as well as, via transplacental route and breast feeding. Due to its lipophilic nature, endosulfan is rapidly absorbed into the gastrointestinal tract and bioaccumulates in the fatty tissues. Similar to other OCPs, endosulfan has been classified as an endocrine disrupting chemical (EDC). Endocrine action of endosulfan on development and reproductive function of males has been extensively discussed; however, endosulfan effects on the female reproductive tract have received less attention. This review provides an overview of: i) the fate and levels of endosulfan in the environment and human population, ii) the potential estrogenic properties of endosulfan in vitro and in vivo, iii) its effects on uterine development, and iv) the long-term effects on female fertility and uterine functional differentiation during early gestation.

Screening of Chlamydia trachomatis and Waddlia chondrophila Antibodies in Women with Tubal Factor Infertility

Waddlia chondrophila is an emerging intracellular pathogen belonging to the order of Chlamydiales, and was previously associated with adverse pregnancy outcomes, as well as tubal factor infertility (TFI). In this study, we investigate the link between both W. chondrophila and Chlamydia trachomatis IgG seropositivity and TFI. Antibodies against both bacteria were measured in 890 serum samples of women visiting a fertility clinic. After a hysterosalpingography and/or laparoscopy, they were classified as either TFI-negative (TFI−) or TFI-positive (TFI+). The total seroprevalence was 13.4% for C. trachomatis and 38.8% for W. chondrophila. C. trachomatis antibodies were present significantly more often in the TFI+ group than in the TFI− group, while for W. chondrophila no difference could be observed. In conclusion, our study confirms the association between C. trachomatis seropositivity and TFI, but no association was found between W. chondrophila seropositivity and TFI. The high percentage of W. chondrophila seropositivity in all women attending a fertility clinic does, however, demonstrate the need for further research on this Chlamydia-like bacterium and its possible role in infertility.

Male Infertility is a Women's Health Issue-Research and Clinical Evaluation of Male Infertility Is Needed

Infertility is a devastating experience for both partners as they try to conceive. Historically, when a couple could not conceive, the woman has carried the stigma of infertility; however, men and women are just as likely to contribute to the couple’s infertility. With the development of assisted reproductive technology (ART), the treatment burden for male and unexplained infertility has fallen mainly on women. Equalizing this burden requires reviving research on male infertility to both improve treatment options and enable natural conception. Despite many scientific efforts, infertility in men due to sperm dysfunction is mainly diagnosed by a semen analysis. The semen analysis is limited as it only examines general sperm properties such as concentration, motility, and morphology. A diagnosis of male infertility rarely includes an assessment of internal sperm components such as DNA, which is well documented to have an impact on infertility, or other components such as RNA and centrioles, which are beginning to be adopted. Assessment of these components is not typically included in current diagnostic testing because available treatments are limited. Recent research has expanded our understanding of sperm biology and suggests that these components may also contribute to the failure to achieve pregnancy. Understanding the sperm’s internal components, and how they contribute to male infertility, would provide avenues for new therapies that are based on treating men directly for male infertility, which may enable less invasive treatments and even natural conception.

Glucose, insulin, insulin receptor subunits α and β in normal and spontaneously diabetic and obese ob/ob and db/db infertile mouse testis and hypophysis

BACKGROUND

Type 2 diabetes touches young subjects of reproductive age in epidemic proportion. This study assesses glucose, total InsulinT, Insulin2 and insulin receptor subunits α and β in testis during mouse development then, in the spontaneously type 2 diabetes models associated with infertility db/db and ob/ob mice. IR-β and α were also assessed in spermatozoa (SPZ), anterior pituitary (AP) and serum.

METHODS

Serum and tissue glucose were measured with enzymatic colorimetric assays and InsulinT and Insulin2 by ELISAs in serum, interstitial tissue- (ITf) and seminiferous tubule (STf) fractions in14- > 60-day-old normal and db/db, ob/ob and wild type (WT) mice. IR subunits were assessed by immunoblotting in tissues and by immunoprecipitation followed by immunoblotting in serum.

RESULTS

Development: Glucose increased in serum, ITf and STf. InsulinT and Insulin2 dropped in serum; both were higher in STf than in ITf. In > 60-day-old mouse ITf, insulinT rose whereas Insulin2 decreased; InsulinT and Insulin2 rose concurrently in STf. Glucose and insulin were high in > 60-day-old ITf; in STf high insulin2 accompanied low glucose. One hundred ten kDa IR-β peaked in 28-day-old ITf and 14-day-old STf. One hundred thirty five kDa IR-α was high in ITf but decreased in STf. Glucose escalated in db/db and ob/ob sera. Glucose doubled in ITf while being halved in STf in db/db mice. Glucose significantly dropped in db/db and ob/ob mice spermatozoa. InsulinT and Insulin2 rose significantly in the serum, ITf and STf in db/db and ob/ob mice. One hundred ten kDa IR-β and 135 kDa IR-α decreased in db/db and ob/ob ITf. Only 110 kDa IR-β dropped in db/db and ob/ob STf and AP. One hundred ten kDa IR-β fell in db/db and ob/ob SPZ. One hundred ten kDa sIR-α rose in the db/db and ob/ob mouse sera.

CONCLUSION

Insulin regulates glucose in tubules not in the interstitium. The mouse interstitium contains InsulinT and Insulin2 whereas tubules contain Insulin2. Decreased 110 kDa IR-β and 135 kDa IR-α in the db/db and ob/ob interstitial tissue suggest a loss of active receptor sites that could alter the testicular cell insulin binding and response to the hormone. Decreased IR-β levels were insufficient to stimulate downstream effectors in AP and tubules. IR-α shedding increased in db/db and ob/ob mice.

The 'Pleasure&Pregnancy' web-based interactive educational programme versus expectant management in the treatment of unexplained subfertility: protocol for a randomised controlled trial

INTRODUCTION

Many subfertile couples are diagnosed with (relatively) unexplained subfertility and a good prognosis. National professional guidelines (eg, the Netherlands and UK) advise 'expectant management (EM)' for 6-12 months, in which no interaction with healthcare staff is offered. Underpowered studies indicate that face-to-face sex-counselling increases the ongoing pregnancy rates of these couples. In patients with other conditions, web-based interactive educational programmes have the same effect on sexual functioning as face-to-face sex counselling. The 'Pleasure&Pregnancy randomised controlled trial (RCT)' will examine in couples with unexplained subfertility and a good prognosis whether a new web-based interactive educational programme results in a higher chance of naturally conceiving an ongoing pregnancy within 6 months as compared with EM.

METHODS AND ANALYSIS

A multicentre RCT with cost-effectiveness analysis will include heterosexual couples diagnosed with (relatively) unexplained subfertility and a good prognosis in Dutch and Belgian secondary or tertiary fertility clinics. Couples will be randomised between 6 months of EM and 6 months of the Pleasure&Pregnancy-programme. This new web-based interactive educational programme includes eight progressive modules of information (on the biology of conception and pleasurable sex) and sensate focus, couple communication and mindfulness exercises. Couples are offered interaction with their coaches via email and can take part in three moderated chat sessions with peers. The primary outcome of this RCT is the probability of naturally conceiving an ongoing pregnancy within 6 months after randomisation. Secondary outcomes include time-to-pregnancy, live birth rate, costs, sexual functioning and personal and relational well-being. Analysis will be according to intention to treat.

ETHICS AND DISSEMINATION

This study has been approved by the Medical Ethical Committees of the Academic Medical Centre (the Netherlands) and the Leuven University Hospital (Belgium). The findings of this RCT will be disseminated through presentations at international scientific meetings and peer-reviewed publications.

TRAIL REGISTRATION NUMBER

NTR5709; Pre-results.

Cholesterol metabolism and Cx43, Cx46, and Cx50 gap junction protein expression and localization in normal and diabetic and obese ob/ob and db/db mouse testes

Decreased fertility and birth rates arise from metabolic disorders. This study assesses cholesterol metabolism and Cx46, Cx50, and Cx43 expression in interstitium- and seminiferous tubule-enriched fractions of leptin-deficient ( ob/ob) and leptin receptor-deficient ( db/db) mice, two type 2 diabetes and obesity models associated with infertility. Testosterone levels decreased and glucose and free and esterified cholesterol (FC and EC) levels increased in serum, whereas FC and EC levels decreased in the interstitium, in ob/ob and db/db mice. In tubules, a decrease in EC caused FC-to-EC ratios to increase in db/db mice. In tubules, only acyl coenzyme A:cholesterol acyl transferase type 1 and 2 protein levels significantly decreased in ob/ob, but not db/db, mice compared with wild-type mice, and imbalances in the cholesterol transporters Niemann-Pick C1 (NPC1), ATP-binding cassette A1 (ABCA1), scavenger receptor class B member I (SR-BI), and cluster of differentiation 36 (CD36) were observed in ob/ob and db/db mice. In tubules, 14-kDa Cx46 prevailed during development, 48- to 49- and 68- to 71-kDa Cx46 prevailed during adulthood, and total Cx46 changed little. Compared with wild-type mice, 14-kDa Cx46 increased, whereas 48- to 49- and 68- to 71-kDa Cx46 decreased, in tubules, whereas the opposite occurred in the interstitium, in db/db and ob/ob mice. Total and 51-kDa Cx50 increased in db/db and ob/ob interstitium and tubules. Cx43 levels decreased in ob/ob interstitium and tubules, whereas Cx43 decreased in db/db interstitium but increased in db/db tubules. Apoptosis levels measured by ELISA and numbers of apostain-labeled apoptotic cells significantly increased in db/db, but not ob/ob, tubules. Testicular db/db capillaries were Cx50-positive but weakly Cx43-positive with a thickened lamina, suggesting altered permeability. Our findings indicate that the db mutation-induced impairment of meiosis may arise from imbalances in cholesterol metabolism and upregulated Cx43 expression and phosphorylation in tubules.

Asiatic acid attenuates high-fat diet-induced impaired spermatogenesis

Testicular cell apoptosis is associated with impaired spermatogenesis. It has been reported that Asiatic acid (AA) may suppress apoptosis. However, little is known about the effect of AA on high-fat diet (HFD)-induced impairment of spermatogenesis. The aim of the present study was to determine whether AA protects against HFD-induced impairment of spermatogenesis. Sprague-Dawley rats were randomly divided into three groups: Control group, HFD group and AA (50 mg/kg) + HFD group. Rats fed an HFD were orally administered with AA (50 mg/kg) daily for 12 weeks, and blood samples, testis and epididymis were harvested for further analysis. Sex hormones were detected and hematoxylin and eosin staining was performed to examine the morphological changes of the testis. Semen samples were collected to evaluate sperm quality and apoptosis was determined. The results indicate that AA treatment significantly increased testis weight, testis/body weight, spermatogonia, Leydig cells and Sertoli cells in the testis of obese mice (P<0.05). AA treatment also attenuated HFD-induced histological change. AA treatment prevented HFD-induced decrease of sex hormones and the quality of semen samples (P<0.05). Furthermore, HFD-induced apoptosis was significantly attenuated by AA treatment (P<0.05). In conclusion, the results suggest that AA is able to ameliorate HFD-induced impaired spermatogenesis via inhibiting apoptosis in Sprague-Dawley rats. AA may have therapeutic value in the treatment of obesity-related impairment of spermatogenesis.

Obesogens and male fertility

In the last decades, several studies evidenced a decrease in male fertility in developed countries. Although the aetiology of this trend in male reproductive health remains a matter of debate, environmental compounds that predispose to weight gain, namely obesogens, are appointed as contributors because of their action as endocrine disruptors. Obesogens favour adipogenesis by an imbalance of metabolic processes and can be found virtually everywhere. These compounds easily accumulate in tissues with high lipid content. Obesogens change the functioning of male reproductive axis, and, consequently, the testicular physiology and metabolism that are pivotal for spermatogenesis. The disruption of these tightly regulated metabolic pathways leads to adverse reproductive outcomes. Notably, adverse effects of obesogens may also promote disturbances in the metabolic performance of the following generations, through epigenetic modifications passed by male gametes. Thus, unveiling the molecular pathways by which obesogens induce toxicity that may end up in epigenetic modifications is imperative. Otherwise, a transgenerational susceptibility to metabolic diseases may be favoured. We present an up-to-date overview of the impact of obesogens on testicular physiology, with a particular focus on testicular metabolism. We also address the effects of obesogens on male reproductive parameters and the subsequent consequences for male fertility.

Identification of Reproductive Education Needs of Infertile Clients Undergoing Assisted Reproduction Treatment Using Assessments of Their Knowledge and Attitude

Background

In order to empower infertile individuals and provide high quality patient-centered infertility care, it is necessary to recognize and meet infertile individuals’ educational needs. This study aims to examine infertility patients’ knowledge and subsequently their education needs given their attitudinal approach to infertility education in terms of patients who undergo assisted reproduction treatment.

Materials and Methods

This descriptive study enrolled 150 subjects by conveni- ence sampling of all patients who received their first assisted reproductive treatment between July and September 2015 at a referral fertility clinic, Royan Institute, Tehran, Iran. We used a questionnaire that measured fertility and infertility information (8 questions) as well as attitude toward education on the causes and treatment of infertility (5 questions). Chi-square, independent sample t test, and one way ANOVA analyses were conducted to examine differences by sex. P<0.05 was considered statistically significant.

Results

Total mean knowledge was 3.08 ± 0.99. Clients’ responses indicated that the highest mean knowledge scores related to knowledge of factors that affected pregnancy (3.97 ± 1.11) and infertility treatment (3.97 ± 1.16). The lowest mean knowledge scores related to knowledge of the natural reproductive cycle (2.96 ± 1.12) and anatomy of the genital organs (2.94 ± 1.16). Most females (92.1%) and males (83.3%) were of the opinion that infertility education programs should include causes of infertility and types of treatment associated with diagnostic and laboratory procedures. No statistically significant difference existed between male and female participants (P=0.245).

Conclusion

Most participants in this study expressed awareness of factors that affect pregnancy and infertility treatment. It is imperative to educate and empower infertile individuals who seek reproduction treatment in terms of infertility causes and types of treatment, as well as diagnostic and laboratory procedures to enable them to make informed decisions about their assisted reproductive procedures.

Male psychological adaptation to unsuccessful medically assisted reproduction treatments: a systematic review

BACKGROUND

Similarly to women, men suffer from engaging in fertility treatments, both physically and psychologically. Although there is a vast body of evidence on the emotional adjustment of women to infertility, there are no systematic reviews focusing on men's psychological adaptation to infertility and related treatments.

OBJECTIVE AND RATIONALE

The main research questions addressed in this review were 'Does male psychological adaptation to unsuccessful medically assisted reproduction (MAR) treatment vary over time?' and 'Which psychosocial variables act as protective or risk factors for psychological maladaptation?'

SEARCH METHODS

A literature search was conducted from inception to September 2015 on five databases using combinations of MeSH terms and keywords. Eligible studies had to present quantitative prospective designs and samples including men who did not achieve pregnancy or parenthood at follow-up. A narrative synthesis approach was used to conduct the review.

OUTCOMES

Twelve studies from three continents were eligible from 2534 records identified in the search. The results revealed that psychological symptoms of maladjustment significantly increased in men 1 year after the first fertility evaluation. No significant differences were found two or more years after the initial consultation. Evidence was found for anxiety, depression, active-avoidance coping, catastrophizing, difficulties in partner communication and the use of avoidance or religious coping from the wife as risk factors for psychological maladjustment. Protective factors were related to the use of coping strategies that involve seeking information and attribution of a positive meaning to infertility, having the support of others and of one's spouse, and engaging in open communication about the infertility problem.

WIDER IMPLICATIONS

Our findings recommend an active involvement of men during the treatment process by health care professionals, and the inclusion of coping skills training and couple communication enhancement interventions in counselling. Further prospective large studies with high-quality design and power are warranted.

Severe Maternal Morbidity and the Use of Assisted Reproductive Technology in Massachusetts

OBJECTIVE

To assess whether risk of severe maternal morbidity at delivery differed for women who conceived using assisted reproductive technology (ART), those with indicators of subfertility but no ART ("subfertile"), and those who had neither ART nor subfertility ("fertile").

METHODS

This retrospective cohort study was part of the larger Massachusetts Outcomes Study of Assisted Reproductive Technology. To construct the Massachusetts Outcomes Study of Assisted Reproductive Technology database and identify ART deliveries, we linked ART treatment records to birth certificates and maternal and infant hospitalization records occurring in Massachusetts between 2004 and 2010. An algorithm of International Classification of Diseases, 9th Revision, Clinical Modification diagnosis and procedure codes identified severe maternal morbidity. We used logistic generalized estimating equations to estimate odds of severe maternal morbidity associated with fertility status, adjusting for maternal demographic and health factors and gestational age, stratifying on plurality and method of delivery.

RESULTS

The prevalence of severe maternal morbidity among this population (n=458,918) was 1.16%. The overall, crude prevalences of severe maternal morbidity among fertile, subfertile, and ART deliveries were 1.09%, 1.44%, and 3.14%, respectively. The most common indicator of severe maternal morbidity was blood transfusion. In multivariable analyses, among singletons, ART was associated with increased odds of severe maternal morbidity compared with both fertile (vaginal: adjusted odds ratio [OR] 2.27, 95% confidence interval [CI] 1.78-2.88; cesarean: adjusted OR 1.67, 95% CI 1.40-1.98, respectively) and subfertile (vaginal: adjusted OR 1.97, 95% CI 1.30-3.00; cesarean: adjusted OR 1.75, 95% CI 1.30-2.35, respectively) deliveries. Among twins, only cesarean ART deliveries had significantly greater severe maternal morbidity compared with cesarean fertile deliveries (adjusted OR 1.48, 95% CI 1.14-1.93).

CONCLUSION

Women who conceive through ART may have elevated risk of severe maternal morbidity at delivery, largely indicated by blood transfusion, even when compared with a subfertile population. Further research should elucidate mechanisms underlying this risk.

Human parasitic protozoan infection to infertility: a systematic review

Protozoan parasitic diseases are endemic in many countries worldwide, especially in developing countries, where infertility is a major burden. It has been reported that such infections may cause infertility through impairment in male and female reproductive systems. We searched Medline, PubMed, and Scopus databases and Google scholar to identify the potentially relevant studies on protozoan parasitic infections and their implications in human and animal model infertility. Literature described that some of the protozoan parasites such as Trichomonas vaginalis may cause deformities of the genital tract, cervical neoplasia, and tubal and atypical pelvic inflammations in women and also non-gonoccocal urethritis, asthenozoospermia, and teratozoospermia in men. Toxopalasma gondii could cause endometritis, impaired folliculogenesis, ovarian and uterine atrophy, adrenal hypertrophy, vasculitis, and cessation of estrus cycling in female and also decrease in semen quality, concentration, and motility in male. Trypanosoma cruzi inhibits cell division in embryos and impairs normal implantation and development of placenta. Decrease in gestation rate, infection of hormone-producing glands, parasite invasion of the placenta, and overproduction of inflammatory cytokines in the oviducts and uterine horns are other possible mechanisms induced by Trypanosoma cruzi to infertility. Plasmodium spp. and Trypanosoma brucei spp. cause damage in pituitary gland, hormonal disorders, and decreased semen quality. Entamoeba histolytica infection leads to pelvic pain, salpingitis, tubo-ovarian abscess, and genital ulcers. Cutaneous and visceral leishmaniasis can induce genital lesion, testicular amyloidosis, inflammation of epididymis, prostatitis, and sperm abnormality in human and animals. In addition, some epidemiological studies have reported that rates of protozoan infections in infertile patients are higher than healthy controls. The current review indicates that protozoan parasitic infections may be an important cause of infertility. Given the widespread prevalence of parasitic protozoa diseases worldwide, we suggest further studies to better understanding of relationship between such infections and infertility.

Beneficial value of testicular sperm extraction-AgarCyto in addition to the standard testicular biopsy for diagnosis of testicular germ cell tumors in nonobstructive azoospermia

OBJECTIVE

To study whether immunohistochemical detection of germ cell neoplasia in situ (GCNIS) in AgarCytos, made of the remnants of the testicular sperm extraction (TESE) specimen, is equally accurate as in a standard testicular biopsy.

DESIGN

Prospective cohort study performed between January 2013 and May 2014.

SETTING

University hospital.

PATIENT(S)

All men with nonobstructive azoospermia (n = 197) undergoing a urological work-up followed by a unilateral or bilateral TESE for fertility treatment were consecutively included.

INTERVENTION(S)

An AgarCyto was made of the remnants of these TESE biopsies. Simultaneously a standard testicular biopsy was performed. For all cases a routine hematoxylin-eosin (H & E) staining was performed as well as immunohistochemistry (PLAP and OCT3/4) to detect GCNIS.

MAIN OUTCOME MEASURE(S)

The presence or absence of GCNIS in the TESE-AgarCyto and standard testicular biopsy.

RESULT(S)

Six men (3.0%) were diagnosed with a germ cell (pre)malignancy by immunohistochemistry. No cases were encountered in which the TESE-AgarCyto was negative, whereas the standard testicular biopsy was positive for GCNIS. In one case the TESE-AgarCyto detected a premalignancy that was missed by standard testicular biopsy. Unfortunately a standard testicular biopsy was not available for direct comparison in 50% of the GCNIS-positive patients due to various reasons.

CONCLUSION(S)

Because GCNIS is heterogeneously distributed in the testis, the TESE-AgarCyto can diagnose GCNIS even when the standard testicular biopsy is negative. Direct comparison of accuracy, however, is not reliable due to the low prevalence of GCNIS and the lack of a standard biopsy when an orchidectomy was performed simultaneously with TESE.

Factors associated with nonresponse to ovulation induction using letrozole among women with World Health Organization group II anovulation

CONTEXT:

Letrozole, a third generation aromatase inhibitor is gaining importance in ovulation induction. Some prefer to use it as a second line agent in women who fail to respond to clomifene citrate. However, our knowledge about the predictors of response to letrozole is limited.

AIMS:

The study was aimed at identifying the factors associated with letrozole resistance among women with World Health Organization (WHO) group II anovulation.

SUBJECTS AND METHODS:

Study was conducted at the infertility clinic at a tertiary care hospital in Sri Lanka. A case–control study design was used and included 50 subjects with WHO group II anovulation (25 clomifene responsive and 25 clomifene resistant). After a treatment cycle of letrozole, the factors were compared between the subjects who responded and those who failed to respond to treatment.

RESULTS:

Ovulation was achieved in 76% (n = 19) of subjects who had responded to clomifene previously and in 24% (n = 6) with clomifene resistance. The factors associated with letrozole resistance included the presence of hirsutism (odds ratio [OR]: 3.89; 95% confidence interval [CI]: 1.2–12.3) and clomifene resistance (OR: 10.03; 95% CI: 2.81–35.7). The early follicular phase mean (standard deviation) luteinizing hormone level was significantly higher among the nonresponders (9.75 [4.78] – 7.28 [2.3]; P = 0.02). Nonresponders showed significantly lower levels of oestradiol on the 5^th and 9^th days (28.50 [3.39] pg/mL vs. 7.49 [3.62] pg/mL; P = 0.0007 and 142.04 [76.22] pg/mL vs. 28.10 [12.8] pg/mL; P = 0.0001) of the menstrual cycle, respectively.

CONCLUSIONS:

The features associated with resistance to Letrozole at a dose of 2.5 mg show some overlap with those associated with clomifene resistance. However, some features do not show similar association. The effectiveness of letrozole at a dose of 2.5 mg in induction of ovulation among women with clomifene resistance is low and it does not seem to be a suitable treatment at a dose of 2.5 mg for this indication.

Neonatal exposure to low doses of endosulfan induces implantation failure and disrupts uterine functional differentiation at the pre-implantation period in rats

We investigated whether neonatal exposure to low doses of endosulfan affects fertility and uterine functional differentiation at pre-implantation in rats. Newborn female rats received the vehicle, 0.2 µg/kg/d of diethylstilbestrol (DES), 6 µg/kg/d of endosulfan (Endo6) or 600 µg/kg/d of endosulfan (Endo600) on postnatal days (PND) 1, 3, 5, and 7. On PND90, the rats were mated to evaluate their reproductive performance on gestational day (GD) 19 and their ovarian steroid serum levels, endometrial proliferation and implantation-associated proteins on GD5. DES and endosulfan decreased the pregnancy rate and the number of implantation sites. On GD5, DES and endosulfan did not change the serum levels of 17β-estradiol (E2) and progesterone (P); the endometrial proliferation decreased, which was associated with silencing of Hoxa10 in the Endo600-treated rats. Both doses of endosulfan increased the progesterone receptor (PR) expression, whereas the higher dose led additionally to an increase in estrogen receptor alpha (ERα). In the Endo600-treated rats, the down-regulation of Hoxa10 was associated with a deregulation of the steroid receptor coregulators. Alterations in endometrial proliferation and the endocrine pathway of Hoxa10/steroid receptors/coregulators might be the mechanism of endosulfan-induced implantation failure.

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.

Alkaline phosphatases contribute to uterine receptivity, implantation, decidualization, and defense against bacterial endotoxin in hamsters

Alkaline phosphatase (AP) activity has been demonstrated in the uterus of several species, but its importance in the uterus, in general and during pregnancy, is yet to be revealed. In this study, we focused on identifying AP isozyme types and their hormonal regulation, cell type, and event-specific expression and possible functions in the hamster uterus during the cycle and early pregnancy. Our RT-PCR and in situ hybridization studies demonstrated that among the known Akp2, Akp3, Akp5, and Akp6 murine AP isozyme genes, hamster uteri express only Akp2 and Akp6; both genes are co-expressed in luminal epithelial cells. Studies in cyclic and ovariectomized hamsters established that while progesterone (P₄) is the major uterine Akp2 inducer, both P₄ and estrogen are strong Akp6 regulators. Studies in preimplantation uteri showed induction of both genes and the activity of their encoded isozymes in luminal epithelial cells during uterine receptivity. However, at the beginning of implantation, Akp2 showed reduced expression in luminal epithelial cells surrounding the implanted embryo. By contrast, expression of Akp6 and its isozyme was maintained in luminal epithelial cells adjacent to, but not away from, the implanted embryo. Following implantation, stromal transformation to decidua was associated with induced expressions of only Akp2 and its isozyme. We next demonstrated that uterine APs dephosphorylate and detoxify endotoxin lipopolysaccharide at their sites of production and activity. Taken together, our findings suggest that uterine APs contribute to uterine receptivity, implantation, and decidualization in addition to their role in protection of the uterus and pregnancy against bacterial infection.

A qualitative study of Ottawa university students' awareness, knowledge and perceptions of infertility, infertility risk factors and assisted reproductive technologies (ART)

BACKGROUND

Awareness of infertility risk factors is an essential first step to safeguard future fertility. Whereas several studies have examined university students' awareness of female fertility and related risk factors, the topic of male infertility has not been well examined. The objective of this study was to assess young men and women's awareness, knowledge and perceptions of infertility, male and female infertility risk factors and assisted reproductive technologies (ART).

METHODS

Semi-structured interviews were conducted in 2008 with a multi-ethnic sample of sixteen male and twenty-three female Ottawa university students, followed by qualitative data analysis to identify major themes. Interview topics included awareness of male and female infertility risk factors, infertility diagnosis/treatments and personal options in the event of future infertility.

RESULTS

Participants were generally familiar with infertility as a biomedical health problem, could identify sex-specific risk factors but overestimated fertility of women in their thirties and ART success rates. Reproductive health knowledge gaps and confusion of the physiological life-stage of menopause with infertility were apparent. Most participants would pursue in vitro fertilization or international adoption in the event of personal infertility. Some participants wished to use a 'natural' approach and were concerned with potential side effects of ART-related medications.

CONCLUSIONS

The general awareness of infertility in young adults is promising and supports the potential uptake for health promotion of fertility preservation. This study underscores the continued need for comprehensive sexual and reproductive health education and promotion for adolescents and young adults.

University students' perceptions of environmental risks to infertility

BACKGROUND

Canadian young adults may be at risk of future infertility due to the high incidence of sexually transmissible infections (STIs) in this population. Young adults' perceptions of environmental risks, including contaminants, STIs and lifestyle habits on infertility, have not been examined. We have therefore designed a qualitative study to explore risk perceptions, awareness and knowledge of common environmental risk factors for infertility in a multiethnic sample of young adults.

METHODS

Semistructured interviews were carried out with 40 university undergraduate students (16 men and 24 women) in Ottawa, Canada, followed by qualitative analysis of interview transcripts to identify major themes.

RESULTS

The following broad themes described participants' risk perceptions about infertility and (1) environmental contaminants: knowledge gaps, media reports and negative perception of chemicals; (2) STIs: superficial understanding of their role in infertility, general awareness, associations with sexual behaviours and knowledge gaps; and (3) lifestyle: protective benefits of healthy lifestyle, dose or exposure effects for smoking and alcohol, and knowledge gaps. Students demonstrated a superficial understanding of environmental risks, at times relying on media reports and anecdotal information to support their beliefs.

CONCLUSIONS

This next generation of potential infertility patients exhibits a general understanding of environmental risks to infertility; however, young adults are overly optimistic that healthy lifestyle behaviours will safeguard future fertility. STIs represent the most significant modifiable risk factors for this age group; a message that can be supported by sexual and reproductive health education and promotion with greater emphasis on the long-term outcomes of STIs, including infertility.

Preterm delivery and low birth weight in singleton pregnancies conceived by women with and without a history of infertility

OBJECTIVE

To determine predictors of low birth weight (LBW) and preterm delivery (PTD) in singleton pregnancies conceived by women with and without a history of infertility.

DESIGN

Retrospective cohort study.

SETTING

Eleven infertility clinics in northern California.

PATIENT(S)

Three groups of women who carried singleton pregnancies to ≥20 weeks' gestation: 542 infertile women who conceived after treatment, 441 infertile women who conceived spontaneously, and 1,008 fertile women for comparison.

INTERVENTION(S)

Chart review.

MAIN OUTCOME MEASURE(S)

Association of LBW or PTD with infertility treatment, maternal age, parity, obesity, or development of gestational diabetes.

RESULT(S)

Infertile women who conceived with treatment were more likely to be obese, develop gestational diabetes, and have ovarian, ovulatory, or male factor infertility than infertile women who conceived spontaneously. Infertile women who conceived after treatment had 1.61 times greater odds of having an LBW infant. Nulliparity was an independent predictor of LBW and PTD in all three groups after controlling for maternal age, history of infertility, infertility treatment, obesity, and gestational diabetes.

CONCLUSION(S)

Nulliparous women and women with a history of infertility who conceive a singleton after treatment may be at increased odds for having an LBW infant. Infertile women do not appear to be at increased odds for PTD.

Helping patients through the pain of infertility

While males and combined couple factors play a large part in infertility cases, women often carry the physical, social, and emotional burden of these diagnoses. Nurse practitioners are in a prime position to assess women at risk for infertility, initiate an investigation to identify potential etiologies, refer women to specialized centers, and provide them with ongoing care and support through this difficult period in their lives.

Adhesions and perioperative complications of repeat cesarean delivery

The unprecedented high rate of cesarean delivery and the declining rate of vaginal birth after cesarean delivery make necessary awareness of the potential complications that are associated with repeat cesarean delivery. This article reviews the epidemiologic features of cesarean delivery and the perioperative risks that are associated with repeat cesarean delivery. These risks include increased adhesions, infections and wound complications, bleeding, bowel injury and obstruction, hysterectomy, operative time, hospital stay, and delays in delivery.

Circulating Anti-PLAC1 Antibodies during Pregnancy and in Women with Reproductive Failure: A Preliminary Analysis

The aims of this study were to determine the prevalence of anti-PLAC1 antibodies in normal pregnant women and in women with infertility or recurrent pregnancy loss (RPL). Secondary outcomes were the development of complications associated with anti-PLAC1 seropositivity and the rate of seroconversion during pregnancy. Sera from 103 healthy pregnant women and 45 women with unexplained infertility or RPL were analyzed by ELISA. The prevalence of anti-PLAC1 antibodies was 2% in healthy pregnant women and 4.5% in women with unexplained infertility or RPL (P=0.355). There was no detectable association of seropositivity with increased risk of pregnancy complications. Finally, 2% of women seroconverted during pregnancy. The prevalence of anti-PLAC1 antibodies in women with unexplained infertility or RPL is not significantly higher than the prevalence in normal pregnant women. However, the sample size in this study was too small. The exposure to the PLAC1 antigen during pregnancy can lead to the spontaneous development of antibodies.

Resolution of anovulation infertility using neuro emotional technique: a report of 3 cases

BACKGROUND

The female menstrual cycle is a complicated interaction of hormonal messages that are under the control of the Hypothalamic-Pituitary-Ovarian axis. Dysfunction in this axis can lead to anovulation and infertility. Stress has the potential to produce such dysfunction.

OBJECTIVES

To review the normal menstrual cycle, and present a number of case studies on how the stress- reducing technique of Neuro Emotional Technique (NET) successfully aided the fertility of a number of female patients by resolving anovulation/menstrual irregularity.

METHODS

Three chronic anovulating, infertile patients underwent NET. A visual analog scale was used to evaluate the effectiveness of the intervention.

OUTCOMES

Anovulating patients started to ovulate following a series of treatments. Initial visual analog scale (VAS) scale on menstrual irregularity was rated 10 out of a possible 10 (anovulation) for all patients. After treatment, these 3 patients rated 0 out of 10 on the VAS scale and had fallen pregnant with subsequent birthing. A discussion of the potential link between stress and anovulation through altered gonadotropin releasing hormone pulsitile activity and how the use of NET may have resolved the anovulation seen in these 3 patients is presented.

CONCLUSION

The success attributed to the NET intervention and the resumption of ovulation warrant the need for further research involving long term prospective randomized controlled trial experiments to determine a direct causal relationship.

Severity of oligo-asteno-teratozoospermia no longer determines overall success rate in male subfertility

In this longitudinal multicentre cohort study, the overall ongoing pregnancy rate after current evidence-based management in male subfertility was studied. All subfertile couples who visited the fertility clinic for the first time between 2002 and 2006, and had male subfertility as a single diagnosis (n = 762 of 2476 couples), were included in this study. Couples were grouped by the severity of male factor. Group I (n = 541) had a total motile sperm count (TMSC) 1-20 × 10(6). Group II (n = 161) had a TMSC <1 × 10(6). Group III (n = 60) had azoospermia. The overall ongoing pregnancy rate was 65.5% (500/762). The overall ongoing pregnancy rates in group I (69.3%) and group II (61.5%) were comparable (p = 0.06). However, group I and group II conceived significantly more frequently than group III (43.3%) (group I vs. group III p < 0.001 and group II vs. group III p = 0.02, respectively). Moreover, the spontaneous ongoing pregnancy rate in group I was 35.3%, in group II 22.4% and in group III, 1.7% (group I vs. group II p = 0.002; group I vs. group III p < 0.001; group II vs. group III p < 0.001). Thus, despite a significant difference in spontaneous ongoing pregnancy rates, except for azoospermia, the overall ongoing pregnancy rates, regardless of the severity of the male factor, were comparable. Couples with poorer sperm parameters, however, have to undergo more invasive treatment to reach the same goal.

Sperm chromatin dispersion test in the assessment of DNA fragmentation and aneuploidy in human spermatozoa

Sperm DNA damage is thought to be increased in men with male factor infertility. Previous studies suggest a correlation between sperm DNA fragmentation and aneuploidy. The sperm chromatin dispersion (SCD) test was modified to produce the Halosperm Kit. The SCD-fluorescent in-situ hybridization (FISH) test allows the simultaneous detection of DNA fragmentation and aneuploidy on the same sperm cell. The objectives of this study were to validate the SCD, SCD-FISH and Halosperm tests for the analysis of sperm DNA fragmentation and compare them to the sperm chromatin structure assay (SCSA). Semen samples from 20 males undergoing IVF/intracytoplasmic sperm injection were processed using FISH, SCD-FISH, SCD and Halosperm, and compared with SCSA results. There was a significant difference between FISH and SCD-FISH results in the detection of aneuploidy (P=0.000) and the level of sperm DNA fragmentation in the samples subjected to SCSA and SCD (P=0.001) or SCSA and SCD-FISH (P=0.001). There was no significant correlation between DNA fragmentation and aneuploidy. If sperm aneuploidy is to be determined, more reliable results will be obtained if FISH is performed rather than SCD-FISH. A lack of validation and unknown clinical significance question the value of DNA fragmentation assays. DNA damage in the male germ line may result in adverse clinical outcomes and the pathophysiology and clinical consequences of sperm DNA damage are being actively researched. Many DNA fragmentation assays such as the Halosperm Kit have been developed recently and are now available at a commercial level. Unfortunately, aimed at vulnerable couples with difficulty conceiving, many of these tests have not been clinically validated. Despite its plausible appeal and fervour of its supporters, the benefits of widespread DNA testing that only achieves the distressing of couples with the knowledge that effectual therapeutic strategies are absent are questionable. Commercially, however, it is no doubt lucrative. Analysis of gametes prior to the initiation of an IVF cycle may improve the quality of embryos transferred. The clinical and scientific community considers it a matter of urgency to translate the basic science behind how a cell prepares for fertilization into routine clinical practice. However, it is equally important, if not more, to allow the science behind such applications to draw level with its practice before its widespread implementation.

Endometriosis and infertility

Endometriosis is a debilitating condition characterized by high recurrence rates. The etiology and pathogenesis remain unclear. Typically, endometriosis causes pain and infertility, although 20-25% of patients are asymptomatic. The principal aims of therapy include relief of symptoms, resolution of existing endometriotic implants, and prevention of new foci of ectopic endometrial tissue. Current therapeutic approaches are far from being curative; they focus on managing the clinical symptoms of the disease rather than fighting the disease. Specific combinations of medical, surgical, and psychological treatments can ameliorate the quality of life of women with endometriosis. The benefits of these treatments have not been entirely demonstrated, particularly in terms of expectations that women hold for their own lives. Although theoretically advantageous, there is no evidence that a combination medical-surgical treatment significantly enhances fertility, and it may unnecessarily delay further fertility therapy. Randomized controlled trials are required to demonstrate the efficacy of different treatments.

Mechanisms of obesity-induced male infertility

Male infertility, characterized by hypogonadism, decreased semen quality or ejaculatory dysfunction, accounts for approximately 20% of infertility cases. Obesity and metabolic dysfunction have been identified, among other causal factors, to contribute to male infertility. In the context of the Western world's 'obesity epidemic', this article discusses three main biological mechanisms linking obesity to impaired male reproductive function: hypogonadism, testicular heat stress/hypoxia-induced apoptosis and endocrine disruption by 'obesogens'. Among these, obesity-induced hypogonadism is undoubtedly the most clinically significant and is easily assessed. Rapidly expanding areas of research in this area include leptin modulation of kisspeptins and hypothalamic-pituitary-testicular hormone pathways, and roles of other adipocytokines in male infertility, as well as the impact of exposure to obesogens on the quality of semen.

The relative contribution of IVF to the total ongoing pregnancy rate in a subfertile cohort

BACKGROUND

Although in vitro fertilization (IVF) was introduced more than 30 years ago, its exact role in the spectrum of fertility treatments has never been studied in an unselected population. The aim of this study was to visualize the contribution of IVF to the ongoing pregnancy rates in a cohort of newly referred subfertile couples.

MATERIALS

All new subfertile couples (n = 1391) that were referred to our fertility clinic by their general practitioner between January 2002 and December 2006 were included. Fertility care was provided according to the national Dutch fertility guidelines. Data on diagnosis, treatment, mode of conception and pregnancy outcome were documented. If follow-up data were missing, couples were contacted. Cumulative pregnancy curves were constructed for the whole cohort and per diagnostic group.

RESULTS

As per December 2008 the overall ongoing pregnancy rate was 72.0% (n = 1001). Almost half of the pregnancies were conceived spontaneously (45.6%), 19.2% after ovulation induction (OI), 14.0% after intrauterine insemination (IUI) and 21.2% after IVF. A quarter (n = 349) of couples received IVF treatment, which was successful in 60% of cases. IVF had the largest contribution to ongoing pregnancies in patients with 'tubal factor', 'endometriosis' and 'male factor' (45, 45 and 37%, respectively) while in couples with 'unexplained subfertility' and 'ovulation disorders' the contribution to ongoing pregnancies of IVF was limited (13 and 4.5%, respectively).

CONCLUSIONS

In a cohort of subfertile couples, most pregnancies were conceived spontaneously. The contribution of IVF to ongoing pregnancy rates was comparable to those of OI and IUI. Compared with the pre-IVF era, couples with 'endometriosis', 'tubal factor' and 'male subfertility' have benefited most from its introduction.

Cumulative pregnancy probabilities among couples with subfertility: effects of varying treatments

OBJECTIVE

To model the cumulative probability of pregnancy among couples with subfertility without a definitive diagnosis, according to different treatment strategies.

DESIGN

A beta distribution of fecundity was fitted that reproduced the cumulative probability of pregnancy in prospective studies of natural fertility, and this distribution was applied to simulated cohorts starting with one million couples each. Probabilities of pregnancy were generated for each cycle of each couple.

SETTING

Simulation study.

PATIENT(S)

Hypothetic subfertile population.

INTERVENTION(S)

After 2 or 4 years of attempting pregnancy and diagnostic evaluation to exclude anovulation, tubal obstruction, and severe male factor, simulated treatments were applied to the remaining nonpregnant couples, with treatment effects based on published literature.

MAIN OUTCOME MEASURE(S)

Simulated cumulative probability of pregnancy.

RESULT(S)

Initially, the cumulative probability of pregnancy was highest for early treatment with IVF, but over time, conservative treatment or frequent intercourse approached the same cumulative probability.

CONCLUSION(S)

In couples without clear indications for IVF, the main benefit of early IVF may be to shorten time to pregnancy, a benefit that must be weighed against costs and potential adverse outcomes. Couples should be encouraged to maintain regular intercourse to maximize chances of pregnancy, even after unsuccessful treatment attempts.

Differences in the clinical characteristics of primarily and secondarily infertile men with varicocele

OBJECTIVE

To compare the clinical characteristics of primarily and secondarily infertile men with varicocele.

DESIGN

Cross-sectional analysis.

SETTING

Male infertility clinic, tertiary health care center.

PATIENT(S)

Two hundred ninety-five infertile men with palpable varicoceles.

INTERVENTION(S)

Clinical evaluation including patient reproductive history (including assessment of primary or secondary infertility), physical examination, hormonal assessment and at least two semen analyses.

MAIN OUTCOME MEASURE(S)

Differences in the characteristics of men with primary vs. secondary infertility.

RESULT(S)

Two hundred five subjects were identified with primary infertility and 90 with secondary infertility. Secondarily infertile men were older (39.6 years vs. 35.0 years), with older partners (35.4 years vs. 33.2 years), but had higher sperm densities (51.3 vs. 36.0 million/mL) and a greater percentage of morphologically normal sperm (30.6% vs. 24.1%). A lower proportion of secondarily infertile men had total motile sperm count (TMC) <20 million compared with primarily infertile men (31.1% vs. 46.5%). Groups did not differ regarding infertility duration, tobacco or alcohol use, varicocele grade or laterality, testis volumes, or hormonal parameters. In multivariate modeling, secondary infertility (vs. primary) was an independent predictor of TMC >20 million (odds ratio 1.9).

CONCLUSION(S)

Men with secondary infertility are older and have older partners than primarily infertile men, yet they have significantly better sperm concentrations. Infertility in this group may be influenced by maternal reproductive potential.

Human exposure to endocrine disrupters and semen quality

Reproductive pathology in the male represents about 20% of infertility cases. Male infertility may be attributed to a number of causes, including genetic and congenital abnormalities, infection, multisystemic diseases, varicocele, and others; however, a significant number of cases are idiopathic. Global declines in semen quality were suggested to be associated with enhanced exposure to environmental chemicals that act as endocrine disrupters as a result of our increased use of pesticides, plastics, and other anthropogenic materials. A significant body of toxicology data based upon laboratory and wildlife animals studies suggests that exposure to certain endocrine disrupters is associated with reproductive toxicity, including (1) abnormalities of the male reproductive tract (cryptorchidism, hypospadias), (2) reduced semen quality, and (3) impaired fertility in the adult. There is, however, a relative paucity of studies designed to measure exposure to endocrine disrupters on semen quality parameters (sperm concentration, motility, morphology). An overview of the human semen quality literature is presented that examines the role of endocrine disrupters including organochlorines (OC), dioxins, phthalates, phytoestrogens, and chemical mixtures (pesticides and tobacco smoke).

Do sperm DNA integrity tests predict pregnancy with in vitro fertilization?

OBJECTIVE

To evaluate the predictive value of sperm DNA integrity tests for pregnancy from in vitro fertilization treatment.

DESIGN

Systematic review and meta-analysis.

SETTING

Studies from infertility centers.

PATIENT(S)

Infertile couples undergoing in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) treatment.

INTERVENTION(S)

Sperm DNA integrity tests before IVF and ICSI cycles.

MAIN OUTCOME MEASURE(S)

Diagnostic test properties for sperm DNA integrity tests with reference to pregnancy after IVF or ICSI treatment.

RESULT(S)

Among 22 relevant studies, 2 x 2 tables were constructed from 13 studies involving 18 estimates of the diagnostic test properties of sperm DNA integrity tests in 2162 cycles of treatment. The sum of sensitivity and specificity ranged from 0.83 to 1.59. In six of 18 estimates abnormal DNA integrity was associated with a higher than expected pregnancy rate. The summary diagnostic odds ratio was 1.44 (95% CI, 1.03, 2.03), but the summary likelihood ratios (LR) were not predictive of pregnancy outcome (LR+ = 1.23; 95% CI, 0.98, 1.54; LR- = 0.81; 95% CI, 0.67, 0.98). Neither sperm chromatin structure assay nor terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate-biotin nick end labeling assay tests were more predictive of pregnancy outcome after IVF/ICSI, and DNA integrity testing was not more predictive for IVF than ICSI.

CONCLUSION(S)

The small but statistically significant association between sperm DNA integrity test results and pregnancy in IVF and ICSI cycles is not strong enough to provide a clinical indication for routine use of these tests in infertility evaluation of men. It is possible that yet to be determined subgroups of infertile couples may benefit from sperm DNA integrity testing.

The Impact of Leukemia Inhibitory Factor in Uterine Flushing on the Reproductive Potential of Infertile Women ? A Prospective Study

PROBLEM

To determine the value of leukemia inhibitory factor (LIF) assessment for predicting the reproductive outcome.

METHOD OF STUDY

Two phase study. Phase I: assessment of LIF in uterine flushing. Phase II: 1,5 years after examining the last patient, a questionnaire was sent to all participants of the phase I. Phase I: Uterine flushing and endometrial samples were collected during implantation window from infertile patients with stage I/II endometriosis (n = 14), patients with idiopathic infertility (n = 27), luteal phase deficiency (n = 13), and fertile control (n = 21). LIF was assessed in uterine flushings in all patients by ELISA. In endometrium, semiquantitative RT-PCR was performed for LIF mRNA expression. Phase II: questionnaire has been sent to all infertile women taking part in the first phase of the experiment, regarding their reproductive outcome.

RESULTS

65.4% patients who had returned the questionnaire did get pregnant. LIF concentration at a cut-off point of 2.31 pg/ml had a 95.7% sensitivity and 81.8% specificity in predicting the reproductive outcome.

CONCLUSION

This prospective study for the first time in literature indicates that the LIF assessment can be used as a predictor of reproductive success.

Cumulative live birth rates following IVF in 41- to 43-year-old women presenting with favourable ovarian reserve characteristics

For women aged 41-43 years old, success rates in IVF are generally poor. This study aimed to assess cumulative live birth rate related to treatment costs over a maximum of three IVF cycles in selected women who were considered to still have adequate ovarian reserve. Fifty-five patients (38% of the total cohort, n = 144) were excluded from IVF treatment based on low antral follicle count (<5 follicles) and/or elevated basal FSH (>15 IU/l). Of those admitted, 66 (74%) actually started and completed a total of 125 IVF/intracytoplasmic sperm injection cycles. Treatment resulted in 10 live births (8% per cycle). Kaplan-Meier survival analysis revealed a realistic cumulative live birth rate after three cycles of 17%. The direct medical costs per live birth were calculated to be approximately 44,000 euro. These results show that selection towards favourable ovarian reserve status in the female age group 41-43 years yielded disappointing results in terms of cumulative live birth rates after IVF. In view of the costs raised per live birth, improvement of selection parameters for treatment in this age group is warranted.

In Vivo Correlation between IL-1beta Concentration in Uterine Fluid and Integrin Expression Pattern in Infertile Women

PROBLEM

To evaluate the possible correlation between interleukin-1beta (IL-1beta) and integrin expression.

METHOD OF STUDY

Endometrium and uterine fluid from 77 infertile women and 24 fertile, healthy control were studied with immunohistochemistry and enzyme-linked immunosorbent assay for the presence of IL-1beta and integrin alphaVbeta3 and alpha4beta1 expression.

RESULTS

Highest expression of alphaVbeta3 was found in epithelium and glands in endometria from fertile women. There was no positive correlation between IL-1beta and integrin expression pattern.

CONCLUSION

This study confirms the importance of alphaVbeta3 as molecular marker of receptive phase. Also supports the views that synchrony in development of endometrium is necessary for successful nidation. There was however, contrary to results of previous in vitro studies, no positive correlation between IL-1beta and endometrial integrin patter expression.

Developmental effects of sublethal mitochondrial injury in mouse oocytes

Mitochondrial dysfunction may be acquired or inherited by oocytes without detectable morphological abnormalities. This pathology may account for some examples of unexplained pregnancy loss in women following transfer of morphologically normal in vitro fertilization (IVF) embryos. The present study was intended to determine whether sublethal mitochondrial injury in mouse oocytes before IVF negatively affects pre- and postimplantation development, and to further define the latency of developmental compromise in relation to aberrant mitochondrial metabolism. Mature mouse oocytes were loaded with the mitochondrial fluorophore rhodamine-123 and photosensitized for 20 sec, a duration previously found to permit preimplantation embryo development to the blastocyst stage and so deemed "sublethal." This treatment resulted in some aberrations in cytoplasmic patterning of organelles, but did not inhibit zygote mitochondrial metabolism. Blastocyst development following IVF was not significantly inhibited following sublethal oocyte photosensitization; however, a decrease in trophectoderm cell numbers was observed relative to untreated controls. Following intrauterine transfer, blastocysts derived from sublethally photosensitized oocytes implanted but later aborted at a higher rate, formed fetuses with lower average weights, and, in rare cases, formed abnormal fetuses relative to controls. Photosensitization for more prolonged durations resulted in failed fertilization (2 min) and rapid oocyte degeneration (10 min). Therefore, photosensitization duration and the consequent degree of mitochondrial dysfunction are negatively related to the onset of developmental compromise. Acquired low-level mitochondrial injury is heritable by the resultant embryos and can cause postimplantation developmental compromise that may be relevant to some clinically observed outcomes following human assisted reproduction strategies, including reduced birth weights for gestational age. Future strategies for the detection and prevention of mitochondrial dysfunction may assist in improving outcomes for some clinically infertile women.

Prediction of laparoscopic surgery outcomes in tubal infertility

This study aimed to elucidate the predictive value of hysterosalpingography (HSG) and laparoscopy (LS) scores for spontaneous pregnancy after laparoscopic surgery in 50 patients with tubal infertility. During a 1-year follow-up period, 28% of these patients became pregnant. Both scores were informative in prediction of pregnancy with the area under the ROC curve being 0.80 (95% CI 0.67-0.93) and 0.74 (95% CI 0.58-0.89) for LS and HSG scores, respectively.