Present concept of unexplained infertility

Cytokine and chemokine profiles in women with endometriosis, polycystic ovary syndrome, and unexplained infertility

Numerous factors (including immunological, congenital, hormonal, and morphological disorders) can lead to infertility. In this regard, 3 specific diseases associated with infertility are discussed in this review study (i.e., polycystic ovary syndrome [PCOS], endometriosis [EMS], and unexplained infertility [UI]). PCOS is a common endocrine disorder characterized by chronic low-grade inflammation, and EMS is a benign disease characterized by the presence of ectopic endometrial tissue. UI refers to couples who are unable to conceive for no known reason. Conception and pregnancy are significantly affected by the immune system; in this regard, chemokines and cytokines play important roles in the regulation of immune responses. Patients with PCOS, EMS, and UI have altered cytokine and chemokine profiles, suggesting that dysregulation of these molecules may contribute to infertility in these conditions. Accordingly, the issue of infertility is addressed in this review study, a condition that affects approximately 16% of couples worldwide.

The definition of unexplained infertility: A systematic review

BACKGROUND

There is no consensus on tests required to either diagnose unexplained infertility or use for research inclusion criteria. This leads to heterogeneity and bias affecting meta-analysis and best practice advice.

OBJECTIVES

This systematic review analyses the variability of inclusion criteria applied to couples with unexplained infertility. We propose standardised criteria for use both in future research studies and clinical diagnosis.

SEARCH STRATEGY

CINAHL and MEDLINE online databases were searched up to November 2022 for all published studies recruiting couples with unexplained infertility, available in full text in the English language.

DATA COLLECTION AND ANALYSIS

Data were collected in an Excel spreadsheet. Results were analysed per category and methodology or reference range.

MAIN RESULTS

Of 375 relevant studies, only 258 defined their inclusion criteria. The most commonly applied inclusion criteria were semen analysis, tubal patency and assessment of ovulation in 220 (85%), 232 (90%), 205 (79.5%) respectively. Only 87/220 (39.5%) studies reporting semen analysis used the World Health Organization (WHO) limits. Tubal patency was accepted if bilateral in 145/232 (62.5%) and if unilateral in 24/232 (10.3%). Ovulation was assessed using mid-luteal serum progesterone in 115/205 (56.1%) and by a history of regular cycles in 87/205 (42.4%). Other criteria, including uterine cavity assessment and hormone profile, were applied in less than 50% of included studies.

CONCLUSIONS

This review highlights the heterogeneity among studied populations with unexplained infertility. Development and application of internationally accepted criteria will improve the quality of research and future clinical care.

Assisted reproductive technology outcomes and gene expression in unexplained infertility patients

Background: Unexplained infertility (UI) can be a frustrating and challenging diagnosis for doctors and couples as it can be difficult to understand why they are unable to conceive despite increasing diagnostic tools. Assisted reproductive technology (ART) procedures have been successfully applied to many couples aiming to overcome UI. However, they can be not only expensive but also require multiple cycles to achieve a successful pregnancy. The endometrium and the follicular fluid have been investigated as target tissues not only to determine the cause of UI but also to increase conception rates. Results: In this study, we analyzed the outcomes of ART in 223 UI couples and gene expression associated with DNA modification, cell death, immune response and senescence (TET1, TET2, BCL2, BAK1, HMGA2, IL-6, IL-8) in infertile women's endometrium and follicular fluid. We found significant differences in women who successfully got pregnant compared to women unable to conceive depending on age, duration of infertility, number of retrieved oocytes, zygotes, transferred embryos. Further, the expression of genes BAK1 (pro-apoptotic), TET2 (associated with epigenetic DNA modification) and IL-6 (associated with immune responses) were significantly higher in the endometrium of women who successfully got pregnant. Conclusion: Younger parental age couples showed higher ART success rates, shorter duration of infertility, higher number of retrieved oocytes, zygotes and transferred embryos. The gene expression analysis revealed significant changes in the endometrium depending on genes associated with cell death and immune response which were upregulated in females with diagnosed unexplained infertility.

β-Defensin 19/119 mediates sperm chemotaxis and is associated with idiopathic infertility

Sperm chemotaxis is required for guiding sperm toward the egg. However, the molecular identity of physiological chemoattractant and its involvement in infertility remain elusive. Here, we identify DEFB19/119 (mouse/human orthologs) as a physiological sperm chemoattractant. The epithelia of the female reproductive tract and the cumulus-oocyte complex secrete DEFB19/119 that elicits calcium mobilization via the CatSper channel and induces sperm chemotaxis in capacitated sperm. Manipulating the level of DEFB19 in mice determines the number of sperm arriving at the fertilization site. Importantly, we identify exon mutations in the DEFB119 gene in idiopathic infertile women with low level of DEFB119 in the follicular fluid. The level of DEFB119 correlates with the chemotactic potency of follicular fluid and predicts the infertile outcome with positive correlation. This study reveals the pivotal role of DEFB19/119 in sperm chemotaxis and demonstrates its potential application in the diagnosis of idiopathic infertility.

Standardized Laboratory Procedures, Quality Control and Quality Assurance Are Key Requirements for Accurate Semen Analysis in the Evaluation of Infertile Male

Semen analysis is a basic test for evaluating male fertility potential, as it plays an essential role in driving the future management and treatment of infertility in couples. Manual semen analysis includes the evaluation of both macroscopic and microscopic parameters, whereas automated semen analysis is conducted through a computer-aided sperm analysis system and can include additional parameters that are not evaluated by manual analysis. Both quality control (QC) and quality assurance (QA) are important to ensure reproducible results for semen analysis, and represent fundamental checks and balances of all stages (pre-analytical, analytical, and post-analytical) of semen analysis. To ensure accuracy and precision, the laboratory technicians' performance should be evaluated biannually. This narrative review aims to describe standardized laboratory procedures for an accurate assessment of semen parameters that incorporate both QC and QA practices.

Unexplained infertility: A French national survey of clinical practices

INTRODUCTION

The aim of our study was to carry out a national survey of French practitioners to evaluate (i) their diagnostic criteria for making a diagnosis of unexplained infertility (UEI) and (ii) their management strategy when facing UEI.

MATERIALS AND METHOD

An online questionnaire comprising ten multiple-choice questions was sent by mail to French reproductive practitioners in 80 fertility centres.

RESULTS

The response rate was 59.6% (195/327). Post coital testing was always or often prescribed by 14.8% of respondents (n=36). Chlamydia trachomatis testing was never prescribed by 31.7% (n=59) of them, 30.2% prescribed a pelvic MRI in cases of UEI and 18.4% (n=33) always or often performed laparoscopy. For 87.6% (n=169), advanced maternal age was always or often an indication of first-line IVF, with an average threshold of 37.4 years. For 68.6% (n=129), diminished AMH was an indication for first-line IVF, with an average AMH threshold of 1.2 ng/ml. With respect to the management of UEI, we did not observe a consensus between the strategies of 2 to 6 intrauterine insemination cycles before IVF or IVF as the first-line treatment.

CONCLUSION

There is no consensus in France on what tests should or should not be carried out to conclude UEI, and there is also no consensus on the management of UEI. UEI is one of the top 10 priorities for future infertility research. The diagnostic criteria must be standardized to enable the comparison of studies on this topic as well as to improve the translation of research into clinical practice.

Comparative study of endometrial & subendometrial angiogenesis in unexplained infertile versus normal fertile women

Background & objectives:

Local angiogenesis in endometrium has been shown to be an essential pre-requisite for endometrial receptivity needed for implantation and gestation. Recently, numerous diagnostic gears have been projected to ‘measure’ or ‘estimate’ the endometrial receptivity relying upon angiogenic factors helping throughout implantation. This study evaluated the endometrial and subendometrial blood flow and the local endometrial gland vascular endothelial growth factor (EG-VEGF) expression as markers of local angiogenesis.

Methods:

The present study was done to give quantitative assessment of endometrial thickness (ET), endometrial blood flow and subendometrial blood flow colour Doppler indices with endometrial vascular zones. Endometrial biopsy was taken and with VEGF stained and scored with immunohistochemistry.

Results:

The mean ET for fertile women was 9.41 mm, while in unexplained infertile women it was around 7.90 mm. Upon comparison of ET with EG-VEGF which is considered as a gold standard with correlation coefficient, the present study suggested a positive correlation of EG-VEGF with ET, endometrial pulsatility index (PI), and subendometrial PI also the vascular zones were considered as significant. However, a strong negative correlation was seen with subendometrial resistivity index and PI.

Interpretation & conclusions:

The present study suggests that uterine ultrasound, uterine colour Doppler and EG-VEGF are parameters which can be used as markers of local angiogenesis for endometrial receptivity in the evaluation of women with unexplained 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.

A missense in HSF2BP causing primary ovarian insufficiency affects meiotic recombination by its novel interactor C19ORF57/BRME1

Primary Ovarian Insufficiency (POI) is a major cause of infertility, but its etiology remains poorly understood. Using whole-exome sequencing in a family with three cases of POI, we identified the candidate missense variant S167L in HSF2BP, an essential meiotic gene. Functional analysis of the HSF2BP-S167L variant in mouse showed that it behaves as a hypomorphic allele compared to a new loss-of-function (knock-out) mouse model. Hsf2bpS167L/S167L females show reduced fertility with smaller litter sizes. To obtain mechanistic insights, we identified C19ORF57/BRME1 as a strong interactor and stabilizer of HSF2BP and showed that the BRME1/HSF2BP protein complex co-immunoprecipitates with BRCA2, RAD51, RPA and PALB2. Meiocytes bearing the HSF2BP-S167L variant showed a strongly decreased staining of both HSF2BP and BRME1 at the recombination nodules and a reduced number of the foci formed by the recombinases RAD51/DMC1, thus leading to a lower frequency of crossovers. Our results provide insights into the molecular mechanism of HSF2BP-S167L in human ovarian insufficiency and sub(in)fertility.

Best laboratory practices and therapeutic interventions to reduce sperm DNA damage

Conventional semen analysis is considered the cornerstone investigation for infertile men. Nonetheless, this routine test does not provide information on important sperm functions like sperm DNA fragmentation (SDF). Abnormalities of human spermatozoal nucleus and chromatin have a detrimental impact on both natural and assisted reproductive outcomes. In vivo, SDF results from abnormalities in chromatin compaction, abortive apoptosis and oxidative stress, while in vitro, a number of factors may be implicated. Various SDF testing methods are available, and the most commonly utilised assays include terminal deoxynucleotidyl transferase dUTP nick end labelling (TUNEL), sperm chromatin dispersion (SCD) test, sperm chromatin structure assay (SCSA) and Comet assay. SDF testing has shown beneficial effects on treatment decision-making; however, its routine use in the initial evaluation of infertile men is still not recommended. One of the treatment options to reduce sperm DNA damage is the use of antioxidants. Despite the documented improvement in semen parameters and sperm DNA integrity following antioxidant therapy, no definitive recommendation is reached due to lack of large, well-designed, randomised, placebo-controlled trials assessing their exact role in male factor infertility. The objectives of this review article are to illustrate the aetiologies of SDF, to describe the effects of SDF on male factor fertility, to explore the common techniques utilised in SDF testing, to review the clinical indications for SDF testing and to review the effect of antioxidant therapy as a method to alleviate SDF.

Comparison of oral dydrogesterone and vaginal micronized progesterone for luteal phase support in intrauterine insemination

This study aims to compare the pregnancy outcomes of vaginal micronized progesterone capsules with oral dydrogesterone in subjects with unexplained subfertility who are undergoing IUI in conjunction with ovarian stimulation by using rFSH. A total of 432 patients with unexplained subfertility who underwent IUI in conjunction with ovarian stimulation were enrolled in this retrospective study. Patients were randomized into two groups: (1) dydrogesterone or (2) vaginal micronized progesterone capsules, for luteal phase support. Clinical pregnancy and live birth were the primary outcome measures of the present study. Dydrogesterone was used in 233 participants (54%) and 337 cycles, while 199 participants (46%) and 233 cycles received vaginal micronized progesterone capsule treatment. The proportion of clinical pregnancies (7.4% vs. 10.2%, p = .213), live births (68% vs. 73%, p = .286) were similar in the two groups. Oral dydrogesterone and vaginal micronized progesterone provide similar pregnancy outcomes in terms of clinical pregnancy and live birth rates in women undergoing IUI in conjunction with ovarian stimulation with rFSH. Given the simple and easy administration, lack of safety concerns and better patient tolerability, we suggest that oral dydrogesterone might be preferred for luteal phase support in IUI.

Predictive serum markers for unexplained infertility in child-bearing aged women

PROBLEM

Unexplained infertility (UI) represents about 25%-40% of all infertility and is a formidable obstacle for successful pregnancy for child-bearing aged women. However, up to now, there is no reliable method to predict this condition with high accuracy, thereby hindering early management of this condition.

METHOD OF STUDY

Our prospective study consists of 84 child-bearing aged women that were clinically diagnosed UI. Forty-four matched healthy fertility (HF) women were served as controls. We examined the profiles of 25 hormones and cytokines that were likely related to pathogeneses and molecular pathways involved in UI with the technique of protein array. The samples were randomly stratified 7:3 into a training set and a testing set. We used the SMOTEboost model with 10 serum proteins in a clinical verification study to identify UI cases.

RESULTS

The predictor had an area under the receiver operating characteristic curve (AUC) of 0.788 with 24 serum protein features. The predictive performance in terms of AUC of the model with the top 10 important serum proteins in the clinical verification study to classify UI cases was 0.809. Three most significantly differentially expressed proteins (DEPs) were prolactin, monocyte chemotactic protein-1 (MCP-1), and leptin.

CONCLUSION

Examination of serum-based protein profile changes could help to identify child-bearing aged women at risk of UI. This would enable early detection and facilitate development of clinical strategies to treat UI and guide their planned parenthood. It may also give clues to pathogeneses of the condition of test subjects.

The Society for Translational Medicine: clinical practice guidelines for sperm DNA fragmentation testing in male infertility

Sperm DNA fragmentation (SDF) testing has been emerging as a valuable tool for male fertility evaluation. While the essential role of sperm DNA integrity in human reproduction was extensively studied, the clinical indication of SDF testing is less clear. This clinical practice guideline provides recommendations of clinical utility of the test supported by evidence. It is intended to serve as a reference for fertility specialists in identifying the circumstances in which SDF testing should be of greatest clinical value. SDF testing is recommended in patients with clinical varicocele and borderline to normal semen parameters as it can better select varicocelectomy candidates. Outcomes of natural pregnancy and assisted reproductive techniques (ART) can be predicted by result of SDF tests. High SDF is also linked with recurrent pregnancy loss (RPL) and failure of ART. Result of SDF testing may change the management decision by selecting the most appropriate ART with the highest success rate for infertile couples. Several studies have demonstrated the benefit in using testicular instead of ejaculated sperm in men with high SDF, oligozoospermia or recurrent in vitro fertilization (IVF) failure. Infertile men with modifiable lifestyle factor may benefit from SDF testing by reinforcing risk factor modification and monitoring patient's progress to intervention.

Leptin as a Predictive Marker in Unexplained Infertility in North Indian Population

INTRODUCTION

According to WHO, the primary infertility in India is about 3.9% (age-standardized to 25-49 year) and 16.8% (age-standardized to 15-49 year), using the "age but no birth" definition. Several factors which affect fertility include low sperm production in men, poor egg quality and blocked fallopian tubes in women and also hormonal imbalances. Leptin plays a critical role in women's reproduction and neuroendocrine health. It is used for treating exercise-induced bone loss, eating disorders and infertility.

AIM

To evaluate the serum leptin levels in Indians and to ascertain the relationship between serum leptin levels, Unexplained Infertility (UI) and related variables [height, weight, Waist Hip Ratio (WHR), Body Mass Index (BMI)] between obese infertile, non-obese infertile and healthy subjects.

MATERIALS AND METHODS

The present case-control study was conducted at the Department of Obstetrics and Gynaecology, King George's Medical University (KGMU), Lucknow, India and funded by Department of Science and Technology, New Delhi, India. The study included 229 female participants in the age group of 18-40 years (120 cases and 109 controls) who were randomly selected. The blood samples were collected from the Infertility Clinic, Queen Mary's Hospital, KGMU, Lucknow, India. All the participants underwent complete physical examination. Initially, the participants were categorized into fertile and infertile groups, they were further divided on the basis of BMI, normal (BMI- 18.5-24.5) and overweight or obese (BMI≥25). Leptin level was measured by Active Human Leptin ELISA kit and BMI of all subjects was calculated in kg/m² (weight in kg and height in m).

RESULTS

A highly positive linear correlation (R=0.754, p<0.001) was found between BMI and serum leptin in unexplained infertile women, which indicates a strong relationship between BMI and serum leptin. The variation in serum leptin is explained by the independent variable, BMI. There was a partial positive linear correlation between BMI and serum leptin in the control group. Statistically there was no significant correlation (R=0.109, p=0.258) between BMI and serum leptin in the control group.

CONCLUSION

The present study clearly demonstrates that level of leptin is higher in unexplained infertile than in the fertile group, and also shows that a strong relationship exists between BMI and serum leptin in the obese group. Serum leptin level was significantly higher in obese than non-obese subjects. Thus, leptin is an important factor for normal reproductive function. Obesity, the main cause of infertility may be controlled by regulating the leptin concentration.

Clinical utility of sperm DNA fragmentation testing: practice recommendations based on clinical scenarios

Sperm DNA fragmentation (SDF) has been generally acknowledged as a valuable tool for male fertility evaluation. While its detrimental implications on sperm function were extensively investigated, little is known about the actual indications for performing SDF analysis. This review delivers practice based recommendations on commonly encountered scenarios in the clinic. An illustrative description of the different SDF measurement techniques is presented. SDF testing is recommended in patients with clinical varicocele and borderline to normal semen parameters as it can better select varicocelectomy candidates. High SDF is also linked with recurrent spontaneous abortion (RSA) and can influence outcomes of different assisted reproductive techniques. Several studies have shown some benefit in using testicular sperm rather than ejaculated sperm in men with high SDF, oligozoospermia or recurrent in vitro fertilization (IVF) failure. Infertile men with evidence of exposure to pollutants can benefit from sperm DNA testing as it can help reinforce the importance of lifestyle modification (e.g., cessation of cigarette smoking, antioxidant therapy), predict fertility and monitor the patient’s response to intervention.

Pregnancy Rates after Testicular Torsion

PURPOSE

To our knowledge the effect of testicular torsion on the pregnancy rate is unknown. In this study we focused on the pregnancy rate, which is the ultimate index of fertility status.

MATERIALS AND METHODS

We reviewed the records of 273 patients who presented to our emergency room with testicular torsion between 1994 and 2014. Study inclusion criteria included being in a relationship with the intent to conceive for at least 1 year, age greater than 25 years and a normal contralateral testis. Patients with primary infertility, those who were unwilling to participate or unreachable and those with a history of undescended testis and/or varicocele were excluded from analysis. Patients were contacted by telephone and interviewed according to a standardized questionnaire. Pregnancy rates in the orchiopexy and orchiectomy groups were compared to each other and to the accepted pregnancy rate in the literature.

RESULTS

A total of 63 patients met study inclusion criteria, including 41 and 22 in the orchiopexy and orchiectomy groups, respectively. The pregnancy rate in the orchiopexy and orchiectomy groups was 90.2% and 90.9%, respectively (p = 1.0). The accepted pregnancy rate in the general population is 82% to 92%. Mean ± SD time to pregnancy in the orchiopexy and orchiectomy groups was 6.6 ± 5.50 and 7.2 ± 5.4 months, respectively (p = 0.27).

CONCLUSIONS

Several studies suggest decreased fertility potential in patients with a history of testicular torsion. However, in the current study in couples in which the male had a history of testicular torsion the pregnancy rate and the interval to pregnancy were within the accepted range of the general population.

FSH treatment of male idiopathic infertility improves pregnancy rate: a meta-analysis

INTRODUCTION

The aim of this study is to comprehensively evaluate whether FSH administration to the male partner of infertile couples improves pregnancy rate, spontaneously and/or after assisted reproductive techniques (ART).

METHODS

Meta-analysis of controlled clinical trials in which FSH was administered for male idiopathic infertility, compared with placebo or no treatment. Randomization was not considered as an inclusion criterion.

RESULTS

We found 15 controlled clinical studies (614 men treated with FSH and 661 treated with placebo or untreated). Concerning the type of FSH, eight studies used recombinant FSH, whereas seven studies used purified FSH. Nine studies evaluated spontaneous pregnancy rate, resulting in an overall odds ratio (OR) of about 4.5 (CI: 2.17-9.33). Eight studies evaluated pregnancy rate after ART, showing a significant OR of 1.60 (CI: 1.08-2.37). Sub-dividing studies according to the FSH preparations (purified/recombinant), pregnancy rate improvement remained significant for each preparation. Eleven studies considered sperm quality after FSH treatment, finding a significant improvement of sperm concentration (2.66×10(6)/ml, CI: 0.47-4.84), but not of concentration of sperm with progressive motility (1.22×10(6)/ml, CI: -0.07 to 2.52). Three trials evaluated testicular volume, showing a non-significant increase in men treated (1.35 ml, CI: -0.44 to 3.14).

CONCLUSION

The results of controlled clinical trials available in the literature indicate an improvement of pregnancy rate after FSH administration to the male partner of infertile couples, both spontaneously and after ART. However, the heterogeneity of studies, the high risk of bias and the lack of precise criteria to guide FSH administration limit the strength of these results. Future studies should be designed to identify the markers of FSH response which are helpful in the decision-making process. Meanwhile, the use of FSH in the treatment of male infertility should be cautious.

Folic acid supplementation and methylenetetrahydrofolate reductase (MTHFR) gene variations in relation to in vitro fertilization pregnancy outcome

OBJECTIVE

To study folic acid intake, folate status and pregnancy outcome after infertility treatment in women with different infertility diagnoses in relation to methylenetetrahydrofolate reductase (MTHFR) 677C>T, 1298A>C and 1793G>A polymorphisms. Also the use of folic acid supplements, folate status and the frequency of different gene variations were studied in women undergoing infertility treatment and fertile women.

DESIGN

Observational study.

SETTING

University hospital.

POPULATION

Women undergoing infertility treatment and healthy, fertile, non-pregnant women.

METHODS

A questionnaire was used to assess general background data and use of dietary supplements. Blood samples were taken to determine plasma folate and homocysteine levels, and for genomic DNA extraction. A comparison of four studies was performed to assess pregnancy outcome in relation to MTHFR 677 TT vs. CC, and 1298 CC vs. AA polymorphisms.

MAIN OUTCOME MEASURES

Folic acid supplement intake, and plasma folate, homocysteine and genomic assays.

RESULTS

Women in the infertility group used significantly more folic acid supplements and had better folate status than fertile women, but pregnancy outcome after fertility treatment was not dependent on folic acid intake, folate status or MTHFR gene variations.

CONCLUSION

High folic acid intakes and MTHFR gene variations seem not to be associated with helping women to achieve pregnancy during or after fertility treatment.

Management of the first in vitro fertilization cycle for unexplained infertility: a cost-effectiveness analysis of split in vitro fertilization-intracytoplasmic sperm injection

OBJECTIVE

To determine the cost-effectiveness of split IVF-intracytoplasmic sperm injection (ICSI) for the treatment of couples with unexplained infertility.

DESIGN

Adaptive decision model.

SETTING

Academic infertility clinic.

PATIENT(S)

A total of 154 couples undergoing a split IVF-ICSI cycle and a computer-simulated cohort of women <35 years old with unexplained infertility undergoing IVF.

INTERVENTION(S)

Modeling insemination method in the first IVF cycle as all IVF, split IVF-ICSI, or all ICSI, and adapting treatment based on fertilization outcomes.

MAIN OUTCOME MEASURE(S)

Live birth rate, incremental cost-effectiveness ratio (ICER).

RESULT(S)

In a single cycle, all IVF is preferred as the ICER of split IVF-ICSI or all ICSI ($58,766) does not justify the increased live birth rate (3%). If two cycles are needed, split IVF/ICSI is preferred as the increased cumulative live birth rate (3.3%) is gained at an ICER of $29,666.

CONCLUSION(S)

In a single cycle, all IVF was preferred as the increased live birth rate with split IVF-ICSI and all ICSI was not justified by the increased cost per live birth. If two IVF cycles are needed, however, split IVF/ICSI becomes the preferred approach, as a result of the higher cumulative live birth rate compared with all IVF and the lesser cost per live birth compared with all ICSI.

Predictive value of hormonal parameters for live birth in women with unexplained infertility and male infertility

BACKGROUND

Infertile women might get pregnant sometime after fertility treatment, but today, there is no prediction model on who will eventually have children. The objective of the present study was to characterize hormone levels in an arbitrary menstrual cycle in women with unexplained infertility and male infertility, and to determine the predictive value for long-term possibility of live birth.

METHODS

In this cross-sectional study, with 71 infertile women with diagnosis unexplained infertility and male infertility, blood samples were obtained during the proliferative and secretory phases of an arbitrary menstrual cycle. Serum concentrations of FSH, LH, AMH, inhibin B, estradiol, progesterone, PRL and TSH were determined. The predictive value of ovulation and hormonal analysis was determined by identifying the proportion of women with at least one live birth. Mann Whitney U test, chi2 test and Spearman's correlation were used for statistical analysis. A value of p < 0.05 was considered statistically significant.

RESULTS

There were no differences in hormone values and live birth rates between women with unexplained infertility and male infertility. The best sole predictors of live birth were age of the women, followed by ovulatory cycle, defined as serum progesterone concentration of greater than or equal to 32 nmol/L, and a serum TSH concentration of less than or equal to 2.5 mIU/L. Combining the age with the ovulatory cycle and serum TSH less than or equal to 2.5 mIU/L or serum AMH greater than or equal to 10 pmol/L the predictive value was close to 90%.

CONCLUSIONS

Age in combination with the presence of an ovulatory cycle and serum TSH or serum AMH is predictive for long-term live birth. The advantage of serum AMH compared with serum TSH is the very little variation throughout the menstrual cycle, which makes it a useful tool in infertility diagnosis.

Human olfactory sensitivity for bourgeonal and male infertility: a preliminary investigation

Olfactory receptor (OR) expression is also present in the sperm cells and could mediate sperm chemotaxis. OR1D2 was the first OR expressed in the testis demonstrated to be involved in chemotaxis and to be expressed also in the nose with a similar behavior. Bourgeonal is the OR1D2 most potent known agonist. Infertility affects ~15 % of couples in western countries and sometimes it is unexplained. This pilot study compared the bourgeonal olfactory thresholds, the ability of sperm to sense the bourgeonal and the frequency of 13 single nucleotide polymorphisms (SNPs) of OR1D2 gene in nine males suffering of unexplained infertility with a control group of 15 healthy males. The mean olfactory threshold for bourgeonal was statistically different between the study group (10.5 ± 3.7; median 12.3) and the control group (14.0 ± 2.8; median 15.5) (p = 0.006). Statistical analysis showed a significantly higher percentage of spermatozoa that migrated toward the capillaries filled with bourgeonal in the control group compared to the study group (p < 0.0001). Sperm migration was equally inhibited in both groups of subjects when, together with bourgeonal, capillaries were filled with undecanal, a strong bourgeonal inhibitor (p = 0.42). The 13 SNPs of OR1D2 revealed a statistically significant difference for allele and genotype frequency of rs769423 in study group versus control group (p = 0.02). The present preliminary study seems to confirm the important role of OR1D2 both in nose and spermatozoa and may explain the idiopathic infertility of the study group. Further studies on larger series are mandatory to confirm our preliminary evidence.

Prevalence of high DNA fragmentation index in male partners of unexplained infertile couples

The sperm chromatin structure assay (SCSA) parameter DNA fragmentation Index (DFI) is a valuable tool for prediction of fertility in vivo. Clinical data show that a DFI above 30% is associated with very low chance for achieving pregnancy by natural conception or by insemination. Already when DFI is above 20% the chance of natural pregnancy is reduced, this despite normal conventional semen parameters. The aim of the present study was to investigate the prevalence of high DFI in male partners of unexplained infertile couples to further identification of male factors contributing to subfertility. Among 212 consecutive men under infertility investigation, 122 cases with the diagnosis 'unexplained infertility' were identified. For all but three, SCSA data were available. The percentage of couples with diagnosis 'unexplained infertility' in which the male partner has DFI >20% or DFI >30% was calculated. In the group diagnosed with 'unexplained infertility' 17.7% of the men (95% CI 10.8-24.5) presented with 20 ≤DFI <30 and 8.4% (95% CI 3.40-13.4) had DFI ≥30%. A significant part of men diagnosed as unexplained infertile according to traditional diagnostic methods has remarkably high degrees of fragmented sperm DNA. Apart from adding to our understanding of biology of infertility our finding has clinical implications. Couples in which the DFI of the male partner is high can avoid prolonged attempts to become spontaneously pregnant or referral for intrauterine insemination, both having low chances of leading to conception.

Prevalence of low serum cobalamin in infertile couples

A high prevalence of low levels of cobalamin had been found in a survey of multi-ethnic normal individuals in Israel. The purpose of this study was to investigate the incidence of cobalamin deficiency among Israeli couples suffering from infertility. All couples seen at the in vitro fertilization clinic at an urban hospital (Shaare Zedek Medical Center) in Jerusalem for a 6-month period were invited. Mean cobalamin levels were 259.2 pg ml(-1) in males and 275.1 pg ml(-1) in females (normal >200 pg ml(-1)), 35.5% of 172 men and 23.3% of 223 females had cobalamin deficiency (P = 0.01). There were 171 couples with complete demographic questionnaires and cobalamin values for each partner. In 74 couples (43.3%), one partner was cobalamin deficient, with no significant difference between those with unexplained infertility versus those with explained infertility; and in 13 couples, both partners were cobalamin deficient. Thirty-nine per cent of all men with an abnormal semen analysis had cobalamin deficiency, a finding that requires further investigation. This study questions whether higher rates of male infertility in Israel are partially ascribable to cobalamin deficiency. Recommendation for supplementation in both males and females to achieve high-normal levels of cobalamin would be prudent.

AZF gene expression analysis in peripheral leukocytes and testicular cells from idiopathic infertility

The aim of this study was to assess the frequency of AZF microdeletions in peripheral leukocytes and testicular cells in Chinese men with idiopathic infertility. Expression in testicular cells was also determined. In this study, we screened 62 idiopathic infertile patients, in whom karyotype, sperm count and hormonal parameters were evaluated. Genomic DNA was extracted from the peripheral leukocytes. Molecular analysis was performed by two multiplex polymerase chain reactions (PCR) using a set of eight sequence tagged sites (STS) from 3 different regions of the Y chromosome. Total cellular RNA was extracted from the testicular tissue using a Trizol-method. Reverse Transcription (RT) reactions were performed to synthesize cDNA. Amplification of DFFRY, RBM and DAZ genes was performed to analyze their expression in testicular cells. In this cohort, we found 12 submicroscopic deletions (12/62, 19.4%). Nine patients (9/33, 27.2%) were detected in the azoospermic group and three (3/29, 10.3%) in the severe oligozoospermic group. RT-PCR analysis from testicular cells gave normal amplifications for SRY and DFFRY mRNA in 62 idiopathic patients; two patients were negative for RBM expression; no RBM and DAZ were detected for a case; 12 patients had no expression in the AZFc region involving the DAZ gene. Of 12 cases, three patients with normal PCR analysis of DAZ gene on genomic DNA showed no RT-PCR amplification for DAZ mRNA. The use of RT-PCR of specific spermatid expressed genes in conjunction with examining microdeletions using peripheral leukocytes is suggested to avoid the transmission of the Y chromosomal microdeletions from a father to a son via testicular sperm aspiration (TESE), intracytoplasmic sperm injection (JCSI).

Serum leptin level in women with unexplained infertility

INTRODUCTION

The aim of this study was to compare serum levels of leptin in women with unexplained infertility with fertile subjects.

MATERIAL AND METHOD

Serum leptin levels of 27 infertile and 30 fertile women on day 3 of the menstrual cycle were assessed and compared in this prospective age and body mass index (BMI) comparable controlled study.

RESULTS

The mean age in the infertile group was 29.3 (range, 23-38), while this figure was 28.9 (range, 19-39) in the fertile group; the mean BMIs were 24.5 (range, 20.6-27.8) and 25.0 (range, 21.8-28.7), respectively. The mean serum leptin level was significantly higher in women with unexplained infertility compared with fertile subjects. Considering normal weight subjects, mean serum leptin levels were increased significantly in the unexplained infertile group compared with the fertile group (7.2 (range, 4.3-10.4) versus 3.5 (range, 1.9-6.2)ng/ml, respectively; p<0.0001, Mann-Whitney U-test). The significant increase in serum leptin levels was observed also in overweight patients (6.8 (range, 1.3-5.2) versus 3.3 (range, 4.2-8.9)ng/ml, respectively; p<0.0001, Mann-Whitney U-test).

CONCLUSION

A significant difference in serum leptin levels between unexplained infertile and fertile women suggests that this cytokine may be involved in pathophysiology of unexplained infertility.

Randomized controlled trial of three doses of letrozole for ovulation induction in patients with unexplained infertility

The aromatase inhibitor letrozole is a novel agent that can be used as an alternative to clomiphene citrate for ovulation induction in patients with unexplained infertility. The dose of letrozole used has varied between studies, and this study aimed to compare the three most commonly used doses: 2.5, 5 and 7.5 mg. A total of 179 patients were randomly recruited in this prospective study with 58, 61 and 60 patients in each dosage group respectively. This study reports a significantly higher (P < 0.05) number of follicles (total, > 14 mm and > or = 18 mm) on the day of administration of human chorionic gonadotrophin in the 7.5 mg group, associated with significantly fewer (P < 0.05) days of stimulation. However the pregnancy and miscarriage rates were similar in the three groups. In conclusion, it seems that the use of higher doses of letrozole offers no advantage in terms of pregnancy rates over the lower (2.5 mg) dose.

Mistiming of intercourse as a primary cause of failure to conceive: results of a survey on use of a home-use fertility monitor

OBJECTIVE

To assess demographics, fecundity characteristics and fertility history of couples who successfully conceived using a home-use Fertility Monitor.

STUDY DESIGN

This was a retrospective US observational study of couples who successfully conceived using a Fertility Monitor. Data were self-reported by volunteers using a questionnaire supplied and collected by mail. Of 276 surveys distributed, 196 (71.0%) were returned and evaluated.

RESULTS

Length of time trying to conceive was < 12 months for 70% of women; proportions were similar across age groupings. After switching to the Fertility Monitor, 49.5% and 91.9% of women had conceived within first and third cycles, respectively. Prior to Fertility Monitor use, conception aids were used by 84.2% and 64.3% had consulted a physician to seek help in attempting to conceive. Average costs of prior treatment were (in US dollars) 6637 dollars; median costs for infertility evaluation were 1075 dollars per cycle. Fertility Monitor costs ranged from 250 dollars for one cycle to 550 dollars after 10 cycles.

CONCLUSIONS

A probable cause for failure to conceive appeared to be mistiming of intercourse. The issue of early intervention with tests and medications were highlighted, resulting in escalating costs and strain on the couple. The use of a home Fertility Monitor that identifies all fertile days of the cycle and allows couples to target intercourse accordingly, should be considered as an alternative choice for couples seeking to conceive during the first year, before other attempts at infertility diagnosis are made, unless there are conflicting clinical reasons.

Increased pregnancy rate with use of the Clearblue Easy Fertility Monitor⁎⁎Unipath Ltd., Bedford, United Kingdom

OBJECTIVE

To determine the effect on pregnancy rates through use of the Clearblue Easy Fertility Monitor (CEFM) in women trying to conceive.

DESIGN

Prospective study, in which volunteers were randomly assigned either to use or not to use the CEFM. All participants could also use other aids to conception. Data were self-reported by volunteers using daily diaries, supplied and collected by mail.

SETTING

Home use, under conditions normally experienced by over-the-counter purchasers of the marketed device.

PATIENT(S)

Women who were trying to conceive; 653 (CEFM 305, control 348) provided evaluable information.

INTERVENTION(S)

CEFM was used for two cycles.

MAIN OUTCOME MEASURE(S)

Cumulative pregnancy rates over two cycles of use.

RESULT(S)

The cumulative pregnancy rate for 2 cycles was significantly higher in the CEFM group (22.7%) compared with the control group (14.4%). More women who had been trying to conceive for <6 months became pregnant than women who had been trying to conceive for >6 months (odds ratio: 2.67). Previous pregnancy and younger age of partners were also significant prognostic factors, but use of other aids to conception was not. After adjustment for other factors, CEFM use remained a significant factor affecting the chance of conceiving within two cycles (odds ratio: 1.89). CEFM users found the device to be easy/very easy to use (90%) and convenient/very convenient (80%).

CONCLUSION(S)

Use of the CEFM increases the likelihood of getting pregnant during the first two cycles of use compared with its nonuse, in women who had been trying to conceive for up to 2 years.

Localization of ubiquitin C-terminal hydrolase L1 in mouse ova and its function in the plasma membrane to block polyspermy

Protein degradation is essential for oogenesis and embryogenesis. The ubiquitin-proteasome system regulates many cellular processes via the rapid degradation of specific proteins. Ubiquitin carboxyl-terminal hydrolase L1 (UCH-L1) is exclusively expressed in neurons, testis, ovary, and placenta, each of which has unique biological activities. However, the functional role of UCH-L1 in mouse oocytes remains unknown. Here, we report the expression pattern of UCH-L1 and its isozyme UCH-L3 in mouse ovaries and embryos. Using immunocytochemistry, UCH-L1 was selectively detected on the plasma membrane, whereas UCH-L3 was mainly detected in the cytoplasm, suggesting that these isozymes have distinct functions in mouse eggs. To further investigate the functional role of UCH-L1 in mouse eggs, we analyzed the fertilization rate of UCH-L1-deficient ova of gad female mice. Female gad mice had a significantly increased rate of polyspermy in in vitro fertilization assays, although the rate of fertilization did not differ significantly from wild-type mice. In addition, the litter size of gad female mice was significantly reduced compared with wild-type mice. These results may identify UCH-L1 as a candidate for a sperm-oocyte interactive binding or fusion protein on the plasma membrane that functions during the block to polyspermy in mouse oocytes.

Tamoxifen citrate for women with unexplained infertility

OBJECTIVE

To assess whether administration of tamoxifen citrate (TMX) to women with unexplained infertility is beneficial. The primary outcome was the clinical pregnancy rate.

STUDY DESIGN

In a prospective randomized trial, 66 consecutive women with unexplained infertility were recruited for the study. Thirty-six women received TMX at a 20-mg dosage and 30 women received no ovulation-induction drugs.

RESULTS

Fourteen patients in the TMX group stopped taking TMX, and observations were terminated because of antiestrogenic effects. The pregnancy rate (PR) per patient and the PR per cycle were significantly decreased (P < 0.005) in the TMX group than in the spontaneous group. Kaplan-Meier tests showed that the cumulative PR in the TMX group was significantly lower than in the spontaneous group (P < 0.05). Ten of 14 patients who had stopped taking TMX became pregnant in spontaneous cycles.

CONCLUSIONS

Administration of tamoxifen to women with unexplained infertility is not efficacious in terms of increasing the clinical PR.

Role of oxidative stress in female reproduction

In a healthy body, ROS (reactive oxygen species) and antioxidants remain in balance. When the balance is disrupted towards an overabundance of ROS, oxidative stress (OS) occurs. OS influences the entire reproductive lifespan of a woman and even thereafter (i.e. menopause). OS results from an imbalance between prooxidants (free radical species) and the body's scavenging ability (antioxidants). ROS are a double-edged sword - they serve as key signal molecules in physiological processes but also have a role in pathological processes involving the female reproductive tract. ROS affect multiple physiological processes from oocyte maturation to fertilization, embryo development and pregnancy. It has been suggested that OS modulates the age-related decline in fertility. It plays a role during pregnancy and normal parturition and in initiation of preterm labor. Most ovarian cancers appear in the surface epithelium, and repetitive ovulation has been thought to be a causative factor. Ovulation-induced oxidative base damage and damage to DNA of the ovarian epithelium can be prevented by antioxidants. There is growing literature on the effects of OS in female reproduction with involvement in the pathophysiology of preeclampsia, hydatidiform mole, free radical-induced birth defects and other situations such as abortions. Numerous studies have shown that OS plays a role in the pathophysiology of infertility and assisted fertility. There is some evidence of its role in endometriosis, tubal and peritoneal factor infertility and unexplained infertility. This article reviews the role OS plays in normal cycling ovaries, follicular development and cyclical endometrial changes. It also discusses OS-related female infertility and how it influences the outcomes of assisted reproductive techniques. The review comprehensively explores the literature for evidence of the role of oxidative stress in conditions such as abortions, preeclampsia, hydatidiform mole, fetal embryopathies, preterm labour and preeclampsia and gestational diabetes. The review also addresses the growing literature on the role of nitric oxide species in female reproduction. The involvement of nitric oxide species in regulation of endometrial and ovarian function, etiopathogenesis of endometriosis, and maintenance of uterine quiescence, initiation of labour and ripening of cervix at parturition is discussed. Complex interplay between cytokines and oxidative stress in the etiology of female reproductive disorders is discussed. Oxidant status of the cell modulates angiogenesis, which is critical for follicular growth, corpus luteum formation endometrial differentiation and embryonic growth is also highlighted in the review. Strategies to overcome oxidative stress and enhance fertility, both natural and assisted are delineated. Early interventions being investigated for prevention of preeclampsia are enumerated. Trials investigating combination intervention strategy of vitamin E and vitamin C supplementation in preventing preeclampsia are highlighted. Antioxidants are powerful and there are few trials investigating antioxidant supplementation in female reproduction. However, before clinicians recommend antioxidants, randomized controlled trials with sufficient power are necessary to prove the efficacy of antioxidant supplementation in disorders of female reproduction. Serial measurement of oxidative stress biomarkers in longitudinal studies may help delineate the etiology of some of the diosorders in female reproduction such as preeclampsia.

Oxidative stress and its implications in female infertility – a clinician's perspective

Reactive oxygen species (ROS) have a role in the modulation of gamete quality and gamete interaction. Generation of ROS is inherent in spermatozoa and contaminating leukocytes. ROS influence spermatozoa, oocytes, embryos and their environment. Oxidative stress (OS) mediates peroxidative damage to the sperm membrane and induces nuclear DNA damage. ROS can modulate the fertilizing capabilities of the spermatozoa. There is extensive literature on OS and its role in male infertility and sperm DNA damage and its effects on assisted reproductive techniques. Evidence is accumulating on the role of ROS in female reproduction. Many animal and human studies have elucidated a role for ROS in oocyte development, maturation, follicular atresia, corpus luteum function and luteolysis. OS-mediated precipitation of pathologies in the female reproductive tract is similar to those involved in male infertility. OS influences the oocyte and embryo quality and thus the fertilization rates. ROS appears to play a significant role in the modulation of gamete interaction and also for successful fertilization to take place. ROS in culture media may impact post-fertilization development, i.e. cleavage rate, blastocyst yield and quality (indicators of assisted reproduction outcomes). OS is reported to affect both natural and assisted fertility. Antioxidant strategies should be able to intercept both extracellular and intracellular ROS. This review discusses the sources of ROS in media used in IVF-embryo transfer and strategies to overcome OS in oocyte in-vitro maturation, in-vitro culture and sperm preparation techniques.