Register data on assisted reproductive technology (ART) in Europe including a detailed description of ART in Denmark

Investigating the Association of Assisted Reproduction Techniques and Adverse Perinatal Outcomes

BACKGROUND

Infertility affects about 80 million individuals worldwide and 10-15% of couples at reproductive age will seek medical assistance. There is increasing evidence that pregnancies after Assisted Reproduction Techniques (ART) are associated with pre-term birth, low birthweight, congenital defects, and increased mortality rates. The aim of this review is to assess all the published literature and provide an updated review on the effect of assisted conception and perinatal and neonatal outcomes.

METHODS

Comprehensive research on Pubmed/Medline, Scopus, and Google scholar electronic databases was conducted from July 2023 up to September 2023, using the terms assisted reproductive techniques, ART, in vitro fertilization, IVF, intracytoplasmic sperm injection, ICSI, preterm birth, PTB, low birth weight, LBW, chromosomal defects, congenital defects, and hypospadias. In total, 87 full text articles were retrieved and after a careful evaluation, 31 studies were selected for data extraction.

RESULTS

Our review demonstrated a higher risk of congenital and chromosomal defects, and a higher incidence of male genital tract defects and heart defects in ART pregnancies. Regarding pre-term birth, our results were contradictory.

CONCLUSIONS

Although assisted reproduction techniques are associated with increased risks, they are safe regarding perinatal outcomes and couples should not be discouraged from utilizing them. Our results aim to alert clinicians to these specific outcomes and offer more personalized care and counseling to infertile couples and their children.

Cohort profile: The SmartSleep Study, Denmark, combining evidence from survey, clinical and tracking data

PURPOSE

The SmartSleep Study is established to comprehensively assess the impact of night-time smartphone use on sleep patterns and health. An innovative combination of large-scale repeated survey information, high-resolution sensor-driven smartphone data, in-depth clinical examination and registry linkage allows for detailed investigations into multisystem physiological dysregulation and long-term health consequences associated with night-time smartphone use and sleep impairment.

PARTICIPANTS

The SmartSleep Study consists of three interconnected data samples, which combined include 30 673 individuals with information on smartphone use, sleep and health. Subsamples of the study population also include high-resolution tracking data (n=5927) collected via a customised app and deep clinical phenotypical data (n=245). A total of 7208 participants are followed in nationwide health registries with full data coverage and long-term follow-up.

FINDINGS TO DATE

We highlight previous findings on the relation between smartphone use and sleep in the SmartSleep Study, and we evaluate the interventional potential of the citizen science approach used in one of the data samples. We also present new results from an analysis in which we use 803 000 data points from the high-resolution tracking data to identify clusters of temporal trajectories of night-time smartphone use that characterise distinct use patterns. Based on these objective tracking data, we characterise four clusters of night-time smartphone use.

FUTURE PLANS

The unprecedented size and coverage of the SmartSleep Study allow for a comprehensive documentation of smartphone activity during the entire sleep span. The study has been expanded by linkage to nationwide registers, which allow for further investigations into the long-term health and social consequences of night-time smartphone use. We also plan new rounds of data collection in the coming years.

Environmental factors in declining human fertility

A severe decline in child births has occurred over the past half century, which will lead to considerable population declines, particularly in industrialized regions. A crucial question is whether this decline can be explained by economic and behavioural factors alone, as suggested by demographic reports, or to what degree biological factors are also involved. Here, we discuss data suggesting that human reproductive health is deteriorating in industrialized regions. Widespread infertility and the need for assisted reproduction due to poor semen quality and/or oocyte failure are now major health issues. Other indicators of declining reproductive health include a worldwide increasing incidence in testicular cancer among young men and alterations in twinning frequency. There is also evidence of a parallel decline in rates of legal abortions, revealing a deterioration in total conception rates. Subtle alterations in fertility rates were already visible around 1900, and most industrialized regions now have rates below levels required to sustain their populations. We hypothesize that these reproductive health problems are partially linked to increasing human exposures to chemicals originating directly or indirectly from fossil fuels. If the current infertility epidemic is indeed linked to such exposures, decisive regulatory action underpinned by unconventional, interdisciplinary research collaborations will be needed to reverse the trends.

Dispensing of clomiphene citrate to treat infertility: medication supplied and population prevalence of assisted pregnancies and multiple births

OBJECTIVE

To determine the proportion of pregnancies resulting in birth that were conceived with the use of clomiphene citrate (CC) and the frequency of multiple pregnancy.

DESIGN

Whole-of-population cohort study, constructed through data linkage. Comprehensive Australian Government records of dispensed medications were linked to state Perinatal Registry records for all births of at least 20 weeks' gestation.

SETTING

The state of South Australia.

PATIENT(S)

Women who maintained pregnancy for at least 20 weeks and gave birth between July 2003 and December 2015, a total of 150,713 women with 241,561 pregnancies.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Ongoing pregnancy occurring in proximity to CC, defined as dispensing from 90 days before to the end of a conception window derived from newborn date of birth and gestational age.

RESULT(S)

Linkage to dispensed prescription records was achieved for 97.9% of women. Women who conceived with CC tended to be older and socioeconomically advantaged and more likely than other women to have a history of miscarriage. Ongoing pregnancies associated with CC comprised 1.6% of the total; 5.7% were multiple births (mostly twins, 94.6%) compared with 1.5% in the remainder (98.5% twins).

CONCLUSION(S)

In South Australia, 1.6% of pregnancies (1 in 60) of at least 20 weeks' gestation were conceived proximal to CC dispensing. Of these, 5.7% were multiple pregnancies. This takes the proportion of women who achieved an ongoing pregnancy with medical assistance from 4.4%, based on reports from assisted reproductive technology clinics, to 6% in total.

Paternity After Treatment for Testicular Germ Cell Cancer: A Danish Nationwide Population-Based Cohort Study

BACKGROUND

Testicular germ cell cancer (TC) incidence peaks in the reproductive age but knowledge on fertility after treatment is insufficient. The aim was to evaluate paternity after today's testicular cancer (TC) treatment.

METHODS

Clinical data were extracted from the Danish Testicular Cancer database and patients were divided into four groups: 1) Surveillance; 2) Bleomycin, etoposide, and cisplatin (BEP); 3) BEP + post-chemotherapy retroperitoneal surgery (BEP + surgery); and 4) Abdominal radiotherapy. For each patient, 10 men matched on date of birth were randomly sampled from the normal population. Paternity was defined as date of birth of first child after TC treatment with or without the use of assisted reproductive technology (ART) and was assessed by linkage to the Danish Medical Birth Register and the Danish in vitro fertilization (IVF)-register.

RESULTS

We included 4,846 unilateral TC patients and 48,456 men from the normal population. The 20 years predicted chance of obtaining fatherhood for a 30-year-old man was 39.7% in TC patients compared to 42.5 % in the normal population. The chance of obtaining fatherhood was statistically significantly decreased after BEP (hazard ratio [HR] = 0.87, 95% confidence interval [CI] = 0.78-0.97) and BEP + surgery (HR = 0.74 95% CI = 0.63-0.87), but not after radiotherapy (HR = 0.89, 95% CI = 0.75-1.06) or surveillance (HR = 0.95, 95% CI = 0.89-1.02). The risk of needing ART to obtain fatherhood was increased after all treatment modalities.

CONCLUSION

The chance of obtaining fatherhood after TC treatment was substantially higher than previously reported. Patients followed on a surveillance program had a similar chance of obtaining fatherhood as non-cancerous men.

Parenthood Rates and Use of Assisted Reproductive Techniques in Younger Hodgkin Lymphoma Survivors: A Danish Population-Based Study

PURPOSE

The majority of young adults with Hodgkin lymphoma (HL) are cured, but chemotherapy-induced infertility can have profound psychosocial consequences. Providing data on parenthood rates and use of assisted reproductive techniques (ARTs) after contemporary HL treatment is important for patient counseling and survivorship care.

MATERIALS AND METHODS

All Danish patients with HL diagnosed during 2000-2015 at the ages 18-40 years who achieved remission after first-line therapy were included and matched on age, sex, and parenthood status to five random persons from the general population. Parenthood rates were defined as the rate of first live birth per 1,000 person years, starting 9 months after HL diagnosis. Nationwide birth and patient registers were used to capture parenthood outcomes and ARTs use.

RESULTS

A total of 793 HL survivors and 3,965 comparators were included (median follow-up 8.7 years). Similar parenthood rates were observed for male and female HL survivors when compared with matched comparators (56.2 v 57.1; P = .871 for males and 63.8 v 61.2; P = .672 for females). For male HL survivors, BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone) therapy was associated with lower parenthood rates as compared to the matched comparators (28.1 v 60.8; P = .020). Live birth after ARTs were more common for HL survivors than for comparators (males 21.6% v 6.3%; P < .001; females 13.6% v 5.5%; P = .001). There were no differences in gestational age, Apgar score, or newborn measurements between HL survivors and matched comparators.

CONCLUSION

The parenthood rates for HL survivors who have not experienced relapse were generally similar to the general population. However, ARTs were used more often before the first live birth in HL survivors, which is relevant information when discussing possible long-term side effects and fertility-preserving treatment options.

The Efficacy of Assisted Reproduction in Women with a Wide Spectrum of Chronic Diseases - A Review

Assisted reproductive technology (ART) treatments in women with underlying chronic diseases have become increasingly frequent. The objective of this review is to provide an overview of the literature examining the chance of having a live born child after ART in women with chronic diseases, compared to other women receiving ART. We focused on some of the most prevalent chronic diseases in women during their reproductive years, ie ulcerative colitis, Crohn's disease, rheumatoid arthritis, multiple sclerosis, epilepsy, hyperthyroidism, hypothyroidism, and diabetes mellitus. Secondly, we studied the chance of successful implantation. The literature search was performed in the database Pubmed.gov. including all studies published before October 2020. Title and abstracts of 58 papers were reviewed, 37 papers were excluded and other 8 studies were excluded after full-text evaluation. Only 13 papers were eligible for review. Results indicate that women with ulcerative colitis, Crohn's disease, rheumatoid arthritis, hyperthyroidism, and diabetes mellitus type 2 might have problems with low implantation rate or early embryo development during ART. On the contrary, the few studies on women with hypothyroidism, diabetes mellitus type 1, and epilepsy suggest an equivalent chance of a live birth compared to other women undergoing ART. A possible explanation behind these differences could reside in the disease-specific dysregulation of the innate or adaptive immune system. To our knowledge, this is the first review on ART in women with chronic diseases, and it has disclosed that the evidence in this area is indeed sparse. We encourage others to examine live birth after ART in women with chronic diseases.

The Danish National Register of assisted reproductive technology: content and research potentials

The Danish National Register of assisted reproductive technology (ART) was initially established in 1994. The register comprises complete information on all ART procedures in public and private clinics in Denmark from 2013 and onwards, including baseline information on the cause of infertility and a number of health-related patient characteristics. The register enables monitoring and research on infertility treatment and reproductive topics in single women or couples seeking assisted reproduction, and the register is thus a key component of the Danish health information system within human reproduction. We aimed to provide an updated description of the register including advantages and pitfalls when using the register for reproductive epidemiological research, and a description of the accessibility for researchers. The Danish ART register is a valuable tool for epidemiological research. However, the inherent strengths and limitations ought to be in perspective when designing studies and interpreting the study results. Reports with annually aggregated data on ART treatments, can be accessed on the Danish Health Data Authority web page and researchers may obtain access to individual pseudonomized data via secure servers at the Danish Health Data Authority and Statistics Denmark.

Pulmonary arterial pressure in at-term in vitro fertilization neonates: A cross-sectional study

Objective:

Hormones consumption in women who conceive through in vitro fertilization (IVF) as well as embryonic manipulations have raised concerns regarding the neonates’ health, including the possibility of pulmonary hypertension. This study, therefore, aimed to assess the pulmonary arterial pressure in at-term IVF neonates.

Materials and Methods:

This prospective cross-sectional study was conducted between March 2013 and October 2017 and compares 160 IVF neonates (group 1) with 160 naturally conceived neonates (group 2). The neonates in both groups were cesarean newborns, matched in terms of gestational and neonatal age. The neonates were three-seven days old, had a full-term gestational age of 37-39 weeks and 6 days, and a normal birth weight of 2500-4000 gr. The systolic pulmonary artery pressure (SPAP) was estimated using real-time echocardiography on the basis of peak flow velocity of tricuspid regurgitation jet.

Results:

A significant difference was observed in the mean SPAPs between the two groups (p<0.001). Although, the effect of gestational age on reducing SPAP was greater and statistically significant in group 1, the gradual decrease in the PAP after birth appeared to be slower in this group. Moreover, in both groups, the effect of gestational age on reducing SPAP was more convincing than that of the neonatal age. Further, in both groups, a significant reverse correlation was observed between the SPAP and the neonatal weight; however, it appeared to be markedly higher in group 1.

Conclusion:

Our study renders IVF as being culpable in the incidence of pulmonary hypertension among neonates. Hence, to detect the likelihood of pulmonary arterial hypertension in IVF neonates, it is recommended to monitor their PAP during the neonatal period, and thereby facilitate them with the required treatment.

Parental time to pregnancy, medically assisted reproduction and pubertal development in boys and girls

STUDY QUESTION

Does parental fertility, measured by time to pregnancy (TTP), or use of medically assisted reproduction (MAR) affect pubertal development in the offspring?

SUMMARY ANSWER

Neither TTP nor type of MAR treatment had clinically relevant implications for mean age at achieving individual pubertal milestones or overall timing of puberty in boys and girls.

WHAT IS KNOWN ALREADY

Parental TTP and MAR have been associated with impaired semen quality in adult sons. Timing of puberty reflects earlier signals of reproductive health, but it remains unclear whether parental fertility or MAR affects pubertal development, especially in the growing generation of children conceived by IVF or ICSI.

STUDY DESIGN, SIZE, DURATION

In this study, 15 819 children born by mothers in the Danish National Birth Cohort from 2000 to 2003 participated in a nationwide puberty cohort (participation rate = 70%). Parental TTP and use of MAR were reported by mothers in early pregnancy and children’s pubertal development data was self-recorded in web-based questionnaires from 11 years of age and 6 monthly throughout puberty (2012–2018).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Pubertal development in children (of planned pregnancies, n = 13 285) born by untreated subfecund (TTP: 6–12 months) (n =2038), untreated severely subfeund (TTP: >12 months) (n = 1242), treated subfecund (n = 230) and treated severely subfecund (n = 1234) parents were compared to children born to more fertile parents (TTP: ≤5 months). We estimated mean monthly differences in mean age at achieving individual pubertal milestones (i.e. age at menarche, voice break, first ejaculation and Tanner stages 2, 3, 4 and 5 for breast or genital development and pubic hair growth) and a combined indicator of timing of puberty. Further, we compared mean age at achieving the individual pubertal milestones in children born by use of IVF or ICSI (n = 480) with children born by controlled ovarian stimulation or ovulation induction with or without intrauterine insemination (n = 902).

MAIN RESULTS AND THE ROLE OF CHANCE

We found tendencies towards slightly later mean age at male pubertal timing and slightly earlier mean age at female pubertal timing among children born by untreated subfecund, treated subfecund, untreated severely subfecund and treated severely subfecund parents. There were no specific patterns with increasing TTP, use of MAR nor type of MAR treatment, and the magnitude of the mean differences for individual milestones and overall timing of puberty were small, i.e. 0.9 months (95% CI: −1.0; 2.8) for first ejaculation and −0.5 months (95% CI: −2.0; 1.0) months for age at menarche in boys and girls, respectively, born by treated severely subfecund parents when compared with children born by more fertile parents.

LIMITATIONS, REASONS FOR CAUTION

Non-differential misclassification of the self-reported information on parental TTP and pubertal development in the offspring may serve as an alternative explanation of the findings, possibly biasing the estimates towards the null. The information on pubertal development was collected from around 11 years of age and onwards.

WIDER IMPLICATIONS OF THE FINDINGS

This study adds to the growing body of literature suggesting only limited harmful effects of parental subfecundity and MAR on offspring’s long-term growth and development.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by the Danish Council for Independent Research [DFF 4183-00152]; and the Faculty of Health at Aarhus University. The authors have no financial relationships or competing interests to disclose.

Infertility in a Cohort of Male Danish Firefighters: A Register-Based Study

Our aim in this study was to examine infertility among male firefighters in Denmark. Thus, we established a cohort of 4,710 past and present male Danish firefighters through personnel and membership records obtained from employers and trade unions. Information on vital status and infertility from the Danish Civil Registration System, the In Vitro Fertilisation Register, and the National Patient Register for the period 1984-2017 was linked to cohort members using their Danish personal identification numbers. Hazard ratios and corresponding 95% confidence intervals were estimated for male-factor infertility and overall infertility through Cox regression analyses comparing the firefighters with 2 reference groups: a sample of employees and military men. Among the full-time firefighters, the risk of male-factor infertility was increased in comparison with the sample of employees (In Vitro Fertilisation Register model: hazard ratio = 1.46 (95% confidence interval: 1.10, 1.94); National Patient Register model: hazard ratio = 1.53 (95% confidence interval: 1.18, 1.98)). Results were less consistent using the military men as the reference group. Further, the increase in infertility seemed restricted to duration of time employed as a firefighter. No increase in risk of either male-factor infertility or overall infertility was seen among the part-time/volunteer firefighters. Thus, full-time firefighting was associated with a greater risk of being diagnosed with male-factor infertility in our cohort.

Effects of diisononyl phthalate on Danio rerio reproduction

Di-isononyl phthalate (DiNP) is a high molecular weight phthalate commonly used as a plasticizer. It was introduced as a replacement for bis (2-ethylhexyl) phthalate (DEHP) which is used in the production of plasticized polyvinyl chloride (PVC). The purpose of this study was to investigate for the first time the effect of DiNP on female reproductive physiology in Danio rerio. Fish were exposed to five different doses of DiNP plus control (0 μg/L; 0.42 μg/L; 4.2 μg/L; 42 μg/L; 420 μg/L; 4200 μg/L) for a period of 21 days. We evaluated fish fecundity, oocyte growth, autophagic and apoptotic processes, as well as changes in morphological and biochemical composition of oocytes, using, qPCR analysis, histology and Fourier transform infrared imaging. The results demonstrate a non-monotonic dose response to DiNP. Greater differences were observed at the lowest (0.42 μg/L) and higher concentrations (420 μg/L; 4200 μg/L) of DiNP. The findings provide evidence that exposure to DiNP adversely affect oocytes growth and maturation, leading to abnormal gonadal development and reproduction in zebrafish.

Parental age and childhood cancer risk: A Danish population-based registry study

BACKGROUND

Though the association between parental age at child's birth and the risk of childhood cancer has been previously investigated, the evidence to date is inconclusive and scarce for rarer cancer types.

METHODS

Cancer cases (N=5,856) were selected from all children born from 1968 to 2014 and diagnosed from 1968 to 2015 in Denmark at less than 16 years of age listed in the nationwide Danish Cancer Registry. Cases were individually matched to controls (1:100) on sex and year of birth with a total of 585,594 controls randomly sampled from all live births in Denmark from the Danish Central Population Registry. Parental age at child's birth was extracted from the Central Population Registry. Conditional logistic regression models were used to estimate odds ratios for the association between parental age at child's birth and childhood cancer risk. Parental age was modeled as both categorical (referent group, parents aged 25-29) and continuous per 5-year increase in age.

RESULTS

Offspring of older mothers were at an increased risk of acute lymphoblastic leukemia [OR=1.10, 95% CI: (1.02, 1.19) per 5-year increase in age]. Older maternal age (40+) increased the risk of non-Hodgkin lymphoma [OR=1.96, 95%CI: (1.12, 3.43)]. The risk of Wilms' tumor also appeared elevated with older paternal age [OR=1.11, 95% CI: (0.97, 1.28) per 5-year increment in age].

CONCLUSION

Older parental age was a risk factor for various childhood cancers in Danish children. Further investigation of the biological and social factors that may be contributing to these associations is warranted.

Effects of BPA on female reproductive function: The involvement of epigenetic mechanism

Epigenetic modifications are classified as heritable and reversible chemical modifications of chromatin that do not cause changes in DNA sequence. Changes in epigenetic modifications can be caused by exposure to certain environmental factors, such as contaminants like bisphenol A (BPA). Bisphenol A is ubiquitous in the environment and produced in large quantities, and known to have hormone-like activity, whereby disrupting endocrine function. Because of evidence for disruption of sex steroid mediated pathways, there is a concern that BPA could have adverse effects on female reproduction. The purpose of this review is to summarize the effects of BPA on adult female reproduction with focus on epigenetic changes that can be heritable.

Epidemiologic Approaches for Studying Assisted Reproductive Technologies: Design, Methods, Analysis and Interpretation

PURPOSE

While considerable progress has been made since the advent of assisted reproductive technology (ART), the field remains a complex and challenging one for clinicians and researchers alike. This review discusses some of the most salient issues pertaining to the study of ART and whenever possible suggestions on how to address them.

RECENT FINDINGS

More than 5 million babies have been born through ART to date, representing up to 4% of all births worldwide. While technologies continue to evolve and demand for treatment grows, it is more important than ever to conduct rigorous and timely research to help guide clinical practice that is safe and effective, and that minimizes potential short- and long-term adverse outcomes to mother and child.

SUMMARY

ART research will require exceedingly more sophisticated research methods, designs, and analyses that are rooted in a reproductive epidemiological framework in order to improve future research and ultimately promote better outcomes for all subfertile couples and their children.

BPA-Induced Deregulation Of Epigenetic Patterns: Effects On Female Zebrafish Reproduction

Bisphenol A (BPA) is one of the commonest Endocrine Disruptor Compounds worldwide. It interferes with vertebrate reproduction, possibly by inducing deregulation of epigenetic mechanisms. To determine its effects on female reproductive physiology and investigate whether changes in the expression levels of genes related to reproduction are caused by histone modifications, BPA concentrations consistent with environmental exposure were administered to zebrafish for three weeks. Effects on oocyte growth and maturation, autophagy and apoptosis processes, histone modifications, and DNA methylation were assessed by Real-Time PCR (qPCR), histology, and chromatin immunoprecipitation combined with qPCR analysis (ChIP-qPCR). The results showed that 5 μg/L BPA down-regulated oocyte maturation-promoting signals, likely through changes in the chromatin structure mediated by histone modifications, and promoted apoptosis in mature follicles. These data indicate that the negative effects of BPA on the female reproductive system may be due to its upstream ability to deregulate epigenetic mechanism.

In-vitro fertilization and spontaneous pregnancies: matching outcomes in Douala, Cameroon

BACKGROUND

Couples are considered infertile if they do not conceive over a 12-month period of unprotected intercourse. Studies have shown that female causes accounted for between 25 to 37 percent of infertility worldwide (with larger proportions in sub-Saharan Africa and Southeast Asia) and male causes accounted for between 8 to 22 percent. Both male and female causes accounted for between 21 to 38 percent. Although the majority of ART children are normal, there are concerns about the increased risk for adverse pregnancy outcomes. More than 30 % of ART pregnancies are twins or higher-order multiple gestations (triplets or greater) and more than one half of all ART neonates are the products of multifetal gestations, with an attendant increase in prematurity complications. The aim of this study was to evaiuate the outcome of pregnancies conceived by In-vitro fertilisation compared to those conceived naturally in two hospitals in Douala, Cameroon.

METHODS

This was a prospective study carried out from October 1, 2011 to September 30, 2012. Participants were recruited from two hospitals: the Douala General Hospital (DGH) and the Clinique de l' Aéroport (CDA), also in Douala. A total of 102 women were recruited for study: 51 who conceived by IVF (cases) and 51 who conceived naturally (controls). Of the 102 women, 52.9 % were between 31 - 39 years of age, while 21.6 % were above 40.

RESULTS

Participants who conceived through IVF-ET were 4.1 times more likely to undergo cesarean delivery than those who conceived naturally [OR 4.10, 95 % CI 1.78-9.42]. Similarly, a higher percentage of patients in the IVF group than those in the control group have never given birth (33.3 % vs 2.0 %) (P < 0.0001). The percentage of multiple pregnancies was 7.5 times higher in the IVF group than in the control group (14.7 % vs.1.96 %) (P = 0.000). The leading indication for cesarean delivery was advanced maternal age (27.3 %) followed by IVF or precious pregnancy (18.2 %).

CONCLUSIONS

Cesarean delivery was more frequent amongst the IVF group than in the control group. The leading indications for cesarean delivery were advanced maternal age and IVF or precious pregnancy. The long-term neonatal outcomes of IVF babies beyond 5-min Apgar scores should be studied in Cameroon and follow-up beyond 1 year encouraged.

Changes in Sperm Motility and Capacitation Induce Chromosomal Aberration of the Bovine Embryo following Intracytoplasmic Sperm Injection

Intracytoplasmic sperm injection (ICSI) has become the method of choice to treat human male infertility. One of the outstanding problems associated with this technique is our current lack of knowledge concerning the effect of sperm capacitation and motility upon the subsequent development of oocytes following ICSI. In the present study, we first examined the capacitation state of sperm exhibiting normal motility, along with sperm that had been activated, and examined the effect of reactive oxygen species (ROS) produced by these sperm types upon embryogenesis following bovine in vitro fertilization (IVF) and ICSI. Data showed that activated sperm reduced the chromosomal integrity of IVF/ICSI embryos at the blastocyst stage, while capacitated sperm produced ROS in capacitation media. Secondly, we treated sperm with carbonyl cyanide m-chlorophenyl hydrazine (CCCP), a chemical known to uncouple cell respiration within the mitochondria, and investigated the effect of this treatment upon blastocyst formation and chromosomal integrity at the blastocyst stage. Activated sperm in which the mitochondria had been treated with CCCP reduced levels of chromosomal aberration at the blastocyst stage following ICSI, by reducing mitochondrial activity in activated sperm. In conclusion, these findings suggest that capacitated sperm exhibiting activated motility induced chromosomal aberration during development to the blastocyst stage following ICSI. The injection of sperm exhibiting normal motility, or activated sperm in which mitochondrial activity had been reduced, improved the quality of ICSI-derived embryos. Therefore, the selection of sperm exhibiting progressive motility may not always be better for early embryo development and fetal growth following human ICSI, and that the use of a bovine model may contribute to a deeper understanding of sperm selection for human ICSI embryo development.

Right ventricular dysfunction in children and adolescents conceived by assisted reproductive technologies

Assisted reproductive technologies (ART) predispose the offspring to vascular dysfunction, arterial hypertension, and hypoxic pulmonary hypertension. Recently, cardiac remodeling and dysfunction during fetal and early postnatal life have been reported in offspring of ART, but it is not known whether these cardiac alterations persist later in life and whether confounding factors contribute to this problem. We, therefore, assessed cardiac function and pulmonary artery pressure by echocardiography in 54 healthy children conceived by ART (mean age 11.5 ± 2.4 yr) and 54 age-matched (12.2 ± 2.3 yr) and sex-matched control children. Because ART is often associated with low birth weight and prematurity, two potential confounders associated with cardiac dysfunction, only singletons born with normal birth weight at term were studied. Moreover, because cardiac remodeling in infants conceived by ART was observed in utero, a situation associated with increased right heart load, we also assessed cardiac function during high-altitude exposure, a condition associated with hypoxic pulmonary hypertension-induced right ventricular overload. We found that, while at low altitude cardiac morphometry and function was not different between children conceived by ART and control children, under the stressful conditions of high-altitude-induced pressure overload and hypoxia, larger right ventricular end-diastolic area and diastolic dysfunction (evidenced by lower E-wave tissue Doppler velocity and A-wave tissue Doppler velocity of the lateral tricuspid annulus) were detectable in children and adolescents conceived by ART. In conclusion, right ventricular dysfunction persists in children and adolescents conceived by ART. These cardiac alterations appear to be related to ART per se rather than to low birth weight or prematurity.

Growth, head growth, and neurocognitive outcome in children born very preterm: methodological aspects and selected results

In light of the growing number of surviving children born very preterm, there is an increasing focus on their long-term outcomes in terms of growth, metabolic status, and neurocognitive development. Therefore, it is of importance to follow such children from birth onwards with the aim of identifying the causes of atypical development, developing preventative measures, and improving outcomes. Since such long-term follow-up needs to be conducted with the least possible burden, clinical investigations such as anthropometry and neurocognitive tests, if conducted rigorously, will continue to have a predominant role. The aim of this review is to discuss the complexity of longitudinal anthropometry in children born very preterm and to provide an overview of the main studies that have examined associations between growth, in particular head growth, and neurocognitive outcomes at around school age.

Does a Caesarean section increase the time to a second live birth? A register-based cohort study

STUDY QUESTION

Does a primary Caesarean section influence the rate of, and time to, subsequent live birth compared with vaginal delivery?

SUMMARY ANSWER

Caesarean section was associated with a reduction in the rate of subsequent live birth, particularly among elective and maternal-requested Caesareans indicating maternal choice plays a role.

WHAT IS KNOWN ALREADY

Several studies have examined the relationship between Caesarean section and subsequent birth rate with conflicting results primarily due to poor epidemiological methods.

STUDY DESIGN, SIZE, DURATION

This Danish population register-based cohort study covered the period from 1982 to 2010 (N = 832 996).

PARTICIPANTS/MATERIALS, SETTING, METHODS

All women with index live births were followed until their subsequent live birth or censored (maternal death, emigration or study end) using Cox regression models.

MAIN RESULTS AND THE ROLE OF CHANCE

In all 577 830 (69%) women had a subsequent live birth. Women with any type of Caesarean had a reduced rate of subsequent live birth (hazard ratio [HR] 0.86, 95% confidence intervals [CI] 0.85, 0.87) compared with spontaneous vaginal delivery. This effect was consistent when analyses were stratified by type of Caesarean: emergency (HR 0.87, 95% CI 0.86, 0.88), elective (HR 0.83, 95% CI 0.82, 0.84) and maternal-requested (HR 0.61, 95% CI 0.57, 0.66) and in the extensive sub-analyses performed.

LIMITATIONS, REASONS FOR CAUTION

Lack of biological data to measure a woman's fertility is a major limitation of the current study. Unmeasured confounding and limited availability of data (maternal BMI, smoking, access to fertility services and maternal-requested Caesarean section) as well as changes in maternity care over time may also influence the findings.

WIDER IMPLICATIONS OF THE FINDINGS

This is the largest study to date and shows that Caesarean section is most likely not causally related to a reduction in fertility. Maternal choice to delay or avoid childbirth is the most plausible explanation. Our findings are generalizable to other middle- to high-income countries; however, cross country variations in Caesarean section rates and social or cultural differences are acknowledged.

STUDY FUNDING/COMPETING INTERESTS

Funding was provided by the National Perinatal Epidemiology Centre, Cork, Ireland and conducted as part of the Health Research Board PhD Scholars programme in Health Services Research (Grant No. PHD/2007/16). L.C.K. is a Science Foundation Ireland Principal Investigator (08/IN.1/B2083) and the Director of the SFI funded Centre, INFANT (12/RC/2272). The authors have no competing interests to declare.

Possible fetal determinants of male infertility

Although common reproductive problems, such as male infertility and testicular cancer, present in adult life, strong evidence exists that these reproductive disorders might have a fetal origin. The evidence is derived not only from large epidemiological studies that show birth-cohort effects with regard to testicular cancer, levels of testosterone and semen quality, but also from histopathological observations. Many infertile men have histological signs of testicular dysgenesis, including Sertoli-cell-only tubules, immature undifferentiated Sertoli cells, microliths and Leydig cell nodules. The most severe gonadal symptoms occur in patients with disorders of sexual development (DSDs) who have genetic mutations, in whom even sex reversal of individuals with a 46,XY DSD can occur. However, patients with severe DSDs might represent only a small proportion of DSD cases, with milder forms of testicular dysgenesis potentially induced by exposure to environmental and lifestyle factors. Interestingly, maternal smoking during pregnancy has a stronger effect on spermatogenesis than a man's own smoking. Other lifestyle factors such as alcohol consumption and obesity might also have a role. However, increasing indirect evidence exists that exposure to ubiquitous endocrine disrupting chemicals, present at measurable concentrations in individuals, might affect development of human fetal testis. If confirmed, health policies to prevent male reproductive problems should not only target adult men, but also pregnant women and their children.

Assisted reproduction policies in Israel: a retrospective analysis of in vitro fertilization-embryo transfer

OBJECTIVE

To analyze whether the results and effectiveness of the open-ended treatment with IVF in Israel justifies the policy of limitless nondonor IVF rounds.

DESIGN

The research sample included 535 patients. The files of these patients were reviewed; data were extracted into a questionnaire, transferred into digital files, and analyzed with SPSS.

SETTING

IVF clinics.

PATIENT(S)

Two hundred ten women who began IVF treatment in 2000 and 325 women who were in IVF treatment during 2010.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Retrospective analysis of the success rates of live births resulting from cycles with IVF in women who started treatment in 2000, retrospective analysis of IVF results during 2010, and number of cycles in women who were in IVF treatment during 2010.

RESULT(S)

In the 2000 cohort, the rate of success with IVF was 54%. The success rate fell as the number of unsuccessful cycles and duration of infertility increased; age at the beginning of the treatment was influential. A similar pattern appeared in the group that was in treatment during 2010. The rate of success in the group that was in IVF treatment during 2010 was 16.6%; of the women in this group (2010, ongoing), 25% had already undergone more than five cycles and 12% of the women had already undergone more than seven cycles.

CONCLUSION(S)

Although limited in scope, this study suggests that the policy of limitless nondonor IVF-ET cycles in Israel should be further examined and assessed.

Demographic relevancy of increased use of assisted reproduction in European countries

BACKGROUND

Delayed childbearing in European countries has resulted in an increase in the number of women having children later in life. Thus more women face the problem of age-related infertility and cannot achieve their desired number of children. Childbearing postponement is one of the main reasons for the increasing use of assisted reproductive technology (ART) and conversely, the latter may be one of the factors contributing to the rise in female childbearing age. The research goal of our article is to evaluate the demographic importance of ART increased use and to examine its impact on both the fertility rate and birth timing.

METHODS

Comparative analysis based on demographic and ART data collected by the European IVF-monitoring (EIM) Consortium for the European Society of Human Reproduction and Embryology (ESHRE).

RESULTS

Most countries with a higher total fertility rate (TFR) also registered a higher number of treatment cycles per 1 million women of reproductive age. Despite the positive relationship between the postponement rate and the demand for ART among women aged 35 and older, the highest share of children born after ART was not found in countries characterized by a "delayed" fertility schedule. Instead, the highest proportion of ART births was found in countries with fertility schedules concentrated on women aged between 25 and 34. Accordingly, the effective use of ART can be expected in populations with a less advanced postponement rate.

CONCLUSIONS

ART can have a demographic relevancy when women take advantage of it earlier rather than later in life. Furthermore it is suggested that the use of ART at a younger age increases women's chance of achieving their reproductive goals and reduces the risk of age-related infertility and failed ART. Based on a demographic approach, reproductive health policy may become an integral part of policies supporting early childbearing: it may keep women from delaying too long having children and increase the chance of diagnosing potential reproductive health problems requiring a timely ART application.

Conazole fungicides inhibit Leydig cell testosterone secretion and androgen receptor activation in vitro

Conazole fungicides are widely used in agriculture despite their suspected endocrine disrupting properties. In this study, the potential (anti-)androgenic effects of ten conazoles were assessed and mutually compared with existing data. Effects of cyproconazole (CYPRO), fluconazole (FLUC), flusilazole (FLUS), hexaconazole (HEXA), myconazole (MYC), penconazole (PEN), prochloraz (PRO), tebuconazole (TEBU), triadimefon (TRIA), and triticonazole (TRIT) were examined using murine Leydig (MA-10) cells and human T47D-ARE cells stably transfected with an androgen responsive element and a firefly luciferase reporter gene. Six conazoles caused a decrease in basal testosterone (T) secretion by MA-10 cells varying from 61% up to 12% compared to vehicle-treated control. T secretion was concentration-dependently inhibited after exposure of MA-10 cells to several concentrations of FLUS (IC₅₀ = 12.4 μM) or TEBU (IC₅₀ = 2.4 μM) in combination with LH. The expression of steroidogenic and cholesterol biosynthesis genes was not changed by conazole exposure. Also, there were no changes in reactive oxygen species (ROS) formation that could explain the altered T secretion after exposure to conazoles. Nine conazoles decreased T-induced AR activation (IC₅₀s ranging from 10.7 to 71.5 μM) and effect potencies (REPs) were calculated relative to the known AR antagonist flutamide (FLUT). FLUC had no effect on AR activation by T. FLUS was the most potent (REP = 3.61) and MYC the least potent (REP = 0.03) AR antagonist. All other conazoles had a comparable REP from 0.12 to 0.38. Our results show distinct in vitro anti-androgenic effects of several conazole fungicides arising from two mechanisms: inhibition of T secretion and AR antagonism, suggesting potential testicular toxic effects. These effects warrant further mechanistic investigation and clearly show the need for accurate exposure data in order to perform proper (human) risk assessment of this class of compounds.

Assisted reproductive technologies impair the expression and methylation of insulin-induced gene 1 and sterol regulatory element-binding factor 1 in the fetus and placenta

OBJECTIVE

To evaluate the cholesterol metabolism linked to assisted reproductive technology (ART) by analyzing the expression levels and DNA methylation patterns of the insulin-induced gene (INSIG), sterol regulatory element-binding protein (SREBP), and SREBP cleavage-activating protein in the fetus and placenta.

DESIGN

Experimental research study.

SETTING

An IVF center, university-affiliated teaching hospital.

PATIENT(S)

Four patients groups were recruited: pregnancies after IVF/intracytoplasmic sperm injection (ICSI) (n = 55), natural pregnancies (n = 40), multifetal reduction after IVF/ICSI (n = 56), and multifetal reduction after controlled ovarian hyperstimulation (COH) (n = 42).

INTERVENTION(S)

Expression and DNA methylation of INSIG-SREBP- SREBP cleavage-activating protein in the fetus and placenta samples were determined.

MAIN OUTCOME MEASURE(S)

The expression and DNA methylation patterns were tested by real-time quantitative polymerase chain reaction (PCR) and pyrosequencing.

RESULT(S)

In the ICSI treatment group, significantly higher levels of triglycerides and apolipoprotein-B were observed in cord blood compared with controls. Meanwhile, in ICSI-conceived fetuses, the expression of INSIG1 was significantly higher, and methylation rates were lower, than in the IVF and control groups. Furthermore, in the placenta, the INSIG1 and SREBF1 transcripts were also significantly higher with lower methylation rates in the ICSI group than in the IVF and control groups.

CONCLUSION(S)

Our results indicated that the dysregulation of INSIG1 and SREBF1 caused by ART were observed not only in the fetus but also in the placenta, primarily in the ICSI group. However, the long-term sequelae of this dysregulation should be closely followed.

Impact of assisted reproduction treatments on Spanish newborns: report of 14,119 pregnancies

PURPOSE

To investigate neonatal malformation, prematurity, and stillbirth in singleton and multiple pregnancies derived from different Assisted Reproductive Techniques (ART).

METHODS

In this prospective cohort study data were collected, from private and public Spanish IVF units, during the years 2008 and 2009. During this period, 8,682 pregnancies were analysed from the initial 14,119 pregnancies reported. Pregnancies included in the study derived from IUI (n = 1,065), IVF (n = 838), ICSI (n = 5,080), FET (n = 1,404) and PGD (n = 295). This first analysis focuses primarily on neonatal malformation, prematurity, and stillbirth both in singleton and multiple pregnancies derived from different ART. Malformations were classified according to the WHO ICD 10 code.

RESULTS

Malformations were found in 0.83 % of our newborns. No differences in malformations were observed between singletons or multiples independently of the ART used. There was a significant difference in prematurity rate among singletons depending on treatment but this association was not observed in multiple pregnancies. Stillbirth was significantly lower in singleton (0.72 %) than in multiple pregnancies (1.82 %).

CONCLUSIONS

The percentage of malformations observed in ART newborns was similar to the rate observed in the normally-conceived Spanish population. Multiplicity seems to be the most important factor associated with an increased incidence of newborn complications such as prematurity or stillbirth.

Does infertility treatment increase male reproductive tract disorder?

OBJECTIVE

To determine the association between assisted human reproduction and male reproductive disorders in infants conceived by this means.

MATERIALS AND METHODS

Between January 2008 and December 2011, 15,332 neonates were born in our hospital. We assessed the birth weight, gestational age, and other characteristics of the 7752 male infants and determined the association between methods of conception and male reproductive disorders in the infants. We also analyzed the influence of male factor on the occurrence of these disorders.

RESULTS

Ninety-nine newborns (1.3%) were diagnosed with cryptorchidism, 8 (0.1%) were diagnosed with hypospadias, and 4 (0.05%) were diagnosed with both. Cryptorchidism was more common in children conceived through in vitro fertilization (IVF) and IVF/intracytoplasmic sperm injection (IVF/ICSI; P <.05), and hypospadias was more common in children conceived through IVF/ICSI (P <.05). Children conceived through intrauterine insemination (IUI), IVF, and IVF/ICSI had higher rates of low birth weight and preterm birth. Logistic regression analysis showed that low birth weight and preterm birth were significantly associated with male reproductive disorders, whereas the method of conception was not. Male factor was not significantly associated with these disorders.

CONCLUSION

IVF and IVF/ICSI increase the risks of low birth weight and preterm birth, resulting in increased rates of hypospadias and cryptorchidism. Male factor was not associated with reproductive disorders in male infants.

Semen parameters can be predicted from environmental factors and lifestyle using artificial intelligence methods

Fertility rates have dramatically decreased in the last two decades, especially in men. It has been described that environmental factors as well as life habits may affect semen quality. In this paper we use artificial intelligence techniques in order to predict semen characteristics resulting from environmental factors, life habits, and health status, with these techniques constituting a possible decision support system that can help in the study of male fertility potential. A total of 123 young, healthy volunteers provided a semen sample that was analyzed according to the World Health Organization 2010 criteria. They also were asked to complete a validated questionnaire about life habits and health status. Sperm concentration and percentage of motile sperm were related to sociodemographic data, environmental factors, health status, and life habits in order to determine the predictive accuracy of a multilayer perceptron network, a type of artificial neural network. In conclusion, we have developed an artificial neural network that can predict the results of the semen analysis based on the data collected by the questionnaire. The semen parameter that is best predicted using this methodology is the sperm concentration. Although the accuracy for motility is slightly lower than that for concentration, it is possible to predict it with a significant degree of accuracy. This methodology can be a useful tool in early diagnosis of patients with seminal disorders or in the selection of candidates to become semen donors.

Role of GnRH Neurons and Their Neuronal Afferents as Key Integrators between Food Intake Regulatory Signals and the Control of Reproduction

Reproductive function is regulated by a plethora of signals that integrate physiological and environmental information. Among others, metabolic factors are key components of this circuit since they inform about the propitious timing for reproduction depending on energy availability. This information is processed mainly at the hypothalamus that, in turn, modulates gonadotropin release from the pituitary and, thereby, gonadal activity. Metabolic hormones, such as leptin, insulin, and ghrelin, act as indicators of the energy status and convey this information to the reproductive axis regulating its activity. In this review, we will analyse the central mechanisms involved in the integration of this metabolic information and their contribution to the control of the reproductive function. Particular attention will be paid to summarize the participation of GnRH, Kiss1, NPY, and POMC neurons in this process and their possible interactions to contribute to the metabolic control of reproduction.

Effects of environmental endocrine disruptors and phytoestrogens on the kisspeptin system

Sex steroid hormones, most notably estradiol, play a pivotal role in the sex-specific organization and function of the kisspeptin system. Endocrine--disrupting compounds are anthropogenic or naturally occurring compounds that interact with steroid hormone signaling. Thus, these compounds have the potential to disrupt the sexually dimorphic ontogeny and function of kisspeptin signaling pathways, resulting in adverse effects on neuroendocrine physiology. This chapter reviews the small but growing body of evidence for endocrine disruption of the kisspeptin system by the exogenous estrogenic compounds bisphenol A, polychlorinated biphenyl mixtures, and the phytoestrogen genistein. Disruption is region, sex, and compound specific, and associated with shifts in the timing of pubertal onset, irregular estrous cycles, and altered sociosexual behavior. These effects highlight that disruption of kisspeptin signaling pathways could have wide ranging effects across multiple organ systems, and potentially underlies a suite of adverse human health trends including precocious female puberty, idiopathic infertility, and metabolic syndrome.

Fertility-awareness knowledge, attitudes, and practices of women seeking fertility assistance

AIMS

To report a descriptive study of fertility-awareness knowledge, attitudes, and practice of infertile women seeking fertility assistance.

BACKGROUND

Previous research has suggested that poor fertility-awareness may be a contributing cause of infertility among women seeking fertility assistance at assisted reproductive technology clinics. The actual practices and attitudes towards fertility-awareness in this particular group of women are unknown.

DESIGN

A cross-sectional questionnaire-based survey.

METHODS

The study was conducted over 6 months, from 2007-2008, of women on admission to two assisted reproductive technology clinics in a major city in Australia.

RESULTS

Two hundred and four of 282 distributed questionnaires were completed (response rate = 72·3%). Eighty-three per cent had attempted conception for 1 year or more, 86·8% actively tried to improve their fertility-awareness from one or more sources of the information, 68·2% believed they had timed intercourse mainly within the fertile window of the menstrual cycle in their attempts at conception, but only 12·7% could accurately identify this window. Ninety-four per cent believe that a woman should receive fertility-awareness education when she first reports trouble conceiving to her doctor.

CONCLUSIONS

Most women seeking assistance at assisted reproductive technology clinics attempt timed intercourse within the fertile window of the menstrual cycle. However, few accurately identify this window, suggesting that poor fertility-awareness may be a contributing cause of infertility.

Systemic and Pulmonary Vascular Dysfunction in Children Conceived by Assisted Reproductive Technologies

Background—

Assisted reproductive technology (ART) involves the manipulation of early embryos at a time when they may be particularly vulnerable to external disturbances. Environmental influences during the embryonic and fetal development influence the individual's susceptibility to cardiovascular disease, raising concerns about the potential consequences of ART on the long-term health of the offspring.

Methods and Results—

We assessed systemic (flow-mediated dilation of the brachial artery, pulse-wave velocity, and carotid intima-media thickness) and pulmonary (pulmonary artery pressure at high altitude by Doppler echocardiography) vascular function in 65 healthy children born after ART and 57 control children. Flow-mediated dilation of the brachial artery was 25% smaller in ART than in control children (6.7±1.6% versus 8.6±1.7%; P <0.0001), whereas endothelium-independent vasodilation was similar in the 2 groups. Carotid-femoral pulse-wave velocity was significantly ( P <0.001) faster and carotid intima-media thickness was significantly ( P <0.0001) greater in children conceived by ART than in control children. The systolic pulmonary artery pressure at high altitude (3450 m) was 30% higher ( P <0.001) in ART than in control children. Vascular function was normal in children conceived naturally during hormonal stimulation of ovulation and in siblings of ART children who were conceived naturally.

Conclusions—

Healthy children conceived by ART display generalized vascular dysfunction. This problem does not appear to be related to parental factors but to the ART procedure itself.

Clinical Trial Registration—

URL: www.clinicaltrials.gov . Unique identifier: NCT00837642.

How Long Should Women Persevere with IVF?

The Israeli public health insurance system covers an (almost) unlimited number of IVF cycles. In a global context, this is a policy which is looked upon as a northern star. However, many women may continue IVF treatment when the probability of a successful pregnancy is ‘zero’. This paper argues that the implication of a policy of unlimited rounds of IVF from the perspective of the ‘culture of perseverance’ that develops in IVF clinics has not yet been fully assessed. A systematic long term assessment of the health and welfare of women after IVF in Israel - especially after prolonged treatment with IVF - is necessary. In a global context, an evidence-based policy on ART may improve both the allocation of resources and the duty of care, not only in Israel, but also in other countries.

Enhanced frequency of CFTR gene variants in couples who are candidates for assisted reproductive technology treatment

BACKGROUND

An increased frequency of (cystic fibrosis transmembrane conductance regulator) CFTR mutations has been detected in some types of male infertility. The aim of this study was to shed light on the link between CFTR mutations and infertility.

METHODS

We sequenced the CFTR gene in 294 subjects (190 males) affected by infertility of different origin who underwent assisted reproductive technology (ART). As a control group, we studied 1000 (353 males) unrelated, unselected subjects from the general population of southern Italy.

RESULTS

The frequency of CFTR mutations, some of which are detected only by gene sequencing, and of the IVS8 poly(TG)12-poly(T)5-V470 haplotype was significantly higher in obstructive [congenital bilateral absence of vasa defer-entes (CBAVD, five cases)] and secretory (23 cases) azoospermic patients than in the general population. Some patients, primarily those with CBAVD, were compound heterozygous for two mutations. Interestingly, the frequency of the TG12-T5-V470 variant haplotype was significantly higher in severe oligospermic patients (88 cases) and in patients with tubal sterility (74 cases) compared with the general population. Finally, neither the frequency of CFTR mutations nor the frequency of the TG12-T5 variants differed between patients with mild oligospermia (74 cases) and patients with ovulatory sterility (30 cases) compared with the general population.

CONCLUSIONS

All subjects affected by obstructive or secretory azoospermia should undergo molecular analysis and counselling for CF using gene scanning which has a high detection rate and also reveals rare CFTR mutations. Molecular analysis seems to be less mandatory in other types of male/female infertility. Furthermore, we found that the CFTR TG12-T5-V470 variant haplotype was associated with both severe oligospermia and tubal infertility, thereby implicating the CFTR protein in both spermatogenesis and tubal functionality.

Comparison of IVF cycles reported in a voluntary ART registry with a mandatory registry in Spain

BACKGROUND

Monitoring assisted reproductive technology (ART) is essential to evaluate the performance of fertility treatment and its impact on birth rates. In Europe, there are two kinds of ART registers: voluntary and mandatory. The validity of register data is very important with respect to the quality of register-based observational studies. The aim of this paper is to determine the degree of agreement between voluntary and mandatory ART registers.

METHODS

The two sources for the data compared in this study (referring to 2005 and 2006) were FIVCAT.NET (an official compulsory Assisted Reproduction Registry within the Health Ministry of the Regional Government of Catalonia, to which all authorized clinics, both public and private, performing assisted reproduction in the region are obliged to report) and the register of the Spanish Fertility Society (SEF), to which data are provided on a voluntary basis. The SEF register data were divided into two groups: (i) data from clinics in Catalonia (SEF-CAT); (ii) data from the rest of Spain, excluding Catalonia (SEF-wCAT). The techniques compared were IVF cycle using patients' own eggs (IVF cycle) versus donor egg cycles.

RESULTS

For IVF cycles, the voluntary ART register reflected 77.2% of those on the official one, but the corresponding figure was only 34.4% with respect to donated eggs. The variables analysed in the IVF cycle (insemination technique used, patients' age, number of embryos transferred, pregnancy rates, multiple pregnancies and deliveries) were similar in the three groups studied. However, we observed significant differences in donor egg cycles with regard to the insemination technique used, pregnancy rates and multiple pregnancies between the voluntary and the official register.

CONCLUSIONS

Data from the voluntary ART register for IVF cycles are valid, but those for donor egg cycles are not. Further study is necessary to determine the reasons for this difference.

Human male infertility associated with mutations in NR5A1 encoding steroidogenic factor 1

One in seven couples worldwide are infertile, and male factor infertility accounts for approximately 30%-50% of these cases. Although many genes are known to be essential for gametogenesis, there are surprisingly few monogenic mutations that have been conclusively demonstrated to cause human spermatogenic failure. A nuclear receptor, NR5A1 (also called steroidogenic factor 1), is a key transcriptional regulator of genes involved in the hypothalamic-pituitary-steroidogenic axis, and it is expressed in the steroidogenic tissue of the developing and adult human gonad. Mutations of NR5A1 have been reported in 46,XY disorders of sex development and in 46,XX primary ovarian insufficiency. To test the hypothesis that mutations in NR5A1 cause male infertility, we sequenced NR5A1 in 315 men with idiopathic spermatogenic failure. We identified seven men with severe spermatogenic failure who carried missense mutations in NR5A1. Functional studies indicated that these mutations impaired NR5A1 transactivational activity. We did not observe these mutations in more than 4000 control alleles, including the entire coding sequence of 359 normospermic men and 370 fertile male controls. NR5A1 mutations are found in approximately 4% of men with otherwise unexplained severe spermatogenic failure.

Male reproductive tract abnormalities: more common after assisted reproduction?

BACKGROUND

In this era of increased use of assisted reproduction (AR) techniques, the prevalence rates of hypospadias, cryptorchidism, poor semen quality have been increasing in parallel with a rising incidence of testicular cancer. It is suggested that these problems result from the disruption of gonadal development during fetal life causing the testicular dysgenesis syndrome (TDS).

AIM

The aim of our study was to evaluate the influence of conventional in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI), on the development of male genital tract abnormalities.

STUDY DESIGN AND SUBJECTS

We analyzed a cohort of 15,206 neonates born from January 1, 1999 through December 31, 2008 at the Department of Obstetrics and Gynecology, Medical School, University of Pécs, including 890 children (5.9%) born after IVF or ICSI. We examined the association between these AR methods and developmental abnormalities of the genital tract (hypospadias, cryptorchidism), after controlling for potential confounding factors, such as prematurity, low birthweight and twinning.

RESULTS

Preterm birth and low birthweight are risk factors for hypospadias and cryptorchidism (p<0.001), twinning increases the risk of hypospadias (p<0.001). ICSI was revealed as a risk factor for hypospadias in singletons (OR: 3.190, 95%CI: 1.266-8.042) and in normal birthweight (>2500 g) infants (OR: 3.966, 95%CI: 1.193-13.181, respectively). Similar but not nonsignificant trends were seen for cryptorchidism.

CONCLUSION

IVF and ICSI, by increasing the risks of prematurity, low birthweight, and multiple gestation, are indirect risk factors for developing male genital malformations. In infants with normal birhtweight or from singleton pregnancies, ICSI is a specific risk factor for hypospadias.