P–731 Correlation between fertility rate, utilisation of ART and gross domestic product across Europe

Study question

Are there any correlations between a country’s wealth determined by GDP per capita and its total fertility rate (TFR) and utilisation of ART in Europe?

Summary answer

There is strong correlation across Europe between GDP and utilisation of ART. This correlation does not exist when only investigating the European Economic Area (EEA)

What is known already

The number of documented ART cycles has increased significantly from 203,893 cycles in 1997 (first European report) to 918,159 in 2016. During the same period, growth was observed in European GDP and, to a lesser extent, TFR following a significant and prolonged decline. Global data suggest that utilisation rate is higher in developed countries, speculated to be due to either generous reimbursement systems or higher affordability for patients paying out of pocket. This study analysed for the first time the relationships between national GDP, TFR and utilisation in Europe both as a whole, and specifically the more affluent EEA

Study design, size, duration

This study was an analysis of publicly available primary international reports: total cycles in the European IVF-monitoring Consortium (EIM) and TFR, GDP and population size from the World Bank indicators (https://data.worldbank.org/indicator). The period studied ranged from the first EIM report for 1997 (published in 1999) to the 20th report for 2016 (published in 2020).

Participants/materials, setting, methods

TFR was described as births per women (BPW) and country wealth was presented as GDP per capita in US Dollars. Utilisation rate was defined as the total national number of cycles (fresh IVF and ICSI, and frozen embryo transfer) divided per population, and presented as cycles per million (CPM). When utilisation was not reported, total cycles were projected by proportional calculation. Pearson Correlations were calculated using Sigmaplot for utilisation, GDP and TFR in 2016

Main results and the role of chance

Forty countries were included in the EIM report for 2016, of which 18 reported in full. The median utilisation rate was 1280 CPM (range 162 - 3,156) and median TFR was 1.6 BPW (range 1.26 - 2.73); only one country, Kazakhstan, had a TFR above the natural fertility replacement level of 2.1 BPW. Mean GDP was $31604 per capita (range $10,610 - $110,650). There was no correlation between TFR and utilisation or between TFR and GDP, however there was a significant positive correlation between GDP and CPM (correlation coefficient = 0.428; P = 0.00661). Compared to Europe as a whole, analysis of only the EEA countries – EU member states plus Norway, Iceland, and Switzerland – revealed a similar median TFR (1.59), but a 27% increase in the utilisation rate to 1629 CPM (range: 317 – 3157) and 24% rise in GDP per capita to $39,300 (range: $19,885- $110,650). For the EEA, no significant correlations were observed, including between GDP and utilisation (correlation coefficient = 0.131; P = 0.507). Additionally, there was no significant correlation between TFR and GDP in the EU for the period of 1997 – 2016.

Limitations, reasons for caution

The data is a snapshot of a single year, but we observed similar outcomes in previous years. Projection calculation of utilisation in partially reporting countries may cause bias, however, with a reporting level of 92% (1347 of 1467 clinics), this bias is probably very limited.

Wider implications of the findings: Findings of this study confirm that there are strong disparities in the availability of ART even in Europe. This difference does not exist in the more affluent countries in Europe suggesting that the reason for lower utilisation in lower-income countries being reduced affordability.

Trial registration number

NA

P–592 Safety and effectiveness of follitropin alfa biosimilar to originator follitropin alfa in real-world clinical practice: A Multinational Comparative, Prospective Cohort Study

Study question

Are safety and effectiveness of Ovaleap® (follitropin alfa), and Gonal-f®, comparable in one treatment cycle of ART in routine clinical practice?

Summary answer

Safety in terms of incidence proportions of OHSS and OHSS severity, as well as pregnancy and live birth rates, were similar between Ovaleap® and Gonal-f®.

What is known already

Ovaleap® (Theramex), a r-hFSH, is a biosimilar medicinal product to Gonal-f® (Merck). As a biosimilar, it went through a rigorous series of physio-chemical, in vitro, in vivo tests and confirmatory Phase I and III studies, to demonstrate similarity/equivalence in quality, safety and efficacy to the reference medicinal product, per the European Medicines Agency (EMA) guidelines. Ovaleap® was approved by the EMA in 2013 for use at the same dose and for the same therapeutic indications as Gonal-f®. Further outcome data from a broader patient population on safety and live birth outcomes provides clinically important insights on newly introduced FSH medicines.

Study design, size, duration

SOFIA (Safety of Ovaleap® Follitropin alfa in Infertile women undergoing superovulation for Assisted reproductive technologies) was a multi-national, comparative, non-interventional, prospective cohort study. The study was performed at 56 centers specializing in ART from six European countries, (Belgium, France, Germany, Italy, Spain, and the United Kingdom) from January 2017 to September 2019 and comprised of 817 infertile women undergoing controlled ovarian hyperstimulation in one treatment cycle for ART

Participants/materials, setting, methods

The study population comprised of infertile women undergoing controlled ovarian hyperstimulation for ART, who were administered Ovaleap® or Gonal-f® and were naïve to any FSH containing products. Eligible patients were enrolled at a ratio of approximately 1:1, both within and between countries. They were followed up to 30 days after the last FSH dose administration. Women who had a confirmed clinical pregnancy were followed until the end of the pregnancy or until delivery.

Main results and the role of chance

A total of 408 and 409 women who were administered Ovaleap® or Gonal-f®, respectively, were eligible for analysis. A total of 382 patients (94%) in the Ovaleap® and 390 patients (95%) in the Gonal-f® cohort completed FSH treatment (up to oocyte maturation triggering), respectively. The two cohorts were generally similar with regard to demographic and baseline characteristics. The incidence proportion of OHSS was 5.1% (95% CI: 3.4, 7.7) in the Ovaleap® and 3.2% (95% CI: 1.9, 5.4) in the Gonal-f® cohort. This difference in OHSS incidence proportion between the two cohorts was not statistically significant neither before (p = 0.159) nor after univariate adjustment for each potential confounder (p > 0.05). The incidence proportion of OHSS severity grades was similar in the two treatment groups (3.4% versus 2.0% for Grade I, 1.2% versus 1.0% Grade II, and 0.5% versus 0.2% Grade III, in the Ovaleap® and Gonal-f® cohorts, respectively) and without a significant statistical difference (p = 0.865, for each grade). Among patients who had embryo transfer, clinical pregnancy rates were 33% and 31%, live birth rates 27% and 26% in the Ovaleap® and Gonal-f® cohorts, respectively.

Limitations, reasons for caution

Since treatment was non-randomised, the study may have been susceptible to selection bias. This was addressed at both the design stage, by balancing recruitment to a 1:1 ratio for Ovaleap® and Gonal-f® treatments, and also at the analysis stage in which, a univariate analysis was performed.

Wider implications of the findings: Findings from this first large European prospective comparative real-world SOFIA study demonstrated that effectiveness (pregnancy and delivery rates) and safety (risk and severity of OHSS), were similar between Ovaleap®and Gonal-f® treatments. Ovaleap, a biosimilar r-hFSH is therefore a suitable option for follicular stimulation in routine clinical practice.

Trial registration number

EUPAS17328

Monoglyceride lipase deficiency causes desensitization of intestinal cannabinoid receptor type 1 and increased colonic μ-opioid receptor sensitivity

Background and Purpose

Monoglyceride lipase (MGL) degrades 2-arachidonoyl glycerol (2-AG), an endogenous agonist of cannabinoid receptors (CB_1/2). Because the CB₁ receptor is involved in the control of gut function, we investigated the effects of pharmacological inhibition and genetic deletion of MGL on intestinal motility. Furthermore, we determined whether defective 2-AG degradation affects μ-opioid receptor (μ receptor) signalling, a parallel pathway regulating gut motility.

Experimental Approach

Gut motility was investigated by monitoring Evans Blue transit and colonic bead propulsion in response to MGL inhibition and CB₁ receptor or μ receptor stimulation. Ileal contractility was investigated by electrical field stimulation. CB₁ receptor expression in ileum and colon was assessed by immunohistochemical analyses.

Key Results

Pharmacological inhibition of MGL slowed down whole gut transit in a CB₁ receptor-dependent manner. Conversely, genetic deletion of MGL did not affect gut transit despite increased 2-AG levels. Notably, MGL deficiency caused complete insensitivity to CB₁ receptor agonist-mediated inhibition of whole gut transit and ileal contractility suggesting local desensitization of CB₁ receptors. Accordingly, immunohistochemical analyses of myenteric ganglia of MGL-deficient mice revealed that CB₁ receptors were trapped in endocytic vesicles. Finally, MGL-deficient mice displayed accelerated colonic propulsion and were hypersensitive to μ receptor agonist-mediated inhibition of colonic motility. This phenotype was reproduced by chronic pharmacological inhibition of MGL.

Conclusion and Implications

Constantly elevated 2-AG levels induce severe desensitization of intestinal CB₁ receptors and increased sensitivity to μ receptor-mediated inhibition of colonic motility. These changes should be considered when cannabinoid-based drugs are used in the therapy of gastrointestinal diseases.

Endothelialization of electrospun polycaprolactone (PCL) small caliber vascular grafts spun from different polymer blends

Small caliber vascular grafts represent a challenge to material scientists. In contrast to large caliber grafts, prostheses with diameter <6 mm, lead to increased hemodynamic disturbances and thrombogenic complications. Thus, endothelialization of small caliber grafts should create a compatible interface for hemodynamic processes. The purpose of our study was to compare different compositions of electrospun scaffolds with conventional ePTFE grafts with an inner diameter of 4 mm as well as different pre-coatings to create an optimized physiological interface for endothelialization. Polycaprolactone, polylactide, and polyethylenglycol (PCL/PLA and PCL/PLA/PEG) electrospun grafts and ePTFE grafts were pre-coated with blood, gelatine or fibronectin and seeded with endothelial cells from the human term placenta. Best results were obtained with fibronectin-coated PCL/PLA/PEG grafts. Here, the number of attached viable cells was 78-81% higher than on fibronectin pre-treated ePTFE grafts. Cells attached to PCL/PLA/PEG grafts appeared in physiological cobblestone morphology. Viability analysis showed a high cell viability of more than 98%. Fibronectin-coated PCL/PLA/PEG grafts may be a promising improvement to conventionally used ePTFE grafts.

The first detection of Toxoplasma gondii DNA in environmental fruits and vegetables samples

Toxoplasma gondii infections are prevalent in humans and animals all over the world. The aim of the study was to estimate the occurrence of T. gondii oocysts in fruits and vegetables and determine the genotype of the parasites. A total number of 216 fruits and vegetables samples were taken from shops and home gardens located in the area of northern Poland. Oocysts were recovered with the flocculation method. Then, real-time polymerase chain reaction (PCR) targeting the B1 gene was used for specific T. gondii detection and quantification. Toxoplasma DNA was found in 21 samples. Genotyping at the SAG2 locus showed SAG2 type I and SAG2 type II. This is the first investigation describing T. gondii DNA identification in a large number of fruits and vegetables samples with rapid molecular detection methods. The results showed that fruits and vegetables contaminated with T. gondii may play a role in the prevalence of toxoplasmosis in Poland.

Effects of recombinant LH treatment on folliculogenesis and responsiveness to FSH stimulation

BACKGROUND

The role of LH in sensitizing antral follicles to FSH is unclear. LH is required for normal hormone production and normal oocyte and embryo development, but follicular responses to LH may depend upon the stage of development. Potential roles at the early follicular phase were explored in a clinical setting by employing a sequential approach to stimulation by recombinant human (r-h) LH followed by r-hFSH in women who were profoundly down-regulated by depo GnRH agonist.

METHODS

We employed a multi-centre, prospective, randomized approach. Women (n = 146) were treated in a long course high-dose GnRH agonist (Decapeptyl, 4.2 mg s.c.) protocol and were randomized to receive r-hLH (Luveris, 300 IU/day) for a fixed 7 days, or no r-hLH treatment. This was followed by a standard r-hFSH stimulation regime (Gonal-F, 150 IU/day). Ultrasound and hormone assessments of responses were measured at the start of r-hLH treatment, on FSH stimulation Days 0 and 8 and at the time of HCG administration.

RESULTS

The LH treatment was associated with increased small antral follicles prior to FSH stimulation (P = 0.007), and an increased yield of normally fertilized (2 PN) embryos (P = 0.03). There was no influence of the r-hLH pretreatment upon hormone profiles or ultrasound assessments during the FSH phase. Anti-mullerian hormone increased in both groups during the week prior to FSH stimulation (P = 0.002).

CONCLUSIONS

This sequential approach to the use of r-hLH in standard IVF showed a possible modest clinical benefit. The results support other recent work exploring up-regulated androgen drive upon follicular metabolism indicating that clinical benefit may be obtainable after further practical explorations of the concept.

Increased Susceptibility to Complement Attack due to Down-Regulation of Decay-Accelerating Factor/CD55 in Dysferlin-Deficient Muscular Dystrophy

Dysferlin is expressed in skeletal and cardiac muscles. However, dysferlin deficiency results in skeletal muscle weakness, but spares the heart. We compared intraindividual mRNA expression profiles of cardiac and skeletal muscle in dysferlin-deficient SJL/J mice and found down-regulation of the complement inhibitor, decay-accelerating factor/CD55, in skeletal muscle only. This finding was confirmed on mRNA and protein levels in two additional dysferlin-deficient mouse strains, A/J mice and Dysf-/- mice, as well as in patients with dysferlin-deficient muscular dystrophy. In vitro, the absence of CD55 led to an increased susceptibility of human myotubes to complement attack. Evidence is provided that decay-accelerating factor/CD55 is regulated via the myostatin-SMAD pathway. In conclusion, a novel mechanism of muscle fiber injury in dysferlin-deficient muscular dystrophy is demonstrated, possibly opening therapeutic avenues in this to date untreatable disorder.

Routine use of r-hFSH follitropin alfa filled-by-mass for follicular development for IVF: a large multicentre observational study in the UK

The technical advance of recombinant biotechnology to manufacture FSH has resulted in a biochemically pure FSH preparation with high batch-to-batch consistency. The protein content of recombinant human FSH (r-hFSH) can be reliably quantified in mass units by size exclusion high performance liquid chromatography (SE-HPLC) enabling r-hFSH follitropin alfa (Gonal-F) to be filled and released in the vial on the basis of mass with dose variability of only +/-2% [filled-by-mass (FbM)]. Observational studies have merit in addressing the effectiveness of a new product in routine clinical practice. This non-interventional study assessed r-hFSH follitropin alfa FbM for the multifollicular stimulation of patients undergoing assisted reproduction. A total of 1427 patients were recruited in 21 centres in the UK and the mean age was 34.3 years (+/-4.48, range 18-48). Of those who started treatment, 1388 (97.3%) received human chorionic gonadotrophin and 1330 (93.2%) underwent oocyte retrieval. A total of 1213 (85%) patients had embryo transfer and in the majority of recorded cases, most embryos replaced were graded as 1 or 2 (74.6%). The ongoing clinical pregnancy rate was 29.2% per cycle and 34.4% per embryo transfer. The routine use of r-hFSH follitropin alfa FbM in normal clinical practice in IVF has been demonstrated to be effective, safe and well received by patients.

Leukemia inhibitory factor in human reproduction

OBJECTIVE

To describe the clinical findings, expressions, interactions, and clinical implications of leukemia inhibitory factor (LIF) in human reproduction.

DESIGN

Review of published articles.

SETTING

Clinical development unit of biotechnology company.

INTERVENTION(S)

None.

RESULT(S)

In the endometrium, LIF is expressed in a menstrual cycle-dependent manner, with the highest level occurring at the time of implantation. LIF is also detected in uterine flushing, and its level is significantly lower in women with unexplained infertility. Likewise, endometrial explants derived from women with unexplained infertility showed reduced levels of LIF secretion. Binding of LIF to LIF receptor and gp130 activates signal transduction pathways. LIF receptor is expressed in endometrium, oocytes, and blastocysts. Cytotrophoblasts cultured in the presence of LIF differentiate toward an anchoring extravillous phenotype.

CONCLUSION(S)

On the basis of reports gathered from animal and human studies, LIF appears to play an important role in implantation and in the establishment of pregnancy.

Protein tyrosine nitration in mouse peritoneal macrophages activated in vitro and in vivo: evidence against an essential role of peroxynitrite

Tyrosine nitration is considered a key reaction of peroxynitrite-triggered tissue injury in inflammatory diseases. We investigated the potential involvement of peroxynitrite in protein tyrosine nitration in isolated murine peritoneal macrophages activated either in vitro with interferon-gamma/lipopolysaccharide or in vivo by priming mice with Corynebacterium parvum (10 mgxkg-1). Both protocols led to release of NO and accumulation of nitrite accompanied by formation of protein-bound 3-nitrotyrosine. Oxidation of dihydrorhodamine 123, a measure of peroxynitrite release, remained close to basal levels upon in vitro activation of the macrophages but was increased approximately twofold in vivo. Tyrosine nitration in macrophages activated in vitro was inhibited by catalase and the time course of nitration correlated with nitrite accumulation, whereas superoxide (O2*-) and H2O2 release occurred at much earlier times. To address the contribution of O2*- and peroxynitrite to in vivo nitration, a O2*- scavenger (MnTBAP; 1 mgxkg-1) was given to C. parvum-primed mice. MnTBAP led to almost complete inhibition of C. parvum-triggered O2*- and peroxynitrite release, whereas nitrite accumulation and formation of 3-nitrotyrosine were less affected ( approximately 50% of controls). These results argue against an essential role of peroxynitrite in protein tyrosine nitration in vivo.

Protein tyrosine nitration in cytokine-activated murine macrophages. Involvement of a peroxidase/nitrite pathway rather than peroxynitrite

Peroxynitrite, formed in a rapid reaction of nitric oxide (NO) and superoxide anion radical (O(2)), is thought to mediate protein tyrosine nitration in various inflammatory and infectious diseases. However, a recent in vitro study indicated that peroxynitrite exhibits poor nitrating efficiency at biologically relevant steady-state concentrations (Pfeiffer, S., Schmidt, K., and Mayer, B. (2000) J. Biol. Chem. 275, 6346-6352). To investigate the molecular mechanism of protein tyrosine nitration in intact cells, murine RAW 264.7 macrophages were activated with immunological stimuli, causing inducible NO synthase expression (interferon-gamma in combination with either lipopolysaccharide or zymosan A), followed by the determination of protein-bound 3-nitrotyrosine levels and release of potential triggers of nitration (NO, O(2)*, H(2)O(2), peroxynitrite, and nitrite). Levels of 3-nitrotyrosine started to increase at 16-18 h and exhibited a maximum at 20-24 h post-stimulation. Formation of O(2) was maximal at 1-5 h and decreased to base line 5 h after stimulation. Release of NO peaked at approximately 6 and approximately 9 h after stimulation with interferon-gamma/lipopolysaccharide and interferon-gamma/zymosan A, respectively, followed by a rapid decline to base line within the next 4 h. NO formation resulted in accumulation of nitrite, which leveled off at about 50 microm 15 h post-stimulation. Significant release of peroxynitrite was detectable only upon treatment of cytokine-activated cells with phorbol 12-myristate-13-acetate, which led to a 2.2-fold increase in dihydrorhodamine oxidation without significantly increasing the levels of 3-nitrotyrosine. Tyrosine nitration was inhibited by azide and catalase and mimicked by incubation of unstimulated cells with nitrite. Together with the striking discrepancy in the time course of NO/O(2) release versus 3-nitrotyrosine formation, these results suggest that protein tyrosine nitration in activated macrophages is caused by a nitrite-dependent peroxidase reaction rather than peroxynitrite.

Sperm banking and assisted reproduction treatment for couples following cancer treatment of the male partner

In recent years, the survival of young males suffering from cancer has been improved. Development of new techniques such as IVF and intracytoplasmic sperm injection enables even low quality spermatozoa to be used successfully. It is possible therefore to preserve fertility potential of cancer patients before embarking on adjuvant chemotherapy and radiotherapy. Recognizing the importance of protecting the fertility potential of these young males, we present our recommendations for sperm cryopreservation based on the 11 year experience of Bourn Hall and the British Joint Council for Clinical Oncology consultation report. This paper discusses the options available for patients who recover from cancer to become fathers. In many cases patients are concerned about possible abnormalities and teratogenic risks to their future children who have been conceived naturally or by fertility treatment. The data available in the literature may reassure the medical community that there is no such increased risk. However, due to the relatively small number of children born after such treatment, a long-term follow-up is required. There is an ongoing debate regarding the justification for the programme due to the small number of patients who make use of their banked spermatozoa. The authors believe in the importance of protecting the fertility potential of cancer patients, enabling them to father their genetic children in the future while fighting their illness.

Assessment of ovarian reserve - is there a role for ovarian biopsy?

The pool of primordial follicles in the ovary or 'ovarian reserve' is a major factor in the human fertility potential. The ageing ovary is characterized by reduction of the number of primordial follicles and this loss accelerates in the late 30's and precedes the menopause by 10-12 years. Woman's age alone or with a combination of biochemical markers, dynamic tests and ultrasound measurements fail to predict this loss accurately. In this manuscript, a novel approach of histopathological examination of ovarian biopsy for the evaluation of infertility, especially in unexplained infertility and in women in the later part of reproductive life, is discussed.

How do patients choose private in vitro fertilization treatment? A customer survey in a tertiary fertility center in the United Kingdom

OBJECTIVE

To assess the relevant factors affecting patients' decision when choosing a clinic for private, self-funded IVF treatment.

DESIGN

Prospective anonymous closed questionnaires.

SETTING

Single tertiary-care private IVF center.

PATIENT(S)

New patients attending primary consultation in a period of 7 months from September 1999 to March 2000.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Primary knowledge about the clinic, source of referral, knowledge of, availability of information pack, and familiarity with the clinic's success rates and treatment's price. The last question assessed the relative importance of each factor in the decision-making process according to the SERVQUAL model, modified version. All items were measured as perceptions on a 5-point Likert scale. 1 = not important, 3 = neutral, and 5 = very important.

RESULTS(S)

One hundred seventy-five patients completed the questionnaire. They were well informed and investigated the market before making their final choice. Patients collect information from many sources, including new channels such as the Internet. Up to one third of patients do not consult their doctor before treatment. By far the most relevant factor in decision making is the success rate (i.e., delivery rates) of the clinic, followed by recommendation by general practitioner (GP) or consultant (respectively, Likert scale score, 4.6; 95% confidence interval [CI], 4.5-4.7; and Likert scale score, 4.0; 95% CI, 3.9-4.2; P<.01). Other factors, such as cost of the treatment, friends and relatives' opinions, and distance from home were not relevant.

CONCLUSION(S)

Units that wish to thrive and increase their market share should deliver high-quality service and concentrate their efforts on excelling in performance.

XX males without SRY gene and with infertility

The case of a 28 year old male with normal male phenotype, in whom repeated seminal analysis showed complete azoospermia, is presented. Peripheral blood culture for chromosome studies revealed 46 chromosomes with XX constitution. Polymerase chain reaction (PCR) analysis of genomic DNA failed to detect the presence of the sex-determining region of the Y chromosome (SRY). A literature review of all SRY-negative XX males with normal male phenotype showed that this case is the sixth reported case but the first to be diagnosed during the investigations of infertility. The frequency, aetiology and diagnosis of this rare syndrome are also reviewed.

IVF performance of women who have fluctuating early follicular FSH levels

OBJECTIVES

The aim was to evaluate whether women who have early follicular follicle-stimulating hormone (FSH) levels > 12 mIU/ml have reduced response to follicular stimulation for in vitro fertilization (IVF) in a following month, in spite of normal FSH levels.

MATERIAL AND METHODS

In a 3-year period from January 1996 to December 1998, 303 women aged 38 years and above and/or who had previously responded poorly to superovulation for IVF gave blood samples for FSH, luteinizing hormone (LH), and estradiol (E2) on day 2 of menstruation before commencing treatment.

RESULTS

In 117 (38.6%) of these women, FSH levels were > 12 mIU/ml (range 12-114 mIU/ml). Sixty-six of these women gave a further 130 blood samples for FSH measurement in the following months. Seventy-eight (60.0%) of the tests showed raised FSH value > 12 mIU/ml. Thirty women whose repeat FSH levels were < 12 mIU/ml underwent 41 IVF cycles (group 1). Sixty-three other women, older than 38 and/or who had a poor response to superovulation previously and whose FSH levels were < 12 mIU/ml, served as the control group (group II). There were no differences in the responses to superovulation and delivery rates between the two groups (14.6% vs. 12.7%).

CONCLUSIONS

Women whose early follicular phase FSH levels were raised > 12 mIU/ml had an increased risk (> 50%) that in subsequent cycles levels would remain raised, and it was not possible to predict which individuals would have favorable FSH levels. If the cycle day 2 FSH level returns to a "normal" level of < 12 mIU/ml, women aged 40 and above had substantial cycle cancellation rates (43%), but patients who achieved the stage of embryo transfer had a good chance of conceiving, regardless of their age.

Effect of coenzyme Q(10) and alpha-tocopherol content of mitochondria on the production of superoxide anion radicals

The effects of coenzyme Q(10) (CoQ(10)) and alpha-tocopherol on the rate of mitochondrial superoxide anion radical (O2(./-)) generation were examined in skeletal muscle, liver, and kidney of 24-month-old mice. Mice were orally administered alpha-tocopherol (200 mg.kg(-1).day(-1)) alone, CoQ(10) (123 mg.kg(-1).day(-1)) alone, or the two together for 13 wk. Administration of alpha-tocopherol resulted in an approximately sevenfold elevation of mitochondrial alpha-tocopherol content. Intake of CoQ(10) alone caused an approximately fivefold increase in CoQ content (CoQ(9) and/or CoQ(10)) and alpha-tocopherol of mitochondria. The rate of (O2(./-)) generation by submitochondrial particles (SMPs) was inversely related to their alpha-tocopherol content but unrelated to CoQ content. Experimental in vitro augmentation of SMPs with varying amounts of alpha-tocopherol caused an up to approximately 50% decrease in the rate of O2(./-) generation. Similar in vitro augmentations of SMPs with CoQ(10) had previously been found to have no effect on the rate of O2(./-) generation The CoQ(10)-induced elevation of alpha-tocopherol in the present study was inferred to be due to a 'sparing/regeneration' by CoQ. Results indicate the involvement of alpha-tocopherol in the elimination of mitochondrially generated O2(./-)

How useful is cervical dilatation in patients with cervical stenosis who are participating in an in vitro fertilization-embryo transfer program? The Bourn Hall experience

OBJECTIVE

To evaluate the place of cervical dilatation performed at the initial visit in an IVF-ET cycle in patients with known cervical stenosis.

DESIGN

Retrospective study.

SETTING

A tertiary care assisted conception unit.

PATIENT(S)

Fifty-seven patients who failed to conceive after a previous ET attempt and in whom the ET was classified as "difficult."

INTERVENTION(S)

Cervical dilatation under general anesthesia after pituitary suppression and before gonadotropin stimulation.

MAIN OUTCOME MEASURE(S)

Ease of the ET procedure and clinical pregnancy rate.

RESULT(S)

Eighteen (31.6%) of 57 women who failed to conceive after a previous attempt at IVF-ET achieved a clinical pregnancy after cervical dilatation. In 40 patients (70.2%), the subsequent ET was classified as "easy," whereas in the other 17 (29.8%), it remained difficult. The pregnancy rate was significantly higher when the ET was easy than when it was difficult (40% versus 11.8%, P<.05).

CONCLUSION(S)

In patients with cervical stenosis and a previous difficult ET, cervical dilatation during the initial visit leads to an easier subsequent ET and improves the pregnancy rate.

The effect of endometrial polyps on outcomes of in vitro fertilization (IVF) cycles

PURPOSE

Our purpose was to investigate the effect of endometrial polyps on pregnancy outcome in an in vitro fertilization (IVF) program.

METHODS

Endometrial polyps less than 2 cm in diameter were suspected by transvaginal ultrasound before oocyte recovery in 83 patients. Forty-nine women (Group I) had standard IVF-embryo transfer, while in 34 women (Group II) hysteroscopy and polypectomy were performed immediately following oocyte retrieval, the suitable embryos were all frozen, and the replacement cycle took place a few months later.

RESULTS

Of the 32 hysteroscopies, a polyp was diagnosed in 24 cases (75%) and polypoid endometrium in another 5 patients (15.6%). An endometrial polyp was confirmed by histopathological examination in 14 women (58.3%). The pregnancy rate in group I was similar to the general pregnancy rate of our unit over the same period (22.4 vs 23.4%) but the miscarriage rate was higher (27.3 vs 10.7%, P = 0.08). In Group II, the pregnancy and miscarriage rates were similar to those of the frozen embryo cycles at Bourn Hall (30.4 and 14.3 vs 22.3 and 12.1%, respectively).

CONCLUSIONS

Small endometrial polyps, less than 2 cm, do not decrease the pregnancy rate, but there is a trend toward increased pregnancy loss. A policy of oocyte retrieval, polypectomy, freezing the embryos, and replacing them in the future might increase the "take-home baby" rate.

The fertility potential of women with a single ovary

The incidence of having a single ovary is quite common in infertile patients and can reach up to 17% of women with severe tubal disease who require in-vitro fertilization (IVF) treatment. Data on the short- and long-term implications of having only one ovary are scarce, and patients in this situation are naturally concerned. This article reviews the effect of possessing a single ovary on the fertility potential and ovarian reserve of these women and their performance in assisted reproduction treatment.

Comparisons of coenzyme Q bound to mitochondrial membrane proteins among different mammalian species

The objective of this study was to elucidate the mechanisms that govern the variations in the rates of mitochondrial superoxide anion radical (O2-*) generation in different species. The amounts of coenzyme Q (CoQ) associated with mitochondrial membrane proteins were compared in five different mammalian species, namely mouse, rat, rabbit, pig, and cow. Micelles of cardiac mitochondria were prepared using Triton X-100 or deoxycholate (DOC) as detergents, and the micelles containing mitochondrial proteins were sedimented by sucrose density ultracentrifugation. The amount of CoQ present in both types of micelles varied in different species, whereas alpha-tocopherol, another lipoidal molecule in mitochondrial membranes, could not be detected in the micelles of any of these species. The amounts of CoQ bound to mitochondrial proteins in DOC micelles were higher in those mammalian species where CoQ10 was the predominant CoQ homologue, and the amounts were found to be inversely correlated with the rate of mitochondrial 02-* generation among different species. Results also indicated that mitochondrial CoQ exists in at least two distinct pools, one of which is associated with the membrane proteins. The degree of association between CoQ and membrane proteins appears to be a factor determining the rate of mitochondrial O2-* generation.

Effects of coenzyme Q10 and alpha-tocopherol administration on their tissue levels in the mouse: elevation of mitochondrial alpha-tocopherol by coenzyme Q10

Coenzyme Q (CoQ) was previously demonstrated in vitro to indirectly act as an antioxidant in respiring mitochondria by regenerating alpha-tocopherol from its phenoxyl radical. The objective of this study was to determine whether CoQ has a similar sparing effect on alpha-tocopherol in vivo. Mice were administered CoQ10 (123 mg/kg/day) alone, or alpha-tocopherol (200 mg/kg/day) alone, or both, for 13 weeks, after which the amounts of CoQ10, CoQ9 and alpha-tocopherol were determined by HPLC in the serum as well as homogenates and mitochondria of liver, kidney, heart, upper hindlimb skeletal muscle and brain. Administration of CoQ10 and alpha-tocopherol, alone or together, increased the corresponding levels of CoQ10 and alpha-tocopherol in the serum. Supplementation with CoQ10 also elevated the amounts of the predominant homologue CoQ9 in the serum and the mitochondria. A notable effect of CoQ10 intake was the enhancement of alpha-tocopherol in mitochondria. alpha-Tocopherol administration resulted in an elevation of alpha-tocopherol content in the homogenates of nearly all tissues and their mitochondria. Results of this study thus indicate that relatively long-term administration of CoQ10 or alpha-tocopherol can result in an elevation of their concentrations in the tissues of the mouse. More importantly, CoQ10 intake has a sparing effect on alpha-tocopherol in mitochondria in vivo.

The role of ovarian volume in reproductive medicine

The human ovary is a dynamic organ which continually changes in size and activity through life, as an integral part of the changes that the female is going through before during and after her reproductive life. Following the rapid increase in the use of transvaginal scan in recent years, the measurement of ovarian volume has become quick, accurate and cost-effective. Ovarian volume is an important tool in the screening, diagnosis and monitoring the treatment of conditions such as polycystic ovarian syndrome, ovarian cancer and adolescent abnormalities. In reproductive medicine, measurement of ovarian volume has a role in the assessment of ovarian reserve and prediction of response to superovulation.

A sensitive chemiluminescence method to measure the lipoxygenase catalyzed oxygenation of complex substrates

Oxidative modification of low-density lipoprotein (LDL) has been implicated as a patho-physiological process in early atherogenesis and 15-lipoxygenases (15-LOX) may be involved. While studying the in vitro kinetics of the 15-LOX/LDL interaction, we found that the conventional spectrophotometric assays failed in the range of substrate saturation owing to the high optical density of concentrated LDL solutions. Therefore, we developed a much more sensitive assay system which was based on peroxide induced isoluminol enhanced chemiluminescence. With this method reliable kinetic data were obtained at LDL concentrations of up to 1 mg/ml. To validate this luminometric method the kinetic parameters of 15-LOX catalyzed oxygenation of linoleic acid (Km=3.7 microM, kcat=17 s-1) were determined and we observed a good agreement with previously published data obtained with a spectrophotometric assay. Moreover, we found that the kinetic constants of 15-LOX catalyzed LDL oxidation (Km=0.64 microM, kcat=0.15 s-1) are quite different from those of free fatty acid oxygenation and that the cholesterol esters are preferentially oxidized during 15-LOX/LDL interaction. Vitamin E depletion does not reduce the rate of LDL oxidation and analysis of the structure of the oxygenation products suggests that the majority of the products were formed via direct LOX catalyzed oxidation of LDL ester lipids. The luminometric method described here is not restricted to the measurement of LOX catalyzed LDL oxidation, but may also be used to determine kinetic constants for the oxidation of other complex substrates such as biomembranes or liposomes.

Mitochondrial coenzyme Q content and aging

The main objective of this study was to determine the nature of the relationship between aging and mitochondrial coenzyme Q (CoQ) content. Mitochondria in the heart, skeletal muscle, kidney and brain of the mouse varied in both the amount of total CoQ (CoQ9 + CoQ10) content as well as in the ratio of the CoQ9 to CoQ10. CoQ content declined with age only in the skeletal muscle. Caloric restriction (CR) resulted in an increase in the amount of CoQ9 in skeletal muscle mitochondria. This effect was partially reversible upon termination of the caloric restriction regimen. Results suggest that a decrease in mitochondrial CoQ content is an integral aspect of aging in skeletal muscle.

Caloric restriction prevents age-associated accrual of oxidative damage to mouse skeletal muscle mitochondria

The purpose of this study was to understand the nature of the causes underlying the senescence-related decline in skeletal muscle mass and performance. Protein and lipid oxidative damage to upper hindlimb skeletal muscle mitochondria was compared between mice fed ad libitum and those restricted to 40% fewer calories--a regimen that increases life span by approximately 30-40% and attenuates the senescence-associated decrement in skeletal muscle mass and function. Oxidative damage to mitochondrial proteins, measured as amounts of protein carbonyls and loss of protein sulfhydryl content, and to mitochondrial lipids, determined as concentration of thiobarbituric acid reactive substances, significantly increased with age in the ad libitum-fed (AL) C57BL/6 mice. The rate of superoxide anion radical generation by submitochondrial particles increased whereas the activities of antioxidative enzymes superoxide dismutase, catalase, and glutathione peroxidase in muscle homogenates remained unaltered with age in the AL group. In calorically-restricted (CR) mice there was no age-associated increase in mitochondrial protein or lipid oxidative damage, or in superoxide anion radical generation. Crossover studies, involving the transfer of 18- to 22-month-old mice fed on the AL regimen to the CR regimen, and vice versa, indicated that the mitochondrial oxidative damage could not be reversed by CR or induced by AL feeding within a time frame of 6 weeks. Results of this study indicate that mitochondria in skeletal muscles accumulate significant amounts of oxidative damage during aging. Although such damage is largely irreversible, it can be prevented by restriction of caloric intake.

One thousand initiated cycles of in vitro fertilization in women > or = 40 years of age

OBJECTIVE

To evaluate the results of IVF in women > or = 40 years of age using their own oocytes.

DESIGN

Retrospective study.

SETTING

Wolfson and Royal Masonic in vitro fertilization units, London, United Kingdom.

PATIENT(S)

A total of 1,087 IVF cycles were started in women > or = 40 years of age.

INTERVENTION(S)

Medical records of patient outcomes were reviewed.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy, miscarriage, and delivery rates.

RESULT(S)

Of the 1,087 cycles started in 471 women > or = 40 years of age, 842 reached oocyte retrieval (77.5%) and 702 had embryos transferred (64.6%). The pregnancy rate (PR) was significantly lower in women > or = 40 years of age than in a control group of women <40 years of age (11.3% versus 28.2%). It decreased sharply in women >42 years of age, and no women >45 years of age had a child. Women > or = 40 years of age were more likely to miscarry (27% versus 12.7%). When only one embryo was available for transfer, the PR was 3.3%. When >2 embryos were available for transfer, the PR was similar whether 2 or 3 embryos were replaced. No triplet pregnancy occurred. Women > or = 40 years of age achieved a cumulative PR of 30% after three cycles with a cumulative "take home baby" rate of 21%.

CONCLUSION(S)

In vitro fertilization is a reasonable treatment for women <45 years of age using their own gametes. Those with a "good response" in their first attempt may be encouraged to complete three cycles with an acceptable chance of conception.

Effect of salpingectomy on ovarian response to superovulation in an in vitro fertilization-embryo transfer program

OBJECTIVE

To investigate the effect of salpingectomy on the response of each ovary in patients undergoing an IVF-ET treatment cycle and to compare the results with those of patients who had not had surgery and were undergoing IVF-ET during the same period.

DESIGN

A prospective study.

SETTING

Tertiary referral academic IVF unit.

PATIENT(S)

Twenty-nine ET cycles were evaluated in 29 patients who previously had undergone unilateral salpingectomy because of ectopic pregnancy (study group). Seventy-three patients with unexplained or male factor infertility served as controls.

INTERVENTION(S)

Ovulation induction and IVF-ET.

MAIN OUTCOME MEASURE(S)

In the study group, mean ovarian volume, number of follicles, and number of oocytes recovered from each ovary were assessed and compared. The overall results, cycle characteristics, and pregnancy rates of the two groups were compared.

RESULT(S)

Among the patients who had undergone salpingectomy, significantly fewer follicles developed and consequently fewer oocytes were retrieved from the ovary on the operated side (4.4 versus 8.2 follicles and 3.8 versus 6.0 oocytes). There were no differences in the total numbers of follicles and oocytes recovered from both ovaries, the cycle characteristics, or the pregnancy rates between study and control groups.

CONCLUSION(S)

Salpingectomy has no detrimental effect on the total ovarian performance during IVF-ET treatment or on the outcome of IVF-ET. However, the ipsilateral ovary could be adversely affected. This could be detrimental in selected patients undergoing IVF-ET, in whom the second ovary already is compromised or missing.

Histological evaluation of endometrium on the day of oocyte retrieval after gonadotrophin-releasing hormone agonist-follicle stimulating hormone ovulation induction for in-vitro fertilization

The objective of this study was to evaluate the histopathological characteristics of endometrial biopsies taken on the day of oocyte recovery in in-vitro fertilization (IVF) cycles with a satisfactory response to ovulation induction. A group of 33 patients who went through ovulation induction for IVF, and in whom an endometrial polyp was suspected on transvaginal ultrasonography during the monitoring phase, were studied. Following oocyte recovery, hysteroscopy, polypectomy and endometrial curettage were performed. Dating of endometrial glands and stroma was carried out in the tissue not containing the polyps. The total dose of follicle stimulating hormone (FSH), duration of ovulation induction, peak oestradiol and luteinizing hormone (LH) concentrations, thickness of endometrium and number of oocytes were recorded and compared to the endometrial dating of the specimens. In 15 cycles (45.5%), the endometrium was classified as 'in phase' (group I), 'advanced' by 2-4 days in a further 15 (45.5%, group II), and in the remaining three cycles (9%) it was delayed in maturation (group III). Younger age was correlated with advanced staging of the endometrium (r = -0.42; P = 0.015). Women with 'in phase' and 'advanced' maturation were similar in their response to ovulation induction; however, there was a strong correlation between advanced dating of endometrium and number of oocytes retrieved (r = 0.49; P = 0.04). Endometrial staging on the day of oocyte retrieval varied widely in patients treated by the same gonadotrophin-releasing hormone agonist (GnRHa)/FSH protocol for ovulation induction. This difference was not predictable by parameters monitored through the cycles.

A programme of semen cryopreservation for patients with malignant disease in a tertiary infertility centre: lessons from 8 years' experience

The improved survival in recent years of young males suffering from cancer, and an understanding of the gonadotoxic effects of chemotherapy treatment, have motivated patients and clinicians to preserve fertility potential before embarking on adjuvant therapy. Among 231 men (mean age 28.0; range 15-56 years) diagnosed with malignant disease and referred to our unit for semen cryopreservation, 112 patients (49.8%) had reduced sperm quality of <10 x 10(6) motile spermatozoa per ejaculate; however, most had sufficient suitable spermatozoa for freezing. In 40 patients (17.3 %) the semen samples were not frozen because of complete azoospermia (n = 32) or only immotile sperm in the ejaculate (n = 2), while six men were unable to produce a single sample. Some 79 men had testicular tumours (group I), 121 suffered from haematological malignancy (leukaemia or lymphoma; group II), and 27 had cancer of different causes (group III). Men in group I had significantly lower (P < 0.001) sperm quality compared with groups II and III. There was no difference between patients with seminoma and non-seminoma tumours. In the haematological malignancy group there was no difference in sperm parameters between leukaemia (n = 12) and lymphoma (n = 77) patients, but patients with Hodgkin's lymphoma had significantly lower sperm quality compared with non-Hodgkin's lymphoma. Following chemotherapy, six couples attended the clinic for assisted conception treatment using the frozen semen. Two had successful intrauterine insemination cycles which each resulted in delivery of a healthy girl; one couple had conceived in their first in-vitro fertilization (IVF) attempt, followed by delivery of healthy twins. Two women conceived after intracytoplasmic sperm injection treatment and the sixth woman achieved only biochemical pregnancy after numerous IVF and frozen embryo replacement cycles. We recommend that a properly designed programme for semen cryopreservation for cancer patients should be developed in leading tertiary assisted conception centres, which have adequate facilities and experience for cryopreservation and can offer the whole range of appropriate assisted reproductive treatment and counselling.

Electron transport-linked ubiquinone-dependent recycling of alpha-tocopherol inhibits autooxidation of mitochondrial membranes

The objective of this study was to elucidate the anti-oxidative roles of coenzyme Q (CoQ) and alpha-tocopherol in mitochondrial membranes by determining whether CoQ directly scavenges peroxyl- and alkoxyl-radicals or indirectly regenerates alpha-tocopherol during autooxidation of mitochondrial membranes. A comparison of the interaction between alpha-tocopherol and CoQ during autooxidation was made between bovine and rat heart mitochondria, which differ approximately 15-fold in their alpha-tocopherol content. Autooxidation of both bovine and rat heart mitochondria resulted in the formation of thiobarbituric-acid-reactive substances and protein carbonyls; however, the differences in the autooxidizability of mitochondria between rat and bovine heart mitochondrial membranes were relatively minor. Supplementation of rat heart mitochondria with succinate caused reduction of CoQ to ubiquinol while alpha-tocopherol concentration remained unaffected during autooxidation. In contrast, in the absence of succinate, CoQ was present in the oxidized form (ubiquinone) and the mitochondrial membranes were depleted of alpha-tocopherol. CoQ concentrations remained unchanged over time irrespective of the presence or absence of succinate. In the absence of succinate, autooxidation of bovine SMPs, supplemented with different amounts of alpha-tocopherol, was inversely related to the amount of alpha-tocopherol, whereas in the presence of succinate autooxidation was greatly reduced. Results of this study indicate that during autooxidation of mitochondria, alpha-tocopherol acts as the direct radical scavenger, whereas ubiquinol regenerates alpha-tocopherol.

Predictive value of the results of a first in-vitro fertilization cycle on the outcome of subsequent cycles

This study examines the relationship between the first cycle of in-vitro fertilization (IVF) and subsequent cycles. The results of all IVF cycles conducted at The Hammersmith Hospital or The Royal Masonic Hospital between 1988 and 1995 were studied including those cycles where egg recovery was abandoned due to poor ovarian response. All patients underwent a standardized treatment protocol. Of those women who achieved a clinical pregnancy during their first IVF attempt, 33% achieved a pregnancy during their second cycle, statistically significantly different from the 24% of patients conceiving during a second cycle who had failed to conceive during their first. 36% of those who achieved a biochemical pregnancy in their first cycle became pregnant in their second. Age was an important factor in the success of IVF treatment, with pregnancy rates of 48% in the 20-25 year age group falling to 8% in those aged > or =41 years. Cumulative pregnancy rates were 26% after one cycle, increasing to 43% after two cycles and reached 80% after seven cycles. A previous pregnancy significantly improved a couple's probability of conception in a later IVF cycle. Overall pregnancy rates per cycle were constant for the first three attempts. Cumulative pregnancy rates continued to rise to 72% after six cycles. Thus the more cycles a couple undergo (up to six) the greater their chance of a pregnancy.

Mitochondrial ubiquinone homologues, superoxide radical generation, and longevity in different mammalian species

Rates of mitochondrial superoxide anion radical (O-2) generation are known to be inversely correlated with the maximum life span potential of different mammalian species. The objective of this study was to understand the possible mechanism(s) underlying such variations in the rate of O-2 generation. The hypothesis that the relative amounts of the ubiquinones or coenzyme Q (CoQ) homologues, CoQ9 and CoQ10, are related with the rate of O-2 generation was tested. A comparison of nine different mammalian species, namely mouse, rat, guinea pig, rabbit, pig, goat, sheep, cow, and horse, which vary from 3.5 to 46 years in their maximum longevity, indicated that the rate of O-2 generation in cardiac submitochondrial particles (SMPs) was directly related to the relative amount of CoQ9 and inversely related to the amount of CoQ10, extractable from their cardiac mitochondria. To directly test the relationship between CoQ homologues and the rate of O-2 generation, rat heart SMPs, naturally containing mainly CoQ9 and cow heart SMPs, with high natural CoQ10 content, were chosen for depletion/reconstitution experiments. Repeated extractions of rat heart SMPs with pentane exponentially depleted both CoQ homologues while the corresponding rates of O-2 generation and oxygen consumption were lowered linearly. Reconstitution of both rat and cow heart SMPs with different amounts of CoQ9 or CoQ10 caused an initial increase in the rates of O-2 generation, followed by a plateau at high concentrations. Within the physiological range of CoQ concentrations, there were no differences in the rates of O-2 generation between SMPs reconstituted with CoQ9 or CoQ10. Only at concentrations that were considerably higher than the physiological level, the SMPs reconstituted with CoQ9 exhibited higher rates of O-2 generation than those obtained with CoQ10. These in vitro findings do not support the hypothesis that differences in the distribution of CoQ homologues are responsible for the variations in the rates of mitochondrial O-2 generation in different mammalian species.

Right or left ovary--which one is better?

This study tests the hypothesis that there is a different response after gonadotrophin-releasing hormone and human menopausal gonadotrophins (GnRH/HMG) stimulation for in-vitro fertilization (IVF) in patients with either a right or left ovary. A total of 56 cycles in 44 women after left oophorectomy (group A) was compared with 42 cycles in 29 women following right oophorectomy (group B). Tubal disease was the sole cause of infertility in all cases. The two groups were similar in age. There was no difference in total amount or days of HMG required for ovulation induction, peak oestradiol concentrations, number of oocytes retrieved and fertilization rate. The pregnancy rate was identical in the two groups (20.0 and 20.9% respectively). Our results indicate that with GnRH/HMG ovulation induction protocol for IVF there is no predilection of one ovary over the other.