O-015 Results of urological consultation in the setting of IVF clinic

Study question

In the management of male infertility, we investigated whether urological consultation could improve the live birth rate, and who should visit urologists in the setting of IVF clinic.

Summary answer

Urologic consultation resulted in improvement of semen quality and live birth rate with more IVF use in those with adverse semen parameters.

What is known already

Male factor infertility exists in about a half of infertility couples. This accounts for about 8% in male reproductive age. Therefore, ideally every male partner of infertility couples attempting conception should have a urological evaluation. However, it is not very easy to access urologists who specialized in reproductive medicine in Japan because we have very few of such urologists. One the other hand, a certain number of couples are wasting their time during IVF failure without urological evaluation.

Study design, size, duration

This is a single-institution retrospective study. We enrolled male partners of infertility couples who visited Kameda IVF clinic Makuhari, Chiba, Japan, between May 2016 and December 2020 and followed at least one year. Live birth rate and the frequency of IVF use were investigated according to semen quality and urological consultation status. Chi-square tests and T tests were used to compare the results between groups.

Participants/materials, setting, methods

Among 2225 couples who visited Kameda IVF clinic Makuhari, 803 male partners (Group A, 36.0%) were evaluated by urologists who were specialized in male reproductive medicine. Remaining 1422 patients did not (Group B, 64.0%). Lifestyle evaluation, physical examination, semen analyses, scrotal ultrasonography, blood test including sexual hormones and zinc concentration were performed in Group A. Semen analyses and lifestyle evaluation were performed in Group B. Urological treatments were done according to factors of male infertility.

Main results and the role of chance

Semen quality was worse in Group A as compared to Group B (sperm motility, 28.5±16.9% vs. 46.0±17.0%; total sperm count, 105±108 million/mL vs. 176±155; total motile sperm count, 34±49 vs.87±98; mean±S.D.; p = 0.0001, 0.0001, 0.0001, A vs. B, respectively). After urologic consultation and managements, sperm motility was improved to 34±18% (p = 0.001). Live birth rate in groups A and B were similar (56.0% vs. 57.2%), however couples who obtained a child in Group A used IVF more often than those in Group B (70% vs. 49.9%, p < 0.001). Among those with adverse semen quality (total motile sperm count less than 15.6 million/mL, n = 472), 350 visited urologists (Group 1, 74.2%) and remaining 122 did not (Group 2, 25.8%). Live birth rate in Group 1 was significantly better than in Group 2 (65.3% vs. 54.1%, p = 0.0359). Use of IVF was significantly more frequent in Group 1 than Group 2 (79.3% vs. 63.6%, p = 0.0359) among who obtained a child. In those with better semen quality (motile sperm count >50 million, n = 900), 119 visited urologist (31.1%, Group 3) and 781 did not (Group 4). Live birth rate and the use of IVF were not different between Groups 3 and 4 (51.1% vs.60.9%; 50.4% vs. 62.9%).

Limitations, reasons for caution

This study is a single-institution, retrospective study in the setting of IVF clinic. There may be a selection bias since men first visit gynecologists. These could affect the study results.

Wider implications of the findings

In the setting of IVF clinic, urologic consultation resulted in improved semen quality and better live birth rate with the use of IVF, especially in those who have adverse semen parameters. The results of this study encourage patients to see urologists and physicians to introduce urologist to patients.

Trial registration number

not applicable

P-199 Effect of the area of oocyte perivitelline space on the fertilization and embryo development following intracytoplasmic sperm injection

Study question

Does the area of oocyte perivitelline space have an effect on fertilization and embryo development following intracytoplasmic sperm injection?

Summary answer

The area of oocyte perivitelline space has not an effect on the fertilization but the embryo development following intracytoplasmic sperm injection.

What is known already

Oocyte perivitelline space has a lot of variation at intracytoplasmic sperm injection (ICSI). Some researchers reported that the characteristics of perivitelline space (large or small) affect embryo development, pregnancy, and implantation. However, these studies did not accurately calculate the area of perivitelline space. Therefore, little information is available on the effect of the area of oocyte perivitelline space on fertilization and embryo development following ICSI. The purpose of this study was to calculate and classify the area of oocyte perivitelline space and investigate the effect of the area of perivitelline space on fertilization and embryo development following ICSI.

Study design, size, duration

1. We retrospectively investigated 634 mature oocytes that were conducted ICSI between January 2021 and December 2021. The area of each oocyte perivitelline space was defined from between the area of circle calculated from the inner layer of zona pellucida and cytoplasm and divided into 3 groups (-9%, 10-19%, 20%-).

2. We retrospectively calculated the diameter of an inner layer of zona pellucida and cytoplasm and compared it with the 3 groups (-9%, 10-19%, 20%-).

Participants/materials, setting, methods

1. The fertilization, survival, good quality day-3 embryo, blastocyst, good quality blastocyst rates following ICSI were compared with the 3 groups (-9%, 10-19%, 20%-).

2. The average diameter of an inner layer of zona pellucida and cytoplasm of each oocyte for the 3 groups (-9%, 10-19%, 20%-) were compared.

The data were analyzed by Fisher’s exact test, residual analysis, one-way ANOVA test, with Bonferroni correction as appropriate to determine the statistical differences among groups.

Main results and the role of chance

1. The survival rates of perivitelline space -9%, 10-19%, 20%- groups were 100% (109/109), 96% (363/378), 94% (138/147), the fertilization rates were 89% (97/109), 88% (331/378), 86% (127/147), the good quality day-3 embryo rates were 56% (54/97), 70% (232/331), 70% (89/127) respectively. No significant difference was observed between these comparison items. The blastocyst rates of perivitelline space -9%, 10-19%, 20%- groups were 51% (47/92), 69% (222/321), 82% (93/114), the good quality blastocyst rates were 22% (20/92), 40% (129/321), 52% (59/114) respectively. The blastocyst and good quality blastocyst rates of perivitelline space -9% group showed significantly lower results. On the other hand, the blastocyst and good quality blastocyst rates of perivitelline space 20%- group showed significantly higher results.

2. The average diameter of an inner layer of zona pellucida of perivitelline space -9%, 10-19%, 20%- groups were 125 ± 4 µm, 129 ± 5 µm, 136 ± 6 µm, the average diameter of the cytoplasm of perivitelline space were 121 ± 4 µm, 119 ± 4 µm, 118 ± 4 µm respectively. Significant differences were observed in all pairs of groups of the average diameter of an inner layer of zona pellucida and cytoplasm.

Limitations, reasons for caution

The area of oocyte perivitelline space was calculated at only one plane.

Wider implications of the findings

Oocytes with narrow perivitelline space might have a wide region of adhesive between the cytoplasm surface and an inner layer of the zona pellucida which resulted in a smaller diameter of the zona pellucida and lower blastocyst rate by forming cytoplasmic fragments (Yumoto K et al. JARG. 2020 ;37(6):1349-1354.).

Trial registration number

Not Applicable

The slow earthquake spectrum in the Japan Trench illuminated by the S-net seafloor observatories

Investigating slow earthquake activity in subduction zones provides insight into the slip behavior of megathrusts, which can provide important clues about the rupture extent of future great earthquakes. Using the S-net ocean-bottom seismograph network along the Japan Trench, we mapped a detailed distribution of tectonic tremors, which coincided with very-low-frequency earthquakes and a slow slip event. Compiling these and other related observations, including repeating earthquakes and earthquake swarms, we found that the slow earthquake distribution is complementary to the Tohoku-Oki earthquake rupture. We used our observations to divide the megathrust in the Japan Trench into three along-strike segments characterized by different slip behaviors. We found that the rupture of the Tohoku-Oki earthquake, which nucleated in the central segment, was terminated by the two adjacent segments.

Publisher Correction: Shedding new light on the Crab with polarized X-rays

A correction to this article has been published and is linked from the HTML and PDF versions of this paper. The error has not been fixed in the paper.

Radionuclide Assessment of the Natural Heart Ejection Fraction before and after LVAD Implantation

Complete pressure unloading of the ventricles can preserve ischemically damaged myocardium. Most clinical left heart assist device (LVAD) systems used after ischemic injury of the heart apply atrial cannulation which does not ensure pressure unloading. In order to assess the effect of the implantation of an intracorporeal LVAD on the function of the natural heart, we determined the ejection fraction (EF) in four male Holstein calves (90–105 kg) before and after insertion of a Cleveland Clinic pneumatic LVAD. A gated blood pool scan was obtained with a gamma camera after injection of 40 mCi Tc-labelled albumin. The animals were restrained in a sling to avoid movement artifacts.

All animals showed a drop of 65 ± 12% to 42 ± 14% EF in the first postoperative (p.o.) week. Left ventricular output did not maintain sufficient blood pressure as assessed by pump-off tests. Systolic blood pressure dropped from 122 ±6.5 mm Hg to 81 ± 6 mm Hg without pump support on the morning of the first p.o. day.

Apical coring and possible restrained heart movement by the implanted LVAD may lead to impaired myocardial function that renders the individual LVAD dependent until adaptative corrections take place.

Can the Artificial Heart Make the Circulation Become Fractal?

In order to analyze the hemodynamic parameters in prosthetic circulation as an entity and not as decomposed parts, non linear mathematical analyzing techniques, including the fractal dimension analyzing theory, were utilized. Two pneumatically actuated ventricular assist devices were implanted, as biventricular bypasses (BVB), in chronic animal experiments, using four healthy adult goats. For the comparison between the natural and prosthetic circulation in the same animals, the BVB type complete prosthetic circulation model with ventricular fibrillation, was adopted. All hemodynamic parameters with natural and prosthetic circulation were recorded under awake conditions, and calculated with a personal computer system. Using the non-linear mathematical technique, the arterial blood pressure waveform was embedded into the return map as the beat-to-beat time series data and fractal dimension analysis were performed to analyze the reconstructed attractor. By the use of the Box counting method, fractal dimension analysis of the hemodynamics was performed. Return map of the hemodynamics during natural and artificial circulation showed fractal characteristics, and fractal dimension analysis of the arterial blood pressure revealed the fact that lower dimensional fractal dynamics were evident during prosthetic circulation. Fractal time series data is suggested to have robustness and error resistance, thus our results suggest that the circulatory regulatory system with an artificial heart may have these desired characteristics.

Impact of the presence of HLA 1-locus mismatch and the use of low-dose antithymocyte globulin in unrelated bone marrow transplantation

HLA 1-locus-mismatched unrelated donors (1MMUD) have been used in allogeneic hematopoietic stem cell transplantation (allo-HCT) for patients who lack an HLA-matched donor. We retrospectively analyzed 3313 patients with acute leukemia or myelodysplastic syndrome who underwent bone marrow transplantation from an HLA allele-matched unrelated donor (MUD) or 1MMUD between 2009 and 2014. We compared the outcomes of MUD (n=2089) and 1MMUD with antithymocyte globulin (ATG) (1MM-ATG(+); n=109) with those of 1MMUD without ATG (1MM-ATG(-); n=1115). The median total dose of ATG (thymoglobulin) was 2.5 mg/kg (range 1.0-11.0 mg/kg) in the 1MM-ATG(+) group. The rates of grade III-IV acute GvHD, non-relapse mortality (NRM) and overall mortality were significantly lower in the MUD group than in the 1MM-ATG(-) group (hazard ratio (HR) 0.77, P=0.016; HR 0.74; P<0.001; and HR 0.87, P=0.020, respectively). Likewise, the rates of grade III-IV acute GVHD, NRM and overall mortality were significantly lower in the 1MM-ATG(+) group than in the 1MM-ATG(-) group (HR 0.42, P=0.035; HR 0.35, P<0.001; and HR 0.71, P=0.042, respectively). The outcome of allo-HCT from 1MM-ATG(-) was inferior to that of allo-HCT from MUD even in the recent cohort. However, the negative impact of 1MMUD disappeared with the use of low-dose ATG without increasing the risk of relapse.

Low-dose thymoglobulin as second-line treatment for steroid-resistant acute GvHD: an analysis of the JSHCT

A nationwide retrospective study for the clinical outcomes of 99 patients who had received thymoglobulin at a median total dose of 2.5 mg/kg (range, 0.5-18.5 mg/kg) as a second-line treatment for steroid-resistant acute GvHD was conducted. Of the 92 evaluable patients, improvement (complete or partial response) was observed in 55 patients (60%). Multivariate analysis demonstrated that male sex and grade III and IV acute GvHD were associated with a lower improvement rate, whereas thymoglobulin dose (<2.0, 2.0-3.9 and ⩾4.0 mg/kg) was NS. Factors associated with significantly higher nonrelapse mortality included higher patient age (⩾50 years), grade IV acute GvHD, no improvement of GvHD and higher dose of thymoglobulin (hazard ratio, 2.55; 95% confidence interval, 1.34-4.85; P=0.004 for 2.0-3.9 mg/kg group and 1.79; 0.91-3.55; P=0.093 for ⩾4.0 mg/kg group). Higher dose of thymoglobulin was associated with a higher incidence of bacterial infections, CMV antigenemia and any additional infection. Taken together, low-dose thymoglobulin at a median total dose of 2.5 mg/kg provides a comparable response rate to standard-dose thymoglobulin reported previously, and <2.0 mg/kg thymoglobulin is recommended in terms of the balance between efficacy and adverse effects.

Methodological Issues in Conducting Pilot Trials in Chronic Pain as Randomized, Double-blind, Placebo-controlled Studies

BACKGROUND

The efficacy of tapentadol extended release (ER) for managing chronic pain has been demonstrated in large-scale, randomized, controlled, phase 3 studies (N=318-1,030) in patients with chronic osteoarthritis (OA) pain, low back pain (LBP), and pain related to diabetic peripheral neuropathy (DPN), which led to registration in many regions, including the United States and Europe. 2 pilot 12-week, randomized, double-blind, placebo-controlled phase 2 studies of tapentadol ER for chronic pain (OA knee pain or LBP, n=91; DPN or peripheral herpetic neuralgia [PHN] pain; n=91) were conducted in Japan. These small exploratory studies were substantially underpowered compared with the registration trials.

METHODS

Patients in both studies were randomized (2:1) to tapentadol ER (25-250 mg) or placebo for 12 weeks (≤6-week titration plus maintenance periods).

RESULTS

For the primary efficacy endpoint (change in pain intensity from baseline to last week of treatment; last observation carried forward), both studies failed to differentiate between tapentadol ER and placebo; least-squares mean differences (95% confidence intervals) for tapentadol ER vs. placebo were -0.1 (-1.04, 0.80) in the OA/LBP study and -0.1 (-1.10, 0.99) in the DPN/PHN study. More than 80% of patients took concomitant analgesics during these studies. Tapentadol was well tolerated.

CONCLUSIONS

Both studies were associated with methodological issues, including populations with different disease entities, small sample sizes, use of concomitant analgesics, and possible placebo effect that may have led to the failure to differentiate between tapentadol ER and placebo.

Reinforced shape-tunable microwrinkles formed on a porous-film-embedded elastomer surface

A new structural design is proposed for wrinkling to improve mechanical durability by exploiting a porous polymer film embedded on the surface of an elastomer, which acts as a hard layer, buckles into wrinkles and effectively suppresses fatal failures such as delamination and cracking.

Test chamber and forensic microscopy investigation of the transfer of brominated flame retardants into indoor dust via abrasion of source materials

Brominated flame retardants (BFRs) have been detected in indoor dust in many studies, at concentrations spanning several orders of magnitude. Limited information is available on the pathways via which BFRs migrate from treated products into dust, yet the different mechanisms hypothesized to date may provide an explanation for the range of reported concentrations. In particular, transfer of BFRs to dust via abrasion of particles or fibers from treated products may explain elevated concentrations (up to 210 mg g(-1)) of low volatility BFRs like decabromodiphenyl ether (BDE-209). In this study, an indoor dust sample containing a low concentration of hexabromocyclododecane, or HBCD, (110 ng g(-1) ΣHBCDs) was placed on the floor of an in-house test chamber. A fabric curtain treated with HBCDs was placed on a mesh shelf 3 cm above the chamber floor and abrasion induced using a stirrer bar. This induced abrasion generated fibers of the curtain, which contaminated the dust, and ΣHBCD concentrations in the dust increased to between 4020 and 52 500 ng g(-1) for four different abrasion experiment times. The highly contaminated dust (ΣHBCD at 52 500 ng g(-1)) together with three archived dust samples from various UK microenvironments, were investigated with forensic microscopy techniques. These techniques included Micro X-ray fluorescent spectroscopy, scanning emission microscopy coupled with an energy dispersive X-ray spectrometer, Fourier transform infrared spectroscopy with further BFR analysis on LC-MS/MS. Using these techniques, fibers or particles abraded from a product treated with BFRs were identified in all dust samples, thereby accounting for the elevated concentrations detected in the original dust (3500 to 88 800 ng g(-1) ΣHBCD and 24 000 to 1,438 000 ng g(-1) for BDE-209). This study shows how test chamber experiments alongside forensic microscopy techniques, can provide valuable insights into the pathways via which BFRs contaminate indoor dust.

Relative incidences and outcomes of Clostridium difficile infection following transplantation of unrelated cord blood, unrelated bone marrow, and related peripheral blood in adult patients: a single institute study

BACKGROUND

Clostridium difficile is a major cause of nosocomial diarrhea. The incidence and prognosis of C. difficile-associated diarrhea (CDAD) has not yet been assessed in adult patients after unrelated cord blood transplantation (uCBT).

METHODS

The medical records of 135 adult unrelated cord blood transplant recipients were reviewed retrospectively to investigate the clinical features of CDAD after uCBT. These data were compared to medical records of 39 unrelated bone marrow transplant recipients and 27 related peripheral blood stem cell transplant recipients as controls.

RESULTS

A total of 17 recipients developed CDAD, with onset occurring at a median of 22 days (range, 0-56 days) after transplantation. Among the unrelated cord blood transplant recipients, 11 (9%) developed CDAD. These results were comparable with those of CDAD after unrelated bone marrow transplantation (uBMT) (2/39, 6%) and related peripheral blood stem cell transplantation (rPBSCT) (4/27, 16%) (P=0.37). Fifteen of the infected recipients were successfully treated with oral metronidazole, vancomycin, or cessation of antibiotics. The remaining 2 recipients who developed CDAD after uCBT died of other causes. The development of CDAD did not negatively affect overall survival after uCBT.

CONCLUSIONS

These data indicate that the incidence and prognosis of CDAD after uCBT are comparable with those after uBMT and rPBSCT.

Influence of losartan intake on the circadian rhythm of melatonin secretion in humans

It has been reported that losartan, an angiotensin II receptor blocker, alters the circadian rhythm of melatonin secretion and significantly reduces melatonin production. However, this finding has been confirmed at the animal experiment level only, and there are no reports of studies in humans. Therefore, we performed this study to confirm the reproducibility of the aforementioned findings of animal experiments in humans. Ten male subjects who were in good general health and free from any medical condition were recruited for this study. After a preliminary observation period of 7 days, the subjects received oral losartan treatment, 50 mg daily for 7 days. Blood samplings for measurement of the plasma melatonin concentrations were performed on day 7 of the preliminary observation period and day 7 of the losartan treatment period. The circadian rhythm of melatonin secretion after the 7-day treatment with losartan showed no significant difference from that recorded before the losartan administration. The significant decrease of the home blood pressure was observed on the afternoons. The blood samples showed significant decrease of the serum sodium and uric acid levels, along with a significant increase of the serum potassium level. The pharmacological actions of losartan at the ordinarily used clinical dose level were confirmed in humans, however, no significant inhibitory effect of the drug on melatonin secretion could be confirmed. These results are expected to be useful for guiding the proper use of angiotensin II receptor blockers.

Multi-system progressive angiomatosis in a dog resembling blue rubber bleb nevus syndrome in humans

A six-year-old, neutered, female golden retriever was presented with generalised, dark purple to black cutaneous nodules and gastrointestinal haemorrhage. Histopathologically, all cutaneous nodules were diagnosed as benign cavernous haemangiomas. Endoscopic analysis revealed similar nodules in the oesophagus, stomach and duodenum. At laparotomy, similar nodules were seen on the visceral peritoneal lining of abdominal organs. Metastatic haemangiosarcoma was ruled out based on histological features and lack of primary tumour in spleen, liver or heart ultrasonographically. Blood loss associated with gastrointestinal haemorrhage was managed with blood transfusion. To the authors' knowledge, this is the first canine case of multi-system progressive angiomatosis resembling blue rubber bleb nevus syndrome in humans.

Rapidly progressive fatal hemorrhagic pneumonia caused by Stenotrophomonas maltophilia in hematologic malignancy

BACKGROUND

Pneumonia caused by Stenotrophomonas maltophilia is rare, but can be lethal in severely immunocompromised patients. However, its clinical course remains unclear.

PATIENTS AND METHODS

Patients with pneumonia caused by S. maltophilia in Toranomon Hospital (890 beds, Tokyo, Japan) were reviewed retrospectively between April 2006 and March 2010.

RESULTS

During the study period, 10 cases of S. maltophilia pneumonia were identified. Seven patients had acute myeloid leukemia, 2 had myelodysplastic syndrome, and 1 had malignant lymphoma. All patients developed symptoms after allogeneic hematopoietic stem cell transplantation (HSCT). Five patients received first cord blood transplantation (CBT), 4 patients received second CBT, and 1 patient received first peripheral blood stem cell transplantation (PBSCT). The overall incidence of S. maltophilia pneumonia among 508 patients who received HSCT during the period was 2.0%. The incidence was 0% (0/95) in patients after bone marrow transplantation, 0.8% (1/133) after PBSCT, and 3.2% (9/279) after CBT. Pneumonia developed a median of 13.5 days (range, 6-40) after transplantation. At onset, the median white blood cell count was 10/μL (range, 10-1900), and the median neutrophil count was 0/μL (range, 0-1720). In all patients, S. maltophilia bacteremia developed with bloody sputum or hemoptysis. The 28-day mortality rate was 100%; the median survival after onset of pneumonia was 2 days (range, 1-10).

CONCLUSIONS

Hemorrhagic S. maltophilia pneumonia rapidly progresses and is fatal in patients with hematologic malignancy. Attention should be particularly paid to the neutropenic phase early after HSCT or prolonged neutropenia due to engraftment failure. A prompt trimethoprim-sulfamethoxazole-based multidrug combination regimen should be considered to rescue suspected cases of S. maltophilia pneumonia in these severely immunosuppressed patients.

Optimal conditions for lentiviral transduction of engrafting human CD34+ cells

Cytokines are required for γ-retroviral transduction of human CD34+ cells. However, cytokines may reduce engraftment of CD34+ cells and may not be necessary for their lentiviral transduction. We sought to optimize transduction and engraftment of human CD34+ cells using lentiviral vectors. Single 24 h transduction of human CD34+ cells with human immunodeficiency virus type 1 (HIV1)-based lentiviral vectors in media containing stem cell factor (SCF), FMS-like tyrosine kinase 3 (FLT3) ligand, thrombopoietin (each 100 ng ml⁻¹) and 10% fetal bovine serum was compared with various cytokine conditions during ex vivo culture and assayed using humanized xenograft mice for 6 months after transplantation. Serum-free media improved transduction efficiency of human CD34+ cells. Interleukin-3 (20 ng ml⁻¹) had little effect on transduction efficiency or engraftment. Threefold higher cytokine mixture (each 300 ng ml⁻¹) reduced engraftment of CD34+ cells. SCF alone (100 ng ml⁻¹) proved insufficient for maintaining engraftment ability and reduced transduction efficiency. Short-term prestimulation had little effect on transduction efficiency or engraftment, yet 24 h prestimulation showed higher transduction efficiency, higher gene expression levels and lower engraftment. In summary, 24 h prestimulation followed by single 24-h lentiviral transduction in serum-free media with SCF, FLT3 ligand and thrombopoietin yields high transduction efficiency to engrafting human CD34+ cells, and is applicable in human clinical gene therapy trials.