Study protocol for a Developmental Epidemiological Study of Children born through Reproductive Technologies (DESCRT)

STUDY QUESTIONS

The primary objective of this study is to determine what parental factors or specific ART may influence the risk for adverse cardiometabolic outcomes among children so conceived and their parents. The secondary objective of this study is to prospectively examine the effects of infertility or ART on the intrauterine environment, obstetric and neonatal outcomes.

WHAT IS KNOWN ALREADY

Pregnancies conceived with ART are at an increased risk of being affected by adverse obstetric and neonatal outcomes when compared to spontaneously conceived (SC) pregnancies among fertile women. Small cohort studies have suggested ART-conceived children may have a higher risk of long-term cardiometabolic disturbances as well. Currently, few studies have compared long-term cardiometabolic outcomes among ART-conceived children and non-IVF treated (NIFT) children, to children conceived spontaneously to parents with infertility (subfertile parents).

STUDY DESIGN SIZE DURATION

The Developmental Epidemiological Study of Children born through Reproductive Technologies (DESCRT) is a prospective cohort study that aims to: establish a biobank and epidemiological cohort of children born to subfertile or infertile parents who either conceived spontaneously (without assistance) or used reproductive technologies to conceive (all offspring were from couples assessed and/or treated in the same institute); prospectively examine the effects of infertility or ART on the intrauterine environment, obstetric and neonatal outcomes; and determine what parental factors or ART may influence the cardiometabolic risk of children so conceived. Pregnancies and resultant children will be compared by mode of conception, namely offspring that were conceived without medical assistance or SC or following NIFT, IVF with fresh embryo transfer or frozen embryo transfer (FET), and by fertilization method (conventional versus ICSI). DESCRT has a Child group evaluating long-term outcomes of children as well as a Pregnancy group that will compare obstetric and neonatal outcomes of children conceived since the commencement of the study. Recruitment started in May of 2017 and is ongoing. When the study began, we estimated that ∼4000 children would be eligible for enrollment.

PARTICIPANTS/MATERIALS SETTING METHODS

Eligible participants are first-trimester pregnancies (Pregnancy group) or children (Child group) born to parents who were evaluated at an infertility center in the University of California, San Francisco, CA, USA who were SC or conceived after reproductive treatments (NIFT, IVF ± ICSI, FET). Children in the Child group were conceived at UCSF and born from 2001 onwards. In the Pregnancy group, enrollment began in November of 2017.The primary outcome is the cardiometabolic health of offspring in the Child group, as measured by blood pressure and laboratory data (homeostatic model assessment for insulin resistance (HOMA-IR), oral glucose disposition). There are several secondary outcome measures, including: outcomes from parental survey response (assessing parent/child medical history since delivery-incidence of cardiometabolic adverse events), anthropomorphic measurements (BMI, waist circumference, skinfold thickness), and laboratory data (liver enzymes, lipid panel, metabolomic profiles). In the Pregnancy group, outcomes include laboratory assessments (bhCG, maternal serum analytes, soluble fms-like tyrosine kinase-1 (sFLT-1), and placental growth factor (PlGF)) and placental assessments (placental volume in the second and third trimester and placental weight at delivery). Importantly, aliquots of blood and urine are stored from parents and offspring as part of a biobank. The DESCRT cohort is unique in two ways. First, there is an extensive amount of clinical and laboratory treatment data: parental medical history and physical examination at the time of treatment, along with ovarian reserve and infertility diagnosis; and treatment specifics: for example, fertilization method, culture O₂ status, embryo quality linked to each participant. These reproductive data will aid in identifying explanatory variables that may influence the primary cardiometabolic outcomes of the offspring-and their parents. Second, the DESCRT control group includes pregnancies and children SC from parents with subfertility, which may help to assess when infertility, as opposed to reproductive treatments, may be affecting offspring cardiometabolic health.

STUDY FUNDING/COMPETING INTERESTS

This study is funded by the National Institutes of Health NICHD (1R01HD084380-01A1). A.J.A. is a shareholder in Carrot and consultant for Flo Health. The other authors have no conflicts of interest.

TRIAL REGISTRATION NUMBER

NCT03799107.

TRIAL REGISTRATION DATE

10 January 2019.

DATE OF FIRST PATIENT’S ENROLLMENT

10 May 2017.

48 Different chromatin accessibility in murine male and female inner cell mass

Previous research has shown that embryos conceived by IVF show a sexual dimorphic phenotype and different metabolite expression into adulthood. Interestingly, female embryos have a higher apoptotic rate and are more vulnerable to environmental stressors. Our prior studies have examined DNA methylation changes in male and female embryos; however, limited knowledge is available with regard to chromatin accessibility in male and female embryos. The objective of this study was to assess if genome-wide chromatin accessibility changes occur in the inner cell mass (ICM) of the male v. female mouse embryo. For this experiment we utilised expanded blastocysts (CF-1 females×B6D2F1 males) that were obtained by IVF or flushed out of the uterus (FB, control). We performed IVF using KSOM with amino acids and 5% O2. The ICM were isolated from trophectoderm cells utilising immunosurgery and complement. The chromatin status was assessed using an assay for transposase-accessible chromatin status using a sequencing (ATAC seq) protocol modified from Wu et al. (2016 Nature 524, 652-657, DOI: 10.1038/nature18606). Briefly, cells were lysed and nuclei incubated with the Tn5 transposome and tagmentation buffer (Nextera, Illumina Inc., San Diego, CA, USA). After tagmentation, PCR amplification (15 cycles), mitochondrial depletion, and library purification were performed. The sex of the embryo was determined based on MSY (male sex region on the Y chromosome) and total Y chromosome aligning reads. Samples were then divided into 2 groups, male (n=20) and female (n=25), and sequencing was completed using Illumina HiSEqn 2500 (Illumina Inc.). Sequencing was completed using Illumina HiSEqn 2500. MACS2 (https://github.com/taoliu/MACS/) was used for peak identification from the sequencing results and DESEqn 2 (https://www.r-project.org/) was used for statistical analysis and false discovery rate<0.1 was considered significant. GREAT analysis (http://great.stanford.edu/public/html/) was used to identify the top biological processes. Overall, 17,136 regions were identified as more open in males and 19,460 regions were identified as more open in females. Interestingly, of these identified regions, only 28 were considered significant (25 increased and 3 decreased in males). The majority of these regions were located on chromosome Y and most of the regions that were increased in male correlated with gene Gm10352, a gene with an unknown function. While some pathway changes were expected, like the ones involved in sex determination, male gonadal development, and male sexual characteristics, others included histone demethylation, regulation of chromatin silencing, negative regulation of DNA replication, and antigen processing and presentation of peptide antigen. Our data are the first to analyse genome-wide chromatin accessibility changes in the ICM of male and female mouse embryos. Importantly, these data indicate that chromatin differences are already present in the ICM of male and female embryos. Further analysis will provide insights into epigenetic and sexual dimorphic changes present in embryos.

In vitro culture of mouse embryos reduces differential gene expression between inner cell mass and trophectoderm

Differences in gene expression and imprinting have been reported, comparing in vivo versus in vitro generated preimplantation embryos. Furthermore, mouse studies have shown that placenta development is altered following in vitro culture. However, the molecular mechanisms underlying these findings are unknown. We therefore isolated trophectoderm (TE) and inner cell mass (ICM) cells from in vivo and in vitro fertilization (IVF) embryos and evaluated their transcriptome using microarrays. We found that the transcriptomes of in vitro produced ICM and TE cells showed remarkably few differences compared to ICM and TE cells of in vivo generated embryos. In vitro fertilization embryos showed a reduced number of TE cells compared to in vivo embryos. In addition, TE of IVF embryos showed significant downregulation of solute transporter genes and of genes involved in placenta formation (Eomesodermin, Socs3) or implantation (Hbegf). In summary, IVF and embryo culture significantly affects the transcriptome of ICM and TE cells.

Sequential assessment of individually cultured human embryos as an indicator of subsequent good quality blastocyst development

BACKGROUND

It is of fundamental importance for IVF clinics to determine the most viable embryos for transfer. The challenge for ART clinics is to transfer fewer embryos, thereby minimizing the risk of multiple-infant births, while still maintaining the greatest chance of pregnancy for their patients. In this study, an investigation was made to determine if developmental markers on the day of fertilization (day 1) can predict good subsequent blastocyst development.

METHODS AND RESULTS

A total of 1550 individually cultured 2PN embryos from 191 patients undergoing IVF/ICSI treatment at the Yale University Center for Reproductive Medicine and Infertility from February to December 2001 was included. The results showed a significant positive relationship between early-cleaving 2-cell embryos and subsequent good quality > or =4-cell, > or =7-cell and blastocyst development (P < 0.05). PN symmetry (the relative size of the PN to each other), when checked at the time fertilization, is also a significant indictor of good quality > or =4-cell, > or =7-cell stage embryos and blastocysts. Combined, a developing embryo showing PN symmetry with early cleavage and subsequent good > or =4-cell and > or =7-cell cleavage, has a one in two chance of developing into a good-quality blastocyst.

CONCLUSION

Early embryo assessment can be used as an indicator of subsequent good blastocyst development.

Microinjection of mitochondria into zygotes creates a model for studying the inheritance of mitochondrial DNA during preimplantation development

OBJECTIVE

To determine the effect of mutant mitochondria on preimplantation embryo development and of preimplantation embryo development on the survival of mutant mitochondrial DNA.

DESIGN

Laboratory research.

SETTING

Academic research laboratory.

PATIENT(S)

None.

INTERVENTION(S)

Mutant and wild-type mitochondria, fractionated from tissue obtained from a patient with MELAS syndrome, a mitochondrial disease, were microinjected into mouse zygotes. Control zygotes received either no injection or sham injection.

MAIN OUTCOME MEASURE(S)

Preimplantation embryo development and survival of mutant mitochondrial DNA as determined by polymerase chain reaction analysis.

RESULT(S)

After microinjection into zygotes, the MELAS mutation could be identified by polymerase chain reaction until the hatched blastocyst stage of embryo development. The survival of MELAS-injected zygotes, observed for 4 days after injection, did not differ from the survival of zygotes injected with wild-type mitochondria or from the survival of uninjected or sham-injected controls.

CONCLUSION(S)

It appears that preimplantation embryo development does not screen out mitochondrial DNA mutations introduced into fertilized oocytes, and low levels of mutant mitochondrial DNA do not disrupt early embryo development.

Atrial septal defect and pregnancy: a retrospective analysis of obstetrical outcome before and after surgical correction

STUDY OBJECTIVES

To describe the obstetrical outcome and long-term cardiac follow-up of a group of patients who had surgery for atrial septal defect repair before pregnancy and a group who underwent pregnancy before surgical correction.

DESIGN

Retrospective.

SETTING

Public Institution.

PATIENTS

Eighty women (mean age 20.15 +/- 4.5 years) complaining of atrial septal defect, 60 of which had surgical correction before pregnancy and subsequently had 115 pregnancies, and 20 of which underwent pregnancy before the correction of cardiac defect and subsequently had 48 pregnancies.

INTERVENTIONS

Surgical correction of atrial septal defect: 49 by open heart technique (13 with cardiopulmonary bypass, 36 with light hypothermic circulatory arrest), 11 by closed heart techniques.

RESULTS

Patients who underwent pregnancy before surgery had an increased incidence of miscarriage, pre-term delivery and cardiac symptoms during pregnancy. Patients operated before pregnancy required more frequently cesarean section and pharmacological therapy. The frequency of stillbirths, malformations in the offspring and long-term cardiac complications were similar in both groups.

CONCLUSIONS

Surgical correction of atrial septal defect before pregnancy is recommended even in case of apparently well compensated hemodinamic situation for the low rate of surgical complications in spite of the higher incidence of obstetrical problems in case of medical therapy alone.

Dissociation between intracellular calcium elevation and development of human oocytes treated with calcium ionophore

OBJECTIVE

To develop an acceptable model system to study calcium activation of human oocytes.

DESIGN

Study of oocyte development and intracellular calcium [Ca]i dynamics of activated oocytes.

SETTING

Research center affiliated with infertility service.

MAIN OUTCOME MEASURE

Morphologic evidence of meiotic maturation and cell division under high-power Hoffman optics with an inverted microscope. Meiotic maturation was determined by the number of polar bodies or the presence of a pronucleus, and cell division was determined by evidence of a cleavage furrow or presence of blastomeres. To monitor the effect of calcium ionophore on [Ca]i levels, oocytes were incubated with fura-2 (2 microM) for 30 minutes and [Ca]i was determined by rationing the emission fluorescence (510-nm long-pass filter) during simultaneous excitation at 340 and 380 nm with a microspectrofluorimeter.

RESULT(S)

All oocytes loaded with fura-2 and then exposed to ionophore exhibited an isolated elevation of [Ca]i, followed by prompt return to baseline levels. None of the oocytes showed signs of cleavage or of meiotic maturation after treatment with calcium ionophore.

CONCLUSION(S)

Human oocytes activated with calcium ionophore A23187 or ionomycin exhibited elevated [Ca]i but remained resistant to subsequent meiotic maturation and cleavage. Our results differ from some reports of parthenogenetic activation of human oocytes. These differences may result from different activation protocols or culture conditions. Because none of the 126 oocytes cleaved after the activation protocols used in these experiments, this approach should provide an ethically acceptable model system to study calcium dynamics in human oocytes.

Hormone induction of ascorbic acid transport in immature granulosa cells

Ascorbic acid serves a vital role as an antioxidant, and like FSH, it inhibits apoptosis of granulosa cells in cultured follicles. In contrast, reactive oxygen species block the action of FSH and induce DNA damage in these cells. As the uptake of ascorbic acid by granulosa cells may be a site for regulation, we examined the nature of this process and whether uptake is under hormone control. Granulosa cells were isolated from immature rats pretreated with estradiol or diethylstilbestrol for 3-4 days and placed in culture. Culture of the cells with either FSH (50 ng/ml) or insulin-like growth factor I (IGF-I; 30 ng/ml) for 48 h increased ascorbic acid uptake by 2.7- and 1.9-fold (P < 0.05), respectively, and the response to FSH plus IGF-I was additive (4.5-fold; P < 0.05). The interval for maximum induction of ascorbic acid transport by FSH was between 4-8 h, whereas a significant response to IGF-I was not seen until 48 h. GnRH (1 microM), phorbol ester (phorbol 12-myristate 13-acetate; 1 microM), and 8-bromo-cAMP (8Br-cAMP; 1 mM) also induced ascorbic acid transport by 1.7-, 1.9-, and 2.3-fold (P < 0.05) within 24 h, and the response to maximal levels of phorbol ester and 8Br-cAMP was synergistic (4.8-fold; P < 0.05). Kinetic analysis showed a similar Michaelis constant (K(m); 50.8 +/- 5.3 microM) and maximum velocity (3.3 +/- 0.4 pmol/10(6) cells.min) for ascorbic acid transport in FSH-, 8Br-cAMP-, or phorbol ester-treated cells. Ouabain (100 microM) or removal of extracellular Na+ significantly inhibited ascorbic acid uptake, as did dinitrophenol (1 mM), an inhibitor of mitochondrial production of ATP. The induction of ascorbic acid transport by FSH, IGF-I, or GnRH was abolished by simultaneous incubation with tyrphostin (AG-18; 80 microM), a specific tyrosine kinase inhibitor, whereas induction was unaffected by an inactive, but chemically similar, compound (A-1; 80 microM). From these results we conclude that ascorbic acid uptake is energy and Na+ dependent and that the induction of ascorbic acid transporters in granulosa cells occurs through multiple hormones that ultimately influence tyrosine-specific protein kinases. The hormone-dependent induction of ascorbic acid accumulation in granulosa cells appears to be an essential process for the development and maintenance of a viable follicle.

Malacoplakia of testis

A case of malacoplakia of testis with a typical clinical course, related to urogenital E. coli infection is presented. By means of electron microscopy, we have identified several forms of Michaelis-Gutmann bodies within the lesion. X-ray spectral analysis revealed that these bodies contain large amounts of calcium, phosphate, sulfur, sodium and chloride. The pathogenesis of malacoplakia and the formation of Michaelis-Gutmann bodies is shortly discussed.