P-010 Sperm selection by birefringence: a promising non-invasive tool to improve ICSI outcomes

Study question

Could the sperm selection by birefringence improve ICSI outcomes in couples with different infertility factors?

Summary answer

Sperm selection by birefringence demonstrated a positive clinical impact on ICSI outcomes in couples with different infertility factors when compared to the conventional sperm selection.

What is known already

Higher sperm DNA fragmentation may affect ICSI outcomes. However, the utilized sperm selection protocols do not allow the evaluation of this parameter. In this sense, the analysis of sperm’s head birefringence has been suggested as an adjuvant of seminal processing in order to select viable sperm for couples with severe male factor. Nevertheless, considering men with normal seminal parameters may also curse with DNA fragmentation, the impact of birefringence on ICSI outcomes of couples with different infertility factors should be investigated.

Study design, size, duration

Retrospective case-control study. One hundred eighty-one couples who underwent ICSI from January 2018 to August 2020 [107 submitted to sperm selection by conventional analysis (Nonbirefringence group) and 74 whose sperm were selected by conventional analysis associated to sperm head birefringence evaluation (Birefringence group)] were included in the study.

Participants/materials, setting, methods

Medical records were assessed for eligibility evaluation and data collection. Clinical characteristics (female age, body mass index, infertility factor, seminal parameters) and ICSI outcomes (eg. fertilization rate, cleavage rate, blastulation rate, number of high quality embryos formed, implantation rate, biochemical pregnancy rate, clinical pregnancy rate per transfer and per initiated cycle) were compared between the groups using (p < 0.05). A multivariate logistic regression model was applied to verify the factors associated with clinical pregnancy.

Main results and the role of chance

Despite the Birefringence group showed higher female age (p = 0.01), lower seminal sperm concentration (p < 0.01) and higher sperm DNA fragmentation (p < 0.01), those patients cursed with higher cleavage rate (p = 0.04), higher clinical pregnancy rate per transfer (p = 0.03) and higher clinical pregnancy rate per initiated cycle (p = 0.02) than the Nonbirefringence group. The logistic regression showed a positive group (Birefrincence) effect on clinical pregnancy achievement.

Limitations, reasons for caution

The unequal inclusion of infertility factors between the groups might represent a bias. In logistic regression analysis, none of those factors interfered with clinical pregnancy, which reinforces the impact of the technique on the results. The endpoint analyzed was clinical pregnancy, while live birth would better reflect ICSI success.

Wider implications of the findings

Sperm selection by birefringence could positively impact ICSI outcomes. Because it is a cheap and easily reproducible technique, it could be combined with conventional ICSI treatments to improve the reproductive chances of those patients.

Trial registration number

not applicable

T-shaped IUDs accommodate in their position during the first 3 months after insertion

The objective of this study was to observe the position dynamics of the T-shaped intrauterine device (IUD) in the uterine cavity, from insertion to 90 days of use. IUD position was evaluated in 214 women by vaginal ultrasound, measuring the IUD-endometrium, IUD-myometrium, and IUD-fundus distances. The 90th percentile of the IUD-endometrium distance was 5, 6, and 8 mm at time of insertion, 30 and 90 days of use; 7, 9, and 10 mm for IUD-myometrium distance; and 23, 24, and 27 mm for IUD-fundus distance, respectively. Seventeen IUDs were classified as misplaced at insertion by using the 90th percentile of the IUD-myometrium distance as standard. Of these, only 6 remained misplaced after 90 days of use. On the other hand, 21 IUDs were beyond the 90th percentile at the 90-day observation, only 6 of which were considered misplaced at insertion. We conclude that the T-shaped IUD accommodates its position in the uterine cavity during the first 3 months following insertion, and that ultrasound evaluation of its position is not a good predictor of future evaluation.

Forearm bone density in users of Depo-Provera as a contraceptive method

OBJECTIVE

To determine the influence of depot medroxyprogesterone acetate (MPA) on bone mineral density when used as a contraceptive method.

DESIGN

Cross-sectional study.

SETTING

Academic tertiary-care hospital.

PATIENT(S)

Fifty premenopausal women who had used depot MPA as a contraceptive method for > or =1 year and 50 women who had never used hormonal contraceptive methods.

INTERVENTION(S)

Bone mineral density was evaluated at the midshaft and at the distal radius of the nondominant forearm using single x-ray absorptiometry.

MAIN OUTCOME MEASURE(S)

Bone mineral density.

RESULT(S)

Bone mineral density at the midshaft of the forearm was lower in depot MPA users than in women who had never used hormonal contraceptive methods, but the difference was not statistically significant. At the distal portion, bone mineral density was significantly lower in the study group. The duration of depot MPA use was not related to bone mineral density.

CONCLUSION(S)

Women > or =35 years of age presented with a lower bone mineral density only at the distal portion of the forearm after the use of depot MPA for > or =1 year. However, this decrease was not related to the duration of depot MPA use. It is not possible to conclude that women who use depot MPA are at risk of osteoporosis.

Timing of onset of contraceptive effectiveness in Depo-Provera users. II. Effects on ovarian function

OBJECTIVE

To determine the timing of onset of contraceptive effectiveness after the first injection of 150 mg of depot medroxyprogesterone acetate (DMPA) administered between days 8 and 13 of the menstrual cycle.

DESIGN

Descriptive, prospective study.

SETTING

A tertiary university referral center.

PATIENT(S)

Thirty healthy women between 18 and 40 years of age.

INTERVENTION

Volunteers were injected with DMPA between days 8 and 13 (5 women on each day) of the menstrual cycle.

MAIN OUTCOME MEASURE(S)

Ovarian function determined by serum levels of E2 and progesterone and follicular development evaluated by vaginal ultrasound.

RESULT(S)

In nine (30%) of 30 women studied, DMPA did not prevent ovulation. All ovulations occurred in women receiving DMPA between days 10 and 13 of the cycle. No woman who received injections on day 8 or 9 ovulated. Ovulation suppression was more effective in women with low ovarian activity. All ovulation occurred within 3 days after the injection.

CONCLUSION

A back-up contraceptive method, used after the 7th day of the menstrual cycle, is recommended for up to 7 days after the first injection of DMPA.

The risk of inadvertent intrauterine device insertion in women carriers of endocervical Chlamydia trachomatis

The most important complication attributed to the use of intrauterine device (IUD) is pelvic inflammatory disease (PID), often associated with Neisseria or Chlamydia infection. Consequently, the IUD should not be inserted in women at risk of infection or with symptoms of endocervicitis. To evaluate the effectiveness of such a policy, a systematic investigation of Chlamydia and Neisseria was carried out among 407 contraceptive acceptors. Twenty-seven cases were positive for Chlamydia and none were positive for Neisseria. There were no statistical differences in the proportion of women with and without Chlamydia who had vulvovaginal or cervical signs or symptoms, although twice as many women had pain at pelvic exam in the Chlamydia-infected group. In 29 women in whom infection was clinically suspected, two were found to be infected with Chlamydia. IUD were not inserted in women suspected of having infection, but 19 of 327 IUD acceptors were subsequently found to have a positive Chlamydia test result. Two women returned with symptoms of PID and 17 were asymptomatic, but all were treated. PID was not suspected in any other subject. These results reinforce the need for careful selection of IUD acceptors and for thorough counseling for symptoms of PID and the need for immediate consultation.

T-shaped IUD move vertically with endometrial growth and involution during the menstrual cycle

Ultrasound has been used to detect and evaluate intrauterine device (IUD) position for some years. Different definitions of the IUD in the uterine cavity have been discussed trying to relate them to bleeding and pain complaints. Most of these definitions do not take into account the uterine wall or endometrial thickness. This is a secondary analysis of a previous cross-sectional study, in which 481 IUD users had their T-shaped IUD evaluated by transvaginal sonography. The correlation between the endometrium thickness and the IUD-myometral distance was studied, defined by the linear measurement between the upper end of the IUD and the myometrium/endometrium interface. These two measurements were highly correlated over the entire sample range (r = 0.29) and an even stronger correlation existed (r = 0.66) when only cases below the 90 percentile of the IUD-endometrial distance distribution were considered. These results suggest that the IUD position in the uterine cavity is influenced by the growth and thinning of the endometrium, and that this information should be considered when evaluating the IUD position by sonography.

No relationship between the IUD position evaluated by ultrasound and complaints of bleeding and pain

The objectives of this study were to define the "normal" position of the T-shaped intrauterine device (IUD) in the endometrial cavity, using transvaginal ultrasound, and to compare the IUD's position in women with and without complaints of bleeding and/or pain. Vaginal ultrasound was carried out in women who had used a T-Cu 200 or T-Cu 380 for at least 6 months. Of these women, 236 registered bleeding complaints and/or pain and 245 had no complaints. The distances, IUD-endometrium, IUD-myometrium, and IUD-fundus, were measured in each woman. Our results showed that women with and without complaints presented no significant differences in age, parity, type of IUD, duration of use, previous contraceptive method used, hysterometry, uterine position, or period of the cycle in which the ultrasound was performed. The values of the three distances in users without complaints were widely dispersed. The 90th percentile of the IUD-endometrium, IUD-myometrium, and IUD-fundus distances were 7, 11, and 27 mm, respectively. The curve of the values for the three distances among women with complaints was similar to that of the subjects without complaints. Using the generally accepted measurement of 20 or 25 mm as the limits of normality of the distance IUD-fundus, and the 90th percentile of the distance IUD-endometrium as the gold standard, 77% and 43% of the women were false positives for "incorrect IUD position." Similar results were obtained when the 90th percentile of the distance IUD-myometrium was used as a gold standard. We concluded that the 90th percentiles of the distance IUD-endometrium, IUD-myometrium, and IUD-fundus were 7, 11 and 27 mm, respectively, among users without complaints. The ultrasonographic diagnosis of the IUD position was unable to discriminate between women who did or did not have complaints of bleeding and/or pain. If ultrasound were to be performed in T-shaped IUD users, the IUD-myometrium distance is likely to be the most reliable measurement.

The use of vaginal ultrasound to identify copper T IUDs at high risk of expulsion

A total of 235 women who had a TCu 380A IUD inserted had a vaginal ultrasound scan performed to identify if the IUDs were correctly placed in the uterine fundus. Women identified as having a misplaced IUD had it removed. The remaining women were compared to 201 women who had an IUD inserted and had no ultrasound evaluation, matched by age and parity. Women were followed-up for one year. Gross cumulative discontinuation rates and continuation rates were calculated by life table analysis. Comparison between groups was done by the Gehan test. The study group had 34 IUDs removed because they were misplaced according to the established criteria. The expulsion rate was significantly higher in the control group, also influencing the continuation rate which was lower in the same group. Of the 34 women who had their IUD removed because it was not correctly placed, only 22 requested and had another IUD inserted. The removal of IUD determined by an ultrasound to be incorrectly placed significantly decreased expulsion rates. However, many IUDs may have been removed unnecessarily, probably resulting in many women not returning to the clinic or deciding to use another contraceptive method.

The influence of human chorionic gonadotrophin administration upon the next ovarian cycle

We examined the influence of human chorionic gonadotrophin (HCG), used as an ovulation inducer and/or for supporting the luteal phase, on the next ovarian cycle. Four women received 10,000 IU of HCG at mid-cycle and another four received the same dose plus 1500 IU on the 17th, 19th and 21st days of the cycle. In the menstrual cycle prior to our experiments, venous blood samples were collected and vaginal ultrasound of the ovaries was performed every other day from day 21-28; the same data were also collected on days 1-10 of the experiment cycle. In such a way, control values were obtained. After the administration of HCG, venous blood samples were collected and ultrasound was performed in the same way and on the same days as in the controls. Follicle stimulating hormone (FSH) and luteinizing hormone were determined by radioimmunoassay in all blood samples, and HCG only in samples collected after the experiment. The results showed that only FSH was lower in the late luteal phase after the administration of 10,000 IU of HCG. Follicular diameters were higher during the follicular phase than during the previous cycle only in women who received the low dose of HCG. In addition, one woman presented with detectable HCG in the following ovarian cycle. The use of HCG in the preceding cycle may reduce FSH and develop persistent follicles in the subsequent cycle. We suggest that an ultrasound of the ovaries should be performed before starting a new ovulation induction cycle in a woman who has received HCG in the previous cycle.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical performance of the Copper T200B IUD after reinsertion following life-span expiration

The purpose of this study was to evaluate the first year clinical performance of the TCu200B IUD in a cohort of women who had the IUD re-inserted immediately after a removal for life-span expiration, compared with a group of initial acceptors, and a cohort of women who continued using the device for more than 60 months. The sample consisted of 1066 users, 339 in each of the two first groups and 388 in the third. Life-table analysis was used to calculate continuation and gross discontinuation rates by reason. Statistical significance of the differences between groups was tested by log-rank method. Pregnancy rates were low, both in the group of re-insertions and first insertions, and no pregnancies occurred in the group using the device beyond the fifth year. The expulsion rate and lost-to-follow-up (LFU) rate were significantly lower in the group of women who used the device beyond the fifth year. In addition, this group showed a significantly higher rate of removal for investigator's choice. These results show that there is no reason to recommend the removal and replacement of the TCu200B before the end of the sixth year of use. When a new IUD is to be inserted after removal for life-span expiration, providers should be instructed to insert it immediately after the removal, because this procedure does not pose additional risks, reduces the number of clinic visits, and relieves the women of the use of a temporary method while waiting for the re-insertion.