Uterine NK cells underexpress KIR2DL1/S1 and LILRB1 in reproductive failure

A significant proportion of recurrent miscarriage, recurrent implantation failure and infertility are unexplained, and these conditions have been proposed to have an etiology of immunological dysfunction at the maternal-fetal interface. Uterine Natural Killer cells (uNK) comprise three subsets and are the most numerous immune cells found in the uterine mucosa at the time of implantation. They are thought to play an important role in successful pregnancy by regulation of extravillous trophoblast (EVT) invasion and spiral artery remodelling. Here, we examine the frequency, phenotype and function of uNK1-3 from the uterine mucosa of 16 women with unexplained reproductive failure compared to 11 controls with no reproductive problems, during the window of implantation. We report that KIR2DL1/S1 and LILRB1 expression is lower in the reproductive failure group for both uNK (total uNK, uNK 2 and 3) and pNK. We also show that degranulation activity is significantly reduced in total uNK, and that TNF-α production is lower in all uNK subsets in the reproductive failure group. Taken together, our findings suggest that reproductive failure is associated with global reduction in expression of uNK receptors important for interaction with HLA-C and HLA-G on EVT during early pregnancy, leading to reduced uNK activation. This is the first study to examine uNK subsets during the window of implantation in women with reproductive failure and will serve as a platform to focus on particular aspects of phenotype and function of uNK subsets in future studies. Further understanding of uNK dysregulation is important to establish potential diagnostic and therapeutic targets in the population of women with unexplained reproductive failure.

Effects of marriage equality legislation on sexual health of the US population

Even though prior research has investigated the relationship between same-sex partnership recognition policies and health outcomes, the impact of same-sex marriage laws on sexually transmitted infections has not received much attention. Using state-level panel data from 2000 to 2019, I show that marriage equality legislation decreases the spread of (shorter-term) syphilis infections and of (longer-term) human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) infections among the general population. Event study analyses correcting for non-staggered treatment implementation confirm these negative effects, but also suggest that standard difference-in-differences models understate the impact of the legislation by up to 8% points. Further analysis supports that these legislation effects operate through three mechanisms: increasing social tolerance, strengthening relationship commitment, and expanding health care access and coverage for HIV/AIDS prevention and treatment. Disaggregating the results by sexual behavior reveals that legal access to same-sex marriage leads to sizable decreases in AIDS rates among men who have sex with men (MSM) (the most at-risk population for an infection). Even though there is economically significant evidence that the legislation improves sexual health of the heterosexual population due to increased utilization of preventive sexual health care, the legislation does not have a direct impact on infection rates for the non-MSM population.

Number and function of uterine natural killer cells in recurrent miscarriage and implantation failure: a systematic review and meta-analysis

BACKGROUND

Uterine natural killer cells (uNK) are the most abundant lymphocytes found in the decidua during implantation and in first trimester pregnancy. They are important for early placental development, especially trophoblast invasion and transformation of the spiral arteries. However, inappropriate uNK function has been implicated in reproductive failure, such as recurrent miscarriage (RM) or recurrent implantation failure (RIF). Previous studies have mainly focussed on peripheral NK cells (pNK), despite the well-documented differences in pNK and uNK phenotype and function. In recent years, there has been an explosion of studies conducted on uNK, providing a more suitable representation of the immune environment at the maternal-foetal interface. Here, we summarize the evidence from studies published on uNK in women with RM/RIF compared with controls.

OBJECTIVE AND RATIONALE

The objectives of this systematic review and meta-analysis are to evaluate: differences in uNK level in women with RM/RIF compared with controls; pregnancy outcome in women with RM/RIF stratified by high and normal uNK levels; correlation between uNK and pNK in women with RM/RIF; and differences in uNK activity in women with RM/RIF compared with controls.

SEARCH METHODS

MEDLINE, EMBASE, Web of Science and Cochrane Trials Registry were searched from inception up to December 2020 and studies were selected in accordance with PRISMA guidelines. Meta-analyses were performed for uNK level, pregnancy outcome and uNK/pNK correlation. Narrative synthesis was conducted for uNK activity. Risk of bias was assessed by ROBINS-I and publication bias by Egger's test.

OUTCOMES

Our initial search yielded 4636 articles, of which 60 articles were included in our systematic review. Meta-analysis of CD56+ uNK level in women with RM compared with controls showed significantly higher levels in women with RM in subgroup analysis of endometrial samples (standardized mean difference (SMD) 0.49, CI 0.08, 0.90; P = 0.02; I2 88%; 1100 women). Meta-analysis of CD56+ uNK level in endometrium of women with RIF compared with controls showed significantly higher levels in women with RIF (SMD 0.49, CI 0.01, 0.98; P = 0.046; I2 84%; 604 women). There was no difference in pregnancy outcome in women with RM/RIF stratified by uNK level, and no significant correlation between pNK and uNK levels in women with RM/RIF. There was wide variation in studies conducted on uNK activity, which can be broadly divided into regulation and receptors, uNK cytotoxicity, cytokine secretion and effect of uNK on angiogenesis. These studies were largely equivocal in their results on cytokine secretion, but most studies found lower expression of inhibitory receptors and increased expression of angiogenic factors in women with RM.

WIDER IMPLICATIONS

The observation of significantly increased uNK level in endometrium of women with RM and RIF may point to an underlying disturbance of the immune milieu culminating in implantation and/or placentation failure. Further research is warranted to elucidate the underlying pathophysiology. The evidence for measuring pNK as an indicator of uNK behaviour is sparse, and of limited clinical use. Measurement of uNK level/activity may be more useful as a diagnostic tool, however, a standardized reference range must be established before this can be of clinical use.

P-703 Developing individualized treatment strategies using detailed subgroup analysis to optimise pregnancy outcomes for women 40 and above

Study question

What are the prognostic factors and treatment strategies for women 40 and above within different ovarian reserve subgroups?

Summary answer

Women in each ovarian reserve subgroup have different prognostic factors of pregnancy success and specific treatment strategies are needed for each subgroup.

What is known already

The number of women 40 and above seeking subfertility treatment is increasing and many are willing to undergo treatment despite extremely poor prognosis. POSEIDON criteria suggested the usage of ovarian reserve and female age as a basis for the study of the management of women in different prognostic categories. However, this classification may not be detailed enough to lead to specific recommendations for individualised management in women 40 and above, as there is rapid decline of oocyte quality and quantity. Large observational studies may lack finer detail due to challenges in recruiting women within different ovarian reserve subgroups.

Study design, size, duration

We carried out a detailed retrospective analysis of 382 IVF/ICSI cycles for 253 women from January 2019 to December 2021 in a special clinical and academic program for reproductive ageing and fertility. Inclusion criteria were all women who had IVF/ICSI cycles aged 40 and over. Analysis was done for all fresh cycles including cancelled cycles, failed fertilization, no eggs collected and embryo arrest. Cycles resulting in freezing of all embryos were excluded in analysis.

Participants/materials, setting, methods

The participants were divided into three main subroups: Group A, “normal ovarian reserve” (AMH 2.5-29.9pmol/l, n = 271 cycles); Group B, “extremely poor ovarian reserve” (AMH <2.5pmol/l, n = 85 cycles); and Group C “extremely high ovarian reserve” (PCOS or AMH ≥30.0pmol/l, n = 26 cycles). Chi-square and Mann-Whitney U tests were used to compare pregnant and non-pregnant groups for nominal and continuous data respectively. Multi-variate logistic regression was performed when indicated. All descriptive statistics are stated in median and percentages.

Main results and the role of chance

In Group A, univariate analysis showed that pregnancies were associated with lower female (41 vs 42) and male age (40 vs 43.5), administering long agonist versus antagonist protocol (73% vs 27%), the absence of androgen pretreatment (12% vs 88%), higher oestradiol level (7681pmol/l vs 6114pmol/l), higher number of oocytes retrieved (8 vs 4) and normally fertilized (4 vs 3), and embryo transfer on day 3 compared to 2 or 5 (all p < 0.05). The use of combined FSH/LH vs FSH only for ovarian stimulation given for 12 days at 300IU daily, higher endometrial thickness (11.3mm vs 10.6mm), IVF versus ICSI (65% vs 35%), and addition of subcutaneous progesterone for luteal support versus vaginal progesterone only (51% vs 43%) were trending towards but were not significant (p > 0.05). Multivariate logistic regression analysis revealed lower female and male age, less number of IVF cycles, and higher number of embryos transferred as independent factors contributing to pregnancy. In Group B, significant predictors of pregnancy included younger female age, higher gravidity, previous successful IVF and higher number of eggs fertilized (p < 0.05). In Group C, factors that contributed to positive pregnancy outcome included antagonist cycles versus agonist and usage of FSH and LH versus FSH alone (p > 0.05).

Limitations, reasons for caution

The retrospective nature of the study design limits control of potential confounding variables. Although there were clear trends, in a few sub-categories there were insufficient numbers to reach statistical significance. Continuing data collection is necessary to achieve adequate power for smaller groups especially Group B and C.

Wider implications of the findings

This detailed analysis will allow us to better understand the prognostic factors in women 40 and above, especially for women with extremes of ovarian reserve, who may benefit substantially from individualised care. We recommend standardisation of data collection and development of artificial intelligence algorithms to streamline management in the future.

Trial registration number

N/A

Exploring the knowledge and attitudes of women of reproductive age from the general public towards egg donation and egg sharing: a UK-based study

STUDY QUESTION

What are the knowledge and views of UK-based women towards egg donation (ED) and egg sharing (ES)?

SUMMARY ANSWER

Lacking knowledge of the practices of ED and ES could be an influential factor in donor egg shortages, rather than negative perceptions or lack of donor anonymity and financial incentives.

WHAT IS KNOWN ALREADY

The increasing age of women trying to conceive has led to donor egg shortages, with ED and ES failing to meet demand. Indeed, in recent years in the UK, ES numbers have fallen. This results in long waiting lists, forcing patients abroad for fertility treatment to take up cross border reproductive care. Previous research suggests a lack of knowledge of ED among members of the general public; however, no study has yet assessed knowledge or views of ES in the general public.

STUDY DESIGN, SIZE, DURATION

Six hundred and thirty-five UK-based women over 18 years were voluntarily recruited from social media community groups by convenience sampling. The recruitment period was from February to April 2020.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants completed a previously validated questionnaire regarding female fertility, ED and ES, including knowledge, perceptions and approval of the practices and relevant legislation. This included ranking key benefits and issues regarding egg sharing. The questionnaire was completed using the online Qualtrics survey software. Statistical analysis was conducted using SPSS.

MAIN RESULTS AND THE ROLE OF CHANCE

Regarding knowledge of ED and ES, 56.3% and 79.8%, respectively had little or no prior knowledge. Upon explanation, most approved of ED (85.8%) and ES (70.4%). A greater proportion of respondents would donate to a family member/friend (49.75%) than to an anonymous recipient (35.80%). Overall, ES was viewed less favourably than ED, with ethical and practical concerns highlighted. Women aged 18-30 years were significantly more likely to approve of egg donation practice compared to those aged >30 years (P < 0.0001). Those against ES found fears of financial coercion or negative psychological wellbeing the most concerning. About 35.8% and 49.7% would personally consider anonymous and known ED, respectively, whilst 56.7% would consider ES. Those answering in favour of egg sharing were significantly more likely to give higher benefit ratings compared to those against the practice (P < 0.001). Most agreed (55.8%) with and were not deterred to donate (60.1%) by the 'Disclosure of Donor Identity' legislation. Only 31.6% agreed with the compensatory cap; however, 52.7% would not be more motivated to donate by an increased cap.

LIMITATIONS, REASONS FOR CAUTION

There were several limitations of the study, including the use of convenience sampling and the voluntary nature of participation opening the study up to sampling and participation bias. Finally, closed questions were predominantly used to allow the generation of quantitative data and statistical analysis. However, this approach prevented opinion justification and qualitative analysis, limiting the depth of conclusions drawn.

WIDER IMPLICATIONS OF THE FINDINGS

To our knowledge, this is the first study to survey the general public's knowledge and views of ED/ES using a previously validated questionnaire. The conclusion that lack of knowledge could be contributing to the current donor shortfall in the UK demonstrates that campaigns to inform women of the practices are necessary to alleviate donor oocyte shortages.

STUDY FUNDING/COMPETING INTEREST(S)

No external funds were used for this study. The authors have no conflicts of interest.

TRIAL REGISTRATION NUMBER

NA.

Impact of socioeconomic and transport indicators on road safety during the crisis period in Europe

The risk of being involved in a road crash is typically influenced by mobility, which in turn is influenced by various socioeconomic indicators. This study aims to investigate the impact of socioeconomic and transport indicators on road safety during the economic crisis period in Europe. A database containing Human Development Index (HDI), suicides, passenger-kilometers and road fatalities per population was developed. Linear Mixed Models were applied for all the examined countries and the different groups that were selected for the period 2006-2015. The results led to the conclusion that HDI has the most important impact and its increase leads to road fatalities decrease. Moreover, the evolution of human development affects the outcomes of road crashes more than suicides and passenger-kilometers travelled. After the end of the crisis, the impact of human development is even higher. Concerning passenger-kilometers travelled, there is an increase in the relative impact on road fatalities after the end of the crisis.

A review on the motivations, decision-making factors, attitudes and experiences of couples using pre-implantation genetic testing for inherited conditions

BACKGROUND

In pre-implantation genetic testing (PGT), fertile couples undergo IVF with genetic testing of embryos to avoid conceptions with a genetic condition. There is an exponentially increasing uptake with over 600 applications listed by the Human Fertilisation and Embryology Authority in the UK. The psychological aspects of the decision-making process and the experience of PGT, however, are relatively underevaluated, with the potential to leave patients unsupported in their journeys.

OBJECTIVE AND RATIONALE

In this review, we aim to comprehensively report on every aspect of couples' experiences of PGT. We consider what motivates users, the practical and ethical decisions involved and how couples navigate the decision-making process. Additionally, we report on the social and psychological impact on couples who are actively undergoing or have completed the PGT process.

SEARCH METHODS

A systematic search of English peer-reviewed journals of three computerized databases was undertaken following PRISMA guidelines. Studies that examined the motivations, attitudes, decision-making factors and experiences of patients who have been actively engaged in the PGT process were included. No restrictions were placed on study design or date of publication. Studies examining patients using PGT in a hypothetical context or solely using PGT for aneuploidy were excluded. Qualitative data were extracted using thematic analysis.

OUTCOMES

The main outcomes were patient motivations, deciding factors and attitudes, as well as the patient experience of coming to a decision and going through PGT.Patients were primarily motivated by the desire to have a healthy child and to avoid termination of pregnancy. Those with a sick child or previous experience of termination were more likely to use PGT. Patients also felt compelled to make use of the technology available, either from a moral responsibility to do so or to avoid feelings of guilt if not. The main factors considered when deciding to use PGT were the need for IVF and the acceptability of the technology, the financial cost of the procedure and one's ethical standpoint on the creation and manipulation of embryos. There was a general consensus that PGT should be applied to lethal or severe childhood disease but less agreement on use for adult onset or variable expression conditions. There was an agreement that it should not be used to select for aesthetic traits and a frustration with the views of PGT in society. We report that couples find it difficult to consider all of the benefits and costs of PGT, resulting in ambivalence and prolonged indecision. After deciding on PGT use, we found that patients find the process extremely impractical and psychologically demanding.

WIDER IMPLICATIONS

This review aimed to summarize the current knowledge on how patients decide to use and experience PGT and to make suggestions to incorporate the findings into clinical practice. We cannot stress enough the importance of holistic evaluation of patients and thorough counselling prior to and during PGT use from a multidisciplinary team that includes geneticists, IVF clinicians, psychologists and also patient support groups. Large prospective studies using a validated psychological tool at various stages of the PGT process would provide an invaluable database for professionals to better aid patients in their decision-making and to improve the patient experience.

Exploring women's attitudes, knowledge, and intentions to use oocyte freezing for non-medical reasons: A systematic review

INTRODUCTION

Women are postponing childbearing and preventing age-related fertility decline with oocyte freezing for non-medical reasons (OFNMR). The objective of this systematic evaluation was to gain an understanding of women's attitudes and knowledge of, and intentions to use OFNMR among users of OFNMR and the general public.

MATERIAL AND METHODS

A systematic search of MEDLINE, EMBASE, and PyschINFO databases was undertaken, for studies that examined the psychosocial attitudes among women toward OFNMR. The search was limited to English language and no time restriction was set for publications. Extracted data were analyzed using thematic analysis and the study was performed according to PRISMA guidelines with prospective PROSPERO registration (CRD4201912578).

RESULTS

Overall, 35 studies met the inclusion criteria. Studies were broadly categorized into studies investigating users or potential users of OFNMR, and studies examining the views of members of the general public. Users of OFNMR have good knowledge of age-related fertility decline and awareness of the OFNMR procedure. Lack of partner was identified as the most common motivating factor to undertake OFNMR, with cost as a predominant concern. Knowledge among the general public of OFNMR is highly variable. Underestimation of age-related fertility decline is common among the general public. Intentions of women to use OFNMR also varied drastically between studies.

CONCLUSIONS

Women are predominantly motivated to freeze eggs by the lack of a suitable partner, but cost is a significant barrier. Increasing the number of women pursuing OFNMR at an earlier stage may positively impact upon the risk of future involuntary childlessness. Better information should be made available to both women and men about their fertility and options to inform their reproductive decision-making.

A systematic review exploring the patient decision-making factors and attitudes towards pre-implantation genetic testing for aneuploidy and gender selection

INTRODUCTION

Pre-implantation genetic testing for aneuploidy (PGT-A) is in high demand worldwide, with ongoing debate among medical societies as to which patient groups it should be offered. The psychological aspects for patients regarding its use, lag behind the genomic technological advances, leaving couples with limited decision-making support. The development of this technology also leads to the possibility for its utilization in gender selection. Despite the controversy surrounding these issues, very few studies have investigated the psychological aspects of patients using PGT-A.

MATERIAL AND METHODS

This systematic review provides an up-to-date analysis of the psychosocial aspects surrounding PGT for aneuploidy and sex selection, as well as decision-making factors. A systematic search of English peer-reviewed journals of three computerized databases were undertaken following PRISMA guidelines. The qualitative data were extracted using thematic analysis. PROSPERO Registration number: CRD42019126439.

RESULTS

The main outcome measures were patients' motivations, decision-making factors, attitudes and experiences surrounding the use of PGT for aneuploidy and sex selection. Ten studies were included, four for PGT-A and six for sex selection. Attitudes towards PGT-A were positive, with the main motivating factors being decreasing miscarriage rate, reducing the risk of termination of pregnancy and reducing the time to pregnancy. Consistently raised concerns regarding PGT-A were the financial burden and moral beliefs. The vast majority of patients felt sufficiently knowledgeable to make the decision; however, studies did reveal that a minority mis-interpreted certain potential benefits of PGT-A. Studies investigating PGT for sex selection predominantly reported the main motivation was to achieve gender balance within the family dynamic, with most studies finding no difference between couples using PGT for gender selection to have male or female offspring.

CONCLUSIONS

Although this systematic review was limited by the small number of studies investigating this topic, a significant minority of patients appeared to misunderstand certain benefits and limitations of PGT-A. Fertility clinics must ensure they provide adequate counseling to all patients using PGT-A. With the use of PGT-A on the rise globally, there is a need to develop decision support tools for couples who have an increasing number of genetic testing options becoming available to them.

Investigation of traffic and safety behavior of pedestrians while texting or web-surfing

Objective: More and more pedestrians use mobile phones in their daily traffic activities by the roadside or even when crossing the street. The objective of this research is to examine pedestrians' traffic and safety behavior while texting or web-surfing, when crossing signalized intersections.Methods: In order to compare the behavior of distracted and non-distracted pedestrians, an experimental process through video recording was carried out in real road conditions, in three signalized intersections in the center of Athens in Greece. Demographic and behavioral characteristics were observed, including use of mobile device. For the statistical analysis, two multiple linear regression models were developed to investigate the association of pedestrians' speed and distraction caused by mobile phone use. Additionally, binary logistic regression models were developed in order to determine the influence of distraction on pedestrians' safety characteristics and more specifically on near misses with oncoming vehicles.Results: Observers recorded crossing behaviors for 2,280 pedestrians and noticed that nearly one-fifth (16.6%) of them performed a phone-distracting activity while crossing. Distractions included texting or web-surfing (6.3%), listening to music (5.4%) and using a handheld phone (4.9%). Τhis research indicated that distraction caused by texting or web-surfing had a negative impact on pedestrians' main traffic and safety characteristics. Results pointed out that in high pedestrian traffic, distracted pedestrians who were texting or web-surfing on their mobile phone present lower speed than non-distracted pedestrians, regardless of their age, as they may be not aware of traffic conditions due to distraction and therefore, they have higher crossing times. Furthermore, their probability of a near miss increases with increasing pedestrian volume as the more pedestrians who occupy the pedestrian crossing the more difficult is for them to observe carefully the rest traffic.Conclusions: Mobile phones are integral to contemporary daily life and their use and penetration is increasing rapidly as well. For this reason, it is crucial to investigate the impacts of distracted walking on pedestrians' traffic and safety behavior. Various measures and strategies should be implemented and further research should be conducted as texting and web-surfing distraction is associated with a rather high risk.

Does cyberbullying impact youth suicidal behaviors?

Even though several youth fatal suicides have been linked with school victimization, there is lack of evidence on whether cyberbullying victimization causes students to adopt suicidal behaviors. To investigate this issue, I use exogenous state-year variation in cyberbullying laws and information on high school students from the Youth Risk Behavioral Survey within a bivariate probit framework, and complement these estimates with matching techniques. I find that cyberbullying has a strong impact on all suicidal behaviors: it increases suicidal thoughts by 14.5 percentage points and suicide attempts by 8.7 percentage points. Even if the focus is on statewide fatal suicide rates, cyberbullying still leads to significant increases in suicide mortality, with these effects being stronger for men than for women. Since cyberbullying laws have an effect on limiting cyberbullying, investing in cyberbullying-preventing strategies can improve individual health by decreasing suicide attempts, and increase the aggregate health stock by decreasing suicide rates.

What is the role of assisted reproduction technology in the management of age-related infertility?

Although in the UK the upper age limit for National Health Service (NHS) provision of in vitro fertilisation (IVF) is 39 years of age there has been an increase in number of women having fertility treatment in their 40s. However, the success rates of IVF and intra-uterine insemination (IUI) in this group remain low. Human Fertilisation and Embryology Authority (HFEA) data from 2006 showed that the live-birth rate from IVF in the UK was 11% in the age group 40-42, 4.6% in the age group 43-44 and less than 4% in women over 44. We performed a literature search for studies using terms and combinations of terms in online databases and published meta-analyses reporting the outcome of interventions in older women. This review showed that assisted reproduction technologies (ARTs) continue to have low live-birth rates in women over 40. Trials showed that assisted hatching may increase the chance of pregnancy in women with poor history. Blastocyst transfer is associated with better outcome, whereas application of pre-implantation genetic screening (PGS) in older women has not increased the success rates. It appears that, with the exception of egg-donation, ART has no answer yet to age-related decline of female fertility.

Impaired insulin-dependent glucose metabolism in granulosa-lutein cells from anovulatory women with polycystic ovaries

BACKGROUND

Insulin resistance and hyperinsulinaemia are well-recognized characteristics of anovulatory women with polycystic ovary syndrome (PCOS) but, paradoxically, steroidogenesis by PCOS granulosa cells remains responsive to insulin. The hypothesis to be tested in this study is that insulin resistance in the ovary is confined to the metabolic effects of insulin (i.e. glucose uptake and metabolism), whereas the steroidogenic action of insulin remains intact.

METHODS

Granulosa-lutein cells were obtained during IVF cycles from seven women with normal ovaries, six ovulatory women with PCO (ovPCO) and seven anovulatory women with PCO (anovPCO). Mean body mass index was in the normal range in all three groups. Granulosa-lutein cells were cultured with insulin (1, 10, 100 and 1000 ng/ml) and LH (1, 2.5 and 5 ng/ml). Media were sampled at 24 and 48 h and analysed for glucose uptake, lactate production and (48 h only) progesterone production.

RESULTS

Insulin-stimulated glucose uptake by cells from anovPCO was attenuated at higher doses of insulin (100 and 1000 ng/ml) compared with that by cells from either ovPCO (P=0.02) or controls (P=0.02). Insulin and LH stimulated lactate production in a dose-dependent manner, but insulin-dependent lactate production was markedly impaired in granulosa-lutein cells from anovPCO compared with either normal (P=0.002) or ovPCO (P<0.0001). By contrast, there was no difference in insulin-stimulated progesterone production between granulosa-lutein cells from the three ovarian types.

CONCLUSIONS

Granulosa-lutein cells from women with anovPCOS are relatively resistant to the effects of insulin-stimulated glucose uptake and utilization compared with those from normal and ovPCO, whilst maintaining normal steroidogenic output in response to physiological doses of insulin. These studies support the probability of a post-receptor, signalling pathway-specific impairment of insulin action in PCOS.

Early ovarian ageing: are women with polycystic ovaries protected?

Screening asymptomatic women in the general population for 'early ovarian ageing' will be more effective in high-risk groups. Recent findings support the hypothesis that women with polycystic ovaries (PCO) may have actually been born with a larger pool of resting follicles. The mechanism is almost certainly genetic and occurs in fetal life. If, as is widely accepted, the rate of depletion of the ovarian reserve depends primarily on the size of the remaining pool of small follicles, women with PCO will be unlikely to undergo an accelerated depletion of their follicle pool, normally seen in the late thirties, significantly earlier. In terms of asymptomatic screening for early ovarian ageing in the general population, women with PCO constitute a low-risk group and should therefore be excluded.

Early ovarian ageing

Observations from reproductive biology, epidemiology, and clinical assisted reproduction support the hypothesis that the time interval between the onset of accelerated decline of the ovarian reserve and the menopause is more or less fixed. Thus, it is estimated that women who become menopausal by the age of 45 may have experienced an accelerated decline of their fertility before the age of 32. Up to 10% of women in the general population may fall into this category, which has been described as "early ovarian ageing". Because of the long latent phase and predictable natural history, this condition is suitable for screening. High-risk groups include, women with a family history of early menopause. IVF has provided a model for the development of ovarian reserve tests, some of which appear promising as potential screening tools for the detection of early ovarian ageing in asymptomatic women in the general population.

The effectiveness of IVF in unexplained infertility: a systematic Cochrane review

BACKGROUND

IVF is an accepted treatment for unexplained infertility. The objective of this review was to determine whether, for unexplained infertility, IVF improves the probability of live birth compared with: (i) expectant management; (ii) clomiphene citrate (CC); (iii) intrauterine insemination (IUI); (iv) IUI with controlled ovarian stimulation; and (v) gamete intra-Fallopian transfer (GIFT).

METHODS

This was based on a Cochrane review. Randomized controlled trials (RCTs) which compared the effectiveness of IVF with expectant management, CC, IUI with or without controlled ovarian stimulation and GIFT were included. Patients included couples with unexplained infertility. Live birth rate per woman/couple was the main outcome measure.

RESULTS

Nine RCT were identified. Five RCTs were included in the final meta-analysis. There were no comparative data for CC and live birth rates for expectant management or GIFT. There was no significant difference in clinical pregnancy rates between IVF and expectant management. There was no evidence of a difference in live birth rates between IVF and IUI either without (OR 1.96, 95% CI 0.88 to 4.36) or with (OR 1.15, 95% CI 0.55 to 2.42) ovarian stimulation. Clinical pregnancy rates with IVF were significantly higher compared with GIFT (OR 2.14, 95% CI 1.08 to 4.22) as were the multiple pregnancy rates (OR 6.25, 95% CI 1.70 to 23.00). Clinical heterogeneity was present among the studies. There was no evidence of statistical heterogeneity.

CONCLUSIONS

The effectiveness of IVF in unexplained infertility remains unproven. Larger trials with adequate power are warranted.

Early ovarian ageing: a hypothesis. Detection and clinical relevance

An important scientific breakthrough of the 20th century, IVF helped open new horizons in medicine, such as pre-implantation genetic diagnosis and embryonic stem-cell therapy. A further contribution of assisted reproduction technology has been the better understanding of reproductive ageing. Data from IVF cycles suggest that there is a fixed time-interval between accelerated decline of fertility and the menopause. This leads to the hypothesis that a significant proportion of asymptomatic women in the early thirties may be at risk of early onset of subfertility. IVF provides a model for the development of ovarian reserve tests, some of which appear promising as potential screening tools for early ovarian ageing in the general population.

Is there a link between an extremely poor response to ovarian hyperstimulation and early ovarian failure?

BACKGROUND

It has been previously reported that a group of 12 infertile women, who had a normal baseline hormonal profile and did not respond to repeated ovarian stimulation with gonadotrophins, developed ovarian failure within a few months. Based on this observation, we carried out a controlled retrospective cohort study to examine whether non-response to ovarian stimulation is linked to early ovarian failure.

METHODS

All patients aged 35-40 years who had cancelled IVF cycles for non-response between 1991 and 1993 in our centre were asked to report on the subsequent development of menopausal symptoms, menopause or commencement of hormone replacement therapy. A control group consisted of patients with the same age and similar medical history, who had IVF the same year and responded well.

RESULTS

Eleven out of the 12 patients of the non-response group developed menopausal symptoms within 7 years, compared with only four out of 24 in the control group. Similarly, eight out of 12 non-responders either went into menopause or started using hormone replacement therapy compared with one out of 24 in the control group. Using Fisher's exact test, the differences were highly significant (P < 0.0001). The median age at development of menopausal symptoms in the study group was 40 years (range 38-45). The median time between non-response and development of menopausal symptoms was 4 years (range 1-7).

CONCLUSION

We carried out a controlled retrospective cohort study that showed a strong association between an extremely poor response to ovarian hyperstimulation and early ovarian failure.

In vitro fertilisation for unexplained subfertility

BACKGROUND

In vitro fertilisation (IVF) is now a widely accepted treatment for unexplained infertility (RCOG 1998). However, with estimated livebirth rates per cycle varying between 13% and 28%, it's effectiveness has not been rigorously evaluated in comparison with other treatments. With increasing awareness of the role of expectant management and less invasive procedures such as intrauterine insemination, concerns about multiple complications and costs associated with IVF, it is extremely important to evaluate the effectiveness of IVF against other treatment options in couples with unexplained infertility.

OBJECTIVES

The aim of this review is to determine, in the context of unexplained infertility, whether IVF improves the probability of livebirth compared with 1. expectant management 2. clomiphene citrate (CC) 3. intra uterine insemination (IUI) alone 4. IUI with controlled ovarian stimulation and 5. Gamete IntraFallopian Transfer (GIFT).

SEARCH STRATEGY

RCTs were identified using the search strategies developed for the Menstrual Disorders and Subfertility Group. See Review group for more information.

SELECTION CRITERIA

Only randomised controlled trials were included. Livebirth rate per woman was the primary outcome of interest.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed eligibility and quality of trials.

MAIN RESULTS

Nine randomised controlled trials were identified. In two we could not extract data separately for unexplained infertility cases, two were non-randomised, one reported no valid rates (included in the review and not in the meta-analysis), leaving four trials for analysis. One trial compared two different interventions (IVF versus IUI with or without ovarian stimulation) and one study compared three interventions (IVF versus IUI with ovarian stimulation and GIFT). The number of trials assessing the effectiveness of IVF with the other treatments were as follows: IVF versus expectant management (one), IVF versus IUI (one), IVF versus IUI with ovarian stimulation (two) and IVF versus GIFT (three). Livebirth rate per woman was reported in two studies and three studies determined clinical pregnancy rate per woman. Multiple pregnancy rate was reported in three trials. Two studies reported ovarian hyperstimulation syndrome (OHSS) as an outcome measure. There were no comparative data for clomiphene citrate, and no comparative data on livebirth rates for expectant management or GIFT. There was no evidence of a difference in livebirth rates between IVF and IUI either without (OR 0.51, 95% CI 0.23 to 1.1) or with (OR 0.87, 95% CI 0.42 to 1.8) ovarian stimulation. There was no evidence of a difference in clinical pregnancy rates between IVF and expectant management. There was no significant difference in the clinical pregnancy rates between IVF and GIFT (OR 0.47, 95% CI 0.24 to 0.92). There was no evidence of a difference in the multiple pregnancy rates between IVF and either IUI with ovarian stimulation (OR 1.59, 95% CI 0.68 to 3.70) or GIFT (OR 0.47, 95% CI 0.08 to 0.58). Clinical heterogeneity was present among the studies included. However, there was no evidence of statistical heterogeneity, which allowed the studies to be combined for statistical analysis.

REVIEWER'S CONCLUSIONS

Any effect of IVF relative to expectant management, clomiphene citrate, IUI with or without ovarian stimulation and GIFT in terms of livebirth rates for couples with unexplained subfertility remains unknown. The studies included are limited by their small sample size, so that even large differences might be hidden. Livebirth rates are seldom reported. Adverse effects such as multiple pregnancies and ovarian hyperstimulation syndrome have also not been reported in most studies. Larger trials with adequate power are warranted to establish the effectiveness of IVF in these women. Future trials should not only report rates per woman /couple but also include adverse effects and costs of the treatments compared as outcomes. Factors that have a major effect on these outcomes such as fertility treatment, female partner's age, duration of infertility and previous pregnancy history should also be considered.

Differences in effective dose estimation from dose-area product and entrance surface dose measurements in intravenous urography

In this study, measurements of dose-area product (DAP) and entrance surface dose (ESD) were carried out in a sample of 25 adult patients who underwent intravenous urography (IVU). These measured quantities were used to estimate the effective dose E from the IVU examination, a quantity closely correlated to radiation risk. Estimating E involves the use of conversion coefficients that have been determined for specific X-ray views in a mathematical phantom. These are obtained under conditions which are not usually met in clinical practice. As a result, the E estimates using the two different measurable quantities can be quite different. Analysis of the calculation procedure suggests that the E estimate using the DAP measurements, in addition to being more practical, could be more accurate than using ESD measurements, as DAP is sensitive to the X-ray field size settings. Furthermore, it is shown that in the absence of the appropriate equipment, a reliable E estimate can be obtained from the ESD calculated using the exposure data for each X-ray view.