Preimplantation genetic testing for aneuploidy: The management of mosaic embryos

As the resolution and accuracy of diagnostic techniques for preimplantation genetic testing for aneuploidy (PGT-A) are improving, more mosaic embryos are being identified. Several studies have provided evidence that mosaic embryos have reproductive potential for implantation and healthy live birth. Notably, mosaic embryos with less than 50% aneuploidy have yielded a live birth rate similar to euploid embryos. This concept has led to a major shift in current PGT-A practice, but further evidence and theoretically relevant data are required. Proper guidelines for selecting mosaic embryos suitable for transfer will reduce the number of discarded embryos and increase the chances of successful embryo transfer. We present an updated review of clinical outcomes and practice recommendations for the transfer of mosaic embryos using PGT-A.

Decision making processes of women who seek elective oocyte cryopreservation

PURPOSE

The aim of this study is to analyze women's opinions and their decision making processes regarding elective oocyte cryopreservation (OC).

METHODS

One hundred twenty-four women who had elective OC counseling at the CHA Seoul Fertility Center were asked to complete a survey after their first visit. Data collection regarding age, marital status, monthly income, occupation, religion, reproductive history, questions about the participant's view on their own fecundity, and future parenthood were included. The modified Reproductive Concerns After Cancer scale and the Decisional Conflict Scale were used for analysis.

RESULTS

The participants' mean age was 37.1 ± 4.8 years old. Eighty-six percent of the participants had regular periods. Ninety-two percent thought it was important to have their own biological offspring, and 86% were willing to pursue OC. Forty-nine percent appeared to have high DCS scores regarding making a decision of OC. Sixty-eight percent pursued OC, and the mean number of oocytes cryopreserved per patient was 10.5 ± 8.3. Multivariate analysis revealed that age was the only factor associated with high DCS scores (P = 0.002). Feeling less fertile than other women of same age and low DCS scores were the factors associated with pursuing OC (P = 0.02 and 0.004, respectively) after adjusting for possible confounding factors, including age.

CONCLUSIONS

Older women had more difficulties in making decisions about OC. Adjusting for age, women who thought that they were less fertile than other women of same age and those with lower decisional conflict were more likely to pursue OC. Further studies should focus on the validation of older women's decisional conflicts regarding OC.

Ion size effects on the osmotic pressure and electrocapillarity in a nanoslit: Symmetric and asymmetric ion sizes

We analyze the effect of asymmetric finite ion size in nanoconfinement in the view of osmotic pressure and electrocapillarity. When the confinement width becomes comparable with the Debye length, the overlapped electric double layer is significantly deformed by the steric effects. We derive the osmotic pressure from the modified Poisson-Boltzmann equation in a nanoslit to examine the deviation from the ideal osmotic pressure and the repulsive force on the wall considering the asymmetry of ion sizes. Then the electrocapillarity due to the steric effect is investigated under constant potential condition with the flat interface assumption. Later, the deformation by the electrocapillarity is also considered in the first order approximation.

Early gonadotropin-releasing hormone antagonist start improves follicular synchronization and pregnancy outcome as compared to the conventional antagonist protocol

OBJECTIVE

To assess whether an early GnRH antagonist start leads to better follicular synchronization and an improved clinical pregnancy rate (CPR).

METHODS

A retrospective cohort study. A total of 218 infertile women who underwent IVF between January 2011 and February 2013. The initial cohort (Cohort I) that underwent IVF between January 2011 and March 2012 included a total of 68 attempted IVF cycles. Thirty-four cycles were treated with the conventional GnRH antagonist protocol, and 34 cycles with an early GnRH antagonist start protocol. The second cohort (Cohort II) that underwent IVF between June 2012 and February 2013 included a total of 150 embryo-transfer (ET) cycles. Forty-three cycles were treated with the conventional GnRH antagonist protocol, 34 cycles with the modified early GnRH antagonist start protocol using highly purified human menopause gonadotropin and an addition of GnRH agonist to the luteal phase support, and 73 cycles with the GnRH agonist long protocol.

RESULTS

The analysis of Cohort I showed that the number of mature oocytes retrieved was significantly higher in the early GnRH antagonist start cycles than in the conventional antagonist cycles (11.9 vs. 8.2, p=0.04). The analysis of Cohort II revealed higher but non-significant CPR/ET in the modified early GnRH antagonist start cycles (41.2%) than in the conventional antagonist cycles (30.2%), which was comparable to that of the GnRH agonist long protocol cycles (39.7%).

CONCLUSION

The modified early antagonist start protocol may improve the mature oocyte yield, possibly via enhanced follicular synchronization, while resulting in superior CPR as compared to the conventional antagonist protocol, which needs to be studied further in prospective randomized controlled trials.

Resistance of uterine radial artery blood flow was correlated with peripheral blood NK cell fraction and improved with low molecular weight heparin therapy in women with unexplained recurrent pregnancy loss

PROBLEM

To investigate whether peripheral blood natural killer (pbNK) cell levels are associated with uterine blood flow, and low molecular weight heparin (LMWH) treatment is effective to improve uterine blood flow in women with decreased uterine blood flow and unexplained recurrent pregnancy loss (RPL).

METHOD OF STUDY

This was a prospective controlled study. Study population included 33 pregnant women (between 5 and 7 weeks gestation) with ≥ 2 RPL and controls were 47 healthy pregnant women. pbNK cell fractions (CD3(-)/56(+)/16(+)) of peripheral blood mononuclear cells were measured by flow cytometry. Uterine color-pulsed Doppler ultrasound was performed to evaluate uterine radial artery resistance index (URa-RI). In RPL women with elevated URa-RI (≥ 0.5), LMWH (ranges 40-60 mg/day) was administered subcutaneously daily and URa-RI was reassessed 1 week later. Pregnancy outcome was analyzed at 12 weeks gestation.

RESULTS

URa-RI was significantly higher in pregnant women with RPL than controls (0.60 ± 0.14 versus 0.54 ± 0.12, P = 0.039). In pregnant women with RPL, pbNK cell fractions displayed a positive correlation with URa-RI (Pearson's r = 0.429, P = 0.013). URa-RI was significantly decreased 1 week after LMWH treatment as compared to that of pretreatment (pretreatment RI: 0.65 ± 0.11 versus post-treatment RI: 0.56 ± 0.13, P = 0.011). Pregnancy outcome of RPL women with LMWH treatment was not different from that of pregnant controls (73.3% versus 85.0%, P = NS).

CONCLUSION

Increased pbNK cells are associated with decreased uterine radial artery blood flow. LMWH treatment effectively decreases URa-RI with improved pregnancy outcome in women with RPLs and elevated URa-RI. A larger scale study is needed to verify these findings.

The evaluation of combined chemical and physical treatments on the reduction of resident microorganisms and Salmonella Typhimurium attached to chicken skin

This study was conducted to evaluate the efficacy of sodium hypochlorite (NaOCl, 0-200 mg/kg), thiamine dilauryl sulfate (TDS, 1,000 mg/kg), and ultrasound (37 kHz, 380 W) on reducing Salmonella Typhimurim, mesophilic aerobic bacteria (MAB), and coliforms on chicken skin. Chemical and physical treatments were applied for 5 min either singly or jointly, and Salmonella previously inoculated on chicken skin were quantitatively assessed using brilliant green agar, and the populations of MAB and coliforms in the native flora were enumerated using plate count agar and violet red bile agar, respectively. In the evaluation of bacterial attachment/detachment, chicken skin was quantitatively assessed for loosely, intermediately, and tightly attached bacteria. The treatment effects on bacteria detachment were also visualized using field emission scanning electron microscopy. In addition, color and textural properties of the skin after treatments were evaluated using a color difference meter and texture analyzer. Antimicrobial activity of NaOCl increased as the NaOCl concentration was increased, especially for loosely attached cells. The combination of 200 mg/kg NaOCl and ultrasound (NaOCl/ultrasound) significant reduced loosely, intermediately, and tightly attached bacteria populations by 0.75 to 0.47, 0.43 to 0.41, and 0.83 to 0.54 log cfu/g for MAB, coliforms, and Salmonella Typhimurium, respectively. However, the combination of NaOCl and TDS (NaOCl/TDS) did not sufficiently reduce those cells on chicken skins, except for loosely attached MAB and coliforms. The NaOCl/ultrasound combination produced a higher reduction in numbers of inoculated and native bacteria flora than any single application, with no negative effect on skin color or texture. Generally, the loosely attached bacteria were less resistant to the chemical and physical treatments than the intermediately and tightly attached bacteria in chicken skin, presumably due to their location in deeper skin layer and crevices. Further research is needed to investigate how the intermediately and tightly attached microorganisms can be effectively eliminated from chicken skin.

Preimplantation genetic diagnosis for Charcot-Marie-Tooth disease

Objective

Preimplantation genetic diagnosis (PGD) is an assisted reproductive technique for couples carrying genetic risks. Charcot-Marie-Tooth (CMT) disease is the most common hereditary neuropathy, with a prevalence rate of 1/2,500. In this study, we report on our experience with PGD cycles performed for CMT types 1A and 2F.

Methods

Before clinical PGD, we assessed the amplification rate and allele drop-out (ADO) rate of multiplex fluorescent polymerase chain reaction (PCR) followed by fragment analysis or sequencing using single lymphocytes. We performed six cycles of PGD for CMT1A and one cycle for CMT2F.

Results

Two duplex and two triplex protocols were developed according to the available markers for each CMT1A couple. Depending on the PCR protocols, the amplification rates and ADO rates ranged from 90.0% to 98.3% and 0.0% to 11.1%, respectively. For CMT2F, the amplification rates and ADO rates were 93.3% and 4.8%, respectively. In case of CMT1A, 60 out of 63 embryos (95.2%) were diagnosed and 13 out of 21 unaffected embryos were transferred in five cycles. Two pregnancies were achieved and three babies were delivered without any complications. In the case of CMT2F, a total of eight embryos were analyzed and diagnosed. Seven embryos were diagnosed as unaffected and four embryos were transferred, resulting in a twin pregnancy. Two healthy babies were delivered.

Conclusion

This is the first report of successful pregnancy and delivery after specific PGD for CMT disease in Korea. Our PGD procedure could provide healthy babies to couples with a high risk of transmitting genetic diseases.

Can high serum anti-Müllerian hormone levels predict the phenotypes of polycystic ovary syndrome (PCOS) and metabolic disturbances in PCOS patients?

OBJECTIVE

To evaluate correlations between serum anti-Müllerian hormone (AMH) levels, phenotypes of polycystic ovary syndrome (PCOS), obesity, and metabolic parameters in patients with PCOS.

METHODS

A total of 175 patients with PCOS were diagnosed according to the Rotterdam Consensus were included. Exclusion criteria were age over 40, FSH>25 mIU/mL, and 17a-OHP>1.5 ng/mL. The Phenotypes of PCOS were divided into a severe form (oligo-anovulation, ANOV/hyperandrogenism/polycystic ovary morphology [PCOM]; n=59) and a mild form without HA (ANOV/PCOM, n=105). The serum AMH levels were classified into 3 groups (<5 vs. 5-10 vs. >10 ng/mL). Obesity was defined as body mass index (BMI) ≥25 kg/m(2) (n=34).

RESULTS

The mean age was 25.9±5.7 year and mean AMH level was 10.1±5.4 ng/mL. The BMI (kg/m(2)) was higher in group 1 (24.2±6.3) than in group 2 (21.9±4.3, p=0.046) or group 3 (21.6±3.3, p=0.019). There was no difference among the three groups in age, menstrual interval, antral follicle counts, androgens, or other metabolic parameters. The obesity group showed significantly lower AMH (7.7±3.9 ng/mL vs. 10.7±5.6 ng/mL), p=0.004) and low-density lipoprotein levels (93.1±21.2 mg/dL vs. 107.5±39.3 mg/dL, p=0.031), and showed higher total T (0.74±0.59 ng/mL vs. 0.47±0.36 ng/mL, p=0.001), free T (2.01±1.9 vs. 1.04±0.8 pg/mL, p=0.0001), and free androgen index (6.2±7.9 vs. 3.5±3.0, p=0.003). After controlling for age factors and BMI, the serum AMH levles did not show any significant correlations with other hormonal or metabolic parmeters.

CONCLUSION

For PCOS patients under the age 40, serum AMH is not negatively correlated with age. High serum AMH levels can not predict the phenotype of PCOS and metabolic disturbances in PCOS patients in the non-obese group. Further study might be needed to define the relation more clearly.

The effectiveness of earlier oocyte retrieval in the case of a premature luteinizing hormone surge on hCG day in in vitro fertilization-embryo transfer cycles

Objective

To evaluate the efficacy of earlier oocyte retrieval in IVF patients with a premature LH surge on hCG day.

Methods

One hundred forty IVF patients (164 cycles) with premature LH surge on hCG day were included, retrospectively. We divided them into 2 study groups: LH surge with timed ovum pick-up (OPU) 36 hours after hCG injection (group B, 129 premature cycles), and LH surge with earlier OPU within 36 hours after hCG injection (group C, 35 cycles). Control groups were tubal factor infertility without premature LH surge (group A, 143 cycles).

Results

The mean age (year) was statistically higher in group C than in groups A or B (38.2±5.4 vs. 36.2±4.2 vs. 36.8±4.9, respectively; p=0.012). The serum LH levels (mIU/mL) on hCG day were significantly higher in group B and C than in group A (22.7±14.9 vs. 30.3±15.9 vs. 3.2±2.9, respectively; p>0.001). Among groups A, B, and C, 4.9%, 31.7%, and 51.4% of the cycles, respectively, had no oocytes, and the overall rates of cycle cancellation (OPU cancellation, no oocyte, or no embryos transferrable) were 15.4%, 65.9%, and 74.3%, respectively. The fertilization rate (%) was significantly higher in group B than in group C (73.2±38.9 vs. 47.8±42.9, p=0.024). The clinical pregnancy rate was significantly higher in group C than in groups A and B (44.4% vs. 27.3% vs. 9.1%, respectively, p=0.021). However, the miscarriage rate was also higher in group C than in group B (22% vs. 0%, respectively, p=0.026).

Conclusion

Earlier OPU may not be effective in reducing the risk of cycle cancellation in patients with premature LH surge on hCG day. A larger scale study will be required to reveal the effectiveness of earlier ovum retrieval with premature LH surge.

Electric double layer at the interface of ionic liquid-dielectric liquid under electric field

The structure of the electric double layer (EDL) is analyzed in order to understand the electromechanical behavior of the interface of ionic liquid-dielectric liquid. The modified Poisson-Boltzmann equation proposed by Bazant et al. is solved to see the crowding and the overscreening effects that are the characteristics of an ionic liquid (Bazant, M. Z.; Storey, B. D.; Kornyshev, A. A. Double layer in ionic liquids: Overscreening versus crowding. Phys. Rev. Lett. 2011, 106, 046102.). From the simple one-dimensional (1-D) analysis, it is found that the changes of the composition and the material properties in the EDL are negligible except under some extreme conditions such as strong electric field over O(10(8)) V/m. From the electromechanical view points, an ionic liquid behaves like a pure conductor at the interface with a dielectric liquid. Based on these findings, three specific application problems are considered. In the first, a new method is suggested for measuring the interfacial tension of an ionic liquid-dielectric liquid system. The deformation of a charged ionic liquid droplet translating between two electrodes is used for this measurement. The second is for the Taylor cone problem, which includes an extreme electric field condition near the tip. The size of the critical region, where the EDL effect should be considered, is estimated by using the 1-D analysis result. Numerical computation is also performed to see the profiles of electric potential and the electric stress along the interface of the Taylor cone. Lastly, the electrowetting problem of the ionic liquid is considered. The discrepancies in the results of previous workers are interpreted by using the results of the present work. It is shown that all the results might be consistent if the leaking of the dielectric layer and/or the adsorption of ions is considered.

Comparison of assisted reproductive technology outcomes in infertile women with polycystic ovary syndrome: In vitro maturation, GnRH agonist, and GnRH antagonist cycles

OBJECTIVE

We compared the assisted reproductive technology (ART) outcomes among infertile women with polycystic ovary syndrome (PCOS) treated with IVM, conventional IVF, GnRH agonist, and GnRH antagonist cycles.

METHODS

The prospective study included a total of 67 cycles in 61 infertile women with PCOS. The women with PCOS were randomized into three IVF protocols: IVM/IVF with FSH and hCG priming with immature oocyte retrieval 38 hours later (group A, 14 cycles), GnRH agonist long protocol (group B, 14 cycles), and GnRH antagonist multi-dose flexible protocol (group C, 39 cycles). IVF outcomes, such as clinical pregnancy rate (CPR), implantation rate (IR), miscarriage rate (MR), and live birth rate (LBR), were compared among the three groups.

RESULTS

Age, BMI, and basal FSH and LH levels did not differ among the three groups. The number of retrieved oocytes and 2 pronucleus embryos was significantly lower in group A compared with groups B and C. The CPR, IR, MR, and LBR per embryo transfer showed no differences among the three groups. There was no incidence of ovarian hyperstimulation syndrome in group A.

CONCLUSION

The IR, MR, and LBR in the IVM cycles were comparable to those of the GnRH agonist and GnRH antagonist cycles. The IVM protocol, FSH and hCG priming with oocyte retrieval 38 hours later, is an effective ART option that is comparable with conventional IVF for infertile women with PCOS.

Duplication of intrachromosomal insertion segments 4q32→q35 confirmed by comparative genomic hybridization and fluorescent in situ hybridization

A 35-year-old man with infertility was referred for chromosomal analysis. In routine cytogenetic analysis, the patient was seen to have additional material of unknown origin on the terminal region of the short arm of chromosome 4. To determine the origin of the unknown material, we carried out high-resolution banding, comparative genomic hybridization (CGH), and FISH. CGH showed a gain of signal on the region of 4q32→q35. FISH using whole chromosome painting and subtelomeric region probes for chromosome 4 confirmed the aberrant chromosome as an intrachromosomal insertion duplication of 4q32→q35. Duplication often leads to some phenotypic abnormalities; however, our patient showed an almost normal phenotype except for congenital dysfunction in spermatogenesis.

Serum anti-Müllerian hormone is a better predictor of ovarian response than FSH and age in IVF patients with endometriosis

Objective

To evaluate the ability of serum anti-Müllerian hormone (AMH), FSH, and age to clinically predict ovarian response to controlled ovarian hyperstimulation (COH) in IVF patients with endometriosis.

Methods

We evaluated 91 COH cycles, including 43 cycles with endometriosis (group I) and 48 cycles with male factor infertility (group II) from January to December, 2010. Patients were classified into study groups based on their surgical history of endometriosis-group Ia (without surgical history, n=16), group Ib (with a surgical history, n=27).

Results

The mean age was not significantly different between group I and group II. However, AMH and FSH were significantly different between group I and group II (1.9±1.9 ng/mL vs. 4.1±2.9 ng/mL, p<0.01; 13.1±7.2 mIU/mL vs. 8.6±3.3 mIU/mL, p<0.01). Furthermore, the number of retrieved oocytes and the number of matured oocytes were significantly lower in group I than in group II. In group II, AMH and FSH as well as age were significant predictors of retrieved oocytes on univariate analysis. Only the serum AMH level was a significant predictor of poor ovarian response in women with endometriosis.

Conclusion

Serum AMH may be a better predictor of the ovarian response of COH in patients with endometriosis than basal FSH or age. AMH level can be considered a useful clinical predictor of poor ovarian response in endometriosis patients.

Multiple displacement amplification for preimplantation genetic diagnosis of fragile X syndrome

Preimplantation genetic diagnosis (PGD) has become an assisted reproductive technique for couples that have genetic risks. Despite the many advantages provided by PGD, there are several problems, including amplification failure, allele drop-out and amplification inefficiency. We evaluated multiple displacement amplification (MDA) for PGD of the fragile X syndrome. Whole genome amplification was performed using MDA. MDA products were subjected to fluorescent PCR of fragile X mental retardation-1 (FMR1) CGG repeats, amelogenin and two polymorphic markers. In the pre-clinical tests, the amplification rates of the FMR1 CGG repeat, DXS1215 and FRAXAC1 were 84.2, 87.5 and 75.0%, respectively, while the allele dropout rates were 31.3, 57.1 and 50.0%, respectively. In two PGD treatment cycles, 20 embryos among 30 embryos were successfully diagnosed as 10 normal embryos, four mutated embryos and six heterozygous carriers. Three healthy embryos were transferred to the uterus; however, no clinical pregnancy was achieved. Our data indicate that MDA and fluorescent PCR with four loci can be successfully applied to PGD for fragile X syndrome. Advanced methods for amplification of minuscule amounts of DNA could improve the sensitivity and reliability of PGD for complicated single gene disorders.

Serum anti-Müllerian hormone levels as a predictor of the ovarian response and IVF outcomes

Objective

The aim of this study was to investigate whether anti-Mullerian hormone (AMH) levels could be predict ovarian poor/hyper response and IVF cycle outcome.

Methods

Between May 2010 and January 2011, serum AMH levels were evaluated with retrospective analysis. Three hundred seventy infertile women undergoing 461 IVF cycles between the ages of 20 and 42 were studied. We defined the poor response as the number of oocytes retrieved was equal or less than 3, and the hyper response as more than 25 oocytes retrieved. Serum AMH was measured by commercial enzyme-linked immunoassay.

Results

The number of oocytes retrieved was more correlated with the serum AMH level (r=0.781, p<0.01) than serum FSH (r=-0.412, p<0.01). The cut-off value of serum AMH levels for poor response was 1.05 ng/mL (receiver operating characteristic [ROC] curves/area under the curve [AUC], ROC_AUC=0.85, sensitivity 74%, specificity 87%). Hyper response cut-off value was 3.55 ng/mL (ROC_AUC=0.91, sensitivity 94%, specificity 81%). When the study group was divided according to the serum AMH levels (low: <1.05 ng/mL, middle: 1.05 ng/mL - 3.55 ng/mL, high: >3.55 ng/mL), the groups showed no statistical differences in mature oocyte rates (71.6% vs. 76.5% vs. 74.8%) or fertilization rates (76.9% vs. 76.6% vs. 73.8%), but showed significant differences in clinical pregnancy rates (21.7% vs. 24.1% vs. 40.8%, p=0.017).

Conclusion

The serum AMH level can be used to predict the number of oocytes retrieved in patients, distinguishing poor and high responders.

Comparison of mild ovarian stimulation with conventional ovarian stimulation in poor responders

Objective

To compare the IVF outcomes of mild ovarian stimulation with conventional ovarian stimulation in poor responders.

Methods

From 2004 to 2009, 389 IVF cycles in 285 women showed poor responses (defined as either a basal FSH level ≥12 mIU/mL, or the number of retrieved oocytes ≤3, or serum E₂ level on hCG day <500 pg/mL) were analyzed, retrospectively. In total, 119 cycles with mild ovarian stimulation (m-IVF) and 270 cycles with conventional ovarian stimulation (c-IVF) were included. Both groups were divided based on their age, into groups over and under 37 years old.

Results

The m-IVF group was lower than the c-IVF group in the duration of stimulation, total doses of gonadotropins used, serum E₂ level on hCG day, the number of retrieved oocytes, and the number of mature oocytes. However, there was no significant difference in the number of good embryos, the number of transferred embryos, the cancellation rate, or the clinical pregnancy rate. In the m-IVF group over 37 years old, the clinical pregnancy rate and live birth rate were higher when compared with the c-IVF group, but this result was not statistically significant.

Conclusion

In poor responder groups, mild ovarian stimulation is more cost effective and patient friendly than conventional IVF. Therefore, we suggest that mild ovarian stimulation could be considered for poor responders over 37 years old.

Laparoscopic management of early primary peritoneal pregnancy: a case report

Peritoneal pregnancy is an implantation in the peritoneal cavity exclusive of tubal, ovarian, or intra-ligamentary implantations. This is a rare obstetric complication with high maternal mortality and even higher perinatal mortality, and secondary type was most common. Risk factors for peritoneal pregnancy are previous history of extrauterine pregnancy or tubal surgery pelvic post-inflammatory status or presence of an intra-uterine device. As it is a life-threatening condition, expectant management carries a risk of sudden life-threatening intra-abdominal bleeding and a generally poor fetal prognosis. So, when it is recognized, immediate termination of pregnancy is usually recommended. Early diagnosis of peritoneal pregnancy is difficult, but is important by their life threatening progress course to patients. Recently, we experienced primary peritoneal pregnancy which meets both the original and modified criteria. In this paper, we reported the case of early diagnosed and successfully treated peritoneal pregnancy despite of their diagnosis was incidentally.

Age specific serum anti-Müllerian hormone levels in 1,298 Korean women with regular menstruation

Objective

To determine the age specific serum anti-Müllerian hormone (AMH) reference values in Korean women with regular menstruation.

Methods

Between May, 2010 and January, 2011, the serum AMH levels were evaluated in a total of 1,298 women who have regular menstrual cycles aged between 20 and 50 years. Women were classified into 6 categories by age: 20-31 years, 32-34 years, 35-37 years, 38-40 years, 41-43 years, above 43 years. Measurement of serum AMH was measured by commercial enzyme-linked immunoassay.

Results

The serum AMH levels correlated negatively with age. The median AMH level of each age group was 4.20 ng/mL, 3.70 ng/mL, 2.60 ng/mL, 1.50 ng/mL, 1.30 ng/mL, and 0.60 ng/mL, respectively. The AMH values in the lower 5th percentile of each age group were 1.19 ng/mL, 0.60 ng/mL, 0.42 ng/mL, 0.27 ng/mL, 0.14 ng/mL, and 0.10 ng/mL, respectively.

Conclusion

This study determined reference values of serum AMH in Korean women with regular menstruation. These values can be applied to clinical evaluation and treatment of infertile women.

Adverse pregnancy outcomes with assisted reproductive technology in non-obese women with polycystic ovary syndrome: a case-control study

OBJECTIVE

To investigate adverse pregnancy outcomes in non-obese women with polycystic ovary syndrome (PCOS) compared with obese-PCOS and control groups.

METHODS

Women with PCOS who underwent assisted reproductive technology (ART) from August, 2003 to December, 2007, were considered. A total of 336 women with PCOS were included in the study group and 1,003 infertile women who had tubal factor as an indication for ART were collected as controls. They were divided into four groups: a non-obese PCOS group, obese-PCOS group, non-obese tubal factor group, and obese tubal factor group, with obesity defined by a body mass index over 25 kg/m(2), and reviewed focusing on the basal characteristics, ART outcomes, and adverse pregnancy outcomes.

RESULTS

There was no difference among the groups' the clinical pregnancy rate or live birth rate. Regarding adverse pregnancy outcomes, the miscarriage rate, multiple pregnancy rate, and prevalence of preterm delivery and pregnancy induced hypertension were not different among the four groups. The incidence of small for gestational age infant was higher in the PCOS groups than the tubal factor groups (p<0.02). On the other hand, the morbidity of gestational diabetes mellitus (GDM) was not high in the non-obese PCOS group but was in the obese groups. And in the obese PCOS group, the newborns were heavier than in the other groups (p<0.02).

CONCLUSION

Non-obese PCOS presents many differences compared with obese PCOS, not only in the IVF-parameters but also in the morbidity of adverse pregnancy outcomes, especially in GDM and fetal macrosomia.

Effects of Guided imagery on Stress and Anxiety of Women Receiving in Vitro Fertilization

PURPOSE

The purpose of this study was to identify effects of guided imagery on stress including cognitive, affective, marital and social, and anxiety among women receiving in vitro fertilization (IVF).

METHODS

Data were collected between April, 21 and June, 17, 2008. The participants in this study were 57 women (26 for the experimental group, 31 for the control group) receiving IVF for primary or secondary infertility in one of the outpatient infertility centers in Seoul. The guided imagery (Suk, 2001) was provided through audio CD to the experimental group by themselves 8 minutes per day for 2 weeks. Data were analyzed by SPSS 12.0 windows program.

RESULTS

After guided imagery, the experimental group showed significantly lower affective stress and total stress scores. Anxiety scores increased significantly in the control group, but not in the experimental group after treatment.

CONCLUSION

The findings suggest that guided imagery is an effective nursing intervention for reducing stress especially affective stress and anxiety among infertile women receiving IVF in outpatient infertility center.

Does blastomere biopsy in preimplantation genetic diagnosis affect early serum β-hCG levels?

Objective

To determine whether the serum β-human chorionic gonadotropin (hCG) profile following preimplantation genetic diagnosis (PGD) is lower than that of intracytoplasmic sperm injection (ICSI) cycles.

Methods

A total of 129 PGD cycles and 1,161 age-matched ICSI cycles, which resulted in pregnancy (serum β-hCG≥5 mIU/mL) on post-ovulation day (POD) 12 were included. We compared the mean serum β-hCG levels on POD 12, 14, 21, and 28, doubling time of serum hCG, and created a cut-off value for predicting a singleton pregnancy in each group.

Results

The mean serum β-hCG concentration of the PGD group was significantly lower than that of the control group on POD 12, 14, and 21. The doubling time of serum β-hCG at each time interval showed no significant difference. The cut-off-value of serum β-hCG for predicting a single viable pregnancy was 32.5 mIU/mL on POD 12 and 113.5 mIU/mL on POD 14 for the PGD group, which was lower than that for the control group.

Conclusion

Blastomere biopsy may decrease the β-hCG-producing activity of the trophoblasts, especially in early pregnancy. Setting a lower cut-off value of serum β-hCG for predicting pregnancy outcomes in PGD may be needed.

Predictive value of sperm motility characteristics assessed by computer-assisted sperm analysis in intrauterine insemination with superovulation in couples with unexplained infertility

Objective

To determine whether characteristics of sperm motility obtained by computer-assisted sperm analysis (CASA) could predict pregnancy after intrauterine insemination (IUI) in couples with unexplained infertility.

Methods

Three hundred eighty-three cycles of intrauterine insemination with superovulation were retrospectively analyzed. Semen analysis was performed with CASA before and after swim-up and the parameters were compared between pregnant and non-pregnant women.

Results

The pregnancy rate per cycle was 14.1%. Pregnant and non-pregnant women were comparable in terms of age, infertility duration, the number of dominant follicles. While sperm concentration, motility, and parameters such as average path velocity (VAP) and percentage rapid (RAPID) before semen preparation were significantly different between the pregnancy and non-pregnancy groups, there were no differences in sperm parameters when comparing the two groups after preparation. Using a receiver operating characteristic curve to measure sensitivity and specificity, the optimal threshold value for the predictors of pregnancy was revealed to be a concentration of ≥111×10⁶/mL, a motility of ≥51.4%, and RAPID ≥30.1% before preparation for IUI.

Conclusion

Sperm parameters including concentration, motility, and RAPID before sperm preparation could have predictive value for pregnancy outcome after intrauterine insemination with superovulation in couples with unexplained infertility, and would be helpful when counseling patients before they make the decision to proceed with IVF/ICSI-ET.

Clinical outcomes of preimplantation genetic diagnosis (PGD) and analysis of meiotic segregation modes in reciprocal translocation carriers

Balanced reciprocal translocation is the most common chromosome rearrangement, with an incidence of 1 out of 625 newborns. In reciprocal translocation carriers, genetically unbalanced gametes can be produced through three principal modes of segregation: adjacent-1, adjacent-2 and 3:1. In this study, we reviewed 133 cycles of preimplantation genetic diagnosis (PGD) for 65 couples with reciprocal translocation and analyzed pregnancy outcomes and the meiotic segregation mode of gametes of the translocation carriers using fluorescent in situ hybridization (FISH). We found that 285 of 1,508 embryos (18.9%) were normal or balanced. Thirty-three clinical pregnancies, including eight spontaneous abortions (21.6% per couple), were established. According to the meiotic segregation analysis, the frequencies of 3:1 and 4:0 segregation modes were significantly higher (P < 0.05) in female carriers, and the frequencies of adjacent-1 and chaotic segregation modes were significantly higher (P < 0.05) in male carriers. Our results indicate that meiotic segregation might be affected by the carrier's sex but not by the carrier's age or breakpoints.

Steric effects of ions in the charge-related wetting phenomena

Steric effects of ions on the charge-related wetting phenomena are studied. Along with a general treatment, three specific problems in two-dimensional system are considered: a droplet on an electrode, a droplet on a charged surface, and an electrowetting phenomenon on a dielectric. For computation of wetting tension, the electromechanical approach is adopted with the principle of mechanical force balance for each phase. The modified Poisson-Boltzmann equation, which was originally proposed by Bikerman [Philos. Mag. 33, 384 (1942)], is adopted for the analysis of the steric effects. It is found that the steric hindrance reduces significantly both the osmotic pressure and the electrical stress near the triple contact line. This reduction results in a considerable decrease in the wetting tension when the ratio of the capacitance per unit area of the electrical double layer to that of the dielectric layer is small.

Estimation of chromosomal imbalances in preimplantation embryos from preimplantation genetic diagnosis cycles of reciprocal translocations with or without acrocentric chromosomes

OBJECTIVE

To estimate chromosomal imbalances in preimplantation embryos from reciprocal translocation carriers with or without acrocentric chromosomes (Acro-Ch) 13, 14, 15, 21, and 22 in preimplantation genetic diagnosis (PGD) cycles.

DESIGN

Fluorescence in situ hybridization was applied to PGD cycles for reciprocal translocation carriers.

SETTING

University-based centers for reproductive medicine.

PATIENT(S)

Ten and 24 patients of reciprocal translocation with and without Acro-Ch, respectively.

INTERVENTION(S)

Fluorescence in situ hybridization in biopsied blastomeres.

MAIN OUTCOME MEASURE(S)

Estimation of meiotic segregation mode in embryos from translocation carriers.

RESULT(S)

The proportion of alternative segregation for normal or balanced chromosome contents in preimplantation embryos from PGD cycles in reciprocal translocations without Acro-Ch was significantly higher than that with Acro-Ch (26.0% vs. 14.6%). The proportion of interchange trisomy in 3:1 segregation was significantly lower in reciprocal translocations without Acro-Ch than that with Acro-Ch (4.3% vs. 9.5%).

CONCLUSION(S)

This is the first report that the incidence of alternative segregation producing normal or balanced embryos was relatively low in reciprocal translocations associated with Acro-Ch. Our data may be useful to predict the possibility of normal or balanced embryos and to counsel with reciprocal translocation carriers for PGD-fluorescence in situ hybridization cycles.

A healthy live birth after successful preimplantation genetic diagnosis for carriers of complex chromosome rearrangements

OBJECTIVE

To report a live birth after successful preimplantation genetic diagnosis (PGD) for carriers of complex chromosomal rearrangements (CCRs) with translocation and deletion.

DESIGN

Fluorescent in situ hybridization (FISH) was applied to PGD for CCR carriers.

SETTING

University-based centers for reproductive medicine.

PATIENT(S)

Three CCR carriers, patient A with 46,XX,t(6;10;8)(q25.1;q21.1;q21.1), patient B with 46,X,del(X)(p22.3),t(2;18)(q14.1;q21)[48]/45,X, t(2;18)(q14.1;q21)[12], and patient C with 46,XY,t(5;13;8)(q21.2;q14.3;q24.3).

INTERVENTION(S)

Balanced or normal embryos were diagnosed by PGD and transferred.

MAIN OUTCOME MEASURE(S)

Diagnosis rate of FISH, pregnancy outcome, and karyotype of amniocentesis.

RESULT(S)

Blastomeres were biopsied from 56 embryos in four PGD cycles, and 54 embryos (96.4%) were successfully diagnosed by FISH. Among them, four embryos were diagnosed as transferable in two cycles of patient B and one cycle of patient C. After three cycles of embryo transfer, a pregnancy was achieved in the second PGD cycle of patient B, and the karyotype of amniocentesis was 46,XY,t(2;18)(q14.1;q21). A healthy baby was delivered at 40 weeks of gestation by cesarean section.

CONCLUSION(S)

This is the first report for a live birth after PGD in the CCR carriers associated with translocation and deletion, 46,X,del(X)(p22.3),t(2;18)(q14.1;q21)[48]/45,X,t(2;18)(q14.1;q21)[12]. Preimplantation genetic diagnosis for CCRs needs more consideration and advanced techniques for full karyotyping.

Outcomes of controlled ovarian hyperstimulation/in vitro fertilization for infertile patients with borderline ovarian tumor after conservative treatment

To evaluate the outcomes of controlled ovarian hyperstimulation (COH)-in vitro fertilization (IVF) such as clinical pregnancy rate (CPR), implantation rate (IR) and live birth rate (LBR) for infertile patients with borderline ovarian tumor (BOT) after conservative treatment, 10 IVF cycles in five patients from January 1999 to July 2005 were analyzed. At the time of diagnosis with BOT, the mean age of patients was 30.0 yr (range, 22-40). For 8 cycles out of 10 attempted IVF cycles, except for 2 cancellation cycles, the mean number of oocytes retrieved was 5.6 (range, 2-16) with a mean fertilization rate of 74.4%. The CPR, IR, and LBR were 50.0% (4/8 cycles), 31.6% (6/19) and 50.0% (4/8 cycles) respectively. The mean follow-up period after COH-IVF initiation was 29.6 (range, 14-61) months. A gynecological oncologist followed all patients every 3 months during the first year and every 6 months thereafter. There was no recurrence during the follow-up period. Our results suggest that COH-IVF may be acceptable for infertile patients with BOT, especially in patients with early-stage BOT after conservative treatment.

Comparison of the efficacy and safety of a new recombinant human follicle-stimulating hormone (DA-3801) with follitropin-? (Gonal-F�) in women undergoing controlled ovarian hyperstimulation for assisted reproductive technology

AIM

To compare the efficacy and safety of a new recombinant human follicle-stimulating hormone (FSH; DA-3801) with follitropin-alpha (Gonal-F) in women undergoing controlled ovarian hyperstimulation (COH) for assisted reproductive technology (ART).

METHODS

This was a phase III, multicenter, randomized, non-inferiority study. A total of 97 women were randomized to receive COH using DA-3801 (DA-3801 group, n = 49) or Gonal-F (Gonal-F group, n = 48). All subjects underwent COH using a gonadotropin-releasing hormone (GnRH) antagonist protocol. The primary efficacy endpoint was the number of oocytes retrieved, and the secondary efficacy endpoints included the total dose of FSH, the duration of stimulation, the serum estradiol levels on the day of human chorionic gonadotropin (hCG) administration, and the fertilization, implantation and pregnancy rates. Safety was evaluated using pre- and post-treatment laboratory tests and all adverse events were recorded.

RESULTS

The number of oocytes retrieved was 13.0 +/- 6.2 (DA-3801) versus 10.6 +/- 6.7 (Gonal-F) in the intention-to-treat (ITT) population, and 12.7 +/- 6.4 (DA-3801) versus 11.0 +/- 7.1 (Gonal-F) in the per-protocol (PP) population. The non-inferiority of DA-3801 was demonstrated with differences of 2.3 +/- 6.5 (95% confidence interval [CI] = 0.13, infinity) and 1.7 +/- 6.7 (95% CI = -0.74, infinity), respectively, in the ITT and PP populations. The total dose of FSH used (1789.8 +/- 465.5 vs 2055.6 +/- 646.7 pg/mL, P = 0.027) and duration of stimulation (8.3 +/- 1.4 vs 9.1 +/- 1.9 days, P = 0.036) in the ITT population were significantly lower in the DA-3801 group. Other secondary efficacy endpoints, including pregnancy and implantation rates and the incidence and severity of adverse events, were comparable between the two groups.

CONCLUSIONS

The results of this study demonstrate that DA-3801 is not inferior to follitropin-alpha in terms of its efficacy and safety in women undergoing COH for ART.

Deformation and motion of a charged conducting drop in a dielectric liquid under a nonuniform electric field

As a tool for transporting a drop inside another fluid, a charged conducting drop driven by Coulombic force is considered. Specifically, deformation and motion of a charged conducting drop under nonuniform electric fields are studied using the perturbation method. For simplicity in analysis, the applied electric field is assumed to be expressed as the sum of a uniform field and a linear field and the flow is assumed to be in the Stokes flow range. The deformed drop shape due to electrical stress is computed to the first order of the electrical Weber number (W). Then the electric force and the hydrodynamic drag are computed to derive the formula of the translation velocity, which is valid up to O(W). Several important results have also been obtained for the effect of drop deformation on the electric and hydrodynamic forces exerted on the drop.

Preimplantation genetic diagnosis for ornithine transcarbamylase deficiency by simultaneous analysis of duplex-nested PCR and fluorescence in situ hybridization: a case report

Ornithine transcarbamylase (OTC) deficiency is an X-linked co-dominant disorder. A couple, with a previous history of a neonatal death and a therapeutical termination due to OTC deficiency, was referred to our center for preimplantation genetic diagnosis (PGD). The female partner has a nonsense mutation in the exon 9 of the OTC gene (R320X). We carried out nested polymerase chain reaction (PCR) for R320X mutation and fluorescence in situ hybridization (FISH) for aneuploidy screening. Among a total of 11 embryos, two blastomeres per embryo from 9 embryos were biopsied and analyzed by duplex-nested PCR and FISH, and one blastomere per embryo from 2 embryos by only duplex-nested PCR. As a result of PCR and restriction fragment length polymorphism analysis, four embryos were diagnosed as unaffected embryos having the normal OTC gene. Among these embryos, only one embryo was confirmed as euploidy for chromosome X, Y and 18 by FISH analysis. A single normal embryo was transferred to the mother, yielding an unaffected pregnancy and birth of a healthy boy. Based on our results, PCR for mutation loci and FISH for aneuploidy screening with two blastomeres from an embryo could provide higher accuracy for the selection of genetically and chromosomally normal embryos in the PGD for single gene defects.

Expression of CD44s, vascular endothelial growth factor, matrix metalloproteinase-2 and Ki-67 in peritoneal, rectovaginal and ovarian endometriosis

OBJECTIVE

To understand the pathogenetic mechanisms of endometriosis by examining the expression of adhesion molecules (CD44s), angiogenic factor (VEGF) and matrix protease and to perform Ki-67 labeling for evaluation of proliferative activity.

STUDY DESIGN

Twenty-nine peritoneal endometriosis lesions (9 red, 12 black and 8 white), 11 rectovaginal and 22 ovarian were obtained. Immunohistochemical staining was performed with antibodies for CD44, VEGF, MMP-2 and Ki-67.

RESULTS

CD44s were expressed mainly in stroma and showed higher expression in glandular epithelium of peritoneal endometriosis than in rectovaginal and ovarian endometriosis. The stroma in red and white lesions showed higher MMP-2 expression than in black lesions. The stromal cells in rectovaginal endometriosis showed significantly lower expression of Ki-67 (p = 0.002) than in peritoneal and ovarian endometriosis. When endometriosis was analyzed according to the revised American Fertility Society classification, Ki-67 expression was high in glandular epithelium in stages I and II (p = 0.025), whereas MMP-2 expression in stromal cells was significantly high (p < 0.001) in stages III and IV.

CONCLUSION

CD44, VEGF and MMP-2 were consistently expressed in endometriotic epithelial and stromal cells. White lesions of peritoneal endometriosis should not be regarded as an inactive state, and MMP-2 in stromal cells may be responsible for the progression of endometriosis. The macroscopic appearance of endometriotic lesions should not be used as a criterion to define the degree of activity.

Identification of a novel single nucleotide polymorphism of HADHA gene at a referred primer-binding site during pre-diagnostic tests for preimplantation genetic diagnosis

The pre-diagnostic test for preimplantation genetic diagnosis (PGD) of long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency was performed by polymerase chain reaction (PCR) and direct sequencing for hydroxyacyl-Coenzyme A dehydrogenase/3-ketoacyl-Coenzyme A thiolase/enoyl-Coenzyme A hydratase (HADHA) gene. We obtained unexpected genotyping results of HADHA gene by allele drop-out in the analysis of patients' genomic DNA samples with a referred PCR primer set. Upon further analysis with a re-designed primer set, we found a novel single nucleotide polymorphism (SNP) at the referred primer-binding site in the normal allele of HADHA gene (NT_022184, 5233296 a>t). We found that the frequency of this novel SNP was 0.064 in Korean population. Pre-diagnostic test using single lymphocytes and clinical PGD were successfully performed with the re-designed primer set. Nineteen embryos (95.0%) among 20 were successfully diagnosed to 5 homozygous mutated, 8 heterozygous carrier and 6 wild type. Among 6 normal embryos, well developed and selected 4 embryos were transferred into the mother's uterus, but a pregnancy was not achieved. We proposed that an unknown SNP at primer-binding sites would be a major cause of allele drop-out in the PGD for single gene dis-order.

Oral misoprostol and uterine rupture in the first trimester of pregnancy: A case report

We are reporting the case of a woman with 8 weeks of amenorrhea who orally received a single dose of misoprostol 400 microg at midnight for ripening of cervix before uterine evacuation of an intrauterine gestational sac containing a single fetus (6.3 weeks of gestation) without cardiac activity. The patient had severe abdominal pain an hour later. Her blood pressure was 70/40 mmHg and her abdomen was slightly distended with direct and rebound tenderness. A transvaginal ultrasonography showed a 3-cm depth of a free fluid collection in the rectouterine pouch. Her hemoglobin and hematocrit levels were of 6.5 g/dL and 18.4%, respectively. A rupture of 1.5 cm at the left uterine horn with a protruding gestational sac was identified by laparoscopy. The gestational sac was removed and hemoperitoneal collection were successfully drained. The site of uterine rupture was primarily sutured and postoperative course was satisfactory. In summary, misoprostol administered in the first trimester of pregnancy may produce uterine rupture.

Ubiquitin-specific protease activity of USP9Y, a male infertility gene on the Y chromosome

Deletions of USP9Y have been observed among infertile males with defective spermatogenesis. Therefore, the gene has been designated as a male infertility gene on the Y chromosome. However, it remains to be determined how male infertility results from deletions of this gene. In order to initiate an investigation into the cellular functions of USP9Y in male germ cell development, in the present study we characterized the enzymatic specificity of USP9Y. Our results show that both USP9Y and Fam, the mouse infertility protein Usp9x, possess a protease activity specific to ubiquitin. These results suggest that, through de-ubiquitination, USP9Y may stabilize a specific target protein that is important for male germ cell development.

Efficacy and clinical outcome of preimplantation genetic diagnosis using FISH for couples of reciprocal and Robertsonian translocations: the Korean experience

OBJECTIVE

To evaluate the efficacy and clinical outcome of preimplantation genetic diagnosis (PGD) using fluorescence in situ hybridization (FISH) for couples with chromosomal translocations.

METHODS

PGD using FISH was performed in 59 cycles of 43 couples with reciprocal translocations, and 11 cycles of 6 couples with Robertsonian translocations. The diagnostic and clinical data were reviewed in a series of 70 treatment cycles of 49 couples from January 2001 to June 2002 at Samsung Cheil Hospital, Korea.

RESULTS

A total of 1408 oocytes were retrieved, and 938 (81.7%) out of 1148 matured oocytes were fertilized by intracytoplasmic sperm injection (ICSI). Single blastomere biopsy and FISH analysis were successfully carried out in 99.3% (890/896) and 94.4% (840/890), respectively. Among 193 normal or balanced embryos, 169 embryos were transferred in 64 cycles (91.4% per started cycle). Twenty clinical pregnancies including two ectopic pregnancies and three spontaneous miscarriages (28.6% per started cycle, 31.3% per transfer cycle, 40.8% per couple) were established. Of the three spontaneous miscarriages, one was karyotyped as normal, one had an unbalanced arrangement and one was tetraploid. One case of preterm twin delivery occurred and 16 healthy babies were delivered in 12 single and 2 twin pregnancies.

CONCLUSION

The clinical outcome was successful in 28.6% (14/49) of the treated couples with translocations after PGD. The spontaneous abortion rate was significantly reduced from 95.8% (69/72) to 16.7% (3/18) in these couples.

Preoperative anxiety and propofol requirement in conscious sedation for ovum retrieval

The purpose of the present study was to evaluate the correlation among the trial number of in vitro fertilization (IVF), preoperative anxiety, and propofol requirement for conscious sedation. One hundred and twenty six Korean women undergoing oocyte retrieval were enrolled. The target-controlled infusion by the anesthesiologist was conducted with initial target propofol concentration of 2.5 microg/mL, which was manipulated until the sedation score 3 and desired clinical end point were achieved. A weak correlation was observed between visual analogue scale (VAS) anxiety and the dose of propofol required for the induction of conscious sedation (r=0.22, p=0.0192). A weak correlation was also found between VAS anxiety and the sedation time needed to reach the proper conscious sedation level for the procedure (r=0.181, p=0.0484). Multiple regression analysis showed that VAS anxiety, preoperative baseline prolactin level, and cortisol level had statistically significant effects on the propofol induction dose for target controlled conscious sedation. We concluded that the induction dose and time requirements for propofol in anesthesiologist-controlled conscious sedation be modified based on the preoperative anxiety level and the baseline blood concentration of stress hormone, cortisol and prolactin.