NSAIDs and spontaneous abortions - true effect or an indication bias?

AIM

The aim of the study was to characterize the extent of indication bias resulting from the excessive use of NSAIDs on the days preceding a spontaneous abortion to relieve pain.

METHODS

We used data from a retrospective cohort study assessing the risk for spontaneous abortions following exposure to NSAIDs. Three definitions of exposure for cases of spontaneous abortions were compared, from the first day of pregnancy until the day of spontaneous abortion and until 3 and 2 days before a spontaneous abortion. Statistical analysis was performed using multivariate time programmed Cox regression.

RESULTS

A sharp increase was observed in the dispensation of indomethacin, diclofenac and naproxen, and a milder increase was found in the use of ibuprofen during the week before a spontaneous abortion. Non- selective COX inhibitors in general and specifically diclofenac and indomethacin were found to be associated with spontaneous abortions when the exposure period was defined until the day of spontaneous abortion (hazard ratio (HR) 1.15, 95% confidence interval (CI) 1.04, 1.28; HR 1.31, 95% CI 1.08, 1.59 and HR 3.33, 95% CI 2.09, 5.29, respectively). The effect disappears by excluding exposures occurring on the day before the spontaneous abortion for non-selective COX inhibitors and on the last week before the spontaneous abortion for indomethacin. In general, decreasing HRs were found with the exclusion of exposures occurring on the days immediately before the spontaneous abortion.

CONCLUSIONS

The increased use of NSAIDs during the last few days that preceded a spontaneous abortion to relieve pain associated with the miscarriage could bias studies assessing the association between exposure to NSAIDs and spontaneous abortions.

Immortal time bias in drug safety cohort studies: spontaneous abortion following nonsteroidal antiinflammatory drug exposure

OBJECTIVE

Experimental research of drug safety in pregnancy is generally not feasible because of ethical issues. Therefore, most of the information about drug safety in general and teratogenicity in particular is obtained through observational studies, which require careful methodologic design to obtain unbiased results. Immortal time bias occurs when some cases do not "survive" sufficient time in the study, and as such, they have reduced chances of being defined as "exposed" simply because the durations of their follow-ups were shorter. For example, studies that examine the risk for spontaneous abortions in women exposed to a drug during pregnancy are susceptible to immortal time bias because the chance of drug exposure increases the longer a pregnancy lasts. Therefore, the drug tested may falsely be found protective against the outcome tested. The objective of the current study was to illustrate the extent of immortal time bias using a cohort study of pregnancies assessing the risk for spontaneous abortions following nonsteroidal antiinflammatory drug exposure.

STUDY DESIGN

We assembled 3 databases containing data on spontaneous abortions, births and drug dispensions to create the present study's cohort. The risk for spontaneous abortion was assessed using 2 statistical analysis methods that were compared for 2 definitions of exposure (dichotomous, exposed vs unexposed, regular Cox regression vs Cox regression with time-varying exposure).

RESULTS

Significant differences were found in the risk for spontaneous abortions between the 2 statistical methods, both for groups and for most specific nonsteroidal antiinflammatory drugs (nonselective Cox inhibitors - hazard ratio, 0.70; 95% confidence interval, 0.61-0.94 vs hazard ratio, 1.10; 95% confidence interval, 0.99-1.22 for dichotomous vs time-varying exposure analyses, respectively). Furthermore, a significant correlation was found between the median misclassified immortal time for each drug and the extent of the bias.

CONCLUSION

Immortal time bias can easily occur in cohort studies assessing the risk for adverse pregnancy outcomes following exposure to drugs. One way to prevent such a bias is by defining exposure only from the time of exposure during follow-up onward using a time-varying exposure analysis.

[Klinefelter syndrome: genetic aspects, characteristics and reproduction--present and future]

Klinefetter syndrome is one of the most common genetic causes of male infertility and the most common cause of primary testicular failure. Beside the infertility issue, the syndrome causes decreases in bone mass, muscle wasting, decline in cognitive ability and increases the risk of diseases such as diabetes mellitus, cancer and cardiovascular diseases. Most men are diagnosed late when fertility problems arise and some even remain undiagnosed. It is probably emerging because of the significant differences in clinical appearance and low "awareness" among primary doctors. Early diagnosis and hormone replacement therapy can significantly improve the quality of patients lives, reduce late health complications, and may even preserve their fertility for a longer period of time. In the past, men with this syndrome, especially those of the non-mosaic type, were considered as having no chance of becoming biological fathers. However today, with the technoLogical development of IVF and the ICSI (intracytoplasmatic sperm injectioni, together with testicular biopsies and sperm extractions (TESE), it is possible to help over 50% of the men who have this syndrome.

Fetal exposure to nonsteroidal anti-inflammatory drugs and spontaneous abortions

BACKGROUND

Spontaneous abortion is the most common complication of pregnancy. Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used during pregnancy. Published data are inconsistent regarding the risk of spontaneous abortion following exposure to NSAIDs.

METHODS

We performed a historical cohort study involving all women who conceived between January 2003 and December 2009 and who were admitted for delivery or spontaneous abortion at Soroka Medical Center, Clalit Health Services, Israel. A computerized database of medication dispensation was linked with 2 computerized databases containing information on births and spontaneous abortions. We constructed time-varying Cox regression models and adjusted for maternal age, diabetes mellitus, hypothyroidism, obesity, hypercoagulation or inflammatory conditions, recurrent miscarriage, in vitro fertilization of the current pregnancy, intrauterine contraceptive device, ethnic background, tobacco use and year of admission.

RESULTS

The cohort included 65,457 women who conceived during the study period; of these, 58,949 (90.1%) were admitted for a birth and 6508 (9.9%) for spontaneous abortion. A total of 4495 (6.9%) pregnant women were exposed to NSAIDs during the study period. Exposure to NSAIDs was not an independent risk factor for spontaneous abortion (nonselective cyclooxygenase [COX] inhibitors: adjusted hazard ratio [HR] 1.10, 95% confidence interval [CI] 0.99-1.22; selective COX-2 inhibitors: adjusted HR 1.43, 95% CI 0.79-2.59). There was no increased risk for specific NSAID drugs, except for a significantly increased risk with exposure to indomethacin (adjusted HR 2.8, 95% CI 1.70-4.69). We found no dose-response effect.

INTERPRETATION

We found no increased risk of spontaneous abortion following exposure to NSAIDs. Further research is needed to assess the risk following exposure to selective COX-2 inhibitors.

Glial cell line-derived neurotrophic factor (GDNF) induced migration of spermatogonial cells in vitro via MEK and NF-kB pathways

Glial cell line-derived neurotrophic factor (GDNF) regulates spermatogonial stem cell (SSC) maintenance. In the present study, we examined the levels and the cellular origin of GDNF in mouse testes during age-development, and the capacity of GDNF to induce migration of enriched GFR-α1 positive cells in vitro. The involvement of MAP kinase (MEK) and NF-kB signal pathways were examined. Our results show high levels of GDNF in testicular tissue of one-week-old mice which significantly decreased with age when examined by ELISA, real time PCR (qPCR) and immunofluorescence staining (IF) analysis. GDNF receptor (GFR-α1) expression was similar to GDNF when examined by qPCR analysis. Only Sertoli cell cultures (SCs) from one-week-old mice produced GDNF compared to SCs from older mice. However, peritubular cells from all the examined ages did not produce GDNF. The addition of recombinant GDNF (rGDNF) or supernatant from SCs from one-week-old mice to GFR-α1 positive cells induced their migration in vitro. This effect was significantly reduced by the addition of inhibitors to MEK (PD98059, U0126), NF-kB (PDTC) and IkB protease inhibitor (TPCK). Our results show for the first time the capacity of rGDNF and supernatant from SCs to induce migration of enriched GFR-α1 positive cells, and the possible involvement of MEK, NF-kB and IkB in this process. This study may suggest a novel role for GDNF in the regulation SSC niches and spermatogenesis.

[Automatic application of clinical guidelines - from theory to practice]

ClinicaL guidelines (GLs) have been shown to be a powerful tool for enhancing the uniformity and quality of care, reducing its costs. However, since they are typically represented in free text, this leads to low rates of compliance. Therefore, physicians might benefit from GL automated decision support. It should be noted that not many studies evaluate the effect of providing support for the application of GLs over significant stretches of time on the quality of medical decisions. In this paper, we will describe the general architecture of medical decision support systems, review several known GL application frameworks, and focus on the research performed in the medicaL informatics research center at Ben-Gurion University [BGU] of the Negev which developed the Digital ELectronic Guideline Library, called DeGeL. In particular, we will describe a new GL application framework called PICARD that is intended for GL application over time, while ensuring that the GLs recommendations were followed. We will briefly introduce a technical evaluation of PICARD in the cardiology domain to manage patients according to a Coumadin [Warfarin] protocoL, and a functional evaluation in a complex pre-eclampsia/ eclampsia GL in the OB/GYN domain, which we performed with 36 physicians. The results showed that the PICARD creates independence in the quality of the decisions from any particular physician, level of expertise, clinicaL scenario, or decision type within the scenarios. CurrentLy, PICARD is a core component in the EU Mobiguide project, which focuses on remote monitoring and care of chronic patients, using mobile devices to send alerts and recommendations.

Seasonal variations of human sperm cells among 6455 semen samples: a plausible explanation of a seasonal birth pattern

OBJECTIVE

To compare the different sperm parameters according to season of the year on sperm production day and the season 70 days prior (during spermatogenesis).

STUDY DESIGN

Retrospective Andrology Laboratory data comparison. A total of 6455 consecutive semen samples were collected as part of the basic fertility evaluation of 6447 couples. According to sperm concentration, the samples were classified as Normozoospermic or Oligozoospermic and analyzed in relation to the season.

RESULTS

The sperm concentration and percentage of fast motility showed a significant decrease from spring toward summer and fall (P < .001) with recovery noticed during the winter. As well, the highest percentage of normal sperm morphology was observed during the winter months.

CONCLUSION

Seasonal sperm pattern seems to be a circannual-rhythmic phenomenon. The winter and spring semen patterns are compatible with increased fecundability and may be a plausible explanation of the peak number of deliveries during the fall.

In vitro fertilization and risk of breast and gynecologic cancers: a retrospective cohort study within the Israeli Maccabi Healthcare Services

OBJECTIVE

To assess long-term cancer risks associated with in vitro fertilization (IVF).

DESIGN

Record-linkage study.

SETTING

Health maintenance organization in Israel.

PATIENT(S)

A total of 87,403 women evaluated and/or treated for infertility on or after September 25, 1994, who were followed for cancer development through June 22, 2011: 522 breast, 41 endometrial, 45 ovarian, 311 in situ cervical, and 32 invasive cervical cancers were identified.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Hazard ratios (HRs) for specific cancers.

RESULT(S)

We found no significant relationships of IVF exposures to the risks of breast, endometrial, or ovarian cancers. However, compared with women with no fertility treatment, the HR for ovarian cancer associated with IVF was 1.58 (95% confidence interval [CI] 0.75-3.29), with higher risk among those receiving four or more cycles (HR 1.78, 95% CI 0.76-4.13). There was also a nonsignificantly elevated risk for endometrial cancer among women who received 1-3 IVF cycles (HR 1.94, 95% CI 0.73-5.12), but additional cycles were associated with less risk. In contrast, the risk of in situ cervical cancer was significantly reduced and invasive cervical cancer nonsignificantly reduced among women receiving IVF as well as other fertility treatments.

CONCLUSION(S)

Our results regarding long-term effects were largely reassuring, but women receiving IVF should continue to be monitored given that the procedures involve potent ovulation stimulators and repeated ovarian punctures.

Increased plasma cell-free DNA is associated with low pregnancy rates among women undergoing IVF-embryo transfer

This prospective repeated measures study was designed to examine the cell-free DNA (cfDNA) concentrations during ovarian stimulation and the relationship between cfDNA concentration and pregnancy rates in women undergoing IVF-embryo transfer. The study examined 37 women undergoing IVF treatment in an IVF unit in a university medical centre in southern Israel. cfDNA concentrations were measured by a direct fluorescence assay, pregnancy rates were identified by plasma β human chorionic gonadotrophin (HCG) concentrations and verified by vaginal ultrasound to determine gestational sac and fetal heart beats. Throughout the IVF cycle, at the three time points measured, the mean concentration of plasma cfDNA among all participants did not statistically significantly change. However, on the day of βHCG test in patients undergoing IVF-embryo transfer, plasma cfDNA concentrations were statistically significantly higher among women who did not conceive in comparison to those who conceived. Plasma cfDNA may reflect the presence of factors which interfere with embryo implantation. Further research is required to determine the usefulness of cfDNA as a biomarker of IVF outcome and to examine the underlying pathologies as potential sources for increased plasma cfDNA concentrations. Cell-free DNA (cfDNA) is particles of DNA which are released from the cell nucleus and are found in high concentrations during a variety of illnesses and injuries. This study was designed to examine the cfDNA concentrations during IVF treatment and the relationship between cfDNA concentration in the bloodstream and pregnancy rates in women undergoing IVF. This study examined 37 women in treatment at the IVF unit of the University Medical Centre in southern Israel. cfDNA concentrations in the bloodstream were measured at three time points by a direct test. Pregnancy rates were identified by pregnancy hormone concentrations in the bloodstream and verified by vaginal ultrasound to determine a pregnancy sac and fetal heart beats. Throughout the IVF cycle, at the three time points measured, the average concentration of cfDNA among all participants did not change. However, on the day of the pregnancy test, blood cfDNA concentrations were significantly higher among women who were not pregnant in comparison to those who were. Plasma cfDNA may reflect the presence of factors which interfere with embryo implantation. Further research is required to determine the usefulness of cfDNA as a biological marker of IVF outcome and examine underlying illnesses and problems as potentials sources for increased cfDNA concentrations.

BeMORE: a novel method for detection of adverse fetal effects induced by drugs

We describe a unique new collaboration which allows linkage of administrative databases in Southern Israel, and hence ascertain risk/safety of prescription drugs in pregnancy. The advantages of this system include availability of rigorous data confounders, solid data on maternal conditions for which the drug is given, ability to capture all cases of elective abortions and not just live births, and ability to construct drug doses.

Differentiation of murine male germ cells to spermatozoa in a soft agar culture system

Establishment of an in vitro system that allows the development of testicular germ cells to sperm will be valuable for studies of spermatogenesis and future treatments for male infertility. In the present study, we developed in vitro culture conditions using three-dimensional agar culture system (SACS), which has the capacity to induce testicular germ cells to reach the final stages of spermatogenesis, including spermatozoa generation. Seminiferous tubules from testes of 7-day-old mice were enzymatically dissociated, and intratubular cells were cultured in the upper layer of the SACS in RPMI medium supplemented with fetal calf serum (FCS). The lower layer of the SACS contained only RPMI medium supplemented with FCS. Colonies in the upper layer were isolated after 14 and 28 days of culture and were classified according to their size. Immunofluorescence and real-time PCR were used to analyse specific markers expressed in undifferentiated and differentiated spermatogonia (Vasa, Dazl, OCT-4, C-Kit, GFR-α-1, CD9 and α-6-integrin), meiotic cells (LDH, Crem-1 and Boule) and post-meiotic cells (Protamine-1, Acrosin and SP-10). Our results reveal that it is possible to induce mouse testicular pre-meiotic germ cell expansion and induce their differentiation to spermatozoa in SACS. The spermatozoa showed normal morphology and contained acrosomes. Thus, our results demonstrate that SACS could be used as a novel in vitro system for the maturation of pre-meiotic mouse germ cells to post-meiotic stages and morphologically-normal spermatozoa.

Ovum donation: examining the new Israeli law

Ovum donation affords countless couples that under natural circumstances would not be able to produce offspring the ability to carry out natural pregnancies. With advancements in biotechnology including egg collection and in vitro fertilization (IVF), physicians can now successfully implant fertilized embryos. Due to Israel's tremendous involvement in IVF for its own citizens, the national laws that govern egg donation are of great importance. On September 5th 2010, the Israeli Parliament (Knesset) passed a law that allows young women between the ages of 21 and 35 to donate their eggs for paid financial compensation. The new law allows infertile women between the ages of 18 and 54 to request egg donation and IVF, which will partially be covered under state insurance plans. This article provides a description of the new Israeli law regulating ovum donation and the practical, moral and ethical debate surrounding the new system.

[Obstetrics and gynecology workforce planning: the Israeli experience 1995-2025]

BACKGROUND

Currently, there is no current obstetricians and gynecologists' workforce (OBGW) planning in Israel. Forecasting the OBGW is a challenge in order to achieve optimal obstetrics and gynecology care in the next decades.

OBJECTIVE

To examine the current Israeli OBGW and to describe, using an equation, the future supply of OBGW, until 2025.

METHODS

A descriptive study of past (1995-2006) and future (through 2025) OBGW trends in Israel. An equation was developed to project physician supply until 2025.

RESULTS

No "optimal ratio" exists regarding OBGW to female population ratio. In addition, information regarding OBGW planning is scarce. In Israel, the ratio of OBGW aged < 65 years per 1000 females aged > or = 15 years, was 0.35 in 2006, 23% more than the higher projected ratio from USA for 2005. In 2020, for comparison, the ratio in Israel will be 18% higher than the US ratio. The ratio calculated by the equation presents a plateau of the supply of Ob-Gyn specialists in Israel until 2025. A continued significant growth in the number of Ob-Gyn female specialists, compared with males, is noted. The interpretation of this data requires further evaluation.

CONCLUSIONS

In order to preserve the quality of care, there is a need for continuous monitoring and structured planning of health care human resources and OBGW in particular. Research and data in this field are scarce and, therefore, there is a need to conduct many additional research studies. Furthermore, additional data collection is needed to evaluate quality of care and its availability according to the relation between manpower needs and expected demands in Israel's health system.

Distinct expression of interleukin-1α, interleukin-1β, and interleukin-1 receptor antagonist in testicular tissues and cells from human biopsies with normal and abnormal histology

Cytokines are paracrine/autocrine growth factors known to affect testicular cell functions. The cellular origin and expression levels of interleukin-1 (IL-1) in human normal and pathological testicular biopsies are not yet clear. In the present study, we have investigated the levels and cellular origin of IL-1 family members [IL-1α, IL-β, and IL-1 receptor antagonist (IL-1ra)] in human testicular normal and abnormal biopsies with incomplete maturation arrest (IMA) or Sertoli only syndrome (SOS), using real-time polymerase chain reaction and immunohistochemical staining analysis. Our results show that the levels of IL-1α were higher in Leydig/interstitial cells of biopsies with IMA and SOS compared with normal. The levels of IL-1α in Sertoli cells of normal biopsies were higher than IMA and SOS. The mRNA levels of IL-1α were similar in all biopsies. IL-1β levels were higher in Leydig/interstitial cells of normal biopsies compared with Sertoli and germ cells. The levels of IL-1β were similar in testicular cells of all biopsies. However, the mRNA levels of IL-1β were significantly lower in SOS and IMA biopsies compared with normal. IL-1ra was expressed only in Leydig/interstitial cells, and their expression in normal biopsies was higher than in biopsies with IMA and SOS. The mRNA levels of IL-1ra were similar in all biopsies. Thus, it is possible to suggest the involvement of IL-1 system in the regulation of spermatogenesis and male infertility.

A scalable architecture for incremental specification and maintenance of procedural and declarative clinical decision-support knowledge

Clinical guidelines have been shown to improve the quality of medical care and to reduce its costs. However, most guidelines exist in a free-text representation and, without automation, are not sufficiently accessible to clinicians at the point of care. A prerequisite for automated guideline application is a machine-comprehensible representation of the guidelines. In this study, we designed and implemented a scalable architecture to support medical experts and knowledge engineers in specifying and maintaining the procedural and declarative aspects of clinical guideline knowledge, resulting in a machine comprehensible representation. The new framework significantly extends our previous work on the Digital electronic Guidelines Library (DeGeL) The current study designed and implemented a graphical framework for specification of declarative and procedural clinical knowledge, Gesher. We performed three different experiments to evaluate the functionality and usability of the major aspects of the new framework: Specification of procedural clinical knowledge, specification of declarative clinical knowledge, and exploration of a given clinical guideline. The subjects included clinicians and knowledge engineers (overall, 27 participants). The evaluations indicated high levels of completeness and correctness of the guideline specification process by both the clinicians and the knowledge engineers, although the best results, in the case of declarative-knowledge specification, were achieved by teams including a clinician and a knowledge engineer. The usability scores were high as well, although the clinicians' assessment was significantly lower than the assessment of the knowledge engineers.

Ability of expert physicians to structure clinical guidelines: reality versus perception

RATIONALE, AIMS AND OBJECTIVES

Structuring Textual Clinical Guidelines (GLs) into a formal representation is a necessary prerequisite for supporting their automated application. We had developed a collaborative guideline-structuring methodology that involves expert physicians, clinical editors and knowledge engineers, to produce a machine-comprehensible representation for automated support of evidence-based, guideline-based care. Our goals in the current study were: (1) to investigate the perceptions of the expert physicians and clinical editors as to the relative importance, for the structuring process, of different aspects of the methodology; (2) to assess, for the clinical editors, the inter-correlations among (i) the reported level of understanding of the guideline structuring ontology's (knowledge scheme's) features, (ii) the reported ease of structuring each feature and (iii) the actual objective quality of structuring.

METHODS

A clinical consensus regarding the contents of three guidelines was prepared by an expert in the domain of each guideline. For each guideline, two clinical editors independently structured the guideline into a semi-formal representation, using the Asbru guideline ontology's features. The quality of the resulting structuring was assessed quantitatively. Each expert physician was asked which aspects were most useful for formation of the consensus. Each clinical editor filled questionnaires relating to: (1) the level of understanding of the ontology's features (before the structuring process); (2) the usefulness of various aspects in the structuring process (after the structuring process); (3) the ease of structuring each ontological feature (after the structuring process). Subjective reports were compared with objective quantitative measures of structuring correctness.

RESULTS

Expert physicians considered having medical expertise and understanding the ontological features as the aspects most useful for creation of a consensus. Clinical editors considered understanding the ontological features and the use of the structuring tools as the aspects most useful for structuring guidelines. There was a positive correlation (R = 0.87, P < 0.001) between the reported ease of understanding ontological features and the reported ease of structuring those features. However, there was no significant correlation between the reported level of understanding the features - or the reported ease of structuring by using those features - and the objective quality of the structuring of these features in actual guidelines.

CONCLUSIONS

Aspects considered important for formation of a clinical consensus differ from those for structuring of guidelines. Understanding the features of a structuring ontology is positively correlated with the reported ease of using these features, but neither of these subjective reports correlated with the actual objective quality of the structuring using these features.

Effect of interleukin-1 receptor antagonist gene deletion on male mouse fertility

Members of the IL-1 family are pleiotropic cytokines that are involved in inflammation, immunoregulation, and other homeostatic functions in the body. IL-1alpha, IL-1beta, and the IL-1 antagonistic molecule [IL-1 receptor antagonist (IL-1 Ra)] are present in the testis under normal homeostasis, and they further increase upon infection/inflammation. In the present study, we examined the effect of IL-1 Ra gene deletion on male mouse fertility. Male mice [wild type (WT) and IL-1 Ra knockout (KO)] were mated with WT females, and the birth and number of offspring were recorded 21-45 d after mating. Furthermore, the concentration, motility, and morphology of sperm isolated from the cauda of the epididymis were evaluated. The ability of the calcium ionophore (A23187) to induce acrosome reaction (AR) in the sperm of WT and IL-1 Ra KO mice was compared with their ability to fertilize in vitro oocytes from WT females. The direct effect of IL-1alpha and IL-1beta on AR and abnormal morphology in sperm from WT were evaluated. The levels of IL-1alpha and IL-1beta in the testes of WT and IL-1 Ra KO mice were examined by specific ELISA and real-time PCR. Our results show a significant reduction in the capacity of IL-1 Ra KO male mice to fertilize WT females (P < 0.05). Furthermore, the number of offspring in mice fertilized with IL-1 Ra KO male mice was significantly lower than with WT males (P < 0.05). Sperm concentration and the percentage of motile sperm from IL-1 Ra KO and WT were similar; however, the percentage of sperm with abnormal morphology (mainly in the head) and acrosome-reacted sperm cells were significantly higher in the IL-1 Ra KO, compared with that of WT males (P < 0.05). In vitro, the ability of sperm from IL-1 Ra KO male mice to fertilize oocytes from WT females was significantly lower than sperm from WT mice (P < 0.05). In addition, the percentage of reacted sperm from IL-1 Ra KO, spontaneously without ionophore induction, was significantly higher than from WT (P < 0.05). Sperm from WT underwent induction of AR only by ionophore; however, sperm from IL-1 Ra KO were unable to undergo the AR by ionophore, indicating that they are induced and, thus, are inactive in fertilization. Testicular IL-1alpha and IL-1beta levels were significantly higher in IL-1 Ra KO, compared with WT male mice (P < 0.05). The addition of recombinant IL-1alpha or IL-1beta to sperm from a WT mouse induced their AR, and significantly increased abnormal sperm morphology, as compared with controls (P < 0.05). This effect was neutralized by the addition of IL-1 Ra. Our results indicate the involvement of IL-1 in sperm physiology, affecting its morphology and fertilization ability. Higher than homeostatic levels of IL-1 in the testis, as observed in IL-1 Ra KO mice, impaired the ability of sperm to fertilize oocytes. Together, these results may explain some of the male infertility cases with an infection/inflammation background and may hint at the ability to use IL-1 Ra in future therapeutic strategies in these cases.

A methodology for evaluation of a markup-based specification of clinical guidelines

We introduce a three-phase, nine-step methodology for specification of clinical guidelines (GLs) by expert physicians, clinical editors, and knowledge engineers, and for quantitative evaluation of the specification's quality. We applied this methodology to a particular framework for incremental GL structuring (mark-up) and to GLs in three clinical domains with encouraging results.

A quality assessment tool for markup-based clinical guidelines

We introduce a tool for quality assessment of procedural and declarative knowledge. We developed this tool for evaluating the specification of mark-up-based clinical GLs. Using this graphical tool, the expert physician and knowledge engineer collaborate to perform scoring, using pre-defined scoring scale, each of the knowledge roles of the mark-ups, comparing it to a gold standard. The tool enables scoring the mark-ups simultaneously at different sites by different users at different locations.

Coculture of spermatogonia with somatic cells in a novel three-dimensional soft-agar-culture-system

Isolation and culture of spermatogonial stem cells (SSCs) has become an approach to study the milieu and the factors controlling their expansion and differentiation. Traditional conventional cell culture does not mimic the complex situation in the seminiferous epithelium providing a basal, intraepithelial, and adluminal compartment to the developing male germ cells. SSCs are located in specific stem cell niches whose features and functional parameters are thus far poorly understood. It was the aim of this study to isolate SSCs and to explore their expansion and differentiation potential in a novel three-dimensional Soft-Agar-Culture-System (SACS). This system provides three-dimensional structural support and multiple options for manipulations through the addition of factors, cells, or other changes. The system has revolutionized research on blood stem cells by providing a tool for clonal analysis of expanding and differentiating blood cell lineages. In our studies, SSCs are enriched using Gfralpha-1 as a specific surface marker and magnetic-activated cell sorting as a separation approach. At termination of the culture, we determined the type and number of germ cells obtained after the first 24 hours of culture. We also determined cell types and numbers in expanding cell clones of differentiating germ cells during the subsequent 15 days of culture. We analyzed a supportive effect of somatic cell lineages added to the solid part of the culture system. We conclude that our enrichment and culture approach is highly useful for exploration of SSC expansion and have found indications that the system supports differentiation up to the level of postmeiotic germ cells.

In vitro culture of testicular germ cells: regulatory factors and limitations

Spermatogenesis is regulated mainly by endocrine factors and also by testicular paracrine/autocrine growth factors. These factors are produced by Sertoli cells, germ cells, peritubular cells and interstitial cells, mainly Leydig cells and macrophages. The interactions and the ratio between Sertoli and germ cells in the seminiferous tubules ensure successful spermatogenesis. In order to culture spermatogonial stem cells (SSCs) in vitro, researchers tried to overcome some of the obstacles -- such as the low number of stem cells in the testis, absence of specific markers to identify SSCs -- in addition to difficulties in keeping the SSCs alive in culture. Recently, some growth factors important for the proliferation and differentiation of SSCs were identified, such as glial cell line derived neurotrophic factor (GDNF), stem cell factor (SCF) and leukemia inhibitory factor (LIF); also, markers for SSCs at different stages were reported. Therefore, some groups succeeded in culturing SSCs (under limitations), or more differentiated cells and even were able to produce in vitro germ cells from embryonic stem cells. Thus, success in culturing SSCs is dependent on understanding the molecular mechanisms behind self-renewal and differentiation. Culture of SSCs should be a good tool for discovering new therapeutic avenue for some infertile men or for patients undergoing chemotherapy/radiotherapy (pre-puberty or post-puberty).

Obstetric outcome of twin pregnancies conceived by in vitro fertilization and ovulation induction compared with those conceived spontaneously

OBJECTIVE

To compare the obstetric characteristics of twin pregnancies conceived by in vitro fertilization (IVF) and ovulation induction with those conceived spontaneously.

DESIGN

Case control study.

SETTING

Tertiary Medical Center.

PATIENTS

All twin deliveries that were achieved by IVF (n=558) and ovulation induction (n=478) from January 1988 through December 2002 were evaluated. Each group was compared with a control group that conceived spontaneously (n=3694) and was delivered during the same period.

INTERVENTIONS

Ovulation induction, IVF-ET.

MAIN OUTCOME MEASURES

Obstetrical complications.

RESULTS

Multivariate analysis showed that patients who conceived with the assistance of IVF and ovulation induction had a significantly higher risk for gestational diabetes mellitus (odds ratio [OR]=2.41, 95% confidence interval [CI]=1.77-3.29 and OR=1.71, CI=1.2-2.42, respectively), cesarean section (OR=2.17, 95% CI=1.74-2.70 and OR=1.76, CI=1.43-2.16, respectively), and a lower gestational age at birth in the IVF group (OR=0.91, 95% CI=0.88-0.94), compared with their controls.

CONCLUSIONS

After controlling for maternal age, and nulliparity we demonstrated that twin pregnancies conceived with the assistance of IVF and ovulation induction are at increased risk for gestational diabetes mellitus, and delivery by cesarean section. In addition, IVF conceived pregnancies have a lower gestational age at birth.

Relationship between age and semen parameters in men with normal sperm concentration: analysis of 6022 semen samples

This study evaluates retrospectively the relationship between age and semen parameters among men with normal sperm concentration. It was based on computerized data and performed in an Academic Fertility and IVF Unit. Six thousand and twenty-two semen samples with sperm concentrations of >or=20 x 10(6) ml(-1) were examined according to WHO criteria and analysed in relation to patients' age. For each age group, mean values +/- SD of semen volume, sperm concentration, percentage of motile spermatozoa, normal morphology, acrosome index, total sperm count/ejaculate, total motile sperm count/ejaculate and sexual abstinence duration were examined. A peak semen volume of 3.51 +/- 1.76 ml(-1) was observed at age >or=30 to <35 years and a lowest volume of 2.21 +/- 1.23 ml(-1) was observed at age >or=55 years (P<0.05). Sperm motility was found to be inversely related to age with peak motility of 44.39 +/- 20.69% at age <25 years and lowest motility of 24.76 +/- 18.27% at age >or=55 years (P<0.05). A reduction of 54% was observed for total motile sperm, between values of 103.34 +/- 107 x 10(6) at age >or=30 to <35 years and 46.68 +/- 53.73 x 10(6) (P<0.05) at age >55 years. A statistically significant and inverse relationship was observed between semen volume, sperm quality and patient age, in spite of prolonged sexual abstinence duration. Top sperm parameters were observed at age >or=30 to <35 years, while the most significant reduction in sperm parameters occurred after the age of 55 years.

Relationship between sexual abstinence duration and the acrosome index in teratozoospermic semen: analysis of 1800 semen samples

A high acrosome index (percentage of sperm with normal acrosome morphology--cutoff value > or =10%) is known to be associated with an improved fertilization rate in conventional IVF. A retrospective evaluation of the relationship between duration of sexual abstinence and acrosome index among oligozoospermic and normozoospermic semen samples with teratozoospermia was undertaken. A significant (P = 0.001) decrease in the acrosome index was observed among the normozoospermic samples (n = 1264) between the peak value of 10.2 +/- 3.6% on day 2 and 8.5 +/- 4.0% on day 5 of abstinence, while for the oligozoospermic samples (n = 536) the peak value of 8.7 +/- 3.5% was observed on day 1 and the lowest values of 6.8 +/- 3.7% (P = 0.04) on day 5 of abstinence. The results suggest that an optimal acrosome index will be obtained following a short sexual abstinence.

Infertility, ovulation induction treatments and the incidence of breast cancer--a historical prospective cohort of Israeli women

CONTEXT

Ovulation induction drugs may be associated with increased breast cancer risk. Results so far have been inconclusive.

OBJECTIVE

To evaluate the association between infertility, exposure to ovulation induction drugs and the incidence of breast cancer.

DESIGN

Historical prospective cohort and nested case-control study.

SETTING

Institutional practice

PATIENTS

About 5,788 women attending five infertility centers in Israel between 1964 and 1984.

INTENTION

Abstracting of medical records and telephone interviews.

MAIN OUTCOME MEASURE

Breast cancer incidence was determined through linkage with the National Cancer Registry database. Standardized incidence ratios (SIRs) and 95% confidence intervals were computed by comparing the observed to the expected cancer rates in the general population. In addition, a nested case-control study within the cohort was performed with interviews of breast cancer cases and two matched controls.

RESULTS

The study cohort included 120,895 women years of follow-up. Compared to 115.2 expected breast cancer cases, 131 cases were observed (SIR = 1.1; 95% CI 0.9-1.4). Risk for breast cancer was significantly higher for women treated with clomiphene citrate (SIR = 1.4; 95% CI 1.0-1.8). Similar results were noted when comparisons were carried out between treated and untreated women, and when multivariate models were applied. In the nested case-control study, higher cycle index (OR = 2.2; 95% CI 1.0-4.8) and treatment with clomiphene citrate (OR=2.7; 95% CI 1.3-5.7) were associated with higher risk for breast cancer.

CONCLUSION

Infertility and usage of infertility drugs in general are not associated with increased risk for breast cancer. However, for infertile women treated with clomiphene citrate, breast cancer risk is elevated.

Impact of hypnosis during embryo transfer on the outcome of in vitro fertilization-embryo transfer: a case-control study

OBJECTIVE

To investigate whether hypnosis during ET contributes to successful IVF/ET outcome.

DESIGN

Case-control clinical study.

SETTING

Academic Fertility and IVF Unit, Soroka Medical Center, Beer-Sheva, Israel.

PATIENT(S)

Infertile couples undergoing IVF.

INTERVENTION(S)

Ninety-eight IVF/ET cycles with hypnosis during the ET procedure were matched with 96 regular IVF/ET cycles.

MAIN OUTCOME MEASURES

Comparison of clinical pregnancy and implantation rates between the two groups.

RESULT(S)

We obtained 52 clinical pregnancies out of 98 cycles (53.1%) with an implantation rate of 28% among hypnosis IVF/ET cycles, and 29 out of 96 (30.2%) clinical pregnancies and an implantation rate of 14.4% in the control cycles. Our overall IVF program pregnancy rate for the same period was 32.1%. Logistic regression analysis was performed emphasizing the positive contribution of hypnosis to the IVF/ET conception rates.

CONCLUSION(S)

This study suggests that the use of hypnosis during ET may significantly improve the IVF/ET cycle outcome in terms of increased implantation and clinical pregnancy rates. Furthermore, it seems that the patients' attitude to the treatment was more favorable.

Induction of IL-1, in the Testes of Adult Mice, Following Subcutaneous Administration of Turpentine

PROBLEM

Interleukin-1 family is present in the testicular homogenates and its cellular compartments. It has been suggested that IL-1 is involved in physiological and pathological functions of the testicular tissues. In the present study we examined the effect of acute mostly localized inflammation, using turpentine, on the expression levels of testicular IL-1 system.

METHODS OF STUDY

Mice were subcutaneously injected with steam-distilled turpentine or saline (control). Three hours to 10 days following the injection, mice were killed and testis and spleen were homogenized and examined for interleukin (IL)-1alpha, IL-1beta, and IL-1 receptor antagonist (IL-1ra) levels by enzyme-linked immunosorbent assay and polymerase chain reaction.

RESULTS

Subcutaneous injection of turpentine induced mice systemic inflammation, as indicated by significant increase in serum IL-1beta levels, and IL-1alpha, IL-1beta and IL-1ra in spleen homogenates. The levels of IL-1alpha, IL-1beta and IL-1ra were significantly induced in testicular homogenates of adult mice following subcutaneous injection of turpentine. The significant induction of testicular IL-1alpha was detected after 3-24 hr of turpentine injection and decreased later (after 3-10 days) to levels similar to the control. However, significant induction of testicular IL-1beta was detected only after 3-10 days of turpentine injection, and for testicular IL-1ra levels was detected after 3 hr to 6 days of turpentine injection, and after 10 days the levels were similar to the control. These results were also confirmed by mRNA expression of these factors.

CONCLUSION

Our results demonstrate for the first time the distant effect of acute localized inflammation on testicular IL-1 levels. Thus, transient inflammatory response to infectious/inflammatory agents at non-testicular sites that elicit systemic IL-1 response should be considered during clinical treatment as a possible factor of male infertility.

Increased prevalence of gestational diabetes mellitus in in vitro fertilization pregnancies inadvertently conceived during treatment with long-acting triptorelin acetate

Thirty-five pregnancies were inadvertently conceived during the midluteal application of the long-acting gonadotropin-releasing hormone agonist triptorelin acetate before ovarian stimulation for in vitro fertilization. Most of the conceptions occurred before the first or second IVF trial, and were associated with a significantly increased tendency to develop gestational diabetes. No increase in pregnancy wastage or appearance of congenital malformations occurred.

Testicular interleukin-6 response to systemic inflammation

Spermatogenesis is a highly controlled process of proliferation, meiosis, and differentiation. Systemic infection and chronic inflammation can impair testicular steroidogenesis and spermatogenesis. In this study, we examined the effect of systemic infection--intraperitoneal (i.p.) injection of lipopolysaccharide (LPS)--on the expression levels of IL-6 in the testis of sexually immature and adult mice. IL-6 levels in testicular homogenates of immature mice were significantly higher than in mature mice (both protein and RNA levels), before and after LPS injection. Injection of LPS (i.p.) into mature mice over 3 hours, significantly increased testicular IL-6 protein and mRNA levels (as demonstrated by ELISA and RT-PCR respectively) compared to the control group. Injection of LPS over 24 hours significantly increased IL-6 mRNA expression, but it did not significantly affect IL-6 protein levels in the homogenates. In contrast, stimulation of immature mice with LPS (2, 20 or 100 microg/mL) over 3 hours or LPS (2 or 20 microg/mL) over 24 hours, significantly increased testicular IL-6 (both protein and mRNA expression). The levels of testicular IL-6 (protein) in the homogenates were not significantly increased after stimulation with 100 microg/mL over 24 hours, but they were significantly increased at the mRNA level. Our results demonstrate, for the first time, the over-expression of IL-6 in testicular homogenates of mature and immature mice following systemic inflammation (i.p. injection of LPS). These results suggest the possibility of the involvement of systemic infection/inflammation, through the elevation of testicular IL-6, in testicular functions, which may affect male fertility. Also, high levels of IL-6 during pathological conditions, could play a role in protecting testicular tissue.

Relationship between the duration of sexual abstinence and semen quality: analysis of 9,489 semen samples

OBJECTIVE

To evaluate the relationship between duration of sexual abstinence and various characteristics of normal and subnormal semen.

DESIGN

A retrospective study based on computerized data.

SETTING

Fertility and IVF unit at a university medical center.

PATIENT(S)

Nine thousand, four hundred eighty-nine semen samples from 6,008 patients were analyzed according to the World Health Organization (WHO) manual and grouped according to sperm concentration (10(6)/mL) into severe (0.2-4 x 10(6)), moderate (>4-10 x 10(6)), and mild (>10-19.99 x 10(6)) oligozoospermia, and normozoospermia (> or =20-250 x 10(6)) groups.

MAIN OUTCOME MEASURE(S)

In each group mean values of semen volume, sperm concentration, percentage of motile sperm and of normal morphology (according to WHO or Kruger criteria), total sperm count, and total motile sperm count per ejaculate were related to duration of abstinence.

RESULT(S)

Among the 3,506 oligozoospermic samples, the peak mean sperm motility of 30.3% was observed after 1 day of abstinence. Similarly, the mean percentage of normal morphology among mild-moderate oligozoospermic samples (n = 2,260) reached peak values of 7.4%-8.6% between 0-2 days of abstinence. The 5,983 normozoospermic samples showed a significant decrease in the percentage of sperm motility and normal morphology to mean values of 33.1% and 7.0%, respectively, on days 11-14 of sexual abstinence.

CONCLUSION(S)

Our data challenge the role of abstinence in male infertility treatments and suggest that to present the best possible semen samples, patients with male factor infertility should collect the semen after just 1 day of sexual abstinence. Patients presenting normal sperm analysis or sperm donors for cryopreservation purposes should be advised not to exceed 10 days of sexual abstinence.