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Practice Committee of the Society for Reproductive Endocrinology and Infertility, Quality Assurance Committee of the Society for Assisted Reproductive Technologies, and the Practice Committee of the American Society for Reproductive Medicine. Electronic address: asrm@asrm.org. Multiple gestation associated with infertility therapy: a committee opinion. Fertil Steril 2022:S0015-0282(21)02302-5. [PMID: 35115166 DOI: 10.1016/j.fertnstert.2021.12.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 12/15/2021] [Indexed: 11/19/2022]
Abstract
This Committee Opinion provides practitioners with suggestions to reduce the likelihood of iatrogenic multiple gestation resulting from infertility treatment. This document replaces the document of the same name previously published in 2012 (Fertil Steril 2012;97:825-34 by the American Society for Reproductive Medicine).
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Prieto B, Diaz-Nuñez M, Lainz L, Vendrell A, Rabanal A, Iglesias M, Jauregui T, Corcostegui B, Matorras A, Perez S, Matorras R. Aspiration of excess follicles before intrauterine insemination in high response cycles. Reprod Med Biol 2022; 21:e12470. [PMID: 35781922 PMCID: PMC9241166 DOI: 10.1002/rmb2.12470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 05/12/2022] [Accepted: 05/23/2022] [Indexed: 11/11/2022] Open
Abstract
Purpose To assess the outcome of excess follicle aspiration before intrauterine insemination (EFABI) in intrauterine insemination (IUI) cycles with 4-6 follicles ≥14 mm. Methods A retrospective case-control study with 1559 patients undergoing IUI (donor and husband's sperm), of whom 86 underwent EFABI. We studied also an historical series of 2213 patients before EFABI implementation. For 3.5 years, all women undergoing IUI developing 4-6 follicles ≥14 mm were offered EFABI on the day of hCG administration. Pregnancy rates (PRs), multiple PRs, and adverse effects were measured. Results EFABI was associated with a similar multiple PR (17.8% vs 17.5% in non-EFABI cases), with no triplets in EFABI patients. Live birth rates were significantly higher in EFABI cycles in IUI overall (25.5% vs 15.2%). When considered separately, the performance of EFABI resulted in significantly increased live birth rates in IUI-donor cycles (32.5% vs 18.5%), whereas the differences in IUI-husband cycles (19.5% vs 12.9%) did not reach statistical significance. The PR was 21.2% during the EFABI implementation period and 19.4% in the pre-EFABI period. Conclusions EFABI in cycles in which 4-6 follicles reach ≥14 mm is a simple option that reduces cycle cancellation rates, results in higher PRs than cycles with 1-3 follicles, and lowers the risk of multiple pregnancy.
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Affiliation(s)
- Begoña Prieto
- Human Reproduction Unit Cruces University Hospital Barakaldo Spain.,Faculty of Medicine University of the Basque Country Lejona Spain.,Biocruces Bizkaia Health Research Institute Barakaldo Spain.,Instituto Valenciano de Infertilidad (IVI) Leioa Spain
| | - Maria Diaz-Nuñez
- Human Reproduction Unit Cruces University Hospital Barakaldo Spain.,Biocruces Bizkaia Health Research Institute Barakaldo Spain
| | - Lucia Lainz
- Human Reproduction Unit Cruces University Hospital Barakaldo Spain.,Biocruces Bizkaia Health Research Institute Barakaldo Spain
| | | | - Aintzane Rabanal
- Human Reproduction Unit Cruces University Hospital Barakaldo Spain.,Faculty of Medicine University of the Basque Country Lejona Spain
| | - Maria Iglesias
- Human Reproduction Unit Cruces University Hospital Barakaldo Spain.,Biocruces Bizkaia Health Research Institute Barakaldo Spain
| | - Teresa Jauregui
- Human Reproduction Unit Cruces University Hospital Barakaldo Spain
| | | | - Ana Matorras
- European University of Madrid Villaviciosa de Odón, Madrid Spain
| | - Silvia Perez
- Biocruces Bizkaia Health Research Institute Barakaldo Spain
| | - Roberto Matorras
- Human Reproduction Unit Cruces University Hospital Barakaldo Spain.,Faculty of Medicine University of the Basque Country Lejona Spain.,Biocruces Bizkaia Health Research Institute Barakaldo Spain.,Instituto Valenciano de Infertilidad (IVI) Leioa Spain
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Chaabane S, Sheehy O, Monnier P, Bissonnette F, Trasler JM, Fraser W, Bérard A. Association between ovarian stimulators with or without intrauterine insemination, and assisted reproductive technologies on multiple births. Am J Obstet Gynecol 2015; 213:511.e1-511.e14. [PMID: 26079626 DOI: 10.1016/j.ajog.2015.06.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 05/10/2015] [Accepted: 06/10/2015] [Indexed: 11/21/2022]
Abstract
OBJECTIVE We sought to quantify the risk of multiple births associated with the use of different modalities of medically assisted reproduction. STUDY DESIGN We conducted a case-control study using a birth cohort from 2006 through 2009. This cohort was built with the linkage of data obtained by a self-administered questionnaire and medical, hospital, pharmaceutical, birth, and death databases in Quebec. Cases were pregnancies resulting in multiple live births (International Classification of Diseases, Ninth Revision/International Statistical Classification of Diseases, 10th Revision codes). Each case was matched, on maternal age and year of delivery, with 3 singleton pregnancies (controls) randomly selected among all Quebec singleton pregnancies. Data on the use of different fertility treatments were collected by a self-administered questionnaire. Multiple logistic regression models, adjusted for body mass index, number of previous live births, ethnicity, family income, place of residence, marital status, subfertility, reduction of embryos, diabetes, metformin treatment, folic acid supplementation, and lifestyle factors, were used to calculate the odds ratios (ORs) and confidence intervals (CIs). We evaluated the associations between each type of fertility treatment (ovarian stimulators used alone, intrauterine insemination [IUI] used with ovarian stimulation, and assisted reproductive technologies [ART]) and the risk of multiple births. RESULTS A total of 1407 cases of multiple births and 3580 controls were analyzed. More than half of multiple births following medically assisted reproduction (53.6%) occurred among women having used ovarian stimulation with or without IUI. The use of ovarian stimulators alone and IUI with ovarian stimulation increase the risk of multiple births (adjusted OR, 4.5; 95% CI, 3.2-6.4; and adjusted OR, 9.32; 95% CI, 5.60-15.50, respectively) compared to spontaneous conception. The use of invasive ART was associated with a greatly increased risk of multiple births. Among only the 465 women who used medically assisted reproduction for conception, the use of IUI with ovarian stimulation was associated with an increased risk of multiple births (adjusted OR, 1.98; 95% CI, 1.12-3.49) when compared to ovarian stimulators used alone. Invasive ART were associated with an increased risk of multiple births (adjusted OR, 6.81; 95% CI, 3.72-12.49) when compared to ovarian stimulators used alone. CONCLUSION Although the risk of multiple births associated with invasive ART can be decreased by elective implementing of single embryo transfer, special attention should be paid to the greatly increased risk associated with ovarian stimulation used alone or with IUI.
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McClamrock HD, Jones HW, Adashi EY. Ovarian stimulation and intrauterine insemination at the quarter centennial: implications for the multiple births epidemic. Fertil Steril 2012; 97:802-9. [PMID: 22463774 DOI: 10.1016/j.fertnstert.2012.02.031] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Revised: 02/20/2012] [Accepted: 02/22/2012] [Indexed: 11/26/2022]
Abstract
Ovarian stimulation and intrauterine insemination (OS/IUI), a mainstay of current infertility therapy and a common antecedent to IVF, is a significant driver of the multiple births epidemic. Redress of this challenge, now marking its quarter centennial, will require a rethinking of current practice patterns. Herein we explore prospects for prevention, mitigation, and eventual resolution. We conclude that the multiple births attributable to OS/IUI may not be entirely preventable but that the outlook for their mitigation is promising, if in need of solidification. Specifically, we observe that low-dose (≤ 75 IU) gondotropin, clomiphene, and especially off-label letrozole regimens outperform high-dose (≥ 150 IU) gonadotropin counterparts in the gestational plurality category while maintaining comparable per-cycle pregnancy rates. Accordingly we recommend that, subject to appropriate exceptions, high-dose gonadotropin regimens be used sparingly and that whenever possible they be replaced with emerging alternatives. Finally, we posit that OS/IUI is not likely to be superseded by IVF absent further commoditization and thus greater affordability.
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Multiple gestation associated with infertility therapy: an American Society for Reproductive Medicine Practice Committee opinion. Fertil Steril 2012; 97:825-34. [DOI: 10.1016/j.fertnstert.2011.11.048] [Citation(s) in RCA: 157] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Accepted: 11/29/2011] [Indexed: 11/23/2022]
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Stoop D, Van Landuyt L, Paquay R, Fatemi H, Blockeel C, De Vos M, Camus M, Van den Abbeel E, Devroey P. Offering excess oocyte aspiration and vitrification to patients undergoing stimulated artificial insemination cycles can reduce the multiple pregnancy risk and accumulate oocytes for later use. Hum Reprod 2010; 25:1213-8. [PMID: 20172866 DOI: 10.1093/humrep/deq026] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The prevention of multiple pregnancies remains a major challenge in patients treated with ovarian stimulation prior to intrauterine insemination (IUI). The pilot study presented here investigates whether multiple pregnancies can be minimized by a microscopically confirmed aspiration of oocytes from supernumerary follicles immediately before intrauterine insemination and evaluates the benefit of concomitant excess oocyte cryopreservation for future use. METHODS Thirty-four aspirations of supernumerary follicles were performed immediately prior to IUI in 31 patients undergoing ovarian stimulation. sIUI was only performed if cumulus-oocyte complexes were microscopically observed in the aspirated follicular fluid. All collected mature excess oocytes were cryopreserved using the vitrification technique. RESULTS Only four sIUI procedures had to be cancelled due to failed oocyte retrieval or premature ovulation. IUI treatment resulted in a clinical pregnancy rate of 23.5% per cycle. All were singleton pregnancies. A total of 111 oocytes were cryopreserved. Patients with polycystic ovary syndrome (PCOS) had an average of 6.07 oocytes vitrified, whereas patients without PCOS had 1.3 oocytes vitrified per cycle. CONCLUSION Microscopically confirmed collection of excess oocytes prior to stimulated IUI reduced cancellation rates, further reduced the risk for multiple pregnancy and may lead to future additional pregnancies because, based on current information, approximately 5% of the vitrified oocytes could potentially establish a pregnancy.
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Affiliation(s)
- D Stoop
- Centre for Reproductive Medicine, University Hospital, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium.
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Abstract
A commentary on contributions of ART to the pandemic of multiple gestations is presented and mechanistic aspects therein are explored.
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Affiliation(s)
- Monica Kapoor
- Department of Obstetrics & Gynecology, Danbury Hospital, Danbury, Connecticut, USA
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Abstract
OBJECTIVE To review factors associated with high-order multiple births (HOMB) due to ovulation induction (OI) and the efficacy of strategies to reduce their occurrence. DESIGN Retrospective analysis of published studies of OI with intrauterine insemination (IUI) where patient and cycle characteristics were fully documented. RESULT(S) High-order multiple pregnancies (HOMP) were positively related to use of high doses of gonadotropin, number of 7-10 mm preovulatory follicles, and E(2), and inversely related to age and number of treatment cycles. Strategies successful in reducing HOMP include: use of clomiphene (CC) before gonadotropins, minimal gonadotropin doses, cancellation for more than three follicles >10-15 mm, and aspiration of excess follicles. Depending on the strategy used, 5%-20% of cycles may be canceled but HOMP rates can be less than 2% and pregnancy rates can average 10%-20% per cycle. Pregnancy rates per patient need not be reduced if low doses are continued for 4-6 cycles. CONCLUSION(S) High-order multiple pregnancies due to OI can be reduced to 2% or less by less aggressive stimulation without reducing overall chances of pregnancy for most patients.
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Affiliation(s)
- Richard Palmer Dickey
- Department of Obstetrics and Gynecology, Louisiana State University School of Medicine, The Fertility Institute of New Orleans, New Orleans, Louisiana, USA.
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Ombelet W, Campo R, Bosmans E, Nijs M. Intrauterine insemination (IUI) as a first-line treatment in developing countries and methodological aspects that might influence IUI success. ACTA ACUST UNITED AC 2008. [DOI: 10.1093/humrep/den165] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Abstract
Solid organ transplantation can prolong the life of individuals with end-stage diseases that affect the kidney, liver, lung, heart, and pancreas. The improved survival of transplant recipients has led to increased attention on quality of life issues, including controlling fertility and having children. Perturbations of the hypothalamic-pituitary-ovarian axis in women with chronic renal failure or severe hepatic dysfunction result in anovulation and reduced fertility. Most often, fertility is restored with successful organ transplantation and good overall health. Although there are case reports of children born subsequent to assisted reproductive technologies (ART) in female transplant recipients, the approach to infertility in this population has not been described. Recognizing the unique medical, ethical, and psycho-social concerns involved in treating infertile female transplant recipients, reproductive endocrinologists must work with a multi-disciplinary team to ensure a successful pregnancy outcome without compromising graft function or maternal health. The primary goal of ART is a singleton pregnancy without complications, such as ovarian hyperstimulation syndrome, that pose greater risks in transplant recipients.
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Affiliation(s)
- Nataki C Douglas
- Division of Reproductive Endocrinology and Infertility, Columbia University, New York, NY 10032, USA.
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Ghesquiere SL, Castelain EG, Spiessens C, Meuleman CL, D’Hooghe TM. Relationship between follicle number and (multiple) live birth rate after controlled ovarian hyperstimulation and intrauterine insemination. Am J Obstet Gynecol 2007; 197:589.e1-5. [PMID: 18060945 DOI: 10.1016/j.ajog.2007.05.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2006] [Revised: 03/04/2007] [Accepted: 05/11/2007] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The goal of this study was to determine the relationship between the number of mature ovarian follicles and the (multiple) live birth rate after controlled ovarian hyperstimulation and intrauterine insemination. STUDY DESIGN A total of 2463 intrauterine insemination cycles performed during a natural cycle (n = 118), or after controlled ovarian hyperstimulation with either clomiphene citrate (n = 663) or with gonadotrophins (n = 1682) were reviewed to assess the impact of the type of stimulation and the number of follicles 14 mm or larger on the (multiple) live birth rate per cycle. RESULTS The live birth rate after intrauterine insemination was significantly higher (P = .02) after stimulation with gonadotrophins (13%) than after clomiphene cirate (8%) if only 1 follicle 14 mm or larger was present. If 2 or more follicles were present, there was no statistically significant difference between both stimulation methods. CONCLUSION Treatment of intrauterine insemination with gonadotrophin is effective with an acceptable (multiple) live birth rate when 1 or 2 follicles 14 mm or larger are present.
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Stojkovic M, Stojkovic P, Leary C, Hall VJ, Armstrong L, Herbert M, Nesbitt M, Lako M, Murdoch A. Derivation of a human blastocyst after heterologous nuclear transfer to donated oocytes. Reprod Biomed Online 2005; 11:226-31. [PMID: 16168222 DOI: 10.1016/s1472-6483(10)60962-5] [Citation(s) in RCA: 128] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This paper describes the derivation of a blastocyst following heterologous nuclear transfer (NT) into a human oocyte. It also demonstrates that a major obstacle to continuing research in human NT is the availability of suitable human oocytes. In this study, 36 oocytes were donated by 11 women undergoing four different treatments and their developmental potential was evaluated after NT. The time from oocyte collection to NT seems to be crucial, and only oocytes that were enucleated within 1 h proved successful. After enucleation of oocytes, fusion with undifferentiated human embryonic stem cells and in-vitro culture, early cleavage and blastocyst development of fused complexes was observed. The DNA fingerprinting comparison of the donor cells and derived blastocyst revealed successful heterologous NT, since both oocytes and donor cells were recovered from different patients. It has therefore been demonstrated that NT can be achieved in humans, using heterologous donor nuclei and surplus and donated oocytes. However, if the promise of this new science is to achieve its potential in the foreseeable future, it will be necessary to identify new sources of oocytes that can be used immediately after retrieval.
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Affiliation(s)
- Miodrag Stojkovic
- Centre for Stem Cell Biology and Developmental Genetics, University of Newcastle, UK.
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Abstract
Iatrogenic multiple pregnancy is the most significant complication of assisted reproductive technology (ART). Approximately half of all children born subsequent to ART result from a plural gestation. Furthermore, the majority of triplets and higher order births are the product of ART. The risks for multiple pregnancy vary with practice patterns and the techniques used to achieve pregnancy. Recognizing the potential for serious morbidity associated with multiple pregnancies, infertility specialists have developed strategies to reduce the complication of multiple pregnancies while maintaining acceptable pregnancy rates. Implementation of these refined practices has led to a reduction in the incidence of higher order multiple births, although the incidence of twins has yet to be minimized. Further reduction in the incidence of multiple births after ART necessitates a redefinition of success to emphasize the healthy singleton birth rate, rather than crude pregnancy rates.
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Affiliation(s)
- Gary S Nakhuda
- Division of Reproductive Endocrinology and Infertility, College of Physicians & Surgeons, Columbia University, New York, NY 10032, USA.
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Abstract
This review summarizes the existing evidence regarding intrauterine insemination (IUI) as a treatment for cervical hostility, male and unexplained subfertility. IUI in natural cycles has been proven effective in patients with cervical hostility and moderate male subfertility. IUI in cycles with mild ovarian hyperstimulation (MOH) should be the treatment of choice in couples with mild male subfertilty (average total motile sperm count above 10 million) and unexplained subfertilty. When MOH is applied, gonadotropins have been proven more effective compared with clomiphene citrate. Further large trials comparing clomiphene citrate with gonadotropins are mandatory. Prevention of multiple pregnancies in MOH/IUI programs is of paramount importance. A strategy with a low-dose step-up protocol and strict cancellation criteria is proposed. When multiple pregnancies are kept to a minimum, MOH/IUI is more cost-effective compared with in vitro fertilization and embryo transfer. Future research should focus on prediction models to predict the outcome of MOH/IUI treatment for individual couples before starting treatment.
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Affiliation(s)
- B J Cohlen
- Department of Obstetrics and Gynaecology, Isala Clinics Zwolle, Location Sophia, Zwolle, The Netherlands.
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Ombelet W, De Sutter P, Van der Elst J, Martens G. Multiple gestation and infertility treatment: registration, reflection and reaction—the Belgian project. Hum Reprod Update 2005; 11:3-14. [PMID: 15528214 DOI: 10.1093/humupd/dmh048] [Citation(s) in RCA: 142] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Multiple pregnancies associated with infertility treatment are recognized as an adverse outcome and are responsible for morbidity and mortality related to prematurity and very low birthweight population. Due to the epidemic of iatrogenic multiple births, the incidence of maternal, perinatal and childhood morbidity and mortality has increased. This results in a hidden healthcare cost of infertility therapy and this may lead to social and political concern. Reducing the number of embryos transferred and the use of natural cycle IVF will surely decrease the number of multiple gestations. Consequently, optimized cryopreservation programmes will be essential. For non-IVF hormonal stimulation, responsible for more than one-third of all multiple pregnancies after infertility treatment, a strict ovarian stimulation protocol aiming at mono-ovulation is crucial. Multifetal pregnancy reduction is an effective method to reduce high order multiplets but carries its own risk of medical and emotional complications. Excellent data collection of all infertility treatments is needed in our discussion with policy makers. The Belgian project, in which reimbursement of assisted reproduction technology-related laboratory activities is linked to a transfer policy aiming at substantial multiple pregnancy reduction, is a good example of cost-efficient health care through responsible, well considered clinical practice.
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Affiliation(s)
- Willem Ombelet
- Genk Institute for Fertility Technology, Department of Obstetrics and Gynaecology, Genk, Belgium.
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Adashi EY, Barri PN, Berkowitz R, Braude P, Bryan E, Carr J, Cohen J, Collins J, Devroey P, Frydman R, Gardner D, Germond M, Gerris J, Gianaroli L, Hamberger L, Howles C, Jones H, Lunenfeld B, Pope A, Reynolds M, Rosenwaks Z, Shieve LA, Serour GI, Shenfield F, Templeton A, van Steirteghem A, Veeck L, Wennerholm UB. Infertility therapy-associated multiple pregnancies (births): an ongoing epidemic. Reprod Biomed Online 2004; 7:515-42. [PMID: 14686351 DOI: 10.1016/s1472-6483(10)62069-x] [Citation(s) in RCA: 117] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Eli Y Adashi
- University of Utah Health Sciences Center, Department of Obstetrics and Gynecology, Salt Lake City, Utah, USA
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Nogueira D, Albano C, Adriaenssens T, Cortvrindt R, Bourgain C, Devroey P, Smitz J. Human oocytes reversibly arrested in prophase I by phosphodiesterase type 3 inhibitor in vitro. Biol Reprod 2003; 69:1042-52. [PMID: 12773402 DOI: 10.1095/biolreprod.103.015982] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
This study addresses the role of cAMP hydrolytic isoenzyme phosphodiesterase type 3 (PDE 3) modulation on human oocyte maturation in vitro. Presence of phosphodiesterase type 3 A (PDE 3A) mRNA was confirmed in human germinal vesicle-stage (GV) oocytes. Making use of a selective PDE 3 inhibitor, Org 9935 (10 microM), oocytes retrieved from immature follicles were arrested in prophase I with a high efficiency for up to 72 h. Cumulus oocyte complexes (COCs) were retrieved in the follicular phase of the cycle before or after exposure to endogenous LH or hCG administration in vivo and randomly distributed into maturation medium with or without the PDE 3 inhibitor. Previous exposure of small follicles to LH activity in vivo had no influence on the arresting capacity of the PDE 3 inhibitor. Reversal from pharmacological arrest leads to a progression through meiosis in a normal time frame with formation of a well-aligned metaphase plate. Ultrastructure analysis of COC derived from follicles between 8 and 12 mm showed that the induced extension of prophase I arrest in vitro resulted in cytoplasm changes but not in apparent nuclear changes during culture.
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Affiliation(s)
- Daniela Nogueira
- Follicle Biology Laboratory, Dutch-Speaking Free University of Brussels (VUB), Brussels, Belgium.
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Affiliation(s)
- Jean Cohen
- Centre de Sterilite, Hospital de Sevres, Paris, France.
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Abstract
Multiple pregnancy rates remain high after assisted conception because of a misconceived assumption that transferring three or more embryos will maximize pregnancy rates. Maternal morbidity is sevenfold greater in multiple pregnancies than in singletons, perinatal mortality rates are fourfold higher for twins and sixfold higher for triplets, while cerebral palsy rates are 1-1.5% in twin and 7-8% in triplet pregnancies. Therefore, multiple pregnancies must be considered a serious adverse outcome of assisted reproductive techniques. Primary prevention of multiple pregnancies is the solution. The overwhelming evidence presented in this chapter demonstrates that limiting the embryo transfer in in vitro fertilization to two embryos would significantly reduce adverse maternal and perinatal outcomes by reducing the incidence of high order multiple pregnancies without reducing take-home-baby rates. Secondary prevention by multifetal pregnancy reduction is effective, but not acceptable to all patients. New developments in blastocyst culture, single embryo transfer, embryo cryopreservation and pre-implantation aneuploidy exclusion, should allow improvements in pregnancy rates without increasing multiple pregnancies.
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Affiliation(s)
- R C Wimalasundera
- Centre For Fetal Care, Queen Charlotte's & Chelsea Hospital, Du Cane Road, Hammersmith, London W12 0HS, UK
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Affiliation(s)
- Howard W Jones
- Jones Institute for Reproductive Medicine, Eastern Virginia Medical School, Norfolk, Virginia 23507, USA.
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Affiliation(s)
- J Smitz
- Follicle Biology Laboratory, Vrije Universiteit Brussel, Laarbeklaan 101, 1090 Brussels, Belgium.
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