Infertility: a review of 291 infertile couples over eight years

The potential of CAR T cell therapy for prostate cancer

Chimeric antigen receptor (CAR) T cell immunotherapy involves the genetic modification of the patient's own T cells so that they specifically recognize and destroy tumour cells. Considerable clinical success has been achieved using this technique in patients with lymphoid malignancies, but clinical studies that investigated treating solid tumours using this emerging technology have been disappointing. A number of developments might be able to increase the efficacy of CAR T cell therapy for treatment of prostate cancer, including improved trafficking to the tumour, techniques to overcome the immunosuppressive tumour microenvironment, as well as methods to enhance CAR T cell persistence, specificity and safety. Furthermore, CAR T cell therapy has the potential to be combined with other treatment modalities, such as androgen deprivation therapy, radiotherapy or chemotherapy, and could be applied as focal CAR T cell therapy for prostate cancer.

Unexplained infertility: a review of diagnosis, prognosis, treatment efficacy and management

The dilemma of unexplained infertility posed by Southam in 1960 remains today: despite advances in the diagnostic assessment of infertility, many couples still have no explanation for their infertility. Even the most sophisticated evaluation of semen, ovulation and genital tract competence cannot reveal all of the possible defects in the complex process leading to conception. Because it arises from these shortcomings in our knowledge of fertilization and from our inability to utilize all of the current knowledge, unexplained infertility is a challenge for both biological and clinical research. This paper attempts to summarize some clinical issues in the management of unexplained infertility: the prevalence of the disorder, problems in the definition and possible explanations for the existence of this diagnostic category. It reviews outcome-based clinical publications as a guide to decision-making on what diagnostic tests to use, provides a summary of the untreated prognosis and evaluates study results that may serve as a basis for treatment decisions in this puzzling diagnostic category of infertility.

Epidemiologic and etiologic aspects of primary infertility in the Kashmir region of India

OBJECTIVE

To assess the magnitude of primary infertility and to study its etiologic aspects in India.

DESIGN

After proper randomization, 10,063 married couples were interviewed to ascertain the prevalence of primary infertility. A definitive protocol was followed to determine the etiology of primary infertility in 250 consecutive couples.

SETTING

Tertiary care medical center in the Kashmir valley of India.

PATIENT(S)

Couples married for > or = 1 year; 250 consecutive couples attending an endocrine clinic for primary infertility.

INTERVENTION(S)

A logical investigative protocol was followed to identify the etiology of infertility.

MAIN OUTCOME MEASURE(S)

Magnitude of primary infertility in the community as well as the male, female, or combined etiology of infertility.

RESULT(S)

Fifteen percent of the couples interviewed had primary infertility, among whom 4.66% had unresolved infertility at the time of the survey. The etiology of infertility in 250 consecutive couples revealed a female factor in 57.6%, a male factor in 22.4%, combined factors in 5.2%, and an undetermined cause in 14.8%.

CONCLUSION(S)

Primary infertility is as common and distressing a problem in India as in other parts of the world. Semen abnormalities (22.4%), anovulation (17.2%), ovarian failure (8.8%), hyperprolactinemia (8.4%) and tubal disease (7.2%) are common causes of infertility. The pattern of infertility in India is the same as in other parts of the world, except that infertile couples report late for evaluation.

Age of the female partner is a prognostic factor in prolonged unexplained infertility: a multicenter study

Among 2,106 couples registered in 12 Canadian infertility clinics, 470 (22.3%) were classed as unexplained infertility after a uniform evaluation of the male ejaculate, ovulation, and tubal patency. The unexplained group included more older female partners; 44% were over 30 years of age at registration in the participating clinics, compared with 36% in other infertility diagnostic groups. The mean duration of infertility was 40.1 months, and the cumulative pregnancy rate was 36.6 +/- 2.9% at 2 years after registration. When the variables were examined with the use of proportional hazards analysis, each additional month of duration of infertility reduced the expected prognosis by 2%, and a history of pregnancy in the partnership improved the prognosis by 80%. Among couples with 3 years or more duration of infertility (cumulative pregnancy rate, 27.5 +/- 3.9%), an additional year in the age of the female partner when conception was first attempted (mean, 26.8 years) reduces the prognosis by 9%.

An analysis of the costs of infertility treatment

For 597 couples receiving care at an infertility clinic in Nova Scotia, the average cost of diagnosis and treatment per successful pregnancy is $10,700. This is compared to the costs of alternatives to infertility treatment. Adoption costs generally range from $3,000 to $10,000, and surrogate mother arrangements are much higher (around $20,000). This study demonstrates the feasibility and value of a systematic analysis of the costs of infertility.

The better prognosis in secondary infertility is associated with a higher proportion of ovulation disorders

To determine the reason for the higher pregnancy rate in couples with secondary infertility, the authors compared 237 infertile couples who had a previous pregnancy in the current partnership (secondary infertility) with 135 infertile couples in whom the woman had been pregnant only in a previous partnership and 925 couples with primary infertility. Couples with secondary infertility had the highest proportion of ovulation disorders (36%); these couples with secondary infertility and an ovulation disorder had the shortest duration of infertility (26 months). Cumulative pregnancy rates at 36 months were 56% in secondary fertility, 44% in primary infertility, and 42% in pregnancy in a previous partnership (P = 0.001). In this study, the better prognosis in secondary infertility may be related to the higher proportion of couples with ovulation disorders, who had a shorter duration of infertility. Abortion rates in the earlier pregnancies with current or previous partners were 37% and 30%, respectively; after the period of infertility, the abortion rates were 14% and 12%, respectively.

A proportional hazards analysis of the clinical characteristics of infertile couples

Evaluated were methods of ordering the many possible predictors of infertility outcome. The clinical characteristics of infertile couples were studied with respect to the occurrence of pregnancy during follow-up, by means of the methods of survival analysis. Among 1,297 couples who were infertile for 12 months or more, the cumulative pregnancy rate at 36 months with 95% confidence limits was 49% +/- 4%. The proportional hazards analysis identified three independent predictors of the occurrence of pregnancy from the couple's history (with P values in brackets): a history of pregnancy in the partnership (0.0001); shorter duration of infertility (0.0001); and shorter length of marriage (0.005). The predictors arising from the diagnostic process (with P values in brackets) were: fewer infertility diagnoses (0.0001); a favorable primary clinical diagnosis (0.001); and the presence of any tubal disease, regardless of the primary clinical diagnosis (0.001). The analysis selected an economical set of significant predictor variables and demonstrated that a longer period of contraception was associated with a lower pregnancy rate among infertile couples. Also, three simple questions from the history were nearly equivalent to the entire diagnostic process as predictors of the outcome.

Evaluation, therapy, and outcome in 493 infertile couples

From 1973 through 1979, 493 infertile couples were evaluated for their infertility problem, allowing for a minimum follow-up of 1 year and a maximum follow-up of 7 years. Accurate records were kept on margin-punched cards for easy review and updating. Ovulation defects; male factor problems, and tubal disease accounted for 60% of the diagnosed causes of infertility. No diagnosis was made in 25% of the patients studied. Therapy began as soon as indicated and continued concurrently as the diagnostic evaluation progressed. Among the 493 infertile couples, 257 (52%) patients had a successful outcome; 90% of this group conceived by 1 year after the initial visit. One hundred thirty-seven patients underwent both hysterosalpingography and laparoscopy during their diagnostic evaluation. The interpretation of the hysterosalpingogram was wrong in about one third of the cases. Of 37 (7.5%) undiagnosed patients who underwent complete evaluation, including visualization of the pelvis by either laparoscopy or laparotomy, only 12 eventually conceived, 11 by the end of 1 year from the initial visit.

Patterns of adnexal inflammatory damage: Chlamydia, the intrauterine device, and history of pelvic inflammatory disease

In a study of 204 consecutive infertile couples, 58 women with adnexal abnormalities consistent with prior pelvic infection were identified. The status of those 58 subjects with respect to prior pelvic infection, prior intrauterine device use, and serologic evidence of past chlamydial infection was correlated with the types of adnexal abnormalities identified. Women with serologic evidence of past chlamydial infection were more likely to exhibit severe adhesions and hydrosalpinx formation, and hydrosalpinx formation was related to a history of clinically detected pelvic infection.

The incidence and outcome of single-factor, multifactorial, and unexplained infertility

Infertility may have many etiologies. Of 141 systematically and completely evaluated couples, 40.4% were found to have multiple factors contributing to their inability to conceive. In 33.3% two factors were present, and in 7.1% three or more factors were found. A total of 53.2% of patients had a single identified factor, and in 6.4% no apparent cause was identified. Long-term pregnancy rates calculated by life-table methodology revealed no significant differences between those with single-factor, multifactorial, or unexplained infertility when all identified factors were treated.

Peritoneal fluid prostanoids in unexplained infertility

Elevated peritoneal fluid thromboxane B2 and 6-keto-prostaglandin F1 alpha have been reported in patients with biopsy-proved endometriosis. In this paper these peritoneal fluid prostanoids were measured in patients with unexplained infertility and a fertile control group matched for age and day of the menstrual cycle. A subgroup of the women with unexplained infertility demonstrated a marked elevation of both prostanoids (p less than 0.01). These elevations may serve to identify women in whom undetected endometriosis or some other peritoneal irritant is associated with infertility.

Nuclear progesterone uptake by endometrial tissue in cases of subfertility

To investigate the ability of steroid hormones to interact with endometrium, particularly in cases of unexplained subfertility, intact cells were incubated with tritiated progesterone and oestradiol and their uptake into the nuclei was measured. Samples were taken at dilatation and curettage from 23 fertile women, 14 women with unexplained primary subfertility, and 9 patients whose primary subfertility could be explained. Serum oestradiol and progesterone levels were not significantly different between the three groups, nor were values of 3H-oestradiol uptake. However, low (below 5 pmol/mg DNA) values for nuclear 3H-progesterone uptake were present in most samples from women with unexplained subfertility but in only about half of the women in the other two groups. This biochemical defect may be the cause of some cases of unexplained subfertility.

Menstrual pattern and fertility after treatment for anovulatory infertility

Sixty-four patients who had been treated for anovulatory infertility and subsequently conceived were reviewed. Information was obtained on subsequent menstrual pattern, contraception used, treatment required to achieve a further pregnancy and the interval to any such pregnancy. Almost half the group had regular cycles following delivery but 2 patients had a recurrence of post oral contraceptive amenorrhoea. Most patients conceived without treatment within 2 years of the initial pregnancy but 10 again required ovulation induction. It is concluded that there is no long-term irreversible suppression of hypothalamic function in this group of patients and, once a pregnancy has been achieved, the prognosis for future fertility without therapy is good.

Correlation between serum antichlamydial antibodies and tubal factor as a cause of infertility

Although salpingitis frequently produces tubal damage and infertility, many women with tubal factor as a cause of their infertility do not have a clinical history of salpingitis. In order to investigate whether or not some such cases might be due to subclinical chlamydial infections, we measured antichlamydial antibodies in the serum of 172 women consecutively undergoing evaluation for infertility. Only 16 (9.3%) had a prior history of salpingitis. Sixty-one (35%) had antichlamydial antibodies (S+), and of these 75% had tubal factor as a sole or contributing cause of their infertility, versus 28% of the seronegative (S-) women (x2 - 34, P less than 0.001). There was no association between chlamydial seropositivity and any infertility factor other than tubal factor in multivariant analyses. Subclinical infections with Chlamydia trachomatitis may be a major cause of tubal infertility in the United States, and chlamydial serologic studies may be useful in identifying the subset of infertile women likely to have tubal factor.

The incidence, characteristics, and prognosis of patients whose infertility is unexplained

Review of the case records of 500 consecutive couples attending one Scottish infertility clinic revealed a group of patients whose infertility remained unexplained after completion of a standard protocol of investigations. The incidence of this condition in the clinic population was 24%. Various patient characteristics were examined, and no differences from patients with a detectable, organic cause for their infertility were found. Life-table analysis was used to provide a prognostic guide for such couples. About 34% of those with primary infertility and 21% of those with secondary infertility will remain infertile after 9 years of attempting to conceive.