The 2004 Italian legislation regulating assisted reproduction technology: a multicentre survey on the results of IVF cycles

Assisted Reproductive Technology without Embryo Discarding or Freezing in Women ≥40 Years: A 5-Year Retrospective Study at a Single Center in Italy

The protocols commonly used in assisted reproductive technology (ART) consist of long-term embryo culture up to the blastocyst stage after the insemination of all mature oocytes, the freezing of all the embryos produced, and their subsequent transfer one by one. These practices, along with preimplantation genetic testing, although developed to improve the live birth rate (LBR) and reduce the risk of multiple pregnancies, are drawing attention to the possible increase in obstetric and perinatal risks, and adverse epigenetic consequences in offspring. Furthermore, ethical-legal concerns are growing regarding the increase in cryopreservation and storage of frozen embryos. In an attempt to reduce the risk associated with prolonged embryo culture and avoid embryo storage, we have chosen to inseminate a limited number of oocytes not exceeding the number of embryos to be transferred, after two days or less of culture. We retrospectively analyzed 245 ICSI cycles performed in 184 infertile couples with a female partner aged ≥40 from January 2016 to July 2021. The results showed a fertilization rate of 95.7%, a miscarriage rate of 48.9%, and a LBR of 10% with twin pregnancies of 16.7%. The cumulative LBR in our group of couples was 13%. No embryos were frozen. In conclusion, these results suggest that oocyte selection and embryo transfer at the cleaving stage constitute a practice that has a LBR comparable to that of the more commonly used protocols in older women who have reduced ovarian reserve.

High-security closed devices are efficient and safe to protect human oocytes from potential risk of viral contamination during vitrification and storage especially in the COVID-19 pandemic

PURPOSE

The main purpose and research question of the study are to compare the efficacy of high-security closed versus open devices for human oocytes' vitrification.

METHODS

A prospective randomized study was conducted. A total of 737 patients attending the Infertility and IVF Unit at S.Orsola University Hospital (Italy) between October 2015 and April 2020 were randomly assigned to two groups. A total of 368 patients were assigned to group 1 (High-Security Vitrification™ - HSV) and 369 to group 2 (Cryotop® open system). Oocyte survival, fertilization, cleavage, pregnancy, implantation, and miscarriage rate were compared between the two groups.

RESULTS

No statistically significant differences were observed on survival rate (70.3% vs. 73.3%), fertilization rate (70.8% vs. 74.9%), cleavage rate (90.6% vs. 90.3%), pregnancy/transfer ratio (32.0% vs. 31.8%), implantation rate (19.7% vs. 19.9%), nor miscarriage rates (22.1% vs. 21.5%) between the two groups. Women's mean age in group 1 (36.18 ± 3.92) and group 2 (35.88 ± 3.88) was not significantly different (P = .297). A total of 4029 oocytes were vitrified (1980 and 2049 in groups 1 and 2 respectively). A total of 2564 were warmed (1469 and 1095 in groups 1 and 2 respectively). A total of 1386 morphologically eligible oocytes were inseminated by intracytoplasmic sperm injection (792 and 594 respectively, P = .304).

CONCLUSIONS

The present study shows that the replacement of the open vitrification system by a closed one has no impact on in vitro and in vivo survival, development, pregnancy and implantation rate. Furthermore, to ensure safety, especially during the current COVID-19 pandemic, the use of the closed device eliminates the potential samples' contamination during vitrification and storage.

Risk Factors for Monozygotic Twins in IVF-ICSI Cycles: a Case-Control Study

In vitro fertilization (IVF) is associated with a higher incidence of monozygotic twin pregnancies, which are known to be burdened by a higher risk of main obstetric complications. The reasons behind this association are still unclear. In the present study, we therefore investigate the risk factors for monozygotic twinning in pregnancies achieved by IVF. We conducted a multicenter retrospective case-control study. All IVF cycles performed between 2014 and 2019 at the infertility units of two Italian academic institutes were retrospectively reviewed. Only pregnancies obtained with single embryo transfer were eligible. A total of 50 monozygotic twin pregnancies (cases) were identified and matched in a 1:5 ratio to 250 singleton pregnancies (controls) by study center and study period. Monozygotic twin pregnancies were diagnosed by ultrasound. Women experiencing miscarriage could be included provided that the pregnancy loss occurred after a definitive diagnosis of monozygotic twin pregnancy. Demographic, clinical, and embryological characteristics were retrieved from patients' charts. Overall, the incidence of monozygotic twin pregnancies was 1.2% (50 out of 4016 single embryo transfers). At univariate analyses, statistically significant differences emerged for BMI, peripheral levels of estradiol and progesterone at the time of hCG administration, total number of retrieved suitable oocytes, freezing-thawing cycles, and assisted hatching. After performing a multivariate logistic analysis, only assisted hatching remained significantly associated with monozygotic twinning (adjusted odds ratio 2.32, 95%CI 1.03-5.25). Blastomere separation during the passage through this artificial hole or interference with the signaling pathway within the embryo could be the mechanisms involved.

Recent advances in the field of ovarian tissue cryopreservation and opportunities for research

PURPOSE

The purpose of this study was to summarize the latest advances and successes in the field of ovarian tissue cryopreservation while identifying gaps in current knowledge that suggest opportunities for future research.

METHODS

A systematic review was performed according to PRISMA guidelines for all relevant full-text articles in PubMed published in English that reviewed or studied historical or current advancements in ovarian tissue cryopreservation and auto-transplantation techniques.

RESULTS

Ovarian tissue auto-transplantation in post-pubertal women is capable of restoring fertility with over 80 live births currently reported with a corresponding pregnancy rate of 23 to 37%. The recently reported successes of live births from transplants, both in orthotopic and heterotopic locations, as well as the emerging methods of in vitro maturation (IVM), in vitro culture of primordial follicles, and possibility of in vitro activation (IVA) suggest new fertility options for many women and girls. Vitrification, as an ovarian tissue cryopreservation technique, has also demonstrated successful live births and may be a more cost-effective method to freezing with less tissue injury. Further, transplantation via the artificial ovary with an extracellular tissue matrix (ECTM) scaffolding as well as the effects of sphingosine-1-phosphate (SIP) and fibrin modified with heparin-binding peptide (HBP), heparin, and a vascular endothelial growth factor (VEGF) have demonstrated important advancements in fertility preservation. As a fertility preservation method, ovarian tissue cryopreservation and auto-transplantation are currently considered experimental, but future research may pave the way for these modalities to become a standard of care for women facing the prospect of sterility from ovarian damage.

Reduction of multiple pregnancies in the advanced maternal age population after implementation of an elective single embryo transfer policy coupled with enhanced embryo selection: pre- and post-intervention study

STUDY QUESTION

Is an elective single-embryo transfer (eSET) policy an efficient approach for women aged >35 years when embryo selection is enhanced via blastocyst culture and preimplantation genetic screening (PGS)?

SUMMARY ANSWER

Elective SET coupled with enhanced embryo selection using PGS in women older than 35 years reduced the multiple pregnancy rates while maintaining the cumulative success rate of the IVF programme.

WHAT IS KNOWN ALREADY

Multiple pregnancies mean an increased risk of premature birth and perinatal death and occur mainly in older patients when multiple embryos are transferred to increase the chance of pregnancy. A SET policy is usually recommended in cases of good prognosis patients, but no general consensus has been reached for SET application in the advanced maternal age (AMA) population, defined as women older than 35 years. Our objective was to evaluate the results in terms of efficacy, efficiency and safety of an eSET policy coupled with increased application of blastocyst culture and PGS for this population of patients in our IVF programme.

STUDY DESIGN, SIZE, DURATION

In January 2013, a multidisciplinary intervention involving optimization of embryo selection procedure and introduction of an eSET policy in an AMA population of women was implemented. This is a retrospective 4-year (January 2010–December 2013) pre- and post-intervention analysis, including 1161 and 499 patients in the pre- and post-intervention period, respectively. The primary outcome measures were the cumulative delivery rate (DR) per oocyte retrieval cycle and multiple DR.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Surplus oocytes and/or embryos were vitrified during the entire study period. In the post-intervention period, all couples with good quality embryos and less than two previous implantation failures were offered eSET. Embryo selection was enhanced by blastocyst culture and PGS (blastocyst stage biopsy and 24-chromosomal screening). Elective SET was also applied in cryopreservation cycles.

MAIN RESULTS AND THE ROLE OF CHANCE

Patient and cycle characteristics were similar in the pre- and post-intervention groups [mean (SD) female age: 39.6 ± 2.1 and 39.4 ± 2.2 years; range 36–44] as assessed by logistic regression. A total of 1609 versus 574 oocyte retrievals, 937 versus 350 embryo warming and 138 versus 27 oocyte warming cycles were performed in the pre- and post-intervention periods, respectively, resulting in 1854 and 508 embryo transfers, respectively. In the post-intervention period, 289 cycles were blastocyst stage with (n = 182) or without PGS (n = 107). A mean (SD) number of 2.9 ± 1.1 (range 1–4) and 1.4 ± 0.8 (range 1–3) embryos were transferred pre- and post-intervention, respectively (P < 0.01) and similar cumulative clinical pregnancy rates per transfer and per cycle were obtained: 26.8, 30.9% and 29.7, 26.3%, respectively. The total DR per oocyte retrieval cycle (21.0 and 20.4% pre- and post-intervention, respectively) defined as efficacy was not affected by the intervention [odds ratio (OR) = 0.8, 95% confidence interval (CI) = 0.7–1.1; P = 0.23]. However, a significantly increased live birth rate per transferred embryo (defined as efficiency) was observed in the post-intervention group 17.0 versus 10.6% (P < 0.01). Multiple DRs decreased from 21.0 in the preintervention to 6.8% in the post-intervention group (OR = 0.3. 95% CI = 0.1–0.7; P < 0.01).

LIMITATIONS, REASONS FOR CAUTION

In this study, the suitability of SET was assessed in individual women on the basis of both clinical and embryological prognostic factors and was not standardized. For the described eSET strategy coupled with an enhanced embryo selection policy, an optimized culture system, cryopreservation and aneuploidy screening programme is necessary.

WIDER IMPLICATIONS OF THE FINDINGS

Owing to the increased maternal morbidity and perinatal complications related to multiple pregnancies, it is recommended to extend the eSET policy to the AMA population. As shown in this study, enhanced embryo selection procedures might allow a reduction in the number of embryos transferred and the number of transfers to be performed without affecting the total efficacy of the treatment but increasing efficiency and safety.

STUDY FUNDING/COMPETING INTEREST(S)

None.

TRIAL REGISTRATION NUMBER

None.

Five years (2004-2009) of a restrictive law-regulating ART in Italy significantly reduced delivery rate: analysis of 10,706 cycles

STUDY QUESTION

Was the delivery rate of ART cycles negatively affected by the enactment of the Law 40/2004 by the Italian Parliament which imposed a long list of restrictions for ART procedures?

SUMMARY ANSWER

This large and extensive comparative analysis of ART outcomes prior to and after the introduction of the Law 40 revealed a significant reduction in pregnancy and delivery rates per cycle, independent of age or other clinical variables, once the law went into effect.

WHAT IS KNOWN ALREADY

Several studies have been published on the effect of Law 40/2004 on ART outcomes, some authors demonstrating a negative impact of the Law in relation to specific etiologies of infertility, other authors showing opposite conclusions.

STUDY DESIGN, SIZE, DURATION

Retrospective clinical study of 3808 patients treated prior to the enactment of the Law, September 1996-March 2004 (Group I) and 6898 treated during the Law, March 2004-May 2009 (Group II).

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 10 706 ART cycles were analysed, 3808 performed before and 6898 after the application of the Law. An intention-to-treat statistical analysis was performed to detect pregnancy and delivery rates (pregnancies ≥ 24 weeks) per started cycle. A P value of <0.05 was considered statistically significant. We analysed different outcomes: differences in fertilization, pregnancy and delivery rate, multiple pregnancies and miscarriage rates between the two time periods.

MAIN RESULTS AND THE ROLE OF CHANCE

The delivery rate for started cycle was 20% before and 16.0% after the introduction of the Law representing a 25% reduction (P < 0.001). The multivariate analysis, corrected by female age of >38 years, duration of infertility, basal FSH level and number of retrieved oocytes, showed a 16% lower delivery rate (odds ratio: 0.84; confidence interval: 0.75-0.94). This statistical approach removed the risk that the observed effects were due to chance and confirmed unequivocally that the Law was an independent factor responsible for the reduced likelihood of a successful outcome.

LIMITATIONS, REASONS FOR CAUTION

This is a retrospective study. A prospective randomized study, with patients treated in the same time period and randomized to restrictions or not, would have minimized potential limitations due to differences in years of treatments.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings based on the analysis of such a large number of cycles proved clearly and unequivocally that imposing restrictions on the practice of ART penalized patients. These data represent a relevant clinical contribution for countries still debating the enactment of restrictive limitations of ART.

Markers of stem cells in human ovarian granulosa cells: is there a clinical significance in ART?

Background

The purpose of the study was to determine the incidence of gene expression of Oct-4 and DAZL, which are typical markers for stem cells, in human granulosa cells during ovarian stimulation in women with normal FSH levels undergoing IVF or ICSI and to discover any clinical significance of such expression in ART.

Methods

Twenty one women underwent ovulation induction for IVF or ICSI and ET with standard GnRH analogue-recombinant FSH protocol. Infertility causes were male and tubal factor. Cumulus–mature oocyte complexes were denuded separately and granulosa cells were analyzed for each patient separately using quantitative reverse-transcription–polymerase chain reaction analysis for Oct-4 and DAZL gene expression with G6PD gene as internal standard.

Results

G6PD and Oct-4 mRNA was detected in the granulosa cells in 47.6% (10/21). The median of Oct-4 mRNA/G6PD mRNA was 1.75 with intra-quarteral range from 0.10 to 98.21. The OCT-4 mRNA expression was statistically significantly correlated with the number of oocytes retrieved; when the Oct-4 mRNA expression was higher, then more than six oocytes were retrieved (p=0.037, Wilcoxon rank-sum). No detection of DAZL mRNA was found in granulosa cells. There was no additional statistically significant correlation between the levels of Oct-4 expression and FSH basal levels or estradiol peak levels or dosage of FSH for ovulation induction. No association was found between the presence or absence of Oct-4 mRNA expression in granulosa cells and ovarian response to gonadotropin stimulation. Also, no influence on pregnancy was observed between the presence or absence of Oct-4 mRNA expression in granulosa cells or to its expression levels accordingly.

Conclusions

Expression of OCT-4 mRNA, which is a typical stem cell marker and absence of expression of DAZL mRNA, which is a typical germ cell marker, suggest that a subpopulation of luteinized granulosa cells in healthy ovarian follicles (47.6%) consists of stem cells, which are not originated from primordial germ cells. Absence of Oct-4 gene expression in more than half of the cases means probably the end of the productive journey of these cells, towards the oocyte.

Results and unsolved problems following the amendment to the Italian Law on assisted reproduction brought about by the Constitutional Court

Since the approval of Law N° 40/2004, Italian specialists have been applying assisted reproductive techniques in compliance with a number of restrictions. Several attempts were made to find a solution to the practical and ethical issues brought about by this restrictive legislation. Finally, in May 2009, the Italian Constitutional Court banned most of the limitations. In the last year the authors worked together to study the impact of the Italian Constitutional Court modifications on assisted reproduction from both a gynecological and medico-legal point of view. Despite the clinically positive impact of the ruling, a lot of technical and legal unsolved issues still exist. Analyzing these problems, the authors stress the importance of a multidisciplinary approach to achieve adequate legislation in order to improve patients' outcome and avoid "reproductive migration" from Italy to other European Countries. New regulation could also be important for practitioners by keeping the risk of legal troubles to the minimum.

The 2004 Italian legislation on the application of assisted reproductive technology: epilogue

OBJECTIVE

To evaluate how the unique Italian fertility regulations (≤3 inseminated oocytes/cycle, transfer of all embryos, prohibition of embryo cryopreservation) affected outcomes of ART.

STUDY DESIGN

Case-control study from the Center of Reproductive Medicine, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy. We compared outcomes of ART patients between five years before (n=1791) and five years after (n=2474) the implementation of the law.

RESULTS

The mean embryo transfer (ET) rate was 3.1±2.1 and 1.7±1.1 before and after the law. Significantly more ICSI procedures were performed in women above 35 years old during the post-law period. The ET rate was higher before (88.6%) than after (80.5%) the law (OR 1.9, 95% CI 1.6, 2.2) especially in women >37 years undergoing ICSI (88.2 vs. 76.1%; OR 2.3, 95% CI 1.3, 4.2). The clinical pregnancy rates were practically unchanged but the proportion of triplet births significantly decreased after the law (10.3 vs. 4.1%, OR 2.7, 95% CI 1.4, 5.0).

CONCLUSION

In contrast to interim analyses, we found that the statutory obligation to transfer all available embryos produced from up to three inseminated oocytes reduced the ET rates, especially in older women, and decreased the triplet births rate.

Egg dates sperm: a tale of a practice change and its stabilization

The aim of this article is to enlarge practice-based studies to the consideration of institutional environment and institutional work, opening a dialogue with neo-institutionalism and, in so doing, advance the growing field of sociology of practice. This study attempts to do this by answering the question: how does a change in a practice become stabilized and what does the new practice do, once stabilized? Within practice-based studies, most studies have considered mainly endogenous changes, emergent from the community of practitioners under study. By contrast, this study discusses an exogenous change (a recent Italian law limits medically assisted reproduction practices) and the emergent relations that stabilize a provisional new practice through negotiation within the institutional context. Stabilization of a new practice is achieved by limitation, by rhetorical closure and by anchoring in technology. The aim of the article is to show the unintended power effects that a new practice generates once stabilized.

Developmental potential of human oocytes after slow freezing or vitrification: a randomized in vitro study based on parthenogenesis

The aim of the this study was to compare the in vitro developmental competence of parthenogenetically activated oocytes cryopreserved with slow-freezing or vitrification. Supernumerary metaphase II oocytes obtained during in vitro fertilization procedures were randomized to slow freezing or vitrification procedure. After thawing or devitrification, oocytes were parthenogenetically activated and cultured. Survival, activation, development rate, and cell number during culture were compared. The 2 groups showed no significant differences between the rates of parthenogenetic activation, development, good quality parthenotes and blastomere number on day 2 of culture. However, parthenotes from the devitrified oocytes continued cleaving till day 3 in a significantly low proportion (27% vs. 42%). On day 3, the mean number of blastomeres was also lower in vitrification group compared to slow-freezing (4.8 + 1.9 vs. 5.8 + 1.7). In conclusion, parthenogenesis highlights a reduced potential of vitrified oocytes to cleave on day 3 compared with oocytes from slow-freezing.

RFD Award Lecture 2009. In vitro maturation of farm animal oocytes: a useful tool for investigating the mechanisms leading to full-term development

Due to logistical and economic reasons, assisted reproduction of domestic animals has been based mostly on the use of oocytes isolated from ovaries collected at the slaughterhouse. In order to propagate valuable or rare genetic material, perform somatic cell nuclear transfer or generate genetically modified animals, it is essential to obtain fully competent oocytes that will allow full-term development of the in vitro-produced embryos. Such a need makes clear the crucial role played by oocyte quality. In fact, it is easy to compromise the oocyte's developmental potential but it is impossible to restore once it has been lost. Almost three decades after the first cow, sheep, goat, horse and pig in vitro-generated offspring were born, a large body of information has accumulated on the mechanisms regulating oocyte competence and on how the latter may be preserved during all the required manipulations. The amount of knowledge is far from complete and many laboratories are actively working to further expand it. In this review we will highlight the aspects of the ongoing research in which we have been actively involved.

Ultra-rapid vitrification of mouse oocytes in low cryoprotectant concentrations

The ideal cryopreservation protocol would combine the benefits of slow freezing with the benefits of vitrification. This report describes a method for the ultra-rapid vitrification of oocytes using slush nitrogen in quartz capillaries. The approach minimizes the thermal mass of the vitrification vessel by using open microcapillaries made of highly conductive quartz and achieves cooling rates of 250,000 degrees C/min. The process of vitrification can be optimized by maximizing the rate at which the sample is cooled, which allows for the use of lower cryoprotectant concentrations. Mouse oocytes can be successfully vitrified using 1.5 mol/l 1,2-propanediol and 0.5 mol/l trehalose and achieve survival rates of 90.0%(36/40). Fertilization and blastocyst formation rates of vitrified-warmed and fresh oocytes were not significantly different. A total of 120 blastocysts from each of the vitrified-warmed and fresh oocytes were transferred to surrogate mothers and 23 and 27 offspring were born respectively. All offspring in both groups were healthy, grew and bred normally and gave rise to a second generation of pups. Thus, an ultra-rapid vitrification technique has been developed for mouse oocytes that uses low concentrations of cryoprotectants and slush nitrogen in quartz capillaries, which combines the benefits of slow freezing and vitrification.

The effect of the 2004 Italian law on outcomes of assisted reproduction technology in severe male factor infertility

The Italian law regulating assisted reproductive technologies that came into force in 2004 restricts the number of fertilized oocytes per cycle to three, obliges the subsequent transfer of all resulting embryos and prohibits the freezing of surplus embryos. This study evaluates the impact of the law on severe oligozoospermic, cryptozoospermic, obstructive azoospermic and non-obstructive azoospermic patients. Intracytoplasmic sperm injection outcomes of 1066 cycles performed in the 4years before the passing of the law were compared with 804 cycles performed in the 4years after the law came to pass. Globally, analysis of clinical and obstetric outcomes showed a significant decrease in terms of pregnancy and delivery rates per cycle (17.8% versus 10.9% and 14.2% versus 8.5%, respectively) and per embryo transfer (18.8% versus 13.8% and 15.0% versus 10.7%, respectively), and a significant drop in multiple deliveries (35.1% versus 17.6%) in the post-law period. Cryptozoospermic and azoospermic couples were affected by the Italian law more than severe oligozoospermic couples. The results showed that the Italian law limits the efficiency of assisted reproduction treatment in couples with severe male factor. It is hoped that the Italian assisted reproductive technologies law is altered as soon as possible, allowing the insemination of more than three oocytes.

Cell lines derived from human parthenogenetic embryos can display aberrant centriole distribution and altered expression levels of mitotic spindle check-point transcripts

Human parthenogenetic embryos have recently been proposed as an alternative, less controversial source of embryonic stem cell (ESC) lines; however many aspects related to the biology of parthenogenetic embryos and parthenogenetic derived cell lines still need to be elucidated. We present here results on human cell lines (HP1 and HP3) derived from blastocysts obtained by oocyte parthenogenetic activation. Cell lines showed typical ESC morphology, expressed Oct-4, Nanog, Sox-2, Rex-1, alkaline phosphatase, SSEA-4, TRA 1-81 and had high telomerase activity. Expression of genes specific for different embryonic germ layers was detected from HP cells differentiated upon embryoid body (EBs) formation. Furthermore, when cultured in appropriate conditions, HP cell lines were able to differentiate into mature cell types of the neural and hematopoietic lineages. However, the injection of undifferentiated HP cells in immunodeficient mice resulted either in poor differentiation or in tumour formation with the morphological characteristics of myofibrosarcomas. Further analysis of HP cells indicated aberrant levels of molecules related to spindle formation as well as the presence of an abnormal number of centrioles and autophagic activity. Our results confirm and extend the notion that human parthenogenetic stem cells can be derived and can differentiate in mature cell types, but also highlight the possibility that, alteration of the proliferation mechanisms may occur in these cells, suggesting great caution if a therapeutic use of this kind of stem cells is considered.

The effect of the 2004 Italian legislation on perinatal outcomes following assisted reproduction technology

OBJECTIVE

To assess the perinatal outcomes of the first three years under the 2004 Italian reproductive legislation obligating transfer of all embryos resulting from insemination of < or =3 oocytes.

STUDY DESIGN

We compared the perinatal results of clinical assisted reproductive technology (ART) pregnancies during the three years following the new Italian legislation with the previous three years.

RESULTS

There were 583 and 571 clinical pregnancies during the respective periods. Before the law, the overall embryonic and fetal loss rates were significantly higher resulting in a significantly lower rate of live born infants and significantly fewer clinical pregnancies with at least one live born infant. Quadruplet and quintuplet pregnancies were entirely eliminated following the 2004 law but the neonatal mortality rate was not different between the two study periods.

CONCLUSION

The 2004 Italian infertility legislation led to improved quantitative and qualitative outcomes of ART.

Co-transfer of embryos derived from cryopreserved and fresh natural cycle oocytes: a pilot study

Italian legislation regarding reproductive medicine prohibits embryo storage while allowing cryopreservation of supernumerary oocytes. This study evaluated the effect of fresh oocytes obtained from natural unstimulated cycles on the clinical success rates derived from the use of frozen-thawed (FR-TH) oocytes obtained following ovarian stimulation. For 36 women, intracytoplasmic sperm injection was performed on FR-TH oocytes supplemented by a fresh oocyte, if available, derived from a natural cycle in which gonadotrophin-releasing hormone-antagonist was used for premature LH surge control. The retrieval rate of fresh oocytes was 61.1% and survival rate of FR-TH oocytes was 43.6%. The fertilization rate of fresh and FR-TH oocytes was 70% and 52.5%, respectively. Fifty embryos were transferred, 14 of them developed from fresh oocytes and 36 from FR-TH oocytes. Six pregnancies occurred in 10 cycles in which the embryos developed from fresh and FR-TH oocytes (pregnancy rate 60.0%) and two in 12 patients in whom the embryos were obtained from only FR-TH oocytes (pregnancy rate 16.7%) (P < 0.05). In summary, the data demonstrate that the transfer of embryos derived from oocytes cryopreserved following a previous ovarian stimulation and an embryo developed from a fresh one retrieved in natural cycle ensures an excellent clinical outcome.

Assisted reproductive technology: official data on the application of the Italian law

In 2004, the Italian parliament enacted Law 40/2004, which established new rules for assisted reproductive technology and included a very long and detailed list of restrictions. Since its enactment, the law has given rise to heated discussion at a national and international scientific level. In June 2007 a report presented to the Italian parliament published data from the National Institute of Health regarding the application of the law in 2005. From an overall comparison of data from the years 2003 (before Law 40/2004) and 2005, it emerges that the situation has been significantly altered by the application of this law. These data clearly demonstrate a drop in the percentage of pregnancies, and a consequent drop in the number of children born; a higher percentage of treatments that do not reach the transfer stage or that have a low possibility of success (non-elective embryo transfer); a decrease in the number of oocytes inseminated but an increase in the number of embryos transferred; a higher incidence of multiple births, with consequent immediate and future negative effects for the children and their mother; an increase in the number of pregnancies with a negative outcome.

Parthenotes as a source of embryonic stem cells

The derivation and study of human embryonic stem cell lines, despite their potential therapeutic usefulness, raise considerable ethical, religious, legal and political concerns because it inevitably leads to the destruction of viable embryos. In an attempt to bridge the division between ethical questions and potential scientific and medical benefits, considerable efforts have been devoted to the search for alternative sources of pluripotent cell lines. In this review we discuss the use of artificial parthenogenesis as a way to create entities, called parthenotes, that may represent an alternative ethical source for pluripotent cell lines. We describe the biological differences between parthenotes and embryos, in order to provide a rationale for the discussion on whether their use can be acceptable as a source of stem cells. We present data derived from animal models on the extent parthenogenetic stem cells are similar to biparental cell lines and discuss these aspects in the context of their extension to the human species. Finally, we present experiments recently carried out in our laboratory that allowed us to generate human parthenotes through artificial activation of human oocytes and to use them as a source for the derivation of parthenogenetic pluripotent cell lines.

The effect of selecting oocytes for insemination and transferring all resultant embryos without selection on outcomes of assisted reproduction

OBJECTIVE

To evaluate the effect of selecting three best oocytes for insemination and transfer of all resultant embryos on outcomes of assisted reproductive technologies (ART).

STUDY DESIGN

Comparative study.

SETTING

The Center of Reproductive Medicine, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy.

PATIENT(S)

Women undergoing ART during the period March 10, 2004 to March 9, 2006.

INTERVENTION(S)

Comparing outcomes of ART following transfers of 3 "excellent" (n = 267) embryos and cycles in which none of the embryos was considered "excellent quality" (n = 176).

MAIN OUTCOME MEASURE(S)

Rates of fertilization, pregnancy, "take-home baby," and multiple pregnancies.

RESULTS

The average number of retrieved oocytes and the average number of inseminated oocytes of good quality were similar in both groups. Intracytoplasmic sperm injection was performed four to five times more often in cycles without "excellent quality" irrespective of the patient's age (odds ratio 4.6, 95% confidence interval 3.0, 7.1). The two groups had similar rates of implantation, total pregnancies/ET, clinical intrauterine pregnancy, singleton and multiple births, and "take-home" baby rate. This similarity persisted irrespective of the patient's age.

CONCLUSION(S)

The selection of oocytes for insemination and transfer of all available embryos irrespective of their quality did not change outcomes of ART.

Results of in vitro fertilization in Italy after the introduction of a new law

OBJECTIVE

To investigate the consequences of a law introduced in Italy in 2004 that forbids the fertilization or injection of more than three oocytes for assisted reproduction and does not allow any embryo selection or cryopreservation.

DESIGN

Retrospective observational analysis.

SETTING

Subfertile patients enrolled in an assisted reproduction program.

PATIENT(S)

Before the introduction of the law there were 1,179 cycles and after its enactment there were 1,860 cycles in 1,619 subfertile couples.

INTERVENTION(S)

Ovarian stimulation for IVF/intracytoplasmic sperm injection (ICSI) attempts.

MAIN OUTCOME MEASURE(S)

Pregnancy and implantation rate.

RESULT(S)

Pregnancy rates (PR) per cycle (24.34% vs. 23.11%), per retrieval (28.64% vs. 25.65%), per transfer (31.37% vs. 27.74%), and the take-home babies per started cycle (19.1% vs. 18%) was not significantly different between the two periods. After introduction of the law, the PR significantly decreased in patients whose total motile sperm count was <1 x 10(6) (40.85% vs. 23.62%) and in patients receiving two embryos (35.71% vs. 23.53%). This difference was mostly the result of a reduced PR in patients <36 years old receiving two unselected embryos (41.16% vs. 30.90%). This result was, however, obscured by the higher proportion of patients <36 years (3.9% vs. 45.12%) receiving three embryos after the enactment of the law, which lead to a significantly higher PR (28.73% vs. 37.56%) and a consequent significantly higher triplet rate (0.58% vs. 4.71%).

CONCLUSION(S)

Women in whom elective transfer of two embryos was allowed before passing the law and couples with a severe male infertility factor had significantly reduced success rates. Although the overall PR did not change after the new law, if the transfer of frozen embryos is not considered, this was mainly the result of a higher number of embryos transferred into women <36 years old. This study shows how the negative effects of the new law are obscured by the transfer of a higher number of embryos in younger patients, resulting in a higher PR at the cost of a significantly higher triplet rate.

Association between human oocyte developmental competence and expression levels of some cumulus genes

At present, oocyte selection is mainly based upon morphological criteria but it is generally acknowledged that its reliability requires further improvement. The aim of this study was to determine whether transcript levels in cumulus cells can provide a useful marker of oocyte developmental competence in vitro. A retrospective study was performed on cumulus cells isolated from 90 oocytes retrieved from 45 patients. Upon fertilization, 35 oocytes originated good-quality embryos and 36 developed into poor-quality embryos, whereas 19 failed to be fertilized. Semi-quantitative measurement of hyaluronic acid synthase 2 (HAS2), gremlin1 (GREM1), and pentraxin 3 (PTX3) mRNAs was performed and data for all genes were obtained from all the samples. Cumulus cells isolated from oocytes that originated high-quality embryos on day 3 of culture had HAS2 and GREM1 transcript levels higher than those detected in cells from oocytes that did not fertilize or developed into poor-quality embryos. No differences were observed in PTX3 levels. Results indicate that the measurement of HAS2 and GREM1 levels in cumulus cells would reliably complement the morphological evaluation providing a useful tool for selecting oocytes with greater chances to be fertilized and develop in vitro.

[In vitro fertilization (IVF): why doing it in stimulated cycles?]

Assisted reproductive technology is a difficult course for the couples. Our purpose is to be effective without damaging the patient and the child to be born. The cumulative rates of success are strictly dependent on the number of oocytes and on the obtained top quality embryos and thus on the realization of an effective stimulation. The risk of multiple pregnancies can be adjusted by an adapted policy of transfer. The transfer of a fresh embryo followed by cycles of frozen embryos transfers gives very satisfactory cumulative pregnancy rates.

The effect of legislation on outcomes of assisted reproduction technology: lessons from the 2004 Italian law

OBJECTIVE

To evaluate the effect of the 2004 Italian regulations (insemination of <or=3 oocytes/cycle, transfer of all embryos, prohibition of embryo cryopreservation) on outcomes of assisted reproduction treatment (ART).

DESIGN

Case-control study.

SETTING

The Center of Reproductive Medicine, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy.

PATIENT(S)

Women undergoing ART for the first time.

INTERVENTION(S)

Comparing outcomes of ART between 2 years before (n = 900) and after (n = 936) the law's implementation (March 10, 2004).

MAIN OUTCOME MEASURE(S)

Rates of fertilization, pregnancy, "take-home baby," and multiple pregnancies.

RESULT(S)

During the pre-law period, statistically significantly more patients reached embryo transfer (odds ratio 1.9; 95% CI, 1.5, 2.5), and embryo transfer rate per cycle was statistically significantly higher (3.1 +/- 1.7 vs. 2.2 +/- 0.7), but the overall transfer of good embryos was lower (OR 0.6; 95% CI, 0.5, 0.8). The pregnancy rates per aspiration cycle were similar between the periods, but the pregnancy rate per embryo transfer and birth rate with at least one liveborn baby per embryo transfer were statistically significantly lower in the pre-law period (OR 0.7; 95% CI, 0.5, 0.9). The multiple births rate was not different between the two periods.

CONCLUSION(S)

In contrast to prior pessimistic expectations, the obligation to transfer all available embryos produced from <or=3 inseminated oocytes neither reduced success rates of ART nor increased the multiple births rate.

Cryotop vitrification of human oocytes results in high survival rate and healthy deliveries

Vitrification, an ultra-rapid cooling technique, offers a new perspective in attempts to develop an optimal cryopreservation procedure for human oocytes and embryos. To further evaluate this method for human oocytes, 796 mature oocytes (metaphase II) were collected from 120 volunteers. Since Italian legislation allows the fertilization of a maximum of only three oocytes per woman, there were 463 supernumerary oocytes; instead of being discarded, they were vitrified. When, in subsequent cycles, these oocytes were utilized, 328 out of 330 (99.4%) oocytes survived the warming procedure. The fertilization rate, pregnancy rate and implantation rate per embryo were 92.9, 32.5 and 13.2% respectively. Thus, as already reported in the literature, the vitrification procedure seems to be highly effective, safe (since healthy babies have been born) and easy to apply. In situations where embryo cryopreservation is not permitted (as in Italy), there is now good indication for routine application of the method, once further standardization is achieved.

GnRH antagonists in ovarian stimulation for ICSI with oocyte restriction: a matched, controlled study

Italian legislation regarding reproductive medicine limits the number of embryos transferred per attempt to three. Thus, in order to achieve pregnancy, more IVF cycles may be required, generating a need for methods of ovarian stimulation with fewer side effects. The gonadotrophin-releasing hormone (GnRH) antagonists have several advantages in this respect, but there is a debate regarding a possible lower pregnancy rate from resulting cycles. This study evaluated the clinical applicability of GnRH antagonists for ovarian stimulation in young women undergoing intracytoplasmic sperm injection (ICSI) in which only three oocytes can be fertilized. The 200 women treated with GnRH antagonist had a significantly shorter stimulation and lower gonadotrophin consumption, oestradiol concentration, total and mature oocyte recovery as compared with 200 matched controls treated with GnRH agonist. No differences were found between the groups in the number of normal zygotes, total cleaved, transferred and high quality embryos, or in the clinical outcomes. Thus, the previously reported lower pregnancy rate in GnRH antagonist cycles may be related to the oocyte characteristics. Finally, under conditions of oocyte number restriction, the GnRH antagonist-based cycles may be proposed as an efficacious, safe and minimally invasive alternative to GnRH agonist in a standard long protocol.

In vitro development of human oocytes after parthenogenetic activation or intracytoplasmic sperm injection

OBJECTIVE

To compare directly in vitro developmental competence between parthenogenetically activated and intracytoplasmic sperm injection (ICSI)-fertilized oocytes.

DESIGN

For each patient, three metaphase II oocytes were randomized to the ICSI procedure, while n-3 were allocated to parthenogenetic activation.

SETTING

University hospital infertility unit.

PATIENTS

Thirty-eight patients, aged 35.2 +/- 3.3 years (mean +/- SD) selected for ICSI.

INTERVENTIONS

After 1 hour from denudation, oocytes were either fertilized by ICSI (n = 114) or chemically activated (n = 104). Fertilized and activated oocytes were cultured for up to 3 and 5 days, respectively.

MAIN OUTCOME MEASURES

Development rate, cell number, and morphological grade during culture.

RESULTS

The two groups showed no significant differences between rates of fertilization and parthenogenetic activation, development, and blastomere number on days 2 and 3 of culture. However, parthenotes showed a lower morphological grade, and a significantly lower proportion went on cleaving to day 3, when only activated rather than total numbers of oocytes were considered. On day 5 after activation, nine oocytes (8.6%) reached the blastocyst stage, representing 12.9% of parthenotes.

CONCLUSIONS

Since most parameters examined in this study were similar between activated and fertilized oocytes, parthenogenetic activation may be a useful tool for the preclinical evaluation of experimental procedures.

Outcome of 518 salvage oocyte-cryopreservation cycles performed as a routine procedure in an in vitro fertilization program

OBJECTIVE

To document outcomes of oocyte cryopreservation performed as a routine procedure in an IVF program.

DESIGN

Describing the rate of oocyte survival, embryo transfer (ET), implantation, and live births of IVF-intracytoplasmic sperm injection performed on thawed oocytes.

SETTING

Reproductive medicine center in Italy.

PATIENT(S)

Women (n = 696) who failed to conceive after IVF-intracytoplasmic sperm injection with fresh oocytes.

INTERVENTION(S)

Surplus oocytes obtained during a failed cycle with fresh oocytes were frozen and then were thawed, micromanipulated, and transferred in a later cycle.

MAIN OUTCOME MEASURE(S)

Rates of oocyte survival, ETs, implantation, and live births were calculated in the entire cohort and in patients aged <or=38 and >38 years.

RESULT(S)

There were 29 pregnancies, for a total implantation rate of 6.3% (95% CI: 4.3, 9.0) per 456 ET cycles. The clinical-pregnancy rate was 19 (4.2%; 95% CI: 2.6, 6.4) of 456 ET cycles, with a take-home-baby rate of 7 (1.5%; 95% CI: 0.7, 3.0) of 456 ET cycles.

CONCLUSION(S)

Cryopreservation performed as a routine procedure for so-called salvaging of surplus oocytes is associated with poor implantation rates and with a probability of 1 live birth in 65 ET cycles.

Pregnancy loss and assisted reproduction: preliminary results after the law 40/2004 in Italy

The new Italian law on assisted reproduction technology rules that no more than three oocytes can be fertilized at one time, and that all embryos obtained must be transferred to the maternal uterus simultaneously. The aim of the present study was to investigate the influence of the new law on spontaneous embryonic/fetal losses through comparison of data collected over an identical period of time: the first year of application of the new law compared with the same time period 1 year before (March 10, 2004 to March 9, 2005 versus March 10, 2003 to March 9, 2004). A total of 271 clinical pregnancies were analysed. In the post-law period, a significantly lower percentage of total spontaneous embryonic losses compared with the pre-law period, and a higher percentage of surviving embryos in singletons and twins was observed. In conclusion, the impact of the limitations imposed by the new legislation regulating assisted reproduction in Italy seems to exert positive effects on spontaneous embryonic loss both in singletons and multiple pregnancies. These findings are in contrast to international predictions on this issue and, in general, are counter-intuitive. This suggests that further investigations on a larger cohort of women are required to confirm these preliminary results.

A retrospective study of New Zealand case law involving assisted reproduction technology and the social recognition of ‘new’ family

The New Zealand Human Assisted Reproductive Technology (HART) Act became law in 2004. In this article, we provide a retrospective analysis of New Zealand case law from September 1990 to March 2004, leading up to the creation of the HART Act. We examine the new understandings of parenting (developed through the routine use of ART in New Zealand) which the case law attempted to test. We examine these concepts against the previous understandings of family enshrined in the pre-existing legislation, which formed the basis for judicial rulings in the various cases to which we refer. In conclusion, we provide a brief summary of the 2004 HART legislation and draw comparisons between the old and new legislative and bureaucratic frameworks that define and support New Zealand family structure. We suggest that a change in cultural backdrop is occurring from the traditional western ideology of the nuclear family towards the traditional Maori concept of family formation, which includes a well-accepted traditional practice of guardianship and a more open and extended family structure. This 'new' structure reflects the contemporary lived experience of family kinship in western societies as individualized and open to choice.

Subfertility guidelines in Europe: the quantity and quality of intrauterine insemination guidelines

BACKGROUND

International collaboration could facilitate systematic development of guidelines to regulate and improve clinical practice. To promote European collaboration in guideline development in reproductive medicine, insight into existing subfertility guidelines in Europe is essential. The study aim was to explore the number and quality of clinical practice guidelines on homologous intrauterine insemination (IUI) in Europe.

METHODS

To identify IUI guidelines in Europe, electronic databases and Internet were systematically searched and key experts on assisted reproduction in 25 European countries were questioned. The quality of IUI guidelines was systematically assessed with the internationally validated Appraisal of Guidelines for Research and Evaluation (AGREE) Instrument. Qualitative methods were used to appraise IUI guideline recommendations and references.

RESULTS

National guidelines on IUI are available in four of 25 European countries. The quality of IUI guidelines in Europe is moderate to high, but the recommendations and references differ considerably.

CONCLUSIONS

The number of IUI guidelines in Europe is surprisingly small, and differences in their recommendations and references are considerable. To overcome these deficiencies in clinical guidance on IUI care in Europe, a central body with expertise in up-to-date guideline development methodology and sufficient resources could be established in Europe for central selection and international exchange of evidence to support guideline recommendations.

Limiting the number of injected oocytes to three impairs ICSI outcomes in patients with nonobstructive azoospermia

BACKGROUND

Since March 2004, only a maximum of three oocytes were allowed to be subjected to ICSI at one time in Italy. A previous study failed to show an impact of this restriction on fresh embryo transfer outcomes. The objective of this study was to compare ICSI outcomes before and after this restriction in patients with nonobstructive azoospermia.

METHODS

Patients underwent testicular sperm extraction followed by ICSI. Biological (fertilization rate and the percentage of good-morphology zygotes and embryos) and clinical (clinical pregnancy and implantation rates) outcomes of the last 100 ICSI attempts before the restriction and outcomes of the first 100 ICSI attempts after the restriction were compared.

RESULTS

Despite comparable fertilization rates (58.8% versus 59.2%; P > 0.05), there was a significant decrease in the percentage of good-morphology zygotes (41.1% versus 88.4%; P < 0.05) and embryos (36.7% versus 74.0%; P < 0.05) in the cohort of embryos transferred, clinical pregnancy rate (22.7% versus 42.4%; P < 0.05) and cumulative pregnancy rate from fresh and frozen embryo transfers (22.7% versus 53.5%; P < 0.05) after the restriction.

CONCLUSION

The oocyte number restriction reduces dramatically the chance of achieving a clinical pregnancy in cases of nonobstructive azoospermia.

Is oocyte morphology prognostic of embryo developmental potential after ICSI?

Metaphase II-stage oocytes collected from patients following ovarian stimulation show varying qualities. Both nuclear and cytoplasmic maturation have to be completed in a co-ordinated mode to ensure optimal conditions for subsequent fertilization. Disturbances or asynchrony of these processes may result in different morphological abnormalities, depending on whether nuclear or cytoplasmic maturation has been affected. In this respect it has been suggested that dysmorphic features occurring early in meiotic maturation may be associated with a higher frequency of aneuploidy and fertilization failure, while those occurring late in maturation may cause a higher incidence of developmental failure. In fact, more than half of the gametes collected show morphological abnormalities, some of which seem to be correlated with an impaired outcome (e.g. aggregation of endoplasmic reticulum, vacuolization, increased ooplasmic viscosity, giant eggs). Therefore, it is strongly recommended to include oocyte quality in all scoring systems applied in IVF laboratories.

IVM – the first choice for IVF in Italy

In March 2004, a new law was introduced in Italy to regulate assisted reproduction; at present it is impossible to use more than a maximum of three oocytes per IVF cycle, nor can embryos or prezygotes (2PN cells) be selected or cryopreserved. The prohibitions introduced by the new law have, on the one hand, reduced the expectations of success of current techniques and, on the other hand, stimulated clinicians and embryologists to work on new therapeutic strategies so as to offer the highest chances of success with the lowest risks. In-vitro maturation (IVM) of oocytes fits very well with these new requirements: ovarian stimulation is avoided and the handling of spare oocytes is facilitated. The IVM protocol is an intriguing alternative to conventional IVF techniques, since it removes the side-effects of drug stimulation, especially ovarian hyperstimulation syndrome, and it also reduces the costs of the entire procedure, both in terms of 'time consumption' and 'patient/society costs for drugs'. In the authors' IVF centre the IVM technique has been used for more than a year, with significant success in terms of maturation and fertilization rates, percentage of embryo transfers, number of pregnancies and, finally, healthy babies born.

Human oocyte cryopreservation: past, present and future

Despite inferior results in the past compared with embryo freezing, oocyte cryopreservation has made great strides in recent years. In fact, it has become a necessity in assisted reproduction technology, providing alternatives to legal, moral and religious problems originating from embryo freezing. Recent advances in freezing technology, modifications of conventional protocols used and continuing optimization of vitrification have efficiently improved the method. A historical description of the method's progression over time, and a comparison of principles, procedures and results as reported in the literature are presented in this review.

Clinical use of the perifollicular vascularity assessment in IVF cycles: a pilot study

BACKGROUND

In Italy, a recent law has imposed a ban on the fertilization of more than three oocytes at one time, and all resulting embryos produced must be transferred simultaneously. The aim of the present controlled study was to assess the clinical feasibility and efficacy of the perifollicular vascularity assessment for oocyte selection in IVF cycles.

METHODS

Fifty-four young primary infertile non-obese women (27 cases and 27 age- and BMI-matched controls) underwent IVF cycles. The choice of the oocytes to fertilize was performed according to perifollicular vascularization in the experimental group, whereas in the control group, the standard morphologic criteria alone were used. The dose of gonadotrophins used, the dominant follicles obtained, the duration of the ovarian stimulation, the number of oocytes retrieved, the number/quality of oocytes fertilized and of cleaved embryos, cycle cancellation, implantation, clinical pregnancy, ongoing pregnancy, multiple pregnancies and ovarian hyperstimulation syndrome rates were assessed in each group.

RESULTS

The assessment of perifollicular vascularity was feasible in 88.9% of cases. No difference between groups was detected in any parameter evaluated.

CONCLUSION

Power Doppler assessment of perifollicular vascularity seems to have no clinical utility for oocyte selection in IVF cycles for young infertile women.

Cryopreservation of supernumerary oocytes in IVF/ICSI cycles

BACKGROUND

The aim of the present study is to investigate cryopreservation of oocytes in patients refusing embryo cryopreservation for ethical reasons, patients from whom no sperm could be retrieved and patients with enough oocytes to yield a number of fresh and cryopreserved embryos to transfer.

METHODS

A total of 2900 oocytes out of 6216 retrieved were cryopreserved in 286 patients undergoing 303 cycles. The reasons for cryopreservation were because no sperm was found in 16 cycles, for ethical or personal reasons in 80, and in 207 only supernumerary oocytes were frozen. In 159 cycles, the oocytes were thawed and the surviving metaphase II oocytes microinjected.

RESULTS

A total of 1087 oocytes were thawed, 760 (69.9%) survived and 687 were microinjected. We obtained 368 (53.5%) normally cleaved embryos, 331 were transferred and 37 were cryopreserved. One hundred and forty-five transfers (range 1-3 embryos/patient) were performed and 18 (12.4%) pregnancies were obtained. Twelve patients delivered 13 healthy children, and six first trimester abortions were observed (33.3%).

CONCLUSION

Although a low implantation rate was observed and a higher abortion rate than in fresh cycles, our results show that in sibling oocytes, the process of cryopreservation apparently does not affect the fertilization and cleavage rate. In this group of patients, producing a large number of mature gametes, oocyte cryopreservation gives the couple extra chances to achieve a pregnancy within a single retrieval and is a good effort towards reducing the number of embryos cryopreserved and enhancing our experience in this new technology.

Italian law on assisted conception: clinical and research implications

The Italian law 40/2004 regulating the use of assisted conception will remain on the statutes after the failure of the referendum in June 2005. Italy is now one of the most restrictive countries in the world in the field of assisted conception. It is thought that the new regulations, which have already increased 'reproductive tourism' in Italian subfertile couples, will also have clinical and research implications.

The Italian law on assisted reproduction: a view from Spain

Despite the pessimistic concerns about the outcome of assisted reproduction in Italy after the application of the new law, initial reports show similar pregnancy rates. However, with increasing numbers, the deleterious effect of such a restrictive law will show up. Moreover, it may seriously affect the scientific production of Italian groups, which may be forced to migrate to other countries to maintain their independence and scientific freedom.