The effects of endotoxins on gametes and preimplantation embryos cultured in vitro

Zona pellucida removal resulted in a successful live birth: Report on a case with recurrent implantation failure due to embryonic bacteria contamination

Key clinical message

In in vitro fertilization (IVF), laser offers several advantages. In this study, we employed laser to eliminate the zona pellucida of a contaminated embryo. This approach helps to rescue embryo with bacterial contamination, and improve embryo-endometrium interaction.

Abstract

To present a case report on the removal of a contaminated zona pellucida from an embryo of patient with a history of recurrent implantation failure (RIF), which was followed by a successful live birth. We present the case of a 34-year-old patient with a history of 3 years of infertility who underwent in vitro fertilization. During the culture process, the embryos became contaminated, leading to three failed implantations. Despite the aneuploidy of the embryo and the implementation of a washing technique, the contamination persisted. In the final attempt, the contaminated zona pellucida was successfully removed using laser, followed by embryo transfer, resulting in a live birth. We provided detailed clinical information, including patient demographics, infertility history, ovarian response, evidence of bacterial contamination, embryo development, treatment protocols, and outcomes. Laser excision of the zona pellucida is a safe and effective method for addressing bacterial infection in embryos.

Contamination of ART culture Media-The role of semen and strategies for prevention

OBJECTIVE

Microbial contamination of ART culture media is rare but serious. We examined our own experience and conducted a review of the literature with a view to preventing its occurrence and recurrence.

CASE REPORT

A total of 12 cases were recorded during January 2006 to March 2019. The contaminations were caused by semen and were shown to be bacteria that were resistant to the prophylactic antibiotics used in the medium. After the procedures were cancelled due to contaminations, nine husbands received antibiotic treatment, while nine couples changed over to the ICSI program. Eventually, eight couples concluded the study with live birth deliveries, and there was no recurrence of contamination.

CONCLUSION

ART laboratories should preserve all sperm suspension samples until embryo transfer has been completed for the purpose of checking whether contamination has occurred. In addition to antibiotic treatment, implementation of the ICSI procedure during the next ART cycle has already been proven to be effective. In the future, the zona-removal technique may be considered as another potential option.

Considerations Regarding Embryo Culture Conditions: From Media to Epigenetics

There are numerous reports on embryo culture media and conditions in the laboratory, as the subject is multifaceted and complex, reflecting the variation in practice. In this scoping review, we attempt to approach the topic of culture media and conditions from the practitioners' perspective aiming to highlight, in a comprehensive fashion, important aspects regarding the options available, introduce points of debate and controversy, while maintaining the viewpoint of the practicing embryologist's concerns.

Transfer of IVF-contaminated blastocysts with removal of the zona pellucida resulted in live births

PURPOSE

Bacterial contamination may cause loss or damage to cultured oocytes or embryos, resulting in cancelation or delaying of a fresh embryo transfer. While live births have been reported following the transfer of embryos contaminated with yeast, very little information is available on how to handle embryos with bacterial contamination. We report two cases of successful pregnancy in patients with bacterial contamination of embryo culture dishes.

METHODS

We retrospectively reviewed 878 oocyte retrievals performed between January 2011 and December 2014. Bacterial contamination was recorded in two split IVF/ICSI cases, where contamination occurred in embryo culture drops containing embryos from conventional insemination but not from ICSI on day 3.

RESULTS

To minimize the adverse effects of bacterial contamination on transfer outcomes, we removed the zona pellucida of contaminated frozen blastocysts and successfully obtained clinical pregnancies following transfer of zona-free blastocysts that were previously contaminated during IVF culture.

CONCLUSIONS

Removal of the zona pellucida is an appropriate approach to handle blastocysts contaminated with bacteria during in vitro culture.

IVF culture media: past, present and future

BACKGROUND

The advances in the world of IVF during the last decades have been rapid and impressive and culture media play a major role in this success. Until the 1980s fertility centers made their media in house. Nowadays, there are numerous commercially available culture media that contain various components including nutrients, vitamins and growth factors. This review goes through the past, present and future of IVF culture media and explores their composition and quality assessment.

METHODS

A computerized search was performed in PubMed regarding IVF culture media including results from 1929 until March 2014. Information was gathered from the websites of companies who market culture media, advertising material, instructions for use and certificates of analysis. The regulation regarding IVF media mainly in the European Union (EU) but also in non-European countries was explored.

RESULTS

The keyword 'IVF culture media' gave 923 results in PubMed and 'embryo culture media' 12 068 results dating from 1912 until March 2014, depicting the increased scientific activity in this field. The commercialization of IVF culture media has increased the standards bringing a great variety of options into clinical practice. However, it has led to reduced transparency and comparisons of brand names that do not facilitate the scientific dialogue. Furthermore, there is some evidence suggesting that suboptimal culture conditions could cause long-term reprogramming in the embryo as the periconception period is particularly susceptible to epigenetic alterations. IVF media are now classified as class III medical devices and only CE (Conformité Européene)-marked media should be used in the EU.

CONCLUSION

The CE marking of IVF culture media is a significant development in the field. However, the quality and efficiency of culture media should be monitored closely. Well-designed randomized controlled trials, large epidemiological studies and full transparency should be the next steps. Reliable, standardized models assessing multiple end-points and post-implantation development should replace the mouse embryo assay. Structured long-term follow-up of children conceived by assisted reproduction technologies and traceability are of paramount importance.

Comparisons of the effects of long-acting and short-acting GnRH agonists on embryo quality, endometrial thickness and pregnancy rate in human in vitro fertilization

INTRODUCTION

The aim was to compare the efficacy of long-acting and short-acting gonadotropin-releasing hormone (GnRH) agonists by long protocol on embryo quality, endometrial thickness and pregnancy rate in in vitro fertilization.

MATERIAL AND METHODS

In this retrospective study, long-term pituitary downregulation, achieved with long- and short-acting GnRH agonists (GnRHa), was performed for patients undergoing in vitro fertilization (n = 175).

RESULTS

There were no significant differences between the long and short-acting GnRH group (63.16% vs. 66.26%, p > 0.05), and the secondary and primary infertility group (63.47% vs. 66.86%, p > 0.05) in embryo quality. Logistic regression analysis showed that type of infertility and endometrial thickness were significantly associated with pregnancy outcome. Patients in the long-acting GnRHa group had a thicker endometrium on the day of human chorionic gonadotrophin (hCG) administration (10.79 ±2.62 mm vs. 9.64 ±1.97 mm, p < 0.01), lower serum luteinizing hormone (LH) concentration (1.21 ±1.13 vs. 2.53 ±3.39) and a higher pregnancy rate (59.60% vs. 43.42%, p < 0.05) than those of patients in the short-acting GnRHa group.

CONCLUSIONS

This work suggests that types of agonist protocol and infertility may not affect embryo quality. Type of infertility and endometrial thickness may be positive predictors for clinical pregnancy, but the key finding is that the long-acting GnRHa protocol may be an effective method of improving endometrial thickness, endometrial receptivity and pregnancy rate in in vitro fertilization.

[Pre-washing catheter dramatically improves the post intrauterine insemination pregnancy rate]

OBJECTIVE

To analyze the effectiveness of pre-washing the intrauterine insemination catheters on IUI outcome.

PATIENTS AND METHODS

Infertile couples (n=322) involved in a IUI program were included in the study. IUI indications were cervical factors, ovulation dysfunction, cryopreserved semen and unexplained infertility. Every other week for two years, IUI catheters were washed with culture medium prior to intrauterine sperm insemination.

RESULT(S)

Only the first IUI for each couple were analyzed. Washing the catheter, prior to use, resulted in a 49.7% increase in clinical pregnancy rate (22.0% vs 14.7% P<0.05). This result is observed with fresh sperm (15.7% vs 11.1%) and frozen-thawed sperm as well (31.1% vs 19.8%). The early pregnancy termination rate was similar in all groups.

DISCUSSION AND CONCLUSION

Pre-washing the catheter before IUI should be recommended in Good Laboratory Practice Guidelines as it is already the case for embryo transfer catheters. This raises the problem of washing all single-use devices, in contact with gametes or embryos during IVF.

Culture system and long-term storage of culture media in the in vitro production of bovine embryos

The optimum culture system for in vitro matured and fertilised oocytes still remains to be clarified. Culture media (CM) for mammalian embryos are routinely prepared fresh for use and preserved under refrigeration during one or two weeks. The purposes of this work were (1) to compare the efficiency of a synthetic oviduct fluid (SOF) with two different bovine serum albumin (BSA) concentrations (3 and 8 g/L) for the in vitro production of bovine blastocysts, (2) to test the effect of timing on adding fetal calf serum (FCS) to the SOF, and (3) to evaluate the effects on bovine embryo development of freezing and lyophilisation as procedures for preserving the SOF. Supplementation of SOF with 3 g/L BSA increased Day-7 blastocyst expansion rates (18.3 ± 1.6 vs. 14.4 ± 0.7; P < 0.05), although no differences in hatching rates were found. Addition of FCS to SOFaa (SOF with amino acids) medium supplemented with sodium citrate (SOFaaci) at 48 and at 72 h post-insemination (PI) allowed obtaining higher Day-6 embryo development rates than when FCS was added at 18 or 96 h PI (Day-6 morulae + blastocyst rate: 30.0 ± 1.1, 40.8 ± 1.1, 43.9 ± 2.3 and 39.3 ± 0.5 for FCS addition at 18, 48, 72 and 96 h, respectively). Hatching rates were significantly improved when serum was added at 72 h PI. Finally, both refrigeration and lyophilisation appeared as useful cryopreservation procedures for SOFaaci, although a significant loss of its ability to support embryo development, compared to the control fresh culture medium, was observed.

In vitro development of bovine embryos as affected by different lots of bovine serum albumin and citrate

The effect of bovine serum albumin (BSA) lots on the development of in vitro-derived bovine embryos in synthetic oviductal fluid was investigated. Citrate concentration was determined for each lot of BSA, and then correlated with differences noted in the ability of BSA lots to support embryo development. Development of bovine embryos to the blastocyst stage was also compared after culture in chemically-defined medium with varying levels of citrate. There were distinct differences in the ability of the different BSA lots to support embryo development to the blastocyst stage (P<or=0.05). Citrate content (based on 3.2% BSA) of the medium varied from 320 to 1280 microM. Although there was an overall linear trend (P<0.001) for increased number of blastocysts with increasing concentrations of citrate in the medium, there were also substantial deviations (P=0.024) from this linear trend, suggesting that factors other than citrate could be responsible for stimulating blastocyst development. In the second experiment, the percentages of cleaved embryos that developed to the blastocyst stage in defined medium with 0, 100, 300 or 900 microM citrate ranged from 18.2 to 27.8% and were similar among treatments (P=0.441). The mean number of cells in the embryos developing to the blastocyst stage did not differ among treatments (P=0.545). Overall, these results indicate citrate has little affect on development of bovine embryos to the blastocyst stage in vitro.

Impact of detection of bacterial endotoxin in menstrual effluent on the pregnancy rate in in vitro fertilization and embryo transfer

OBJECTIVE

To examine whether bacterial endotoxin is detectable in menstrual effluent and to analyze a possible association between endotoxin levels and a pregnancy rate after IVF-ET.

DESIGN

Prospective observational study.

SETTING

University hospital.

PATIENT(S)

Thirty-eight infertile women undergoing endotoxin assay and IVF-ET.

INTERVENTION(S)

Endotoxin was assayed by the limulus amoebocyte lysate test.

MAIN OUTCOME MEASURE(S)

Levels of bacterial endotoxin and a pregnancy rate.

RESULT(S)

In 38 samples of menstrual effluent taken from 38 women, bacterial endotoxin was detected with a range of 7.1 to >1,000 pg/mL in 37 samples and was not detected in 1 sample. After IVF-ET, pregnancy occurred in 9 of the 38 women. The mean (+/- SD) endotoxin level in these 9 pregnant women was 71.3 +/- 52.5 pg/mL and was significantly lower compared with >236.2 +/- 333.6 pg/mL in the 29 nonpregnant women. All pregnancies occurred in 28 women with an endotoxin level of </=200 pg/mL, whereas no pregnancies occurred in 10 women with an endotoxin level of >200 pg/mL, producing the significantly higher pregnancy rate in the former group than in the latter.

CONCLUSION(S)

Bacterial endotoxin was detectable in menstrual effluent from infertile women. The pregnancy rate after IVF-ET was significantly higher in women with an endotoxin level of </=200 pg/mL than in women with an endotoxin level of >200.0 pg/mL.

Comprehending the role of LPS in Gram-negative bacterial vaginosis: ogling into the causes of unfulfilled child-wish

INTRODUCTION

Intrauterine infection is frequently associated with pregnancy loss in pregnant women.

DISCUSSION

This article reviews the role of Gram-negative bacterial infection in various complications related to early pregnancy and subsequent pregnancy loss. Here we discuss the pathways of ascending intrauterine infection, microbiology and the pathophysiology of such infections. The clinical impact, therapy, consequences, prevention and implications of Gram-negative bacterial infections in women during their reproductive life span is also discussed. This article also makes an attempt to discuss our studies and findings, related to the effect of the LPS component of the Gram-negative bacterial endotoxin on preimplantation stage embryonic development and implantation. This early phase of pregnancy remains mostly unnoticed by the mother as well as the health care provider, and therefore holds more threat to the life of the fetus and the mother. The molecular mechanisms of LPS-induced pregnancy losses through abnormal embryonic development, implantation failure, and preterm labor and birth with specific references to the role of proinflammatory cytokines like IL-1 and TNF are discussed.

CONCLUSION

Once these inflammatory mediators have increased in the feto-maternal tissues, it may be too late or harmful to try and prevent the adverse outcomes of pregnancy.

Gram-Negative Bacterial Endotoxin- Induced Infertility: A Birds Eye View

Alleviation of infertility on the one hand and development of improved methods of contraception on the other are global concerns to woman's health. The molecular signals that regulate implantation are of clinical relevance since understanding the nature of these signals may lead to strategies to correct implantation failure and to develop novel contraceptive approaches. The other pressing concern is the poor pregnancy rate resulting from in vitro fertilization (IVF). The pregnancy rate in IVF programs remains about 20-30% in spite of the high rate of successful fertilization. This has led to the proposition that additional uterine factors, critical for the implantation process, must be limiting. Identification of such parameters could help in determining the appropriate physiological state of the uterus for embryo transfer. Several factors are known to have a direct or indirect impact on the ability of the uterus to develop to a functionally receptive state. This would disrupt the normal coordination between embryonic and uterine development even though all molecular players may seem otherwise normal.

Identification of Possible Mediators of Embryonic Mortality Caused by Mastitis: Actions of Lipopolysaccharide, Prostaglandin F2α , and the Nitric Oxide Generator, Sodium Nitroprusside Dihydrate, on Oocyte Maturation and Embryonic Development in Cattle

PROBLEM

Mastitis and immunization against constituents of organisms causing mastitis can reduce fertility of cattle and sheep, respectively. For the current experiments, it was hypothesized that these effects are mediated via actions of lipopolysaccharide (LPS), prostaglandin F2alpha (PGF2), and nitric oxide on oocyte maturation and embryonic development.

METHOD OF STUDY

To evaluate effects on oocyte maturation, oocytes were matured with various concentrations of LPS, PGF2alpha, or the nitric oxide (NO) generator, sodium nitroprusside (SNP). Following maturation, oocytes were fertilized and cultured until day 8 after fertilization. To test effects on embryo growth, oocytes were matured and fertilized and cultured after fertilization with LPS, PGF2alpha, or SNP.

RESULTS

Addition of 100 and 1000 ng/mL LPS and 50 and 100 ng/mL PGF2alpha to oocyte maturation medium reduced the proportion of oocytes that became blastocysts at day 8 after fertilization. When added after fertilization, in contrast, neither LPS nor PGF2alpha reduced development to the blastocyst stage. Unlike for LPS and PGF2alpha, addition of SNP during oocyte maturation was without effect on the proportion of oocytes that became blastocysts at day 8 after fertilization. However, addition of 10 microM SNP to culture medium after fertilization completely prevented development to the blastocyst stage while 0.1 and 1 microM SNP did not affect development.

CONCLUSIONS

Results indicate that increased local concentrations of LPS, PGF2alpha, and NO can have deleterious consequences on oocyte function (LPS, PGF2alpha) and embryonic development (NO). Thus, these molecules are putative mediators of effects of infectious disease or inflammation, including mastitis, on fertility of cattle.

The incidence of cytoplasmic fragmentation in mouse embryos in vitro is not affected by inhibition of caspase activity

OBJECTIVE

To investigate the relationship between cytoplasmic fragmentation and caspase activity in the mouse embryo.

DESIGN

Experimental laboratory study.

SETTING

University gynacology unit.

ANIMAL(S)

One-cell zygote of mouse (MF1 x BALB/c).

INTERVENTION(S)

Mouse embryos were treated with caspase inhibitors: benzyloxycarbonyl-Val-Ala-Asp fluoromethylketone (z-VAD-fmk) and benzyloxycarbonyl-Asp-glu-Val-Asp-fluoromethyl ketone (Z-DEVD-fmk).

MAIN OUTCOME MEASURE(S)

Morphological development of the embryo, proportion of fragmented embryos, caspase-3-like activity, DNA breakage, and phosphatidylserine exposure in blastomeres.

RESULT(S)

The proportion of embryo reaching two-cell, three- to four-cell, and morula stage at 48, 72, and 96 hours after hCG administration, respectively, were comparable between the control embryos and those treated with either z-VAD-fmk or z-DEVD-fmk, at three concentrations (10 microM, 50 microM, and 200 microM). Although the inhibitors suppressed the caspase-3-like activity in the embryo fragment before compaction and decreased DNA breakages, there was no statistically significant difference in the percentage of fragmented embryo between the control and those treated with caspase inhibitors. The inhibitors did not affect the incidence of phosphatidylserine exposure in the blastomere of the treated embryos.

CONCLUSION(S)

Cytoplasmic fragmentation in precompaction mouse embryos is not a consequence of caspase-related apoptosis.

Intrauterine infusion of bacterial lipopolysaccharide (LPS) prior to mating has no adverse effect on fertility, fetal survival and fetal development

Lipopolysaccharide (LPS, endotoxin) is a component of the cell wall of gram-negative bacteria and a potent inducer of severe inflammatory reactions. In mice, systemically administered LPS induces fetal resorption and increases fetal mortality. However, effects of intrauterine LPS on fertility, fetal survival and development have not been reported. In the present study, pigs were used to determine the effect of intrauterine infused LPS on fertility, fetal survival and development. Prior to mating, gilts received intrauterine infusion of either a single dose of saline or increasing doses of LPS in saline using an insemination catheter. On day 30 of pregnancy, gilts were hysterectomized and litter size, fetal length, number of corpora lutea (CL), ovarian and placental weights, and allantoic and amniotic fluid volumes were recorded. Blood progesterone levels from days 10-30 of pregnancy were also determined. Results indicated that intrauterine infusion of LPS had no adverse effects on blood progesterone levels, fertility, fetal survival or fetal development. Intrauterine injection of LPS did cause an increase in fetal weight and amniotic fluid volume (P < 0.05). These results suggest that sperm, oocytes and gametes are tolerant of local LPS challenge and, to some extent, this mechanism protects gametes and conceptuses from maternal response to mating introduced bacteria and their potential endotoxins.

Setting standards for the levels of endotoxin in the embryo culture media of human in vitro fertilization and embryo transfer

OBJECTIVE

To clarify the optimum set standards for the levels of endotoxin in a culture medium for human IVF-ET programs.

DESIGN

Retrospective and randomized study.

SETTING

One hundred patients underwent 163 cycles of IVF-ET at Fukuoka University Hospital.

INTERVENTIONS

Measurements for endotoxin were performed using the Limulus Amoebocyte Lysate test. The negative group was administered media with < 1 pg/mL of endotoxin and the positive group was given media with > or = 1 pg/mL of endotoxin.

MAIN OUTCOME MEASURES

Human embryo development, clinical outcomes, and pregnancy outcomes were evaluated in each group and also the levels of endotoxin.

RESULTS

The rates of clinical pregnancy (26.1%) and the live birth rates (20.7%) in the negative media were significantly higher than those in the positive media (9.9% and 5.6%, respectively). Rates of embryo development were decreased and a gestational sac and fetal heart beat were not detected in media with > 2 pg/mL of endotoxin.

CONCLUSION

The set standard for the level of endotoxin in a medium should be < 1 pg/mL to obtain the best outcome. The allowable levels of endotoxin in a medium should be < or = 2 pg/mL in human IVF.

Factors affecting bovine embryo development in synthetic oviduct fluid following oocyte maturation and fertilization in vitro

Employing a total of 3465 bovine oocytes this study was aimed at improving the efficiency of bovine embryo production under defined and undefined conditions. Following in vitro maturation (IVM) and in vitro fertilization (IVF), oocytes were allocated to various culture treatments using synthetic oviduct fluid (SOF). In our 3 experiments we showed that: 1) the addition of fetal calf serum (FCS 10% v/v) to SOF droplets after 20 to 24 h significantly improved blastocyst yields on Day 6 (21 vs 12%; P < 0.01), but not at later stages and resulted in significantly higher Day-8 blastocyst cell numbers (148 +/- 61 vs 92 +/- 35; P < 0.05); 2) the removal of bovine serum albumin (BSA) from the standard SOF medium resulted in significantly reduced blastocyst yields on Days 6, 7 and 8, respectively (17 vs 8%; 28 vs 18%; 31 vs 21%; P < 0.05); 3) the presence or absence of cumulus cells surrounding the presumptive zygote in culture in SOF had no effect on cleavage rate, percentage of 5-8 cell embryos or blastocyst yields (Day 6,7 or 8); 4) the culture of presumptive zygotes in SOF in an atmosphere of 5% CO2 in air (20% O2) resulted in significantly reduced development compared with culture in 5% CO2, 5% O2, 90% N2 in terms of blastocyst yield on Days 6, 7 and 8 and on Day 8 hatching rate, respectively (5 vs 22%; 9 vs 33%; 13 vs 48%; 50 vs 8%; P < 0.001) and 5) embryo density (1 embryo per 1 or 3 microl SOF) or replacing the culture medium every 48 h had no effect when SOF was supplemented with serum; however, under serum-free conditions, changing of the media resulted in a slightly improved Day-6 blastocyst yield such that renewal of serum-free medium mimicked the effect of serum addition.

Use of endotoxin as a positive (toxic) control in the mouse embryo assay

PURPOSE

The mouse embryo assay (MEA) is used to test media used for in vitro fertilization (IVF). Negative controls usually consist of previously tested media known to support growth of embryos to the blastocyst stage by 72 h. Often, no concurrent positive (toxic) controls are reported. Thus, any unusually hardy cohort of embryos may go undetected. Endotoxin was tested for its suitability as a positive control in the MEA.

RESULTS

Female mice were stimulated with gonadotropins mated with males, and embryos flushed from their oviducts 36 h after HCG injection. Two-cell embryos were pooled and randomly distributed to culture dishes containing media without protein supplement. Endotoxin inhibited blastocyst growth beginning at 50 micrograms/ml, with complete suppression of development at 5000 micrograms/ml. With 500 micrograms/ml endotoxin, an average of 34.8% of the embryos developed to the blastocyst stage for eight separate assays. The interassay coefficient of variation (CV) was 76%, while the intraassay CV was 9.4%. At 48 h the zona pellucida was absent from all of the embryos exposed to the endotoxin. A large difference was found between two lots of endotoxin with the same claimed potency.

CONCLUSIONS

These studies demonstrate the importance for inclusion of a well-defined positive control when performing the mouse embryo assay.

Effects of medium composition on murine and human blastocyst formation and hatching rate

PURPOSE

Murine two-cell embryos (n = 5573) were cultured for 96 hr in human tubal fluid (HTF) medium (n = 2709) or alpha modification of minimum essential medium (MEM; n = 2864) through the hatched blastocyst stage from mid-1990 to mid-1991. An additional 373 embryos were cultured in MEM or HTF with 0, 1, 5, or 10 ng/ml E. coli endotoxin. A total of 17 patients had supernumerary embryos simultaneously cultured in HTF (n = 48) or MEM (n = 61). Additionally, pregnancy rates were compared for July to December 1990, when MEM was used as growth medium, and for July to December 1989, when HTF was used.

RESULTS

Blastocyst formation was higher (P < 0.001) for murine embryos cultured in MEM (blasts = 95%) compared to HTF (blasts = 70%). When cultured with endotoxin, blastocyst formation was higher (P < 0.01) for embryos cultured in MEM compared with HTF for controls and at each endotoxin level. No difference in human blastocyst development was observed in HTF and MEM. However, more MEM-cultured blastocysts were cryopreserved (P < 0.05). There also was a lower spontaneous abortion rate and a higher multiple gestation rate when embryos were cultured in MEM.

CONCLUSION

Thus, MEM may result in healthier blastocyst development, especially when culture conditions are substandard, although this is not an acceptable substitution for meticulous technique.