Age, pregnancy and miscarriage: uterine versus ovarian factors

Recurrent implantation failure and inflammatory markers in serum and follicle fluid of women undergoing assisted reproduction

It has been shown previously that the immune system plays a role in implantation and embryo development. The objective was therefore to evaluate cytokine levels and Th1/Th2 ratio in women with recurrent implantation failure in this nested case-control study. Women with no implantation after ≥ 3 embryo transfers were included in the recurrent implantation failure group (n = 29) and were compared with women with successful pregnancy after the first embryo transfer, with an indication of male factor (n = 26). Cytokines analyzed with the Meso scale discovery (MSD) technology Proinflammatory Human Kit 1 and calculated Th1/Th2 ratios were the main outcome measures. In serum there was a difference between the recurrent implantation failure group and the control group in ratios for IFN-γ/IL-10 (p = 0.01), IL-1β/IL-10 (p = 0.04), IL-2/IL-10 (p = 0.00), TNF-α/IL-10 (p = 0.02), IFN-γ/IL-13 (p = 0.01), IL-12/IL-13 (p = 0.02), IL-2/IL-13 (p = 0.00), and TNF-α/IL-13 (p = 0.00), where the control group had higher ratios, i.e. a shift towards a Th1 pro-inflammatory profile before treatment start. In follicular fluid there were differences in ratios between IL-2/IL-10 (p = 0.02), IL-8/IL-10 (p = 0.02), TNF-α/IL-10 (p = 0.02), IFN-γ/IL-13 (p = 0.01), and TNF-α/IL-13 (p = 0.03). The recurrent implantation failure group had higher ratios except for IFN-γ/IL-13, indicating a shift towards a Th1 pro-inflammatory profile in their follicular fluid. Pro-inflammatory activity in both serum and follicle fluid differs in recurrent implantation failure patients and patients with successful assisted reproduction treatment. Women at risk of immune-related recurrent implantation failure could be identified proactively. Because it is taken at a timepoint closer to implantation, ratios in follicular fluid are specifically interesting as risk markers.

The making of 'old eggs': the science of reproductive ageing between fertility and anti-ageing technologies

This article proposes going back in the history of reproductive medicine to shed light on the role of assisted reproductive technology (ART) in the making of 'old eggs'. Focusing on two key technologies - egg donation and cytoplasmic transfer - both of which contributed significantly to the production of scientific knowledge about reproductive ageing, the article suggests that ART can be analysed as 'in-vivo models' playing a pivotal role in the shift from age as a demographic variable to ageing understood in biological terms. It will shed light on the role of ART in locating age in the eggs and producing a cellular understanding of fertility decline. It argues that ART not only offers new means of reconfiguring the biological clock by extending fertility, but also reconfigures the biology of reproductive ageing itself. This becomes both the target and the means for new technological interventions, imaginaries and norms, anchored in women's bodies and a more plastic biology, and thereby illuminates hitherto underexplored aspects of the encounter between the science and technology of reproduction and anti-ageing.

Association between obesity and miscarriage among women of reproductive age in Nepal

Background

Obesity is a major health problem in low and middle income countries (LMICs) and is associated with miscarriage. This study aims to examine the association between obesity and miscarriage among reproductive age women (15–49 years) in Nepal.

Methods

The combined 19160 cross-sectional pregnancy data from the Nepal Demographic and Health Survey (NDHS) for the years 2001, 2006, 2011 and 2016 was utilized. Miscarriage was defined as a spontaneous loss of pregnancy that occurred before the foetus reached 7 months of gestational age. Logistic regression analyses that adjusted for clustering, stratification and sampling weights were used to examine the association between obesity and miscarriage among women of reproductive age.

Results

The odds of miscarriage were 1.45 times higher (Adjusted odds ratio (AOR) =  1.45; 95%Cl: 1.06, 1.98, P = 0.021) among women with obesity. Women who did not use contraception, younger (15–19 years), and older women (35 years or more) were significantly more likely to have miscarriage. Women who smoked tobacco reported higher odds of miscarriage than women who did not smoke tobacco (AOR =  1.27; 95%Cl: 1.07,1.50, P = 0.006). Stratification of maternal smoking status by maternal Body Mass Index (BMI), after adjusting for contraception, mother age and year of survey revealed that tobacco smoking and obesity are associated with miscarriage (AOR =  1.46; 95%Cl: 1.05,2.04, P = 0.025).

Conclusions

Findings from this study show that obesity and tobacco smoking are associated with miscarriage. Smoking cessation, pregnancy planning and counselling on healthy weight for women of reproductive age in Nepal may help promote healthy behaviours and decrease the likelihood of miscarriage.

Evaluation of etiology and pregnancy outcome in recurrent miscarriage patients

The purpose of this study was to evaluate etiology and pregnancy outcome of recurrent miscarriage women. The enrolled patients (280) were evaluated for Triiodothyronine, Thyroxine, Thyroid stimulating hormone, prolactin, chromosomal analysis, Haemoglobin A1C, blood sugar, Magnetic resonance imaging, 3D-ultrasound, auto-antibodies profile (antiphospholipid antibodies, anticardiolipin antibodies, lupus anticoagulant, antinuclear antibodies, anti-thyroid antibodies and β2 glycoprotein1), torch profile (Toxoplasmo gondii, rubella, cytomegalo virus and herpes simplex virus), blood vitamin D3 levels, psychological factors, Body mass index and thrombotic factors (protein S and C deficiency, Prothrombin G20210A mutation, anti-thrombin III, Factor V Leiden and Methylenetetrahydrofolate reductase mutation), uterosalpingography (hysteronsalpingography) and hysteroscopy. The therapeutic regimens either singly or combined were employed for the treatment of recurrent miscarriage patients on the basis of etiology (single or multiple) and include intravenous immunoglobulin, low molecular weight heparin, low dose aspirin, levothyroxine, progesterone, folic acid, human chorionic gonadotrophin, vitamin D3, psychotherapy, genetic counselling. However, patients with idiopathic recurrent miscarriage were treated with progesterone supplementation, anticoagulation and/or immune modulatory agents. The incidence of primary recurrent miscarriage was highest and most of the women experienced recurrent miscarriage during first trimester. Endocrinological disorders (39%) were found as the major pathological factor for recurrent miscarriage. Other factors include uterine abnormalities (5.7%), vitamin D3 deficiency (3.5%), psychological factors (3.2%) infection (3.6%), autoimmune abnormalities (1.8%) and protein S deficiency (1.8%). However, 40% cases were idiopathic. The overall live birth rate achieved after the management of recurrent miscarriage patients was 75.7%. Enocrinopathy was the major cause of recurrent miscarriage. The overall live birth rate achieved was 75.7% with highest pregnancy outcome in secondary recurrent miscarriage patients after the management.

Association between Maternal High-Risk Fertility Behavior and Childhood Morbidity in Bangladesh: A Nationally Representative Cross-Sectional Survey

In this cross-sectional study, we evaluated data from the 2014 Bangladesh Demographic and Health Survey (BDHS), which consisted of 7,707 married women aged 15-49 years who lived with at least one child younger than 5 years. This study's primary aim was to examine the relationship between maternal high-risk fertility behavior and child morbidity. To define high-risk fertility behaviors, we considered three variables: maternal age at the time of delivery, birth order, and birth interval. The main outcome measures were mortality-related disease in the past 2 weeks (acute respiratory infection [ARI], diarrhea, and fever) and low birth weight (LBW). We used modified Poisson regression with generalized estimating equations to assess the relationships between the variables of interest. Results indicate that a substantial portion of women (34%) exhibited high-risk fertility patterns; 28.7% engaged in a single high-risk behavior and 5.4% engaged in multiple high-risk behaviors. After adjusting for relevant covariates, high-risk fertility behaviors were significantly associated with an increased likelihood of ARI (adjusted relative risk [ARR]: 1.22, 95% CI: 1.05-1.50), diarrhea (ARR: 1.18, 95% CI: 1.03-1.35), fever (ARR: 1.29, 95% CI: 1.11-1.58), and LBW (ARR: 1.27, 95% CI: 1.10-1.52). In addition, engaging in multiple high-risk fertility behaviors appeared to have far-reaching consequences on the outcomes measured. Maternal high-risk fertility behaviors are important predictors of morbidity in children younger than 5 years. Preventing high-risk fertility behavior may reduce childhood morbidity and mortality in Bangladesh.

A predictive formula for selecting individual FSH starting dose based on ovarian reserve markers in IVF/ICSI cycles

BACKGROUND

Although exogenous follicle-stimulating hormone (FSH) has been used for decades and millions of cycles have been performed worldwide until now, criteria for selecting the proper FSH starting dose have not been clearly identified. The aim of this study was to elaborate a formula based on markers of ovarian reserve for the calculation of the appropriate starting dose of FSH.

METHODS

A total of 931 patients underwent in vitro fertilization (IVF) treatment using long GnRH agonist protocol was retrospectively identified and reviewed. 673 cases of them with a normal ovarian response (4-14 retrieved oocytes) were used to analysis the predictive formula. All follicles 4-7 mm in diameter were counted in the same day of blood sample in both ovaries using transvaginal ultrasound scan. The modified protocol of each patient was recorded and analyzed in the same center. In another center were the numbers of retrieved oocytes of 750 validated patients recorded and analyzed.

RESULTS

A formula model based on age, AMH, and antral follicle count (AFC) was able to accurately predict the ovarian sensitivity and accounted for 57.2% of the variability of ovarian response to FSH. When tested in the same total population used to elaborate the model it predicts a high 46.88% rate of step-down protocol in higher-starting FSH dose group and about 57.92% of patients had their dose step-up modified in lower-starting FSH dose group during their treatment, respectively. And when tested in different population from another center used to elaborate the model it predicts a high 64.40% rate of ≥ 15 retrieved oocytes in higher-starting FSH dose group and about 22.50% of patients had ≤ 7 retrieved oocytes in lower-starting FSH dose group during their treatment, respectively.

CONCLUSIONS

In the present study we demonstrated that the individualized FSH starting dose may be calculated on the basis of a woman's age, AMH and AFC. The formula model might be a useful, immediate, and easily applicable tool for clinicians to predict the tailored starting dose of FSH during their daily clinical practice.

Gestational carrier in assisted reproductive technology

OBJECTIVE

To compare clinical outcomes of in vitro fertilization (IVF) cycles with the use of gestational carriers (GCs) with non-GC IVF cycles.

DESIGN

Retrospective cohort study of assisted reproductive technology (ART) cycles performed with (24,269) and without (1,313,452) the use of a GC.

SETTING

ART centers.

PATIENT(S)

Infertile patients seeking IVF with or without use of a GC.

INTERVENTIONS(S)

Autologous and donor oocyte cycles, fresh and cryopreserved embryo transfer cycles.

MAIN OUTCOME MEASURE(S)

Live birth rate (LBR), twin and high-order multiple birth rates.

RESULT(S)

Approximately 2% of embryo transfers used a GC. Per embryo transfer, GCs had greater pregnancy rate and LBR across all IVF types compared with non-GC cycles in crude models and models adjusted a priori for potential confounders. For women with uterine-factor infertility, embryo transfer with the use of a GC resulted in a higher odds of live birth for autologous fresh embryos and for cryopreserved embryos compared with patients with non-uterine-factor infertility diagnoses.

CONCLUSION(S)

GC benefits LBRs for some patients seeking ART. The highest LBRs occurred when the indication for GC was uterine-factor infertility.

Effects of maternal age on embryo quality and pregnancy outcomes using testicular sperm with intracytoplasmic sperm injection

Objective

The aim of this study was to evaluate the influence of maternal age on fertilization, embryo quality, and clinical pregnancy in patients undergoing intracytoplasmic sperm injection (ICSI) using testicular sperm from partners with azoospermia.

Methods

A total of 416 ICSI cycles using testicular spermatozoa from partners with obstructive azoospermia (OA, n=301) and non-obstructive azoospermia (NOA, n=115) were analyzed. Female patients were divided into the following age groups: 27 to 31 years, 32 to 36 years, and 37 to 41 years. The rates of fertilization, high-quality embryos, clinical pregnancy, and delivery were compared across maternal age groups between the OA and NOA groups.

Results

The rates of fertilization and high-quality embryos were not significantly different among the maternal age groups. Similarly, the clinical pregnancy and delivery rates were not significantly different. The fertilization rate was significantly higher in the OA group than in the NOA group (p<0.05). Age-group analysis revealed that the fertilization and high-quality embryo rates were significantly different between the OA and NOA groups in patients aged 27 to 31 years old, but not for the other age groups. Although the clinical pregnancy and delivery rates differed between the OA and NOA groups across all age groups, significant differences were not observed.

Conclusion

In couples using testicular sperm from male partners with azoospermia, pregnancy and delivery outcomes were not affected by maternal age. However, women older than 37 years using testicular sperm from partners with azoospermia should be advised of the increased incidence of pregnancy failure.

Retrospective cohort study: AMH is the best ovarian reserve markers in predicting ovarian response but has unfavorable value in predicting clinical pregnancy in GnRH antagonist protocol

BACKGROUND

Various ovarian reserve markers have been used to predict ovarian response and pregnancy. However, concerning Chinese population, fewer trials have been performed using the combined ovarian reserve markers to predict ovarian response and pregnancy in GnRH antagonist protocols.

METHODS

Data from a total of 373 patients' in vitro fertilization cycles using GnRH antagonist protocol was retrospectively included. According to our center's daily practice, circulating follicle-stimulating hormone, luteinizing hormone, and estradiol (E2) were tested on menstrual cycle day 2-4 or hCG trigger day, and the concentration of AMH was determined despite of menstrual cycle. The antral follicle count (AFC) was assessed by transvaginal ultrasound on day 2-4 of menstrual cycle. Different ovarian response was defined as 0-4 and 5-15 and >15 oocyte retrieved for low and normal and high ovarian response, respectively. Gestational sac with fetal heartbeat detected by ultrasound was considered as clinical pregnancy.

RESULTS

Serum AMH levels was the most accurate marker in predicting ovarian response [area under the receiver operating characteristic (ROC) curve = 0.767]. Significant difference was found in age between non-clinical pregnancy and clinical pregnancy groups (p < 0.001).

CONCLUSIONS

Our data demonstrated that the circulating AMH despite of menstrual cycle was preferable in prediction of oocyte retrieved outcome during GnRH antagonist protocol than age, AFC and the other currently used hormone markers. Furthermore, age is the only marker in predicting clinical pregnancy.

Telomerase activity in pregnancy complications (Review)

Telomeres are specific DNA regions positioned at the ends of chromosomes and composed of functional non-coding repeats. Upon cell division, the telomeres decrease in length by a preordained amount. When the telomeres become critically short, cells lose the ability to divide and enter a specific functioning mode designated as 'cellular senescence'. However, human tissues express an enzyme that deters the shrinking of the telomeres, the telomerase. Due to its ability to maintain telomere length, the telomerase slows down and possibly suspends the aging of the cells. In regard to this, solid evidence demonstrates that female human fertility decreases with increased maternal age and that various adverse factors, including alterations in telomerase activity, can contribute to age-associated infertility in women. The fact that telomerase activity is regulated in a time- and location-dependent manner in both embryo and placental tissues, highlights it potential importance to the successful completion of pregnancy. Since maternal age is a crucial determining factor for the success of in vitro and in vivo fertilization, numerous studies have focused on telomerase activity and its correlation with mammalian fertilization, as well as the following cleavage and pre-implantation developmental processes. Associations between telomerase activity and pregnancy complications have been previously observed. Our aim in this review was to summarize and critically discuss evidence correlating telomerase activity with pregnancy complications.

Spontaneous abortion and recurrent miscarriage: A comparison of cytogenetic diagnosis in 250 cases

Objective

The purpose of this study was to determine the frequency and distribution of cytogenetically abnormal miscarriages in couples with spontaneous abortions (SA) or recurrent miscarriages (RM).

Methods

Karyotyping of specimens from 164 abortuses with SA and 86 abortuses with RM was successfully performed according to the standard cytogenetic methods using G-banding technique.

Results

Among the total 164 cases of SA group, 81 (49.4%) were euploid and the rest (83, 50.6%) showed chromosomal abnormalities. In RM(≥2) and RM(≥3) group, 31 (36.0%)/27 (34.6%) cases were euploid and 55 (64.0%)/51(65.4%) cases were abnormal, respectively. A statistically significant difference was found in the rate of cytogenetic abnormality between SA and RM groups (P<0.05). In all groups, women with advanced maternal age (≥35 years) had a higher rate of chromosome anomalies compared with women younger than age 35 (normal:abnormal = 32.4%:67.6% for ≥35 years and 53.8%:46.2% for <35 years in SA; 19.2%:80.8%/21.7%:78.3% for ≥35 years and 43.3%:56.7%/40.0%:60.0% for <35 years in RM(≥2) and RM(≥3), respectively; P<0.05). In SA group, an increase of normal karyotypes was noted with increased gestational age (<10 week, 38.0%; 10-15 week, 53.5%; 16-20 week, 65.7%). In RM group, most of cases were in <10 week and the frequency of trisomies with chromosomes 1 to 10 were increased compared with that of SA.

Conclusion

There was a statistically significant difference in the frequency and distribution of chromosomal abnormalities between SA and RM groups. Our results will provide useful information for diagnosis and genetic counseling of patients with SA or RM.

Deficiency in clonogenic endometrial mesenchymal stem cells in obese women with reproductive failure--a pilot study

OBJECTIVES

The mechanisms of obesity associated reproductive complications remain poorly understood. Endometrial mesenchymal stem-cells are critical for cyclic renewal and uterine function. Recently, W5C5(+) cells, with high clonogenicity, capable of producing endometrial stroma in vivo, have been described. We sought to investigate the abundance and cloning efficiency of W5C5(+) and W5C5(-) endometrial cells in relation to Body Mass Index, age and reproductive outcome.

DESIGN

W5C5(+) and W5C5(-) cells were purified from mid-luteal endometrial biopsies (n = 54) by magnetic bead separation and subjected to in vitro colony-forming assays.

RESULTS

First trimester pregnancy losses were significantly higher in obese subjects (n = 12) compared to overweight (n = 20) and subjects with normal Body Mass Index (n = 22) (P<0.05, P<0.01, respectively). W5C5(+) cells (%) were significantly lower in obese subjects compared to subjects with normal Body Mass Index (P<0.05). W5C5(+) cloning efficiency was significantly lower in obese subjects compared to overweight and subjects with normal Body Mass Index (P<0.05, respectively). W5C5(-) cloning efficiency was significantly lower in obese subjects compared to subjects with normal Body Mass Index (P<0.05). Body Mass Index was significantly negatively correlated with W5C5(+) cloning efficiency and W5C5(-) cloning efficiency (P<0.01, respectively), and positively correlated with first trimester loss (P<0.01). We found no significant results with age (P>0.05).

CONCLUSIONS

Our observations suggest that the regenerative capacity and plasticity of the endometrium of obese women is suboptimal, which in turn may account for the increased risk of reproductive complications associated with obesity.

Should few retrieved oocytes be as an indication for intracytoplasmic sperm injection?

OBJECTIVE

To reevaluate whether relatively few oocytes obtained in one cycle are an indication for intracytoplasmic sperm injection (ICSI).

METHODS

A total of 406 cycles with three or fewer retrieved oocytes performed in 396 non-male infertile couples were retrospectively reviewed. Cycles were classified into three groups by different fertilization techniques: the in vitro fertilization (IVF) group, insemination with conventional IVF; the ICSI group, insemination with ICSI though semen parameters were normal; and the rescue ICSI group, re-insemination with ICSI after conventional IVF failure.

RESULTS

The ICSI group resulted in higher normal fertilization compared with the conventional IVF group. Correspondingly, the cycle cancellation rate was decreased in the ICSI group, though it was not statistically significant. The clinical pregnancy rate and implantation rate were lower in the ICSI group compared with the conventional IVF group. Rescue ICSI was a method to avert total fertilization failure in conventional IVF, increasing fertilization and ensuring embryo availability for transfer, but the normal fertilization was the lowest due to delayed insemination and the chance of pregnancy was very little.

CONCLUSIONS

Obtaining only few oocytes in one cycle is not considered as an indication for ICSI when the sperm sample is apparently normal. Rescue ICSI is either not recommended if conventional insemination fails. Such patients should not be subjected to the unnecessary costs and potential risks of ICSI.

Trends in self-reported spontaneous abortions: 1970-2000

Little is known about how the miscarriage rate has changed over the past few decades in the United States. Data from Cycles IV to VI of the National Survey of Family Growth (NSFG) were used to examine trends from 1970 to 2000. After accounting for abortion availability and the characteristics of pregnant women, the rate of reported miscarriages increased by about 1.0% per year. This upward trend is strongest in the first seven weeks and absent after 12 weeks of pregnancy. African American and Hispanic women report lower rates of early miscarriage than do whites. The probability of reporting a miscarriage rises by about 5% per year of completed schooling. The upward trend, especially in early miscarriages, suggests awareness of pregnancy rather than prenatal care to be a key factor in explaining the evolution of self-reported miscarriages. Any beneficial effects of prenatal care on early miscarriage are obscured by this factor. Differences in adoption of early-awareness technology, such as home pregnancy tests, should be taken into account when analyzing results from self-reports or clinical trials relying on awareness of pregnancy in its early weeks.

Differential apoptotic staining of mammalian blastocysts based on double immunofluorescent CDX2 and active caspase-3 staining

Several approaches have been described for differential staining of blastocysts, but these methods are often time-consuming and unreliable. Here we describe a method for simultaneous differential staining and detection of apoptosis. The differential staining is based on the transcription factor CDX2 which is localized in the nucleus of trophectoderm (TE) cells but absent in the inner cell mass (ICM). Apoptosis is detected by staining of active caspase-3, a key player in several apoptotic pathways. This new approach represents a robust method for quantifying simultaneously ICM/TE ratio and apoptotic cell ratio in bovine, murine, porcine, and human blastocysts.

Biological versus chronological ovarian age: implications for assisted reproductive technology

BACKGROUND

Women have been able to delay childbearing since effective contraception became available in the 1960s. However, fertility decreases with increasing maternal age. A slow but steady decrease in fertility is observed in women aged between 30 and 35 years, which is followed by an accelerated decline among women aged over 35 years. A combination of delayed childbearing and reduced fecundity with increasing age has resulted in an increased number and proportion of women of greater than or equal to 35 years of age seeking assisted reproductive technology (ART) treatment.

METHODS

Literature searches supplemented with the authors' knowledge.

RESULTS

Despite major advances in medical technology, there is currently no ART treatment strategy that can fully compensate for the natural decline in fertility with increasing female age. Although chronological age is the most important predictor of ovarian response to follicle-stimulating hormone, the rate of reproductive ageing and ovarian sensitivity to gonadotrophins varies considerably among individuals. Both environmental and genetic factors contribute to depletion of the ovarian oocyte pool and reduction in oocyte quality. Thus, biological and chronological ovarian age are not always equivalent. Furthermore, biological age is more important than chronological age in predicting the outcome of ART. As older patients present increasingly for ART treatment, it will become more important to critically assess prognosis, counsel appropriately and optimize treatment strategies. Several genetic markers and biomarkers (such as anti-Müllerian hormone and the antral follicle count) are emerging that can identify women with accelerated biological ovarian ageing. Potential strategies for improving ovarian response include the use of luteinizing hormone (LH) and growth hormone (GH). When endogenous LH levels are heavily suppressed by gonadotrophin-releasing hormone analogues, LH supplementation may help to optimize treatment outcomes for women with biologically older ovaries. Exogenous GH may improve oocyte development and counteract the age-related decline of oocyte quality. The effects of GH may be mediated by insulin-like growth factor-I, which works synergistically with follicle-stimulating hormone on granulosa and theca cells.

CONCLUSION

Patients with biologically older ovaries may benefit from a tailored approach based on individual patient characteristics. Among the most promising adjuvant therapies for improving ART outcomes in women of advanced reproductive age are the administration of exogenous LH or GH.

A critical evaluation of ovarian tissue cryopreservation and grafting as a strategy for preserving the human female germline

Ovarian tissue freezing has been used successfully in animals and it has recently begun to be offered clinically to young women who have medical conditions with a high risk of sterility. Although no frozen human ovarian grafts have yet been returned to the donor and resulted in a pregnancy, there are many indications that this procedure should be feasible. Although live young have been derived from frozen grafts in several species, research should aim to make further improvements to the cryopreservation and grafting procedures to optimize follicle survival, and hence minimize the amount of tissue that needs to be collected, stored and returned. Ovarian tissue freezing, particular if used in combination with egg and embryo freezing, should allow a patient to safeguard their chance of becoming a parent later (Table 1). In cases where the patient has a systemic cancer or infection and malignant cells or viruses may be present in the systemic circulation and the gonadal tissue, ovarian tissue could be collected and frozen, but grafting is not currently recommended (Table 3).

Intrauterine insemination with husband semen: an evaluation of pregnancy rate and factors affecting outcome

PURPOSE

The aim was to determine pregnancy rate following intrauterine insemination (IUI) and its associated factors in a university assisted reproductive technique center in Tehran, Iran.

METHODS

A retrospective analysis of 350 IUI cycles with ovarian stimulation by clomiphene citrate and/or gonadotropins was performed.

RESULTS

The overall pregnancy rate was 22% (77/350). Of the 77 pregnancies, 88.3% resulted in live birth, 7.8% in spontaneous abortion, 2.6% in blighted ovum and 1.3% were ectopic. Logistic regression analysis revealed three predictive variables as regards pregnancy: number of the treatment cycle (OR:3.5 CI:1.9 - 6.4 p:0.006), duration of infertility (OR:2.1 CI:1.2 - 3.7 p = 0.001) and age (OR:2.15 CI:1.1 - 4.4 p = 0.04). Pregnancy rate did not have any independent relation to sperm count, type of infertility, number and size of follicle and side of ovulatory ovary.

CONCLUSION

Our results indicate that clomiphene citrate and/or gonadotropins IUI is a convenient and useful treatment option in women with younger age ( <30 years) and fewer treatment cycles and fewer infertility duration (4 years).

Assessment of the proliferative status of epithelial cell types in the endometrium of young and menopausal transition women

BACKGROUND

We determined protein and mRNA expressions of markers of normal human endometrial proliferation and hypothesized that dysregulation of the endometrial response to estradiol (E(2)) and progesterone would be observed in the older menopausal transition (MT) women compared with mid-reproductive age (MRA) controls.

METHODS

Endometrial biopsies were prospectively obtained from MRA and MT non-randomized healthy volunteers during proliferative (+/- exogenous E(2)) and secretory (MRA only) menstrual cycle phases. mRNA and/or nuclear protein expressions of proliferative markers (MKI67, PCNA and MCM2), cell-cycle regulators (cyclins A1, E1 and D1 and cyclin dependent kinase Inhibitor B; CCNA1, CCNE1, CCND1 and CDKN1B) and sex-steroid receptors [estrogen receptor (ER) and progesterone receptor (PR)] were assessed in endometrial lumen, gland and stroma.

RESULTS

MRA women had significantly higher proliferative than secretory expression of MKI67, PCNA, MCM2, CCNA1, CCNE1, ESR1 and PGR in lumen and gland (minimal stromal changes), whereas CDKN1B protein expression was higher during the secretory phase. E(2)-treatment of MT women led to relatively less MKI67 glandular protein expression compared with MRA women; no other age-related differences were observed.

CONCLUSION

Although the MT does not appear to alter the proliferative cell phenotype of endometrial epithelium and stroma, the data suggest that prior to the MT, age is associated with a decrease in some proliferative markers and steroid receptor expression status within different endometrial cell types.

Reproductive ageing in women

The traditional view in respect to female reproduction is that the number of oocytes at birth is fixed and continuously declines towards the point when no more oocytes are available after menopause. In this review we briefly discuss the embryonic development of female germ cells and ovarian follicles. The ontogeny of the hypothalamic-pituitary-gonadal axis is then discussed, with a focus on pubertal transition and normal ovulatory menstrual cycles during female adult life. Biochemical markers of menopausal transition are briefly examined. We also examine the effects of age on female fertility, the contribution of chromosomal abnormalities of the oocyte to the observed decline in female fertility with age and the possible biological basis for the occurrence of such abnormalities. Finally, we consider the effects of maternal age on obstetric complications and perinatal outcome. New data that have the potential to revolutionize our understanding of mammalian oogenesis and follicular formation, and of the female reproductive ageing process, are also briefly considered.

Embryonic synergism may reduce pregnancy loss: a multivariate regression analysis

OBJECTIVE

To evaluate clinical and assisted reproductive technology (ART) cycle variables related to spontaneous embryo reduction.

DESIGN

Observational retrospective cohort study.

SETTING

Private ART center.

PATIENT(S)

A total of 3,467 patients achieving a first-trimester pregnancy after IVF.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Rate of any spontaneous embryo reduction and rate of spontaneous single embryo reduction.

RESULT(S)

Adjusting for all analyzed variables, only initial gestational sac count, age, and body mass index were associated with the spontaneous embryo reduction rate. Twins had a lower chance of having a spontaneous embryo reduction than singletons (odds ratio 0.6, 95% confidence interval 0.50-0.79). When only spontaneous single embryo reduction was assessed, women with two or three initial gestational sacs were less prone to have a spontaneous single embryo reduction than women with one initial gestational sac.

CONCLUSION(S)

When spontaneous embryo reduction and spontaneous single embryo reduction were evaluated independently of other clinical and ART cycle variables, they were less frequent in twin pregnancies than in singleton pregnancies. This suggests a role for embryonic synergism in sustaining implantation.

The rate at which serum total beta-subunit human chorionic gonadotropin increases after embryo transfer is a predictor of the viability of pregnancy and an identifier of determinants of pregnancy

OBJECTIVE

To determine whether elements of treatment associated with faster doubling times of total beta-hCG in serum (beta-t2) in pregnant patients are also associated with a higher likelihood of pregnancy in all patients.

DESIGN

Retrospective analysis of beta-t2 values, elements of ovarian stimulation (COH), and outcomes.

SETTING

Private assisted reproductive technology (ART) center.

PATIENT(S)

Initial analysis of data from 432 cycles in which conception occurred after COH and embryo transfer, followed by analysis of pregnancy outcomes after 1,287 cycles of COH/ embryo transfer.

INTERVENTION(S)

No interventions.

MAIN OUTCOME MEASURES

The beta-t2 values initially computed from consecutive serum beta-hCG levels in ongoing pregnancies were correlated with multiple properties of the patients and their treatment cycles.

RESULT(S)

The beta-t2 values during early pregnancy increased exponentially from about 1.6 days at 12 days to about 3.0 days at 24 days after embryo transfer. In those pregnancies which spontaneously aborted, early average beta-t2 values were higher than those for ongoing pregnancies; absolute beta-hCG levels did not differ. Positive correlations were established between beta-t2 values, the number of days of stimulation, and the number of ampules of drug administered per oocyte retrieved. The beta-t2 values were inversely related to average numbers of blastomeres in transferred embryos. Ongoing pregnancy rates (PR) were higher for cycles with lower gonadotropin dosages per oocyte retrieved, and when the average number of blastomeres in transferred embryos was higher.

CONCLUSION(S)

Steeper beta-hCG doubling times in early pregnancy were associated with lower gonadotropin dosages during ovarian stimulation and with higher numbers of blastomeres in transferred embryos. The latter variables were, in turn, associated with a higher likelihood of pregnancy after embryo transfer.

Basal FSH concentration as a predictor of IVF outcome in older women undergoing stimulation with GnRH antagonist

The aim of this study was to determine the value of basal FSH as a predictor of assisted reproduction outcome in women >or=35 years undergoing ovarian stimulation with gonadotrophin-releasing hormone (GnRH) antagonist. A retrospective clinical study was carried out on 83 infertile women, 35-45 years old, divided into three groups according to their day 3 FSH concentration (group A = FSH <or=10 mIU/ml, group B = FSH >10 and <15 mIU/ml, group C = FSH >15 mIU/ml). Patients underwent ovarian stimulation with a GnRH-antagonist protocol. Group A women had significantly higher basal inhibin B concentrations (P < 0.001), lower cancellation rate (P < 0.001), required a significantly lower dosage of recombinant FSH (P < 0.0001) and had significantly higher oestradiol concentration under stimulation compared with the other groups (P < 0.0001). Oocyte and embryo numbers were comparable in all groups, although groups B and C had more low quality embryos compared with group A. The number of metaphase II oocytes and embryos was related to patients' ovarian reserve markers only in group C. Pregnancy and delivery rates were 35 and 22.5% in group A, 22.2 and 16.6% in group B and 5 and 0% in group C. It is concluded that a basal FSH cut-off of 10 mIU/ml seems predictive of ovarian reserve, while basal FSH cut-off of 15 mIU/ml seems predictive of pregnancy potential and probably of oocyte quality.

Developmental potential of aged oocyte rescued by nuclear transfer following parthenogenetic activation and in vitro fertilization

Mouse oocyte aged in vitro cannot develop normally following activation. To investigate the roles of nucleus or cytoplasm elements in oocyte aged in vitro process and their subsequent development capability following activation, we reconstructed oocytes with MII chromosome spindle and cytoplasm from aged and fresh oocytes by nuclear transfer. The subsequent developmental potential after parthenogenetic activation (PA) or in vitro fertilization (IVF) was evaluated. After nuclear transfer, more than 75.6% of karyoplast and cytoplast pairs can be fused and reconstructed oocytes have a normal haploid karyotype. Following PA, aged oocytes cannot develop beyond four-cell stage, reconstructed oocytes from fresh nucleus and aged cytoplasm developed to blastocyst with a low percentage (9.1%). Instead, blastocyst formation rate of reconstructed oocyte from aged nucleus and fresh cytoplasm was higher (60.0%). Following IVF, zygote with diploid karyotype can be formed from zona pellucida (ZP)-free oocyte. After cultured in vitro, aged oocytes cannot develop beyond two-cell; reconstructed oocytes from fresh nucleus and aged cytoplasm developed to blastocyst with low percentage (15.0%). However, high blastocyst formation rate (86.2%) can be obtained from reconstructed oocytes from aged nucleus and fresh cytoplasm. Furthermore, after embryo transfer, three viable pups have been obtained, although the efficiency is very low. These observation demonstrated that cytoplasm is more crucial than nucleus to aging process. Fresh cytoplasm could partly rescue nucleus susceptibility to apoptosis from aging in vitro.

Improvement of delivery and live birth rates after ICSI in women aged >40 years by ovarian co-stimulation with growth hormone

BACKGROUND

Growth hormone (GH) is required for ovarian follicular development, and its administration during ovarian stimulation improves pregnancy rate in cow and sheep. Data on the use of exogenous GH in human assisted reproduction treatment are inconsistent. This prospective randomized study evaluates the usefulness of GH administration in women of >40 years undergoing ovarian stimulation for assisted reproduction treatment.

METHODS

One hundred women of >40 years undergoing assisted reproduction treatment were randomized between a GH treatment group and a placebo group. Assisted reproduction treatment outcomes were evaluated.

RESULTS

In patients of the GH treatment group, a similar number of oocytes, embryos and pregnancies was achieved as compared with the placebo group. However, the patients treated with GH suffered fewer pregnancy losses, resulting in higher delivery and live birth rates. These patients also showed higher peak serum estradiol concentration and higher concentrations of GH and estradiol in pre-ovulatory follicular fluid as compared with the placebo group.

CONCLUSIONS

Administration of GH during ovarian stimulation alleviates age-related decrease in assisted reproduction treatment efficiency. This effect appears to be mainly due to an improvement of oocyte developmental potential, but GH action on the uterus cannot be excluded.

Recurrent miscarriage

Recurrent miscarriage, the occurrence of three consecutive first-trimester losses of pregnancy, affects 1% of women. The purported causes of recurrent miscarriage include chromosomal abnormalities, thrombophilia, metabolic disorders, anatomical causes and immune factors. At present, the only recommended investigations are testing for lupus anticoagulant and anticardiolipin antibody levels (to diagnose antiphospholipid syndrome, an acquired thrombophilia) and the karyotyping of both parents for chromosomal abnormalities. Women with antiphospholipid syndrome should be offered treatment with aspirin and low molecular weight heparin. Couples with chromosomal abnormalities should be referred to a clinical geneticist with whom the options of prenatal diagnosis, pre-implantation genetic diagnosis, donor gametes and adoption in subsequent pregnancies should be discussed. Couples with unexplained recurrent miscarriage should be offered appropriate emotional support and reassurance that they have a good prognosis for future pregnancies.

Does underlying infertility aetiology impact on first trimester miscarriage rate following ICSI? A preliminary report from 1244 singleton gestations

BACKGROUND

We evaluated the impact of using ICSI for assisted fertilization on first trimester survival rates of singleton gestations among an unselected infertile population.

METHODS

The 1244 singleton gestations achieved by ICSI were segregated according to underlying infertility aetiology, with 55.0% having male factor, 3.6% endometriosis, 4.3% polycystic ovarian disease, 9.1% tubal factor, 24.3% unexplained and 3.3% other. None of the patients had coexisting infertility factor.

RESULTS

The survival rate of all ICSI singleton gestations during the first trimester was 72.2%. There were no differences in early pregnancy loss (EPL) rate by infertility factor. Among patients undergoing ICSI because of male factor, there were no differences in EPL using ejaculated or non-ejaculated sperm. Regardless of aetiology, women aged >40 years had significantly higher EPL (42.1%).

CONCLUSION

Our preliminary results demonstrate that first trimester miscarriage rates of ICSI gestations are not affected by underlying infertility aetiology but are affected by maternal age.

Implantation in patients over 40 and raising FSH levels--a review

There is an evident decline of female fertility with age. This decline is mainly due to increased risk of pregnancy termination either after conception or after embryo implantation. Very likely the major cause of this embryo and pregnancy loss is chromosomal aneuploidies caused mostly by increasing rates of 'poor quality' oocytes. This phenomenon can be explained either by an age dependent accumulation of damage and/or by the hypothesis that the defective oocytes are there in the ovaries from the fetal life. 'Good quality' oocytes are ovulated first, leaving 'poor quality' oocytes to be ovulated later in life. Besides the quality of the oocytes which is mainly responsible of the embryo quality (we have not to forget a paternal effect) the process of implantation is dependent upon two variables: the probability of a viable embryo and that of a receptive uterine environment. From the oocyte donation model it seems that the endometrium also plays a minor role in human reproductive ageing as it does in some laboratory animals. However, besides some macroscopic possible causes which may play a role in the reduction of the age-related endometrial receptivity, there are so many endometrial factors possibly related to its receptivity which need to be further studied especially in older women.

Minimal stimulation using recombinant follicle-stimulating hormone and a gonadotropin-releasing hormone antagonist in women of advanced age

OBJECTIVE

To determine whether minimal stimulation with short-term application of low-dose recombinant follicle-stimulating hormone (FSH) together with a gonadotropin-releasing hormone (GnRH) antagonist represents a cost-effective treatment regimen for patients with elevated FSH levels, aged 40 and above.

DESIGN

Retrospective cohort study.

SETTING

Academically affiliated private in vitro fertilization (IVF) program.

PATIENT(S)

Eighty-five IVF cycles using minimal ovarian stimulation and 85 cycles with a standard long-stimulation protocol, conducted between January 2000 and January 2002, in women aged 40 and above who had slightly increased FSH levels.

INTERVENTION(S)

Patients on the long protocol underwent standard cycle monitoring and stimulation. In contrast, women with minimal stimulation had transvaginal sonography initiated on day 8 of the menstrual cycle and at a follicle size of 13 mm. We administered 0.25 mg of GnRH antagonist and 75 IU recombinant FSH daily until ovulation induction.

MAIN OUTCOME MEASURE(S)

Numbers of oocytes, and rates of cancellation and pregnancy.

RESULT(S)

Minimal stimulation cycles resulted in a clinical pregnancy rate of 8.2% per started cycle and 10% per embryo transfer (ET), whereas the control group yielded a clinical pregnancy rate of 10.6% per started cycle and of 10.7% per ET (not statistically significant).

CONCLUSION(S)

In women aged 40 and above with abnormal FSH levels, minimal stimulation protocol achieves similar pregnancy rates to a standard protocol, and thus represents a cost-effective alternative.

Previous miscarriages influence IVF and intracytoplasmatic sperm injection pregnancy outcome

Previous conceptions are one predictor for the outcome of assisted reproductive technology procedures. Approximately 18-34% of clinical pregnancies following assisted reproduction procedures result in spontaneous abortion. The risk of such pregnancy loss is believed to increase with women's age, previous miscarriages and use of frozen-thawed embryos. This study analyses German IVF Registry data to examine the impact of previous miscarriages on the outcome of assisted reproduction procedures. The data set consists of a total of 174,909 assisted reproduction procedures performed between January 1998 and December 2000. Multiple logistic regression is used to assess the correlation between women's age, spousal/partner change, and infertility diagnosis. It is demonstrated that any previous miscarriage will increase the treatment-dependent miscarriage rate in assisted reproduction procedures. A significantly higher impact is shown for one previous miscarriage achieved by assisted reproduction procedures compared with spontaneous conception. Partner change is shown to have no specific impact on the treatment dependent miscarriage rate, whereas a statistically significant increase in miscarriages in all assisted reproduction procedures was found among women older than 34 years of age. Overall, the highest rate of treatment-dependent miscarriages was seen in assisted reproduction procedures with cryopreserved embryo transfer.

Transplantation of the uterus

Most women with uterine factor infertility have today no prospect of carrying a pregnancy to term. The development of a method for transplantation of the human uterus would be a means for many of these women to become both genetic and gestational mothers. In this article we review the literature concerning the history and recent development in the area of uterine transplantation. We describe our newly developed model for heterotopic uterine transplantation in the mouse, which we are using for studies of pregnancy outcome and rejection mechanisms. We also address some of the specific questions that need to be solved before attempts to transplant the human uterus should be performed.

An essential role for functional telomeres in mouse germ cells during fertilization and early development

Late generations of telomerase-null (TR(-/-)) mice exhibit progressive defects in highly proliferative tissues and organs and decreased fertility, ultimately leading to sterility. To determine effects of telomerase deficiency on germ cells, we investigated the cleavage and preimplantation development of embryos derived from both in vivo and in vitro fertilization of TR(-/-) or wild-type (TR(+/+)) sperm with either TR(-/-) or TR(+/+) oocytes. Consistently, fertilization of TR(-/-) oocytes with either TR(+/+) or TR(-/-) sperm, and TR(-/-) sperm with TR(+/+) oocytes, resulted in aberrant cleavage and development, in contrast to the normal cleavage and development of TR(+/+) oocytes fertilized by TR(+/+) sperm. Many (>50%) of the fertilized TR(-/-) eggs developed only one pronucleus, coincident with increased incidence of cytofragmentation, in contrast to the normal formation of two pronuclei and equal cleavage of wild-type embryos. These results suggest that both TR(-/-) sperm and oocytes contribute to defective fertilization and cleavage. We further found that a subset (7-9%) of telomeres was undetectable at the ends of some metaphase I chromosomes from TR(-/-) spermatocytes and oocytes, indicating that meiotic germ cells lacking telomerase ultimately resulted in telomere shortening and loss. Dysfunction of meiotic telomeres may contribute to aberrant fertilization of gametes and lead to abnormal cleavage of embryos, implying an important role of functional telomeres for germ cells undergoing fertilization and early cleavage development.

Paternal age and maternal age are risk factors for miscarriage; results of a multicentre European study

BACKGROUND

It is well known that miscarriage risk increases with age. However, studies usually investigate only maternal age effects. We investigated both maternal age and paternal age effects on miscarriage risk to provide insight into this frequent reproductive failure.

METHODS

The last planned pregnancies (n = 3174) that ended in a birth or miscarriage were analysed in a retrospective population-based study on women aged 25-44 years in Denmark, Germany, Italy and Spain. Maternal and paternal ages were analysed together, using a single variable 'couple age' in a multivariate logistic regression analysis, with couples composed of a woman and a man both aged 20-29 years forming the reference group.

RESULTS

After adjustment for various factors (e.g. reproductive history, country), we found that the risk of miscarriage was higher if the woman was aged > or = 35 years, as has already been reported in a number of studies. However, the increase in risk was much greater for couples composed of a woman aged > or = 35 years and of a man aged > or = 40 years. Potential source of bias (especially 'reproductive compensation') are discussed.

CONCLUSIONS

The risk of an adverse pregnancy outcome is highest if both partners are advanced in age.

Features associated with reproductive ageing in female rhesus monkeys

BACKGROUND

The specific aims were to determine the effects of maternal age on the meiotic and developmental competence of oocytes and incidence of chromosomal anomalies in oocytes from a population of fertile rhesus monkeys.

METHODS

Monkeys were divided into two age groups (4-15 and 16-26 years of age) and underwent ovarian stimulation for collection of oocytes.

RESULTS

In the older, compared with younger, monkeys, serum basal concentrations of FSH were elevated (P < 0.05), peak concentrations of estradiol during a stimulation cycle were diminished (P < 0.05), and mean numbers of oocytes retrieved following ovarian stimulation were markedly (P < 0.05) reduced. There were no significant maternal age-related impairments in oocyte maturation, fertilization or blastocyst development. Both abnormal numbers of whole chromosomes, as well as free chromatids, were detected in a limited number of rhesus oocytes.

CONCLUSIONS

Similarities between female rhesus monkeys and women in several features associated with reproductive ageing, in conjunction with our ability to perform IVF and other assisted reproductive techniques in monkeys, demonstrate the suitability of these animals for studies on human reproductive ageing and maternal age-related infertility. Although maternal age-related impairments in oocytes were not evident prior to implantation, further studies may reveal more subtle impairments, manifested during post-implantation development.

Risk factors in miscarriage: a review

Miscarriage is one of the most frequent problems in human pregnancy. The most widely accepted definition is that proposed by the World Health Organization (WHO) in 1977. The incidence among clinical pregnancies is about 12-15% but including early pregnancy losses it is 17-22%. The only two etiologic factors recognized by all authors are uterine malformations and parental balanced chromosomal rearrangements. There have been many other suggested risk factors. In this revision we discuss these.

Fertility treatment in the forty and older woman

PURPOSE

To determine the outcomes and logical progression of fertility treatment in women forty years and older using their own oocytes.

METHODS

This was a retrospective study in which 401 completed treatment cycles in 152 women aged forty and older were reviewed.

RESULTS

Assisted reproductive technology (ART) cycles (n = 58) were reviewed, comprising both in vitro fertilization (IVF) and gamete intrafallopian transfer (GIFT). Intrauterine insemination (IUI) cycles (n = 343) were reviewed, consisting of 38 unstimulated natural cycle-IUI (NC-IUI), 194 clomiphene citrate-IUI (CC-IUI), and 111 injectable gonadotropins-IUI (INJ-IUI) cycles. The live birth rate of 15.5% for ART cycles was significantly higher than the live birth rate of 3.2% seen for all IUI cycles (p = 0.0007). There were no differences among treatment groups in spontaneous abortion, preterm delivery, or ectopic pregnancy rates.

CONCLUSIONS

For women > or = 40 years of age who wish to use their own eggs, ART offers the best chances for conception and delivery.

Effect of the interval between pregnancies on perinatal outcomes among white and black women

OBJECTIVE

We evaluated interpregnancy interval in relation to adverse perinatal outcomes and whether the relationship differed by race.

STUDY DESIGN

We analyzed the vital statistics data for multiparous white and black women in Michigan who delivered a singleton live birth during the period 1993 through 1998, using stratified and logistic regression techniques.

RESULTS

Among women of both races, the risk for delivering low birth weight, premature, and small-for-gestational-age birth was lowest if the interpregnancy interval was 18 to 23 months. In comparison, among white women, the odds ratios for the 3 outcomes were 1.5, 1.3, and 1.3, respectively, if the interval was <6 months, and 1.9, 1.4, and 1.7, respectively, if the interval was > or =120 months, controlling for other factors. Similarly, among black women, the odds ratios were 1.5, 1.2, and 1.3, respectively, if the interval was <6 months, and 1.6, 1.3, and 1.4, respectively, if the interval was > or =120 months.

CONCLUSION

An interpregnancy interval of 18 to 23 months is associated with the lowest risk for adverse perinatal outcomes among both white and black women.

Chromosomal anomalies in human gametes and pre-implantation embryos, and their potential effect on reproduction

This paper reviews the latest data on chromosomal abnormalities in human gametes and embryos. A close relationship between such anomalies and reproduction failure in humans has been postulated, thereby underscoring the importance of ongoing studies into the mechanisms leading to anomalies. Until recently, knowledge of chromosomal anomalies in human gametes and embryos has been limited. Newly developed strategies (in vitro fertilization combined with micromanipulation techniques followed by multicolour fluorescence in situ hybridization, and PCR analyses) allow precise investigation of this problem. This review of the available information on the etiology of chromosomal anomalies indicates that some of the genetic anomalies in human gametes and early embryos result in reproductive failure.

ICSI outcome in patients of 40 years age and over: a retrospective analysis

OBJECTIVE

To report and analyse our experience with ICSI treatment in infertile women >/=40 years of age, with the intention of contributing to current debates on the effect of aging on the reproductive potential.

STUDY DESIGN

107 infertile couples in which the female partner was aged >/=40 years and who received ICSI treatment between January 1996 and December 1998.

RESULTS

A total of 107 women underwent 171 treatment cycles during this period. Of 171 cycles initiated 33 were cancelled (cancellation rate=19.3%). In this way, 17 women did not have embryo transfer at all, while 90 patients had 138 cycles with oocyte retrieval and successful embryo transfer, with a mean number of embryos per transfer 2.36. Sixteen pregnancies occurred and eight of them ended in spontaneous abortion. The implantation rate was 4.9%, the pregnancy rate per initiated cycle was 9.35% and per transfer cycle 11.59%. The miscarriage rate was 50%. Moreover, 12 patients had supernumerary embryos, that were cryopreserved and transferred in 17 thawing cycles and resulted in two pregnancies ending in abortion. All pregnancies occurred when three embryos were available, except in two cases with two available embryos. The great majority of the total pregnancies (16 of 18) resulting in women aged between 40 and 42 years.

CONCLUSION

Our data show that women 40 and older with existing ovarian function may benefit from ICSI treatment, even when the indication for treatment is male factor infertility. Supernumerary embryos, that are cryopreserved and transferred in subsequent cycles can improve the overall pregnancy rates per oocyte retrieval, although these women should be aware of the very high risk of miscarriage.

Relatively poor oocyte quality is an indication for intracytoplasmic sperm injection

OBJECTIVE

To determine the relation between the insemination method used and the quality of oocytes and embryos.

DESIGN

Prospective study.

SETTING

Assisted reproductive centers at Yamagata University Hospital and Kuramoto Women's Clinic in Yamagata, Japan.

PATIENT(S)

Forty patients undergoing IVF and 40 patients undergoing intracytoplasmic sperm injection (ICSI).

INTERVENTION(S)

To estimate oocyte quality, the granulosa cells surrounding the oocyte were fixed and stained with a commercial dye in both groups of patients. One thousand granulosa cells were examined under a fluorescence microscope.

MAIN OUTCOME MEASURE(S)

The incidence of apoptotic granulosa cells surrounding each oocyte.

RESULT(S)

The incidence of apoptosis in the granulosa cells enclosing the oocytes that were fertilized by IVF was significantly lower than that in the oocytes that were fertilized by ICSI. Moreover, the incidence of apoptosis in the granulosa cells enclosing the oocytes that grew into good-quality or fair-quality embryos was significantly lower after conventional IVF than after ICSI. With ICSI, the incidence of apoptosis was not significantly different among the granulosa cells surrounding the oocytes that were inseminated, were fertilized, or developed into good-quality or fair-quality embryos. With IVF, the incidence of apoptosis was highest in the granulosa cells surrounding the oocytes that were inseminated and lowest in the granulosa cells surrounding the oocytes that developed into good-quality and fair-quality embryos.

CONCLUSION(S)

A good-quality oocyte is necessary for the development of a good-quality embryo with IVF but not with ICSI. Thus, relatively poor oocyte quality is a good indication for the use of ICSI.

Donor age is paramount to success in oocyte donation

Several reports suggest increasing age in oocyte donors decreases the chances of in-vitro fertilization (IVF) success, while others describe no effect. The published data concerning gravidity and parity are similarly conflicting. To further address these questions, we retrospectively studied 445 consecutive donor IVF cycles at two large university-based IVF practices. Donor cycles were analysed for the number of oocytes retrieved, gravidity, parity, and age of the donor, and pregnancy outcome in recipients. The previous gravidity and parity of the donor were not associated with successful pregnancy in recipients. The number of oocytes retrieved was positively correlated with pregnancy. However, after adjusting for donor age, neither prior fertility nor the number of oocytes retrieved were significant predictors. In contrast, the donor's age was highly associated with recipient success. We conclude that the age of the oocyte donor is a significant predictor of pregnancy success and should be a major factor in selecting prospective candidates. The gravidity and parity of the donor are insignificant predictors, as are the total number of oocytes retrieved at the time of oocyte harvest.

Oocyte donation: insights into implantation

OBJECTIVE

To ascertain whether obstetric, gynecologic, or congenital variables affect implantation efficiency or eventual delivery in donor oocyte recipients.

DESIGN

Clinical study.

SETTING

Academic tertiary care infertility clinic.

PATIENT(S)

A total of 370 recipients.

INTERVENTION(S)

Fresh ET following oocyte donation in a hormone replacement cycle.

MAIN OUTCOME MEASURE(S)

Regression analyses were performed to detect any statistically significant difference in the pregnancy rate (PR), delivery rate, miscarriage rate, or implantation rate associated with different obstetric, gynecologic, and congenital independent variables while accounting for the age of the recipient in each analysis.

RESULT(S)

For all recipients, a clinical PR per transfer of 58.9% was achieved, with an implantation rate of 30%. A significant decline in the implantation rate was noted in relation to increasing age of the recipient. A history of tubal disease was associated with a significantly lower implantation rate and a significantly lower ongoing and delivered PR. Asherman's syndrome, despite surgical correction, appeared to negatively affect the ongoing and delivered PR.

CONCLUSION(S)

With the exceptions of recipient age and a history of tubal disease, all other uterine factors studied did not appear to influence the implantation potential of an embryo resulting from oocyte donation. A history of tubal disease had a distinctly negative effect on implantation efficiency and delivery potential for a given recipient. This finding highlights the need to identify the mechanisms underlying the negative effect of tubal disease so that donor oocyte recipients and all other patients with this cause of infertility can benefit from directed therapy.

Fertility and infertility in aging women

Age is often a dominant factor for women wanting to conceive. The objective of this study was to examine the outcome of an in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) program in relation to a woman's age. Between January 1995 and June 1997 we stimulated 2511 cycles. The mean age of the women was 34 years, with 21.9% under 30, 45.9% between 30 and 35, 24.5% between 36 and 39, and 7.7% over 39 years. All patients aged > or = 40 years had day 3 serum follicle-stimulating hormone (FSH) concentrations < 20 IU/l. The stimulation regimen consisted of 150-450 IU of human menopausal gonadotropin (hMG) or FSH combined with either clomiphene citrate (CC) or gonadotropin-releasing hormone agonist (GnRHa) in a short or long protocol. Age had a significantly negative effect on the stimulation and fertilization failure rates. The clinical pregnancy rate per transfer and the embryo implantation rate declined significantly from 29.4% and 18.9% in women < 30 years to 19.8% and 14.3% in patients between 30 and 35 years, 17.1% and 9.0% between 36 and 39 years and to 12.8% and 7.4% in those aged > or = 40 years. The spontaneous abortion rate was 14.9%, 16.5%, 22.4% and 33.2%, respectively. The clinical pregnancy rate per transfer reflected only imperfectly the performance of the older women because the discharge rate during stimulation and spontaneous abortions reduced the 'take home baby' rate to about 7% per cycle in patients aged > or = 40 years. It is very important in fertility practice to recognize the major impact of advancing maternal age.

Long-term down-regulation does not improve pregnancy rates in an in vitro fertilization program

OBJECTIVE

To investigate the effects of long-term down-regulation (4 months) used in combination with gonadotropin ovarian stimulation for IVF-ET.

DESIGN

Prospective randomized study.

SETTING

Assisted Reproduction Unit of the Hospital Clinic i Provincial in Barcelona, a tertiary care setting.

PATIENT(S)

Thirty pairs of IVF patients who were matched for age, indication for IVF, and number of attempts.

INTERVENTION(S)

Women were randomized to receive a standard long protocol of SC leuprolide acetate (n = 30, group L) or a monthly injection of leuprolide acetate depot for 4 months (n = 30, group D) before gonadotropin stimulation.

MAIN OUTCOME MEASURE(S)

Ovarian response and IVF outcome.

RESULT(S)

Days of ovarian stimulation, follicular recruitment and growth during gonadotropin treatment, and the endometrial thickness on the day of hCG administration were similar for the 2 groups of IVF patients. However, the serum concentration of E2 was significantly higher in group L even though group D received a higher total dose of gonadotropins. The number of follicles punctured, the number of oocytes retrieved, the number of oocytes fertilized, the number of embryos suitable for replacement and cryopreservation, the number of patients with ET, and implantation and clinical pregnancy rates were similar for groups L and D. However, the percentage of metaphase II oocytes was significantly higher in group L than in group D.

CONCLUSION(S)

Long-term down-regulation does not improve pregnancy rates in a general IVF program.

Multivariate analysis of factors predictive of successful live births in in vitro fertilization (IVF) suggests strategies to improve IVF outcome

PURPOSE

Our purpose was (1) to identify characteristics correlated with pregnancy outcome, (2) to use these characteristics to predict in vitro fertilization (IVF) outcome, and (3) to develop strategies that might improve IVF success.

METHODS

Maternal age, cause for IVF, donor insemination, rank of attempt, serum estradiol and luteinizing hormone levels on the day of human chorionic gonadotropin administration, flexible vs rigid catheter, number of embryos transferred of each morphologic type, and cell number were analyzed by logistic regression.

RESULTS

Variables positively correlated with success are as follows: (1) for pregnancy, endometriosis and 2-, 3-, and 4-cell good and 4-cell excellent embryos; (2) for live births, 2-, 3-, and 4-cell good and 4-cell excellent embryos and donor insemination; and (3) for multiple births, 2- and 4-cell good and 4-cell excellent embryos. Maternal age was negatively correlated with live births.

CONCLUSIONS

Embryos derived from IVF have different potentials for implantation, live births, and multiple births. Transferring one additional good-quality embryo for each 5 years of incremental increase in maternal age is predicated to improve live birth rates without increasing multiple births.

The influence of advanced age on the outcome of assisted reproduction

PURPOSE

Our purpose was to determine the influence of age on the outcome of assisted reproduction, with particular interest in women aged 40 years or older.

METHODS

A retrospective review of the 779 patients enrolled in the Royal Hospital for Women Fertility Group fertility program between 1987 and 1994 was performed. The results for women aged 40 years or older were compared with those for women between 36 and 39 years and those younger than 36 years. The main outcome measures were pregnancy rate, pregnancy outcome, fertilization rate, and ovarian response.

RESULTS

Compared with those in younger women, pregnancy rate, pregnancy outcome, fertilization rate, and ovarian response to controlled ovarian stimulation were significantly worse in women aged 40 years or older.

CONCLUSIONS

The outcome of assisted reproduction in women of 40 years of age or older was extremely poor. Compared with those in younger women, pregnancy outcome and ovarian response to controlled ovarian stimulation were significantly worse in women of 40 years or more.