Diagnostic sensitivity and specificity of CT angiography for renal artery stenosis in children

BACKGROUND

Children with suspected renal artery stenosis (RAS) are screened with renal Doppler ultrasonography or computed tomography (CT) angiography/magnetic resonance (MR) angiography depending on institutional preference. CT angiography produces images with superior resolution, allowing higher quality multiplanar two-dimensional reformats and three-dimensional reconstructions. However, there is a paucity of data in the literature regarding the utility and diagnostic performance of renal CT angiography in pediatric RAS.

OBJECTIVE

The objective of this study is to retrospectively review our experience with renal CT angiography in the diagnosis of pediatric RAS relative to digital subtraction angiography (DSA) as the reference standard.

MATERIALS AND METHODS

All patients 0-18 years of age who underwent CT angiography for evaluation of RAS as a cause of hypertension between January 2012 and May 2019 were identified for the study. A total of 131 patients were identified, 23 of whom had DSA correlation.

RESULTS

Twenty-three patients (17 boys, 6 girls) with a mean age of 6 years 3 months (range: 3 months to 14 years 7 months) were included in this study. Of the 59 renal arteries studied by DSA, 22 were abnormal on CT angiography and 20 were abnormal on DSA. Of the 59 renal arteries, CT angiography was true positive in 18 and true negative in 35. The sensitivity and specificity of CT angiography for RAS diagnosis were 90.0% and 89.7%, respectively. CT angiography identified all cases of main RAS.

CONCLUSION

Renal CT angiography has a high sensitivity and specificity for pediatric RAS diagnosis in patients referred for DSA.

Reclassification of adolescent hypertension by ambulatory blood pressure monitoring using adult norms and association with left ventricular hypertrophy

2017 pediatric blood pressure (BP) guidelines applied adult BP norms to define clinic hypertension (HTN) in patients ≥ 13 years. 2014 pediatric ambulatory BP monitor (ABPM) guidelines recommend age‐ and sex‐specific percentile norms for patients < 18 years. The authors evaluated reclassification of HTN when applying adult ABPM norms in patients ≥ 13 years and assessed the association of left ventricular hypertrophy (LVH) with HTN. Charts of patients 13–17 years with ABPM 9/2018–5/2019 were reviewed for sex, age, height, weight, BP medication, ABPM results, and left ventricular mass index (LVMI). American Heart Association 2005 (AHA 2005), AHA 2017 (AHA 2017), and European Society of Hypertension 2018 (ESH 2018) guidelines for adult ABPM were compared with 2014 AHA pediatric norms (pABPM). HTN was defined by each guideline using only ABPM. ABPM and clinic BP were used to classify white coat hypertension (WCH) and masked hypertension (MH). LVH was defined as LVMI > 51 g/m^2.7. 272 patients had adequate ABPM. 124 patients also had echocardiogram. All adult norms resulted in significant reclassification of HTN. LVMI correlated significantly with systolic BP only. The odds of a patient with HTN having LVH was significant using AHA 2005 (OR: 8.75 [2.1, 36.4], p = .03) and ESH 2018 (OR: 4.94 [1, 24.3], p = .002). Significant reclassification of HTN occurs with all adult norms. HTN is significantly associated with LVH using AHA 2005 and ESH 2018. Applying pediatric norms for ABPM while using adult norms for clinic BP causes confusion. Guideline selection should balance misdiagnosis with over‐diagnosis.

Hyperuricosuria, hematuria, and novel bladder images with IgA nephropathy

Episodic (recurrent) macroscopic hematuria in patients with IgA nephropathy is usually associated with a benign prognosis, although some patients experience a transient fall in glomerular filtration rate during the episodes. We present a 15-year-old girl with mild IgA nephropathy who had multiple episodes of macroscopic hematuria associated with severe but transient decreases in estimated glomerular filtration rate, low levels of serum uric acid, and marked increases in fractional excretion of uric acid. Ultrasound studies showed marked inflammatory changes in the bladder, especially involving the trigone. Cystoscopic findings were consistent with these changes. We hypothesize that the macroscopic hematuria may have resulted, at least in part, from hyperuricosuria causing acute irritation of the bladder mucosa in the trigone area.

First record of Hysterothylacium sp. Moravec, Kohn et Fernandes, 1993 larvae (Nematoda: Anisakidae) infecting the ornamental fish Hyphessobrycon eques Steindachner, 1882 (Characiformes, Characidae)

This study reports for the first time infection with Hysterothylacium sp. larvae in the ornamental fish Hyphessobrycon eques from the Paranapanema River, Jurumirim Reservoir, São Paulo State, Brazil. A sample of 33 specimens of H. eques was collected in October, 2011. Four specimens of H. eques were parasitized by Hysterothylacium sp. larvae in the intestine and coelomic cavity, with prevalence of 12.1%, mean intensity of infection of 1, and mean abundance of 0.121 ± 0.05. A total of 40 unidentified free-living nematodes were found in the stomach content of 17 fish. This fish species is introduced in the Paranapanema River. Invasive species may affect the native fauna given the introduction of pathogens and parasites. This study also complements data on the diet of H. eques due to the records of free-living nematode as part of the stomach content. Infections with Hysterothylacium sp. larvae may affect the biology of this fish and bring about profit losses to aquarists.

Helminth fauna of Astyanax fasciatus Cuvier, 1819, in two distinct sites of the Taquari River, São Paulo State, Brazil

This study assessed the helminth fauna of Astyanax fasciatus in two distinct sites of the Taquari River, São Paulo State, with 30 individuals sampled in a lotic site and 30 in a lentic site, recording the monogeneans: Cacatuocotyle paranaensis, Characithecium costaricensis, Diaphorocleidus kabatai, Jainus sp., Notozothecium sp. and Gyrodactylus sp., the digenean Antorchis lintoni and no-identified metacercariae; the nematode Procamallanus (Spirocamallanus) inopinatus and no-identified larvae. The mean abundances of total monogeneans (U = 1053; p = 0.042) and C. costaricensis (U = 1107; p = 0.005) were higher in the lotic site. This difference may be due to the higher density of the host population in the lotic site, and the water transparence in lentic environments that prevents A. fasciatus to form shoals, precluding the exchange of parasites with direct cycle within a host population. This study is the first report of the helminth fauna of A. fasciatus in the Taquari River, with ten taxa recorded, and reports A. fasciatus as a new host for Notozothecium sp. and C. paranaensis.

[Resident of emergency attitude towards patients-physician relationship at the Hospital de Clínicas- Asunción, Paraguay]

INTRODUCTION

The doctor-patient relationship is reaching great importance in recent times, is highlighted their importance in areas as varied as satisfaction, compliance, perception of professional competence, the frequency of legal issues relating to malpractice and even the prognosis of the disease or the general health of the patient.

OBJECTIVE

To evaluate the doctor-patient relationship from the point of view of residents of emergency unit.

METHODS

An observational, descriptive study. The sample consisted of 36 doctors from different areas of the Emergency Rooms of the Hospital de Clínicas- Asunción, Paraguay. The patient-physician relationship was evaluated using an instrument developed by RA Chavarria-Islas et al. with four indicators: Respect, Information, Consent and Dedication.

RESULTS

69.4% of residents have a regular patient-physician relationship; despite the 2.78% has a good relationship, 25% bad relationship and 2.78% a very bad relationship.

CONCLUSION

Gaps in doctor-patient relationship were found in this study.. It is interesting to invest greater efforts to enhance the doctor-patient relationship as one of the edges to improve health care, which is vital in emergency care.

Prevalence of persistent prehypertension in adolescents

OBJECTIVE

To measure the prevalence of persistent prehypertension in adolescents.

STUDY DESIGN

We collected demographic and anthropometric data and 4 oscillometric blood pressure (BP) measurements on 1020 students. The mean of the second, third, and fourth BP measurements determined each student's BP status per visit, with up to 3 total visits. Final BP status was classified as normal (BP <90th percentile and 120/80 mm Hg at the first visit), variable (BP ≥ 90th percentile or 120/80 mm Hg at the first visit and subsequently normal), abnormal (BP ≥ 90th percentile or 120/80 mm Hg at 3 visits but not hypertensive), or hypertensive (BP ≥ 95th percentile at 3 visits). The abnormal group included those with persistent prehypertension (BP ≥ 90th percentile or 120/80 mm Hg and <95th percentile on 3 visits). Statistical analysis allowed for comparison of groups and identification of characteristics associated with final BP classification.

RESULTS

Of 1010 students analyzed, 71.1% were classified as normal, 15.0% as variable, 11.5% as abnormal, and 2.5% as hypertensive. The prevalence of persistent prehypertension was 4.0%. Obesity similarly affected the odds for variable BP (OR, 3.9; 95% CI, 2.5-6.0) and abnormal BP (OR, 3.4; 95% CI, 2.0-5.9), and dramatically increased the odds for hypertension (OR, 38.4; 95% CI, 9.4-156.6).

CONCLUSION

Almost 30% of the students had at least one elevated BP measurement significantly influenced by obesity. Treating obesity may be essential to preventing prehypertension and/or hypertension.

Rasburicase for hyperuricemia in hemolytic uremic syndrome

BACKGROUND

Acute kidney injury (AKI) with elevated serum uric acid (UA) levels has been reported in patients with hemolytic uremic syndrome (HUS). AKI is thought to result from tubular obstruction by UA crystals. Inducing a diuresis may ameliorate the oligoanuria in such patients. We describe a child with HUS in whom reducing UA with fluids and rasburicase appeared to accelerate the recovery of renal function.

CASE-DIAGNOSIS/TREATMENT

A 9-month-old Caucasian male infant presented with 6 days of diarrhea, 3 days of vomiting, and 24 h of oliguria. On admission, hemoglobin was 8.3 g/dL, platelet count 36,000/L, blood urea nitrogen 73 mg/dL, and serum creatinine (SCr) 2.7 mg/dL. Diarrhea-associated HUS was diagnosed. The day after admission, SCr was 2.9 mg/dL and UA 12.3 mg/dL. On hospital day 2, he received a dose of intravenous rasburicase 0.18 mg/kg, and less than 12 h later, the UA had fallen to 0.3 mg/dL. The SCr level also started to fall, and urine output progressively increased without the use of diuretics. Renal function continued to improve, and the UA level remained normal despite ongoing hemolysis requiring a second red blood cell transfusion on hospital day 5. The patient was discharged on hospital day 7 in good physical condition. Two months later, he was in good health, with a SCr level of 0.2 mg/dL and UA of 4.2 mg/dL.

CONCLUSIONS

We postulate that aggressive management of the high serum UA level with rasburicase and fluid hydration accelerated the recovery of our patient. Further studies are needed to determine the role of rasburicase in the treatment of hyperuricemia in patients with HUS.

Development of hypertension in adolescents with pre-hypertension

OBJECTIVE

To evaluate the risk for developing incident hypertension (HTN) in adolescents with pre-hypertension.

STUDY DESIGN

A secondary analysis of students participating in multiple school-based blood pressure (BP) screens from 2000 to 2007 was completed. At each screen, height, weight, and 2 to 4 BPs were measured on as many as 3 occasions when BP remained ≥ 95th percentile. Students with confirmed HTN at their initial screen were excluded, and incident HTN was defined as having a BP ≥ 95th percentile at all 3 visits of a later screen. Incidence rates (IR) and hazard ratios (HR) were calculated by using Cox Proportional models.

RESULTS

Of 1006 students, HTN developed in 11 (IR 0.5%/year) in a mean of 2.1 years of observation. IRs were higher in "at-risk" students (pre-hypertensive or hypertensive with follow-up BP <95th percentile), 1.4%/year (HR, 4.89; 1.48-16.19) and students with a BP ≥ 90th percentile at 3 baseline visits, 6.6%/year HR 24.33 (5.68-104.29)]. Although not significant, students with pre-hypertension by the 2004 Task Force definition also had an increased IR of 1.1%/year (HR, 2.98; 0.77-11.56)].

CONCLUSION

Elevated BP increases the risk for the development of HTN during adolescence. Effective strategies for preventing HTN in at-risk adolescents are needed.

Male antisperm antibodies: association with a modified sperm stress test and lipid peroxidation

We previously reported a modified sperm stress test (MOST), low scores (< 0.39) in which were associated with sperm-related abnormal in vitro fertilization. Preliminary observations suggested that the presence of male sperm antibodies (ASA) could give low MOST scores. It was therefore decided to undertake a study to verify this possible association and also to ascertain if such a relationship was causal in nature. Six hundred and fifty semen samples from patients consulting for infertility were assessed for basic seminal characteristics, motion parameters (CASA), ASA and MOST. Thirty-nine samples (6%) were ASA-positive. Samples with and without ASA showed similar characteristics, except for percentage of normal forms and MOST scores (0.35 +/- 0.03 vs. 0.67 +/- 0.01, P < 0.001, for ASA-positive and -negative, respectively). There was a strong statistical association between presence of ASA and low MOST scores (P < 0.0001). One-hundred per cent of ASA-positive samples displayed low MOST scores. To verify the nature of this relationship, we incubated ASA-free spermatozoa with ASA-positive and -negative (control) sera. Despite an increase in the percentage of ASA-bearing spermatozoa in those aliquots incubated with ASA-positive serum, their original (pre-incubation) MOST scores remained unchanged. Furthermore, the rate of lipid peroxidation, indirectly reflected in MOST scores, was not different in the aliquots incubated with ASA. In conclusion, there seems to be a strong association between presence of ASA and low MOST values in semen samples of infertile patients; however, the relationship does not appear to be causal.

Serum inhibin B may be a reliable marker of the presence of testicular spermatozoa in patients with nonobstructive azoospermia

OBJECTIVE

To establish the predictive value of serum inhibin B levels as an indicator of the presence of testicular spermatozoa in nonobstructive azoospermia, compared with the traditional serum FSH marker.

DESIGN

Prospective study.

SETTING

Private high-complexity reproductive center with university affiliation.

PATIENT(S)

Seventy-eight patients with nonobstructive azoospermia, 15 patients with obstructive azoospermia, and 10 fertile volunteers.

INTERVENTION(S)

Blood samples, testicular sperm extraction, percutaneous epididymal sperm aspiration, and semen collection.

MAIN OUTCOME MEASURE(S)

Serum levels of inhibin B and FSH and presence of spermatozoa on TESE, PESA, or regular semen analysis.

RESULT(S)

Patients with nonobstructive azoospermia has significantly higher levels of serum FSH and significantly lower levels of inhibin B. Mean inhibin B serum levels were significantly higher in patients with nonobstructive azoospermia who had spermatozoa on TESE than in those in whom no spermatozoa were found (89.31 +/- 73.24 pg/mL vs. 19.23 +/- 22.34 pg/mL), but mean FSH serum levels did not have similar predictive power (21.37 +/- 12.92 IU/mL vs. 19.27 +/- 10.28 IU/mL). The cut-off level of inhibin B separating both groups, as determined by the receiver-operating characteristic curves, was >53 pg/mL.

CONCLUSION(S)

Serum inhibin B level seems to be more accurate than serum FSH level in prediction of the presence of testicular spermatozoa in patients with nonobstructive azoospermia.

Effects of long-term in vitro incubation of human spermatozoa: functional parameters and catalase effect

Prolonged incubation of human spermatozoa can have deleterious effects on sperm function. The aim of this paper was to describe the effects of a prolonged in vitro incubation, under similar conditions to those employed in human assisted reproduction, on various sperm functional parameters, and to investigate the effect of an antioxidant (catalase) on this system. Freshly collected ejaculates from 20 healthy donors were studied. Samples were divided into two aliquots: the first was incubated with Ham's F10 containing 3.5% HAS, and the second was incubated in the same medium plus catalase (100 units ml-1). All experiments were carried out with spermatozoa isolated using the swim-up technique. Spermatozoa recovered from the supernatant after 1 h (T1) of incubation in 5% CO2 in air at 37 degrees C, and after 5 h (T6), 23 h (T24) and 47 h (T48), were evaluated for concentration, motion parameters including hyperactivation (computer-assisted analysis), viability, ATP concentration, reactive oxygen species (ROS) generation, DNA integrity (acridine orange), and acrosome reaction (AR). The major alteration observed in sperm function during the prolonged in vitro incubation was a reduction in the number of motile spermatozoa, together with an impairment in the quality of sperm movement. ROS levels increased with the incubation time. No substantial modifications of sperm viability, chromatin condensation and AR inducibility were observed. The addition of catalase to the medium, while keeping ROS values within baseline levels, did not prevent the loss of motility or the corresponding increase in ATP.

Incidence of tail structure distortions associated with dysplasia of the fibrous sheath in human spermatozoa

Dysplasia of the fibrous sheath (DFS) is an anomaly found in spermatozoa of severe asthenozoospermic patients. Marked hypertrophy and hyperplasia of the fibrous sheath is the common characteristic. Immunocytochemistry allowed us to visualize the distortions and incidence of tail structure abnormalities associated with this phenotype in six patients; four with a complete form and two with an incomplete form of this pathology previously diagnosed and studied by electron microscopy. Microtubules and fibrous sheaths were studied using monoclonal antibodies against alpha-acetylated tubulin and anti-FSC1 (the major protein component of the fibrous sheath). Mitochondrial sheaths were visualized using the mitochondrion-specific vital dye MitoTracker green FM(TM). Phase contrast and fluorescent microscopy of semen samples showed large numbers of spermatozoa with short, rigid, thick and irregular tails. As expected, anomalous and completely distorted fibrous sheaths, severe alterations of the axonemal microtubules and different patterns of mitochondrial sheath configurations were found. While ultrastructural studies of thin sections allow an in-depth knowledge of the internal organization of the sperm tail, fluorescence labelling of selected sperm components affords a unique view of the whole flagellum including topographical relationships of various organelles. The combination of these different approaches is essential for a comprehensive understanding of this particular pathology.

Present and future of maternal mortality in Latin America

Twenty-three thousand maternal deaths per year in Latin America and the Caribbean reflects clearly the critical situation in this part of the world. Although we don't know exactly how many women die every year from pregnancy and childbirth, it is clear that the majority of these women are from low socioeconomic backgrounds, live in remote places and have a low level of education. Hemorrhages, infections and hypertension induced by pregnancy are the most common causes of maternal mortality. These pathologies can in many cases be prevented if there is a will for a positive change that involves different sectors related with health. The role of the scientific societies, and the role of FIGO through the 'Save the Mothers' Project are of extreme importance, assuming a chief role and compromise that can help in the right way to be able to revert this situation.

Cytoskeletal organization defects and abortive activation in human oocytes after IVF and ICSI failure

In this study, we analysed the distribution of beta tubulins to detect spindle and cytoplasmic microtubules, alpha acetylated tubulins for sperm microtubules and chromatin configuration in oocytes showing fertilization failure after conventional IVF or intracytoplasmic sperm injection (ICSI). A total of 450 human oocytes that failed to fertilize were studied 20-40 h after IVF or ICSI. In all, 287 oocytes were stained for immunofluorescence and chromosomal spreads were performed by Tarkowski's air-drying method in 163 IVF or ICSI oocytes that did not develop pronuclei after the extrusion of a second polar body. Immunofluorescence analysis showed that the main reason of fertilization failure after IVF was no sperm penetration (55.5%). The remaining oocytes showed different abnormal patterns, e.g. oocyte activation failure (15.1%) and defects in pronuclei apposition (19.2%). On the other hand, fertilization failure after ICSI was mainly associated to incomplete oocyte activation (39.9%), and to a lesser extent with defects in pronuclei apposition (22.6%) and failure of sperm penetration (13.3%). A further 13.3% of the ICSI oocytes arrested their development at the metaphase of the first mitotic division. The chromosomal spreads allowed the analysis of abortive activations, in which no pronuclei formed but a second polar body was extruded. Immunofluorescence and cytogenetic analysis provided a useful tool to improve infertility diagnosis and prognosis in each particular case.

Pregnancies established through intracytoplasmic sperm injection (ICSI) using spermatozoa with dysplasia of fibrous sheath

AIM

Dysplasia of the fibrous sheath (DFS) is an anomaly found in asthenozoospermic patients with extremely low or absent motility. In order to determine the efficacy of ICSI in these patients, a retrospective analysis of ICSI results in DFS patients has been done.

METHODS

Ten ICSI attempts were performed in 6 patients with diagnosis of Dysplasia of the Fibrous Sheath studied by transmission and scanning electron microscopy.

RESULTS

In the cases studied, sperm concentration was (29.62 +/- 18.05) x 10(6)/mL, total motility was 1.14 +/- 1.31%. Progressive motility was 0% except for one case with 0.1% . One hundred and three preovulatory oocytes were obtained and 94 metaphase II oocytes were injected. Sixty-nine of them showed two pronuclei (fertilization rate: 73.4%). Forty-nine embryos were obtained and 34 were transferred (mean: 3.4 embryos per transfer). Five pregnancies were diagnosed by beta-hCG plasma level determinations that resulted to be one preclinical abortion, one clinical abortion and three deliveries. Another pregnancy (ongoing) was achieved from a cryopreserved embryo transfer.

CONCLUSION

These results showed that ICSI provides a suitable solution for patients suffering from irreversible sperm defects such as DFS. Nevertheless, it is mandatory to inform couples of possible transmission risks to offspring, which are unknown at present. Only when the etiology of this problem is disclosed, it will be possible to assess the real genetic risk.

Endometrial dating and determination of the window of implantation in healthy fertile women

OBJECTIVE

To reassess endometrial morphological criteria of normality identifying the best morphological and molecular "implantation window" indicators in normal women.

DESIGN

Prospective clinical study.

SETTING

Assisted reproductive unit.

PATIENT(S)

Fourteen healthy volunteers.

INTERVENTION(S)

Blood sampling for LH, E(2), and progesterone (P4) determinations. Daily vaginal ultrasounds. Two endometrial biopsies per volunteer, 7 days apart, during luteal phase.

MAIN OUTCOME MEASURE(S)

Endometrial dating, pinopodes formation, immunohistochemical determination of integrins (alphavbeta3, alpha4beta1), leukemia inhibitory factor (LIF), interleukin-1 receptor type I (IL-1R tI), mouse ascites Golgi (MAG), the transmembrane mucin (MUC-1), and P4 receptor expression.

RESULT(S)

In 26 of 28 biopsies observers agreed; in two biopsies there was a discrepancy (difference of 72 hours). With use of LH peak, 24 of 26 samples were in phase, and 2 were 3 days behind. Pinopodes appeared on days 20-21 and persisted through day 28 in small groups or larger areas. beta3 Integrin was highly expressed in luminal and glandular epithelium from day 22 through 28; 48 hours thereafter pinopodes appeared. alpha4 Subunit exhibited luminal epithelium reaction positivity on days 22-23 and glands on days 18-23. LIF and IL-1R tI showed weak, erratic expression. MAG antibodies showed luminal epithelium expression up to day 22 and glands up to day 25. MUC-1 showed positivity during the whole luteal phase. P4 receptors were positive through day 20 and at the end of the luteal phase.

CONCLUSION(S)

The three most cited markers that frame the window of implantation do not correlate in our material. Pinopodes are present from day 20 on; beta3 and alpha4 integrin subunits indicate a window opening on days 22-23.

Birth of twin males with normal karyotype after intracytoplasmic sperm injection with use of testicular spermatozoa from a nonmosaic patient with Klinefelter's syndrome

OBJECTIVE

To report the birth of healthy twin males after the use of testicular spermatozoa from a nonmosaic patient with Klinefelter's syndrome.

DESIGN

Case report.

SETTING

Private reproduction center with university affiliation.

PATIENT(S)

A couple undergoing intracytoplasmic sperm injection (ICSI) combined with testicular sperm extraction because of the husband's secretory azoospermia and a nonmosaic 47,XXY peripheral blood karyotype. The wife, a healthy female, presented with a history of oligomenorrhea.

INTERVENTION(S)

ICSI was performed using testicular spermatozoa; 3 mM pentoxifylline solution was used to induce sperm motility because the spermatozoa recovered were all immotile.

MAIN OUTCOME MEASURE(S)

Normal fertilization, embryo cleavage, pregnancy outcome, and peripheral blood karyotype of the newborns.

RESULT(S)

Thirteen metaphase II oocytes were injected. Seven of them fertilized normally and six did not fertilize. Three good-quality embryos (4-cell stage class II) were transferred, and four were cryopreserved at the two-cell and four-cell stages using a slow freezing protocol. Twelve days after ET, a beta-hCG determination was positive. Ultrasonographic examination revealed three intrauterine fetal sacs, but one of them showed a fetal pole without cardiac activity and vanished in subsequent ultrasonographic examinations. The patient delivered twins with normal male peripheral blood karyotypes.

CONCLUSION(S)

Normal outcome after the use of testicular sperm extraction and ICSI in a nonmosaic patient with Klinefelter's syndrome reaffirms the notion of low transmission risk of this gonosomal aneuploidy.

Detection of aneuploidy for chromosomes 4, 6, 7, 8, 9, 10, 11, 12, 13, 17, 18, 21, X and Y by fluorescence in-situ hybridization in spermatozoa from nine patients with oligoasthenoteratozoospermia undergoing intracytoplasmic sperm injection

Recent evidence suggests that infertile males donating semen for intracytoplasmic sperm injection (ICSI) may be at an increased risk of transmitting numerical (predominantly sex chromosome) abnormalities to their offspring. The present study was designed to determine aneuploidy in spermatozoa from oligoasthenoteratozoospermic (OAT) patients undergoing ICSI. Aneuploidy frequencies of 12 autosomes and the sex chromosomes were determined by fluorescence in-situ hybridization (FISH) on spermatozoa from fresh ejaculate of nine severe OAT patients and four proven fertile donors. FISH, using directly labelled (fluorochrome-dUTP) satellite or contig DNA probes specific for chromosomes 4, 6, 7, 8, 9, 10, 11, 12, 13, 17, 18, 21, X, and Y, was performed on decondensed spermatozoa. Per chromosome disomy frequencies for autosomes and sex chomosomes in OAT males were 0-5. 4%. In contrast, the disomy frequencies in controls were 0.05-0.2%. The frequency of diploid spermatozoa in OAT patients was 0.4-9.6%; controls showed a mean of 0.04%. Using recently developed formulae, the total aneuploidy in our OAT patient population was estimated to be 33-74%. In contrast, estimates of mean total aneuploidy in the spermatozoa of controls ranged from 4.1 to 7.7%, depending upon method of calculation. Six series of ICSI were performed on five of the OAT patients. Four resulted in no establishment of pregnancy; the others failed to establish ongoing pregnancies. Our cytogenetic data show significantly elevated frequencies of diploidy, autosomal disomy and nullisomy, sex chromosome aneuploidy, and total aneuploidy in OAT patients, which may contribute to the patients' infertility.

Modified sperm stress test: a simple assay that predicts sperm-related abnormal in-vitro fertilization

Loss of sperm motility is associated with the process of sperm senescence and occurs at different rates within a given normal or abnormal sperm population. Reactive oxygen species attack cell membrane phospholipids, generating fatty acid peroxides and other degradation products, that also have deleterious effects on sperm motility and fertilizing ability. The objective of this investigation was to study a modification of the original sperm stress test (MOST), changing the culture medium to one offering transitional metals and shortening the total test time, to ascertain whether it can predict fertilization under these laboratory conditions. A total of 41 semen samples was obtained from patients undergoing in-vitro fertilization (IVF) at our institution. Semen samples were grouped into those producing total fertilization rates (FR) within normal limits (>50%) and those showing low total FR (<50%). The normal FR group had a significantly greater MOST mean value than the low FR group (0.71 versus 0.44). Furthermore, there was a statistically significant correlation between the MOST score and ungrouped fertilization rates (r = 0.53, P = 0.0004). Diagnostic statistics for MOST ratio values predicting <50% FR showed an optimal threshold of 0.39. Collectively, sensitivity, specificity, positive predictive value and negative predictive value have their largest values at this threshold. Taking into account the above mentioned threshold figures, there is a significant association between MOST and FR categories (P = 0.0009). In conclusion, MOST is a simple assay that has significant predictive value for sperm related IVF abnormalities.

Cytogenetics of somatic cells and sperm from a 46,XY/45,X mosaic male with moderate oligoasthenoteratozoospermia

OBJECTIVE

To determine aneuploidy frequencies in sperm from a patient with normal phenotype and 46,XY/45,X mosaicism in somatic cells (peripheral lymphocytes).

DESIGN

Case report.

SETTING

Infertility clinic and genetics laboratory.

PATIENT

A 30-year-old male with primary infertility and moderate oligoasthenoteratozoospermia.

INTERVENTION(S)

Cytogenetic analysis of somatic cells and determination by fluorescence in situ hybridization of aneuploidy frequencies for the gonosomes (sex chromosomes) and chromosome 18 in sperm from whole and Percoll-separated semen.

MAIN OUTCOME MEASURE(S)

Somatic and gametic aneuploidy were scored.

RESULT(S)

Analysis of lymphocyte metaphase cells showed a mosaic 46,XY (90%)/ 45,X (10%) karyotype. Significantly higher frequencies of gonosomal (semen, 1.92% versus 0.70%; Percoll, 1.12% versus 0.46%), and chromosome 18 (semen, 0.89% versus 0.28%; Percoll, 0.26% versus 0.10%) disomy were detected in the sperm of the patient compared with those observed in spermatozoa from a proved fertile control.

CONCLUSION(S)

Significantly higher frequencies of aneuploid sperm suggest that the patient is at elevated risk of producing offspring with numerical chromosome abnormalities.

[The male factor. III. Importance, diagnosis and perspectives]

According to the World Health Organization, the male factor is present in 40-50% of infertile couples, therefore the importance of the continuity in multidisciplinary studies related to understand the mechanisms regulation the male reproductive process. Semen analysis is still almost the only instrument for the study of men with disruptions in their fertility. However, the main problem to establish a diagnosis with predictive value for male infertility, is the fact that the morphological and/or functional characteristics of the male gamete that determine its fertilizing capacity are still in the process of validation. Even more, the correlations among semen characteristics and bioactive hormones concentrations in serum, and the individual fertility potential have not been established either. In this context, we discuss here some topics that we considered of great importance in relation to male fertility diagnosis, i.e. the main causes of infertility, the advances in the recognition of the morpho-functional correlation that determines the fertilizing capacity of the male gamete and the criteria that prevail in the laboratory to proper handle and evaluate the semen samples.

Effect of sperm viability, plasmalemma integrity, and capacitation on patterns of expression of mannose-binding sites on human sperm

The objective of this study was to characterize patterns of surface expression of mannose-binding sites (MBS) on human spermatozoa while evaluating the influence of sperm viability, plasma membrane integrity, and capacitation, D-Mannose binding sites were visualized by fluorescence microscopy using fluoresceinated mannose-enriched bovine serum albumin (FITC-DMA). To verify the probe specificity, 200 mM D-mannose and D-mannosylated albumin 200 micrograms/mL (DMA) were used as competitive inhibitors. Fluoresceinated bovine serum albumin (FITC-BSA) was used as control. Sperm membrane integrity was checked with a hypoosmotic swelling test (HOST) and sperm viability with Hoechst 33,258 at 1 microgram/mL. Viable spermatozoa with intact plasma membrane presented two main patterns: light bar (weak labeling of the equatorial segment) and slot (labeling of the pre- and postequatorial areas with a negative band in between). These patterns were significantly inhibited when unlabeled D-mannose or DMA were included in the medium. The percentages of spermatozoa displaying these two patterns increases significantly during capacitation. Nonviable spermatozoa with altered plasma membrane integrity presented multiple fluorescent patterns, all of which were present when FITC-BSA was used as the marker. None of them could be suppressed by unlabeled D-mannose or DMA. Viable spermatozoa displayed two main patterns which increased their incidence with capacitation and may be the only specific patterns for surface MBS. Other patterns detected in spermatozoa bearing altered plasma membranes may be due to nonspecific BSA binding or intracellular MBS recognition.

Mannose-binding sites on human spermatozoa and sperm morphology

OBJECTIVE

To verify a possible association between the expression of sperm head mannose-binding sites and sperm morphology.

DESIGN

Prospective in vitro study.

SETTING

University-based sperm biology and andrology laboratories.

PARTICIPANTS

Twenty-seven fertile donors and 45 patients consulting for infertility.

INTERVENTIONS

D-mannose-binding sites were identified using a fluoresceinated mannose-enriched bovine serum albumin. Hoechst 33258 was included to confirm sperm viability and hypo-osmotic swelling test to assess plasma membrane integrity. Sperm morphology was judged by strict criteria and semen samples were classified into three groups: normal (group N, > 10% morphologically normal sperm, n = 27), good prognosis (group G, 5% to 10%, n = 23), or poor prognosis (group P, < or = 4%, n = 22).

RESULTS

Only viable (Hoechst 33258 negative) spermatozoa with intact plasma membrane (hypo-osmotic swelling test positive)were considered in the evaluation of mannose-binding sites. The incidence of spermatozoa showing surface mannose-binding sites was higher in the N group (48.1% +/- 1.9%; mean +/- SEM) then in the G (17.6% +/- 4.4%) or P (7.6% +/- 2.3%) groups. Total mannose-binding site expression and percentage of morphologically normal sperm showed a high positive correlation (r = 0.80).

CONCLUSION

Altered expression of mannose-binding sites, putative zona receptors, may be one of the molecular defects causing decreased fertility in morphologically abnormal human sperm.

Female age is an important parameter to predict treatment outcome in intracytoplasmic sperm injection

OBJECTIVE

To assess the results obtained in our clinic with intracytoplasmic sperm injection (ICSI) in severe male factor infertility and failed fertilization and to determine if the age of the female has any impact on those results.

DESIGN

Retrospective study.

SETTING

Private high-complexity Human Reproduction Center.

PATIENTS

One hundred five couples with a total of 114 procedures. Eighty-six were classified as severe male factor and 19 were classified as previous failed fertilization.

INTERVENTIONS

Treatment was performed by ICSI.

MAIN OUTCOME MEASURE

Normal fertilization, cleavage, and implantation, total, term, and ongoing pregnancy rates in the total population and in different age brackets.

RESULTS

Excellent fertilization, cleavage, and implantation rates were obtained with this procedure (78%, 85%, and 13.5%, respectively). The total pregnancy rates were 43% and 46% per cycle and per transfer and 31.5% and 33.6% in terms of term and ongoing pregnancy rates. A significant reduction in implantation and total, and term and ongoing pregnancy rates was seen after the age of 35 years.

CONCLUSIONS

The results obtained with ICSI are quite satisfactory with proper equipment and careful training. The age of the female is an important parameter in determining prognosis and treatment outcome.

Impact of immunoglobulin isotype and sperm surface location of antisperm antibodies on fertilization in vitro in the human

OBJECTIVE

To investigate the impact of immunoglobulin (Ig) isotypes and their location on the human sperm surface on fertilization in vitro.

DESIGN

Restrospective review and analysis.

SETTING

Reproductive endocrine division of a level 3 academic center.

PATIENTS

Forty-eight couples (80 IVF cycles) with males showing positive antisperm antibodies on the sperm surface by immunobead test, treated by IVF at the Norfolk Program.

MAIN OUTCOME MEASURE

Evaluation of total fertilization rate of preovulatory oocytes (metaphase II-metaphase I).

RESULTS

Immunoglobulin G and IgA antibody levels have no significant correlation with total fertilization rate of preovulatory oocytes by logistic regression. Immunoglobulin M, present in 44% of the couples, had a strong correlation with fertilization. When IgA showed very high levels of binding (> 68%) and IgM binding was > 40%, the fertilization rate dropped significantly. A strong correlation between presence of antibodies and fertilization rate was seen when IgM was directed to the head or tail tip of the sperm. Immunoglobulin A induced a statistically significant reduction of fertilization only when it was present on the head.

CONCLUSION

Two male antisperm Ig isotypes significantly impaired fertilization rates. Immunoglobulin A exerted its impact only when high level of binding was detected on the head. Immunoglobulin M, present in 44% of the males, was the Ig isotype that most significantly affected fertilization rates when localized both at the head and at the tail tip level.

Expression of mannose-binding sites on human spermatozoa and their role in sperm-zona pellucida binding

A D-mannosylated albumin (DMA) neoglycoprotein was assessed to validate experimentally a probe capable of detecting mannose-binding sperm receptors involved in human sperm-egg interaction. DMA specifically blocked zona binding of swim-up human spermatozoa in a concentration-dependent manner. While no considerable effect was observed on sperm-zona initial contact, almost 50% of spermatozoa bound to the zona during a 2-hour period detached from it when DMA was introduced in the incubation medium. DNA inhibition was evident when 10% fetal bovine serum, but not 3.5% human serum albumin (HSA), was used as Ham's F10 medium supplementation. This may be due to the amount of free calcium in the medium since addition of 40 mM CaCl2 to F10-HSA restored DMA inhibition. Furthermore, the higher the calcium concentration in the incubation buffer, the greater the DMA blockage of sperm-zona binding. Unfixed sperm presented fluorescent DMA label over the entire acrosomal area (cap pattern), or concentrated at the equatorial segment (bar pattern). These patterns increased during capacitation, appearing on an average of 20% of the sperm after overnight incubation. They also increased, especially the bar pattern, following calcium ionophore treatment. Nearly all of methanol-fixed spermatozoa displayed the fluorescent label at the head level. Concomitant assessment of sperm membrane integrity and DMA fluorescent patterns revealed that DMA fluorescence coincided mostly with permeabilized or altered sperm plasma membrane. In conclusion, DMA is a suitable probe to identify human sperm mannose-binding sites crucially involved in sperm-zona interaction. These sites appear to require free calcium concentrations to operate, and their expression changes with capacitation and acrosome reaction.(ABSTRACT TRUNCATED AT 250 WORDS)

Fertilization efficiency of morphologically abnormal spermatozoa in assisted reproduction is further impaired by antisperm antibodies on the male partner's sperm

OBJECTIVE

To investigate the influence of antisperm antibodies on the sperm surface on the outcome of IVF and GIFT.

DESIGN

Matched controlled retrospective review of two large series.

SETTING

Reproductive endocrine divisions of two level-three academic centers.

PATIENTS

Twenty-nine male factor patients (38 IVF cycles) showing positive antisperm antibodies on the sperm by immunobead test treated by IVF at the Norfolk program and 56 similar patients (57 cycles) treated by GIFT at the Tygerberg program. Twenty-nine male factor patients (29 IVF cycles) with negative antisperm antibodies screening matched by wife's stimulation protocol and baseline semen analysis characteristics were used as controls in Norfolk; 56 GIFT patients (56 GIFT cycles) matched similarly were the Tygerberg controls. Study and control groups were divided according to sperm morphology pattern in normal, good, and poor prognosis subgroups for comparison.

MAIN OUTCOME MEASURES

Fertilization rate of preovulatory oocytes used in IVF in Norfolk and of GIFT supernumerary preovulatory oocytes in Tygerberg; total and term pregnancy rates (PRs) and abortion rates.

RESULTS

Fertilization rate was significantly lower in the IVF (41.9% +/- 2.8%) as well as in the GIFT (26.8% +/- 3.8%) (mean +/- SE) study groups than in the respective control groups (73.1% +/- 3.9% and 61.8% +/- 3.9%). Total and term PRs in IVF per cycle (21.1% +/- 6.6%; 13.2% +/- 5.5%) and per transfer (23.5% +/- 7.4%; 14.7% +/- 6.1%), and in GIFT (25.0% +/- 5.8%; 19.6% +/- 5.3%) in the study groups were also lower when compared with their control counterparts (IVF per cycle: 62.1% +/- 6.2% and 41.4% +/- 6.0%; IVF per transfer: 41.9% +/- 2.0% and 27.9% +/- 1.9%; GIFT: 31.6% +/- 6.2% and 28.1% +/- 6.0%), but the difference did not reach statistical significance. Abortion rates were similar in the IVF study group (37.5% +/- 17.1%) and its control groups (39.9% +/- 11.5%). The abortion rate in the GIFT study group was 14.3% +/- 9.4%, and no abortions were recorded in the control group (not significant).

CONCLUSIONS

The presence of antisperm antibodies on the sperm surface per se impairs the outcome of assisted reproduction, mainly in terms of fertilization rate of preovulatory oocytes, and possibly in terms of total and term PRs. This holds true regardless of the impact of other semen parameters, particularly the morphology of the sperm within the semen sample.

The process of carcinogenesis for endometrial adenocarcinoma could be short: development of a malignancy after endometrial ablation

Endometrial ablation has been proposed as an alternative to hysterectomy for the treatment of dysfunctional uterine bleeding. We describe what we believe to be the first reported case of an endometrial adenocarcinoma that may have developed shortly after endometrial ablation.

Defective calcium influx and acrosome reaction (spontaneous and progesterone-induced) in spermatozoa of infertile men with severe teratozoospermia

OBJECTIVE

To evaluate the acrosome reaction and its prerequisite, a calcium influx, in spermatozoa of infertile men with a high incidence of abnormal sperm forms.

DESIGN

Prospective, controlled study.

SETTING

Academic tertiary assisted reproduction center.

PATIENTS

Patients (n = 14) were allocated in the study after semen evaluation showed teratozoospermia (< 14% normal sperm forms) as diagnosed by strict criteria.

INTERVENTIONS

After swim-up separation of the motile fraction, acrosome reactions were evaluated using Pisum sativum agglutinin (both spontaneously and exogenously induced with P and the calcium ionophore A23187, both at 10 microM); the intracellular-free [Ca2+]i was assessed by the fluorescent fura-2 indicator (basal and after P).

RESULTS

Patients did not show the typical P-induced wave of [Ca2+]i that was observed in controls but rather a blunted response, no response at all, or abnormal basal [Ca2+]i levels. The percent of basal acrosome reaction was significantly lower for patients versus controls postswim-up, and at 1 hour and 3 hours. Furthermore, there was a significant difference in the response of acrosome reaction to P both at 1 hour and 3 hours, with patients showing almost no response at all. However, patients' acrosome reaction response to the calcium ionophore was similar to those of fertile men.

CONCLUSION

Infertile patients with a high incidence of abnormal sperm forms as diagnosed by strict criteria have a low incidence of spontaneous acrosome reaction and a diminished P-stimulated acrosome reaction, whereas the nonspecific response to a calcium ionophore is conserved. Parallel abnormalities of [Ca2+]i were observed in patients, suggesting that these sperm populations may have a defective nongenomic P sperm receptor and/or abnormalities of other membrane transduction systems.

Fucoidin binding activity and its localization on human spermatozoa

We previously reported that fucoidin (a polymer of predominantly sulfated L-fucose) significantly inhibits: (1) tight binding of human sperm to human zona pellucida in vitro and (2) stimulation of the acrosome reaction by acid solubilized human zona pellucida. Here, we determined fucoidin binding activity on human spermatozoa and its localization on both live and permeabilized human sperm populations. A typical binding curve was demonstrated with biotinylated fucoidin. In competitive inhibition assays with unlabelled fucoidin or human sperm membrane extracts, IC50's were 4.0 micrograms/ml and 31.4 micrograms/ml, respectively. Fucoidin binding was localized over the acrosomal region of methanol-fixed human sperm and this pattern of binding significantly decreased from 92 +/- 3% to 74 +/- 6% with calcium ionophore A23187 treatment (p < 0.01). Binding of fucoidin-coated beads to live (non-permeabilized) human sperm was less than 1%. Addition of the detergent, Triton-X, to permeabilize sperm membranes resulted in a significant increase in binding (p = 0.001). These results provide evidence for the presence of a fucoidin binding compound in human spermatozoa that is localized to the membranes of the acrosomal region and can be extracted by a mild detergent extraction. Absence of binding by fucoidin to intact but not permeabilized spermatozoa suggests that the heteropolysaccharide binds to a receptor within the acrosomal matrix. However, further investigation is warranted to determine whether a fucoidin binding site is present both at the sperm's surface for the initial contact with the zona pellucida, and also for secondary binding after exposure of the acrosomal membranes.

Therapeutic intrauterine insemination improves with gonadotropin ovarian stimulation

Therapeutic intrauterine insemination (IUI) is frequently used as a first line of treatment of infertility. The reported results vary, depending on the indication and the use of ovulation simulation protocols. In the present study, we review the experience at the Jones Institute for Reproductive Medicine in Virginia from January 1989 to January 1991. The patients were preferentially treated with ovulation induction with gonadotropins. With the addition of gonadotropin stimulation, the total and term pregnancy rates per cycle were 14% and 11%, respectively, including all etiologic factors. These rates were improved over the 3% and 2.6% rates reported in our previous study in which ovarian stimulation was not generally used. In male factor patients, the term pregnancy rate was 9%, higher than the 4% term pregnancy rate reported in our previous study. In the present series, morphology was the only severely impaired parameter. The term pregnancy rate was 11% for patients with ovulatory dysfunction, 10% for those with cervical factor, and 10.5% for those with unexplained infertility.

Effect of progesterone on human zona pellucida sperm binding and oocyte penetrating capacity

OBJECTIVE

To determine if sperm exposure to P produces an enhancement in its fertilizing capacity.

DESIGN

Sperm from fertile donors were exposed to P at 0.1 and 1.0 microgram/mL for 1 or 24 hours. The effects on hyperactivated (HA) motility at 1 and 4 hours, acrosome reaction (as determined by Pisum sativum agglutinin or T6/antibody techniques), on human zona pellucida binding (by using the hemizona assay), and on the penetrating ability (by using the zona-free hamster ova assay) were evaluated.

RESULTS

Exposure to P at 1.0 microgram/mL enhanced HA motility after 1 and 4 hours of P exposure, the acrosome reaction after 24 hours' incubation, the number of sperm bound/hemizona after 1-hour incubation, and the penetration rates in the hamster ova assay at both incubation intervals.

CONCLUSION

Sperm exposure to P enhances its fertilizing capacity in fertile men, and further investigation is warranted as a possible treatment for male factor patients.

Validation of the hemizona assay (HZA) in a monkey model. II. Kinetics of binding and influence of cryopreserved-thawed spermatozoa

We compared fresh and frozen-thawed cynomolgus monkey spermatozoa tight binding to the zona pellucida under hemizona assay (HZA) conditions. Monkey oocytes were recovered after superovulation and stored in salt solution. Matching hemizonae were obtained by micromanipulation. Semen, obtained by electroejaculation, was used fresh or was cyropreserved, thawed, and washed by swim-up separation. At the standard initial dilution of 500,000 motile sperm/ml (or 5 x 10(4) motile sperm/hemizona), binding was significantly higher for fresh sperm (P = 0.00004). For frozen-thawed samples, there was a linear increase in the number of tightly bound sperm with increasing sperm concentration (r = 0.95). At 1.5 x 10(6) motile sperm/hemizona, binding of frozen-thawed spermatozoa was similar to that of fresh at a standard concentration. Kinetic studies showed peak binding at 1 hr of gametes coincubation. We conclude that, in this monkey model, the HZA is a valuable bioassay for evaluation of sperm binding to the zona pellucida, the initial requisite for fertilization and embryo development.

The hemizona assay: its role in identifying male factor infertility in assisted reproduction

OBJECTIVES

To identify male factor infertility among a group of patients in an assisted reproductive program (phase 1) and to evaluate the hemizona assay (HZA) in the diagnosis and prognosis of such a program (phase 2).

DESIGN

The IVF performance of normal gametes in the Tygerberg program were critically evaluated. Female patients were classified as pure tubal factor infertility, having a normal FSH:LH ratio on day 3 of the menstrual cycle. All participating women produced three or more preovulatory oocytes at retrieval and were inseminated with sperm considered normal by all present diagnostic criteria. The total and normal fertilization rate thresholds were defined in that group. Using those thresholds, couples tested for sperm binding in the HZA (n = 48) were used and divided into two groups according to their fertilization rates, namely group 1, low fertilization (< 55%) and group 2, normal fertilization (> 55%).

SETTING

University-based tertiary care center.

PATIENTS

Ninety-nine couples (589 oocytes) with pure tubal factor infertility and normal male factor were used in phase 1. Forty-eight couples with normal and abnormal male factors that had both HZA performed and IVF treatment were included in phase 2.

RESULTS

Investigation of the performance of normal gametes in 99 couples (589 oocytes) revealed the total fertilization rate (total number of oocytes fertilized/total number of oocytes inseminated) was (mean +/- SD) 88.6% +/- 16.8% and the normal fertilization rate (total number of oocytes with normal fertilization/total number of oocytes inseminated) was 81.3% +/- 22%. The minimum total fertilization rate that can be considered normal in the Tygerberg program using mean--2 SD is therefore 55% and for normal fertilization rate is 37%. The group with low fertilization rate (< 55%) showed a mean hemizona index (HZI) significantly lower; nevertheless, the distribution overlapping indicates a low discriminating power of the HZA. A sensitivity of 75% and a specificity of 75% were found; the positive and negative predictive values were 81% and 68%, respectively.

CONCLUSIONS

The results indicated the HZA and HZI contribute important information and can serve in conjunction with other semen characteristics as useful tools during the diagnosis of the male factor in assisted reproduction.

A new computerized method of reading sperm morphology (strict criteria) is as efficient as technician reading

OBJECTIVES

To compare the ability of a computerized method of sperm morphology with the manually recorded method in predicting in vitro fertilization (IVF) results, to compare results obtained by both methods, and to determine the intraobservation variability.

DESIGN, SETTING, PATIENTS

Forty-three stained semen slide preparations from two large level-three academic institutions' reproductive endocrinology units (IVF programs) were blindly evaluated, and the sperm were classified into normal and amorphous forms.

RESULTS

Experiment 1: Twenty-one slide preparations from the Tygerberg gamete intrafallopian transfer program were manually evaluated; the fertilization rates for the groups with < 14% and > 14% normal sperm forms were 33.3% (15/45 oocytes) and 76.6% (46/60 oocytes), respectively. Corresponding fertilization rates with FERTECH were 46.8% (30/64) and 75.6% (31/41). Experiment 2: Twenty-two slide preparations from the Norfolk IVF program were evaluated. The manual method reported a fertilization rate in the group with < 14% normal forms of 27.4% (14/51 oocytes) compared with 90.0% (127/141 oocytes) in the group with > 14% normal forms. Corresponding figures for the FERTECH method were 33.9% (18/53) and 88.4% (123/139), respectively. Experiment 3: When the 43 slide preparations were blindly evaluated using both methods, 84% of the FERTECH evaluations correlated well with the manual method and FERTECH ability to diagnose the subfertile male (< 14% normal forms) was 95% (sensitivity). Experiment 4: A total of 16 different slides (8 per group) were randomly selected and analyzed five times (100 cells per reading) by the computerized method. The slides were obtained from men with normal sperm morphology of < 14% and > 14% as classified by the manual method. In the first group (< 14%) 97.5% (39/40) of the readings classified the sperm in the proper category, whereas in the second group (> 14%) 95% (38/40) of the cases were correctly identified.

CONCLUSION

Using strict criteria for morphology evaluation, there is a positive and significant correlation between FERTECH evaluation and manual assessment. The reproducibility of the computerized method and the ability to distinguish between fertile and subfertile groups using those criteria are good.

Prediction of fertilization in vitro with human gametes: is there a litmus test?

OBJECTIVES

The objectives of this study were as follows: (1) to evaluate the relationships between sperm concentration, morphologic pattern, motion parameters, and sperm-zona pellucida binding capacity and (2) to assess their ability to predict fertilization outcome under in vitro fertilization conditions.

STUDY DESIGN

Semen samples from 44 infertile men were prospectively evaluated for density, morphologic pattern (strict criteria), computerized motion parameters (motility, velocity, and linearity), and hemizona assay (outcome expressed as hemizona assay index), and results were correlated with fertilization outcomes of preovulatory oocytes during in vitro fertilization.

RESULTS

Of all sperm parameters, morphologic pattern was the best predictor of the ability of the sperm to bind to the zona pellucida. Hemizona assay index was the best predictor of fertilization rate. Stepwise regression analysis provided a model of hemizona assay index plus motility with highest predictability (R2 = 53.4%).

CONCLUSIONS

(1) The influence of sperm morphologic pattern as a prognosticator of fertilization outcome is established in major part as a determinant of sperm binding ability to the zona pellucida; (2) the hemizona assay provides a robust index that is highly predictive of the potential of human gametes to achieve fertilization and highlights its use in infertility and contraception testing.

Effect of fucoidin on human sperm-zona pellucida interactions

The authors recently reported that fucoidin (a polymer of predominantly L-fucose sulfate) produced a strong, significant, and dose-dependent inhibition of sperm-zona binding under hemizona assay conditions. The current studies were designed to evaluate the mechanisms underlying this inhibitory activity. Using computerized semen analysis, the monoclonal anti-sperm antibody T-6 and indirect immunofluorescence technique, and the fura-2 indicator, no significant impact of fucoidin on sperm motion parameters, on the spontaneous acrosome reaction, or its prerequisite, the increase in calcium influx, were observed. Subsequently, a mild acid hydrolysis of the fucoidin molecule was performed, followed by sizing hydrolysates in a Biogel P2 column and separating fractions (n = 6). All fucoidin fragments significantly inhibited tight binding of human sperm to human zona pellucida under hemizona assay conditions (range, 56%-94%) when tested individually. These results provide further evidence that the effect of fucoidin is produced by a receptor-ligand association.

Pure human follicle stimulating hormone has a role in the treatment of severe male infertility by assisted reproduction: Norfolk's total experience

Fifty patients [79 in-vitro fertilization (IVF) cycles] with severe male factor infertility were included in an experimental clinical trial running from October 1987 to March 1991 to assess the potential of systemic follicle stimulating hormone (FSH) treatment to improve sperm fertilizing ability in IVF. Two groups were defined: a secondary group (24 patients, 33 IVF cycles) with a history of failed fertilization in previous IVF attempts and a primary group (26 patients, 46 IVF cycles) with poor sperm parameters which suggested that fertilization would not occur according to previously established criteria. Basic semen analysis and a battery of endocrine radioimmunoassays [serum FSH, luteinizing hormone (LH), oestradiol, prolactin and testosterone] were performed in these patients. Bioactive-FSH and LH were also determined in some patients. For this study, pure FSH was administered (150 IU i.m. three times per week) for at least 3 months, after which the semen analysis and endocrine tests were repeated. Although no significant changes were observed after FSH therapy, either in the endocrine profile or in the basic semen parameters, except for FSH radioimmunoassay levels, the fertilization rate of pre-ovulatory oocytes was significantly improved from 2 to 54.4% in the secondary group; the primary group showed a 52.3% fertilization rate. Eighteen clinical pregnancies were achieved, 11 in the primary group and seven in the secondary group, giving 30 and 26% term pregnancy rates per transfer respectively. These results, which are in complete agreement with our preliminary study, re-emphasized the benefits of systemic FSH administration as an adjunct to assisted reproduction in selected cases of severe male factor infertility.(ABSTRACT TRUNCATED AT 250 WORDS)

Sonographic appearance of the endometrium: the predictive value for the outcome of in-vitro fertilization in stimulated cycles

We evaluated the predictive value for pregnancy of the endometrial thickness and pattern assessed by vaginal sonography on the day of human chorionic gonadotrophin (HCG) injection and the day of embryo transfer in 74 stimulated cycles for in-vitro fertilization (IVF) which were analysed prospectively. Thickness was measured from the echogenic interface of the endometrial-myometrium junction in transverse fundal sections. The distribution of endometrial pattern on the day of HCG was 19 A (poor quality) cases (25.7%) and 55 B (good quality) cases (74.3%). On the day of embryo transfer, 16 out of the 19 A cases (84%) remained as A pattern, while the remaining three cases (16%) had changed to B pattern; of the 55 B cases, 29 (53%) remained the same, while 26 cases (47%) changed to A pattern. There was no significant correlation between the endometrial pattern on the day of HCG and/or on the day of embryo transfer and the peak serum oestradiol levels, the number of preovulatory oocytes aspirated, the serum progesterone levels and oestradiol: progesterone ratio on the day of transfer. In contrast, on the day of HCG, endometrial thickness correlated with serum oestradiol levels on that day (P = 0.02). The presence of pattern A on the day of HCG was associated with a lower pregnancy rate [three out of 19 cases, (15.8%)], compared to pattern B [16 out of 55 cases, (29.1%)], although this was not statistically significant (P greater than 0.05). On the day of embryo transfer, comparable pregnancy rates between A pattern [11 out of 42 cases, (26.1%)] and B pattern [eight out of 32 cases, (25%)] were found.(ABSTRACT TRUNCATED AT 250 WORDS)

Embryo transfer to the uterus or the fallopian tube after in vitro fertilization yields similar results

The outcome of ZIFT and IVF-ET was compared in consecutive nontubal factor patients in a prospective fashion. Groups did not differ in characteristics and were matched by the number of prezygotes/pre-embryos transferred. Overall, implantation, pregnancy, miscarriage, and ongoing PRs were not statistically different. These results suggest that ZIFT offers no significant advantage over IVF-ET for the treatment of nontubal infertility.

Significance of basal follicle-stimulating hormone levels in women with one ovary in a program of in vitro fertilization

OBJECTIVE

To understand the impact of having a single ovary on basal follicle-stimulating hormone (FSH) level and its diagnostic and prognostic usefulness in in vitro fertilization (IVF).

DESIGN

All IVF cases from July 1987 to June 1990 with known basal FSH (n = 1,272) were divided into those with one and those with two ovaries to compare outcomes based on basal FSH levels.

SETTING

Tertiary care academic center with a large IVF practice.

MAIN OUTCOME MEASURES

Basal FSH, age, and IVF outcomes including peak estradiol, numbers of follicles aspirated, oocytes retrieved, fertilized, and transferred, and pregnancies (clinical and ongoing).

RESULTS

In women with only one ovary, basal FSH was increased, and IVF outcomes were poorer. The rise in FSH was able, in large part, to account for the diminished performance in the single ovary cases.

CONCLUSIONS

Women with only one ovary have higher basal FSH levels than those with two ovaries, and this rise can be used to predict their IVF performance.

Male infertility: the impact of assisted reproductive technologies

Spermatozoal abnormalities are present in up to 40% of infertile couples. Multiple etiologies may be responsible for these disorders, including pretesticular, testicular, and ductal causes. An adequate andrologic consultation, including history, physical examination, and repeated semen analysis, should be performed routinely in these cases. Evaluation of the basic sperm parameters, including sperm concentration, motion parameters (as evaluated by computer-assisted semen analysis), and sperm morphology (as judged by strict criteria), constitute the first obligatory step for a critical evaluation of male factor patients. Patients in whom fertilization disorders are suspected should be evaluated through bioassays of sperm-oocyte interaction, including the heterologous sperm penetration assay and hemizona assay, a bioassay of sperm-zona binding capacity highly predictive of in vitro fertilization outcome. Male disorders can be subjected to specific therapies (surgical or medical), or to empiric therapeutic modalities. Assisted reproductive technologies have enhanced our understanding of the physiopathology of spermatozoal disorders and also have ostensibly improved pregnancy rates in male factor patients.

Performance of cryopreserved pre-embryos obtained in in vitro fertilization cycles with or without a gonadotropin-releasing hormone agonist

OBJECTIVE

To evaluate the viability and potential for pregnancy of cryopreserved/thawed pre-embryos obtained after ovarian stimulation using gonadotropin-releasing hormone agonist (GnRH-a) adjunct therapy.

DESIGN

Retrospective clinical evaluation of all patients receiving a gonadotropin ovarian stimulation protocol (follicle-stimulating hormone/human menopausal gonadotropin [FSH/hMG]) with/without GnRH-a.

SETTING

Academic tertiary clinical care unit.

PATIENTS

Patients receiving leuprolide acetate (LA)/FSH/hMG (n = 136: LA in the luteal phase; long protocol) were compared with patients receiving FSH/hMG alone (n = 130) within the same time-frame in our program (April 1987 through October 1989).

INTERVENTIONS

All patients had both a cycle in which pre-embryos were transferred fresh and a cycle of thaw of cryopreserved pre-embryos (frozen at the pronuclear stage in a slow freeze-thaw protocol using 1,2 propanediol) transferred in monitored natural cycles.

MAIN OUTCOME MEASURES

Groups were similar in age, etiology of infertility, and cycle day 3 serum FSH levels; a significantly higher (P less than 0.001) number of preovulatory oocytes was recovered in the GnRH-a group. Both groups of patients were transferred an equal number of pre-embryos at the time of IVF. Cycles with frozen/thawed pre-embryos were evaluated based on the analysis of the three main variables that demonstrate cryopreservation efficiency: survival rate, implantation rate, and term pregnancy rate (PR).

RESULTS

Non-GnRH-a group (113 transfers): pre-embryo survival, 71.5%; PR/transfer, 24.7%; implantation rate, 16.0%; GnRH-a group (125 transfers): pre-embryo survival 71.6%; PR/transfer, 32.8%; implantation rate, 12.0% (no significant differences).

CONCLUSIONS

The use of GnRH-a produced pre-embryos of equal aptitude for development after cryopreservation at the pronuclear stage when compared with a similar gonadotropin stimulation treatment without GnRH-a.

Successful fertilization and pregnancy outcome in in-vitro fertilization using cryopreserved/thawed spermatozoa from patients with malignant diseases

Cryopreservation of spermatozoa before treatment is the only proven effective method available to circumvent the sterilizing effect of therapy in some patients with malignant diseases. Because of impaired sperm quality after freezing and thawing in-vitro fertilization/embryo transfer (IVF/ET) was indicated in 10 patients (12 cycles) during 1986-1990. The patient's mean age was 33.4 +/- 1.6 years. The following diagnoses were made: seminoma (1), testicular carcinoma (3), leiomyosarcoma of the prostate (1), Wegener's granulomatosis (1), non-Hodgkin's (1) and Hodgkin's lymphoma (3). When motile spermatozoa could be recovered after thawing, the total fraction of motile spermatozoa after swim-up separation ranged from 0.2 to 4.2 x 10(6) spermatozoa/ml (eight patients, nine cycles). In all these cases, insemination was performed with multiple oocytes per dish. Fertilization was achieved when swim-up recovered a mean of 1.8 +/- 0.5 x 10(6) spermatozoa/ml and when insemination was performed with at least a calculated concentration of motile spermatozoa of 1 x 10(5) spermatozoa/oocyte. The fertilization rate of preovulatory oocytes was 60%. Four patients achieved a pregnancy: two of them delivered a single healthy baby, one delivered triplet healthy babies and one had a preclinical abortion. In two patients (three cycles), no motile spermatozoa were recovered after thawing, and micromanipulation of oocytes for assisted fertilization was performed. Although fertilized oocytes were transferred, those couples did not achieve a pregnancy. Patients with lymphopathies had the best results, whilst those with testicular neoplasms had the poorest outcome, thus suggesting a poor gametogenic function in the non-affected testis. These results give hope to some patients with malignant diseases to maintain their reproductive capacity through sperm banking and IVF/ET.