Protocol for a pilot cluster randomised controlled trial of a multicomponent sustainable return to work IGLOo intervention

BACKGROUND

Long-term sickness costs businesses in the United Kingdom (UK) approximately £7 billion per annum. Most long-term sickness absences are attributed to common mental health conditions, which are also highly prevalent in people with acute or musculoskeletal health conditions. This study will pilot the IGLOo (Individual, Group, Leaders, Organisation, overarching context) intervention which aims to support workers in returning to and remaining in work following long-term sickness absence. The potential impact of the intervention is a timely return to work (main trial primary outcome) and prevention of a further episode of long-term sick leave. The intervention will be piloted in a randomised controlled trial (RCT) to examine the feasibility of the intervention (pilot trial primary outcome) and to inform a fully powered definitive trial to evaluate sustainable return to work (RTW) in people with primary or secondary mental ill-health who go on long-term sick leave.

METHODS AND DESIGN

A two-arm feasibility randomised controlled trial (with a 30-month study period including 12-month follow-up) of the IGLOo intervention will be conducted in large organisations (≥ 600 workers) from the Yorkshire and Humberside regions, in the UK. Eight consenting organisations will be recruited and randomised to the intervention or control arms of the study (1:1 ratio), with a minimum recruitment target of 13 workers eligible to participate from each. Organisations assigned to the control group will continue with their usual practice. Feasibility data will include data collected on recruitment, retention and attrition of participants; completion of research outcome measures; and intervention compliance. Measurements of mental health, RTW, work outcomes, quality-of-life, workplace support and communication and other demographic data will be taken at baseline, 3, 6, 9 and 12 months in all participants. Qualitative interviews and survey data with all participants will explore the experiences of participants, acceptability of the intervention components and evaluation measures. Exploratory economic evaluation will be conducted to further inform a definitive trial.

DISCUSSION

The findings from this pilot study will help to inform the development of a definitive cluster RCT designed to examine the efficacy of this intervention on health and work-related outcomes in UK workers on long-term sick leave.

TRIAL REGISTRATION

ISRCTN11788559 (prospectively registered, date registered 6 October 2022).

Henri Michaux's program for the psychedelic humanities

This article presents an analytical reading of the extraordinarily rich cultural production around drugs by the 20th-century French poet, writer, critic, and visual artist Michaux (1899-1984). Over about a decade, from the mid-1950's, the otherwise habitually sober Michaux wrote five books, included within which were dozens of drawings, and made one half-hour film, charting his adventures as an initially reluctant yet persistent psychonaut, principally with mescaline, but also with psilocybin, LSD, and cannabis. This has rightly been described as one of the most creative cultural explorations of mescaline. It is more extensive, texturally complex, and esthetically demanding than Aldous Huxley's far better known near-contemporaneous published work on psychedelics in English, which is well-known within and arguably foundational for psychedelic studies. Yet, this very complexity, as well as the national-linguistic context of its articulation-there was no mass psychedelic counterculture in France-have limited wider engagement with it. I argue that Michaux's esthetic reconstruction of psychedelics' effects on his creative brain can be read as a "program" for the emerging field of the psychedelic humanities and that it makes a substantial contribution, which I sketch in outline here, to the following of core concerns: (1) the role of psychedelics in enhancing "creativity"; (2) conceptualization of the politics of psychedelics; and (3) the meaning and value of psychedelic mysticism. I aim to show that Michaux's work on drugs has much to contribute to the cultural understanding of psychedelics today and accordingly that this unjustly neglected classic of French-and global-drug culture deserves to be far better known.

Abnormal Chromatin Folding in the Molecular Pathogenesis of Epilepsy and Autism Spectrum Disorder: a Meta-synthesis with Systematic Searching

How DNA is folded and packaged in nucleosomes is an essential regulator of gene expression. Abnormal patterns of chromatin folding are implicated in a wide range of diseases and disorders, including epilepsy and autism spectrum disorder (ASD). These disorders are thought to have a shared pathogenesis involving an imbalance in the number of excitatory-inhibitory neurons formed during neurodevelopment; however, the underlying pathological mechanism behind this imbalance is poorly understood. Studies are increasingly implicating abnormal chromatin folding in neural stem cells as one of the candidate pathological mechanisms, but no review has yet attempted to summarise the knowledge in this field. This meta-synthesis is a systematic search of all the articles on epilepsy, ASD, and chromatin folding. Its two main objectives were to determine to what extent abnormal chromatin folding is implicated in the pathogenesis of epilepsy and ASD, and secondly how abnormal chromatin folding leads to pathological disease processes. This search produced 22 relevant articles, which together strongly implicate abnormal chromatin folding in the pathogenesis of epilepsy and ASD. A range of mutations and chromosomal structural abnormalities lead to this effect, including single nucleotide polymorphisms, copy number variants, translocations and mutations in chromatin modifying. However, knowledge is much more limited into how abnormal chromatin organisation subsequently causes pathological disease processes, not yet showing, for example, whether it leads to abnormal excitation-inhibitory neuron imbalance in human brain organoids.

Participant acceptability of digital footprint data collection strategies: an exemplar approach to participant engagement and involvement in the ALSPAC birth cohort study

IntroductionDigital footprint records -- the tracks and traces amassed by individuals as a result of their interactions with the internet, digital devices and services -- can provide ecologically valid data on individual behaviours. These could enhance longitudinal population study databanks; but few UK longitudinal studies are attempting this. When using novel sources of data, study managers must engage with participants in order to develop ethical data processing frameworks that facilitate data sharing whilst safeguarding participant interests. ObjectivesThis paper aims to summarise the participant involvement approach used by the ALSPAC birth cohort study to inform the development of a framework for using linked participant digital footprint data, and provide an exemplar for other data linkage infrastructures. MethodsThe paper synthesises five qualitative forms of inquiry. Thematic analysis was used to code transcripts for common themes in relation to conditions associated with the acceptability of sharing digital footprint data for longitudinal research. ResultsWe identified six themes: participant understanding; sensitivity of location data; concerns for third parties; clarity on data granularity; mechanisms of data sharing and consent; and trustworthiness of the organisation. For cohort members to consider the sharing of digital footprint data acceptable, they require information about the value, validity and risks; control over sharing elements of the data they consider sensitive; appropriate mechanisms to authorise or object to their records being used; and trust in the organisation. ConclusionRealising the potential for using digital footprint records within longitudinal research will be subject to ensuring that this use of personal data is acceptable; and that rigorously controlled population data science benefiting the public good is distinguishable from the misuse and lack of personal control of similar data within other settings. Participant co-development informs the ethical-governance framework for these novel linkages in a manner which is acceptable and does not undermine the role of the trusted data custodian.

Significant Locus and Metabolic Genetic Correlations Revealed in Genome-Wide Association Study of Anorexia Nervosa

OBJECTIVE

The authors conducted a genome-wide association study of anorexia nervosa and calculated genetic correlations with a series of psychiatric, educational, and metabolic phenotypes.

METHOD

Following uniform quality control and imputation procedures using the 1000 Genomes Project (phase 3) in 12 case-control cohorts comprising 3,495 anorexia nervosa cases and 10,982 controls, the authors performed standard association analysis followed by a meta-analysis across cohorts. Linkage disequilibrium score regression was used to calculate genome-wide common variant heritability (single-nucleotide polymorphism [SNP]-based heritability [h²_SNP]), partitioned heritability, and genetic correlations (r_g) between anorexia nervosa and 159 other phenotypes.

RESULTS

Results were obtained for 10,641,224 SNPs and insertion-deletion variants with minor allele frequencies >1% and imputation quality scores >0.6. The h²_SNP of anorexia nervosa was 0.20 (SE=0.02), suggesting that a substantial fraction of the twin-based heritability arises from common genetic variation. The authors identified one genome-wide significant locus on chromosome 12 (rs4622308) in a region harboring a previously reported type 1 diabetes and autoimmune disorder locus. Significant positive genetic correlations were observed between anorexia nervosa and schizophrenia, neuroticism, educational attainment, and high-density lipoprotein cholesterol, and significant negative genetic correlations were observed between anorexia nervosa and body mass index, insulin, glucose, and lipid phenotypes.

CONCLUSIONS

Anorexia nervosa is a complex heritable phenotype for which this study has uncovered the first genome-wide significant locus. Anorexia nervosa also has large and significant genetic correlations with both psychiatric phenotypes and metabolic traits. The study results encourage a reconceptualization of this frequently lethal disorder as one with both psychiatric and metabolic etiology.

Retrenched Welfare Regimes Still Lessen Social Class Inequalities in Health

This article builds on recent work that has explored how welfare regimes moderate social class inequalities in health. It extends research to date by using longitudinal data from the EU-SILC (2003–2010) and examines how the relationship between social class and self-reported health and chronic conditions varies across 23 countries, which are split into five welfare regimes (Nordic, Anglo-Saxon, Eastern, Southern, and Continental). Our analysis finds that health across all classes was only worse in Eastern Europe (compared with the Nordic countries). In contrast, we find evidence that the social class gradient in both measures of health was significantly wider in the Anglo-Saxon and Southern regimes. We suggest that this evidence supports the notion that welfare regimes continue to explain differences in health according to social class location. We therefore argue that although downward pressures from globalization and neoliberalism have blurred welfare regime typologies, the Nordic model may continue to have an important mediating effect on class-based inequalities in health.

Transcriptional activation of RagD GTPase controls mTORC1 and promotes cancer growth

The mechanistic target of rapamycin complex 1 (mTORC1) is recruited to the lysosome by Rag guanosine triphosphatases (GTPases) and regulates anabolic pathways in response to nutrients. We found that MiT/TFE transcription factors-master regulators of lysosomal and melanosomal biogenesis and autophagy-control mTORC1 lysosomal recruitment and activity by directly regulating the expression of RagD. In mice, this mechanism mediated adaptation to food availability after starvation and physical exercise and played an important role in cancer growth. Up-regulation of MiT/TFE genes in cells and tissues from patients and murine models of renal cell carcinoma, pancreatic ductal adenocarcinoma, and melanoma triggered RagD-mediated mTORC1 induction, resulting in cell hyperproliferation and cancer growth. Thus, this transcriptional regulatory mechanism enables cellular adaptation to nutrient availability and supports the energy-demanding metabolism of cancer cells.

Historical versus contemporary medicinal plant uses in the US Virgin Islands

ETHNOPHARMACOLOGICAL RELEVANCE

Hidden in the documents of the dark past of the trans-Atlantic slavery are gems of ethnomedicinal observations, supported by herbarium specimens, which tell of the traditional medicine of a by-gone slave society in the Caribbean. In the context of the former Danish West Indies (now US Virgin Islands), we identify pre-1900 medicinal plants and their historical uses, and trace their status in the traditional medicine of St. Croix today (2014). By a combined historical and ethnobotanical approach we assess the scale of loss and preservation of traditional medicinal knowledge on St. Croix, and explore the drivers involved in the disappearance of knowledge in the oral tradition of medicine.

MATERIALS AND METHODS

Names, uses and identities of 18th and 19th century medicinal plant uses in the Danish West Indies were derived from manuscripts and publications of Von Rohr (1757/58), Oldendorp (1777), West (1793), Benzon (1822), Riise (1853), Eggers (1876;1879) and Berg and Eggers (1888). The presence of the plant species in the pre-1900 Danish West Indies was confirmed by review of herbarium specimens in the University of Copenhagen Herbarium (C). The same species were collected on St. Croix in 2014 or their ecological status discussed with local specialists. Semi-structured interviews supported by photographs and specimens were conducted with six medicinal plant specialist on St. Croix, to document and compare contemporary names and uses of the historically used medicinal plants.

RESULTS AND DISCUSSION

The historic ethnomedicinal sources revealed 102 medicinal uses of 64 plant species. Thirty-eight (37%) of the pre-1900 medicinal uses were traced in interviews, while sixty-four uses (63%) appear to be forgotten, discontinued or otherwise lost. Thirteen species appear to have entirely lost their status as medicinal plants on St. Croix, while 32 species (50%) have lost uses while retaining or gaining others. While 20% of the lost medicinal plant uses can be explained by biodiversity loss, and others likely have become obsolete due to advances in public health and scientific medicine, 33 of the 64 lost medicinal uses of non-rare species uses fall in the same categories as the preserved uses (fever, stomach, wound, laxative, pulmonary, intestinal, pain, anthelmintic, blood purifier, eye-inflammation). We therefore argue that at least half of the known pre-1900 medicinal plant uses have become culturally extinct for other reasons than to biodiversity loss or modern obsoleteness.

CONCLUSIONS

The present study utilized knowledge from an oral medicinal tradition, documented in the context of a colonial society. Without doubt, basis for further similar studies exists in the more or less accessible archives, herbaria and collections of former colonial powers. Such studies could directly benefit the descendants of the original intellectual property holders culturally and economically, or serve as stepping stones to integrate, or re-integrate, lost medicinal plant uses in both local and wider evidence-based contexts.

Genetic predictors of antidepressant side effects: a grouped candidate gene approach in the Genome-Based Therapeutic Drugs for Depression (GENDEP) study

BACKGROUND

The unwanted side effects associated with antidepressants are key determinants of treatment adherence in depression; propensity to experience these adverse drug reactions (ADRs) may be influenced by genetic variation. However, previous work attempting to ascertain the genetic variants involved has had limited success, in part due to the range of ADRs reported with antidepressants.

METHOD

ADRs reported with antidepressant treatment were categorised using their likely pharmacological basis; adrenergic, cholinergic, serotonergic and histaminergic. To identify genetic predictors of susceptibility to each group of ADRs, a candidate gene analysis was performed with data from 431 depressed patients (from a total sample size of 811 patients) enrolled in the Genome-Based Therapeutic Drugs for Depression (GENDEP) project, who were randomly allocated to receive treatment with escitalopram or nortriptyline. Data from 474 patients treated with citalopram or reboxetine in the GenPod project (total sample of 601 patients) were used for replication of significant findings.

RESULTS

We found no significant predictors of presumed adrenergic, cholinergic and histaminergic ADRs. Putative serotonergic ADRs were significantly associated with variation in the gene encoding the serotonin 2C receptor (HTR2C, rs6644093, odds ratio (OR)=1.72, 95% confidence interval (CI)=1.31-2.25, p=7.43×10(-5)) in GENDEP. However, this finding was not replicated in GenPod.

CONCLUSIONS

The association between serotonergic side effects and variation in the HTR2C gene in the GENDEP sample supports the hypothesis that serotonin receptor-mediated mechanisms underlie these adverse reactions, however this finding was not replicated in GenPod.

Fertility preservation in breast cancer patients: IVF and embryo cryopreservation after ovarian stimulation with tamoxifen

BACKGROUND

Breast cancer chemotherapy commonly causes premature ovarian failure and infertility. Because increased estrogen levels are thought to be potentially risky in breast cancer patients, natural cycle IVF (NCIVF) has been used to preserve fertility and treat infertility in these women.

METHODS

Twelve women with breast cancer received 40-60 mg tamoxifen for 6.9 +/- 0.6 days beginning on days 2-3 of their menstrual cycle (15 cycles), and had IVF (TamIVF) with either fresh embryo transfer (six cycles) or cryopreservation (nine cycles). They were compared to a retrospective control group (n = 5) who had natural cycle IVF (NCIVF, nine cycles).

RESULTS

Cycle cancellation was significantly less frequent in TamIVF, compared with NCIVF (1/15 versus 4/9, P < 0.05). Compared with NCIVF, TamIVF patients had a greater number of mature oocytes (1.6 +/- 0.3 versus 0.7 +/- 0.2, P = 0.03) and embryos (1.6 +/- 0.3 versus 0.6 +/- 0.2, P = 0.02) per initiated cycle. TamIVF resulted in the generation of embryo(s) in every patient (12/12) while only three out of five patients had an embryo following NCIVF. Two out of six patients in TamIVF, and 2/5 in NCIVF conceived. One patient in the TamIVF group delivered a set of twins. After a mean follow up of 15 +/- 3.6 months (range 3-54), none of the patients had a recurrence of cancer.

CONCLUSIONS

Tamoxifen stimulation appears to result in a higher number of embryos and may provide a safe method of IVF and fertility preservation in breast cancer patients.

Expression of apoptosis-related genes in human oocytes and embryos

PURPOSE

The objective was to study whether apoptosis occurs in human embryogenesis.

METHODS

Human viable, arrested, and nonviable embryos and immature, and nonfertilized oocytes donated by our patients were used to detect apoptosis by Tunel labeling, annexin staining, and single-cell reverse transcriptase-polymerase chain reaction (RT-PCR).

RESULTS

DNA fragmentation and phosphotidylserine translocation, the two markers for apoptosis, were detected frequently in fragmented human embryos derived from in vitro fertilization-embryo transfer (IVF-ET). Using RT-PCR, apoptotic genes also were detected in these embryos. The frequencies of gene expression in viable embryos, arrested embryos, nonviable embryos, immature oocytes, and non-fertilized oocytes were: 7/8, 5/5, 5/6, 0/6, 0/3, for Bax; 8/8, 5/5, 7/7, 0/4, 0/5 for Fas; 2/8, 0/2, 0/3, 0/5, 0/3 for BCL-2; 0/8, 1/3, 0/2, 0/3, 0/2 for Fas-ligand; and 8/8, 17/17, 21/21, 24/24, 15/15 for actin, respectively.

CONCLUSIONS

Our preliminary data did not show a significant difference in the expression frequency of all studied genes between viable embryos and nonviable or arrested embryos. However, the expression of Bax and Fas was noticeably higher in nonviable embryos than in viable embryos as judged by the intensities of amplicons visualized after ethidium bromide staining. In addition, BCL-2 was only detected in viable embryos. Whether embryos quality is related to the regulation of BCL-2, Bax, and Fas expressions requires further study.

Recycling of a single human blastomere fixed on a microscopic slide for sexing and diagnosis of specific mutations by various types of polymerase chain reaction

OBJECTIVE

To investigate the suitability of recycling single blastomeres to assess multiple genetic variables for preimplantation genetic diagnosis.

DESIGN

Prospective randomized study.

SETTING

An academic medical center.

PATIENT(S)

Patients undergoing IVF-ET.

INTERVENTION(S)

Blastomeres were disaggregated from donated embryos obtained from patients.

MAIN OUTCOME MEASURE(S)

Polymerase chain reaction (PCR) amplification products.

RESULT(S)

Fifty-eight blastomeres individually fixed on slides were separated into four groups. Sequential PCRs (group I, n = 30), primed in situ labeling (PRINS) before five sequential PCRs (group II, n = 10), staining with hematoxylin before performing five sequential PCRs (group III, n = 11) and preamplification of whole DNAs by degenerate oligonucleotide primer (DOP) before performing PCR were executed. The amplification efficiencies of five sequential PCRs were 100%, 100%, 96.6%, 83.3%, 56.7% for group I; 100% 100%, 100%, 80%, 40% for group II; 54.5%, 36.4%, 18.2%, 9.1% for group III; and 100%, 100%, 100%, 100%, 100% for group IV.

CONCLUSION(S)

Blastomeres fixed for PRINS can be recycled for PCR to obtain more genetic information. Hematoxylin staining appears to increase the incidence of failed amplification. Preamplification of whole genomic DNAs by DOP-PCR appears to facilitate diagnosis with high efficiency.

The embryo toxicity of hydrosalpinx fluid is only apparent at high concentrations: an in vitro model that stimulates in vivo events

OBJECTIVE

To simulate the in vivo model in studying the effect of hydrosalpinx fluid on embryonic development.

DESIGN

Controlled prospective study.

SETTING

Academic research center.

PATIENT(S)

Five hundred eighty-seven two-cell murine embryos.

INTERVENTION(S)

Embryos were grown under two sets of conditions. Half were cultured using 10% fetal calf serum in RPM1 medium in varying concentrations of hydrosalpinx fluid (0, 1%, 10%, 50%, 75%, and 100%). To more closely mimic the in vivo environment, the other half were grown in an endometrial coculture system with the same media and hydrosalpinx fluid concentrations.

MAIN OUTCOME MEASURE(S)

Embryonic development.

RESULT(S)

For each stage of embryogenesis, diminished development was noted with increasing concentrations of hydrosalpinx fluid. In the group of embryos grown without endometrial coculture, only at a minimum concentration of 50% hydrosalpinx fluid was diminished development noted for the blastocyst, hatching, and outgrowth stages. When an endometrial coculture system was used, development was not inhibited until exposure to a minimum of 75% hydrosalpinx fluid. Embryogenesis was enhanced when an endometrial coculture system was used for each concentration of hydrosalpinx fluid.

CONCLUSION(S)

When a model is used that more accurately mimics the in vivo conditions of IVF-ET in a patient with hydrosalpinges, it appears that high concentrations of hydrosalpinx fluid are required to signiticantly impede embryogenesis. The endometrium appears to help detoxify hydrosalpinx fluid.

Expression of inhibin/activin subunits and their receptors and binding proteins in human preimplantation embryos

PURPOSE

Our purpose was to study the role of inhibin/activin during embryogenesis.

METHODS

Transcripts of inhibin/activin subunits (alpha, beta A, beta B), activin receptors (types I and II), and follistatin were detected by a reverse transcriptase-polymerase chain reaction in human reproductive cells and preembryos cultured alone or co-cultured with human endometrial cells.

RESULTS

Transcripts of alpha, beta A, beta B subunits were all detected in granulosa luteal cells, but only beta A units were detected in endometrial stromal and decidualized cells. In human preimplantation embryos, none of these subunits were detected in embryos from the four-cell to the morula stage and only beta A subunits were detectable in blastocyst embryos. Activin receptors were detectable in all of the studied embryos and cells. Transcripts of beta A, activin receptors, and follistatin were differentially expressed in human preimplantation embryos cultured in vitro and their expressions were significantly enhanced with the presence of endometrial stromal cells.

CONCLUSIONS

Our data suggest that there is a possible endometrium-embryo interaction via endometrial activins and preimplantation embryo receptors and that the embryonic expressions of these activins, their receptors, and binding proteins are dependent on embryonic stage.

Human endometrial stromal cells improve embryo quality by enhancing the expression of insulin-like growth factors and their receptors in cocultured human preimplantation embryos

OBJECTIVE

To demonstrate the mechanism by which human endometrial stromal cells improve embryo quality in coculture.

DESIGN

Randomized study.

SETTING

Academic research center.

PATIENT(S)

Patients undergoing IVF-ET.

INTERVENTION(S)

Donated human embryos were cultured randomly either alone (group A) or with human endometrial stromal cells (group B), and the embryonic expression of insulin-like growth factors (IGFs) and their receptors was detected by reverse transcriptase polymerase chain reaction after culture.

MAIN OUTCOME MEASURE(S)

The embryo frequency distribution of groups A and B before and after culture and the embryonic transcripts of the IGF family genes of the two study groups after culture were compared.

RESULT(S)

The embryo frequency distribution of the day 3 embryonic stages in groups A and B was not different. However, after culture, a statistically significant difference in blastocyst formation was observed between groups A and B. A significant increase in the expression of IGF-1, IGF-2, the IGF-1 receptor, and the insulin-receptor also was noted. Among the embryos that reached the blastocyst stage, the expression of IGF-1 and the IGF-1 receptor also was significantly different in the two study groups.

CONCLUSION(S)

Human endometrial stromal cells enhanced the expression of IGFs and their receptors in cocultured human embryos, which may be essential for improving embryo quality.

Ovarian estradiol production in vivo. Inhibitory effect of leuprolide acetate

OBJECTIVE

To determine the impact of reducing the dose of gonadotropin-releasing hormone agonist (GnRH-a) for controlled ovarian stimulation in in vitro fertilization (IVF) on subsequent response to stimulation and cycle outcome.

STUDY DESIGN

An IVF database was searched to identify patients who underwent at least two cycles of ovarian stimulation at a university-based medical center, and a retrospective chart review was performed. Fifty-one patients whose IVF stimulation protocols during the two cycles were identical except for the leuprolide dosage utilized for luteal pituitary suppression were included in the study. Two leuprolide dosages were utilized for suppression: a low dose, 0.5 mg daily, and a high dose, 1 mg daily. The leuprolide dose was uniformly halved upon initiation of gonadotropin stimulation; the gonadotropin dose and preparation were identical in the two protocols. Day 3 follicle-stimulating hormone levels, duration of stimulation, amount of gonadotropins required, midcycle and peak estradiol levels, oocyte yield and implantation rates were compared.

RESULTS

Lowering the dose of GnRH-a while maintaining the same stimulation protocol resulted in a faster estradiol rise and higher mean peak estradiol level. The higher estradiol levels were obtained with a lower total gonadotropin dose. The oocyte yield was not affected by the stimulation protocol utilized.

CONCLUSION

Lowering the dosage of leuprolide allows higher estradiol levels in those patients. This suggests an inhibitory in vivo effect of leuprolide acetate on ovarian steroidogenesis.

Withholding gonadotropin administration is an effective alternative for the prevention of ovarian hyperstimulation syndrome

OBJECTIVE

To evaluate the outcomes of IVF and the incidence of ovarian hyperstimulation syndrome (OHSS) after discontinuing gonadotropin therapy in patients at risk of developing OHSS by delaying hCG administration until a drop in serum E2 levels was observed.

DESIGN

Retrospective study.

SETTING

IVF program at a university center.

INTERVENTIONS

Gonadotropin administration was withheld in 22 patients (group 1) when their serum E2 level was > or = 3,000 pg/mL (conversion factor to SI unit, 3.671). Patients continued GnRH analogue injections daily, and hCG was administered when serum E2 levels dropped to < or = 3,000 pg/mL. Outcomes were compared with 26 patients (group 2) in whom embryo transfer was canceled and all embryos cryopreserved for transfer during a subsequent unstimulated cycle.

MAIN OUTCOME MEASURES

Outcomes of IVF and incidence of OHSS were compared in both groups of patients. In group 1, follicular and hormonal parameters before and after the coasting interval were compared in pregnant versus nonpregnant patients. In addition, serum hormonal profiles were evaluated daily during the coasting period to determine the effects of gonadotropin withdrawal.

RESULTS

Although the mean number of oocytes retrieved was significantly higher in group 2, fertilization rates, miscarriage rates, delivery rates/stimulation cycle, and the incidence of OHSS did not differ significantly between the two groups.

CONCLUSION

Withholding gonadotropin administration is an effective alternative to prevent the development of severe OHSS in a high-risk population. Although the risk of cancellation cannot be completely eliminated, this strategy can provide a high pregnancy rate without the need to repeat multiple frozen-thawed cycles.

Simultaneous detection of multiple gene expression in mouse and human individual preimplantation embryos

OBJECTIVE

To detect simultaneously multiple gene expression in mouse and human individual embryos by reverse transcriptase-polymerase chain reaction.

DESIGN

Transcripts involved in the insulin-like growth factor (IGF) system were detected in mouse and human preimplantation embryos.

SETTING

An academic teaching hospital.

MAIN OUTCOME MEASURE(S)

Transcripts of the IGF family genes.

RESULT(S)

In the mouse, genes are expressed differentially and messenger RNA transcripts of maternal origin in nonfertilized ova decline gradually until the initiation of the embryonic genome transcription. Insulin-like growth factor-binding protein-2 (IGFBP)-2, -3, -4, and beta-actin transcripts appear to be initiated at the two- to four-cell stage, whereas IGFBP-1, -5, and -6 transcripts are initiated at later stages. Transcription, once initiated, appears to continue through to the blastocyst stage. In humans, almost all genes of the IGF system were expressed in preimplantation embryos. This is the first report of the assessment of IGF family transcripts in individual embryos, and introduces a novel method for research and clinical diagnosis of preimplantation embryos.

Hormonal regulation of expression of messenger RNA encoding insulin-like growth factor binding proteins in human endometrial stromal cells cultured in vitro

To investigate the presence of messenger RNA (mRNA) encoding insulin-like growth factor binding proteins (IGFBP) in human secretory endometrial stromal cells cultured in vitro, total cellular mRNA and protein extracted from cells treated with various hormones were detected and identified by Northern and Western blotting techniques respectively. Northern blot analysis detected 1.4 and 2.5 kilobase (kb) mRNA transcripts for IGFBP-2 and IGFBP-3 respectively, in both control and progestin-treated human endometrial stromal cells in vitro. However, the 1.5 kb mRNA transcript of IGFBP-1 was detected only in progestin-treated cells but not in the controls. Progestin alone markedly stimulated cellular BP-1 protein and mRNA, but only moderately stimulated cellular IGFBP-2 and IGFBP-3 protein mRNA in a dose-dependent fashion. Adding relaxin at the same time as progestin further enhanced the stimulatory effects of progesterone. Oestradiol had a stimulatory effect on cellular IGFBP-2 mRNA, but had an inhibitory effect on protein and mRNA of IGFBP-3, also in a dose-dependent fashion. In general, for each specific binding protein, the amount of cellular mRNA correlated well with the amount of cellular protein. Therefore, IGFBP protein and mRNA transcript in human secretory endometrial stromal cells appears to be under hormonal influence. These hormones may control the synthesis of IGFBPs at the transcription rather than the translation level.

Active corpus luteum function at pre-, peri- and postimplantation is essential for a viable pregnancy

Luteal-phase estrogen and progesterone concentrations were measured every other day and used to monitor the corpus luteum activity. The patterns of estrogen and progesterone concentrations were compared relative to the day of endogenous human chorionic gonadotropin (hCG) detection (defined as the day of implantation). The relationship between estrogen and progesterone and hCG concentrations was studied in 71 viable pregnancies, 12 clinical abortions, five preclinical abortions and 84 non-pregnant cycles after IVF/ET. Although all patients received luteal-phase progesterone support (25-50 mg/ml), low late luteal-phase progesterone concentrations of < 30 ng/ml from day + 11 to day + 15 were found in 64 patients (17% of viable pregnancies, 33.3% of clinical abortions, 60% of preclinical abortions and 53.6% of non-pregnant cycles) day + 1 was the day of retrieval). Implantation always occurred before or on day + 13 and 86% of pregnant cycles implanted on day + 8 to day + 11. Viable pregnancies had significantly higher mean progesterone concentrations on day + 3 to day + 7 (pre-implantation) and on day + 9 to day + 15 (postimplantation) than those of non-pregnant cycles or abortions. On the day of implantation, the mean +/- standard of deviation of estrogen (pg/ml) and progesterone (ng/ml) levels for viable pregnancies, clinical abortion and preclinical abortions were 314 +/- 210, 40.5 +/- 25; 226.7 +/- 246, 48.7 +/- 31; and 39.6 +/- 24.5, 28.6 +/- 24.5, respectively. On the same day, 73.2% of viable pregnancies, 41.7% of clinical abortions, and 20% preclinical abortions had a progesterone concentration > 30 ng/ml; 73.2% of viable pregnancies, 41.7% of clinical abortions and 20% of preclinical abortions had an estrogen concentration > 100 pg/ml. Although not precluding implantation completely, late luteal-phase hormonal deficiencies may impair endometrial growth and might ultimately lead to failure or abnormal implantation. A viable pregnancy requires not only a functional corpus luteum in the early luteal phase to develop a receptive endometrium, but also a responsive corpus luteum in the late luteal phase to support pregnancy. The time of implantation is critical. Implantation that occurs before the demise of the corpus luteum will facilitate a normal pregnancy.

In vitro fertilization versus tubal surgery: is pelvic reconstructive surgery obsolete?

OBJECTIVE

To compare the results of pelvic reconstructive surgery with cumulative success rates of IVF for couples with tubal factor infertility.

DATA RESOURCES

Outcomes of pelvic surgery were obtained from a review of articles from the literature identified by directed Medline searches. Cumulative pregnancy rates of 771 couples with tubal factor infertility treated at the Cornell IVF program between December 1989 and December 1992 were calculated by life-table analysis.

RESULTS

Overall delivery rate per transfer for patients with tubal factor was 28.9% (303 deliveries per 1,048 transfers) and did not appear to be affected significantly by the presence of a secondary diagnosis. A significant decline in pregnancy rates was observed with advancing age: age < 30 years, 48.4%; 30 to 34 years, 44%; 35 to 38 years, 28%; 39 to 40 years, 20%; 41 to 42 years, 9%; and > 42 years, 4.3%. Cumulative pregnancy rates for cycles 1 to 4 were 32%, 59%, 70%, and 77%, respectively, in patients with only tubal factor, and 28%, 55%, 62%, and 75% in patients with tubal combined with other associated infertility factors.

CONCLUSIONS

Our experience suggest that > 70% of women with tubal factor infertility will have a live birth within four cycles of treatment with IVF. These results compare favorably with the best outcomes after tubal reconstructive surgery. In older women, because of the rapid decline of fertility potential with advancing age, efforts should be directed toward the treatment method that provides the highest likelihood of success within the shortest time interval.

Clomiphene citrate and hMG: an alternative stimulation protocol for selected failed in vitro fertilization patients

PURPOSE

This study was carried out to evaluate the potential role of the combination clomiphene citrate/human menopausal gonadotropin (CC/hMG) for patients who failed previous in vitro fertilization (IVF) attempts with gonadotropin-releasing hormone analogs (GnRH-a) and/or exogenous gonadotropins.

METHODS

Patients were stimulated with CC/hMG (n = 93) after unsuccessfully undergoing 182 gonadotropin cycles with (n = 106) or without (n = 76) luteal-phase GnRH-a. Cancellation rate, length of stimulation, and peak estradiol levels did not differ significantly between the two regimens.

RESULTS

Although fewer oocytes were retrieved when the CC/hMG combination was used, 16 patients were able to successfully achieve a pregnancy (26.2% delivery rate/transfer). When daily follicle stimulating hormone (FSH) levels were measured in two successive cycles in those women who conceived with the CC/hMG stimulation, baseline levels did not differ when compared with a previous GnRH-a/hMG cycle. Nevertheless, serum FSH levels rose rapidly and remained higher in the GnRH-a/hMG cycle, reaching significantly higher levels on day of human chorionic gonadotropin (hCG) administration.

CONCLUSION

Selected patients who failed previous IVF attempts with gonadotropins with or without GnRH analogs may benefit from the addition of CC to their ovarian stimulation protocol.

Effects of alprazolam on pituitary-adrenal and catecholaminergic responses to metabolic stress in humans

Concurrent effects of benzodiazepines on stress-induced activation of the three classical "stress" systems: pituitary-adrenal, adrenomedullary, and sympathoneural systems have not been extensively investigated in humans. In the present study, the effects of alprazolam (1.5 mg) on plasma levels of adrenocorticotropin hormone (ACTH), epinephrine, norepinephrine, dihydroxyphenylglycol (DHPG, the intraneuronal metabolite of norepinephrine), and mood states were examined in 10 healthy volunteers undergoing glucoprivic stress. Glucoprivic stress was induced by intravenous administration of the glucose analog, 2-deoxyglucose (2DG), at a dose (50 mg/kg) that impairs cellular glucose metabolism and produces a state comparable to hypoglycemia. Alprazolam and 2DG were administered in a double-blind, placebo-controlled manner. 2DG produced robust elevations in plasma ACTH and epinephrine levels, modest elevations in plasma norepinephrine levels, and decreases in plasma DHPG levels. Alprazolam significantly attenuated the 2DG-induced increases in plasma ACTH and epinephrine, but did not significantly effect plasma norepinephrine and DHPG. These data suggest that benzodiazepines attenuate metabolic stress-induced activation of the pituitary-adrenal and adrenomedullary systems but do not effect 2DG-related effects on peripheral sympathoneural function. The possible mechanisms involved are discussed.

Improved pregnancy outcome with gonadotropin releasing hormone agonist (GnRH-a) stimulation is due to the improvement in oocyte quantity rather than quality

The impact of gonadotropin releasing hormone agonist (GnRH-a) on the quality and quantity of oocytes harvested in in vitro fertilization-embryo transfer (IVF-ET) patients was studied by comparing the results for patients stimulated with gonadotropin alone and with gonadotropin plus GnRH-a. Adding GnRH-a significantly improved the viable pregnancies per transfer and reduced the spontaneous abortions, which seemed to improve oocyte quality. However, when oocyte quality was evaluated by the fertilization rate and the implantation and delivery rates per embryos transferred, there were no significant difference in the results, indicating that GnRH-a did not improve the oocyte quality. On the other hand, GnRH-a significantly increased the average number of oocytes harvested, fertilized, and transferred, and this increased number of oocytes transferred has been demonstrated to increase pregnancy and multiple-pregnancy rates. Multiple pregnancy with more embryos implanted would significantly reduce the abortion rate. Abortion rates decreased inversely to the number of embryos implanted. Our data strongly suggest that the efficacy of GnRH-a on IVF-ET patients was due more to the quantity increase than the quality of embryos transferred.

Microsurgical fertilization procedures: the absence of stringent criteria for patient selection

Subzonal sperm insertion and partial zona dissection were applied in 250 in vitro fertilization cycles in couples (n = 200) with abnormal semen analyses; 61 clinical pregnancies were established (24% per egg retrieval). Patients were selected without using minimal cutoff criteria. The study included patients with 0% normal sperm forms (strict criteria), no motile sperm (but some live cells), and sperm counts which could be assessed only after centrifugation. Patients were categorized into three subsets. Group A (n = 116 cycles) failed to fertilize in a previous cycle. Group B (n = 40) was excluded from IVF due to the severity of sperm profiles, such as a maximum of 2% normal forms. Group C (n = 94) constitutes those patients for whom a standard cycle could possibly result in failure. Monospermic fertilization rates were 18% (A), 19% (B), and 24% (C). The incidences of embryo replacement were 63% (A), 53% (B), and 69% (C). Rates of clinical pregnancy were 22% (A), 23% (B), and 28% (C). The presence of one, two, or three semen abnormalities did not correlate with the outcome of microsurgical fertilization. Twenty-two percent of patients with combined oligoasthenoteratozoospermia became pregnant. Moreover, ongoing pregnancies were established in instances with 0% normal sperm forms and no progressively motile spermatozoa. It is concluded that stringent cutoff criteria may not be necessary when both partial zona dissection and subzonal sperm insertion are performed efficiently.

Late luteal estradiol patterns are a better prognosticator of pregnancy outcome than serial beta-human chorionic gonadotropin concentrations

OBJECTIVE

Since the corpus luteum (CL) is known to play an important role in early pregnancy, its activity could possibly be a marker for pregnancy outcome.

DESIGN

The late estradiol (E2) concentration in 48 viable pregnancies and 39 pregnancies which resulted in spontaneous abortions after in vitro fertilization and embryo transfer were used to evaluate such predictability.

SETTING

All patients studied were of the Center for Reproductive Medicine at Cornell University Medical College.

PATIENTS, PARTICIPANTS

Eighty-seven patients.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

Serum E2 and human chorionic gonadotropin (hCG) concentrations on day +11, +13, +15 (day +1 = day of ovum pick-up) were measured and studied.

RESULTS

The late luteal CL activity after rescue had a positive correlation with the number and quality of the implanted embryos. Reduced CL activity was indicative of abortion. The late luteal E2 pattern when compared with hCG doubling time had a better abortion predictability (37.8% versus 63.9%, respectively).

CONCLUSION

Corpus luteum activity demonstrated to be a better prognosticator of abortion than serial beta-hCG titers.

Microsurgical fertilization and teratozoospermia

Semen parameters were correlated with the outcome of partial zona dissection (PZD) in 42 couples with male factor infertility. Although fertilization rates were reduced, 12% of the embryos implanted following replacement. Spermatozoa from teratozoospermic sperm populations were able to fuse with oocytes following zona penetration through the artificial gaps. PZD followed by insemination with less than 5% normal spermatozoa led to 20 embryos which, upon replacement, did not implant. Motility and sperm count were not clearly correlated with the outcome of PZD and are therefore less useful indicators for patient selection. Teratozoospermic patients who previously failed to fertilize were compared to a group of similar patients who had not attempted IVF before. Although fertilization was significantly improved in first-time patients, 41% of the patients whose spermatozoa were initially unable to fertilize had at least one embryo when PZD was performed. Several pregnancies were established in this group. Subzonal sperm insertion (SZI) and PZD were compared in 19 patients using sibling oocytes. A significant fraction of spermatozoa from infertile men were able to fuse with the oolemma when directly inserted into the perivitelline area. Using a sucrose solution to shrink the ooplasm, only 1% of the oocytes were damaged during SZI. Monospermic fertilization rates following PZD and SZI were 15 and 16%, respectively. Both micromanipulation methods were successful in most patients. However, in two small groups of patients, only one technique resulted in fertilization.