Mental health and behavioural problems in adolescents conceived after ART

STUDY QUESTION

Does mental health and behaviour differ between those conceived with and those conceived without ART?

SUMMARY ANSWER

Our study observed less externalizing behaviour (delinquent/aggressive), and more parent-reported internalizing behaviour, as well as more (clinical) depression at age 14 years, in adolescents conceived after ART compared to their non-ART counterparts.

WHAT IS KNOWN ALREADY

Health outcomes of ART-conceived offspring may differ from those conceived without ART, and previous studies have reported differences in behaviour and mental health, particularly in childhood.

STUDY DESIGN, SIZE, DURATION

The Growing Up Healthy Study (GUHS) is a prospective cohort study, investigating the long-term health of offspring conceived after ART (aged 14, 17 and 20 years), in the two operational fertility clinics in Western Australia 1991-2001 (n = 303). Their long-term health outcomes were compared to those of offspring conceived without ART from the Raine Study Generation 2 (Gen2) born 1989-1991 (n = 2868). Both cohorts are representative of the local adolescent population.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Mental health parameters and behaviour were assessed at ages 14 and 17 years, through the parent completed 'Child Behaviour Checklist' (CBCL; ART versus non-ART: age 14 years: N = 150 versus N = 1781, age 17 years: N = 160 versus N = 1351), and the adolescent completed equivalent 'Youth Self-Report' (YSR; age 14 years: by N = 151 versus N = 1557, age 17 years: N = 161 and N = 1232). Both tools generate a T-score (standardized for age and sex) for internalizing (withdrawn, somatic complaints, anxious/depressed), externalizing (delinquent/aggressive behaviour) and total behaviour. Adolescents also completed the 'Beck Depression Inventory for Youth' (BDI-Y; age 14 years: N = 151 versus N = 1563, age 17 years: N = 161 versus N = 1219). Higher scores indicate poorer mental health and behaviour on all the above tools. Parent-reported doctor-diagnosed conditions (anxiety, behavioural problems, attention problems and depression) were also univariately compared between the cohorts. In addition, univariate comparisons were conducted between the GUHS adolescents and Gen2 adolescents born to subfertile parents (time to pregnancy >12 months), as well as between offspring born to subfertile versus fertile parents within the Gen2 cohort. A subgroup analysis excluding offspring born preterm (<37 weeks' gestation) or at low birthweight (<2500 g) was also performed. Generalized estimating equations that account for correlated familial data were adjusted for the following covariates: non-singleton, primiparity, primary caregiver smoking, family financial problems, socio-economic status and both maternal and paternal ages at conception.

MAIN RESULTS AND THE ROLE OF CHANCE

At both 14 and 17 years of age, ART versus non-ART-conceived adolescents reported lower mean T-scores for externalizing problems (age 14 years: 49 versus 51, P = 0.045, age 17 years: 49 versus 52, P < 0.001). A similar effect was reported by parents, although not significant (age 14 years: P = 0.293, age 17 years: P = 0.148). Fewer ART-conceived adolescents reported a T-score above the clinical cut-off for externalizing behaviour (≥60; age 14 years: 7.3% versus 16.3%, P = 0.003, age 17 years: 8.1% versus 19.7%, P < 0.001). At both ages, no differences in internalizing behaviour were reported by adolescents (age 14 years: P = 0.218, age 17 years: P = 0.717); however, higher mean scores were reported by parents of the ART-conceived adolescents than by parents of the non-ART conceived adolescents (age 14 years: 51 versus 48, P = 0.027, age 17 years: 50 versus 46, P < 0.001). No differences in internalizing behaviour above the clinical cut-off (T-score ≥ 60) were observed. At age 17 years, parents who conceived through ART reported higher total behaviour scores than those parents who conceived without ART (48 versus 45, P = 0.002). At age 14 years, ART versus non-ART-conceived adolescents reported significantly higher mean scores on the BDI-Y (9 versus 6, P = 0.005); a higher percentage of adolescents with a score indicating clinical depression (≥17; 12.6% versus 8.5%, aOR 2.37 (1.18-4.77), P = 0.016), as well as more moderate/severe depression (≥21; 9.3% versus 4.0%, P = 0.009). At age 17 years, no differences were reported on the BDI-Y. There was also a higher percentage of parent-reported doctor-diagnosed anxiety in the ART cohort (age 14 years: 8.6% versus 3.5%, P = 0.002, at age 17 years: 12.0% versus 4.5%, P < 0.001). Removing adolescents born preterm or at low birthweight did not alter the above results. Comparing outcomes between GUHS adolescents and Gen2 adolescents born to subfertile parents, as well as between those born to subfertile versus fertile parents within Gen2, did not alter results for CBCL and YSR outcomes. Those born to subfertile parents showed higher rates of clinical depression than those born to fertile parents at age 14 years (13.7% versus 6.9%, P = 0.035).

LIMITATIONS, REASONS FOR CAUTION

The main limitation of the study is the time difference between the GUHS and Gen2 assessments. Even though we have adjusted for covariates, additional socio-economic and lifestyle factors affecting behaviour and mental well-being could have changed. We were unable to differentiate between different types of ART (e.g. IVF versus ICSI), owing to the low number of ICSI cycles at the time of study. Fertility sub-analyses need to be replicated in larger cohorts to increase power, potentially using siblingship designs. Lastly, selection bias may be present.

WIDER IMPLICATIONS OF THE FINDINGS

The reported lower prevalence of externalizing behaviour (delinquent/aggressive), and higher prevalence of internalizing behaviour, as well as more (clinical) depression at age 14 years, in ART versus non-ART-conceived adolescents, is in line with some previous studies, mostly conducted in childhood. It is reassuring that differences in the rates of depression were not observed at age 17 years, however, these findings require replication. As the use of ART is common, and mental health disorders are increasing, knowledge about a potential association is important for parents and healthcare providers alike.

STUDY FUNDING/COMPETING INTEREST(S)

This project was funded by an NHMRC Grant (Hart et al., ID 1042269). R.J.H. is the Medical Director of Fertility Specialists of Western Australia and a shareholder in Western IVF. He has received educational sponsorship from MSD, Merck-Serono and Ferring Pharmaceuticals. P.B. is the Scientific Director of Concept Fertility Centre, Subiaco, Western Australia. J.L.Y. is the Medical Director of PIVET Medical Centre, Perth, Western Australia.

TRIAL REGISTRATION NUMBER

N/A.

O-087 Asthma and allergies in a cohort of adolescents conceived after assisted reproductive technologies (ART)

Study question

Are adolescents conceived after assisted reproductive technologies (ART) at an increased risk of asthma and allergies, compared to their counterparts conceived without ART?

Summary answer

No difference in asthma prevalence, better lung-function, and an increase in allergic rhinoconjunctivitis, food allergies and positive skin-prick tests are reported in the ART cohort.

What is known already

Over 8 million children have been born after conception with ART worldwide. Emerging evidence shows an increased risk of atopic disorders, such as asthma and allergies, in such children, potentially due to epigenetic alterations or underlying parental subfertility and perinatal risk factors. Studies to date are highly heterogeneous, including non-standardized diagnostic tools, non-representative reference populations, and lacking appropriate covariate adjustment. With the increase in atopic disorders worldwide, and the burden they bring to the life of individuals and to society, in combination with the increase in ART, it is important to further investigate the risk of atopy in such offspring.

Study design, size, duration

The Growing Up Healthy Study (GUHS) is a prospective study that recruited 303 offspring conceived after ART (aged 13-21), born 1991-2001 in Western Australia. Their health parameters, including asthma and allergy assessments, were compared with those of counterparts conceived without ART, from the Raine Study Generation 2 (Gen2). The 2,868 Gen2 participants are representative of the local population. At age 14 (2013-2017), 152 GUHS participants replicated atopy assessments previously completed by similarly aged Gen2 participants.

Participants/materials, setting, methods

Asthma and allergy assessments consisted of a parent-completed modified version of the ‘International Studies of Asthma and Allergies in Childhood’ (ISAAC) questionnaire, spirometry, methacholine challenge- and skin-prick testing (SPT). Chi2, Fisher’s Exact and Mann-Whitney U tests, performed in SPSS V25, examined cohort differences, and generalized estimating equations adjusted for (a subset of) the following covariates: sex, age, height, singleton pregnancy, gestational age, birthweight, mode of delivery, primary caregiver smoking, and being an only child.

Main results and the role of chance

Current asthma and asthma severity, based on the ISAAC questionnaire, appeared similar between the cohorts. Lung function (mean Forced Expiratory Volume [FEV1], Forced Vital Capacity [FVC] and FEV1/FVC ratio) was better in the ART cohort (3.10 vs. 2.96 L, p = 0.011; 3.72 vs. 3.29 L, p &lt; 0.001; 85.5 vs. 91.8%, p &lt; 0.001, respectively). No difference in mean Forced Expiratory Flow was reported. Bronchial hyperresponsiveness was significantly less prevalent in the ART cohort (8.8% vs.18.6% p = 0.006).

Current allergic rhinoconjunctivitis (ARC) rates were significantly higher in the ART cohort (32.4% vs. 25.2%, aOR 1.52 [1.03-2.26], p = 0.036), while prevalence of current atopic dermatitis did not differ. Food allergies were twice as prevalent in the ART cohort (20.7 vs. 10.9%, aOR 1.89 [1.17-3.06], p = 0.010). Significantly more GUHS participants had a positive SPT (68.0% vs. 45.4%, aOR 3.034 [1.989-4.628], p &lt; 0.001). The percentage of polysensitisation (&gt; 1 allergen) did not differ between the cohorts. Sub-analyses comparing offspring conceived after in vitro fertilisation (IVF)[n = 100] and intracytoplasmic sperm injection (ICSI)[n = 40], and fresh and frozen embryo transfers (ETs n = 82, FETs n = 58) within the ART cohort, showed no significant differences, although all allergy outcomes appeared more prevalent in the ET group.

Limitations, reasons for caution

Despite substantial study size, numbers did not allow for adjustment for all covariates. Sub-analyses (IVF vs. ICSI and ET vs. FET), were conducted with limited power and require replication in larger cohorts. Both cohorts were largely of Caucasian decent (&gt;88.0%), which reduces applicability of findings to other ethnicities.

Wider implications of the findings

Reassuringly, adolescents conceived after ART had better lung-function than their counterparts and no differences in asthma prevalence. The reported increase in allergies in ART conceived adolescents is of importance to families and healthcare providers, and opens possibilities for targeted screening and treatment. Further studies are required to confirm our findings.

Trial registration number

Not applicable

Comparison of the cardiometabolic profiles of adolescents conceived through ART with those of a non-ART cohort

STUDY QUESTION

Is the cardiometabolic health of adolescents conceived through ART worse than that of their counterparts conceived without ART?

SUMMARY ANSWER

The majority of cardiometabolic and vascular health parameters of adolescents conceived through ART are similar or more favourable, than those of their counterparts of similar age and conceived without ART.

WHAT IS KNOWN ALREADY

It has been proposed that the cardiometabolic health of offspring conceived with ART may be unfavourable compared to that of their counterparts conceived without ART. The literature pertaining to cardiometabolic health of offspring conceived after ART is contradictory, but generally suggests unfavourable cardiometabolic health parameters, such as an increase in blood pressure (BP), vascular dysfunction and adiposity, as well as unfavourable glucose and lipid profiles. With over 8 million children and adults born through ART worldwide, it is important to investigate whether these early signs of adverse cardiometabolic differences persist into adolescence and beyond.

STUDY DESIGN, SIZE, DURATION

The Growing Up Healthy Study (GUHS) is a prospective cohort study that recruited 303 adolescents and young adults conceived after ART (aged 13-21 years) and born between 1991 and 2001 in Western Australia. Their health parameters, including cardiometabolic factors, were assessed and compared with counterparts from the Raine Study Generation 2 (Gen2). The 2868 Gen2 participants were born 1989-1992 and are representative of the Western Australian adolescent population. At ∼17 years of age (2013-2017), 163 GUHS participants replicated assessments previously completed by Gen2 at a similar age.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Cardiometabolic parameters were compared between a total of 163 GUHS and 1457 Gen2 adolescents. Separate male (GUHS n = 81, Gen2 n = 735) and female (GUHS n = 82, Gen2 n = 722) analyses were conducted. Assessments consisted of a detailed questionnaire including health, lifestyle and demographic parameters, anthropometric assessments (height, weight, BMI, waist circumference and skinfold thickness), fasting serum biochemistry, arterial stiffness and BP (assessed using applanation tonometry). Abdominal ultrasonography was used to assess the presence and severity of hepatic steatosis, and thickness of abdominal fat compartments. Non-alcoholic fatty liver disease (NAFLD) was diagnosed if there was sonographic fatty liver in the absence of significant alcohol consumption. Chi2, Fisher's exact and Mann-Whitney U tests, performed in SPSS V25, examined cohort differences and generalized estimating equations adjusted for the following covariates: singleton vs non-singleton pregnancy, birthweight (z-score), gestational age, BMI, smoking, alcohol consumption in the past 6 months and parent cardiovascular status. Arterial stiffness measures and waist circumference were additionally adjusted for height, and female analyses were additionally adjusted for use of oral contraceptives in the preceding 6 months.

MAIN RESULTS AND THE ROLE OF CHANCE

In adjusted analyses, GUHS females had a lower BMI (22.1 vs 23.3 kg/m2, P = 0.014), and thinner skinfolds (triceps, subscapular, mid-abdominal; 16.9 vs 18.7 mm, P = 0.021, 13.4 vs 15.0 mm, P = 0.027, 19.7 vs 23.2 mm, P < 0.001, respectively), whereas males were not significantly different. Waist circumference was lower in GUHS adolescents (males: 78.1 vs 81.3 cm, P = 0.008, females: 76.7 vs 83.3 cm, P = 0.007). There were no significant differences between the two groups in glucose, insulin, homeostatic model assessment for insulin resistance, low-density lipoprotein cholesterol, non-high-density lipoprotein cholesterol (non-HDL-C), total cholesterol (TC), alanine aminotransferase and high-sensitivity C-reactive protein in both sexes. In females, serum triglycerides were lower in GUHS adolescents (1.0 vs 1.2 mmol/l, P = 0.029). GUHS males had higher serum HDL-C (1.1 vs 1.0 mmol/l, P = 0.004) and a lower TC/HDL-C ratio (3.2 vs 3.6, P = 0.036). There were no significant differences in the prevalence of NAFLD or steatosis severity scores between the cohorts in males and females. GUHS females had less subcutaneous adipose tissue (9.4 vs 17.9 mm, P < 0.001), whereas GUHS males had greater visceral adipose thickness (44.7 vs 36.3 mm, P < 0.001). There was no significant difference in pre-peritoneal adipose thickness. Pulse wave velocity was lower in GUHS males (5.8 vs 6.3 m/s, P < 0.001) and heart rate corrected augmentation index was lower in GUHS females (-8.4 vs -2.7%, P = 0.048). There were no significant differences in BP or heart rate in males or females between the two groups.

LIMITATIONS, REASONS FOR CAUTION

Despite the substantial study size and the unique study design of the ART cohort, we were unable to differentiate between different types of ART, due to the low number of ICSI cycles (e.g. IVF vs ICSI), draw definite conclusions, or relate the outcomes to the cause of infertility. Considering the differences in time points when both cohorts were studied, external factors could have changed, which could not be accounted for. Given the observational nature of this study, causation cannot be proven.

WIDER IMPLICATIONS OF THE FINDINGS

Contrary to our hypothesis and previous findings focussing mainly on childhood, this study reports mostly similar or favourable cardiometabolic markers in adolescents conceived with ART compared to those conceived without ART. The greater visceral adipose thickness, particularly present in males, requires further investigation. While these findings are generally reassuring, future well-designed and appropriately powered studies are required to definitively address the issue of cardiometabolic health in ART adults.

STUDY FUNDING/COMPETING INTEREST(S)

This project was supported by NHMRC project grant number 1042269 and R.J.H. received education grant funding support from Ferring Pharmaceuticals. R.J.H. is the Medical Director of Fertility Specialists of Western Australia and a shareholder in Western IVF. He has received educational sponsorship from MSD, Merck-Serono and Ferring Pharmaceuticals. P.B. is the Scientific Director of Concept Fertility Centre, Subiaco, Western Australia. J.L.Y. is the Medical Director of PIVET Medical Centre, Perth, Western Australia.

TRIAL REGISTRATION NUMBER

N/A.

OUP accepted manuscript

STUDY QUESTION

Are there differences in thyroid function between adolescents and young adults conceived with and without ART?

SUMMARY ANSWER

This study demonstrated no evidence of clinically relevant differences in thyroid function between adolescents and young adults conceived with and without ART.

WHAT IS KNOWN ALREADY

Studies to date have reported an increase in subclinical hypothyroidism in offspring conceived after ART. It has been suggested that the increase in maternal estrogen (E2) after fresh embryo transfers could affect thyroid function of the offspring. Suboptimal thyroid function at a young age can cause irreversible damage to the central nervous system, which makes early detection and correct treatment essential.

STUDY DESIGN, SIZE, DURATION

The Growing Up Healthy Study (GUHS) is a prospective cohort study, which aimed to recruit all adolescents born after conception with ART between 1991 and 2001 in the study area. The included participants (n = 303, aged 13–20 years) completed various health assessments. Depending on the age at enrolment, participants completed thyroid assessments at the 14- or 20-year follow-up. The outcomes of these replicated thyroid assessments were compared to those of participants conceived without ART from the Raine Study Generation 2 (Gen2). The Gen2 participants (n = 2868) were born between 1989 and 1992 and have been recognized to be representative of the local population.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Thyroid function assessments were compared between n = 134 GUHS and n = 1359 Gen2 adolescents at age 14 years and between n = 47 GUHS and n = 914 Gen2 young adults at age 20 years. The following mean thyroid hormone concentrations were compared between the cohorts: thyroid-stimulating hormone (TSH), free triiodothyronine (fT3), free thyroxine (fT4) and thyroid peroxidase antibodies (TPOAb). The prevalence of the following thyroid hormone profiles, based on individual thyroid hormone concentrations, was compared: euthyroidism, subclinical and overt hypo- and hyperthyroidism and thyroid autoimmunity. Outcomes were compared between the cohorts, and univariately between fresh embryo transfers (ET) and frozen ET (FET) within the GUHS. The correlation between maternal peak E2 concentrations (pE2) and fT4 was assessed within the GUHS.

MAIN RESULTS AND THE ROLE OF CHANCE

All mean thyroid function outcomes fell within the normal range. At both ages, we report no differences in TSH concentrations. At age 14 years, lower fT3 concentrations (4.80 versus 5.35 pmol/L, P < 0.001) and higher fT4 concentrations (12.76 versus 12.19 pmol/L, P < 0.001) were detected in the GUHS adolescents compared to Gen2 adolescents. At age 20 years, higher fT3 and fT4 concentrations were reported in GUHS adolescents (4.91 versus 4.63 pmol/L, P = 0.012; 13.43 versus 12.45 pmol/L, P < 0.001, respectively) compared to Gen2 participants. No differences in the prevalence of subclinical and overt hypo- and hyperthyroidism or thyroid autoimmunity were demonstrated between the cohorts at age 14 and 20 years. Thyroid function did not differ between ET and FET, and no correlation between pE2 and fT4 was reported.

LIMITATIONS, REASONS FOR CAUTION

The observational nature of the study limits the ability to prove causation. Furthermore, the comparison of ET and FET offspring at age 20 years may be lacking power. We were unable to differentiate between different types of ART (e.g. IVF versus ICSI) owing to the low number of ICSI cycles at the time of study. As ART laboratory and clinic data were collected contemporaneously with the time of treatment, no other data pertaining to the ART cycles were sought retrospectively; hence, some factors could not be accounted for.

WIDER IMPLICATIONS OF THE FINDINGS

This study does not support previous findings of clinically relevant differences in thyroid function when comparing a cohort of adolescents conceived after ART to counterparts conceived without ART. The minor differences detected in fT3 and fT4 were considered not biologically relevant. Although these findings appear reassuring, they warrant reinvestigation in adulthood.

STUDY FUNDING/COMPETING INTERESTS

This project was funded by an NHMRC Grant (Hart et al., ID 1042269). R.J.H. is the Medical Director of Fertility Specialists of Western Australia and a shareholder in Western IVF. He has received educational sponsorship from MSD, Merck-Serono and Ferring Pharmaceuticals. P.B. is the Scientific Director of Concept Fertility Centre, Subiaco, Western Australia. J.L.Y. is the Medical Director and a shareholder of PIVET Medical Centre, Perth, Western Australia.

TRIAL REGISTRATION NUMBER

N/A.

DNA methylation patterns within whole blood of adolescents born from assisted reproductive technology are not different from adolescents born from natural conception

STUDY QUESTION

Do the epigenome-wide DNA methylation profiles of adolescents born from ART differ from the epigenome of naturally conceived counterparts?

SUMMARY ANSWER

No significant differences in the DNA methylation profiles of adolescents born from ART [IVF or ICSI] were observed when compared to their naturally conceived, similar aged counterparts.

WHAT IS KNOWN ALREADY

Short-term and longer-term studies have investigated the general health outcomes of children born from IVF treatment, albeit without common agreement as to the cause and underlying mechanisms of these adverse health findings. Growing evidence suggests that the reported adverse health outcomes in IVF-born offspring might have underlying epigenetic mechanisms.

STUDY DESIGN, SIZE, DURATION

The Growing Up Healthy Study (GUHS) is a prospective study that recruited 303 adolescents and young adults, conceived through ART, to compare various long-term health outcomes and DNA methylation profiles with similar aged counterparts from Generation 2 from the Raine Study. GUHS assessments were conducted between 2013 and 2017. The effect of ART on DNA methylation levels of 231 adolescents mean age 15.96 ± 1.59 years (52.8% male) was compared to 1188 naturally conceived counterparts, 17.25 ± 0.58 years (50.9% male) from the Raine Study.

PARTICIPANTS/MATERIALS, SETTING, METHODS

DNA methylation profiles from a subset of 231 adolescents (13-19.9 years) from the GUHS, generated using the Infinium Methylation Epic Bead Chip (EPIC) array were compared to 1188 profiles from the Raine Study previously measured using the Illumina 450K array. We conducted epigenome-wide association approach (EWAS) and tested for an association between the cohorts applying Firth's bias reduced logistic regression against the outcome of ART versus naturally conceived offspring. Additionally, within the GUHS cohort, we investigated differences in methylation status in fresh versus frozen embryo transfers, cause of infertility as well as IVF versus ICSI conceived offspring. Following the EWAS analysis we investigated nominally significant probes using Gene Set Enrichment Analysis (GSEA) to identify enriched biological pathways. Finally, within GUHS we compared four estimates (Horvath, Hanuum, PhenoAge [Levine], and skin Horvath) of epigenetic age and their correlation with chronological age.

MAIN RESULTS AND THE ROLE OF CHANCE

Between the two cohorts, we did not identify any DNA methylation probes that reached a Bonferroni corrected P-value < 1.24E-0.7. When comparing IVF versus ICSI conceived adolescents within the GUHS cohort, after adjustment for participant age, sex, maternal smoking, multiple births, and batch effect, three methylation probes (cg15016734, cg26744878 and cg20233073) reached a Bonferroni correction of 6.31E-08. After correcting for cell count heterogeneity, two of the aforementioned probes remained significant and an additional two probes (cg 0331628 and cg 20235051) were identified. A general trend towards hypomethylation in the ICSI offspring was observed. All four measures of epigenetic age were highly correlated with chronological age and showed no evidence of accelerated epigenetic aging within their whole blood.

LIMITATIONS, REASONS FOR CAUTION

The small sample size coupled with the use of whole blood, where epigenetic differences may occur in other tissue. This was corrected by the utilized statistical method that accounts for imbalanced sample size between groups and adjusting for cell count heterogeneity. Only a small portion of the methylome was analysed and rare individual differences may be missed.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings provide further reassurance that the effects of the ART manipulations occurring during early embryogenesis, existing in the neonatal period are indeed of a transient nature and do not persist into adolescence. However, we have not excluded that alternative epigenetic mechanisms may be at play.

STUDY FUNDING/COMPETING INTEREST(S)

This project was supported by NHMRC project Grant no. 1042269 and R.J.H. received funding support from Ferring Pharmaceuticals Pty Ltd. R.J.H. is the Medical Director of Fertility Specialists of Western Australia and a shareholder in Western IVF. He has received educational sponsorship from Merck Sharp & Dohme Corp.- Australia, Merck-Serono Australia Pty Ltd and Ferring Pharmaceuticals Pty Ltd. P.B. is the Scientific Director of Concept Fertility Centre, Subiaco, Western Australia. J.L.Y. is the Medical Director of PIVET Medical Centre, Perth, Western Australia. The remaining authors have no conflicts of interest.

A direct action for GH in improvement of oocyte quality in poor-responder patients

Declining female fecundity at later age and the increasing tendency for women to delay childbirth have lead to a drastic rise in the number of women seeking assisted reproductive technology. Many women fail to respond adequately to standard ovarian stimulation regimens, raising a significant therapeutic challenge. Recently, we have demonstrated that the administration of GH, as an adjunct to ovarian stimulation, has improved the clinical outcomes by enhancing the oocyte quality. However, the mechanism(s) by which GH facilitated this improvement is yet to be understood. This study aimed to determine these potential mechanism(s) through the use of immunofluorescent localisation of GH receptors (GHRs) on the human oocyte and unbiased computer-based quantification to assess and compare oocyte quality between women of varying ages, with or without GH treatment. This study demonstrates for the first time, the presence of GHRs on the human oocyte. The oocytes retrieved from older women showed significant decrease in the expression of GHRs and amount of functional mitochondria when compared with those from younger patients. More interestingly, when older patients were treated with GH, a significant increase in functional mitochondria was observed in their oocytes. We conclude that GH exerts a direct mode of action, enabling the improvement of oocyte quality observed in our previous study, via the upregulation of its own receptors and enhancement of mitochondrial activity. This result, together with recent observations, provides scientific evidence in support of the use of GH supplementation for the clinical management of poor ovarian response.

Optimising vitrification of human oocytes using multiple cryoprotectants and morphological and functional assessment

Oocyte vitrification is a clinical practice that allows preservation of fertility potential in women. Vitrification involves quick cooling using high concentrations of cryoprotectants to minimise freezing injuries. However, high concentrations of cryoprotectants have detrimental effects on oocyte quality and eventually the offspring. In addition, current assessment of oocyte quality after vitrification is commonly based only on the morphological appearance of the oocyte, raising concerns regarding its efficiency. Using both morphological and functional assessments, the present study investigated whether combinations of cryoprotectants at lower individual concentrations result in better cryosurvival rates than single cryoprotectants at higher concentrations. Surplus oocytes from IVF patients were vitrified within 24 h after retrieval using the Cryotop method with several cryoprotectants, either individually or in combination. The morphological and functional quality of the vitrified oocytes was investigated using light microscopy and computer-based quantification of mitochondrial integrity, respectively. Oocyte quality was significantly higher using a combination of cryoprotectants than vitrification with individual cryoprotectants. In addition, the quality of vitrified oocyte varied depending on the cryoprotectants and type of combination used. The results of the present study indicate that observations based purely on the morphological appearance of the oocyte to assess the cryosurvival rate are insufficient and sometimes misleading. The outcome will have a significant implication in the area of human oocyte cryopreservation as an important approach for fertility preservation.

Cytogenetic analysis of embryos generated from in vitro matured mouse oocytes reveals an increase in micronuclei due to chromosome fragmentation

PURPOSE

(i) To determine the prevalence of micronuclei in the cytoplasm of embryos generated from in vitro matured oocytes. (ii) Assess whether micronuclei presence are the result of chromosome fragmentation or the loss of whole chromosomes.

METHODS

In vitro fertilization was performed on mature oocytes generated from superovulated mice (control) and in vitro matured mouse oocytes. Fertilized oocytes were cultured to the two-cell stage and fixed to slides. Micronuclei assessment was performed after staining with Giemsa. Centromere assessment was made using immunofluorescent staining (CREST) of the centromeric kinetochores.

RESULTS

Micronuclei were observed in 2% (4/197) of control two-cell embryos and 36.2% (46/127) of two-cell embryos generated from in vitro matured oocytes (P < 0.02). Centromeres were not detected in micronuclei from either group.

CONCLUSIONS

A significant increase in micronuclei was observed in embryos generated from in vitro matured oocytes. The lack of accompanyingcentromeres would suggest the micronuclei are the result of chromosome fragmentation.

Cytogenetic analysis of unfertilized oocytes following intracytoplasmic sperm injection using spermatozoa from a globozoospermic man

A man with globozoospermia was treated in our in-vitro fertilization-intracytoplasmic sperm injection (ICSI) programme. In the treatment cycle, 24 oocytes were collected from his wife. All the oocytes were at metaphase II stage. The semen sample produced on the day had a normal sperm count, good motility, but with 100% globozoospermia. All oocytes were injected with randomly selected spermatozoa and of these, two oocytes showed two pronuclei and another contained a single pronucleus. The remainder were unfertilized. The normally fertilized oocytes (two pronuclear) cleaved to the four-cell stage and were transferred to the patient. At 48 h after ICSI, the 21 unfertilized oocytes were processed for cytogenetic analysis. All oocytes contained a haploid chromosome set. The only abnormality seen was a chromosome fragment in one metaphase. Eighteen oocytes contained decondensed sperm nuclei and of these, 14 nuclei were beginning to show signs of premature chromatin condensation (PCC) and the other four showed strong signs of PCC. Thus it appears that in some forms of globozoospermia, arrest of nuclear decondensation and/or PCC are another cause of fertilization failure. The most likely cause for this is the absence or down-regulation of spermatozoa associated activating factor in round-headed spermatozoa.

Evidence that male smoking affects the likelihood of a pregnancy following IVF treatment: application of the modified cumulative embryo score

Female cigarette smoking has been implicated as having a detrimental effect on in-vitro fertilization (IVF) outcomes mediated through: (i) a diminished ovarian reserve (DOR), and (ii) an elevated pregnancy loss. Research is sparse regarding the effect of male smoking. The objective of this retrospective cohort study was to investigate the effect of male and female smoking on: (i) the collective quality of embryos selected for uterine transfer, and (ii) the likelihood of achieving an ongoing pregnancy at 12 weeks. A total of 498 consecutive IVF treatment cycles were analysed. Female smokers were significantly younger (P < 0.05) and achieved a better modified cumulative embryo score (mCES) (P < 0.05) than female non-smokers. Female age correlated inversely with the number of oocytes collected (r = -0.42, P < 0.01) and the number of oocytes in turn was important in terms of predicting mCES. The decreasing number of oocytes aspirated with increasing age was of a significantly stronger magnitude for female smokers than for female non-smokers (P < 0.05). Multiple logistic regression was used to determine whether smoking affected the likelihood of achieving a 12-week pregnancy. The mCES, tubal infertility and male smoking were found to be significant. Male smoking interacted with male age (P = 0.0164), indicating for male smokers a decrease of 2.4% in the likelihood of achieving a 12-week pregnancy with every 1-year increase in age. This is the first study to show that male smoking has a deleterious effect on pregnancy outcome among IVF patients. Our study supports the increased risk of DOR but fails to support the elevated incidence of pregnancy loss among female smokers. A reduced pregnancy rate was associated with male smoking possibly through pre-zygotic genetic damage. The growing realization of a paternal component of reproductive impairment suggests that studying the male is necessary.

Cytogenetic abnormalities of unfertilized oocytes generated from in-vitro fertilization and intracytoplasmic sperm injection: a double-blind study

In the present study we have assessed the cytogenetic abnormalities of unfertilized oocytes from in-vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) programmes during a one year period (July 1995 to July 1996) with the cytogenetic analysis being carried out in a double-blind manner. A total of 88 unfertilized ICSI and 85 unfertilized IVF oocytes were used for the study and of these 51 and 62 oocytes, in each respective group, were suitable for analysis. The haploidy, diploidy and aneuploidy rates between ICSI (62.7, 7.8 and 5.9%) and IVF (61.3, 9.7 and 14.5%) groups were similar. A significant inter-patient variation in the incidence of hypohaploidy was observed within the IVF group. Chromosomal fragmentation or breakage was observed at a similar rate in both groups of unfertilized oocytes (23.5 and 14.5% for ICSI and IVF respectively). A significantly higher proportion of ICSI oocytes contained sperm nuclei (27/51, 52.9%) than did IVF oocytes (20/62, 32.3%, P < 0.01). The distribution and state of sperm head chromatin in relation to oocyte chromosomal complement was studied in both groups. ICSI oocytes contained decondensed or swollen sperm nuclei in association with haploid oocyte chromosomes (12/27, 44.4%) or condensed sperm heads in oocytes showing no chromosomal complements (7/27, 25.9%). In IVF oocytes sperm heads were either arrested in the condensed state (5/20, 25%), metaphase stage (3/20, 15%) or had undergone premature chromosome condensation (PCC; 6/20, 30%) in association with haploid oocyte chromosomes. The incidence of PCC was similar in the two groups. A marked variation in the incidence of total chromosomal abnormality was observed between patients within both ICSI (0-75%) and IVF (0-71%) groups indicating a possible similarity in oocyte quality between the majority of male factor and tubal infertility patients. The type of sperm used in the two fertilization procedures showed an increased incidence of chromosomal breakage with ICSI-MESA (microepididymal sperm aspiration) spermatozoa (4/6, 67%) compared to the ICSI-ejaculated (6/35, 17.1%; P < 0.05), ICSI-testicular biopsy (2/10, 20%) and IVF-normospermic (9/62, 14.5%; P < 0.01) spermatozoa. Chromosomal fragmentation may be associated with the degree of difficulty experienced at sperm injection, especially with sperm retrieved from the reproductive tract. Thus chromosomal fragmentation in ICSI may need further investigation using a larger sample size in order to assess the possible causative factors.

Cryopreservation of oocytes and embryos: use of a mouse model to investigate effects upon zona hardness and formulate treatment strategies in an in-vitro fertilization programme

Mouse oocytes and embryos were obtained following ovulation induction of (C57B16 x CBA) F1 animals. Zonae pellucidae were exposed to alpha-chymotrypsin in phosphate-buffered medium (PB1) supplemented with 3 mg/ml bovine serum albumin upon a heated stage (37 degrees C) and were observed constantly through an inverted microscope. The endpoint of the bioassay was the limits of the zona no longer being seen clearly at x 200 magnification, and the time taken for each zona to dissolve was recorded. A dose-dependent response in dissolution time was clearly seen, with 1% alpha-chymotrypsin being chosen as the routine working solution. Cryopreservation of 2-cell mouse embryos using propanediol did not cause zona hardening but induced a small and significant softening, as gauged by the time taken for zona dissolution (2181 +/- 167 versus 1864 +/- 82 s). Zona hardening was not suspected to occur after the freezing of human embryos as there was no difference in implantation rates per embryo for in-vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) treatment cycles between fresh [IVF: 63/644 (9.7%); ICSI: 51/330 (15.5%)] and frozen embryos [IVF: 36/458 (7.9%); ICSI: 18/112 (16.1%)]. Conversely, significant hardening of the zonae of mature oocytes was seen following cryopreservation (747 +/- 393 s) compared with freshly ovulated oocytes (151 +/- 68 s). It is concluded that (i) the freezing of murine oocytes with propanediol results in zona hardening, implying a possible benefit of ICSI after the cryopreservation of human oocytes, and (ii) the cryopreservation of embryos is not associated with zona hardening or reduced implantation, making microdissection of the zona in such cases generally unwarranted.

Birth from cryopreserved embryos following in-vitro maturation of oocytes and intracytoplasmic sperm injection

This case report describes the birth of a baby following the transfer of cryopreserved embryos generated from intracytoplasmic sperm injection (ICSI) carried out on the second day after oocyte pick-up of in-vitro-matured metaphase I and germinal vesicle stage oocytes. The couple had a history of three failed intrauterine insemination attempts and reduced fertilization rates in two previous in-vitro fertilization (IVF) cycles. In the IVF-ICSI treatment cycle, 6/11 mature oocytes became fertilized following ICSI on the first day. However, the patient failed to conceive following the transfer of three embryos. Five oocytes were immature (two at metaphase I stage and three with a germinal vesicle) and these were cultured overnight. All had extruded a polar body by the following day and ICSI was therefore performed; four oocytes became fertilized, and were cryopreserved at the pronulear stage in propanediol. In the next treatment cycle, transfer of frozen embryos was planned. The pronuclear zygotes were thawed and cultured for 24 h prior to the transfer of two embryos in a cycle stimulated with low doses of follicle stimulating hormone. This resulted in a pregnancy and the delivery of a healthy baby boy. In-vitro maturation of metaphase I and germinal vesicle oocytes which are routinely collected in IVF-ICSI cycles, followed by second day ICSI fertilization, may provide a valuable source of embryos for infertile couples.

Changes in motility patterns during in-vitro culture of fresh and frozen/thawed testicular and epididymal spermatozoa: implications for planning treatment by intracytoplasmic sperm injection

The present report describes the motility changes in vitro (percentage motile and progressively motile) of freshly collected testicular and epididymal spermatozoa and following freeze/thaw of the same spermatozoa from a man with obstructive azoospermia. Washed spermatozoa were cultured in micro droplets under paraffin oil or in test tubes using HEPES-buffered or bicarbonate-buffered medium containing 10% human serum. In fresh testicular sperm cultures 60-65% of the sperm cells became motile within 2 days of culture; the motility was maintained for a further 4-5 days before a decline was observed. The progressive motility improved markedly on the third day of culture and it peaked around day 5. Only a small number of frozen/thawed testicular spermatozoa became motile during in-vitro culture (15-20%) and the motility was maintained for only 2-3 days before it declined. Furthermore, only 10-12% of the spermatozoa showed progressive motility. Spermatozoa recovered from micro-epididymal sperm aspiration (MESA) showed a gradual decrease in progressive motility and in 5 days all sperm cells were found to be immotile in both freshly collected and frozen/thawed spermatozoa. All culture systems supported sperm motility. It is clear that testicular spermatozoa, particularly from men with obstructive azoospermia, can be collected and maintained in vitro for up to 1 week before the oocyte retrieval but when frozen testicular or epididymal spermatozoa are used it is more reliable to thaw these spermatozoa on the day of intracytoplasmic sperm injection.

Trophoblast antigen levels in the first trimester of a trisomy 22 pregnancy

We report trophoblast antigen (pregnancy-associated plasma protein-A, PAPP-A; free beta-human chorionic gonadotrophin, F beta hCG) expression in a trimosy 22 pregnancy. Maternal concentrations of these antigens were depressed prior to detection of abnormalities by ultrasonography. Immunohistochemical findings were consistent with depressed marker expression.

An argument for the past and continued use of pentoxifylline in assisted reproductive technology

Pentoxifylline was first used within an in-vitro fertilization (IVF) programme before the advent of alternative treatment strategies such as oocyte micromanipulation. Over the years, it has continued to be useful in aiding fertilization in selected IVF cases, with a beneficial effect also being seen in certain cases treated by intrauterine insemination. In both instances, the acrosome reaction to ionophore challenge test appears to have been invaluable in identifying suitable patients. The stimulation of spermatozoa by pentoxifylline should remain a therapeutic option in the treatment of couples with a male factor present. As an adjunct to IVF, it has the advantage of being simpler and less costly to perform compared with micromanipulation. However, its use should be restricted to selected cases, and the merits over and above those of invasive procedures such as intracytoplasmic sperm injection should be discussed with the individual patients. The pretreatment of spermatozoa prior to intrauterine insemination in selected cases gives an alternative therapeutic strategy to those patients not wishing or unable to undertake IVF.

Sperm stimulants can improve fertilization rates in male-factor cases undergoing IVF to the same extent as micromanipulation by partial zona dissection (PZD) or subzonal sperm insemination (SUZI): a randomized controlled study

PURPOSE

Our purpose was to evaluate the efficacy of direct insemination (IVF), micromanipulation by partial zona dissection (PZD), and subzonal sperm insemination (SUZI) using sperm-treated with pentoxifylline (PF) +/- 2-deoxyadenosine (2DA).

RESULTS

The overall fertilization rate achieved was similar for all three fertilization techniques (33.1, 30.2, and 26.9% for IVF, SUZI, and PZD, respectively). Patients who had reduced fertilization in previous IVF attempts showed improved fertilization with sperm stimulants, either PF alone or PF in combination with 2DA in standard IVF. In certain cases, SUZI or PZD gave significantly improved fertilization rates in comparison to IVF.

CONCLUSION

Selective use of sperm stimulants in IVF can achieve fertilization for the majority of male-factor cases. However, PZD and SUZI techniques are useful, especially when sperm stimulants fail to achieve fertilization or achieve poor fertilization in direct insemination.

Factors influencing the outcome of in-vitro fertilization with epididymal spermatozoa in irreversible obstructive azoospermia

Microsurgical epididymal sperm aspiration (MESA) and in-vitro fertilization (IVF) were found to offer limited opportunity for fatherhood to 45 men with obstructive azoospermia, due principally to poor embryo implantation. Adequate sperm preparations were obtained in 46/50 treatment cycles (92%), with the best motility found in the caput epididymis in 89% of cases. The mean fertilization rate was 11.2% and fertilization occurred in 23 cycles (50%), with embryo transfer arising from 12/26 men with vas aplasia (CAV), 4/9 with genital tract obstruction (EV) and 7/11 with irreversible vasectomy (VV). The overall implantation rate was low, 8.7% per embryo transfer (11.7% per 2-3 embryo transfers) and was not improved by Fallopian transfer. There were two pregnancies (4% per cycle), both in the EV group where embryo formation and implantation (2/4, 50% per cycle) were optimum even though sperm preparations were paradoxically inferior to the CAV and VV groups. The spermatozoa retrieved in the two successful EV cycles were appreciably blood contaminated. Analysis of the 21 failed embryo transfers showed delayed fertilization in 10 cycles, cystic fibrosis (CF) mutation or familial disease in 7/12 CAV men and the VV men were older (P < 0.001). A pregnancy which miscarried arose from a case of Young's syndrome, a carrier of CF mutation DF508. Male factors could thus be implicated in the high embryo wastage of MESA cycles and might also be influencing implantation in other IVF procedures. Where feasible, male reconstructive surgery is preferable unless fertilization can be improved, possibly by speedier retrieval techniques or by permitting sperm capacitation in vitro, but probably more effectively by micro-assisted insemination.

Use of the acrosome reaction to ionophore challenge test in managing patients in an assisted reproduction program: a prospective, double-blind, randomized controlled study

OBJECTIVE

To assess the utility of the acrosome reaction (AR) to ionophore challenge test in determining the sperm treatment protocols for patients undergoing assisted reproduction.

DESIGN, SETTING, PATIENTS

One hundred twenty-one couples undergoing an IVF-ET or GIFT procedure from January to July 1992 were included in this prospective study. All cases had a preliminary semen analysis within the previous 3 months and an AR to ionophore challenge test was carried out unless an acceptable fertilization rate occurred on previous IVF. For those patients whose AR to ionophore challenge score was below the accepted fertile range of > or = 10%, a second AR to ionophore challenge test was performed after exposure of sperm to the stimulant pentoxifylline. Couples then were managed by assisted reproduction with randomized allocation of oocytes for fertilization with a standard sperm preparation or with added sperm stimulants, either 3.6 mM pentoxifylline alone or combined with 3.0 mM 2-deoxyadenosine. The study was double-blind with neither the patients nor the embryologist knowing the AR to ionophore challenge result at the time of the IVF procedure.

MAIN OUTCOME MEASURES

Data from the preliminary semen analyses and AR to ionophore challenge scores were correlated with the fertilization rates achieved using control and treated sperm preparations. The rates of total fertilization failure and the numbers of clinical pregnancies occurring in each subgroup were also recorded.

RESULTS

All AR to ionophore challenge groups showed normal sperm counts except the groups with poor AR to ionophore challenge, which demonstrated reduced sperm counts. The group with normal AR to ionophore challenge scores or previous normal fertilization showed satisfactory fertilization rates with either control or treated sperm, although some individual cases showed reduced fertilization with treated sperm. The fertilization rate for the group with low AR to ionophore challenge scores improved significantly with pentoxifylline, and the benefit was greatest when this had been predicted from the AR to ionophore challenge studies. Cases with persisting poor AR to ionophore challenge despite pentoxifylline showed no significant improvement in fertilization rates with sperm exposed to either sperm stimulant regimens. Poor AR to ionophore challenge scores were also predictive of total fertilization failure, but this problem was reduced by sperm stimulation. The AR to ionophore challenge score at 10% cutoff level showed optimal levels of sensitivity (82.1%), highest negative predictive value (82.1%), and lowest false negative rate (17.9%).

CONCLUSIONS

The AR to ionophore challenge test is useful in the assessment and management of the male factor in assisted reproduction. It can be used to identify the majority of cases who will benefit from the use of sperm stimulants.

Pentoxifylline increases sperm penetration into zona-free hamster oocytes without increasing the acrosome reaction

Several drugs have been used to stimulate human sperm motility, including 3-deoxy-adenosine, caffeine, and pentoxifylline. Pentoxifylline is an inhibitor of the phosphodiesterase and may stimulate sperm motility by increasing the intracellular levels of cAMP. In this study we have evaluated the effect of pentoxifylline in the outcome of the sperm penetration assay into zona-free hamster oocytes. Twenty-seven semen samples, obtained for diagnostic purposes, were used. After the motile sperm were selected by the swim-up technique, the samples were divided into two aliquots. One aliquot was incubated with 1 mg ml-1 of pentoxifylline at 37 degrees C, 5% CO2 for 30 min. The control aliquot was incubated with culture medium. The samples were then washed and resuspended in fresh, pentoxifylline-free medium, at a sperm concentration of 10 x 10(6) cells ml-1. One hundred microlitres of each sperm suspension was then deposited under oil and 30-40 zona-free hamster oocytes were added. After 6 h of gamete coincubation, the percentage of penetrated oocytes and the number of decondensed sperm heads were evaluated. The percentage of acrosome-reacted sperm was evaluated using the Pisum sativum lectin. The percentage of zona-free hamster oocytes penetrated was increased after pentoxifylline-treatment. The percentage of acrosome reacted sperm and the number of decondensed sperm heads per egg were not different between the control and the pentoxifylline-treated groups. The results suggest that the beneficial effect of pentoxifylline upon the sperm cells is not mediated by stimulation of the acrosome reaction.

Pentoxifylline: actions and applications in assisted reproduction

Data are presented covering various studies on the use of the phosphodiesterase inhibitor pentoxifylline (PF) in the sperm preparation for procedures in assisted reproduction. Significant improvements have been shown in the fertilization rate of oocytes along with a reduced risk of failed fertilization cycles utilizing oligo/asthenozoospermic semen samples. Fertilization is also improved for normozoospermic samples when the acrosome reaction is suboptimal. PF has proven effects on sperm motility, increasing the proportion of hyperactivated spermatozoa. It can also enhance the acrosome reaction and this may be the more relevant function for clinical prediction. There is a further action as a suppressor or scavenger of reactive oxygen species although higher concentrations than that in current clinical use may be required to optimize this effect. PF should be washed out of the sample used for insemination to avoid inhibiting the completion of oocyte maturation.

Is luteal function maintained by factors other than chorionic gonadotrophin in early pregnancy?

Women with ectopic pregnancy (n = 14) and early embryonic arrest ('blighted ovum') (n = 9) were studied 16 days after conception, at a time when they were asymptomatic and serum concentrations of beta-human chorionic gonadotrophin (HCG) were in the normal range and increasing at an apparently normal rate. Serum progesterone and oestradiol concentrations were compared with those from normal women matched for gestational age and serum beta-HCG concentration whose singleton intra-uterine pregnancies proceeded normally beyond 20 weeks. Mean serum progesterone concentrations were significantly lower in the women with ectopic pregnancies than in matched controls (P < 0.002); however, there was no difference in the serum progesterone concentrations between women with blighted ova and matched controls. Statistically significant differences were not seen in serum oestradiol concentrations between either group and matched controls. Similarly there was no difference in serum progesterone or oestradiol concentrations in 20 women who conceived ectopic pregnancies and 20 women conceiving blighted ovum pregnancies and their matched intra-uterine controls when conception followed ovarian stimulation. The low serum progesterone concentrations seen in ectopic pregnancy suggest that there is a specific and selective deficiency in progesterone synthesis, which implies that factors other than HCG may influence luteal function.

Failed oocyte retrieval after lack of human chorionic gonadotropin administration in assisted reproductive technology

OBJECTIVE

To document the absence of oocytes in follicular aspirates in women who, during controlled ovarian stimulation with gonadotropin-releasing hormone agonist (GnRH-a) and menotropins, fail to receive human chorionic gonadotropin (hCG) administration.

DESIGN

Retrospective analysis of clinical laboratory data.

SETTING

Multicentric.

PATIENTS

Five women undergoing controlled ovarian hyperstimulation with GnRH-a and menotropins for programs of assisted reproductive technologies.

RESULTS

The documented absence of an hCG injection produced "empty follicles" at transvaginal guided aspiration, despite numerous follicular lavages and aspiration of peritoneal fluid. The lack of oocytes and granulosa-cumulus complex in the follicular fluid was reverted in other cycles in the same patients when hCG was properly administered.

CONCLUSIONS

(1) This study emphasizes the importance of proper patients' and nurses' instructions for preparation of hCG injections and proper mixture of vehicle and powder before follicular aspiration. (2) In the absence of cumulus-corona-oocyte complex at aspiration, measure serum beta-hCG to ascertain whether hCG injection was administered or not. (3) Routine preoperative beta-hCG levels may be helpful to avoid unnecessary surgeries.

The value of serum levels of oestradiol, progesterone and beta-human chorionic gonadotrophin in the prediction of early pregnancy loss

Serial serum levels of oestradiol, progesterone and the beta-subunit of human chorionic gonadotrophin (beta-HCG) had been performed in 674 cycles in women conceiving a singleton pregnancy, either spontaneously or as a result of assisted conception. To determine the value of these estimations in the prediction of early pregnancy loss, frequency distribution curves and receiver operating characteristic curves were derived for the respective hormones measured at weeks 4-7 of gestation and expressed as multiples of the median (MoM) values in pregnancies occurring both with and without ovarian stimulation. A cut-off level of beta-HCG less than 0.5 MoM gave a sensitivity of 68% with an odds ratio of 4.0 at 7 weeks in unstimulated cycles in the prediction of pregnancy failure. A cut-off of 0.8 MoM for progesterone gave a sensitivity of 59% and an odds ratio of 2.8. Prospective hormonal monitoring during the early weeks of gestation may be useful in the prediction of early pregnancy loss and should help to avoid the emergency presentation of some of the complications of early pregnancy, in particular ectopic pregnancy. The limitations imposed by multiple pregnancies and uncertain gestation due to menstrual data may restrict the use of this strategy to specialist fertility centres.

Cytogenetic analysis of human oocytes and embryos in an in-vitro fertilization programme

Oocytes (unfertilized and preovulatory) and embryos (normal and polypronuclear), which were donated to research by patients undergoing procedures of assisted reproductive treatment, were analysed for cytogenetic abnormalities. A total of 362 oocytes and embryos were analysed. The unfertilized oocytes with readable metaphases (53.4%) gave 25.2% chromosomal abnormality with diploidy being the main aberration observed. A high incidence of premature chromosome condensation (PCC) was observed and the incidence of PCC in oocytes exposed to colcemid was significantly higher (14/62, 22.6%) than in those not exposed to this treatment (3/41, 7.3%, P less than 0.05). When chromosomal anomalies and PCC in the unfertilized oocytes were correlated to various patient criteria such as stimulation regimen, number of human menopausal gonadotrophin ampoules, peak oestradiol levels, age of patient and number of previous attempts, none of the criteria tested had any significant relationship to the incidence of chromosomal abnormality. However a significant increase in the incidence of PCC was noted in the gonadotrophin-releasing hormone (GnRH) 'flare' group (6/15, 40.0%) compared to the GnRH 'down-regulation' group (11/88, 12.5%). The incidence of chromosomal abnormalities among preovulatory oocytes was 16.7% and diploidy was the only abnormality noted. For embryos arising from two-pronuclear oocytes, the chromosomal constitution related mainly to embryo quality. The rate of chromosomal abnormality for apparently good quality embryos was 23.5% and for poor or fragmented embryos 83.3%. The majority (77.3%) of the readable metaphase plates for polypronuclear 1-cell and cleaved embryos showed grossly abnormal chromosome complements but 19% of the cleaved embryos contained sets of normal diploid chromosomes.(ABSTRACT TRUNCATED AT 250 WORDS)

Chromosome abnormalities detected in chorionic villus biopsies of failing pregnancies in a subfertile population

OBJECTIVE

To determine the range and prevalence of chromosomal abnormalities occurring in failing pregnancies in subfertile women.

DESIGN

Prospective biochemical and ultrasound monitoring of all pregnancies conceived between 1988 and 1990 in a subfertile population.

SETTING

A single-centre specialist fertility clinic in Perth, Western Australia.

SUBJECTS

Tissue from 50 early pregnancy losses was successfully cultured for chromosomal analysis from 46 pregnancies comprising 29 anembryonic pregnancies, 9 miscarriages and 8 ectopic pregnancies.

MAIN OUTCOME MEASURES

Impending pregnancy loss was identified at an early stage. Chromosomal analysis was performed on chorionic villi obtained before the diagnosis became clinically evident.

RESULTS

Significant chromosomal abnormalities were identified in 54% (14/26) of early pregnancy losses where gamete manipulation was involved and 45% (9/20) of those following spontaneous conception. The most common abnormalities were trisomies (12 pregnancies, mainly trisomy 16), triploidies (3 pregnancies) and monosomy X (3 pregnancies). An excess of female fetuses was noted with only 24% of conceptuses (11/46) bearing a Y chromosome.

CONCLUSIONS

The data indicate a similar rate of chromosomal abnormalities underlying pregnancy losses at earlier stages of pregnancy and after infertility treatments as that reported from the general population. Gamete manipulation does not appear to confer a higher rate of chromosomal abnormalities in ensuing pregnancies.

A test of the human sperm acrosome reaction following ionophore challenge. Relationship to fertility and other seminal parameters

Acrosome reaction capacity was tested on semen samples from 53 fertile and 26 subfertile men. Preparations were divided into two aliquots after 3 or 24 hours of culture. One aliquot received 10 mumol/L calcium ionophore A23187 in dimethyl sulfoxide (DMSO) and the other received DMSO alone. Acrosome reactions were scored on ethanol-permeabilized smears using fluorescein isothiocyanate (FITC)-conjugated Pisum sativum lectin. The following factors were analyzed: the spontaneous reaction rates (control); induced reaction rates (ionophore-challenged); and the difference between the two, being the proportion of spermatozoa in the population capable of reacting in response to calcium influx (acrosome reaction to ionophore challenge [ARIC]). While spontaneous reactions bore no relation to fertility, induced reactions and ARICs were significantly reduced or absent in subfertile men, indicating acrosomal dysfunction as a likely cause of fertilization failure. The test was shown to have a predictive value for fertility comparable to that of the hamster ovum sperm penetration assay and to be a simple and cost-effective addition to existing semenology.

Assisted fertilization of mouse oocytes and preliminary results for human oocytes using zona drilling

The zona-drilling procedure was investigated in mouse oocytes prior to a study on human oocytes. The procedure involved the injection of 5-nl volumes of acidic Hepes-buffered medium at pH 2.5 using a microinjection instrument. Zona-drilled mouse oocytes had significantly higher rates of fertilization (60/99; 61%) than zona-intact oocytes (6/103; 6%) at an insemination concentration of 1 x 10(4) sperm/ml (P less than 0.001). The procedure did not induce parthenogenetic activation of oocytes and more than 97% of zygotes developed to the blastocyst stage. A similar rate of live progeny was observed when zona-drilled (38.0%) and control embryos (38.5%) were transferred to pseudopregnant recipients. Chromosome analyses were performed on zona-intact, zona-free, and zona-drilled oocytes inseminated with varying concentrations of sperm and analysed at the first cleavage division. Zona-free oocytes had high rates of polyploidy (greater than or equal to 40%) with varying insemination numbers but the zona-drilled oocytes did not reveal significant increases in the rate of polyploidy or aneuploidy when compared to controls. In the human studies, zona-drilled oocytes achieved higher rates of fertilization than zona-intact oocytes, with sperm numbers as low as 1 x 10(4)/ml (6/8; 75%). Polyspermic fertilization was observed in 1/2 and 2/6 of fertilized oocytes inseminated with 1 x 10(5) and 1 x 10(4) sperm/ml, respectively. With the low sperm concentration 2/4 of those which were normally fertilized developed to healthy blastocysts. These studies suggest that the zona-drilling technique as described can be performed without apparent harm to oocytes and generate normal embryos.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of luteal support therapy in a randomized controlled study within a gamete intrafallopian transfer program

A randomized controlled study of luteal support therapy (using intramuscular injections of progesterone and/or human chorionic gonadotropin) was conducted in a trial designed to minimize variables that might adversely affect the change of pregnancy. After applying rigid selection criteria, 207 women were recruited into one of four groups. Mathematical modeling was applied to the results to determine if there were degrees of improvement in uterine receptivity relative to various grades of embryo quality ("E" factor). Although the trial size was insufficient to enable the detection of significant improvements in the pregnancy rates that ranged from 27.5% for non-treatment to 41.2% for those receiving combined treatment, the birth rates were significantly better with luteal support (11.8% versus 29.4%). Similarly, the overall implantation rate just failed to reach statistical significance for luteal support, but the ongoing implantations were significantly better (3.6% versus 9.0%). Data modeling indicated that luteal support, particularly with the combined regimen, could improve the ongoing implantation rate by up to 2.5-fold when the E factor was poorest.

Transcervical tubal embryo-stage transfer (TC-TEST)

Ultrasound-guided transcervical tubal cannulation (TC-TEST) was used to replace embryos to the fallopian tubes in 17 women whose fallopian tubes were inaccessible by the abdominal route but where at least one tube was shown to be freely patent on a preliminary hysterosalpingogram investigation. In two further cases, the fallopian tubes proved impossible to cannulate, and along with two instances where difficulty was experienced, a common underlying feature was an arcuate or septate configuration of the uterus. Three pregnancies ensued (17%) in cases where the procedure was free of difficulty and the transfers were demonstrably intratubal: two went to term and the third resulted in an ectopic pregnancy. The procedure has so far not shown a benefit over conventional IVF-ET and probably should be avoided in women with any type of tubal disorder.

Influence of pentoxifylline in severe male factor infertility

Two in vitro fertilization sperm preparation protocols using pentoxifylline (long and short exposure before insemination) were studied in 57 couples (61 cycles) with male factor infertility. For each cycle, oocytes were divided into two groups for insemination using either pentoxifylline-treated or control semen. Fertilization rates improved over controls in the short protocol (P less than 0.001) and fewer couples experienced fertilization failure (P = 0.02). Sixteen pregnancies ensued (30% per collection with the short protocol), and 4 were from cases with less than 1.0 X 10(6) progressively motile sperm count per milliliter, 1 being as low as 0.2 X 10(6) progressively motile count per milliliter. Seventeen healthy infants have now delivered and pregnancy wastage is not increased. Pentoxifylline is thus a useful sperm treatment for cases of male factor infertility.

The influence of infertility etiology on the outcome of IVF-ET and GIFT treatments

The present report examines retrospectively the success rates of both in-vitro fertilization and embryo transfer (IVF-ET) and gamete intrafallopian transfer (GIFT) in relation to the underlying infertility disorder. Reduced fertilization rates were seen when the male partner was oligospermic or had both IgA and IgG in his semen, or the female partner had elevated LH concentrations during the follicular phase. In IVF-ET, the chance of pregnancy was reduced in women with elevated LH concentrations or endometriosis. Pregnancy rates for patients treated in the GIFT program were significantly better (P less than .001) than for those treated by IVF-ET. Of special interest was the finding of an improved chance of pregnancy for patients with severe endometriosis treated by GIFT (P less than .001). With oligospermia, pregnancies were only achieved in the GIFT program when the insemination number was increased. The pregnancy outcome was similar in both programs, with approximately 70% of pregnancies delivering beyond 20 weeks' gestation. However, there was a high rate of ectopic pregnancy, particularly in cases with underlying tubal disease. These findings have led to revised guidelines for the accurate counseling of patients, and provide further insight into the possible mechanism of various disorders contributing to infertility.

Pituitary down-regulation using leuprolide for the intensive ovulation management of poor prognosis patients having in vitro fertilization (IVF)-related treatments

A review of 118 treatment cycles in 115 women under prolonged GnRH analogue (GnRHa; leuprolide) treatment is presented. Patients were selected for treatment primarily on the grounds of poor previous response to stimulation (n = 40), advanced age (greater than 35 years; n = 29), previous premature luteinizing hormone (LH) surge (n = 30), polycystic ovarian disease (PCO; n = 12), and elevated androgens without evidence of PCO (n = 5). An overall pregnancy rate of 28.8% per treatment cycle was attained, compared with a pregnancy rate of 6.2% (6/97, of which none went to term) in the previous completed treatment cycle for the same patients. Ovarian response, as measured by oocytes recovered and maximum estradiol levels observed, was significantly improved in all groups and this was associated with a prolonged follicular phase, significantly more human menopausal gonadotropin (hMG) stimulation and a relatively high incidence of ovarian hyperstimulation, particularly in pregnant patients. Of specific techniques in the GnRHa cycle, GIFT produced a pregnancy rate per treatment of 50% (10/20); IVF-ET, 22% (8/36); PROST, 28% (13/46); and TEST, 19% (3/16). No cycles were abandoned, compared with a cancellation rate of 24% in previous cycles without GnRHa. Patients with PCO performed particularly well on GnRHa management, with a pregnancy rate per treatment of 58% (7/12). Pregnancy rates per treatment for the other groups were as follows: elevated age, 27% (9/33), high androgens, 40% (2/5); premature LH surges, 32% (9/28); and poor responders, 17.5% (7/40).(ABSTRACT TRUNCATED AT 250 WORDS)

Ultrastructural observations on gamete interactions using micromanipulated mouse oocytes

Cumulus-free mouse oocytes were subjected to zona opening by cracking with microhooks (ZC) or acid drilling (ZD) and fixed 30-90 min after insemination (10(5) pre-capacitated motile sperms/ml). Ultrastructural observations were made on serially thin-sectioned oocytes: 15 ZC and 12 ZD. The zona lesion in ZC oocytes was a clean cut, whereas in ZD oocytes it formed a patchy area of partial zona loss, with reduced microvillar height on the underlying oocyte surface. Spermatozoa were observed within the perivitelline space and partially fusing with the oocyte after 30 min in both situations. Only acrosome-reacted sperm heads were observed to fuse: acrosome intact forms were generally in contact with the zona pellucida, either with the inner or outer surface. Acrosome-intact spermatozoa were also observed deeply embedded in the zona matrix, possibly indicating surface enzyme activity preceding the membrane fusion events of the acrosome reaction proper. The observations are consistent with the need for spermatozoa to make contact preferentially with the zona pellucida during the course of the acrosome reaction.

The optimization of laparoscopic oocyte recovery

Although there is an increasing trend to ultrasound-guided techniques of oocyte recovery, the laparoscopic method has had a traditional role which will continue to be applied in many circumstances. The optimization of oocyte recovery is dependent upon timing factors (inducing the surge at the appropriate stage of follicle maturation); the instrumentation (a dual-lumen needle which allows for continuous flushing is optimal); and improving the accessibility of the ovaries using preliminary pelvic adhesiolysis to create improved access.

The incidence and influence upon fertility of antisperm antibodies in seminal fluid following vasectomy reversal

Seminal plasma samples from men undergoing vasovasostomy were analysed for antisperm antibodies using the indirect immunobead test. A pre-operative assessment showed antisperm antibodies of either IgA or IgG class to be present in 9/27 (33.3%) men. A significant increase (P less than 0.05) in the post-operative incidence of the antibodies was seen in the men who achieved patency (27/45, 60%) but not in those men for whom no sperm were seen in the ejaculate (4/10, 40%). After follow-up for a minimum of 1 year, conception rates for couples in which the male partner had achieved patency were similar in the groups with no antibodies detected post-operatively (12/18, 66.7%) or with IgA alone (2/3, 66.7%), but was reduced significantly in the presence of IgG (1/9, 11.1%; P less than 0.05) or IgA + IgG (3/15, 20.0%; P less than 0.01).

The treatment of infertility by the high intrauterine insemination of husband's washed spermatozoa

A total of 345 couples with non-tubal infertility on an IVF waiting list underwent 702 treatment cycles involving daily intrauterine inseminations of husband's washed spermatozoa (AIH) over 3 days of the periovulatory period, following ovarian stimulation. Pregnancy rates achieved were dependent upon the underlying infertility disorder, with similar rates noted in those with a negative post-coital test (15.8%) or where antispermatozoal antibodies were present in either the male (18.5%) or female (17.1%) partner. These rates were significantly higher than for couples with poor cervical mucus (4.7%), asthenozoospermia (0%), endometriosis (mild, 7.7%; severe, 4.1%) or unexplained infertility (8.5%), while discrete oligozoospermia showed mid-range results (10.3%). Pregnancy outcome revealed a high level of early wastage (33.3%), mainly in the blighted ovum category, however congenital abnormalities (5.6%) were not significantly increased. It is concluded that the procedure of AIH should be considered for infertility due to poor sperm--mucus interaction, antispermatozoal antibodies and simple oligozoospermia, prior to IVF-related treatments.

Early pregnancy wastage after gamete manipulation

The outcome of 1034 pregnancies in women who conceived after referral for infertility management in seven treatment groups is detailed. The mean early pregnancy wastage (before 20 weeks gestation) was 27% and ranged from 18% after AID (artificial insemination by donor semen) to 33% after IVF-ET (in-vitro fertilization and embryo transfer). These differences were not due to maternal age which was similar in all groups (means between 29.7 and 32.7 years). Excluding the AID group, there was a high rate of ectopic pregnancy which was significantly higher after GIFT (gamete intrafallopian transfer) and was only partly related to underlying tubal disease. Blighted ova was the main category of early pregnancy loss and was highest after AIH (artificial insemination by husband's semen). There was a higher rate of biochemical pregnancies after GIFT, PROST (pronuclear stage tubal transfer) and IVF-ET. Our findings confirm a high pregnancy wastage rate in subfertile women and highlight deficiencies in the sperm separation, gamete handling and IVF/embryo culture techniques.

Medroxyprogesterone acetate therapy in early pregnancy has no apparent fetal effects

Medroxyprogesterone acetate (MPA; Provera) was given orally to 449 women from the 5th to 7th week of pregnancy until at least the 18th week. Data are recorded from two treatment groups (recurrent abortion and threatened abortion) and are compared to a matched series. A total of 1,016 pregnancies are included in the study, and all patients were recruited from a subfertile population conceiving from a range of infertility treatments. Early pregnancy wastage was high throughout the groups and was significantly elevated (43%; P less than .001) in those women who had vaginal bleeding in early pregnancy. The study focuses on the question of potential teratogenicity of progestagens administered in the first trimester. There were 15/366 (4.1%) infants with congenital abnormalities in the MPA-treated group and 15/428 in the untreated group (3.5%). The difference was not significant, and MPA is considered to have no embryopathic risk, nor is it likely to retain an abnormal fetus that might otherwise abort. It appears that MPA is a safe drug to use in pregnancy although the question of efficacy has not been addressed in this report. Considering other recent negative epidemiologic studies with regard to teratogenicity, we add to the conclusion that MPA cannot be demonstrated to have a measurable teratogenic risk and certainly does not present a risk for congenital heart disease and limb reduction defects.

Hormonal profiles and embryo quality in women with severe endometriosis treated by in vitro fertilization and embryo transfer

A study was undertaken comparing the outcomes of 30 women with infertility due to untreated severe (grade IV) pelvic endometriosis with a comparable series of 28 women whose infertility was caused solely by irreversible tubal disease. There were no significant differences in either the follicular phase or luteal phase hormonal profiles of estradiol and progesterone, but there was a significantly reduced pregnancy rate in those women with severe endometriosis. In part, this was due to the recovery of fewer oocytes from the endometriosis patients (P less than 0.001) despite the fact that the peak estradiol levels and ovarian accessibility were similar in the two groups. However, there were no significant differences in the proportion of oocytes that fertilized or the number that demonstrated normal embryo growth and high-grade embryo quality. There also appears to be an implantation inhibitory factor in patients with severe endometriosis as the pregnancy rate/embryo transferred and number of gestational sacs identified/embryo transferred were significantly reduced (P less than 0.05).

Preliminary results using pentoxifylline in a pronuclear stage tubal transfer (PROST) program for severe male factor infertility

In vitro trials with washed spermatozoa incubated in medium containing 1 mg/ml of the methyl xanthine phosphodiesterase inhibitor PF showed improved counts of total motile and total progressively motile spermatozoa in cases of oligospermia/asthenospermia. Application of this agent in a PROST program for a series of nine couples presenting for treatment with histories of failed fertilization in vitro resulted in five pregnancies (four singleton, one triplet) and the subsequent delivery of normal infants. The results warrant further evaluation of this sperm treatment for cases of severe male factor infertility.