Preimplantation genetic testing and child health: a national register-based study

STUDY QUESTION

Is preimplantation genetic testing (PGT) associated with adverse perinatal outcome and early childhood health?

SUMMARY ANSWER

Children born after PGT had comparable perinatal outcomes to children born after IVF/ICSI and comparable findings regarding early childhood health.

WHAT IS KNOWN ALREADY

PGT is offered to couples affected by monogenic disorders (PGT-M) or inherited chromosomal aberrations (PGT-SR), limiting the risk of transferring the disorder to the offspring. PGT, an invasive technique, requires genetic analysis of one or up to ten cells from the embryo and is combined with IVF or ICSI. Several studies, most of them small, have shown comparable results after PGT and IVF/ICSI concerning perinatal outcome. Only a few studies with limited samples have been published on PGT and childhood health.

STUDY DESIGN, SIZE, DURATION

We performed a register-based study including all singletons born after PGT (n = 390) in Sweden during 1 January 1996-30 September 2019. Singletons born after PGT were compared with all singletons born after IVF/ICSI (n = 61 060) born during the same period of time and with a matched sample of singletons (n = 42 034) born after spontaneous conception selected from the Medical Birth Register. Perinatal outcomes, early childhood health, and maternal outcomes were compared between pregnancies after PGT and IVF/ICSI as well as between pregnancies after PGT and spontaneous conception. Primary outcomes were preterm birth (PTB) and low birthweight (LBW) whereas childhood morbidity was the secondary outcome.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Data on women who went through PGT and gave birth were obtained from the local databases at the two PGT centres in Sweden, whereas data on IVF treatment for the IVF/ICSI group were obtained from the national IVF registers. These data were then cross-linked to national health registers; the Medical Birth Register, the Patient Register, and the Cause of Death Register. Logistic multivariable regression analysis and Cox proportional hazards models were performed with adjustment for relevant confounders.

MAIN RESULTS AND THE ROLE OF CHANCE

The mean follow-up time was 4.6 years for children born after PGT and 5.1 years for children born after spontaneous conception, whereas the mean follow-up time was 9.0 years for children born after IVF/ICSI. For perinatal outcomes, PTB occurred in 7.7% of children after PGT and in 7.3% of children after IVF/ICSI, whereas the rates were 4.9% and 5.2% for LBW (adjusted odds ratio (AOR) 1.22, 95% CI 0.82-1.81 and AOR 1.17, 95% CI 0.71-1.91, respectively). No differences were observed for birth defects. In comparison to spontaneous conception, children born after PGT had a higher risk for PTB (AOR 1.73, 95% CI 1.17-2.58). Regarding early childhood health, the absolute risk of asthma was 38/390 (9.7%) in children born after PGT and 6980/61 060 (11.4%) in children born after in IVF/ICSI, whereas the corresponding numbers were 34/390 (8.7%) and 7505/61 060 (12.3%) for allergic disorders. Following Cox proportional hazards models, no significant differences were found for these outcomes. Sepsis, hypothyroidism, attention deficit hyperactivity disorder, autism spectrum disorders, mental retardation, cerebral palsy, and epilepsy were diagnosed in a maximum of three PGT children. No PGT children died during the follow-up period. Regarding maternal outcomes, the rates of placenta praevia and caesarean delivery were significantly higher after PGT in comparison to spontaneous conception (AOR 6.46, 95% CI 3.38-12.37 and AOR 1.52, 95% CI 1.20-1.92, respectively), whereas no differences were seen comparing pregnancies after PGT and IVF/ICSI.

LIMITATIONS, REASONS FOR CAUTION

The rather small sample size of children born after PGT made it impossible to adjust for all relevant confounders including fertilization method and culture duration. Moreover, the follow-up time was short for most of the children especially in the PGT group, probably lowering the absolute number of diagnoses in early childhood.

WIDER IMPLICATIONS OF THE FINDINGS

The results are reassuring and indicate that the embryo biopsy itself has no adverse effect on the perinatal, early childhood, or maternal outcomes. Although the results are comparable to IVF/ICSI also regarding early childhood outcome, they should be taken with caution due to the low number of children with diagnoses and short follow-up time. Long-term follow-up studies on children born after PGT are scarce and should be conducted considering the invasiveness of the technique.

STUDY FUNDING/COMPETING INTEREST(S)

The study was financed by grants from the Swedish state under the agreement between the Swedish government and the county councils, the ALF-agreement (LUA/ALF 70940), the Board of National Specialised Medical Care at Sahlgrenska University Hospital and Hjalmar Svensson Research Foundation. There are no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Progesterone supplementation in natural cycles improves live birth rates after embryo transfer of frozen-thawed embryos-a randomized controlled trial

STUDY QUESTION

Does supplementation with vaginal tablets of progesterone after frozen-thawed embryo transfer in natural cycles improve the live birth rate?

SUMMARY ANSWER

Supplementation with vaginal tablets of progesterone after frozen-thawed embryo transfer in natural cycles significantly improves the number of live births.

WHAT IS KNOWN ALREADY

Progesterone supplementation during luteal phase and early pregnancy may improve the number of live births after frozen-thawed embryo transfer. However, due to the limited number of previous studies, being mainly retrospective, evidence is still limited.

STUDY DESIGN, SIZE, DURATION

This is a prospective randomized controlled trial, performed at two university clinics. In total, 500 subjects were randomized with a 1:1 allocation into two groups, during the period February 2013 to March 2018. Randomization was performed after a frozen embryo transfer in a natural cycle by use of opaque sealed envelopes. The primary outcome was live birth rate; secondary outcomes were pregnancy, biochemical pregnancy, clinical pregnancy and miscarriage rate, and if there was a possible association between the serum progesterone concentration on the day of embryo transfer and live birth rate.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women, receiving embryo transfer in natural cycles participated in the study. The embryos were frozen on Day 2, 3, 5 or 6. In total, 672 women having regular menstrual cycles were invited to participate in the study; of those, 500 agreed to participate and 488 were finally included in the study. Half of the study subjects received progesterone supplementation with progesterone vaginal tablets, 100 mg twice daily, starting from the day of embryo transfer. The other half of the subjects were not given any treatment. Blood samples for serum progesterone measurements were collected from all subjects on the day of embryo transfer.

MAIN RESULTS AND THE ROLE OF CHANCE

There were no differences in background characteristics between the study groups. In the progesterone supplemented group, 83 of 243 patients (34.2%) had a live birth, compared to 59 of 245 patients (24.1%) in the control group (odds ratio 1.635, 95% CI 1.102–2.428, P = 0.017*). The number of pregnancies was 104 of 243 (42.8%) and 83 of 245 (33.9%), respectively (odds ratio 1.465, 95% CI 1.012–2.108, P = 0.049*) and the number of clinical pregnancies was 91 of 243 (37.4%) and 70 of 245 (28.6%), respectively (odds ratio 1.497, 95% CI 1.024–2.188, P = 0.043*). There were no significant differences in biochemical pregnancy rate or miscarriage rate. There was no correlation between outcome and serum progesterone concentration.

LIMITATIONS, REASONS FOR CAUTION

The study was not blinded because placebo tablets were not available. Supplementation started on embryo transfer day, regardless of the age of the embryos, which resulted in a shorter supplementation time for Day 5/6 embryos compared to Day 2/3 embryos.

WIDER IMPLICATIONS OF THE FINDINGS

Supplementation with progesterone in natural cycles improved the number of live births after frozen-thawed embryo transfer and should therefore be considered for introduction in clinical routine.

STUDY FUNDING/COMPETING INTEREST(S)

The study was funded by Uppsala University, the Uppsala-Family Planning Foundation, and Ferring Pharmaceuticals AB, Malmö, Sweden. The authors have no personal conflicting interests to declare.

TRIAL REGISTRATION NUMBER

NL4152.

TRIAL REGISTRATION DATE

5 December 2013.

DATE OF FIRST PATIENT’S ENROLMENT

18 February 2013.

National survey of donor-conceived individuals who requested information about their sperm donor-experiences from 17 years of identity releases in Sweden

STUDY QUESTION

What characterizes the group of donor-conceived (DC) individuals who request information about their identity-release sperm donor in Sweden, and what are their experiences of disclosure, information receipt and donor contact?

SUMMARY ANSWER

Following three decades of identity-release donation in Sweden, few DC individuals have requested donor information with varying experiences of information receipt and donor contact.

WHAT IS KNOWN ALREADY

In 1985, Sweden was the first country worldwide to enact legislation that gave DC individuals the right to obtain identifying information about their donor. Since then, identity-release gamete donation has become available in many countries but there is limited knowledge about the individuals who request donor information.

STUDY DESIGN, SIZE, DURATION

A nation-wide cross-sectional survey study was performed at all seven University hospitals that provided donation treatment in Sweden during 1985-2002. During this period only donor insemination to heterosexual couples was permitted. Inclusion criteria were being 18 years of age or older, conceived with donor sperm and having requested information about the donor by December 2020. Recruitment was performed during 2016-2020.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 60 individuals had requested information about their donor. Of these, 53 were approached and 40 individuals, representing 34 families, accepted study participation (75% response rate). Participants completed a postal survey with the WHO-10 well-being index and study-specific questions about experiences of disclosure, motivations for requesting donor information, receipt of information, as well as intentions and experiences of donor contact. Independent t-test and chi-square tests were used to compare ratings of participants with early and late disclosure.

MAIN RESULTS AND ROLE OF CHANCE

Of ∼900 DC individuals who had reached adult age, a total of 60 (≈7%) had requested information about the donor. Most of the 40 study participants (78%) made their requests within 2 years after reaching 18 years of age, or following disclosure at later ages (up to 32 years). Several participants had adult DC siblings in the family who had not requested any donor information. All except five participants received identifying information about the donor from the clinic. However, some donors had died or lacked contact information. Among those participants who were able to contact their donor, 41% had done so at the time of the study, while a third of the participants were unsure about potential contact. Several had met the donor in person and a few were in regular contact. About half of the participants had been informed about their donor conception in adolescence or adulthood (age 12-32), and there were significant differences between participants based on age at disclosure. Compared to those with early disclosure, participants with late disclosure were significantly more likely to be dissatisfied with the timing of their disclosure (P = 0.021), to react with negative emotions (P < 0.001), and to subsequently contact the donor (P = 0.047).

LIMITATIONS, REASONS FOR CAUTION

The limited population available for inclusion resulted in a small sample size, despite a high response rate. In addition, men's lower participation rate must be taken into consideration when interpreting the results.

WIDER IMPLICATIONS OF THE FINDINGS

The small number of individuals requesting information about their identity-release sperm donor is surprising. While not all DC individuals appear to be interested in donor information, it is reasonable to assume that some are unaware of their donor conception and thus unable to make informed decisions regarding their genetic origins. During the coming years, young women and men in many countries will become eligible to access identifying information about their donor. In order to meet the needs of these individuals, and to support positive outcomes for all involved parties, it is essential that adequate protocols and resources are developed.

STUDY FUNDING/COMPETING INTEREST

Financial support from The Swedish Research Council. There are no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Physical and Sedentary Activities in Association with Reproductive Outcomes among Couples Seeking Infertility Treatment: A Prospective Cohort Study

BACKGROUND

The aim of this study was to investigate the association of physical activity (PA) with assisted reproductive technology (ART) treatment and pregnancy outcomes among couples seeking infertility treatment.

METHODS

This prospective cohort study was carried out among 128 infertile individuals (64 couples), entering the infertility clinic for ART procedures. Baseline PA (before entering any treatment) was assessed using accelerometry for both women and men. For every couple the infertility treatment outcomes were recorded.

RESULTS

The couples that required invasive ART procedures such as in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) spent less time in vigorous PA (-73 min/week per couple, woman + man) than those couples who became spontaneously pregnant after entering the study (p = 0.001). We observed no significant associations between the time spent in physical activities and positive pregnancy test or live birth.

CONCLUSIONS

Our results do not support a positive nor negative relation between the time the couples spent in physical activities and the chances of getting pregnant or having a baby among patients seeking infertility treatment. However, couples undergoing invasive ART procedures did less vigorous PA than couples that became spontaneously pregnant, suggesting that PA may interfere with their reproductive health.

A prospective study of women and girls undergoing fertility preservation due to oncologic and non-oncologic indications in Sweden-Trends in patients' choices and benefit of the chosen methods after long-term follow up

INTRODUCTION

In Scandinavian countries, programs for fertility preservation are offered free of charge at tertiary-care university hospitals to all patients facing treatments with risk of subsequent sterility. In this prospective study we aimed to investigate trends in female patients' choices after counseling and fertility preservation outcomes during follow up in relation to benign vs malignant indications.

MATERIAL AND METHODS

Data on 1254 females including 1076 adults and 178 girls who received fertility preservation counseling for either oncologic (n = 852) or benign indications (n = 402) at Karolinska University Hospital, Stockholm, between 1 October 1998 and 1 December 2018 were analyzed. As appropriate, t tests and chi-square tests were used to compare groups. Logistic regression was used to compare outcomes among groups depending on indications.

RESULTS

Adult women generally elected to undergo oocyte retrieval after controlled ovarian stimulation for cryopreservation of embryos or oocytes (n = 538, 73%), whereas a minor proportion opted for cryopreservation of ovarian tissue retrieved through laparoscopy (n = 221, 27%). More than half of the women with a partner chose either not to fertilize their oocytes aiming at cryopreservation of oocytes or to share obtained oocytes attempting both cryopreservation of oocytes and cryopreservation of embryos. All pre-pubertal (n = 48) and 73% of post-pubertal girls (n = 66) elected cryopreservation of ovarian tissue. In recent years, an increasing number of teenagers have opted for controlled ovarian stimulation aiming at cryopreservation of oocytes, either before (n = 24, 17%) or after completion of cancer treatment (n = 15, 10%). During follow up, 27% of the women returned for a new reproductive counseling, additional fertility preservation or to attempt pregnancy. Utilization rates among individuals who were alive and of childbearing age by December 2018 indicated 29%, 8% and 5% for embryos, oocytes and ovarian tissue with live birth rates of 54%, 46% and 7%, respectively. Women with benign indications were significantly younger than women with previous malignant indications at the time of attempting pregnancy. Although the pregnancy rates were similar among both groups, the live birth rate was significantly higher in women with benign vs previous malignant indications (47% vs 21%, P = .002).

CONCLUSIONS

Trends in fertility preservation choices have changed over time. Women with previous malignancy had lower live birth rates than women with benign fertility preservation indications.

Attitudes toward surrogacy among doctors working in reproductive medicine and obstetric care in Sweden

INTRODUCTION

The aim of this study was to investigate attitudes and opinions towards surrogacy among physicians working within obstetrics and reproductive medicine in Sweden.

MATERIAL AND METHODS

Physicians working within medically assisted reproduction (MAR), antenatal care and obstetrics were invited to participate in a cross-sectional nationwide survey study. The study-specific questionnaire measured attitudes and experiences in three domains: attitudes towards surrogacy, assessment of prospective surrogate mothers, and antenatal and obstetric care for surrogate mothers.

RESULTS

Of the 103 physicians who participated (response rate 74%), 63% were positive or neutral towards altruistic surrogacy being introduced in Sweden. However, only 28% thought that it should be publicly financed. Physicians working at fertility clinics were more positive towards legalization as well as public financing of surrogacy compared than were those working within antenatal and delivery care. The majority of the physicians agreed that surrogacy involves the risk of exploitation of women's bodies (60%) and that there is a risk that the commissioning couple might pay the surrogate mother "under the table" (82%). They also expressed concerns about potential surrogate mothers not being able to understand fully the risks of entering pregnancy on behalf of someone else.

CONCLUSION

There is a relatively strong support among physicians working within obstetrics and reproductive medicine for the introduction of surrogacy in Sweden. However, the physicians expressed concerns about the surrogate mothers' health as well as the risk of coercion. Further discussions about legalization of surrogacy should include views from individuals within a wide field of different medical professions and laymen.

Survey shows that Swedish healthcare professionals have a positive attitude towards surrogacy but the health of the child is a concern

AIM

In February 2016, Sweden upheld its ban on surrogacy following a Government enquiry. This survey investigated attitudes towards surrogacy among primary health professionals working with children and their experiences of working with families following surrogacy abroad.

METHODS

From April to November 2016, nurses, physicians and psychologist working in primary child health care in four counties in Sweden were invited to participate in a cross-sectional online survey about surrogacy.

RESULTS

The mean age of the 208 participants was 49.2 years (range 27-68) and nearly 91% were women. Approximately 60% supported legalised surrogacy. Wanting a conscience clause to be introduced in Sweden was associated with not supporting surrogacy for any groups, while personal experiences of infertility and clinical experiences with families following surrogacy were associated with positive attitudes towards surrogacy for heterosexual couples. The majority (64%) disagreed that surrogate children were as healthy as other children, and many believed that they risked worse mental health (21%) and social stigmatisation (21%).

CONCLUSION

We found that 60% supported legalised surrogacy, but many expressed concerns about the children's health and greater knowledge about the medical and psychosocial consequences of surrogacy is needed.

Compliance to the recommended use of folic acid supplements for women in Sweden is higher among those under treatment for infertility than among fertile controls and is also related to socioeconomic status and lifestyle

Background: Folate has been discussed in relation to fertility among women, but studies on women under treatment for infertility are lacking.

Objective: The objective of this study was to investigate folic acid supplement use and folate status among women under treatment for infertility (hereafter infertile) and fertile women also in regard to socioeconomic and lifestyle factors.

Design: Lifestyle and dietary habits, and use of dietary supplements were assessed using a questionnaire. Blood samples were obtained for analysis of folate status. 24-hour recall interviews were also performed.

Results: Highly educated, employed and infertile women were most prone to using folic acid supplements. The infertile women had a significantly better folate status than the fertile women. Folate status did not correlate with socioeconomic or lifestyle factors. The infertile women were physically more active, smoked less and were employed. Our questionnaire data had only fair agreement with the data from 24-hour recalls, but the folate status data was clearly correlated to our questionnaire results.

Conclusions: Infertile women were most prone to using folic acid supplements and had better folate status than the controls. High educational and employment status were found to be key factors for high compliance to the recommended use folic acid supplements.

Do subfertile women adjust their habits when trying to conceive?

AIM

The aim of this study was to investigate lifestyle habits and lifestyle adjustments among subfertile women trying to conceive.

MATERIALS AND METHODS

Women (n = 747) were recruited consecutively at their first visit to fertility clinics in mid-Sweden. Participants completed a questionnaire. Data were analyzed using logistic regression, t tests, and chi-square tests.

RESULTS

The response rate was 62% (n = 466). Mean duration of infertility was 1.9 years. During this time 13.2% used tobacco daily, 13.6% drank more than three cups of coffee per day, and 11.6% consumed more than two glasses of alcohol weekly. In this sample, 23.9% of the women were overweight (body mass index, BMI 25-29.9 kg/m(2)), and 12.5% were obese (BMI ≥30 kg/m(2)). Obese women exercised more and changed to healthy diets more frequently than normal-weight women (odds ratio 7.43; 95% confidence interval 3.7-14.9). Six out of ten women (n = 266) took folic acid when they started trying to conceive, but 11% stopped taking folic acid after some time. Taking folic acid was associated with a higher level of education (p < 0.001).

CONCLUSIONS

Among subfertile women, one-third were overweight or obese, and some had other lifestyle factors with known adverse effects on fertility such as use of tobacco. Overweight and obese women adjusted their habits but did not reduce their body mass index. Women of fertile age would benefit from preconception counseling, and the treatment of infertility should routinely offer interventions for lifestyle changes.

Physical activity, fatness, educational level and snuff consumption as determinants of semen quality: findings of the ActiART study

In this study, the association between physical activity and other potential determinants, objectively measured by accelerometry, was examined. Sixty-two men attending an infertility clinic participated in the study. Obese men (body mass index ≥ 30) and those with a waist circumference 102 cm or more had lower semen volume than the other men (P < 0.05). Higher values in sperm parameters were observed in participants who completed university studies and those who did not consume snuff, compared with the other participants (P < 0.05). Finally, men who spent an average number of 10 min-bouts of moderate-to-vigorous physical activity had significantly better semen quality than those who engaged in low or high numbers of bouts of activity (P < 0.05). No associations were found for sedentary or moderate-to-vigorous physical activity time when it was not sustained over 10 min, i.e. not in bouts. Men who have average levels of physical activity over sustained periods of 10 min are likely to have better semen quality than men who engage in low or high levels of such activity. Similarly, high levels of total and central adiposity, low educational level and snuff consumption are negatively related to semen quality.

Folic acid supplementation and methylenetetrahydrofolate reductase (MTHFR) gene variations in relation to in vitro fertilization pregnancy outcome

OBJECTIVE

To study folic acid intake, folate status and pregnancy outcome after infertility treatment in women with different infertility diagnoses in relation to methylenetetrahydrofolate reductase (MTHFR) 677C>T, 1298A>C and 1793G>A polymorphisms. Also the use of folic acid supplements, folate status and the frequency of different gene variations were studied in women undergoing infertility treatment and fertile women.

DESIGN

Observational study.

SETTING

University hospital.

POPULATION

Women undergoing infertility treatment and healthy, fertile, non-pregnant women.

METHODS

A questionnaire was used to assess general background data and use of dietary supplements. Blood samples were taken to determine plasma folate and homocysteine levels, and for genomic DNA extraction. A comparison of four studies was performed to assess pregnancy outcome in relation to MTHFR 677 TT vs. CC, and 1298 CC vs. AA polymorphisms.

MAIN OUTCOME MEASURES

Folic acid supplement intake, and plasma folate, homocysteine and genomic assays.

RESULTS

Women in the infertility group used significantly more folic acid supplements and had better folate status than fertile women, but pregnancy outcome after fertility treatment was not dependent on folic acid intake, folate status or MTHFR gene variations.

CONCLUSION

High folic acid intakes and MTHFR gene variations seem not to be associated with helping women to achieve pregnancy during or after fertility treatment.

Attitudes toward embryo donation among staff at in vitro fertilization clinics

OBJECTIVE

To examine attitudes towards embryo donation among staff at in vitro fertilization clinics in Sweden.

DESIGN

Descriptive questionnaire study.

SETTING

University-based in vitro fertilization clinic.

SAMPLE

Study participants were the staff at all in vitro fertilization clinics in Sweden.

METHODS

A questionnaire with questions regarding different aspects of embryo donation was sent to the 338 healthcare professionals working at Swedish in vitro fertilization clinics.

MAIN OUTCOME MEASURES

Attitudes towards embryo donation.

RESULTS

A total of 207 persons (61%) responded to the questionnaire. A majority of the respondents (77%) considered that embryo donation to infertile couples should be permitted in Sweden. Most respondents (76%), and especially the men (96%), stated that it should be possible to donate surplus embryos for research. Forty-two percent of the respondents agreed with embryo donation to single women. A majority of respondents stated that special requirements with regard to the recipient's age, medical condition and criminal background should potentially be considered. The women stated that there should be special demands made concerning recipients' tobacco (48%) and alcohol abuse (92%). A majority considered that donors should be anonymous to the recipients (66%), but not to the child (9%).

CONCLUSIONS

Swedish in vitro fertilization staff have positive attitudes concerning embryo donation to infertile couples and also the use of surplus embryos for research.

Folic acid supplementation and IVF pregnancy outcome in women with unexplained infertility

Folic acid supplements are commonly used by infertile women which leads to a positive folate status. However, the effect of folic acid supplements on pregnancy outcome in women with unexplained infertility has not been well investigated. This study evaluated folic acid supplement use and folate status in women with unexplained infertility in relation to IVF pregnancy outcome. In addition, use of folic acid supplements and folate status were compared between women with unexplained infertility and fertile, nonpregnant control women. Women with unexplained infertility used significantly more folic acid supplements and had higher median total folic acid intake from supplements compared with fertile control women (both P < 0.001). Women with unexplained infertility also had significantly higher median plasma folate and lower median plasma homocysteine concentrations than fertile women (both P < 0.001), but folic acid supplementation or folate status were not related to pregnancy outcome in women with unexplained infertility. In conclusion, folic acid supplementation or good folate status did not have a positive effect on pregnancy outcome following infertility treatment in women with unexplained infertility. Folate is one of the B vitamins which has been suggested to be related to infertility. Folic acid is an artificial form of folate which is commonly used in dietary supplements. Folic acid supplementation has been shown to increase folate concentrations and decrease concentrations of the amino acid homocysteine in the blood. Folic acid supplementation is commonly used by infertile women, but the effect on pregnancy outcome in women with a diagnosis of unexplained infertility has not been thoroughly investigated. In the present study, folic acid supplement use and folate status (concentrations of folate and homocysteine) in women with unexplained infertility were evaluated in relation to pregnancy outcome. In addition, the use of folic acid supplements and folate status were compared between women with unexplained infertility and fertile control women. Our results showed that women with unexplained infertility used considerably more folic acid supplements and had higher total folic acid intake from supplements compared with fertile control women. Women with unexplained infertility had better blood folate and homocysteine concentrations than fertile women, but folic acid supplementation or folate status were not related to pregnancy outcome following the infertility treatment. In conclusion, high folic acid intake or good folate status did not increase the possibility of a birth of a healthy baby after infertility treatment in women with unexplained infertility.

Attitudes towards embryo donation in Swedish women and men of reproductive age

BACKGROUND

When performing in-vitro fertilization (IVF), more embryos than needed are often derived. These embryos are usually frozen and stored, but as ruled by Swedish law they have to be discarded after 5 years. In other countries it is legal to donate the excess embryos to other infertile couples who for different reasons cannot undergo the procedure of IVF. The aim of the present study was to investigate public opinion in Sweden regarding different aspects of embryo donation.

METHODS

A questionnaire regarding attitudes towards aspects of embryo donation was sent to a randomized sample of 1,000 Swedish women and men of reproductive age.

RESULTS

A total of 34% responded to the questionnaires. A majority of the respondents (73%) were positive towards embryo donation. Seventy-five per cent agreed that it should be possible to donate embryos to infertile couples. Approximately half of the participants (49%) supported embryo donation to single women. A majority of the participants emphasized that demands should be imposed on the recipient's age (63%), alcohol addiction (79%), drug addiction (85%), and criminal record (67%). Forty-seven per cent of the respondents agreed that the recipient should be anonymous to the donor, and 38% thought that the donor should remain anonymous to the child.

CONCLUSIONS

The results of the present study indicate support for embryo donation among a subset of the Swedish population of reproductive age. If embryo donation were to be allowed in Sweden, strategies for treatment and counselling need to be developed.

Glycoprotein 130 promotes human blastocyst development in vitro

OBJECTIVE

To investigate the efficacy of leukemia inhibitory factor (LIF) and/or glycoprotein 130 (gp130) on in vitro growth of human embryos.

DESIGN

Laboratory study.

SETTING

University hospital-based IVF clinic.

PATIENT(S)

A total of 164 frozen embryos that survived thawing were cultured in media supplemented with LIF and/or gp130 or control media.

INTERVENTION(S)

Morphological development was evaluated by light microscopy. Protein expression profiles of single blastocysts were evaluated using matrix-assisted laser desorption/ionization time of flight-based intact cell mass spectrometry.

MAIN OUTCOME MEASURE(S)

Embryo development and protein content.

RESULT(S)

Addition of gp130 to culture media improved blastocyst formation (73% vs. 43%). Addition of LIF to the culture media did not improve embryo development. Protein fingerprint spectra were obtained that revealed significant intensity changes for multiple molecular species including thymosin beta-10, thymosin beta-4, histone H2A, histone H2B, histone H4, ubiquitin, ubiquitin-T, and acyl-CoA binding protein.

CONCLUSION(S)

Glycoprotein 130, but not LIF, seems to be beneficial for preimplantation embryo development, implicating a physiological role in regulating preimplantation development in humans and thus ought to be included in culture media designed for embryo culture to the blastocyst stage. Furthermore, these findings highlight the great potential of matrix-assisted laser desorption/ionization time of flight mass spectrometry and intact cell mass spectrometry as a versatile tool in reproductive medicine research.

N-glycans of human protein C inhibitor: tissue-specific expression and function

Protein C inhibitor (PCI) is a serpin type of serine protease inhibitor that is found in many tissues and fluids in human, including blood plasma, seminal plasma and urine. This inhibitor displays an unusually broad protease specificity compared with other serpins. Previous studies have shown that the N-glycan(s) and the NH₂-terminus affect some blood-related functions of PCI. In this study, we have for the first time determined the N-glycan profile of seminal plasma PCI, by mass spectrometry. The N-glycan structures differed markedly compared with those of both blood-derived and urinary PCI, providing evidence that the N-glycans of PCI are expressed in a tissue-specific manner. The most abundant structure (m/z 2592.9) had a composition of Fuc₃Hex₅HexNAc₄, consistent with a core fucosylated bi-antennary glycan with terminal Lewis^x. A major serine protease in semen, prostate specific antigen (PSA), was used to evaluate the effects of N-glycans and the NH₂-terminus on a PCI function related to the reproductive tract. Second-order rate constants for PSA inhibition by PCI were 4.3±0.2 and 4.1±0.5 M⁻¹s⁻¹ for the natural full-length PCI and a form lacking six amino acids at the NH₂-terminus, respectively, whereas these constants were 4.8±0.1 and 29±7 M⁻¹s⁻¹ for the corresponding PNGase F-treated forms. The 7–8-fold higher rate constants obtained when both the N-glycans and the NH₂-terminus had been removed suggest that these structures jointly affect the rate of PSA inhibition, presumably by together hindering conformational changes of PCI required to bind to the catalytic pocket of PSA.

Teaching pelvic examination technique using professional patients: a controlled study evaluating students' skills

OBJECTIVE

To compare the skills in pelvic examination technique between students who have had training with professional patients and a control group of students trained using clinical patients.

DESIGN

Prospective controlled study.

SETTING

University hospital.

POPULATION

Students attending three consecutive courses in obstetrics and gynecology at Karolinska University Hospital.

METHODS

A study group of 53 students received training in pelvic examination with professional patients and was compared with a control group of 34 students who were trained using clinical patients.

MAIN OUTCOME MEASURES

The students' skills in pelvic examination technique were examined by teachers in a practical test. Students' skills were also evaluated by the students themselves and by the patients who participated in the examination.

RESULTS

Students who had training with professional patients were more skilled in performing a pelvic examination and better prepared to examine their own patients than students trained using clinical patients.

CONCLUSIONS

Training with professional patients is more effective in teaching pelvic examination technique than training with clinical patients. We recommend that the use of professional patients is considered in the training of medical students.

Regulation of muscular contractions in the human Fallopian tube through prostaglandins and progestagens

BACKGROUND

Transport of gametes and embryos is an important function of the Fallopian tube. Both muscular contractions and cilia activity are involved in the transportation. Prostaglandins (PGs) are known mediators of muscular contractility. PG receptors have previously been demonstrated in the human Fallopian tube. The aim was to study the effect of PGs and progestagens, antiprogestin, hCG and oxytocin on muscular contractions in the human Fallopian tube, and the hormonal regulation of PG receptors.

METHODS

Twenty-two healthy women operated for benign causes were included in the study. The ampullary-isthmic junction of the Fallopian tubes was excised and used for in vitro contractility studies. The effect of PGE(1), PGE(2), PGF(2alpha), progesterone, mifepristone, levonorgestrel, oxytocin and hCG on contractility was studied. Explants of Fallopian tubes were cultured for 24 h to study the effect of progestagens and hCG on the expression of PG receptors using immunohistochemistry and real-time PCR.

RESULTS

Muscular contractions increased after treatment with PGF(2alpha) and PGE(2) (P < 0.05). The contractions decreased after PGE(1), progesterone, levonorgestrel, mifepristone, oxytocin and hCG (P < 0.05). In tubal explant studies, relative mRNA expression of EP1, EP2, EP3 and FP increased after levonorgestrel treatment (P < 0.05). Mifepristone and levonorgestrel treatment increased immunostaining intensity of EP1 and EP2 protein, in lumen, muscle and vessels. Progesterone and mifepristone increased immunostaining of FP in vessels.

CONCLUSIONS

These data suggest that the transport of gametes and embryos involves the action of PGs, progesterone, oxytocin and hCG on muscular contractility.

Leukaemia inhibitory factor receptor and gp130 in the human Fallopian tube and endometrium before and after mifepristone treatment and in the human preimplantation embryo

Leukaemia inhibitory factor (LIF) is a cytokine, which is associated with reproductive processes such as embryo development and implantation. The objectives of this study were to detect the presence of LIF receptor (LIFR) and glycoprotein 130 (gp 130) in the human Fallopian tube, endometrium and preimplantation embryo and to study the effect of mifepristone on the expression of LIFR and gp130 in the Fallopian tube. Twenty-two healthy fertile women received a single dose of 200 mg mifepristone or placebo immediately after ovulation (LH + 2). Biopsies were obtained from the Fallopian tubes during laparoscopic sterilization once between days LH + 4 and LH + 6 and from endometrium once between days LH + 6 and LH + 8. Preimplantation embryos were received from couples undergoing in vitro fertilization treatment. Immunohistochemistry was used to detect the presence of LIFR and gp130 in the Fallopian tube, endometrium and preimplantation embryo. Real-time PCR was used to study LIFR and gp130 expression in the Fallopian tube and endometrium. LIFR and gp130 were localized in the Fallopian tube, preimplantation embryo and endometrium. LIFR was more abundant in the Fallopian tube than in the endometrium. In the blastocyst, the staining of gp130 was mainly localized in the inner cell mass, whereas LIFR was expressed in all cells. The presence of LIFR and gp130 in the Fallopian tube and preimplantation embryo indicates a role for LIF in communication between the embryo and the Fallopian tube. Mifepristone did not affect the expression of LIFR and gp130 in the Fallopian tube, nor in the endometrium suggesting that progesterone might not be directly involved in the regulation of LIFR or gp130.

Prostaglandin E2 and F2alpha receptors in the human Fallopian tube before and after mifepristone treatment

Prostaglandins are associated with several reproductive processes in addition to their effects on the vascular system and muscular contractility. The aim of this study was to gain information about the localization of the receptors for PGE(2) (EP1-EP4) and PGF(2alpha) (FP) in the human Fallopian tube and their regulation following treatment with mifepristone. Sixteen healthy fertile women received a single dose of 200 mg mifepristone or placebo immediately after ovulation (LH+2). Laparoscopic sterilization was performed on days LH+4 to LH+6. Biopsies were taken from the Fallopian tubes bilaterally. The expression of EP1, EP2, EP3, EP4 and FP was analysed using immunohistochemistry and RT-PCR. The co-localization of prostaglandin receptors and c-kit or e-nos was analysed using confocal microscopy. The effect of progesterone, mifepristone and prostaglandin on tubal contractility was studied. The presence of EP1-EP4 and FP in the Fallopian tube was detected using immunostaining. The receptors were expressed in serosal cells, luminal epithelial cells, and the muscular wall and vessels of the Fallopian tube. Co-localization studies showed that the endothelial cells stained positive for EP1-EP4 and FP and that co-localization was seen for EP4 and c-kit. Decreased contractility was seen after progesterone treatment, whereas increased contractility was seen after PGF(2alpha) and PGE(2) treatment. These data suggest that both the transport of the embryo and the communication between the embryo and the Fallopian tube involve the action of prostaglandins through EP and FP receptors in addition to the effect of prostaglandins on the vascular system and muscular contractility.

Detection of Tc-99m labelled albumin particles in the Fallopian tubes after intraperitoneal deposition

OBJECTIVE

To study the Fallopian tube uptake of intra-abdominal albumin particles.

STUDY DESIGN

Six healthy women volunteered for ultrasound guided deposition of Tc-99m labelled albumin particles into the pouch of Douglas, before undergoing sterilisation by salpingectomy.

RESULTS

On gamma camera images radioactivity spread evenly over the parietal peritoneum. Autoradiography of the Fallopian tubes showed radioactive "hot spots" on the inner tubal surface. A rapid increase in blood radioactivity stabilised after 2-3 h while radioactivity remained high in the peritoneal cavity. Cervical mucus showed a significant radioactivity.

CONCLUSION

Autoradiography strongly indicated that Tc-99m labelled particles deposited into the pouch of Douglas were transported to the Fallopian tubes. The small uptake of radioactivity identified in blood was most likely due to a rapid diffusion of free Tc-99m pertechnetate from the peritoneal cavity. The radioactivity identified in cervical mucus could be pertechnetate or labelled albumin particles or a combination of both. Future development of the present technique may be used for fertility investigation.

Teaching medical students gynaecological examination using professional patients-evaluation of students' skills and feelings

Gynaecological examinations are especially sensitive, both for the inexperienced student and for the woman being examined. To assist the students in this process, we have introduced a separate training session for medical students using so-called professional patients during the first week of the course in obstetrics and gynaecology. The aim of the study was to evaluate the outcome, attitudes and feelings towards this type of training and to gain knowledge on how to further develop the method. After the training session, students, teachers and professional patients were asked to fill in anonymously different questionnaires assessing their views on the education. In conclusion students, teachers and professional patients found this training programme with professional patients to be of great value. It was felt that the teaching session reduced stress and anxiety; the students were relieved, calmer and more secure after the training. It is strongly recommended that this type of programme with professional patients should be used for teaching gynaecological examination techniques to medical students.

Severe jaundice in early IVF pregnancy

Jaundice in early pregnancy after in vitro fertilization (IVF) is extremely rare. We report a case of severe jaundice in an IVF treated patient, with a clinical picture similar to intrahepatic cholestasis of pregnancy (ICP). We suggest strategies to prevent similar cases in the future.

Radioactivity in cervical mucus after intraperitoneal deposition of Tc-99m labelled albumin particles before and after sterilisation

OBJECTIVE

To study the transport of radiolabelled albumin particles from the pouch of Douglas to cervical mucus.

STUDY DESIGN

A prospective randomised study, including 10 healthy women, undergoing laparoscopic sterilization. A solution of human serum albumin particles, labelled with Technetium 99(m) (Tc-99(m)) was injected into the pouch of Douglas, either before or after sterilisation.

RESULTS

Gamma camera images showed gradual spread to the entire peritoneal cavity. Blood samples, showed increasing levels of radioactivity. Measurement of radioactivity in cervical mucus showed significant activity both in women sterilized before and after the deposition.

CONCLUSION

The study showed evidence of transport of radioactivity from the pouch of Douglas to cervical mucus. The transport seemed to consist of free activity since no radionuclide labelled particles could be detected in cervical mucus. The transport was probably haematogenous or lymphatic and not intraluminal through the fallopian tube. Further studies utilizing particles comparable in size to fertilized ova are required to design methods for evaluating the transport from the fallopian tube to the uterine cavity.

Diagnostic evaluation of intrauterine fetal deaths in Stockholm 1998-99

BACKGROUND

To evaluate the diagnostic methods and to elucidate the etiology of intrauterine fetal death.

MATERIAL AND METHODS

A prospective study was conducted on all intrauterine fetal deaths occurring in Stockholm County in 1998-99. During a 24-month period, 188 cases of intrauterine fetal death with gestational ages of > or = 22 weeks were investigated in accordance with structured test protocol. All information from antenatal and delivery records as well as all test results were entered in to an Internet-based database for continuous evaluation.

RESULTS

A presumptive explanation to the stillbirth was established in 91% of the cases. The most common factors associated with intrauterine fetal death could be identified as infections (24%), placental insufficiency/intrauterine growth restriction (22%), placental abruption (19%), intercurrent maternal conditions (12%), congenital malformations (10%), and umbilical cord complications (9%).

CONCLUSIONS

A relevant test protocol in cases of intrauterine fetal death reduces the number of unexplained cases to a minimum. An Internet-based register on test results of fetal deaths may enable a continuous evaluation of the diagnostic tools and etiologic factors in an ever-changing panorama. The results from the present study can serve as a base for a case-control study in Sweden.