Compensating human subjects providing oocytes for stem cell research: 9-year experience and outcomes

PURPOSE

Human oocytes are arguably one of the most important cell types in humans, yet they are one of the least investigated cells. Because oocytes are limited in number, the use of high-quality oocytes is almost entirely in reproduction. Furthermore, regulatory hurdles for research on gametes and regulations on funding related to research on gametes present significant obstacles to research and the advancement of reproductive treatments. Here we report the outcomes of the largest compensated oocyte donation program for research in the USA to date, and probably worldwide.

METHODS

Women who participated in oocyte donation for research between 2008 and 2017 were contacted in a phone interview and completed a standardized questionnaire.

RESULTS

Of 114 participants, 98 oocyte donors completed donation, donating 1787 mature MII oocytes and a total of 86 skin biopsies. Complication rate, including minor complications, of oocyte donation was 8/98, or 8.1%, for which two involved follow-up. Fifty-seven donors answered questions about their experience. Participants were incentivized primarily by money and a desire to help others and reported an overall favorable experience. Most, but not all, human subjects recalled that they had donated for research, and approximately half recalled that their oocytes were being used specifically for stem cell research.

CONCLUSIONS

Compensated oocyte donation provides a reliable path to obtaining high-quality oocytes for research and is reviewed favorably by oocyte donors. The continuation of programs that offer compensation for oocyte donation is invaluable to continued progress and advancements in stem cell research and human embryology, and for the advancement of novel reproductive treatments.

Providing assisted reproductive care to male haemophiliacs infected with human immunodeficiency virus: preliminary experience

Outlined is our experience with couples in whom the male was both human immunodeficiency virus (HIV) seropositive and a haemophiliac who underwent assisted reproductive technologies (ART) in order to attain family goals while minimizing the risk of HIV transmission. We report their demographics, attitudes towards assisted reproduction, and ART performance and outcomes. The study included HIV serodiscordant couples (n = 11) who underwent ART at a university-based infertility practice from August 1997 to May 2002. Prior to treatment, couples prospectively completed a survey regarding their demographics and attitudes towards assisted reproduction. All couples underwent ART and pregnancy outcomes were analysed. The majority of the patients were fully employed, college-educated, in good health, married and motivated to have a child while minimizing the risk of HIV transmission. Eleven couples underwent 25 cycles of ART [19 in vitro fertilization (IVF) cycles; five frozen embryo transfer cycles; and one oocyte donation cycle] resulting in nine successful pregnancies. The ongoing/delivered pregnancy rate per initiated IVF cycle was 42.1% per embryo transfer. Eight of 11 (72.7%) couples achieved a successful pregnancy. More than half (six of 11; 54.5%) the couples conceived during their initial attempt. Four of nine (44.4%) pregnancies were multiple gestations, including three sets of triplets. All female recipients tested seronegative for HIV at 3 and 6 months post-embryo transfer. All delivered babies (n = 8) tested seronegative for HIV at birth and 3 months postpartum. Four pregnancies are currently ongoing. ART should be considered for HIV serodiscordant couples with haemophilia who desire to have children in order to minimize the risk of viral infection.

Understanding the effects of age on female fertility

This review focuses on age-related changes occurring in the female reproductive system and their effect on reproductive material. Aging significantly impact the female reproductive system but, despite this fact, there is nowadays a trend to postpone pregnancy to pursue educational and vocational goals. Therefore a remarkable effort is now being made by the medical establishment to understand the effects of aging in women. The assessment and treatment of this decline in fertility is discussed, as well as assisted reproductive techniques and new therapeutic options.

Development and characterization of a long-acting recombinant hFSH agonist

BACKGROUND

Fusion of the carboxyterminal peptide (CTP) of hCG to FSH results in a follitropin agonist with an extended half-life, presumably due to the four O-oligosaccharides on the CTP. Alternatively, an rhFSH analogue containing additional N-linked carbohydrate is described in this report.

METHODS

A DNA sequence containing two N-oligosaccharide signal sequences was ligated into a vector containing hFSHbeta- and alpha-subunit encoding cDNA, and expressed in CHO-K1 cells. In-vitro bioactivity of the single-chain hormone was assessed in CHO cells expressing the hFSH receptor. Pharmacokinetic values were derived from serial serum assays of the analogue in immature female rats following a single i.v. injection. In-vivo bioactivity was assessed by measuring ovarian weight gain 3 days post-injection.

RESULTS

rhFSH-N2 and native rhFSH induced comparable levels of cAMP in vitro. t(1/2) for native rhFSH, rhFSH-CTP and rhFSH-N2 were 3.7, 7.1 and 7.3 h respectively. Rats receiving rhFSH-N2 had a mean +/- SD ovarian weight 3 days post-i.v. injection (22 +/- 3.6 mg) significantly greater than rats receiving rhFSH and saline (16.7 +/- 1.5 and 15.3 +/- 0.47 mg respectively, P < 0.05).

CONCLUSIONS

rhFSH-N2 has prolonged half-life and increased bioactivity compared with native rhFSH. This rhFSH agonist, and other analogues containing additional N-oligosaccharides may have important clinical applications.

Assessing the influence of payment on motivations of women participating as oocyte donors

We report on the motivations of potential ovum donors entering an assisted reproduction program and discuss the potential ramifications of escalating payments to donors. From July 1995 to July 1998, recruitment of ovum donors was directed at healthy women between 21 and 34 years of age. Financial remuneration for services rendered was USD 2,500 from July 1995 through March 1998 and increased to USD 5,000 after that. Donors were screened and consented according to established SART guidelines. The demographic background of the women was similar for women paid USD 2,500 to those receiving USD 5,000. The financial motivation was greater in those receiving USD 5,000 (68%) than USD 2,500 (39%). Some form of expressed altruism was similarly present in both groups (USD 5,000 90%, and USD 2,500 91%). However, altruism expressed as the sole motivation occurred more in those receiving USD 2,500 (61%) compared to USD 5,000 (32%). Financial reimbursement has escalated for the services of ovum donors in order to maintain the increasing demand. While money has become a dominant factor motivating ovum donors, its seductive nature requires even greater attention to adequate informed consent. Young donors may be unable to adequately weigh the risks of ovarian hyperstimulation and oocyte retrieval against the monetary reward.

Assessing fertility in women of advanced reproductive age

Reproductive capacity in women declines dramatically beyond the fourth decade of life. Oocyte quality seems to be the primary determinant of reproductive potential, although age-related uterine changes may also contribute. Underlying reasons for reproductive decline in women remain unclear, and both ovarian and neuroendocrine mechanisms have been proposed.A number of age-related endocrinologic changes precede menopause and predict diminished reproductive capacity. Thus, "ovarian reserve" screening may identify patients in whom attempts at conventional assisted reproduction is warranted before proceeding with ovum donation. Techniques to preserve the maternal genetic contribution to offspring (in lieu of egg donation), including germinal vesicle transfer and donor ooplasm, are under investigation.

Preovulatory treatment of mice with anti-VEGF receptor 2 antibody inhibits angiogenesis in corpora lutea

Adult mammalian angiogenesis occurs predominantly in female reproductive organs: the ovary and the uterus. Angiogenesis is very active during corpus luteum formation. A key regulator of angiogenesis is vascular endothelial growth factor (VEGF), which is highly expressed during corpus luteum formation. Inhibition of VEGF activity can block the formation and function of the corpora lutea by preventing angiogenesis. The VEGF receptor 2 (VEGF-R2) mediates the angiogenic action of VEGF and is expressed during corpus luteum formation. We hypothesized that treatment with an antibody against VEGF-R2 would inhibit luteal angiogenesis by blocking VEGF/VEGF-R2 interaction. Immature mice were induced to superovulate with PMSG/hCG resulting in neovascularization in the corpora lutea, as evidenced by abundant staining for the endothelial-specific adhesion molecule PECAM. Multiple doses of a monoclonal antibody against the VEGF-R2 (DC101) were administered to immature mice. Treatment was initiated 2 days prior to the induction of superovulation with PMSG/hCG. This antibody inhibited luteal angiogenesis as evidenced by the lack of PECAM staining in the center of the corpora lutea. Multiple dose treatment with antibody initiated prior to gonadotropin administration could not dissociate the luteal inhibition from the consequences of inhibition of angiogenesis in the developing follicle. Administration of a single, preovulatory dose of anti-VEGF-R2 antibody, such that follicular angiogenesis would not be affected, also inhibited luteal development, demonstrating that luteal angiogenesis is required for corpus luteal development. We conclude that VEGF acting through VEGF-R2 has an obligatory role in luteal angiogenesis and corpus luteum formation.

Controlled ovarian hyperstimulation. Relationship of early serum E2 levels to the ultimate response of oocyte donors

OBJECTIVE

To assess the predictive value of measuring serum day 5 E2 and in vitro fertilization (IVF) cycle outcome of oocyte donors undergoing controlled ovarian hyperstimulation (COH).

STUDY DESIGN

Retrospective data analysis.

RESULTS

Day 5 E2 significantly correlated with the peak serum E2 and number of retrieved mature oocytes. The pregnancy rates associated with stimulated day 5 E2 > 70 pg/mL were significantly greater than in cycles with levels < 70 pg/mL (58%, 71/123, versus 25%, 15/60; P < .05).

CONCLUSION

The cycle performance of an oocyte donor can be predicted by measuring cycle day 5 serum E2 during COH. Poor-prognosis cycles can be identified and discontinued, saving patients and the program unnecessary exspense.

Posthumous reproduction in a human immunodeficiency virus-discordant couple

A human immunodeficiency virus-discordant couple failed to conceive through in vitro fertilization and intracytoplasmic sperm injection of cryopreserved semen banked by the human immunodeficiency virus-positive partner. The husband subsequently had acquired immunodeficiency syndrome and died. The subsequent transfer of cryopreserved embryos resulted in pregnancy. Both mother and child are human immunodeficiency virus negative.

Testicular sperm aspiration (TESA) and its application in oocyte donation

This study was conducted to assess the outcomes of TESA in women undergoing oocyte donation. Descriptive reports from a university IVF practice were reviewed to evaluate the outcomes of women (n = 10) who underwent 12 cycles of ovum donation and required testicular sperm aspiration due to obstructive azoospermia (n = 6) and nonobstructive azoospermia (n = 4). Percutaneous needle aspiration of the testes was performed prior to oocyte retrieval to recover sperm, and intracytoplasmic sperm injection was subsequently performed on the donated oocytes. Fertilization was documented 16-18 h later and transcervical embryo transfer performed 72 h postretrieval. Successful retrieval of testicular spermatozoa utilizing the percutaneous technique was achieved in all 12 cycles. All cycles resulted in an ET with the achievement of 7 (58%) pregnancies, of which 5 (42%) are ongoing or delivered. The individual embryo implantation rate was 18.4% (9/49). Two cycles (16.6%) produced supernumerary embryos for cryopreservation. TESA represents a simple procurement technique associated with minimal morbidity. It may be offered even in cases of nondestructive azoospermia.

Prolonged inhibition of presynaptic catecholamine synthesis with alpha-methyl-para-tyrosine attenuates the circadian rhythm of human TSH secretion

OBJECTIVE

Originating from the pituitary gland, TSH secretion is regulated predominantly by thyroid-releasing hormone (TRH) neurons located in the hypothalamus. Norepinephrine and dopamine have important effects in modulation of TSH secretion. An inhibitor of catecholamine synthesis, alpha-methyl-para-tyrosine (AMPT) has been used in several studies of the regulation of human TSH secretion. The short-term effects (<8 hours) of low doses of AMPT include stimulation of pituitary TSH secretion by selective lowering of brain dopamine levels. After prolonged administration of AMPT (>24 hours), theoretically both dopamine and norepinephrine levels are lowered significantly in the brain, although this has not been reported previously.

METHODS

Nine subjects (five women and four men) received a total of five 1-g doses of AMPT or five 50-mg doses of promethazine (active placebo) over 28 hours in a randomized, double-blind, placebo-controlled crossover design in which the active and control tests were separated by 4-6 weeks. Blood samples were obtained over 24 hours (18 time points) on day 2 of each condition.

RESULTS

Changes in prolactin secretion and 6-hydroxymelatonin sulfate excretion indirectly showed the effects of AMPT on dopamine and norepinephrine. The typical circadian rhythm of TSH secretion was blunted by AMPT throughout the night; at ten time points, the difference between the two groups was statistically significant (P <.01). The long-term effects of repeated doses of AMPT were inhibition of TSH secretion and significant attenuation of the circadian rhythm of TSH. Additionally, AMPT induced low norepinephrine levels, which counteracted the stimulatory effect of low dopamine levels on TSH.

CONCLUSION

Through its inhibitory effect on TRH, norepinephrine appeared to be involved in the regulation of TSH.

On the association between valproate and polycystic ovary syndrome

Recent studies by Isojärvi et al. have raised the issue of an increased incidence of polycystic ovary syndrome (PCOS) in women with epilepsy treated with valproate (VPA) and have proposed replacement with lamotrigine (LTG). Polycystic ovaries (PCO) are a common finding, with a prevalence >20% in the general population, and are easily detected by pelvic or vaginal ultrasonography, whereas PCOS is comparatively rare: few women with PCO have fully developed PCOS, which includes hirsutism, acne, obesity, hypofertility. hyperandrogenemia, and menstrual disorders. From an extensive review of the current literature, it appears that there are no reliable data on the actual prevalence of PCOS in normal women and in women with epilepsy. The pathogenesis of PCO is multifactorial, including genetic predisposition and the intervention of environmental factors, among which weight gain and hyperinsulinism with insulin resistance may play a part. The roles of central (hypothalamic/pituitary), peripheral, and local ovarian factors are still debated. PCO and PCOS appear to be more frequent in women with epilepsy, but there are no reliable data showing a greater prevalence after VPA. The recent studies by Isojärvi et al. may have been biased by the retrospective selection of patients. To date, there is no reason to contraindicate the use of VPA in women with epilepsy. However, patients should be informed about the risk of weight gain and its consequences.

Oocyte donation treats infertility in survivors of malignancies: ten-year experience

Women who are survivors of malignancy may achieve pregnancy through oocyte donation. The largest obstacle to successful reproduction in cancer patients relates to iatrogenic damage to the primary reproductive organs associated with their primary oncology treatment. Reactive damage from surgery, radiation, or chemotherapy may render these organs nonfunctional and irreparable. In cases where the ovary is primarily affected, oocyte donation provides a logical alternative for childbearing.

Short-term administration of antivascular endothelial growth factor antibody in the late follicular phase delays follicular development in the rhesus monkey

Indirect evidence in the nonhuman primate and human suggests that angiogenesis and regulators of angiogenesis such as vascular endothelial growth factor (VEGF) may play an active role in cyclic folliculogenesis. Indeed, the follicle selected for maturation and ovulation possesses a denser microvascular network, and VEGF messenger ribonucleic acid and its protein have been identified in granulosa cells of the developing follicle during the mid- and late follicular phases, with a more intense signal in the mature follicle. The objective of this study was to obtain direct evidence in the nonhuman primate for an active role of VEGF in follicular growth and maturation by studying the effect of VEGF-blocking antibodies in this process. After documenting two normal ovulatory cycles, female rhesus monkeys (n = 7) received iv injections of anti-VEGF antibodies (0.5 mg) twice on successive days in the late follicular phase. Three monkeys also received nonspecific goat IgG (0.5 mg) twice on successive days in the late follicular phase. Daily measurements of estradiol, progesterone, LH, and FSH were obtained during the two control cycles, the anti-VEGF treatment and posttreatment cycles, and the IgG treatment cycle. Anti-VEGF antibody administration significantly lengthened the follicular phase in six of seven monkeys to 17.8 +/- 1.7 vs. 10.0 +/- 0.7 and 9.8 +/- 0.6 in control cycles and 10.7 +/- 0.3 days (mean +/- SE) in IgG-treated cycles. The expected late follicular phase rise in estradiol, as documented in the control cycles (day 0, 96.1 +/- 6.0; day 1, 125.5 +/- 20.0; day 2, 165.5 +/- 24.9; day 3, 183.8 +/- 11.0 pg/mL), was interrupted by anti-VEGF antibody treatment (99.3 +/- 5.0, day 0, preinjection control) to 63.3 +/- 12.2 (day 1), 48.5 +/- 8.7 (day 2), and 57.6 +/- 9.0 (day 3). Mean FSH levels were significantly increased by day 2 of anti-VEGF antibody treatment. After a variable delay, estradiol concentrations increased to reach a preovulatory peak in all anti-VEGF-treated animals, followed by ovulation, normal luteal function, and a normal posttreatment cycle. The data clearly demonstrate that short-term inhibition of angiogenesis with an anti-VEGF-blocking antibody during the later growth phase of the dominant follicle interferes with normal follicular development. Persistence of estradiol secretion and delayed resumption of its rise also suggest recovery of the follicle. We conclude that the angiogenic regulator VEGF is a crucial component in the process of follicular growth in the primate.

Defining the incidence of serious complications experienced by oocyte donors: a review of 1000 cases

A review of 1000 aspirations of oocyte donors was performed. Only witnessed events necessitating hospitalization or emergent intervention were considered significant. Seven (0.7% incidence) cases were noted, including severe ovarian hyperstimulation syndrome (n = 3), adverse reaction to intravenous anesthesia (n = 2), intra-abdominal bleeding after aspiration (n = 1), and bladder atony with hematuria after aspiration (n = 1).

Circulating leptin levels during ovulation induction: relation to adiposity and ovarian morphology

OBJECTIVE

To assess serum leptin levels based on body habitus and ovarian morphology during controlled ovarian hyperstimulation.

DESIGN

Prospective analysis.

SETTING

University IVF program.

PATIENT(S)

Women undergoing IVF-ET were divided into two groups, obese ovulatory women (n = 6; mean (+/-SD) body mass index, 30.1 +/- 0.6 kg/m(2)) and lean ovulatory women (n = 20); mean (+/- SD) body mass index 22.0 +/- 0.2 kg/m(2)). Lean women were categorized further according to whether they had polycystic-appearing ovaries (n = 8) or normal-appearing ovaries (n = 12).

INTERVENTION(S)

Controlled ovarian hyperstimulation and IVF.

MAIN OUTCOME MEASURE(S)

Serum estradiol, testosterone, and leptin.

RESULT(S)

Mean (+/- SD) leptin levels were significantly higher before and after GnRH agonist down-regulation in obese women (41.7 +/- 5.2 pg/mL and 36.1 +/- 5.8 pg/mL, respectively) compared with lean women (8.4 +/- 1.0 pg/mL and 6.9 +/- 1.1 pg/mL, respectively). Mean (+/- SD) leptin levels increased significantly in both groups (54.5 +/- 5.1 pg/mL and 11.7 +/- 1.2 pg/mL, respectively), and the mean (+/-SD) percentage increase was similar (55% +/- 18% and 54.8% +/- 17%, respectively). Mean (+/-SD) leptin levels were similar in women with polycystic-appearing and normal-appearing ovaries before controlled ovarian hyperstimulation, but increased significantly in women with polycystic-appearing ovaries afterward (14.7 +/- 1.8 pg/mL and 9.3 +/- 1.0 pg/mL, respectively).

CONCLUSION(S)

Significant increases in leptin levels occur during controlled ovarian hyperstimulation, suggesting that leptin plays a role in follicular growth and maturation. The exaggerated response in women with polycystic-appearing ovaries reflects either a greater number of recruited follicles or a predisposition of adipocytes to leptin production.

Normal ovulatory women with polycystic ovaries have hyperandrogenic pituitary-ovarian responses to gonadotropin-releasing hormone-agonist testing

Women with polycystic ovary syndrome (PCOS) have chronic anovulation and hyperandrogenism and frequently have abnormalities in their lipid profiles and insulin/insulin-like growth factor axis that increase their lifetime risk for cardiovascular disease. Normal ovulatory women may have polycystic ovaries on ultrasonography and yet lack the clinical features of PCOS. To further explore whether ovulatory women without clinical/biochemical hyperandrogenism but with polycystic appearing ovaries (ov-PAO) have subclinical features of PCOS, we prospectively characterized 26 ov-PAO women and matched them by age and body mass index to 25 ovulatory women with normal appearing ovaries (ov-NAO) and to 22 women with PCOS. After an overnight fast, all women had baseline endocrine and metabolic assessments. In addition, a subset of each group of women underwent GnRH-agonist (leuprolide acetate 1 mg s.c.) testing, ACTH stimulation, and an insulin tolerance test (ITT). At baseline, ov-PAO and ov-NAO women had similar endocrine profiles (LH, LH:FSH, androstenedione, and DHEAS). Compared with ov-NAO, 31% of ov-PAO women had reduced glucose responses after insulin (K(itt)), suggesting mild insulin resistance, and 35% had high density lipoprotein levels below 35 mg/dL, a level considered to represent significant cardiovascular risk. After GnRH-agonist, ov-PAO women had response patterns in LH, total testosterone, and 17-hydroxyprogesterone (17-OHP) that were intermediate between ov-NAO and women with PCOS. Ovarian responses were above the normal range in 30-40% of women with ov-PAO. In ov-PAO, peak responses of LH after leuprolide correlated with triglyceride levels (P < 0.05) and peak responses of 17-OHP correlated inversely with Kitt values (P < 0.05). No significant differences were noted with ACTH testing. In conclusion, occult biochemical ovarian hyperandrogenism may be uncovered using GnRH-agonist in ovulatory women with ov-PAO, while adrenal responses remain normal. Subtle metabolic abnormalities may also be prevalent.

Operative hysteroscopy in the office setting

STUDY OBJECTIVE

To describe the feasibility of operative hysteroscopy in the office setting. DESIGN. Descriptive study (Canadian Task Force classification II-2).

SETTING

University-based private practice.

PATIENTS

Women undergoing assisted reproduction in whom diagnostic evaluation revealed uterine cavity pathology.

INTERVENTION

Patients were offered office hysteroscopy and allowed to choose between paracervical block anesthesia supplemented with mild intravenous sedation or full conscious sedation, administered by an anesthesiologist. A MicroSpan Hysteroscopy system or HysteroSys Flexible Hysteroscope system was used for diagnostic purposes. When pathology was identified, resection was performed with 2-mm operative instruments or a VersaPoint hysteroscopic electrosurgical electrode using bipolar coagulation through an expandable operating channel.

MEASUREMENTS AND MAIN RESULTS

Of 69 women with abnormal sonohysterographic and hysterosalpingogram studies, 44 agreed to office hysteroscopy. Thirty-three (48%) underwent VersaPoint resection and/or scissors resection, which was successfully accomplished in 32 (97%). Significant cervical stenosis in one woman precluded resection because of concern of creating a false passage. Concomitant diagnostic laparoscopy and operative hysteroscopy was performed in one patient. Average operating and anesthesia times were 45.2 +/- 20.3 minutes and 67.2 +/- 28.4 minutes, respectively. One uterine perforation occurred (3.3%) during resection of intrauterine adhesions.

CONCLUSION

Office hysteroscopy is a time-efficient and cost-effective procedure, made possible by the development of small instruments. Proper patient selection and training of office personnel are mandatory to minimize complications and maximize efficacy.

Embryo donation: a programmed approach

OBJECTIVE

To describe the establishment of an embryo donation program using a large oocyte donor registry to produce embryos.

DESIGN

Descriptive study.

SETTING

A university-based practice.

PATIENT(S)

Embryos were obtained either through traditional donation from couples who underwent IVF-ET (n = 8) or through ovum donation (n = 15) with embryos produced by the program. In select cases, ovum donors were inseminated either with donor sperm selected following an advance directive from the patient or couple (n = 13) or with sperm designated by an IVF medical advisory board (n = 11).

INTERVENTION(S)

Donated embryos or donor oocyte/donor sperm embryos were provided to patients with backgrounds and physical attributes compatible with the embryonic phenotype. In some of the cycles, fresh ET was performed, with embryos shared among two, three, or four couples (n = 18); in other cycles, embryos were cryopreserved and transferred later (n = 21).

MAIN OUTCOME MEASURE(S)

Clinical and ongoing-delivered pregnancy rates.

RESULT(S)

The mean (+/-SD) numbers of embryos for cycles in which fresh ET and frozen ET was performed were 3.1+/-0.7 (range, 2-5) and 3.6+/-0.2 (range, 3-5), respectively. The clinical and ongoing-delivered pregnancy rates were 44.4% (8/18) and 33.3% (6/18), respectively, for cycles in which fresh ET was performed and 57.1% (12/21) and 47.6% (10/21), respectively, for cycles in which frozen ET was performed.

CONCLUSION(S)

Embryo donation is an alternative approach to assisted reproduction that meets the needs of single and lesbian women as well as older and less affluent couples. It is a cost-effective and efficacious means of achieving pregnancy.

Y chromosome microdeletion in a father and his four infertile sons

Microdeletions of Yq are associated with azoospermia and severe oligozoospermia. In general, men with deletions are infertile and therefore deletions are not transmitted to sons unless in-vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) are performed. We report an unusual family characterized by multiple members with infertility and Yq microdeletion. Complete reproductive history, semen analyses and blood samples were elicited from relevant family members. DNA preparation and quantification were performed using commercial kits. A total of 27 pairs of sequence tagged sites based primer sets specific for the Y microdeletion region loci were used for screening. Southern blots using deleted in azoospermia (DAZ) and ribosomal binding motif (RBM) cDNAs were then analysed for confirmation. The proband, his three brothers and father were all found to be deleted for DAZ but not RBM. At the time of analysis, the proband's father was azoospermic whereas his four sons were either severely oligozoospermic or azoospermic. Unlike their father, the four sons are infertile and have no offspring, except for one of them who achieved a daughter only after IVF/ICSI treatment for infertility. Microdeletions of Yq involving the DAZ gene are associated with a variable phenotypic expression that can include evidently normal fertility.

Donor age is paramount to success in oocyte donation

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

21-hydroxylase deficiency and Turner's syndrome: a reason for diminished endometrial receptivity

OBJECTIVE

To report a case of cryptic 21-hydroxylase deficiency identified at the time of ovum donation in a patient with Turner's syndrome.

DESIGN

Case report.

SETTING

University IVF practice.

PATIENT(S)

A 28-year-old woman with Turner's syndrome who presented for ovum donation.

INTERVENTION(S)

Four cycles of donor IVF.

MAIN OUTCOME MEASURE(S)

Pregnancy, endometrial appearance, progesterone, and 17-hydroxyprogesterone values.

RESULT(S)

The patient failed two fresh and two frozen ET cycles with donated oocytes. The appearance of the endometrium suggested elevated progesterone before progesterone supplementation. An elevated progesterone was detected but not suppressed by leuprolide acetate. Progesterone was suppressed by adding dexamethasone. The diagnosis of cryptic 21-hydroxylase deficiency was confirmed biochemically.

CONCLUSION(S)

Patients with Turner's syndrome reportedly have poorer outcomes with donor IVF than other women. They also have an increased incidence of carrying a defective 21-hydroxylase gene. We suggest that some of the poorer outcomes may be explained by the presence of elevated progesterone and recommend evaluation of possible congenital adrenal hyperplasia in patients with Turner's syndrome who want oocyte donation.

Reproductive outcome after sterilization reversal in women of advanced reproductive age

OBJECTIVE

Our objective was to assess the clinical outcome of tubal reversal in women of advanced reproductive age.

METHODS

A multicenter retrospective chart review of 153 patients who underwent a tubal ligation reversal was carried out. Patients were evaluated according to age. All patients had documented ovulation and a partner with a normal semen analysis by WHO criteria. Outcome measures included rates of clinical pregnancy, ectopic pregnancy, spontaneous abortion, and live birth, and the time to conception.

RESULTS

Clinical pregnancy rates were significantly lower in women > or = 40 compared to younger groups. The time to conception was significantly shorter for women < 30 compared to women > or = 35. No pregnancies occurred in women > or = 42.

CONCLUSIONS

Our data support the judicious use of sterilization reversal for infertile women with no male factor through their early forties. Women > or = 42 years should be especially counseled as to the very low success rates.

Ultrasound guided embryo transfer significantly improves pregnancy rates in women undergoing oocyte donation

OBJECTIVES

Recent reports suggest ultrasound (US) guided embryo transfer (ET) improves pregnancy rates. Using the ovum donation model to eliminate confounding variables, we assessed the impact of US guided ET on pregnancy rates, implantation rates, and multiple gestation rates.

METHODS

All women who underwent IVF-ET cycles using donated oocytes from November 1997 to September 1998 (n = 137) were evaluated retrospectively. ET from November 1997 to April 1998 were performed without US, while all ET from May 1998 to September 1998 were performed using transvaginal or transabdominal US. ET was further categorized as easy or difficult. Difficult ET was defined as requiring at least two attempts and/or the presence of blood on the catheter and/or > 5 min.

RESULTS

Pregnant patients (n = 73) were similar with respect to the number and morphology of the embryos transferred compared to non-pregnant patients (n = 65). US guidance significantly improved implantation and pregnancy rates in cycles with easy transfers [28.8 vs. 18.4% and 63.1 vs. 36.1%, respectively (P < 0.05)] without impacting multiple pregnancy rates.

CONCLUSION

US guided ET is simple and reassuring and appears to significantly improve pregnancy outcomes in ovum donation cycles by optimizing the placement of embryos.

Serum progesterone before and after human chorionic gonadotropin injection depends on the estradiol response to ovarian hyperstimulation during in vitro fertilization-embryo transfer cycles

PURPOSE

Our purpose was to assess if periovulatory serum progesterone is reflective of ovarian responsiveness in controlled ovarian hyperstimulation (COH).

METHODS

One-hundred forty-two in vitro fertilization-embryo transfer cycles in women using GnRH-a suppression and human menopausal gonadotropin (hMG) stimulation were evaluated. Responses were studied according to ovarian response to hMG and age. Outcome measures included peak serum estradiol, serum progesterone and estrogen/progesterone ratios on the day of hCG injection, number of harvested oocytes, fertilization rates, and delivered pregnancy rates.

RESULTS

A periovulatory rise in serum progesterone (> 0.9 ng/ml) occurred only among younger women (< 40 years old) with a good response (P < 0.05). Though the number of oocytes was greater in good responders, fertilization and pregnancy rates were similar among all women regardless of age and ovarian response.

CONCLUSIONS

Periovulatory levels of serum progesterone vary according to ovarian response to COH. Elevations in progesterone do not appear to be a manifestation of poor responders. Reduced periovulatory progesterone may reflect inadequate steroidogenesis.

Utilizing routine sonohysterography to detect intrauterine pathology before initiating hormone replacement therapy

OBJECTIVE

To assess the utility of performing routine sonohysterography in conjunction with endometrial thickness measurement for detecting intrauterine pathology in asymptomatic postmenopausal women.

DESIGN

Asymptomatic postmenopausal women (n = 60, mean age 52.7 +/- 4.5 years, amenorrhea > or = 6 months, follicle stimulating hormone > or = 40 mIU/mL) were evaluated with sonohysterography followed by endometrial biopsy before initiating hormone replacement therapy.

RESULTS

Hyperplasia was detected in 5 of 22 (22.7%) patients with endometrial thickness of > 5 mm and in 0 of 38 (0.0%) patients with endometrial thickness of < or = 5 mm. When sonohysterography was performed, intracavitary pathology was discovered in 14 of 38 (36.8%) patients with endometrial thickness of < or = 5 mm (10 polyps, three submucosal myomas, and one septate uterus) and 14 of 22 (63.6%) patients with endometrial thickness of > 5 mm (nine polyps, four submucosal myomas, and one Asherman's syndrome).

CONCLUSIONS

Endometrial thickness of < or = 5 mm excludes hyperplasia but does not eliminate other intrauterine pathology that may be discovered by sonohysterography.

Hydrosalpinges adversely affect implantation in donor oocyte cycles

Hydrosalpinges have been associated with poor in-vitro fertilization (IVF) outcome in some, but not all, studies, perhaps through endometrial effects. To determine whether hydrosalpinges affect IVF outcome via endometrial factors alone, we analysed the results of recipients of donor oocytes with hydrosalpinges, thereby controlling for confounding variables, while isolating the intrauterine environment. We retrospectively analysed 110 patients who underwent 121 donor oocyte cycles in a university-based assisted reproduction programme. Thirteen cycles involving recipients (n = 10) with hydrosalpinges were compared to 108 cycles involving recipients (n = 100) without hydrosalpinges. Pregnancy, implantation, miscarriage, and ectopic pregnancy rates were compared between women with and without hydrosalpinges. There were no significant differences between the hydrosalpinx and no hydrosalpinx groups with respect to donor age, recipient age, or number or grade of embryos transferred. Patients with a hydrosalpinx had significantly lower embryo implantation rates (7.1 versus 19.3%, P < 0.05) and significantly higher miscarriage (75.0 versus 14.9%, P < 0.05) and ectopic pregnancy rates (33.3 versus 0.0%, P < 0.05) than normal controls. We conclude that the presence of a hydrosalpinx adversely affects early pregnancy events by altering the intrauterine environment.

Use of progesterone in assisted reproduction

Progesterone, supplied in a variety of formulations, is commonly used in assisted reproduction. However, even the commonly accepted uses of progesterone in fertility care are believed to be largely empirical, as are the current available treatment options. While a critical balance of estrogen and progesterone is necessary for successful embryo implantation, achieving that balance is subject to differences in prescribing practice. In evaluating recommendations for the use of progesterone, discussion of its role in assisted-reproduction procedures must distinguish between known therapeutic benefits and empirical benefits.

Follicular fluid insulin-like growth factor-I and insulin-like growth factor-binding protein-1 and -3 vary as a function of ovarian reserve and ovarian stimulation

PURPOSE

Follicular fluid concentrations of insulin-like growth factor (IGF)-I, IGF-II, IGF-binding protein (BP)-1, and IGFBP-3 in 57 women undergoing in vitro fertilization and embryo transfer were examined to determine whether levels reflected differences in patients' exposure to gonadotropin stimulation and a diminished ovarian reserve.

METHODS

Preovulatory follicular fluid was obtained from both gonadotropin-stimulated and unstimulated cycles. Subjects were grouped according to normal or decreased ovarian reserve and whether or not they received gonadotropin stimulation.

RESULTS

The mean follicular fluid concentrations of IGF-I and IGFBP-1 were significantly lower in the "decreased" ovarian reserve group compared with the "normal" ovarian reserve group, with no change in estradiol or IGF-II levels. This resulted in a decreased molar IGF-I: BP ratio and an increased molar IGF-II:IGFBP-1 ratio. In unstimulated cycles, mean follicular fluid concentrations of IGFs did not differ significantly compared with those in stimulated cycles, whereas concentrations of IGFBP-1 and IGFBP-3 were significantly lower, leading to higher molar ratios of the IGFs to the binding proteins.

CONCLUSIONS

Follicular fluid IGF and binding proteins vary as a function of ovarian reserve and gonadotropin stimulation. This may reflect either differences in oocyte quality or a suboptimal follicular fluid environment.

The impact of age on reproductive potential: lessons learned from oocyte donation

OBJECTIVE

Oocyte donation allows a unique opportunity to separately study the effect of aging on uterine receptivity and oocyte quality. The purpose of this report is to review the published experience on reproductive aging in both laboratory animals and humans as it pertains to oocyte and embryo donation.

METHODS

A review of the published medical literature.

RESULTS

Natural fertility rates decline in most animals with age, becoming dramatically apparent in women as they enter the fifth decade of life. By the time of the perimenopause, pregnancy rarely occurs, whether or not assisted reproductive techniques are initiated. However, if oocytes are donated by young women to older women, both embryo implantation and pregnancy rates are restored to normal levels in recipients.

CONCLUSIONS

These results strongly suggest the pregnancy wastage experienced by older women is largely a result of degenerative changes within the aging oocyte, rather than senescent changes in the uterus. The poor prognosis for fertility in older women can be reversed through oocyte donation from younger individuals.

Operative ultrasonography for upper genital tract pathology

PURPOSE

A procedure using transvaginal sonohysterography (SHG) to perform operative intrauterine biopsies and resections is described.

METHODS

Seven women, six with intrauterine pathology noted on diagnostic SHG and one with a thickened endometrium noted on transvaginal ultrasonography, underwent attempted operative SHG. The indications were peri- and postmenopausal bleeding (n = 4) and infertility requiring assisted reproduction (n = 3). Access to the uterine cavity was accomplished with a 9-F cervical access catheter (CAC) with a 3-ml balloon (BEI Medical Systems, ZSI Gynecology Products Division, Chatsworth, CA), which was placed in the cervical canal or lower uterine segment. Depending on the position of the noted uterine pathology, a 6-F uterine ostial access catheter (UOAC) (BEI Medical Systems, ZSI Gynecology Products Division) was placed through the CAC. The uterine cavity was distended with 5-10 ml of 1% Lidocaine and a 3-F loop grasper or finger-like biopsy grasper was then passed through the UOAC or a 5-F operative instrument directly within the CAC with attempted resection under ultrasound guidance. Biopsied samples were sent to pathology for definitive diagnosis. Office hysteroscopy was then performed to confirm adequate resection.

RESULTS

Three of six patients had adequate resection or biopsy of intrauterine pathology, while the seventh patient successfully had a directed biopsy of the fundal cavity under ultrasound guidance. In one case, the visualized lesion could not be grasped. In the other two cases, each patient had severe cervical stenosis and declined in-office cervical dilation precluding the procedure. Each procedure was well tolerated, with an average time from start to finish of about 25 min (range, 18-43 min) without complications.

CONCLUSIONS

Operative SHG makes it possible to resect and biopsy intrauterine pathology often missed on Pipelle sampling. If found to be as effective as hysteroscopy, operative SHG would provide a cost-effective alternative. Further study is ongoing to perfect the existing instruments to allow removal of larger lesions both safe and possible.

The utility of serum progesterone and inhibin A for monitoring natural-cycle IVF-ET

PURPOSE

Our purpose was to assess the value of monitoring serum P and inhibin A to determine how values might improve the clinical monitoring of natural cycle in vitro fertilization (IVF)-embryo transfer (ET) patients.

METHODS

All patients (n = 26) who underwent natural-cycle IVF-ET (n = 35) were analyzed. Groups were evaluated according to patients who had a spontaneous luteinizing hormone (LH) surge (group I) and women receiving human chorionic gonadotropin (hCG) who underwent subsequent oocyte aspiration (group II). Group II was further evaluated according to women who did (n = 10) and did not (n = 7) have an ET. All cycles were evaluated with serial transvaginal ultrasonography and serum estradiol, progesterone, and inhibin A. When follicle maturity was achieved, hCG, 10,000 IU, was administered intramuscularly if a LH surge was not detected. Transvaginal ultrasound-guided aspiration was performed 34-36 hr after hCG administration followed by a 48-hr transcervical ET.

RESULTS

No differences were seen in cycles the day prior to (d-1) and the day of a spontaneous LH surge, (n = 18) or hCG (d-0)(n = 17) in group I or group II with respect to lead follicular diameter (d-1, 15.3 +/- 0.6 vs. 14.2 +/- 0.9 mm; d-0, 17.4 +/- 0.8 vs. 17.8 +/- 0.6 mm) and serum estradiol (d-1, 148 +/- 15 vs. 150 +/- 15 pg/ml; d-0, 218 +/- 15 vs. 199 +/- 16 pg/ml), respectively. However, serum progesterone was significantly elevated in group I compared with group II on d-1 (0.82 +/- 0.6 vs. 0.48 +/- 0.04 ng/ml; P < 0.05) and d-0 (1.1 +/- 0.12 vs. 0.63 +/- 0.08 ng/ml; P < 0.05). Inhibin A was significantly greater on d-1 in group I (24 +/- 2.5 vs. 15 +/- 2.2 pg/ml; P < 0.05). In group II, cycles that resulted in an ET (n = 10) compared with group II cycles that did not (n = 7) revealed a significant difference in serum progesterone (0.51 +/- 0.05 vs. 0.7 +/- 0.07 ng/ml; P < 0.05) and inhibin A (15 +/- 2.5 vs. 37.3 +/- 5 pg/ml; P < 0.05) the day of hCG.

CONCLUSIONS

The possible application of serum progesterone and inhibin A in managing natural-cycle IVF-ET is suggested. These assays may predict women who should be set up for egg retrieval, while cancelling others in spite of the absence of an LH surge.

Expectations of recipient couples awaiting an anonymous oocyte donor match

PURPOSE

Our purpose was to survey recipients in an ovum donation program and report on their expectations while waiting for their potential donor recipient match.

METHODS

Accepted or rejected anonymous ovum donor matches (n = 80) from January 1996 to May 1997 were evaluated. Patients generated a "wish list" of desired traits and physical characteristics. From an approved donor pool of medically and psychologically screened women, candidates were drawn upon as potential matches and presented to the potential recipient, who decided whether to accept the donor. Reasons for accepting or rejecting the donor were tallied and were compared to the patient's wish list.

RESULTS

Medical history and race were ranked by 33 and 23% of recipient couples as the two most important characteristics, while 74 and 54% stated that these were among the three most important factors in a potential donor compared with other traits. Fifty-seven (71%) recipients accepted, while 23 (29%) rejected, the first donor presented to them. Eleven were subsequently given a second choice within 6 months, with 10 (91%) accepting the next presented match. Recipients waiting for a donor were just as likely to accept or reject a potential candidate whether waiting < 3 months (33%; 15/46), 3-6 months (25%; 4/16), or > 6 months (22%; 4/18) (P > 0.05; NS). In all but five recipients, the reason for rejection was consistent with their top three priorities reported in their wish list.

CONCLUSIONS

Phenotypic, ethnic, educational, and other interests are important in the selection of an ovum donor. Recipients are proactive in their decision process, making educated and well considered decisions in spite of the limited pool and the extended time frame in waiting for an appropriate ovum donor.