Rezidivierende Aborte und frustrane In-vitro-Fertilisation

Antikörper gegen das antikoagulatorisch wirkende Annexin V, das in der Plazenta vorkommt, wurden in aktuellen Arbeiten in Zusammenhang mit rezidivierenden Aborten oder wiederholten Fehlversuchen von In-vitro-Fertilisierungen (IVF) gebracht und zum Teil kontrovers diskutiert. Patientinnen, Material, Methoden: Wir untersuchten die Plasmen von 56 Frauen (mittleres Lebensalter 34,7 Jahre) mit wiederholten IVF-Fehlversuchen und/oder rezidivierenden Frühaborten auf APC-Resistenz, Lupusantikoagulanzien und Antikörper gegen Annexin V, Cardiolipin oder β2-Glykoprotein-1. Ergebnisse: Das Vorkommen von APC-Resistenz war mit 14% (8/56) am häufigsten, gefolgt von erhöhten Antikörperspiegel gegen Cardiolipin (IgG/ IgM) mit 12% (7/56), Antikörper gegen β2-Glykoprotein-1 (3/56, 5%) und Annexin-V (1/56, 2%). 42 (75%) dieser Patientinnen hatten einen weiteren IVF-Versuch und erhielten niedermolekulares Heparin und/oder Azetylsalizylsäure im Falle einer APC-Resistenz, eines Lupusantikoagulanz oder eines erhöhten Antikörperspiegels gegen Cardiolipin oder β2-Glykoprotein-1. Bei den neuerlichen IVF-Versuchen resultierten 19 (34%) Schwangerschaften, davon nur 4 Frühaborte (7%). Die einzige Patientin mit erhöhter Anti-Annexin-V-Konzentration, die davor 7 frustrane IVF-Versuche hatte, erhielt während des 8. IVF-Versuchs 40 mg Enoxaparin (Lovenox®) einmal täglich subkutan und wurde schwanger. Diskussion, Schlussfolgerung: Unsere Ergebnisse zeigen, dass bei Frauen mit häufigen IVF-Misserfolgen eine Anti-Annexin-V-Positivität weitaus seltener vorkommt als APC-Resistenz, Lupusantikoagulanzien oder erhöhte Antikörperspiegel gegen Cardiolipin oder β2-Glykoprotein. Das IVF-Ergebnis von Frauen mit APCResistenz, Lupusantikoagulanzien oder erhöhte Antikörperspiegel gegen Cardiolipin oder β2-Glykoprotein scheint durch niedermolekulares Heparin positiv beeinflusst zu werden.

Embryoid body formation of human amniotic fluid stem cells depends on mTOR

Human amniotic fluid stem cells (hAFSCs) harbor high proliferative capacity and high differentiation potential and do not raise the ethical concerns associated with human embryonic stem cells. The formation of three-dimensional aggregates known as embryoid bodies (EBs) is the principal step in the differentiation of pluripotent embryonic stem cells. Using c-Kit-positive hAFSC lines, we show here that these stem cells harbor the potential to form EBs. As part of the two kinase complexes, mTORC1 and mTORC2, mammalian target of rapamycin (mTOR) is the key component of an important signaling pathway, which is involved in the regulation of cell proliferation, growth, tumor development and differentiation. Blocking intracellular mTOR activity through the inhibitor rapamycin or through specific small interfering RNA approaches revealed hAFSC EB formation to depend on mTORC1 and mTORC2. These findings demonstrate hAFSCs to be a new and powerful biological system to recapitulate the three-dimensional and tissue level contexts of in vivo development and identify the mTOR pathway to be essential for this process.

Contraceptive efficacy and safety of a low-dose oral contraceptive, (0.03 mg ethinyl oestradiol and 2 mg chlormadinone acetate) Belara®, over three medication cycles

OBJECTIVE

To describe the modulation of ovarian function during three medication cycles with 0.03 mg ethinyl oestradiol (EE) and 2 mg chlormadinone acetate (CMA), leading to inhibition of conception in healthy women.

METHODS

Phase II, single-centre, open, non-controlled trial. The main outcome measure was inhibition of ovarian activity, assessed by frequent monitoring of the presence, size and persistence of follicle-like structures using ultrasonography. Secondary parameters included: cervical reaction score (CRS-probability of fertilization), endometrial thickness (probability of nidation), and serum levels of the sex hormones oestradiol, progesterone, luteinizing hormone and follicle stimulating hormone. Safety was primarily assessed by monitoring the occurrence of adverse events.

RESULTS

Thirty-three subjects were eligible for the trial and were included in the efficacy assessment (per protocol analysis, PPA). All subjects ovulated during the pretreatment cycle, but none during the three medication cycles. Follicular growth was profoundly suppressed during the medication phase, with residual ovarian activity occurring in only 12/83 (14.5%) treatment cycles. The CRS was negative during each medication cycle and endometrial thickness was suppressed on each medication day, with median values of 4.0-6.0 mm. EE/ CMA was well tolerated, with few adverse events reported; most were typically cycle-related and included headache, breast discomfort, nausea and vomiting.

CONCLUSION

During the administration of EE/CMA follicular development, cervical reaction and endometrial thickness are profoundly suppressed, resulting in unfavourable conditions for fertilization, implantation and, thus, pregnancy.

An intriguing Y chromosome in Heteromys anomalus (Rodentia, Heteromyidae)

The mitotic chromosomes of the pocket mouse Heteromys anomalus (Rodentia, Heteromyidae) from Venezuela were analyzed by means of conventional staining and various banding techniques. The karyotype of this species is distinguished by a Y chromosome with exceptional banding properties. The very large heterochromatic Y long arm shows a remarkable bright quinacrine fluorescence, but only moderate or dull fluorescence when labeled with other AT base pair-specific fluorochromes. The implications of these findings are discussed.

[Recurrent miscarriage or failed in-vitro fertilization: antibodies against annexin V, cardiolipin, beta-2-glycoprotein-1 and APC-resistance]

Antibodies against annexin-V, a potent anticoagulant abundant in placental tissues, were recently controversially reported to be associated with recurrent miscarriages or failures of in-vitro-fertilization (IVF) attempts.

PATIENTS, MATERIAL, METHODS

We screened 56 women (34.7 +/- 4.3 years of age: mean +/- 1 SD) with recurrent IVF failures and/or early pregnancy losses for resistance against activated protein C, lupus anticoagulant and antibodies against annexin V, cardiolipin or beta(2)-glycoprotein-1. Among them the prevalence of APC-R (8/56, 14%) and elevated levels of IgG- or IgM-anti-cardiolipin antibodies (7/56, 12%) were more common than elevated levels of (IgG or IgM) antibodies against beta(2)-glycoprotein-1 (3/56, 5%) or annexin-V (1/56, 2%). 42 (75%) of the women had another IVF-attempt after this haemostaseological evaluation and received low molecular weight heparin and/ or acetylsalicylic acid in the case of positivity for APC-resistance, lupus anticoagulant or antibodies against annexin V, cardiolipin or beta(2)-glycoprotein-1.

RESULTS

The outcome of these IVF-attempts were 19 pregnancies (34%): 4 early miscarriages (7%) and 15 so far uncomplicated pregnancies (27%). The only woman with an elevated anti-annexin V (IgG) level had had 7 IVF before and received 40 mg Enoxaparin (Lovenox) subcutaneously once daily during the 8(th) IVF, which resulted in a healthy pregnancy.

DISCUSSION, CONCLUSION

Our findings suggest that among women with recurrent IVF failures anti-annexin V antibody positivity is less prevalent than APC-resistance, lupus anticoagulant (LA) or elevated levels of antibodies against cardiolipin, beta(2)-glycoprotein-1 and that the IVF-result of women with APC-R, LA or with elevated levels of antibodies against annexin V, cardiolipin or beta(2)-glycoprotein might be positively influenced by low molecular weight heparin.

Comparative chromosome painting of chicken autosomal paints 1-9 in nine different bird species

In a Zoo-FISH study chicken autosomal chromosome paints 1 to 9 (GGA1-GGA9) were hybridized to metaphase spreads of nine diverse birds belonging to primitive and modern orders. This comparative approach allows tracing of chromosomal rearrangements that occurred during bird evolution. Striking homologies in the chromosomes of the different species were noted, indicating a high degree of evolutionary conservation in avian karyotypes. In two species, the quail and the goose, all chicken paints specifically labeled their corresponding chromosomes. In three pheasant species as well as in the American rhea and blackbird, GGA4 hybridized to chromosome 4 and additionally to a single pair of microchromosomes. Furthermore, in the pheasants fission of the ancestral galliform chromosome 2 could be documented. Hybridization of various chicken probes to two different chromosomes or to only the short or long chromosome arm of one chromosome pair in the species representing the orders Passeriformes, Strigiformes, and Columbiformes revealed translocations and chromosome fissions during species radiation. Thus comparative analysis with chicken chromosome-specific painting probes proves to be a rapid and comprehensive approach to elucidate the chromosomal relationships of the extant birds.

Chromosome banding in Amphibia. XXVIII. Homomorphic XY sex chromosomes and a derived Y-autosome translocation in Eleutherodactylus riveroi (Anura, Leptodactylidae)

Extensive cytogenetic analyses on a population of the leptodactylid frog Eleutherodactylus riveroi in northern Venezuela revealed the existence of multiple XXAA male/XYAA female/XAA(Y) female sex chromosomes. The XAA(Y) karyotype originated by a centric (Robertsonian) fusion between the original, free Y chromosome and an autosome. 46.2% of the male individuals in this population are carriers of this Y-autosome fusion. In male meiosis the XAA(Y) sex chromosomes pair in the expected trivalent configuration. In the same population 53.8% of the male animals still possess the original, free XY sex chromosomes. E. riveroi is only the second vertebrate species discovered in which a derived Y-autosome fusion coexists with the ancestral free XY sex chromosomes. The free XY sex chromosomes, as well as the multiple XA(Y) sex chromosomes are still in a very primitive (homomorphic) stage of differentiation. With no banding technique applied it is possible to distinguish the Y from the X. Various banding techniques and in situ hybridizations have been carried out to characterize the karyotypes. DNA flow cytometric measurements show that the genome size of E. riveroi resembles that of other Eleutherodactylus species. The cytogenetic data obtained in E. riveroi are compared with those of the sole other vertebrate known to possess the extremely rare, multiple XXAA male/XYAA female/XAA(Y) female sex chromosomes. Surprisingly enough, this vertebrate again is a frog belonging to the genus Eleutherodactylus [E. ((maussi) biporcatus] which lives exactly in the same habitat in northern Venezuela as does E. riveroi.

X chromosomes of American marsupials contain minimal amounts of euchromatin

The karyotypes of four South American didelphid marsupials, representing diploid numbers of 2n = 14 and 18, have been analyzed by a variety of banding techniques. The 2n = 14 karyotypes display a high degree of homoeology, but there also exist distinct similarities between the 2n = 14 and 2n = 18 karyotypes. The interspecific differences found are due to centric fissions, pericentric inversions, and variations in the amount and composition of the constitutive heterochromatin. Contrary to the evolutionary conservation of the banding patterns in all autosomal arms, there are multiple differences in the number and chromosomal location of the nucleolus organizer regions. In species with X-linked nucleolus organizers, the 18S + 28S ribosomal RNA genes escape inactivation in female cells. Measurements on the X chromosomes of Marmosa fuscata and Micoureus demerarae unexpectedly reveal the lowest quantities of euchromatin so far determined in the X chromosomes of mammals: 1.5% and 1.8%, respectively, of their haploid female genomes. This is significantly less than the amount of euchromatin in the basic X chromosomes of other marsupials (3%) or eutherians (5%).

Chromosome banding in Amphibia. XXVI. Coexistence of homomorphic XY sex chromosomes and a derived Y-autosome translocation in Eleutherodactylus maussi (Anura, Leptodactylidae)

A 15-year cytogenetic survey on one population of the leaf litter frog Eleutherodactylus maussi in northern Venezuela confirmed the existence of multiple XXAA male symbol /XAA(Y) female symbol sex chromosomes which originated by a centric (Robertsonian) fusion between the original Y chromosome and an autosome. 95% of the male individuals in this population are carriers of this Y-autosome fusion. In male meiosis the XAA(Y) sex chromosomes pair in the expected trivalent configuration. In the same population, 5% of the male animals still possess the original, free XY sex chromosomes. In a second population of E. maussi analyzed, all male specimens are characterized by these ancestral XY chromosomes which form normal bivalents in meiosis. E. maussi apparently represents the first vertebrate species discovered in which a derived Y-autosome fusion still coexists with the ancestral free XY sex chromosomes. The free XY sex chromosomes, as well as the multiple XA(Y) sex chromosomes are still in a very primitive (homomorphic) stage of differentiation. With no banding technique applied it is possible to distinguish the Y from the X. DNA flow cytometric measurements show that the genome of E. maussi is among the largest in the anuran family Leptodactylidae. The present study also supplies further data on differential chromosome banding and fluorescence in situ hybridization experiments in this amphibian species.

The rare human fragile site 16B

The rare human fragile site 16B (FRA16B) has been found to occur spontaneously. Its expression in lymphocyte cultures can also be induced or greatly enhanced by addition of chemicals which are known to bind to AT-rich DNA regions. Following optimal treatment with 150 microg/ml berenil 24 h prior to fixation, the heterozygote frequency of FRA16B is found to be about 5% in populations of European descent. Thus, FRA16B represents the most common of the rare fragile sites. Consistent with cytogenetic observations, the molecular characterization of FRA16B revealed that it is an amplified 33-base pair AT-rich minisatellite repeat. These interindividually variable, extremely large repeat expansions of 15-70 kb in size do not seem to interfere with the expression of genes essential for human development since heterozygotes and homozygotes for FRA16B are normal.

Chromosome banding in Amphibia. XXII. Atypical y chromosomes in Gastrotheca walkeri and Gastrotheca ovifera (Anura, Hylidae)

The chromosomes of the rare South American marsupial frogs Gastrotheca walkeri and G. ovifera were extensively reexamined with various banding techniques. The karyotypes of both species are distinguished by a new category of XY female symbol /XX male symbol female sex chromosomes. The unusual Y chromosomes are characterized by containing the least amount of constitutive heterochromatin in the karyotypes. This is in contrast to all previously known amphibian Y chromosomes and does not fit the evolutionary model of early XY differentiation in vertebrates. In male meiosis, the heteromorphic XY chromosomes of both species still exhibit the same pairing configurations as the autosomes. DNA flow cytometric measurements show the nuclear DNA amount of G. walkeri to be 10.90 pg. The significance of the XY/XX sex chromosomes of these marsupial frogs, the various classes of constitutive heterochromatin detected, and the data obtained from meiotic analyses are discussed in detail.

Chromosome banding in amphibia. XXIII. Giant W sex chromosomes and extremely small genomes in Eleutherodactylus euphronides and Eleutherodactylus shrevei (Anura, Leptodactylidae)

Highly differentiated, heteromorphic ZZ female symbol /ZW male symbol sex chromosomes were found in the karyotypes of the neotropical leptodactylid frogs Eleutherodactylus euphronides and E. shrevei. The W chromosomes are the largest heterochromatic, female-specific chromosomes so far discovered in the class Amphibia. The analyses of the banding patterns with AT- and GC base-pair specific fluorochromes show that the constitutive heterochromatin in the giant W chromosomes consists of various categories of repetitive DNA sequences. The W chromosomes of both species are similar in size, morphology and banding patterns, whereas their Z chromosomes exhibit conspicuous differences. In the cell nuclei of female animals, the W chromosomes form very prominent chromatin bodies (W chromatin). DNA flow cytometric measurements demonstrate clear differences in the DNA content of male and female erythrocytes caused by the giant W chromosome, and also shows that these Eleutherodactylus genomes are among the smallest of all amphibian genomes. The importance of the heteromorphic ZW sex chromosomes for the study of Z-linked genes, the similarities and differences of the two karyotypes, and the significance of the exceptionally small genomes are discussed.

IVF-patients with nonmale factor "to ICSI" or "not to ICSI" that is the question?

PURPOSE

Intracytoplasmic sperm injection (ICSI) guarantees high fertilization rates and could theoretically lead to higher implantation rates as well. Furthermore injection into oocyte creates a hole in the zona pellucida similar to the procedure of assisted hatching. We were therefore interested to assess such a potential benefit for infertile IVF patients without male factor.

MATERIALS AND METHODS

Open randomized prospective study according to the rules "Good Clinical Practice" with informed consent of the patients and institutional review board approval. Ninety-one consecutively seen patients with tubal infertility or hostile cervical mucus were randomized to undergo either ICSI (44 patients) or IVF (45 patients). In two patients fertilization of oocytes failed and so a repeated ICSI had to be performed. All these patients were stimulated with the same protocol, using the gonadotropin releasing hormone-agonist (GnRH-a) buserelin acetate in an ultrashort flair-up protocol together with pure follicle stimulating hormone (rFSH). The two study groups did not differ in terms of age, BMI, and all baseline hormone levels.

RESULTS

The total pregnancy rate was 42% in the normal IVF group with 33% ongoing pregnancies. The ICSI group had a total pregnancy rate of 39% with 23% ongoing pregnancies. The implantation rate per transferred embryo was higher for normal IVF but not significant (18% versus 11%). The variables, fertilization rate, age, body mass index, baseline hormone levels, endometrial thickness, embryo score, and the highest grade embryo per transfer were very similar in both groups.

CONCLUSION

ICSI should be applied only when conventional IVF fails, that is, for male factor patients and for patients with unexplained infertility.

An interstitial nucleolus organizer region in the long arm of human chromosome 7: cytogenetic characterization and familial segregation

An unusual NOR-bearing chromosome 7 was detected in a phenotypically normal, healthy 29-year-old male proband. Differential banding techniques as well as in situ hybridization employing various DNA-probes were performed in order to characterize the chromosome in detail. The nucleolus organizer region was found to be located between bands 7q21.3 and 7q22.1. No further rearrangements were detected in this chromosome. Analysis of spontaneously occurring micronuclei revealed 9% of them to contain a 7q fragment distal to (or including) the inserted NOR, suggesting that the inserted secondary constriction represents a potential hot spot for chromosomal breakage and rearrangement. Segregation analysis of the variant chromosome 7 in 51 members of the probands' family showed transmission in a Mendelian fashion. 27 individuals were found to be heterozygous for the inserted chromosome. A three-year-old child in the consanguineous marriage of two heterozygous carriers exhibited the NOR-insertion in both of his chromosome 7 homologues. To our knowledge, this is the first report on a homozygous carrier of a non-acrocentric NOR-bearing chromosome.

Cumulus assessment by three-dimensional ultrasound for in vitro fertilization

OBJECTIVE

To correlate the appearances of intrafollicular cumulus-like structures using three-dimensional (3D) ultrasound technology with the recovery of mature oocytes.

MATERIALS AND METHODS

A prospective, observational study using 3D ultrasound examination was performed in 50 women undergoing in vitro fertilization (IVF) after ovarian stimulation. Examination was performed on the day of human chorionic gonadotropin (hCG)-ovulation induction. Estradiol-17-beta (E2) levels were measured on the same day. The ovaries were examined for the presence of cumuli in all follicles greater than 15 mm in diameter. Only cumuli demonstrable in all three planes, or in a computer-animated 3D reconstruction, were recorded as 'visible'. The number, maturity, and fertilization rate of retrieved oocytes were compared with the pre-ovulatory assessment of cumuli by 3D ultrasound.

STATISTICS

Correlation coefficients (Pearson) between the variables were calculated and stepwise regression analyses performed.

RESULTS

A total of 262 cumuli were visualized within 318 follicles from which 296 mature oocytes were retrieved and 218 fertilized. There was a significant correlation between the number of detected cumuli and the number of retrieved oocytes (r2 = 0.83; P < 0.0001), mature oocytes (r2 = 0.78; P < 0.0001), and the number of the fertilized oocytes (r2 = 0.65; P < 0.0001). There was a marked correlation between E2 and the number of follicles and the number of fertilized oocytes.

CONCLUSIONS

Cumulus visualization by 3D ultrasound appears to be an indicator for mature oocytes and successful fertilization. Follicles in which the cumulus cannot be visualized in all three planes are unlikely to contain mature oocytes or oocytes in which fertilization is achieved.

Number and size of antral follicles as predictive factors in vitro fertilization and embryo transfer

PURPOSE

The purpose of the study was to evaluate whether number and size of antral follicles can predict the outcome of in vitro fertilization-embryo transfer.

METHODS

A total of 113 patients were prospectively included into this study. After 19 days of down-regulation, number and size of follicles were determined by using recent three-dimensional transvaginal ultrasound technology. Before application of gonadotropin, all follicles had been defined as antral follicles. According to size, antral follicles were categorized into four different groups: group I included antral follicles < 5 mm, group II follicles 5-10 mm; group III 11-20 mm; and group IV > 20 mm. Pregnant and non-pregnant patients were compared in terms of their number of antral follicles of group I-IV. These four groups were then compared regarding implantation rate, number of retrieved oocytes, endometrium thickness, and age.

RESULTS

Pregnant patients showed an significant higher number of follicles with the size between 5 and 10 mm (P = 0.04). A significant correlation was found between number of retrieved oocytes and antral follicle size of 5-10 mm (P = 0.0001). Antral follicles with a diameter between 5 and 10 mm decreased significantly with age (P = 0.008). In group III and IV, a significant correlation was found between antral follicle size (P = 0.016) and serum estradiol level after gonadotropin-releasing hormone-agonist down-regulation (P = 0.011).

CONCLUSIONS

We demonstrated that patients with a higher number of follicles between 5 and 10 mm showed a significantly higher pregnancy rate, whereas patients with a dominant number of antral follicles > 11 mm have a higher cancellation rate due to ovarian low response.

Spectral karyotyping of the human colon cancer cell lines SW480 and SW620

The cell lines SW480 and SW620, derived from different stages of colon carcinoma in the same patient, have been used for a number of biochemical, immunological, and genetic studies on colon cancer. A comparative analysis of their karyotypes may identify chromosomal aberrations that might represent markers for metastatic spread. In the present study spectral karyotyping (SKY) was applied to these two colon cancer cell lines. Compared to previously reported G-banded karyotypes, 9 (SW480) and 7 (SW620) markers were identical, 3 (SW480) and 3 (SW620) markers could be redefined, 5 (SW480) and 8 (SW620) markers were newly identified, and 4 (SW480) and 5 (SW620) of the previous described markers could not be confirmed. The redefined aberrations include very complex rearrangements, such as a der(16) t(3;16;1;16;8;16; 1;16;10) and a der(18)t(18;15;17)(q12; p11p13;??) in SW620 and a der(19)t(19;8;19;5) in SW480, that have not been identified by conventional banding techniques. The resulting chromosome gains (5q11-->5q15, 7pter-->q22, 11, 13q14-->qter, 20pter-->p12, X) and losses (8pter-->p2, 18q12-->qter, Y) found in both SW480 and SW620 were in good agreement with those frequently described in colorectal tumors as primary changes in the stem cell. Abnormalities found exclusively in SW620 cells only (gains of 5pter-->5q11, 12q12-->q23, 15p13-->p11, and 16q21-->q24 and losses of 2pter-->2p24, 4q28-->qter, and 6q25-->qter) can be viewed as changes that occurred in a putative metastatic founder cell.

[Painfulness of transvaginal follicle aspiration for oocyte retrieval in in-vitro-fertilization]

OBJECTIVE

The aim of this study was to analyze the painfulness of a transvaginal ultrasound-guided follicle punction.

MATERIAL AND METHODS

Patients could choose to have either a neuroleptanalgesia or to be supported by the partner or a psychotherapist during the oocyte pick up. Based on a questionnaire, 277 patients tried to describe their level of pain in a horizontal alphanumeric scale divided in 15 categories, while other painful physical interacts could be quantified, too. Furthermore, patients were asked for the cause of sterility, former IVF-ET treatments and whether the partner or the psychotherapist looked after them during the oocyte retrieval. Statistical analysis was performed using a standardized computer program (Stat View, Abacus Concepts, USA).

RESULTS

The neuroleptanalgesia reduced the intensity of pain (average value of pain: 1.21 vs 9.26 without analgesia) in a significant way (p = 0.0001). Some patients compared the pain at oocyte retrieval with a bone fracture (8.08) or surgeries (10.12). More painful was a colic (13.67), infections (13.5), some diagnostic surgeries (12.09) or a delivery (11.91). Younger woman and patients with dysmenorrhea felt significantly more pain than others. Neither the presence of the partner or psychotherapist during punction nor the indication, number of previous IVF-ET treatments or a following pregnancy had any influence on the statistics.

CONCLUSION

Age as well as the rate of problems with menstruation should help the patient to decide on whether to have the follicle punction with or without anesthesia.

Homozygotes for FRA16B are normal

Homozygotes for the rare folate-sensitive autosomal fragile sites have never been recorded. Two non-folate-sensitive rare fragile sites (FRA10B and FRA17A) have been previously recorded in normal individuals. We document two unrelated normal individuals who are homozygotes for the rare fragile site FRA16B and record the patterns of induction of this fragile site with berenil. The existence of normal homozygotes for FRA16B suggests that this fragile site is not within a gene essential for normal development.

Vascular endothelial growth factor and its receptors in male fertility

OBJECTIVE

To determine the concentration of vascular endothelial growth factor in the seminal fluid, the presence of vascular endothelial growth factor receptors Flt-1 and KDR in spermatozoa, and the predictive value of seminal vascular endothelial growth factor on fertilization and the chance of pregnancy in patients undergoing intracytoplasmic sperm injection (ICSI) or IVF.

DESIGN

Retrospective analysis.

SETTING

Private institute (semen collection, IVF/ICSI) and academic research environment (analysis of seminal fluid and spermatozoa).

PATIENT(S)

Eighty men whose spermatozoa were subsequently used for IVF or ICSI.

INTERVENTION(S)

Seminal vascular endothelial growth factor was measured by an EIA. Spermatozoa were analyzed by fluorescence-activated cell sorter analysis and by immunocytochemistry.

MAIN OUTCOME MEASURE(S)

Oocyte fertilization rate, pregnancy rate, and presence of vascular endothelial growth factor receptors on spermatozoa.

RESULT(S)

Patients with a seminal concentration of vascular endothelial growth factor of 2-100 ng/mL had a sixfold increased chance of pregnancy. Vascular endothelial growth factor concentration and patient's age remained the only independent prognostic factors for pregnancy. The concentration of vascular endothelial growth factor did not correlate with indices of male factor infertility or with the oocyte fertilization rate. Expression of vascular endothelial growth factor receptors (Flt-1, KDR) on spermatozoa was demonstrated.

CONCLUSION(S)

The seminal concentration of vascular endothelial growth factor correlates with the chance of pregnancy in patients undergoing IVF or ICSI. Vascular endothelial growth factor receptors Flt-1 and KDR were detected on spermatozoa for the first time.

The effect of smoking on oocyte quality and hormonal parameters of patients undergoing in vitro fertilization-embryo transfer

PURPOSE

The aim of the present study was to investigate the influence of smoking on different parameters such as oocyte count, embryo score, and basal hormone values within the scope of in vitro fertilization-embryo transfer (IVF-ET).

METHODS

Eight hundred thirty-four women undergoing IVF-ET treatment were classified as smokers or nonsmokers on the basis of questionnaires. Additionally, we divided them into three groups according to their stimulation protocol--"combined stimulation" [I; clomiphene citrate plus human menopausal gonadotropin (hMG)], "ultrashort" [II; gonadotropin releasing hormone agonist (GnRHa) plus hMG or follicle-stimulating hormone (FSH)], and "long downregulation protocol" (III)--and further classified again as smokers or nonsmokers within the groups.

RESULTS

In general, smoking patients were significantly (P = 0.0195) younger than nonsmokers and showed a significantly (P = 0.0379) lower embryo score and a tendency (P = 0.0931) to produce fewer oocytes. There was no significant difference concerning the number of normally or pathologically fertilized and transferred oocytes and embryos suitable for cryopreservation. Women who smoked had significantly (P = 0.0112) higher basal 17-beta-estradiol (E2), luteinizing hormone (LH) (P = 0.0001), and dehydroepian-drosteronesulfate (DHEAS) (P = 0.0039) levels, but their basal human prolactin (HPRL) levels were significantly (P = 0.0033) lower than those of nonsmokers. According to the stimulation protocol used, we found the following results. Smoking patients in group I showed a significantly (P = 0.023) lower embryo score and produced fewer oocytes (P = 0.0113), with fewer of them being fertilized (P = 0.0072) and transferred (P = 0.0067). Women who smoked had significantly (P = 0.0002) higher basal LH levels, but their HPRL levels were significantly (P = 0.031) lower than those of nonsmokers. Furthermore, they had a thinner endometrium on the day of embryo transfer (P = 0.0366). In group II we measured significantly elevated basal E2 levels (P = 0.0089) and higher LH values (P = 0.0092) in smokers. Group III showed a trend (P = 0.0565) toward lower HPRL values in smokers.

CONCLUSIONS

Although the fertilization rate of oocytes and the pregnancy rate were not significantly different between smokers and nonsmokers, we found significantly alterated hormonal parameters and negatively influenced oocyte parameters, particularly after clomiphene stimulation. So we might consider using only GnRHa protocols for smoking patients. Additionally, we advise our patients to stop smoking before an IVF-ET treatment because of the complex effects of smoking on the reproductive and hormonal system.

Psychotherapeutic counseling and pregnancy rates in in vitro fertilization

PURPOSE

Since the Austrian propagation bill of July 1, 1992, was passed into law, Austrian physicians are committed to offer psychological counseling to women before performing assisted reproductive techniques, unless refused by the patient. The acceptance of psychotherapeutic counseling (PSITCO) and its influence on pregnancy rate were carefully reviewed.

METHODS

The study comprised 1156 consecutive patients (mean age, 33.3 years) and 1736 in vitro fertilization (IVF) cycles. In a consent form for follicle puncture, the patients were interviewed about PSITCO as follows. Several methods of psychological support during IVF-embryo transfer treatment were offered to patients especially psychotherapy, hypnotherapy, and relaxation and physical perception exercises.

RESULTS

Forty-two and three-tenths percent of patients rejected PSITCO, 17.8% had already received PSITCO, and 10.4% were willing to undergo PSITCO. The acceptance of PSITCO had no relevance on pregnancy rate. The cumulative calculation of pregnancy rates showed that up to 56.4% of women who had undergone PSITCO conceived. In patients who were planning to undergo PSITCO, the pregnancy rate was 41.9%. Concerning the cumulative pregnancy rate, this study showed that patients who accepted or underwent PSITCO had a higher pregnancy rate than those who did not avail themselves of this possibility.

CONCLUSIONS

These results should encourage sterility specialists to consider psychological therapy as an essential aspect of IVF. Solely a written declaration of the patient stating his/her awareness of the possibility to undergo PSITCO is, in our opinion, insufficient.

Follicle aspiration with interactive three-dimensional digital imaging (Voluson): a step toward real-time puncturing under three-dimensional ultrasound control

OBJECTIVE

To evaluate the possibility of performing puncturing procedures under three-dimensional ultrasound (US) control in close to real time using a new commercially available system and to describe the technique.

DESIGN

Descriptive case study.

SETTING

Private outpatient infertility clinic.

PATIENT(S)

A volunteer undergoing IVF-ET treatment.

INTERVENTION(S)

Transvaginal needle-guided aspiration of 10 follicles using a newly developed US machine with a built-in rapid and powerful calculation software program for three-dimensional interactive volume and flow translation during operation. Interactive three-dimensional imaging was carried out during the aspiration of each follicle.

MAIN OUTCOME MEASURE(S)

The delays caused by volume acquisition and the search for the needle tip with and without "power Doppler" were estimated and compared.

RESULT(S)

Oocyte recovery was successful from all follicles. There was a mean (+/-SD) delay of 5.00 +/- 1.22 seconds from coasting to resuming real-time US scanning during interactive volume calculation and the search for the needle tip in the three-dimensional mode. This did not delay the procedure remarkably but enabled the precise localization of both the needle and its tip after each penetration. The integration of flow signals allowed an impressive color-coded demonstration of the needle within the tissue, but the delay was significantly longer for color-coded volume acquisition (18.40 +/- 4.56 seconds).

CONCLUSION(S)

Recent technology enables the performance of three-dimensional puncture procedures in close to real time; this technology is demonstrated for follicle punctures but will be of more importance in fields such as fetal medicine, oncology, and surgery.

Terminal deletion of the long arm of chromosome 10: a new case with breakpoint in q25.3

Since the first patient with partial deletion of the long arm of chromosome 10 was described in 1978, another 23 cases have been reported, with the breakpoint ranging from 10q23.3-26.2. To contribute further to the delineation of the monosomy 10qter syndrome, we describe a female child who, at age 3 6/12 years, was diagnosed with a de novo deletion of the long arm of chromosome 10, with a breakpoint in 10q25.3. The phenotypic manifestations in this child are compatible with those of previously reported cases. However, in contrast to most other patients, we found a moderate expression of the syndrome, with no genitourinary or cardiac malformations and with only mild retardation. Based on our observations and those of others, we conclude that a typical craniofacial appearance and varying degrees of psychomotor retardation are always found in patients with 10q- syndrome.

Successful treatment of a heterotopic pregnancy by sonographically guided instillation of hyperosmolar glucose

OBJECTIVE

To describe a new conservative approach in the treatment of heterotopic pregnancy.

DESIGN

Case report.

SETTING

A university hospital and an outpatient IVF center.

INTERVENTION(S)

Transvaginal ultrasonography-guided puncture of the ectopic gestational sac and instillation of hyperosmolar glucose.

RESULT(S)

The ectopic pregnancy resolved without further intervention. The intrauterine pregnancy resulted in a full-term live birth.

CONCLUSION(S)

Transvaginal injection of hyperosmolar glucose may be an effective conservative treatment for unruptured ectopic pregnancies in cases of heterotopic pregnancy.

Smoking and in vitro fertilization: a meta-analysis

PURPOSE

Including our own data and seven relevant publications from the literature, this meta-analysis aimed to establish the influence of the status of female smokers on the clinical pregnancy rate after the first attempt at in vitro fertilization-embryo transfer (IVF-ET).

METHODS

We started to collect information about our own patient's smoking habits in January 1996 to evaluate prospectively the influence on IVF success. Information regarding 799 patients (607 nonsmokers and 192 smokers) was obtained. Additionally we retrieved seven relevant publications from the unabridged MEDLINE 1982-1996. They were recalculated to first cycles, because from a biometrical point of view, only the results of the first IVF cycle are really well comparable, as the number of necessary IVF cycles always correlates with the number of pregnancies. These data were compared in the nonparametric sign test according to Dixon-Mood and calculated as relative success ratios, defined as the quotient of the probability of IVF-ET success of nonsmokers divided by that of smokers for each publication.

RESULTS

This meta-analysis, based on a total of 2314 first IVF-ET treatments, showed that almost twice as many IVF-ET cycles were needed for smokers as for nonsmokers to become pregnant. For the success quotient, we obtained a ratio of 1.79, with an associated 95% confidence interval of from 1.24 to 2.59. The total analysis shows, with a P value of less than 0.01, significantly higher pregnancy rates (21%) in nonsmokers compared to smokers (14%).

CONCLUSIONS

Based on the analyzed data there exists--from a statistical point of view--a significant negative effect on the chances of success for smokers to become pregnant compared to nonsmokers.

Ultrastructural observations in human oocytes and preimplantation embryos after zona opening using an erbium-yttrium-aluminium-garnet (Er:YAG) laser

For more than 3 years we have performed laser-assisted hatching prior to embryo transfer in patients with recurrent implantation failure using an erbium-yttrium-aluminium-garnet (Er:YAG) laser system that operates in the infrared region of the light spectrum. The laser beam is guided through a quartz fibre and is brought into direct contact with the zona pellucida. This study was undertaken to evaluate the ultrastructural effects of this laser on the zona pellucida and underlying cell membrane of unfertilized human oocytes and pathologically fertilized preimplantation embryos using light and scanning electron microscopy. The Er:YAG laser produces an almost circular zona opening in the shape of a truncated cone tapering off towards the inside, with a mean diameter of 18 mm. The exact diameter of the drilled site depends on the diameter of the fibre tip and the total number of pulses applied. After laser interaction, the zona matrix and the surface of the underlying ooplasm membrane showed no degenerative alterations. We conclude that the Er:YAG laser is an effective microsurgical tool for achieving reproducible, precise zona openings particularly suitable for purposes of assisted hatching because of their characteristic shape.

Modulation of ovarian function by an oral contraceptive containing 30 micrograms ethinyl estradiol in combination with 2.00 mg dienogest

Twenty-two healthy female volunteers with normal ovulatory cycles, aged between 20 and 34 years (27.3 +/- 4.1), were included in a single-center, noncomparative study to investigate the modulation of ovarian function by an oral contraceptive containing 30 micrograms ethinyl estradiol in combination with 2.00 mg dienogest. At baseline, during three treatment cycles and post-treatment, serum levels of luteinizing hormone, follicle-stimulating hormone, 17 beta-estradiol, and progesterone were assayed and ultrasonography was used to measure follicular size and the thickness of the endometrium. The primary efficacy variable was inhibition of ovulation as measured by ovarian activity grading. All volunteers ovulated during the pretreatment cycle. During treatment, none of the subjects had ovulatory cycles, although there was still some ovarian activity in several subjects. During the first treatment cycle, only 4% (1 subject) of cycles showed active follicle-like structures. The frequency of follicle-like structures increased to 33% and 35% during treatment cycles 2 and 3. The frequency of presumptive luteinized unruptured follicle-like structures was 5% (1 subject) and 15% (3 subjects) in treatment cycles 2 and 3. The serum hormone concentrations were effectively suppressed in comparison to baseline. The ovarian activity returned to baseline during the post-treatment period. One subject was excluded from further study because of a medical problem believed unrelated to use of the oral contraceptive. No serious adverse events were recorded during the course of the study. The results of the present investigation indicate that the modulatory effects on ovarian function of the monophasic oral-contraceptive containing 30 micrograms ethinyl estradiol combined with 2.00 mg dienogest lead to adequate suppression of ovarian activity and effective inhibition of ovulation.

Double-blind, randomized, placebo controlled study on the effects of the monophasic oral contraceptive containing 30 micrograms ethinyl estradiol and 2.00 mg dienogest on the hemostatic system

Forty healthy female volunteers aged between 19 and 35 years (27.3 +/- 4.1 years) with normal menstrual cycles were included in a double-blind, randomized, placebo-controlled study to investigate the influence on the hemostatic system of an oral contraceptive containing 30 micrograms ethinyl estradiol in combination with 2.00 mg dienogest, which is a 19-norprogestin without a 17 alpha-ethinyl group. At baseline and during one treatment cycle, 12 hemostatic parameters were measured on cycle days 7, 14, and 21. The hemostatic parameters were categorized as either procoagulatory, anticoagulatory and profibrinolytic, or antifibrinolytic and indicative of fibrin turnover. Differences between placebo and 30 micrograms ethinyl estradiol and 2.00 mg dienogest of plasma levels of hemostatic parameters on cycle days 21 of the precycle and treatment cycle were chosen as target variables. Prothrombin fragment 1 + 2 (F 1 + 2) was chosen as the main target variable. Equivalence of F 1 + 2 between placebo and active treatment was noted. Among the procoagulatory factors, only factor VII activity was found to be increased over placebo in the active treatment group, but decreased in the placebo group. Protein C activity increased during the treatment with 30 micrograms ethinyl estradiol and 2.00 mg dienogest, and was higher than that of the placebo group in which this parameter decreased during the treatment cycle. There was a corresponding increase in fibrinolytic activity being reflected by higher plasminogen levels in the active treatment group in comparison with placebo. An increase was noted for the fibrinolytic parameter D-dimer. Apart from isolated measurements, the parameters remained in their respective normal ranges. The data combine to suggest that 30 micrograms ethinyl estradiol and 2.00 mg dienogest has a balanced effect on the hemostatic system stimulating both procoagulatory and fibrinolytic activity.

Prospective randomized study of an ultrashort gonadotrophin-releasing hormone agonist versus a modified suppression protocol for ovarian stimulation in intracytoplasmic sperm injection cycles

To compare oocyte quality and clinical outcome after an ultrashort or a modified suppression gonadotrophin-releasing hormone agonist (GnRHa) protocol for ovarian stimulation in intracytoplasmic sperm injection (ICSI) cycles, we conducted a prospective randomized study of 60 consecutive couples with severe male infertility admitted for their first in-vitro fertilization (IVF) and ICSI attempt. More cycles were cancelled after the ultrashort protocol (8/30) than after the modified suppression protocol (3/30), although the difference was not significant. There were no cases of severe ovarian hyperstimulation syndrome (OHSS) in the ultrashort group compared to three cases in the suppression group. The percentage of mature metaphase II oocytes recovered in both groups was similar (88 versus 86%), as were the fertilization or cleavage rates after ICSI. In the ultrashort group, a total of 64 embryos was replaced in 22 transfers (mean 2.9 embryos per transfer), resulting in three first trimester abortions and seven deliveries. In the suppression group, 11 deliveries were achieved after transfer of a total of 75 embryos in 27 patients (mean 2.8 embryos per transfer). In conclusion, there was no apparent difference between the two GnRHa protocols in terms of oocyte quality and clinical outcome. However, because of the lower rate of severe OHSS, in our study the ultrashort protocol was more appropriate for ovarian stimulation in ICSI cycles than the modified suppression protocol.

[Ultrasound-guided transvaginal puncture of ovarian cysts]

Ultrasound-guided transvaginal aspiration of ovarian cysts offers a simple outpatient strategy for immediate pain relief and effective treatment but bears the risk of an iatrogenic spread of malignant cells. This study evaluated the cellular composition of the cyst fluids in a group of 26 sterility patients, in all of whom one or more ovarian cysts had been diagnosed and punctured. None of the patients had complications or evidence of malignant cells on cytological examination after the puncture. Only in one case dyskariotic cells were diagnosed causing an operative exploration that revealed a benign tumour. In 9 patients the ovarian cysts recurred and therefore 2 patients finally underwent an exploratory operation. In our opinion transvaginal ultrasound aspiration of functional cysts is an easy and safe procedure and may be undertaken in sterility patients in the context of specific criteria.