Should single embryo transfer be used in patients with any kind of infertility factor? Preliminary outcomes

OBJECTIVE

Multiple embryos have been transferred to compensate for low implantation rates, which in turn, increase the likelihood of multiple pregnancies. Despite the publication of clinical guidelines and a reduction in the number of embryos transferred, double embryo transfer still is the most common practice. There is no clear evidence of who should receive the single embryo transfer (SET), and it is more commonly indicated for patients of good prognosis. However, it is not clear how much the presence of other infertility factors can affect the SET prognosis. The aim of this study was to evaluate differences in clinical pregnancy rates (CPR) of frozen-thawed SET cycles for women presenting with different infertility factors.

METHODS

Retrospective cohort study evaluating 305 frozen-thawed SET cycles performed in the last 10 years in a private IVF center. We included patients undergoing ovarian stimulation cycles, using ejaculated sperm and a frozen-thawed ET. Embryos were routinely vitrified and warmed up, and the blastocysts were transferred after endometrium preparation. The cycles were categorized according to the infertility factor classified by the Society for Assisted Reproductive Technologies (SART) as anatomic female factor (n=55), endocrine female factor (n=26), endometriosis (n=37), male factor (n=60), ovarian insufficiency (n=26), unexplained (n=24), multiple factors (n=45) and other (n=32). CPR were compared between the groups and the multivariate analysis was performed to evaluate the association of each infertility factor and the CPR, adjusted for confounders.

RESULTS

The women varied in age from 18 to 44 years (35.9±3.8), presented Body Mass Index of 22.4±3.1kg/m², baseline serum FSH of 7.4±8.3 IU/ml, and had a mean of 11.0±8.4 MII oocytes recovered and 6.4±5.3 embryos cryopreserved. The CPR, according to infertility factors were: anatomic female factor (25.9%), endocrine female factor (30.8%), endometriosis (27.8%), male factor (20.7%), ovarian insufficiency (21.7%), unexplained (9.5%), multiple factors (17.1%) and other (20.7%). Multivariate analysis did not show significant association of infertility factors and CPR adjusted for confounders.

CONCLUSIONS

Patients presenting different infertility factors seem to have a satisfactory CPR for a SET cycle, except those with unexplained infertility. This is a preliminary outcome and the number of patients by category is small; in addition, the retrospective characteristics of the study are its limitations. Overall, our findings suggest that patients presenting any infertility factor, except unexplained infertility, are suitable to receive a SET with satisfactory outcomes.

Total fertilization failure in intra-cytoplasmic sperm injection cycles--classification and management

In this retrospective cohort study we intended to propose a classification and preliminary management strategy for couples exhibiting total fertilization failure (TFF) in intra-cytoplasmic sperm injection (ICSI) cycles. Sixteen couples with a total of 27 cycles exhibiting TFF, age <40 and/or more than four M2 oocytes aspirated were enrolled. While TFF occurred in 4.3% of all 3723 ICSI cycles, in women younger than 40 with at least 5 M2 oocytes the TFF rate was 0.7%. Indications for ICSI were severe male factor and unexplained infertility. Of the 16 couples with TFF, 4 demonstrated a single episode of TFF, with either subsequent or former normal fertilizations, thus implying possible sporadic faulty laboratory conditions. Ten couples demonstrated repeated total or very low fertilization rates, hinting at a gamete defect not overcome by ICSI. Two couples experienced TFF in the first and only cycle performed at our unit. We conclude that initial and repeated TFF hints at severe gamete defects for which only donor gametes may prove successful while sporadic TFF events could simply imply a technical modifiable condition.

Unexplained infertility: does it really exist?

Recent medical literature has quite extensively addressed the use of various terminologies within the field of reproductive medicine. This discussion has, however, so far overlooked the fact that one of the most frequently made diagnosis, so-called unexplained infertility (UI), not only didactically but, even more importantly, clinically, appears unsustainable as an independent diagnosis. The arguments in support of such a contention are manifold. The diagnosis of UI is highly subjective. It is dependent on which diagnostic tests have been performed (or have been omitted) and at what level of quality. Paradoxically, a diagnosis of UI will, therefore, be more often reached if the diagnostic workup is incomplete or of poor quality. Supported by evidence from the literature, the argument is made that the conditions, most frequently misdiagnosed as UI, are endometriosis, tubal infertility (especially distal and peritubal disease), premature ovarian ageing and immunological infertility. Because of the obvious unreliability of a diagnosis of UI and the widely reported unevenness in diagnostic criteria, we recommend the abandonment of UI as a formal infertility diagnosis. Better efforts to reach infertility diagnoses more accurately should improve the diagnostic accuracy of hitherto frequently missed diagnoses, which often falsely have led to a diagnosis of UI.

Use of carbon-13 as a population marker for Anopheles arabiensis in a sterile insect technique (SIT) context

Background

Monitoring of sterile to wild insect ratios in field populations can be useful to follow the progress in genetic control programmes such as the Sterile Insect Technique (SIT). Of the numerous methods for marking insects most are not suitable for use in mass rearing and mass release. Suitable ones include dye marking, genetic marking and chemical marking.

Methods

The feasibility of using the stable isotope of carbon, ¹³C, as a potential chemical marker for Anopheles arabiensis was evaluated in the laboratory. Labeled-¹³C glucose was incorporated into the larval diet in a powder or liquid form. The contribution of adult sugar feeding to the total mosquito carbon pool and the metabolically active carbon pool was determined by tracing the decline of the enrichment of the adult male mosquito as it switched from a labeled larval diet to an unlabeled adult diet. This decline in the adult was monitored by destructive sampling of the whole mosquito and analyzed using isotope ratio mass spectrometry.

Results

A two-pool model was used to describe the decline of the ¹³C-enrichment of adult mosquitoes. The proportion of the total adult carbon pool derived from the adult sugar diet over the life span of mosquitoes was determined and the ratio of structural carbon, with a low turnover rate to metabolically active non-structural carbon was assessed. The uptake and turnover of sugar in the metabolically active fraction suggests that after 3 days >70% of the active fraction carbon is derived from sugar feeding (increasing to >90% by day 7), indicating the high resource demand of male mosquitoes.

Conclusion

It was possible to "fix" the isotopic label in adult An. arabiensis and to detect the label at an appropriate concentration up to 21 days post-emergence. The optimum labeling treatment would cost around 250 US$ per million mosquitoes. Stable isotope marking may thus aid research on the fate of released insects besides other population-based ecological studies.

Infertility classification: A work in progress sounds like SOAP revisited

Documentation and communication regarding infertility evaluation and management continue to be a work in progress. Grading systems focused on the degree of infertility and the associated prognosis are a step in the right direction. A subjective, objective, assessment, plan (SOAP) approach is a logical way to provide a detailed method of communication and documentation when dealing with infertile couples.

Legal issues to address when managing clinical information across Europe: the ECIT case study (www.ECIT.info)

This paper identifies issues which will need to be addressed in pursuing the aims and objectives of the European Classification of Infertility Taskforce (ECIT), namely: to establish classification codes for infertility management; to improve the consistency of infertility information collection by specialist centres, particularly but not exclusively by computerised systems; to use these codes to enable the transfer of infertility information from specialist centres to national infertility data registries; to develop a Grid linking the data held in European infertility data registries; to use Grid processing to mine the data in the European infertility data registries to optimise patient management improving the effectiveness of treatment and reducing the risk.

Value of the serum estradiol level for preventing ovarian hyperstimulation syndrome: a retrospective case control study

OBJECTIVE

To assess the value of different serum E(2) cut-off levels for predicting women at risk for ovarian hyperstimulation syndrome (OHSS).

DESIGN

Retrospective case-control study of a cohort of women undergoing assisted reproduction treatment (ART) over 12 months.

SETTING

Tertiary university hospital.

PATIENT(S)

The study group included women with OHSS who fulfilled the endocrine inclusion criteria (n = 40). The control group was a random sample (n = 40) from the cohort of women undergoing ART.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

To evaluate the sensitivity and specificity of different serum E(2) cut-off levels on day 11 of ovarian stimulation in preventing the establishment of OHSS.

RESULT(S)

Three hundred ninety-nine cycles (IVF and intracytoplasmic sperm injection) were undertaken between June 2000 and May 2001. The study group (n = 40) was compared with the control group (n = 40) undergoing ART during the same period of time. On day 8 of ovarian stimulation, the mean (SD) E(2) level in the study group was 8,517(5.3) pmol/L (2,320 pg/mL), and in the control group it was 2,540 (2.6) pmol/L (691 pg/mL). On day 11 of stimulation the mean (SD) E(2) level was 15,662 (4.2) pmol/L (4,266 pg/mL) and 5,804 (4.5) pmol/L (1,581 pg/mL), respectively. Twenty-four (60%) women who developed OHSS had E(2)levels >6,000 pmol/L (1,634 pg/mL) on day 8 and above 11,000 pmol/L (2,996 pg/mL) on day 11. Sixteen (40%) had E(2) levels <6,000 pmol/L (1,634 pg/mL) on day 8, but all had levels above 11,000 pmol/l (2,996 pg/mL) on day 11.

CONCLUSION(S)

A serum E(2) level of 12,315 pmol/L (3,354 pg/mL) on day 11 of ovarian stimulation gives a sensitivity and specificity of 85% for the detection of women at risk for OHSS.

Temperament and character in couples with fertility disorders: a double-blind, controlled study

OBJECTIVE

To evaluate the personality features of infertile patients.

DESIGN

A double-blind, controlled study.

SETTING

An outpatient facility for diagnosis and care of infertility.

PATIENT(S)

We assessed 142 infertile couples with obstetric-gynecologic clinical and instrumental examinations. The couples were divided into three groups: organic infertility, functional infertility, and infertility of uncertain origin. The third group was excluded.

INTERVENTION(S)

Organic infertility and functional infertility were ascertained with gynecologic and andrologic clinical examinations, seminal liquid examination, postcoital testing, progesterone assay, hysterosalpingography, biopsy of endometrium, and laparoscopy. Personality traits were assessed with the Temperament and Character Inventory (TCI).

MAIN OUTCOME MEASURE(S)

Results of the Temperament and Character Inventory.

RESULT(S)

Infertile women showed lower Cooperativeness than control women. Women with functional infertility had lower scores in Cooperativeness and Self-Directedness than women with organic infertility. Men belonging to the functional infertility group had a lower Novelty Seeking score than did those of the organic infertility group. Men and women in the functional infertility group showed higher Harm Avoidance than those in the organic infertility and control groups.

CONCLUSION(S)

The results emphasize that the study of personality in the diagnostic and therapeutic assessment of infertility might provide useful predictive elements for functional infertility.

Modern concepts of endometriosis. Classification and its consequences for therapy

OBJECTIVE

To review the development of the American Society for Reproductive Medicine (ASRM) classification forms for endometriosis and assess efforts to validate their clinical utility.

STUDY DESIGN

The relevant medical literature was reviewed.

RESULTS

ASRM has established classification forms for endometriosis in women with infertility and pelvic pain. The utility of these new forms has not been assessed. Studies using earlier versions of the ASRM classification reported that the stage of disease correlates better with pain symptoms than fertility outcome.

CONCLUSION

The ASRM classification form for infertility and the form to assist in the management of pelvic pain in women with endometriosis permit clear documentation of the extent and morphologic type of disease. Further studies are needed to refine the classification and enhance its predictive ability.

Are we managing the infertile couple effectively?

The purpose of our study was to construct a management sequence allowing classification of infertile couples into specific groups according to the available treatment modalities. We achieved this by the following: a search of the existing medical literature; critical evaluation of personal experience gained by extensive practice in treating infertile couples; and perusal of methods and modalities for diagnosis and treatment of infertility available at present. We present a new concise classification of infertility, permitting efficient use of existing techniques and treatment modalities and conforming to the expectations of a modern consumer society.

Classification of adverse reproductive effects can be improved by measurements of multiple biomarkers for ovarian toxicity and early fetal loss

Hormone assays have been developed and applied for monitoring reproductive function using self-collected urine samples in non-clinical populations of women. Early pregnancy loss, menstrual dysfunction, reduced fertility as well as the site of toxicity can now be assessed using daily early morning urine samples. The understanding of the specific limitations of individual assay systems is important, however, to make the best use of these systems. The use of multiple end-points and computer algorithms is suggested to avoid misclassification of adverse reproductive events.

The prevalence of subfertility: a review of the current confusion and a report of two new studies

The difficulties inherent in measuring the prevalence of subfertility are discussed. Four subtypes of subfertility are defined, enabling comparisons to be made between the widely different approaches previously reported. A detailed assessment was made of the prevalence of subfertility in two different samples of British women aged 25 to 44 years, using interviews, postal questionnaires, and medical record searches. Data were collected on 872 women from a general practice and 702 hospital patients. The combined data showed that 24% of all women attempting to conceive experience an episode of subfertility at some stage in their reproductive life. Thirteen percent experience this in attempting to conceive their first child, and 17% when attempting to conceive a subsequent child. Three percent of women are involuntarily childless and 6% of parous women are not able to have as many children as they would wish.

Research on infertility: definition makes a difference. The Cancer and Steroid Hormone Study Group

Although different definitions of infertility are used, research findings based on various definitions have not been systematically compared. To contrast the impact of five definitions of infertility on research findings, the authors analyzed data from the control group (randomly selected US women aged 20-54 years) of the Cancer and Steroid Hormone Study (1980-1983). For all definitions, an absence of recognized conception was the outcome of interest. Specifically, the authors examined the effect of various definitions of infertility on demographic characteristics of women classified as infertile, prevalence of a history of infertility, age at infertility classification, and cumulative incidence of conception after infertility classification. Results indicated that women classified as infertile by definitions based on unprotected intercourse for 12 months and unprotected intercourse for 24 months were more likely to be black, less educated, and classified as infertile at younger or older ages that women classified by alternative definitions. The prevalence of a history of infertility ranged from 6.1% (physician diagnosis) to 32.6% (unprotected intercourse for 12 months). For the definitions based on unprotected intercourse for 12/24 months and for physician diagnosis, the cumulative incidence of conception by greater than 120 months after infertility classification was 86.3%, 76.7%, and 75.4%, respectively. The authors conclude that the definition of infertility has an impact on research findings related to which and how many women are classified as infertile, the age at infertility classification, and the probability of future conception.