Arie Herman

Delayed fertilization and poor embryonic development associated with impaired semen quality

Delayed fertilization is common in cycles with immature oocytes. This phenomenon was observed in 42 of 423 with mature oocytes. Of the 42 cycles, 16 were excluded because of the presence of sperm autoantibodies. Sperm parameters of the remaining 26 (6.1%) cycles (group A) were compared with those in cycles with no fertilization at all (group B) and those in the control group (group C). The percentage of normal forms was 15% in group B and 24% in group A compared with 51% in group C. Fertilization rates were 32% in group A compared with 81% in group C. The incidence of poor embryonic morphology was 82% in group A compared with 29% in group C. Delayed fertilization and poor embryonic morphology associated with impaired sperm quality is of clinical and prognostic importance.

Male genital mycoplasmas and Chlamydia trachomatis culture: its relationship with accessory gland function, sperm quality, and autoimmunity

To study the effect of mycoplasmas and Chlamydia trachomatis infection on semen quality, these microorganisms were cultured from the semen and anterior urethra respectively, in a group of 175 infertile men suspected of a silent genital infection with a poor postcoital test. Chlamydia infection, but not mycoplasmas, was parodoxically more frequent in the apparently normal than oligotetratoasthenozoospermia patients. Mycoplasmas male infection, but not chlamydia, was more frequent in cases with female, mechanical, and/or organic infertility factors. Infection was unrelated to the accessory gland evaluation or sperm variables. However, seminal antisperm antibody activity was significantly increased in cases with any positive culture. By this local antibody increase, chlamydia and mycoplasmas may significantly reduce sperm egg penetration ability.

Pregnancy rate and ovarian hyperstimulation after luteal human chorionic gonadotropin in in vitro fertilization stimulated with gonadotropin-releasing hormone analog and menotropins.

The value of luteal phase supplementation with human chorionic gonadotropin (hCG) was assessed after a combined protocol of ovarian stimulation, using a long acting gonadotropin releasing hormone analog (GnRH-a) and human menopausal gonadotropins (hMG), in a randomized prospective study of 36 consecutive cycles in an in vitro fertilization (IVF) program. The patients were allocated on the transfer day to either luteal phase supplementation with hCG (Group A, n = 18) or none (Group B, n = 18). Nine patients of Group A conceived as compared with 3 in Group B. Five patients, all in Group A, developed ovarian hyperstimulation syndrome (OHSS) (3 moderate and 2 severe forms). Analysis of the hormonal profiles disclosed similar progesterone (P), estradiol (E2), and E2/P ratio up to the 6th post ovum pick-up day. Then, E2 and mainly P levels decreased only in Group B resulting in a rising E2/P ratio. These findings stress the importance of luteal support in IVF cycles treated with GnRH-a. In light of the increased risk of OHSS among hCG treated patients, further studies are needed to assess the optimal preparation needed.

Ovarian hyperstimulation syndrome following D-Trp-6 luteinizing hormone-releasing hormone microcapsules and menotropin for in vitro fertilization.

In 143 cycles of in vitro fertilization the ovarian hyperstimulation syndrome (OHSS) occurred in 12 (8.4%) cycles. Six were in the moderate form and 6 severe. Ovarian stimulation by menotropins was preceded by induction of hypopituitary hypogonadism using D-Trp6-LH-RH microcapsules. The OHSS cycles are characterized by improved ovarian response expressed by the increased serum levels of estradiol, number of follicles, oocytes, embryos and pregnancy rate as compared to cycles with no OHSS. All patients recovered uneventfully. The follicular puncture did not have the suggested protective effect against OHSS. It is suggested that the substantial incidence of OHSS is probably related to the excessive ovarian stimulation not interrupted by early luteinization which is practically abolished by this protocol. The role of the given luteal hCG doses in the genesis of OHSS is questioned.

Dynamic ultrasonographic imaging of the third stage of labor: New perspectives into third-stage mechanisms

OBJECTIVE Dynamic ultrasonographic imaging of the third stage of labor was performed to document ultrasonographic findings and to present new perspectives into third-stage mechanisms. STUDY DESIGN Twenty-five normal deliveries and five with prolonged third-stage labor were studied. RESULTS Normal third-stage labor could be divided into four phases: (1) latent phase, characterized by thick, placenta-free wall and thin, placenta-site wall; (2) contraction phase, with thickening of placenta-site wall (from < 1 cm to > 2 cm); (3) detachment phase, in which the placenta completes its separation and detaches; and (4) expulsion phase, with a sliding movement of the placenta. Although oxytocic agents were routinely used, they do not seem to influence the findings. In five cases with retained placenta the placenta-site wall was initially thin. In four of them it became thick, and the placenta was removed by traction of the cord, whereas in the fifth case the placenta-site wall remained thin and the placenta had to be removed manually. CONCLUSION Shearing forces seem to tear the decidual septae and thereby separate the placenta. This process is completed only when the placenta-site wall attains full thickness. In cases of prolonged third-stage labor, traction of the cord should be applied only when this phase is completed and the actual sliding movement of the placenta is observed.

Results of in vitro fertilization and embryo transfer by combined long-acting gonadotropin-releasing hormone analog D-Trp-6-luteinizing hormone-releasing hormone and gonadotropins

To avoid cancellation of in vitro fertilization (IVF) because of early luteinization, pituitary suppression by gonadotropin-releasing hormone (GnRH) was carried out in 111 cycles. D-Trp-6-luteinizing hormone-releasing hormone (LH-RH) microcapsules were administered intramuscularly at menstruation and menotropin (hMG) stimulation was started 19 days (mean) later. In 3 cycles (2.7%), only early luteinization occurred. The mean number of oocytes per cycle was 6.7, with a fertilization and cleavage rate of 50 and 95%, respectively. A mean of 3.4 embryos were transferred per cycle. The 111 cycles resulted in 34 clinical pregnancies, 41% per cycle with embryo transfer. The early abortion, multiple pregnancy, and ovarian hyperstimulation rates were 24, 18, and 11%, respectively. It is concluded that D-Trp-6-LH-RH/hMG cycles are associated with a very low occurrence of early luteinization, high number of oocytes and embryos, and a substantial incidence of ovarian hyperstimulation syndrome.

Development of children born after ovarian superovulation induced by long-acting gonadotropin-releasing hormone agonist and menotropins, and by in vitro fertilization☆☆☆★

The use of a gonodotropin-releasing hormone (Gn-RH) agonist in an in vitro fertilization (IVF) program raises the question of any influence on the physical, neurologic, and mental development of the children. We compared the development of children born after long-acting Gn-RH agonist treatment with that of children born after spontaneous pregnancies. Children from singleton pregnancies and > or = 28 months of age were examined by a pediatric neurologist and a psychologist who did not know to which group the children belonged. The General Cognitive Index test was used. Each group included 30 children. Five children cooperated only partly. Physical and neurologic findings were normal in all children, except that one in the group born after in vitro fertilization had diffuse hypotonia, attention-deficit hyperactivity disorder, and hyperactivity. The General Cognitive Index for the 26 children in the study group and the 29 children in the control group who fully cooperated were 102 +/- 13.3 and 106 +/- 13.5, respectively (p = 0.37). The verbal perception, motor, and memory indexes were not significantly different. We conclude that the long-acting Gn-RH agonist had no clinically identifiable influence on the development of these children.

GONADOTROPINS AND COMBINED GONADOTROPIN-RELEASING HORMONE AGONIST : GONADOTROPINS PROTOCOLS IN A RANDOMIZED PROSPECTIVE STUDY

A prospective study was designed to compare cycles stimulated by human menopausal gonadotropin (hMG) (group A) with cycles pretreated with gonadotropin-releasing hormone agonist causing pituitary desensitization followed by hMG stimulation (group B). Three hundred two cycles were randomly allocated to each group. Cancellation rate was 27.2% in group A compared with only 3.3% in group B. Significantly less hMG ampules for a shorter period were needed in group A patients. Lower estradiol and higher luteinizing hormone levels were detected in the hMG group. Patients in group B yielded significantly more oocytes and more embryos per retrieval. A significantly higher pregnancy rate per cycle was obtained in group B (27%) as compared with that of group A (13%). Moderate and severe ovarian hyperstimulation syndrome was significantly more frequent in group B than in group A.

Torsion of normal adnexa in postmenarchal women and risk of recurrence.

OBJECTIVE: To compare the incidence of recurrent torsion of normal adnexa to recurrent torsion of abnormal adnexa in postmenarchal women. METHODS: All cases of surgically confirmed adnexal torsion operated on in our department from January 2002 to April 2006 were retrospectively analyzed. Classification as torsion of pathologic adnexa versus torsion of normal adnexa was based on pre- and postoperative pelvic sonograms, operative findings, and pathologic diagnoses (when available). The torsion recurrence rates were evaluated by a telephone questionnaire, with 90.5% compliance. RESULTS: Twelve women had twisted normal adnexa and 50 women had twisted abnormal adnexa. The women with twisted normal adnexa were younger (25.5±7.9 years versus 31.4±11.4 years, P=.10) and had a lower median parity (0 versus 1, P=.06). Both groups had similar clinical presentations and a similar mean time from admission to surgery. The torsion recurrence rates were 63.6% (95% confidence interval [CI] 0.3–0.9) in the twisted normal adnexa group and 8.7% (95% CI 0.02–0.2) in the twisted abnormal adnexa group (P<.001). The retorsion risk of the pathologic adnexa was especially low after cystectomy (5.3%, 95% CI 0.001–0.3) or salpingo-oophorectomy (0%). The Kaplan-Meier life table analysis also showed a higher retorsion risk for normal adnexa (P=.008). CONCLUSION: The current adnexa-sparing laparoscopic management of adnexal torsion by simply untwisting may predispose to recurrent torsion of normal adnexa. The role of ovariopexy procedures in the prevention of recurrent torsion events remains uncertain. LEVEL OF EVIDENCE: III

Prediction of in vitro fertilization outcome by sperm penetration assay with TEST-yolk buffer preincubation *

OBJECTIVE To evaluate sperm penetration assay (SPA) value as a screening tool before in vitro fertilization (IVF). DESIGN Follow-up study comparing sperm variables and IVF outcome. SETTING Infertile couples in an academic research environment. PATIENTS, PARTICIPANTS Two hundred forty-one infertile couples scheduled for IVF. INTERVENTIONS Sperm penetrating assay with cold Tes-TRIS (TEST) Yolk buffer semen preincubation and IVF. MAIN OUTCOME MEASURES Percent of egg penetration recoded into poor and good category (0% to 20%, 21% to 100%) and compared with fertilization, embryo transfer, and pregnancy rate (PR) in IVF, as well as sperm count motility and morphology. RESULTS Sperm penetrating assay predicted fertilization with a high negative (74%) and positive (82%) predictive rate and good specificity value (0.96). One of 31 patients in the poor SPA category (3%) fertilized less than 50% of eggs; no pregnancy occurred. In the good SPA category, 87 of 210 patients (41%) fertilized greater than or equal to 50% of eggs with 34.3% PR. Sperm penetrating assay correlated better with fertilization rate than did sperm count and motility but not morphology. CONCLUSIONS Sperm penetrating assay is a useful screening assay before IVF together with sperm morphology.