C. Sifer

Successful childbirth after intracytoplasmic morphologically selected sperm injection without assisted oocyte activation in a patient with globozoospermia

We here report a successful pregnancy and healthy childbirth obtained in a case of total globozoospermia after intracytoplasmic morphologically selected sperm injection (IMSI) without assisted oocyte activation (AOA). Two semen analyses showed 100% globozoospermia on classic spermocytogram. Motile sperm organelle morphology examination (MSOME) analysis at ×10,000 magnification confirmed the round-headed aspect for 100% of sperm cells, but 1% of the spermatozoa seemed to present a small bud of acrosome. This particular aspect was confirmed by transmission electron microscopy and anti-CD46 staining analysis. Results from sperm DNA fragmentation and fluorescence in situ hybridization analyses were normal. The karyotype was 46XY, and no mutations or deletions in SPATA16 and DPY19L2 genes were detected. Considering these results, a single IMSI cycle was performed, and spermatozoa were selected for the absence of vacuoles and the presence of a small bud of acrosome. A comparable fertilization rate with or without calcium-ionophore AOA was observed. Two fresh top-quality embryos obtained without AOA were transferred at Day 2 after IMSI, leading to pregnancy and birth of a healthy baby boy. This successful outcome suggests that MSOME may be useful in cases of globozoospermia in order to carefully evaluate sperm morphology and to maximize the benefit of ICSI/IMSI.

Use of laparoscopy in unexplained infertility

OBJECTIVEnThe use of laparoscopy in unexplained infertility work-up is still a subject of debate, although laparoscopy remains the gold standard for diagnosis and treatment of several pelvic pathologies. The objective of this study was to assess the rates and types of pelvic pathologies observed during diagnostic laparoscopy, and the pregnancy rate in couples with unexplained infertility following laparoscopy.nnnSTUDY DESIGNnProspective study, from November 2003 to October 2009, including 114 infertile, spontaneously ovulating women with normal clinical examination, ovarian reserve assessment, pelvic ultrasound scan and patent tubes on hysterosalpingography. Semen analyses were normal according to the World Health Organization criteria. After three cycles of ovulation induction with or without intra-uterine insemination and no pregnancy, women were referred for diagnostic laparoscopy.nnnRESULTSnLaparoscopy revealed pelvic pathology in 95 patients. Endometriosis, pelvic adhesions and tubal disease were observed and treated in 72, 46 and 24 patients, respectively. Following laparoscopy, bilateral and unilateral tubal patencies were observed in 107 and five patients, respectively. Pregnancy was observed in 77 out of 102 patients who tried to conceive after surgery, 35 of whom conceived using their own tubes.nnnCONCLUSIONnDiagnostic laparoscopy should be strongly considered in unexplained infertility work-up, and tubal efficiency should not be underestimated.

Motile sperm organelle morphology evaluation-selected globozoospermic human sperm with an acrosomal bud exhibits novel patterns and higher levels of phospholipase C zeta

STUDY QUESTIONnDoes motile sperm organelle morphology examination (MSOME) affect levels and localization patterns of the oocyte activation factor phospholipase C zeta (PLCζ) in globozoospermic sperm with and without an acrosomal bud?nnnSUMMARY ANSWERnMSOME identified round-headed globozoospermic sperm with increased levels of PLCζ relative to sperm from the same sample that did not undergo MSOME, and identified novel patterns of PLCζ localization in sperm exhibiting an acrosomal bud.nnnWHAT IS KNOWN ALREADYnAbsence or reduction in the level of PLCζ in the sperm head, abnormal localization patterning, or defective functional ability as a result of PLCζ gene mutation, have been linked to certain types of human male factor infertility in which oocyte activation is deficient. It has been determined that a subpopulation of sperm (1%) from a patient exhibiting 100% globozoospermia presented with an acrosome bud upon MSOME. A cycle of intracytoplasmic morphologically selected sperm injection, carried out with sperm exhibiting an acrosomal bud led to pregnancy and birth of a healthy baby boy, without the use of assisted oocyte activation (AOA).nnnSTUDY DESIGN, SIZE, DURATIONnImmunofluorescent analysis of PLCζ in globozoospermic sperm from three patients, before and after MSOME.nnnPARTICIPANTS/MATERIALS, SETTING, METHODSnQuantitative immunofluorescence was used to investigate PLCζ levels and localization patterns in individual sperm (n = 1 patient) identified by MSOME and isolated by micromanipulation, and presenting with and without the acrosomal bud. A secondary aim was to investigate levels and localization patterns of PLCζ in sperm before and after MSOME from two other globozoospermic men.nnnMAIN RESULTS AND THE ROLE OF CHANCEnNon-globozoospermic control sperm exhibited characteristic localization patterns of PLCζ immunofluorescence. Completely round-headed globozoospermic sperm from patients 1-3 were either devoid of PLCζ immunofluorescence, or exhibited an abnormal, punctate, pattern of PLCζ localization. PLCζ immunofluorescence in sperm exhibiting an acrosomal bud was observed in the midpiece with varying fluorescent intensity and was detected in 28.5% of such sperm. The majority of sperm with an acrosomal bud (43.0%) exhibited punctate patterns of PLCζ localization within the sperm head. A further 28.5% of sperm exhibited PLCζ in both the head and the midpiece. Total levels of PLCζ, and the proportions of sperm exhibiting PLCζ immunoreactivity, showed significant variance (P ≤ 0.05) amongst control [45.8 arbitrary units (a.u.) and 95.7%, respectively], non-MSOME-selected (25.9 a.u. and 46.1%, respectively) and MSOME-selected globozoospermic sperm (33.4 a.u. and 65.0%, respectively). Total levels of PLCζ immunofluorescence, and proportions of sperm exhibiting PLCζ immunoreactivity, in control sperm was significantly higher (P≤ 0.05) compared with non-MSOME-selected sperm, but not significantly different from MSOME-selected sperm.nnnLIMITATIONS, REASONS FOR CAUTIONnThe low numbers of sperm analysed may not be ideal for conclusive statistical analysis. Evaluation of the effects of MSOME on morphologically normal sperm would confirm conclusions.nnnWIDER IMPLICATIONS OF THE FINDINGSnThe present findings provide hope for the future treatment of globozoospermia without the need for AOA, and provide further evidence for the clinical application of PLCζ as a therapeutic and prognostic tool.nnnSTUDY FUNDING/COMPETING INTEREST(S)nThe research described herein was funded by the Nuffield Department of Obstetrics and Gynaecology, University of Oxford. The authors report no conflict of interest.

Is polycystic ovarian morphology related to a poor oocyte quality after controlled ovarian hyperstimulation for intracytoplasmic sperm injection? Results from a prospective, comparative study

OBJECTIVEnTo evaluate the relationship between polycystic ovarian morphology (PCOM) and oocyte quality after controlled ovarian stimulation for intracytoplasmic sperm injection (ICSI).nnnDESIGNnProspective, comparative study with concurrently treated and age-matched controls.nnnSETTINGnAcademic IVF unit of the Lille University Hospital.nnnPATIENT(S)nA total of 194 women were prospectively included before their first IVF-ICSI attempt for exclusive male infertility. They were classified into PCOM (n = 97) or control groups (n = 97) according to their follicle number per ovary. The nuclear maturation and morphologic aspects of 1,013 oocytes from PCOM patients were assessed and compared with those of 774 oocytes from controls.nnnINTERVENTION(S)nNone.nnnMAIN OUTCOME MEASURE(S)nRate of metaphase II (MII) and morphologically abnormal oocytes.nnnRESULT(S)nThe mean number of total and MII oocytes retrieved was significantly higher in the PCOM group. The rate of MII and morphologically abnormal oocytes was equivalent between the two groups. The mean number of embryos was significantly higher in the PCOM group. However, the percentage of top-quality embryos on day 3 was similar between the two groups. The implantation and clinical pregnancy rates were significantly higher in the PCOM group.nnnCONCLUSION(S)nPolycystic ovarian morphology does not have a negative impact on the quality of oocytes and embryos or the outcome of IVF-ICSI.

Évaluation prospective de l'impact des paramètres spermatiques sur le succès des inséminations intra-utérines

OBJECTIVESnThresholds of sperm parameters associated with intrauterine insemination (IUI) success are controversial. This entails heterogeneous practices and leads to low success rate (approximately 8% per attempt). The aim of this study was to evaluate the influence of sperm parameters on the outcome of IUI.nnnPATIENTS AND METHODSnThis study included 248 cycles of IUI. Parameters of the raw and selected sperm, as well as the main female characteristics, have been prospectively tabulated and compared, according to the presence or not of a clinical pregnancy.nnnRESULTSnIn all, 28 clinical pregnancies were obtained (11.3% per cycle). Thresholds of 10% for the forward motility a in the whole sperm and of 20% for the percentage of typical spermatozoa in the selected sperm were related to the success of IUI. The number of motile inseminated spermatozoa, concentration and overall motility of sperm, determined before or after selection, did not have any significant influence on the outcome of IUI.nnnDISCUSSION AND CONCLUSIONnThresholds determined in our study should help to optimize the use of IUI.

What threshold values of antral follicle count and serum AMH levels should be considered for oocyte cryopreservation after in vitro maturation

STUDY QUESTIONnWhat threshold values of ultrasonographic antral follicle count (AFC) and serum anti-Müllerian hormone (AMH) levels should be considered for ensuring the cryopreservation of sufficient number of in vitro matured (IVM) oocytes, in cancer patients seeking fertility preservation (FP)?nnnSUMMARY ANSWERnAFC and serum AMH values >20 follicles and 3.7 ng/ml, respectively, are required for obtaining at least 10 IVM oocytes for cryopreservation.nnnWHAT IS KNOWN ALREADYnIVM of cumulus oocyte complexes (COCs) followed by oocyte cryopreservation has emerged recently as an option for urgent FP. Recent data have reported that, in healthy patients, 8-20 cryopreserved oocytes after ovarian stimulation would maximize the chance of obtaining a live birth. Although both AFC and AMH have been reported as predictive factors of IVM success in infertile patients with polycystic ovary syndrome (PCOS), there is a dramatic lack of data regarding the values of these parameters in oncological patients as candidates for FP.nnnSTUDY DESIGN, SIZE, DURATIONnFrom January 2009 to April 2015, we prospectively studied 340 cancer patients, aged 18-41 years, as candidates for oocyte cryopreservation following IVM.nnnPARTICIPANTS/MATERIALS, SETTING, METHODSnAll patients had AFC and AMH measurements, 48-72 h before oocyte retrieval, regardless of the phase of the cycle. COCs were recovered under ultrasound guidance 36 h after hCG priming. Logistic regression allowed the determination of threshold values of AFC and AMH, for obtaining at least 8, 10 or 15 matures oocytes frozen after the IVM procedure. Similar analyses were performed for a final number of mature oocytes ≤2.nnnMAIN RESULTS AND THE ROLE OF CHANCEnAmong the 340 cancer patients included, 300 were diagnosed with breast cancers, 14 had hematological malignancies and 26 underwent the procedure for others indications. Overall, the mean age of the population was 31.8 ± 4.5 years. Mean AFC and serum AMH levels were 21.7 ± 13.3 follicles and 4.4 ± 3.8 ng/ml, respectively. IVM was performed in equal proportions during the follicular or luteal phase of the cycle (49 and 51%, respectively). Statistical analysis showed that AFC and AMH values above 28 follicles and 3.9 ng/ml, 20 follicles and 3.7 ng/ml and 19 follicles and 3.5 ng/ml are required, respectively, for obtaining at least 15, 10 or 8 frozen IVM oocytes with a sensitivity ranging from 0.82 to 0.90. On the contrary, ≤2 IVM oocytes were cryopreserved when AFC and AMH were <19 follicles and 3.0 ng/ml, respectively.nnnLIMITATIONS, REASONS FOR CAUTIONnAlthough the potential of cryopreserved IVM oocytes from cancer patients remains unknown, data obtained from infertile PCOS women have shown a dramatically reduced competence of these oocytes when compared with that of oocytes recovered after ovarian stimulation. As a consequence, the optimal number of IVM oocytes frozen in candidates for FP is currently unpredictable.nnnWIDER IMPLICATIONS OF THE FINDINGSnCryopreservation of oocytes after IVM should be considered in the FP strategy when ovarian stimulation is unfeasible, in particular when markers of the follicular ovarian status are at a relatively high range. Further investigation is needed to objectively assess the real potential of these IVM oocytes after cryopreservation. Therefore, even when a good COCs yield is expected, we should systematically encourage IVM in combination with ovarian tissue cryopreservation.nnnSTUDY FUNDING/COMPETING INTERESTSnNo external funding was obtained for the present study. The authors have no conflict of interest to declare.nnnTRIAL REGISTRATION NUMBERnNot applicable.

A Review of Outcome Data concerning Children Born following Assisted Reproductive Technologies

Assisted reproductive technologies (ARTS) are used for more than 30 years to help infertile couples. Concerns about long-term health of children conceived following ART have led to start follow-up studies. Despite methodological limitations and discrepant results, many of the studies and meta-analyses have reported an increased risk of birth defects after ART. Etiologies may be multiple births, a major drawback of ART, parents subfertility, or technologies themselves. Prematurity and intrauterine growth retardation (IUGR) seem to cause most of the pathologies reported in ART children. Nevertheless, epigenetic disorders need to be followed up since increases of imprinting diseases were reported. Consequently, alteration of gametes and early embryo development with ART may have consequences on children health since periconceptional period is critical for long-term development. Yet general condition of most of children conceived with ART is reassuring, but long-term followup is still strongly needed.

Non-ART pregnancy predictive factors in infertile patients with peritoneal superficial endometriosis

OBJECTIVEnTo study the predictive factors for non-ART pregnancy in infertile women after laparoscopic diagnosis and surgery for isolated superficial peritoneal endometriosis (SUP).nnnSTUDY DESIGNnRetrospective observational study from January-2004 to December-2015 in a tertiary care university hospital and Assisted Reproductive Technology (ART) centre. Infertile women with laparoscopic surgery for SUP (with histologic diagnosis) were included. The surgical treatment was followed by spontaneous fertility or post-operative ovarian stimulation (pOS) using superovulation (gonadotrophins)±Intra Uterine Insemination (IUI). The main outcomes were the non-ART clinical pregnancy rates and its predictive factors.nnnRESULT(S)nOver the period study, 315 women were included. Of these, 133 (42.3%) women had non-ART pregnancy. The mean time to conceive was 6 months (±6days). Univariate analysis for non-ART pregnancy after surgery showed that: (i) no difference was observed according to age, length of infertility, Body Mass Index (BMI), the rate of previous pregnancy, and the pre-operative ovarian stimulation rate; (ii) diminished ovarian reserve and previous miscarriage were higher in the non-pregnant women group (8.3 versus 19.1%, p<0.05; 3.5% versus 9%, p=0.06, respectively); (iii) the mean EFI score and pOS were higher in pregnant women (7.7 versus 7.2, p=0.02; 49.2% versus 26.7%, p<0.01); and (iv) IUI did not show any benefit for pregnancy (22% after superovulation versus 27.2% after superovulation and IUI). In the multivariate analysis, only pOS (adjusted OR 2.504, 95% CI [1.537-4.077]) and DOR (aOR 0.420, 95% CI [0.198-0.891]) remained significantly associated with the incidence of pregnancy.nnnCONCLUSION(S)nAfter laparoscopic surgery for peritoneal superficial endometriosis related infertility, ovarian stimulation improved pregnancy rate, while diminished ovarian reserve had a worse prognosis for pregnancy.

Endometriosis Fertility Index ou classification de l’American Society of Reproductive Medicine pour les patientes infertiles endométriosiques opérées. Lequel est le plus pertinent ?

The revised American Fertility Society classification system has been most used after surgery by all consensus on endometriosis fertility. However, it does not predict pregnancy. The EFI score has been recently developed to aim at predicting clinical pregnancy after surgery. Several study performed its external validation. It may be a useful new tool to counsel couples for personalized postoperative management.

Second live birth after undergoing assisted reproductive technology in women operated on for endometriosis.

OBJECTIVEnTo determine prognostic factors for a second live birth, after a first child obtained through assisted reproductive techniques (ART).nnnDESIGNnObservational study from January 2004 to December 2014.nnnSETTINGnTertiary care university hospital and ART center.nnnPATIENT(S)nA total of 164 infertile patients with endometriosis, who underwent laparoscopy surgery and had a first baby obtained by ART, were included and 65 wished a second baby.nnnINTERVENTION(S)nNo iterative surgery.nnnMAIN OUTCOME MEASURE(S)nSpontaneous pregnancy rate (PR) according to endometriosis fertility index.nnnRESULT(S)nAmong the cohort, 27 patients (41.5%) gave birth to a second child through spontaneous pregnancy, whereas 23 patients (35.3%) required ART to obtain a second live birth. No difference was observed between patients regarding age, endometriosis staging, complete removal of endometriosis lesions and pelvic adhesion, except for the least function score, and the endometriosis fertility index. Taking into account irrespective of both mode of conception a total of 78% of patients obtained a second child, with a median conception time of 17 months.nnnCONCLUSION(S)nThe second live birth rate in infertile patients with endometriosis and with surgical treatment was high (78%). Spontaneous PR was 54%. Endometriosis fertility index could be considered as a predictive factor for a spontaneous second pregnancy in fertility management. Our results need to be confirmed in larger prospective studies.