Charles Kingsland

The long protocol of administration of gonadotropin-releasing hormone agonist is superior to the short protocol for ovarian stimulation for in vitro fertilization

Objective To investigate whether pituitary desensitization with the gonadotropin-releasing hormone agonist (GnRH-a), buserelin acetate, before the administration of human menopausal gonadotropin (hMG) for ovarian stimulation in in vitro fertilization (IVF) is superior to the simultaneous administration of both hormones at the beginning of the treatment cycle. Design Prospective randomized study. Patients Ninty-one patients having their first attempt at IVF. Interventions Patients in group 1 (long protocol) were administered subcutaneous (SC) buserelin acetate 200 μ g/d from day 1 of the menstrual cycle, and hMG was started only after pituitary desensitization had been achieved at least 14days later. Patients in group 2 (short protocol) were administered SC buserelin acetate 200 μ g/d from day 2 and the same dose of hMG used in the long protocol from day 3 of the menstrual cycle. Results The median total amount of hMG required in both groups was comparable. There were significantly more follicles ( P =0.0001), oocytes ( P =0.0008), fertilized oocytes ( P =0.0001), and cleaved embryos ( P =0.0001), and a higher fertilization rate ( P =0.0047) in patients in group 1. The pregnancy rates per initiated cycle and per embryo transfer were 19.57% and 25.71% in group 1 compared with 8.89% and 16.67% in group 2. Conclusions The long protocol is superior in terms of significantly greater follicular recruitment, oocyte recovery and fertilization rates, and significantly greater number of embryos available for transfer. In general, it is the preferred method when GnRH-a are used for ovarian stimulation in IVF.

The hypo-osmotic swelling test in recurrent miscarriage

OBJECTIVE To determine whether there is any association between sperm membrane integrity as determined by the hypo-osmotic swelling test score and unexplained recurrent miscarriage. DESIGN Prospective observational study. SETTING Tertiary referral center for recurrent miscarriage. PATIENT(S) Semen samples from 20 male partners of women who had had three or more first trimester miscarriages of unexplained etiology and semen samples from 20 prospective semen donors of unknown fertility potential. MAIN OUTCOME MEASURE(S) Sperm density, sperm motility, sperm morphology, and hypoosmotic swelling test score. RESULT(S) There was no difference in the median sperm density, the mean sperm motility, or the mean sperm morphology between the two groups. However, the recurrent miscarriage group had a significantly lower hypo-osmotic swelling test score than the control group. CONCLUSION(S) The hypo-osmotic swelling test score is significantly lower in samples from men whose partners have had unexplained recurrent spontaneous abortions. With the exception of cytogenetic abnormalities in peripheral blood karyotype, this is the first study to identify a male factor component in recurrent miscarriage.

The sperm deformity index: a reliable predictor of the outcome of oocyte fertilization in vitro *

OBJECTIVE To evaluate a novel expression of sperm morphological parameters, the sperm deformity index, as a predictor of fertilization in vitro. DESIGN Prospective blind clinical trial. SETTING Academic tertiary referral center. INTERVENTION(S) Detailed sperm morphological assessment applying strict morphological criteria and a multiple entry technique for an unselected male population undergoing IVF. The sperm deformity index, defined as the average number of deformities per sperm assessed, was calculated. PATIENT(S) One hundred fifty-eight patients undergoing IVF treatment. Females with conditions negatively influencing fertilization were excluded. MAIN OUTCOME MEASURE(S) Fertilization rates and pregnancy. RESULT(S) Seventy-three percent of patients achieved fertilization. Patients achieving fertilization had a significantly higher median proportion of normal forms and a significantly lower median sperm deformity index than the nonfertilizers. The receiver operator characteristic (ROC) curves identified cutoff points that maximized the sum of sensitivity and specificity at sperm deformity index 1.6 and normal forms 4%. The sperm deformity index had a greater sensitivity (96%), specificity (72%), positive predictive value (90%), and negative predictive value (86%) than the proportion of normal sperm morphology (87%, 69%, 89%, 66%, respectively) at the optimal cutoff points. The area under the ROC curve was greater for the sperm deformity index (0.875) than for the proportion of normal sperm morphology (0.622). Achieving pregnancy did not correlated with sperm morphology. CONCLUSION(S) The sperm deformity index is a more reliable predictor of the outcome of fertilization in vitro than the proportion of normal sperm morphology and can assist to identify patients who require techniques such as intracytoplasmic sperm injection.

Evaluation of different sperm function tests as screening methods for male fertilization potential—the value of the sperm migration test

OBJECTIVE To assess the value of different sperm function screening tests in predicting fertilization. DESIGN Prospective study. SETTING Academic tertiary referral center for fertility treatment. PATIENTS Ninety-five couples attending for initial screening and IVF-ET. Only cycles where three or more grade I oocytes were collected were included, and patients with endometriosis were excluded. INTERVENTIONS Each patient had a standard semen analysis, cervical mucus (CM) penetration test, hypo-osmotic swelling test, and sperm migration test performed between 4 and 8 weeks before IVF-ET. MAIN OUTCOME MEASURES The correlation between sperm function test results and the percentage of fertilized oocytes and the power of the tests to predict fertilization. RESULTS The sperm migration test correlated highly with fertilization rate (r = 0.62) and was most useful in identifying the group of patients likely to achieve fertilization (Odds ratio [OR] 0.07, confidence interval [CI] 0.02 to 0.2). The CM penetration test showed a moderate correlation with fertilization rate (r = 0.45) and some predictive power (OR 0.37, CI 0.13 to 1.00). Sperm concentration, but not motility or normal morphology, showed slight correlation with fertilization rate (r = 0.28) but the combination of normal semen parameters did not distinguish patients likely to achieve fertilization (OR 1.51, CI 0.62 to 3.65). The hypo-osmotic swelling test did not correlate with fertilization rate (r = 0.21). CONCLUSIONS This study evaluated the predictive power of several simple tests available for use in most laboratories as screening tests of sperm fertilization potential. Apart from sperm concentration, normal traditional semen characteristics were of little clinical benefit. The hypo-osmotic swelling test had no predictive power. The CM penetration test correlated with fertilization rate but might be difficult to perform routinely as a continuous supply of suitable CM would be required. The sperm migration test proved to be the best discriminator of sperm fertilization potential and should be considered as a first level screening test in the assessment of male fertility.

Endometrial integrin expression in women undergoing in vitro fertilization and the association with subsequent treatment outcome

OBJECTIVE To study the endometrial expression of three integrins (alpha v beta 3, alpha 4 beta 1, and alpha 1 beta 1) in women undergoing IVF-intracytoplasmic sperm injection (ICSI) treatment and assess whether they could be used to predict subsequent treatment success.Prospective observational study. Healthy volunteers in a large teaching hospital. PATIENT(S) Sixty-six patients attending for IVF-ICSI treatment. INTERVENTION(S) Timed endometrial biopsies were taken, during the implantation window at LH + 7-9 days, from women before IVF-ICSI treatment. MAIN OUTCOME MEASURE(S) Histological dating of endometrium and immunohistochemical staining intensity of alpha 4 beta 1, alpha v beta 3, and alpha 1 beta 1 integrins. The integrin levels were correlated with subsequent success rates. RESULT(S) There was a statistically significantly greater expression of alpha v beta 3 in the luminal epithelium of those patients who had successful treatment. However, treatment was successful in some patients with negative expression. CONCLUSION(S) Integrins are important markers of endometrial receptivity. There is an association between an in-phase endometrial biopsy, with positive luminal alpha v beta 3 integrin expression, and subsequent treatment success. However, the clinical value of assessing the endometrium before treatment has drawbacks, and further work needs to be done before this can be considered a clinically useful test.

Reproductive potential of fresh and cryopreserved epididymal and testicular spermatozoa in consecutive intracytoplasmic sperm injection cycles in the same patients

OBJECTIVE To determine if the cryopreservation of epididymal and testicular spermatozoa alters their reproductive potential by examination of patients who underwent consecutive cycles of ICSI using fresh and then cryopreserved spermatozoa. DESIGN Retrospective review. SETTING Tertiary care university hospital. PATIENT(S) One hundred sixty-two consecutive cycles of ICSI were analyzed. Thirteen patients were identified as having undergone treatment with freshly retrieved epididymal spermatozoa; these patients subsequently underwent treatment with spermatozoa cryopreserved from that cycle. Eighteen patients underwent ICSI with freshly retrieved testicular spermatozoa; these patients subsequently underwent treatment with spermatozoa cryopreserved from that cycle. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Fertilization rates and pregnancy rates. RESULT(S) The fertilizing capacity of epididymal spermatozoa remained unchanged after cryopreservation and subsequent thawing, with fertilization rates of 58% and 57% for fresh and cryopreserved spermatozoa, respectively. Testicular spermatozoa, however, showed a significant decrease in fertilizing capacity after cryopreservation when compared with freshly retrieved spermatozoa (52% and 71%, respectively). Pregnancy rates appeared unaffected by the cryopreservation of epididymal spermatozoa (fresh, 3/13; frozen, 2/13) or testicular spermatozoa (fresh, 2/18; frozen, 5/18). CONCLUSION(S) This study offers further evidence that motile epididymal spermatozoa retain their fertilizing capacity after cryopreservation. The data presented on testicular spermatozoa suggest that although cryopreservation may reduce the fertilizing capacity of testicular spermatozoa, there is no decrease in pregnancy rates.

A randomized controlled clinical trial of 2295 ultrasound-guided embryo transfers

BACKGROUND We wanted to test the hypothesis that using abdominal ultrasound at the time of embryo transfer to guide replacement, improved pregnancy rates by at least 5%. METHODS An RCT in a large assisted conception unit. A pilot study and power calculation suggested that at least 2000 embryo transfers were required to demonstrate a difference of 5%, for a test with 80% power and Type 1 error 0.05. Randomization, data entry and analysis were arranged independently. Randomization was stratified for age and fresh/frozen embryo transfer. Analysis was by intention to treat. RESULTS There was no difference in clinical pregnancy or live birth rates between the two groups. The clinical pregnancy rate for ultrasound-guided embryo transfer was 22% and for non-ultrasound-guided embryo transfer was 23% (odds ratio: 0.96; 95% confidence interval: 0.79-1.18). CONCLUSIONS We set out to determine whether ultrasound-guided embryo transfer improved clinical pregnancy rates and live birth rates in assisted conception. We used an appropriately powered RCT design. We did not demonstrate a difference. This outcome is at odds with the UKs National Institute of Clinical Excellence recommendations for fertility treatment (Fertility Assessment and Treatment for People with Fertility Problems. London, UK: RCOG Press, 2004, 112.) which used a meta-analysis of four smaller trials (range 362-800 patients, totalling 2051 embryo transfers) to conclude that ultrasound should be offered. We suggest that the current Cochrane review should be updated with data from our trial and recommend that consideration is given to accounting for heterogeneity between the included trials.

Human sperm head morphometric distribution and its influence on human fertility

OBJECTIVE To study the distribution of live sperm head size in semen and sperm preparations as a predictor of fertility. DESIGN Prospective blind clinical trial. SETTING Academic tertiary referral center. PATIENT(S) One hundred fifty-five patients undergoing IVF treatment. Females with conditions negatively influencing fertilization were excluded. INTERVENTION(S) Morphometric analysis (head area, major axis, minor axis, and elongation ratio) of video images of sperm in semen and swim-up preparations used for IVF treatment was performed with a Hamilton-Thorne analyzer V 8.1 (Hamilton-Thorn Research, Beverly, MA). MAIN OUTCOME MEASURE(S) Oocyte fertilization. RESULT(S) Seventy-four percent of patients achieved fertilization. Fertilizers and nonfertilizers had different sperm head area distribution. The fertilizers had a significantly smaller interquartile range of sperm head area and of major axis in both semen and sperm preparation compared with the nonfertilizers. A subgroup of men who had fathered a child naturally had a more uniform sperm head area in semen with a significantly smaller median compared with those who failed to father a child naturally with their healthy female partner. We used multiple logistic regression applying forward stepwise selection of variables in building three predictive models of probability of fertilization. CONCLUSION(S) Successful IVF or history of fathering a child was associated with a more uniform sperm head area in semen and sperm preparation.

Follicular fluid concentrations of interleukin-12 and interleukin-8 in IVF cycles

OBJECTIVE To investigate the role of interleukin-12 (IL-12) and IL-8 in the periovulatory follicular fluid during in vitro fertilization cycles. DESIGN A prospective study. SETTING Reproductive Medicine Unit, Liverpool Womens Hospital, United Kingdom. PATIENT(S) Women undergoing in vitro fertilization treatment. INTERVENTION(S) IL-8 and IL-12 concentrations in follicular fluid samples that had been collected during transvaginal oocyte retrieval were measured using an enzyme-linked immunosorbent assay (ELISA). Cytokine concentrations were correlated to fertilization rates and treatment outcome. MAIN OUTCOME MEASURE(S) Fertilization rates and ultrasonographic evidence of intrauterine pregnancy by 4 weeks after embryo transfer. RESULT(S) Failed fertilization in women with detectable IL-12 was significantly higher (45.5%) than in the IL-12 negative group (6.1%), P=.01. None of the women with detectable IL-12 achieved a pregnancy at the end of the treatment (P=.01). IL-8 was present in the follicular fluid of all women, and no difference in its concentrations was found between the pregnant and nonpregnant groups. No correlation was found between the follicular fluid concentrations of IL-8 and fertilization rates. CONCLUSION(S) The presence of IL-12 in the follicular fluid appears to be associated with a negative outcome in IVF treatment. Interleukin-8 appears to be an essential part of folliculogenesis, although its concentration is not associated with fertilization or implantation rates.

Effect of abnormal hypo-osmotic swelling test on fertilization rate and pregnancy outcome in in vitro fertilization cycles

OBJECTIVE To assess the value of the hypo-osmotic swelling test in predicting fertilization, pregnancy, implantation, miscarriage, and live birth rates in IVF-ET cycles. DESIGN Prospective study. SETTING Academic tertiary referral center for fertility treatment. PATIENTS Three hundred twenty-six couples having IVF-ET for tubal damage or male factor infertility with the female partner < 38 years of age. INTERVENTIONS Each male had a hypo-osmotic swelling test performed between 4 and 8 weeks before IVF-ET. MAIN OUTCOME MEASURES Fertilization, implantation, miscarriage, and live birth rates. RESULTS Eighty of 326 men had abnormal hypo-osmotic swelling tests. An abnormal test was not associated with lower fertilization rates (odds ratio [OR] = 1.14; 95% confidence interval [CI] = 0.97 to 1.14) or pregnancy rate (OR = 0.98; CI = 0.50 to 1.96). However, although couples with a normal test had a miscarriage rate of 26.9% (14/52), in the group with an abnormal test the miscarriage rate was 50.0% (7/14) (OR = 0.37; CI = 0.09 to 1.49). This resulted in a reduction in the live birth rate from 14.1% in the group with a normal test to 11.8% in patients with an abnormal test (OR = 1.23; CI = 0.45 to 3.87). CONCLUSIONS The hypo-osmotic swelling test has little value in predicting fertilization in IVF-ET procedures. However, an abnormal test may help predict adverse outcome if pregnancy is achieved.