Clifford Librach

Increased risk of preterm birth in singleton pregnancies after blastocyst versus Day 3 embryo transfer: Canadian ART Register (CARTR) analysis

STUDY QUESTION Are the fetal outcomes of singleton pregnancies that result from cleavage stage embryo transfer (ET) different from the outcomes from Day 5/6 blastocyst stage ET? SUMMARY ANSWER There was a significantly higher risk of preterm birth (<37 weeks) in singletons after extended embryo culture (Day 5/6) compared with cleavage stage (Day 3) transfer. WHAT IS KNOWN ALREADY Two recent studies, from Sweden and the USA, reported an increased risk of preterm birth in singleton pregnancies after Day 5/6 ET compared with Day 3 ET. The US study also showed increased early preterm births and the Swedish study showed increased fetal malformations in this group. STUDY DESIGN, SIZE AND DURATION A retrospective cohort study was performed. Data were collected from the Canadian ART Register database for all singleton births after fresh IVF/ICSI ET cycles (2001-2009). PARTICIPANTS/MATERIALS, SETTING, METHODS A total of 12 712 singleton births were included. Of these, 9506 resulted from a Day 3 ET and 3206 resulted from a blastocyst (Day 5/6) ET. MAIN RESULTS AND THE ROLE OF CHANCE Preterm birth rate <37 weeks (unadjusted by potential confounding factors) was higher with Day 5/6 versus Day 3 transfers (17.2 versus 14.1%, P < 0.001). Using logistic regression analysis to adjust for confounding factors, preterm birth rate <37 weeks was the only outcome significantly increased after Day 5/6 compared with Day 3 transfer (odds ratio 1.32, 95% confidence interval 1.17-1.49). The following confounding factors were adjusted for: year of treatment (2001-2009), maternal age (continuous), parity (0 versus ≥1 birth), diagnosis category, number of oocytes retrieved [≤20 versus >20 (high responder group)], insemination method (IVF versus ICSI), number of embryos transferred (1, 2 or ≥3) and the presence of a vanishing twin (≥1 fetal heart on the initial ultrasonographic examination). LIMITATIONS, REASONS FOR CAUTION Post-natal follow-up studies will be required to determine if this difference we observed translates into adverse long-term effects on these offspring. The rate of early preterm births (<32 weeks) was higher in Day 5/6 versus Day 3, but the low number of cases in this category did not have the power to show a difference (3.0 versus 2.7%, P = 0.34). WIDER IMPLICATIONS OF THE FINDINGS We found a significantly higher risk of preterm birth (<37 weeks) in singletons after extended embryo culture (Day 5/6) compared with cleavage stage (Day 3) transfer, even when adjusting for confounding factors. Our findings are in agreement with the previous two studies; however, we did not show a difference in the very preterm deliveries (unlike the US study) or in fetal malformations (as in the Swedish study). We hypothesize that there may be a deleterious effect of prolonged in vitro embryo culture on subsequent placentation. Longer term follow-up studies will be required to determine if prolonged in vitro culture to the blastocyst stage has an adverse effect on the long-term health of offspring when compared with shorter cleavage stage culture. STUDY FUNDING/COMPETING INTEREST(S) None.

Sperm-derived WW domain-binding protein, PAWP, elicits calcium oscillations and oocyte activation in humans and mice

Mammalian zygotic development is initiated by sperm‐mediated intracellular calcium oscillations, followed by activation of metaphase II‐arrested oocytes. Sperm postacrosomal WW binding protein (PAWP) fulfils the criteria set for an oocyte‐activating factor by inducing oocyte activation and being stored in the perinuclear theca, the sperm compartment whose content is first released into oocyte cytoplasm during fertilization. However, proof that PAWP initiates mammalian zygotic development relies on demonstration that it acts upstream of oocyte calcium oscillations. Here, we show that PAWP triggers calcium oscillations and pronuclear formation in human and mouse oocytes similar to what is observed during intracytoplasmic sperm injection (ICSI). Most important, sperm‐induced calcium oscillations are blocked by coinjection of a competitive inhibitor, derived from the WWI domain‐binding motif of PAWP, implying the requirement of sperm PAWP and an oocyte‐derived WWI domain protein substrate of PAWP for successful fertilization. Sperm‐delivered PAWP is, therefore, a unique protein with a nonredundant role during human and mouse fertilization, required to trigger zygotic development. Presented data confirm our previous findings in non‐mammalian models and suggest potential applications of PAWP in the diagnosis and treatment of infertility.—Aarabi, M., Balakier, H., Bashar, S., Moskovtsev, S. I., Sutovsky, P., Librach, C. L., and Oko, R., Sperm‐derived WW domain‐binding protein, PAWP, elicits calcium oscillations and oocyte activation in humans and mice. FASEB J. 28, 4434–4440 (2014). www.fasebj.org

Neonatal outcomes among singleton births after blastocyst versus cleavage stage embryo transfer: a systematic review and meta-analysis

BACKGROUND Several studies have evaluated outcomes of singleton pregnancies after blastocyst versus cleavage stage embryo transfer. Higher incidences of preterm birth (PTB), very preterm birth (VPTB), low birthweight (LBW) and congenital malformations were identified in a few of them. The objective of our study was to systematically review and meta-analyze pregnancy and neonatal outcomes among singleton births following blastocyst versus cleavage stage embryo transfer. METHODS EMBASE, MEDLINE, EBM Reviews and bibliographies of included studies were searched from their inception until March 2013. Observational studies or clinical trials comparing blastocyst with cleavage stage embryo transfer and reporting on outcomes of PTB (<37 weeks), VPTB (<32 weeks), LBW (<2500 g), very low birthweight (VLBW) (<1500 g) and/or congenital anomalies in singleton neonates were included. Data on the outcomes were extracted by two reviewers. Statistical heterogeneity among studies was evaluated by calculating I(2) values and χ(2) statistics. Meta-analyses were conducted to estimate the pooled unadjusted odds ratio (OR) and the adjusted OR (AOR) with a 95% confidence interval (CI) using the random effect model. RESULTS Six observational studies, of low to moderate risk of bias, were included in this review. There were significantly higher odds of PTB (four studies, 54 792 cleavage stage and 20 724 blastocyst stage births; AOR 1.32, 95% CI 1.19-1.46) and congenital anomalies (two studies, 22 068 cleavage stage and 4517 blastocyst stage births; AOR 1.29, 95% CI 1.03-1.62) among births after blastocyst transfer compared with cleavage stage transfer. There was no difference in the adjusted odds of VPTB (four studies, 54 792 cleavage stage and 20 724 blastocyst stage births; AOR 1.18, 95% CI 0.93-1.49), LBW (four studies, 54 109 cleavage stage and 20 392 blastocyst stage births; AOR 1.06, 95% CI 0.99-1.15) or VLBW (three studies, 22 088 cleavage stage and 5772 blastocyst stage births; AOR 1.01, 95% CI 0.73-1.38). CONCLUSIONS Risk of PTB in IVF singleton pregnancies is significantly higher following blastocyst transfer compared with cleavage stage transfer. Risk of congenital anomalies may also be higher but further studies are needed to confirm this finding and to identify reasons for such outcomes.

Experience of Young Women Diagnosed With Breast Cancer Who Undergo Fertility Preservation Consultation

BACKGROUND Fertility preservation (FP) is of increasing concern to young patients with breast cancer. The American Society of Clinical Oncology has recommended referral to a reproductive specialist as early as possible before beginning systemic adjuvant therapy. AIM To gather information from young patients with breast cancer about their experiences with FP referral, consultation, and decision making. METHODS An anonymous questionnaire was mailed to consecutive patients with breast cancer who were referred, from January 2005 to January 2010, from our center to the CReATe fertility clinic. Topics included demographics; cancer stage and treatment; previous fertility problems; referral source and timing; options presented and chosen; and satisfaction with the referral, consultation, and decision-making processes. RESULTS Of the 53 women identified, 27 (51%) participated. The mean age was 31 years (range, 24-41 years). Fifteen (56%) women opted for embryo or oocyte cryopreservation, 2 for ovarian suppression, and 10 for no FP. The choice was not affected by disease stage or by already having a child. Of the 22 women who responded, 14 (64%) were satisfied or very satisfied overall. Eighteen out of 23 (78%) respondents felt that the right amount of information was given. Thirty-nine percent had difficulty with decision making, but only 1 (4%) woman indicated that cost was a deciding factor. A common theme among respondents was inadequate time for decision making. A common complaint was the lack of written material before and/or after their consultation. Sixty-three percent expressed an interest in meeting with a psychosocial counselor. CONCLUSIONS (1) FP referral should be initiated by the surgeon as soon as a diagnosis of invasive cancer is made, (2) women need written materials before and after FP consultation is needed, and (3) a FP counselor who is able to spend additional time after the consultation could help with decision making.

Absence of sperm RNA elements correlates with idiopathic male infertility.

Absence of required RNA elements in sperm correlates with infertility but can be overcome with assisted reproductive technologies. Counting on the sperm RNA Infertility affects many couples of reproductive age. Male infertility is typically evaluated by visual assessment of the sperm to determine sperm counts and morphological characteristics. Unfortunately, this approach is ineffective for patients whose sperm are morphologically normal, making it difficult to distinguish patients who require assisted reproductive technology from those who could benefit from cheaper and less invasive approaches. Jodar et al. have now identified a set of sperm RNA elements whose absence correlates with infertility, such that the more elements are lacking in a patient’s sperm, the less likely he is to achieve fertility without technological assistance. If confirmed in prospective studies, these findings could help guide the selection of optimal fertility treatments for couples with idiopathic male infertility. Semen parameters are typically used to diagnose male infertility and specify clinical interventions. In idiopathic infertile couples, an unknown male factor could be the cause of infertility even when the semen parameters are normal. Next-generation sequencing of spermatozoal RNAs can provide an objective measure of the paternal contribution and may help guide the care of these couples. We assessed spermatozoal RNAs from 96 couples presenting with idiopathic infertility and identified the final reproductive outcome and sperm RNA elements (SREs) reflective of fecundity status. The absence of required SREs reduced the probability of achieving live birth by timed intercourse or intrauterine insemination from 73 to 27%. However, the absence of these same SREs does not appear to be critical when using assisted reproductive technologies such as in vitro fertilization with or without intracytoplasmic sperm injection. About 30% of the idiopathic infertile couples presented an incomplete set of required SREs, suggesting a male component as the cause of their infertility. Conversely, analysis of couples that failed to achieve a live birth despite presenting with a complete set of SREs suggested that a female factor may have been involved, and this was confirmed by their diagnosis. The data in this study suggest that SRE analysis has the potential to predict the individual success rate of different fertility treatments and reduce the time to achieve live birth.

Characterization of organic cation/carnitine transporter family in human sperm

Spermatozoan maturation, motility, and fertility are, in part, dependent upon the progressive increase in epididymal and spermatozoal carnitine, critical for mitochondrial fatty acid oxidation, as sperm pass from the caput to the cauda of the epididymis. We demonstrate that the organic cation/carnitine transporters, OCTN1, OCTN2, and OCTN3, are expressed in sperm as three distinct proteins with an expected molecular mass of 63 kDa, using Western blot analysis and our transporter-specific antibodies. Carnitine uptake studies in normal control human sperm samples further support the presence of high-affinity (OCTN2) carnitine uptake (K(m) of 3.39+/-1.16 microM; V(max) of 0.23+/-0.14 pmol/min/mg sperm protein; and mean+/-SD; n=12), intermediate-affinity (OCTN3) carnitine uptake (K(m) of 25.9+/-14.7 microM; V(max) of 1.49+/-1.03 pmol/min/mg protein; n=26), and low-affinity (OCTN1) carnitine uptake (K(m) of 412.6+/-191 microM; V(max) of 32.7+/-20.5 pmol/min/mg protein; n=18). Identification of individuals with defective sperm carnitine transport may provide potentially treatable etiologies of male infertility, responsive to L-carnitine supplementation.

Infertility knowledge and attitudes in urban high school students

OBJECTIVE To assess knowledge and attitudes about infertility through a survey. DESIGN Descriptive study with stratified random sampling. SETTING Eighteen high schools were selected in Toronto, Ontario, Canada. PATIENT(S) Seven hundred seventy-two students participated in the study. The mean age of students was 17.5 +/- 0.98 years. Females were 49.02% (n = 377) of the sample. The sample was ethnically diverse, consisting of >13 groups. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) The main outcome was infertility knowledge and attitudes. Secondary analysis compared gender and socioeconomic status. RESULT(S) The majority (608; 79%) of high school students were familiar with the term infertility (95% confidence interval: 76%, 82%). More than 94% did not know that chlamydia or gonorrhea could lead to infertility. Seventy percent felt that protecting their fertility was important to them, with significantly more females feeling this way. There was a higher proportion of students from schools with low socioeconomic status who gave incorrect answers to knowledge-related questions and were unaware of the association between sexually transmitted infections and infertility. CONCLUSION(S) Although the majority of students value their fertility, knowledge about preventable factors causing infertility was limited. Increased efforts are needed to educate students on factors that may affect their fertility.

The influence of prolonged pregnancy on infant development at one and two years of age: a prospective controlled study

Isolated reports of developmental disturbances following prolonged pregnancy led us to compare, prospectively, at 1 and 2 years of age, infants born after normal term gestations with those born after prolonged pregnancies (exceeding 294 days). The infants were subgrouped according to their physical condition at birth, that is, normal or dysmature (mild or advanced dysmaturity). Infant assessments included: (1) height and weight, (2) hospitalizations, and (3) mental development by the Griffiths Mental Development Scales. Follow-up testing was obtained on 130 term control infants and 89 infants of prolonged pregnancies at 1 year of age and 111 term control infants and 76 infants of prolonged pregnancies at 2 years of age. At 1 and 2 years the general intelligence quotient, physical milestones, and intercurrent illnesses for normal infants and those of prolonged pregnancies were not significantly different.

Microsurgical reversal of sterilization: A six-year study

A prospective study of 113 personal consecutive microsurgical reversals of female sterilization during the 6-year period from 1979 to 1984 was carried out to determine factors affecting the pregnancy rate. The sterilizations were performed by laparoscopic unipolar coagulation in 54% of the patients, by the Pomeroy technique in 28%, by fimbriectomy in 8%, by the Irving operation in 5%, and by clips or rings in 4%. In the group with no minimum follow-up period, 50% had intrauterine pregnancies and 5% had ectopic gestations. Eighty-nine patients had at least 12 months of follow-up after reversal surgery. This group is studied in detail. Factors affecting the pregnancy rate were length of tube, type of sterilization performed, anastomotic site, and availability of both tubes for reconstruction. Age, parity, and interval from sterilization to reversal surgery did not affect the pregnancy rate. Fifty percent of the intrauterine pregnancies were conceived within 6 months of reversal surgery.

In vitro fertilization–intracytoplasmic sperm injection outcome in patients with a markedly high DNA fragmentation index (>50%)

OBJECTIVE To investigate differences in fertilization, clinical pregnancy, and miscarriage rates between men with a markedly high sperm DNA fragmentation index (DFI) (>50%) and those with low DFI (≤ 15%) in couples matched by female partner age and ovarian reserve as determined by antimüllerian hormone (AMH) level. DESIGN Retrospective cohort study. SETTING University-affiliated fertility center. PATIENT(S) Men undergoing intracytoplasmic sperm injection (ICSI) cycles who had low (n = 114) or markedly high (n = 36) DNA damage. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Sperm DNA damage evaluated by acridine orange flow cytometry and expressed as the DFI, with the potential confounders of ovarian reserve and age controlled for by multivariable logistic regression analysis. RESULT(S) The fertilization and clinical pregnancy rates were not different between the two groups. We observed a trend toward a higher miscarriage rate with the high DFI group, but it did not reach statistical significance. CONCLUSION(S) Intracytoplasmic sperm injection in men with a high DFI with sperm selected by movement and morphology characteristics resulted in a similar pregnancy rate compared with the controls with a normal DFI. However, the trend observed of an increase in miscarriages suggests that any potential negative impact may appear later in development. Future studies involving a larger cohort may determine if the miscarriage trend reaches statistical significance.