Eitan Lunenfeld

Fertility drugs and the risk of breast and ovarian cancers: results of a long-term follow-up study

OBJECTIVE To investigate a possible linkage between the use of fertility drugs for infertility and the risk of breast and ovarian cancers. DESIGN Long-term, historic-prospective study. SETTING Fertility clinic in a university hospital. PATIENT(S) Files of 1,197 infertile women with a mean (+/- SD) follow-up of 17.9+/-5 years (21,407 person-years) were reviewed. Diagnoses, number of courses, and dosage of fertility drugs were extracted from the files. INTERVENTION(S) Cancers were identified by record linkage to the National Cancer Registry. Histopathologic reports and data on estrogen and progesterone receptors in breast cancer tissue were also reviewed. MAIN OUTCOME MEASURE(S) Standardized incidence ratio with 95% confidence interval (CI) were used for risk assessment. RESULT(S) Of 20 breast cancers (standardized incidence ratio, 1.40 [95% CI, 0.83-2.10]), 16 were detected among 780 women who had been exposed to 3,978 cycles of clomiphene citrate (CC) and/or hMG (standardized incidence ratio, 1.65 [95% CI, 0.94-2.68]). The standardized incidence ratio for this cancer was significantly increased only in patients with one or two CC treatments and a dose of < or =1,000 mg (2.6 [1.19-5.0] and 2.52 [1.21-4.64], respectively). Two cases of ovarian cancer (1 patient unexposed) were observed with no evidence of excessive risk. Six of the eight patients with data on estrogen and progesterone receptors were exposed to CC, and all tested positive for these receptors. CONCLUSION(S) An association between the use of fertility drugs and an increased risk of breast and ovarian cancers has not been confirmed.

Obstetric outcome of singleton pregnancies conceived by in vitro fertilization and ovulation induction compared with those conceived spontaneously

OBJECTIVE To compare the obstetric characteristics of singleton pregnancies conceived by IVF and ovulation induction with those conceived spontaneously. DESIGN Case-control study. SETTING Tertiary care medical center. PATIENT(S) All singleton pregnancies that were achieved by IVF (n = 169) and ovulation induction (n = 646) and were delivered from January 1989 through December 1994 were evaluated. Each group was compared with a separate control group that conceived spontaneously (n = 469 and n = 1,902 for the IVF and ovulation induction groups, respectively) and delivered during the same period and was matched in terms of maternal age, gestational age, and parity. INTERVENTION(S) Ovulation induction, IVF-ET. MAIN OUTCOME MEASURE(S) Obstetric complications. RESULT(S) Multivariate analysis showed that patients who conceived by IVF and ovulation induction had a significantly higher risk for gestational diabetes mellitus (odds ratio [OR] = 2.0; 95% confidence interval [CI] = 1.23-3.30 and OR = 1.9, 95% CI = 1.09-1.79, respectively), pregnancy-induced hypertension (OR = 2.1, 95% CI = 1.04-4.10 and OR = 1.5, 95% CI = 1.04-2.02, respectively), and cesarean section (OR = 3.6, 95% CI = 2.44-5.29 and OR = 1.4, 95% CI = 1.09-1.79, respectively) compared with their matched controls. CONCLUSION(S) After controlling for maternal age, gestational age, and parity, we demonstrated that singleton pregnancies conceived by IVF and ovulation induction are at increased risk for maternal gestational diabetes mellitus and pregnancy-induced hypertension, and at greater risk for delivery by cesarean section.

The effect of the duration of the second stage of labour on the acid‐base state of the fetus

A prospective study was made in 153 patients with a second stage of labour lasting 1 to 120 min. Maternal venous, umbilical artery and vein blood were analysed for acid‐base variables and lactate levels. Blood was obtained immediately at delivery. Fetal heart rate monitoring data and blood test results were related to the duration of the second stage of labour and clinical outcome. In primiparae and multiparae there was a steady rise in umbilical artery lactate levels, with duration of second stage of labour, P>0·025 and P= 0·023, respectively. The median umbilical artery pH decreased significantly from 7·31 in patients with a second stage of labour that lasted ≤15 min to a pH of 7·25 in patients with a second stage of labour that lasted more than 30 min. Changes in Po2 and Pco2 were not statistically significant.

Distinct expression levels of cytokines and soluble cytokine receptors in seminal plasma of fertile and infertile men

OBJECTIVE To compare the levels of interleukin (IL) 1 beta, IL-6, tumor necrosis factor (TNF) alpha, and soluble TNF (sTNF) receptors types I and II, and IL-1 receptor antagonist in seminal plasma of fertile and infertile men. DESIGN Prospective and comparative study. SETTING Andrology clinic of a university hospital. PATIENTS Four groups of normogonadotropic men: group 1, donors with proven fertility (controls, n = 15); group 2, azoospermic men (n = 12); group 3, infertile men with oligoteratoasthenospermia (n = 20); and 11 men with oligoteratoasthenospermia and genital infection (n = 11). INTERVENTIONS None. MAIN OUTCOME MEASURE Measurement of cytokines and cytokine-soluble receptors in the semen by specific commercial kits. RESULTS The levels of IL-1 beta, TNF-alpha, and IL-6 were similar in seminal plasma of controls and infertile men. The mean level of sTNF-I receptor in the seminal plasma of group 4 was 2.4 +/- 0.2 ng/mL, which was significantly lower than observed in seminal plasma of group 1 (3.88 +/- 0.5 ng/mL), the group 3 (4.1 +/- 0.4 ng/mL), or group 2 (3.03 +/- 0.35 ng/mL). The soluble receptor of TNF-II could not be detected in any group. Interleukin 1ra was 120 +/- 10 pg/mL in seminal plasma of group 1, but increased levels were detected in group 2 (420 +/- 180 pg/mL), group 3 (480 +/- 90 pg/mL), and even higher (760 +/- 120 ng/mL) in group 4 patients. CONCLUSIONS During genital infection cytokines and various soluble receptors of immunoregulatory cytokines are expressed distinctly in seminal plasma. These factors also may be involved in the regulation of sperm cell functions and thus may affect male fertility. Our results may indicate local production of these factors in the secondary sex glands, independently of spermatogenesis.

Relationship between age and semen parameters in men with normal sperm concentration: analysis of 6022 semen samples

This study evaluates retrospectively the relationship between age and semen parameters among men with normal sperm concentration. It was based on computerized data and performed in an Academic Fertility and IVF Unit. Six thousand and twenty‐two semen samples with sperm concentrations of ≥20 × 106 ml−1 were examined according to WHO criteria and analysed in relation to patients’ age. For each age group, mean values ± SD of semen volume, sperm concentration, percentage of motile spermatozoa, normal morphology, acrosome index, total sperm count/ejaculate, total motile sperm count/ejaculate and sexual abstinence duration were examined. A peak semen volume of 3.51 ± 1.76 ml−1 was observed at age ≥30 to <35 years and a lowest volume of 2.21 ± 1.23 ml−1 was observed at age ≥55 years (P < 0.05). Sperm motility was found to be inversely related to age with peak motility of 44.39 ± 20.69% at age <25 years and lowest motility of 24.76 ± 18.27% at age ≥55 years (P < 0.05). A reduction of 54% was observed for total motile sperm, between values of 103.34 ± 107 × 106 at age ≥30 to <35 years and 46.68 ± 53.73 × 106 (P < 0.05) at age >55 years. A statistically significant and inverse relationship was observed between semen volume, sperm quality and patient age, in spite of prolonged sexual abstinence duration. Top sperm parameters were observed at age ≥30 to <35 years, while the most significant reduction in sperm parameters occurred after the age of 55 years.

Differentiation of murine male germ cells to spermatozoa in a soft agar culture system

Establishment of an in vitro system that allows the development of testicular germ cells to sperm will be valuable for studies of spermatogenesis and future treatments for male infertility. In the present study, we developed in vitro culture conditions using three-dimensional agar culture system (SACS), which has the capacity to induce testicular germ cells to reach the final stages of spermatogenesis, including spermatozoa generation. Seminiferous tubules from testes of 7-day-old mice were enzymatically dissociated, and intratubular cells were cultured in the upper layer of the SACS in RPMI medium supplemented with fetal calf serum (FCS). The lower layer of the SACS contained only RPMI medium supplemented with FCS. Colonies in the upper layer were isolated after 14 and 28 days of culture and were classified according to their size. Immunofluorescence and real-time PCR were used to analyse specific markers expressed in undifferentiated and differentiated spermatogonia (Vasa, Dazl, OCT-4, C-Kit, GFR-α-1, CD9 and α-6-integrin), meiotic cells (LDH, Crem-1 and Boule) and post-meiotic cells (Protamine-1, Acrosin and SP-10). Our results reveal that it is possible to induce mouse testicular pre-meiotic germ cell expansion and induce their differentiation to spermatozoa in SACS. The spermatozoa showed normal morphology and contained acrosomes. Thus, our results demonstrate that SACS could be used as a novel in vitro system for the maturation of pre-meiotic mouse germ cells to post-meiotic stages and morphologically-normal spermatozoa.

Expression of IL-12, IL-10, PGE2, sIL-2R and sIL-6R in seminal plasma of fertile and infertile men

The involvement of cytokines and other immunoregulatory factors in male infertility is still unclear. In the present study we compared the levels of IL‐12, IL‐10, PGE2, sIL‐2R and sIL‐6R in the seminal plasma (SP) of fertile and infertile men. Four groups were included: fertile donors (FERT), infertile men with azoospermia (AZOO), and infertile men with either oligo‐terato‐asthenoazoospermia (OTA), or OTA with genital infection (OTA‐INF). Cytokines and cytokine‐soluble receptors in semen were evaluated by specific ELISA commercial kits. The levels of IL‐12, sIL‐2R and sIL‐6R were similar in SP of fertile and infertile men. The mean levels of IL‐10 in the SP of FERT, OTA and AZOO were 5.6±0.9, 4±2.8 and 8±3.5 pg ml−1, respectively, and did not differ significantly. The mean level of IL‐10 in SP from OTA‐INF (0.9±0.5 pg ml−1) was significantly lower than that for FERT (5.6±1.9 pg ml−1; P=0.02) and AZOO (8.2±3.4 pg ml−1; P=0.05), but not significantly different from that for OTA (3.7±2.1 pg ml−1). The mean SP level of PGE2 was significantly lower in SP of OTA‐INF than FERT (7.67±2.26 and 19.67±3.69 μg ml−1, respectively; P<0.02). In conclusion, the seminal plasma from fertile and infertile men contained similar levels of IL‐12, sIL‐2R and sIL‐6R. However, the levels of IL‐10 were significantly lower in SP from OTA‐INF compared to FERT and AZOO. Our results indicate that specific cytokines and their soluble receptors are involved in the male reproductive system.

A quantitative assessment of a methodology for collaborative specification and evaluation of clinical guidelines

We introduce a three-phase, nine-step methodology for specification of clinical guidelines (GLs) by expert physicians, clinical editors, and knowledge engineers and for quantitative evaluation of the specifications quality. We applied this methodology to a particular framework for incremental GL structuring (mark-up) and to GLs in three clinical domains. A gold-standard mark-up was created, including 196 plans and subplans, and 326 instances of ontological knowledge roles (KRs). A completeness measure of the acquired knowledge revealed that 97% of the plans and 91% of the KR instances of the GLs were recreated by the clinical editors. A correctness measure often revealed high variability within clinical editor pairs structuring each GL, but for all GLs and clinical editors the specification quality was significantly higher than random (p<0.01). Procedural KRs were more difficult to mark-up than declarative KRs. We conclude that given an ontology-specific consensus, clinical editors with mark-up training can structure GL knowledge with high completeness, whereas the main demand for correct structuring is training in the ontologys semantics.

Placebo-controlled trial of topical interferon in labial and genital herpes

The efficacy of topical interferon-beta (IFN-beta) treatment was assessed in 25 patients with herpes of the lips or genitals who completed a 2-year follow-up in a double-blind placebo-controlled trial. IFN-beta gel (10(5) U/g) 4 times daily (about 2 x 10(4) U) applied locally during eruptions (about 10 days) reduced the mean number of recurrences (p less than 0.007) and the duration of eruptions (p less than 0.007): in the placebo group these indices did not change significantly. Reduction of symptoms and severity was noted in 11 of 12 patients on IFN-beta and in only 1 on placebo. No important side-effects were recorded. Topical IFN-beta may therefore be advantageous as a time-limited local treatment of recurrent herpes simplex virus infections of the genitals and lips.

Production of interleukin-1–like molecules by human sperm cells

OBJECTIVE To characterize and localize interleukin (IL)-1alpha and IL-1beta in human sperm cells. DESIGN Prospective and comparative study. SETTING Andrology clinic of a university hospital. PATIENT(S) Two groups of normogonadotropic men: 17 fertile men (donors with proved fertility) and 8 oligoteratoasthenospermic infertile men. INTERVENTION(S) None. MAIN OTUCOME MEASURE(s): Evaluation of IL-1alpha and IL-1beta levels and expression in sperm cells by immunohistochemical staining, immunoassay, and Western blot analysis. RESULT(S) Both types of IL-1-like molecules (IL-1alpha and IL-1beta) were expressed in the tail, neck, and head of sperm cells of fertile men and patients with oligoteratoasthenospermia. Swim-up sperm cells from fertile men and patients with oligoteratoasthenospermia secreted similar levels of IL-1-like molecules. The levels of IL-1beta-like molecules were higher than those of IL-1alpha-like molecules in both groups. The expressed IL-1-like molecules were characterized by the presence a 60-kd protein for both IL-1alpha-like and IL-1beta-like molecules. In some samples of both fertile men and infertile men with oligoteratoasthenospermia, 17-kd, 33-kd, and 45-kd IL-1beta-like molecules were detected. Impairment of sperm function, such as decreased sperm count and motility and/or impaired morphology, was not related to the capacity of sperm cells to produce IL-1-like molecules. CONCLUSION(S) IL-1 molecules originating in sperm cells may play a role in the physiologic functions of sperm cells (autocrine effect) and/or in cell-cell interactions within the testis (paracrine effect).