Ertug Kovanci

Sperm maturity and treatment choice of in vitro fertilization (IVF) or intracytoplasmic sperm injection: diminished sperm HspA2 chaperone levels predict IVF failure ☆

OBJECTIVEnTo reexamine whether low sperm HspA2 ratios (formerly sperm CK-M ratio) are predictive for failure to cause pregnancies by in vitro fertilization (IVF) and to explore whether there are other male or female factors that may be predictive for IVF pregnancy outcome.nnnDESIGNnRetrospective, cohort study.nnnSETTINGnUniversity-based IVF program.nnnPATIENT(S)nIn 119 IVF cycles, three patient groups were studied: 25 men had a <10% sperm HspA2 ratio and a lack of pregnancies (HS <10% group), 50 men had a >10% sperm HspA2 ratio and no pregnancies (HS >10%NP group), and another 44 couples had a >10% sperm HspA2 ratio but did achieve pregnancies (HS >10%P group).nnnINTERVENTION(S)nSperm HspA2 ratio determinations within 1 year of the IVF cycles and analysis of male and female IVF cycle parameters.nnnMAIN OUTCOME MEASURE(S)nSperm HspA2 ratio determinations within 1 year of the IVF cycles and analysis of male and female IVF cycle parameters.nnnRESULT(S)nIn the three groups, male and female ages, number and maturation level of oocytes, and morphology of embryos were similar. In the HS < 10% group, mean sperm concentration and motility were close to normal, the fertilization and cleavage rates were lower, and cycles without any oocyte fertilization were higher. These parameters were similar in the two HS > 10% groups. The receiver operating characteristic curve in men with sperm HspA2 ratios of <17% (diminished and borderline sperm maturity) provided a cutoff value of 10.84% HspA2 ratio with a 100% positive predictive value for failure to achieve pregnancy, whether the men were oligospermic or normospermic.nnnCONCLUSION(S)nHspA2 ratios of <10% in the diminished sperm maturity range predict the failure to cause pregnancies by IVF. Thus, IVF should be bypassed in favor of ICSI. The occurrence of pregnancy with ICSI depends on the maturity of sperm selected, and it may not be as likely as in other indications for ICSI.

New Down syndrome screening algorithm: ultrasonographic biometry and multiple serum markers combined with maternal age.

OBJECTIVEnWe compared the Down syndrome screening efficiency of a new algorithm that combines humerus length measurement and serum analytes versus that of the traditional triple-analyte serum screen.nnnSTUDY DESIGNnHumerus length measurements were obtained prospectively in 1743 midtrimester (14 to 24 weeks) singleton fetuses before genetic amniocentesis. All patients had triple-marker serum screening before amniocentesis. Data on humerus length were expressed as multiples of the median, and were normalized by log transformation. Backward multiple stepwise logistic regression analysis was performed to determine which combination of biometry and serum markers best predicted fetal Down syndrome. The screening efficiency of the traditional triple-analyte algorithm was compared with that of a new multivariate gaussian algorithm that combined biometry and serum markers.nnnRESULTSnThere were 31 (1.8%) fetuses with Down syndrome in the study population. In the regression analysis humerus length, human chorionic gonadotropin, alpha-fetoprotein, and maternal age were significant predictors of Down syndrome, but unconjugated estriol was not. The combined algorithm (humerus length, human chorionic gonadotropin, and alpha-fetoprotein and age) was superior to the traditional triple screen for Down syndrome detection. The sensitivities at fixed false-positive rates were consistently higher in the combination than in the triple-screen protocol. For example, at a 10% false-positive rate the sensitivities were 65.0% and 52.3%, respectively. Similarly, at a 15% false-positive rate the sensitivities were 73.5% and 55.0%, respectively.nnnCONCLUSIONnA new screening algorithm combining humerus length and serum analytes was superior to the traditional triple screen. Although we used a high-risk population in this study, it is expected that the observed superiority of the combination screen would persist in a population of younger women. The development of a combined biometric and serum analyte screening algorithm for estimating individual odds could represent an advance in prenatal Down syndrome screening.

A new splenic artery Doppler velocimetric index for prediction of severe fetal anemia associated with Rh alloimmunization.

OBJECTIVEnWe developed a new Doppler index for the noninvasive prediction of severe fetal anemia by means of Doppler velocimetry of the main splenic artery.nnnSTUDY DESIGNnDoppler velocimetry of the main splenic artery was performed in 85 healthy fetuses and in 22 nonhydropic study case patients (41 measurements) at risk for anemia from Rh sensitization. The deceleration angle between the line describing the average slope during the diastolic phase of the cycle and the vertical axis was measured and expressed in multiples of the median (MoM) for gestational age. Severe anemia was defined as a hemoglobin deficit (mean hemoglobin for gestational age minus measured hemoglobin) >/=5 g/dL. Anemia overall was defined as a hemoglobin deficit >/=2 g/dL.nnnRESULTSnMean gestational age at cordocentesis was 28.6 weeks. Severe anemia was noted on 7 occasions (12.6%) and anemia was noted on 21 (51.2%) occasions. There was a significant correlation between deceleration angle and hemoglobin deficit >/=2 g/dL (r = 0.5763, P <.0001) and also with hemoglobin deficit >/=5 g/dL (r = 0.6418, P <.0001). At deceleration angles <0. 90 MoM, a 90.5% sensitivity and a 30% false-positive rate were achieved for anemia detection. At a threshold deceleration angle of <0.60 MoM, the sensitivity for severe anemia was 100%, with an 8.8% false-positive rate.nnnCONCLUSIONnWe report a new and sensitive Doppler velocimetric technique for predicting severe anemia. By means of splenic artery velocimetry, all cases of severe anemia could be identified before the development of hydrops, with a >91% reduction in the rate of cordocentesis.

Midtrimester urine human chorionic gonadotropin β-subunit core fragment levels and the subsequent development of pre-eclampsia☆☆☆★

OBJECTIVEnOur purpose was to determine whether midtrimester maternal urine human chorionic gonadotropin beta-subunit core fragment predicts later pre-eclampsia.nnnSTUDY DESIGNnUrine beta-core fragment levels standardized to spot creatinine concentration and expressed as multiples of the median were prospectively determined in 347 midtrimester singleton pregnancies undergoing genetic amniocentesis. All women considered in the analysis were white and nonsmokers. Obstetric chart review was undertaken after delivery to identify cases in which pre-eclampsia developed. The risk of pre-eclampsia at different threshold levels of beta-core fragment of human chorionic gonadotropin was determined.nnnRESULTSnThe median maternal age was 36.0 years, with a median gestational age at urine collection of 16.0 weeks. The median level of the beta-core fragment of human chorionic gonadotropin was 1385.5 ng/mg of creatinine in those with pre-eclampsia, whereas that in those without pre-eclampsia was 1061.2 ng/mg. The difference was significant (Mann-Whitney U test, P = .03). A significant linear association was found between the beta-core fragment concentration and the risk of pre-eclampsia (Mantel-Haenszel test of linear association, P = .03). The relative risk and 95% confidence interval of subsequent pre-eclampsia increased from 2.07 (1.06 to 4.05) at beta-core fragment levels of human chorionic gonadotropin > or = 2.0 multiples of the median to 5.17 (1.95 to 13.7) at > or = 4.0 multiples of the median.nnnCONCLUSIONnClinically normal patients with elevated midtrimester levels of urine beta-core fragment of human chorionic gonadotropin are at increased risk for the subsequent development of pre-eclampsia. The clinical value of this urine analyte as a marker for pre-eclampsia needs to be further investigated.

Gestational age standardized nuchal thickness values for estimating mid-trimester Down's syndrome risk.

OBJECTIVEnOur aim was to develop gestational age standardized indices of fetal nuchal thickening. In addition, we wanted to develop a method for combining nuchal thickness data with maternal age for calculating individual Downs syndrome risk.nnnMETHODSnNuchal thickness was measured prospectively in pregnancies undergoing genetic amniocentesis. A regression equation for expected median nuchal thickness based on the biparietal diameter (BPD) was developed. Nuchal thickness values were expressed as multiples of the median (MoM). Additionally, a new parameter, percentage increase in nuchal thickness (PIN) (measured minus expected nuchal thickness) X100/expected nuchal thickness, was used. Receiver operator characteristics curves for Downs syndrome detection based on nuchal thickness values expressed as MoM, PIN, and in mm were compared. Log10 transformation of MoM data resulted in a Gaussian distribution, and the Downs syndrome likelihood ratios were calculated based on the heights of the Gaussian curves. Likelihood ratios were also calculated based on PIN values. The screening efficiency of maternal age alone was compared to age plus MoM, and age plus PIN values by multiplying age-related risk by the likelihood ratio corresponding to the given nuchal thickness MoM or PIN values.nnnRESULTSnThere were 3,574 chromosomally normal and 50 Downs syndrome fetuses in the study. Both PIN and MoM values for nuchal thickness were closely correlated (R = 1.00, P<0.001) and each was poorly correlated with gestational age (R = 0.018, P = 0.28). The Downs syndrome screening efficiency of PIN, MoM, and nuchal thickness values in mm were not significantly different. The addition of nuchal thickness data to maternal age-related risk significantly improved the Downs syndrome screening efficiency: Area under the ROC curve for maternal age risk = 0.58, maternal age + PIN area = 0.79 (P<0.001 compared to maternal age alone) and for maternal age + MoM = 0.77 (P<0.005 compared to maternal age alone).nnnCONCLUSIONSnThe development of gestational age standardized nuchal thickness indices makes it possible to combine ultrasound and maternal age-related risk to derive individual Downs syndrome odds.

A high-sensitivity alternative to “routine” genetic amniocentesis: Multiple urinary analytes, nuchal thickness, and age

OBJECTIVEnOur purpose was to evaluate the Down syndrome screening efficiency of a new algorithm consisting of multiple urinary biochemical and ultrasound markers for use in high-risk groups such as women of advanced maternal age.nnnSTUDY DESIGNnThe urinary beta-core fragment of human chorionic gonadotropin (beta-core fragment) and total urinary estriol, along with fetal nuchal thickness, were measured prospectively in pregnant women who were undergoing genetic amniocentesis at midtrimester (15 to 24 weeks). The most common indication for amniocentesis was advanced maternal age (90.2%). An analyte ratio (beta-core fragment/total estriol ratio) was developed. The values were expressed as multiples of the normal median. An increase in the observed nuchal thickness (delta nuchal thickness) above that expected on the basis of the biparietal diameter was calculated. On the basis of the mean and standard deviations of the urinary analyte ratio in normal fetuses and also Down syndrome, we calculated individual Down syndrome likelihood ratios for each of the two parameters, using gaussian analysis. The product of the likelihood ratios, based on delta nuchal thickness and urinary beta-core fragment-total estriol values times the maternal age-related risk, gave the overall Down syndrome risk. The screening efficiency of our algorithm at various risk thresholds was determined.nnnRESULTSnThere were 13 (2.8%) cases of Down syndrome in a total study population of 457. At a risk threshold of >1 in 70, the sensitivity was 92.3% for a false-positive rate of 4.5%. Corresponding values at a risk threshold of >1 in 78 were a sensitivity of 100% with a false-positive rate of 5.2%.nnnCONCLUSIONnBy combining urinary analyte, nuchal thickness, and maternal age data, we achieved a high Down syndrome detection rate with a low false-positive rate. This algorithm would be attractive as an alternative to routine amniocentesis based solely on advanced maternal age. The potential benefits of this protocol could include a significant reduction in the rate of amniocentesis, along with substantial savings in medical expenditures.

New triple screen test for down syndrome: Combined urine analytes and serum AFP

In this study we report a new triple test that combines serum AFP, urine beta-core fragment of hCG, total urine estriol, and maternal age for calculating individual Down syndrome odds in the second trimester. The urine beta-core fragment/estriol ratio was used as a single screening variable. Analyte levels were measured prospectively in 10 Down syndrome cases and 346 normals. Individual Down syndrome odds were calculated by multiplying the product of the Down syndrome likelihood ratios of serum AFP and urine beta-core/estriol levels by the age-related midtrimester risk. The screening efficiency of an algorithm that combines urine beta-core/estriol with maternal age was compared to one that included serum AFP data. A 90% detection rate for Down syndrome was obtained at a 4.65% false positive rate. This was superior to the 75% sensitivity at 5% false positive rate observed when beta-core/estriol and age alone were used. This new triple test has a higher screening efficiency than that generally reported for the traditional serum triple screen and other urine tests, and it also provides information on the risk of neural tube defects. If confirmed in larger trials, the new algorithm could be used as an alternative to the traditional serum triple screen.

Preparation of Sperm Fractions and Individual Sperm With Low Levels of Chromosomal Aneuploidies for IVF and ICSI

This chapter presents an overview of our ongoing work focusing upon the relationship between diminished sperm maturity and the frequencies of chromosomal aneuploidies, and on the efficiency of the various sperm preparation methods utilized in assisted reproduction for elimination of immature sperm. This chapter will also extend to the major new breakthrough of hyaluronic acid (HA) binding by mature sperm for ICSI sperm selection. First we will discuss research carried out by the Huszar laboratory in the past 15 years relating to objective biochemical markers of sperm function and fertility. Subsequently, we will review the current data and will evaluate the relative utilities of swim-up, gradient centrifugation and HA binding for selection of sperm with low levels of chromosomal aneuploidies and high levels of DNA integrity for IVF and ICSI. The key points to be emphasized are the following: n n(1) n nCytoplasmic retention as a marker of sperm immaturity, and the two-wave expression pattern of the testis specific HspA2 chaperone protein in developing sperm during meiosis and late spermiogenesis. n n n n n(2) n nCellular maturation, plasma membrane remodeling and their contributions to the fertilization function of human sperm. n n n n n(3) n nThe relationship between sperm immaturity and increased frequencies of chromosomal aneuploidies. n n n n n(4) n nThe relative efficiencies of density gradient and swim up methodologies in eliminating aneuploid and diploid sperm. n n n n n(5) n nThe use of HA binding for selection of mature individual sperm with low levels of both chromosomal aneuploidies and DNA degradation.