Erwin Strehler

Influence of acupuncture on the pregnancy rate in patients who undergo assisted reproduction therapy

OBJECTIVE To evaluate the effect of acupuncture on the pregnancy rate in assisted reproduction therapy (ART) by comparing a group of patients receiving acupuncture treatment shortly before and after embryo transfer with a control group receiving no acupuncture. DESIGN Prospective randomized study. SETTING Fertility center. PATIENT(S) After giving informed consent, 160 patients who were undergoing ART and who had good quality embryos were divided into the following two groups through random selection: embryo transfer with acupuncture (n = 80) and embryo transfer without acupuncture (n = 80). INTERVENTION(S) Acupuncture was performed in 80 patients 25 minutes before and after embryo transfer. In the control group, embryos were transferred without any supportive therapy. MAIN OUTCOME MEASURE(S) Clinical pregnancy was defined as the presence of a fetal sac during an ultrasound examination 6 weeks after embryo transfer. RESULT(S) Clinical pregnancies were documented in 34 of 80 patients (42.5%) in the acupuncture group, whereas pregnancy rate was only 26.3% (21 out of 80 patients) in the control group. CONCLUSION(S) Acupuncture seems to be a useful tool for improving pregnancy rate after ART.

Influence of smoking on fertility in women attending an in vitro fertilization program

OBJECTIVE To investigate the influence of cigarette smoking of women on the fertilization and pregnancy rates obtained by IVF treatment. PATIENTS One hundred ninety-seven infertile, otherwise healthy women who entered an IVF program for the first time. SETTING Fertility unit at the Womens University hospital of the University of Ulm, Ulm, Germany. INTERVENTIONS The study population consisted of 197 women (23 to 39 years old) who were divided into the following groups: nonsmokers (n = 68), passive smokers (n = 26), and active smokers (n = 103) according to the cotinine concentration measured in follicular fluid. The reason for infertility was strictly a tubal factor with apparently normal ovulatory cycles. To guarantee an objective recording of tobacco smoke exposure, the smoking habit was not determined by questionnaires, but by cotinine, the principal metabolite of nicotine. RESULTS There were no significant differences in fertilization and pregnancy rates between the different groups. The E2 serum levels were decreased significantly in women who smoked when compared with the results obtained from nonsmokers and passive smokers. Overall, a strong negative correlation of the cotinine and E2 levels was observed (r = -0.65). CONCLUSION The results suggest that there is no clinically detectable impairment of fertilization potential due to female smoking and that there is a greater influence on the outcome of IVF by other factors.

Impact of recombinant follicle-stimulating hormone and human menopausal gonadotropins on in vitro fertilization outcome

OBJECTIVE To investigate possible differences between using recombinant FSH (rFSH) and hMG for ovarian stimulation in IVF/intracytoplasmic sperm injection (ICSI) cycles. DESIGN Parallel group design. Prospective, randomized clinical study. SETTING A tertiary care infertility clinic. PATIENT(S) A total of 578 patients of our IVF/ICSI routine were recruited. INTERVENTION(S) Treatment with hMG was used for 282 patients (282 cycles), whereas 296 patients (296 cycles) were treated with rFSH. The number of cycles leading to an embryo transfer were 248 and 259, respectively. MAIN OUTCOME MEASURES Primary: clinical pregnancy rate. Secondary: treatment days, total dose of gonadotropin administered, number of oocytes retrieved, number of mature oocytes, and embryo quality. RESULT(S) Of the cycles with embryo transfer, the pregnancy rates were 30.1% and 32.3% in the rFSH and the hMG groups, respectively. This difference is not statistically significant (P=0.798). Treatment with rFSH resulted in a significantly higher number of recovered oocytes compared with the hMG group but was also associated with a higher number of ampoules needed to reach the criterion for hCG administration. No significant differences were found with regard to the number of mature oocytes, the number of treatment days, and the embryo quality. CONCLUSION(S) In terms of the clinical pregnancy rate, no significant differences between the two stimulation regimens can be stated.

Twin pregnancy after vitrification of 2-pronuclei human embryos

OBJECTIVE To report an ongoing twin pregnancy after transfer of embryos that were vitrified at the 2-pronuclei stage in a new vitrification solution. DESIGN Case report. SETTING A tertiary-care infertility clinic. PATIENT(S) A 26-year-old infertile woman in whom two previous IVF implantations failed. INTERVENTION(S) Vitrification of 2-pronuclei embryos, in vitro culture for 48 hours, and transfer into the uterus. MAIN OUTCOME MEASURE(S) Survival and cleavage after vitrification and achievement of clinical pregnancy. RESULT(S) Six zygotes were vitrified by using a three-step protocol (4% ethylene glycol for 3 minutes, 20% ethylene glycol for 1 minute, and 38% ethylene glycol and 1.2 M trehalose for 0.5 minute). After 2 months of storage in a double-straw system in liquid nitrogen, two zygotes were warmed and cryoprotectants were removed by using a four-step protocol (1 M, 0.5 M, 0.25 M, and 0.125 M of trehalose). Two embryos were transferred after 48 hours of in vitro culture, cleaving to 5 and 6 cells. The resulting twin pregnancy was confirmed by ultrasonography at the sixth week. CONCLUSION(S) Vitrification by using ethylene glycol and trehalose appears to be a safe, promising method for cryopreservation of human zygotes. Storage of vitrified zygotes in a double-straw system does not compromise their subsequent potential for survival and development.

Quantitative evaluation of spermatozoa ultrastructure after acupuncture treatment for idiopathic male infertility

Objective To evaluate the ultramorphologic sperm features of idiopathic infertile men after acupuncture therapy. Design Prospective controlled study. Setting Christian-Lauritzen-Institut, Ulm, IVF center Munich, Germany, and Department of General Biology, University of Siena, Siena, Italy. Patient(s) Forty men with idiopathic oligospermia, asthenospermia, or teratozoospermia. Intervention(s) Twenty eight of the patients received acupuncture twice a week over a period of 5 weeks. The samples from the treatment group were randomized with semen samples from the 12 men in the untreated control group. Main Outcome Measure(s) Quantitative analysis by transmission electron microscopy (TEM) was used to evaluate the samples, using the mathematical formula based on submicroscopic characteristics. Result(s) Statistical evaluation of the TEM data showed a statistically significant increase after acupuncture in the percentage and number of sperm without ultrastructural defects in the total ejaculates. A statistically significant improvement was detected in acrosome position and shape, nuclear shape, axonemal pattern and shape, and accessory fibers of sperm organelles. However, specific sperm pathologies in the form of apoptosis, immaturity, and necrosis showed no statistically significant changes between the control and treatment groups before and after treatment. Conclusion(s) The treatment of idiopathic male infertility could benefit from employing acupuncture. A general improvement of sperm quality, specifically in the ultrastructural integrity of spermatozoa, was seen after acupuncture, although we did not identify specific sperm pathologies that could be particularly sensitive to this therapy.

Cytogenetics of human spermatozoa: correlations with sperm morphology and age of fertile men

Sperm chromosomes from 15 fertile men were analyzed after fusion of their spermatozoa with zona-free hamster eggs. The total proportion of abnormal metaphases as well as the proportions of aneuploidy and structural aberrations were calculated for every man and examined for linear correlations with [1] sperm morphology and [2] the age of the persons studied. A positive correlation between the cytogenetic parameters and the percentage of abnormal sperm morphology was not evident, suggesting that assessment of sperm morphology cannot be used as an indicator of chromosomal damage in human spermatozoa. In contrast, there was a more distinct positive correlation between the age of donors and the three cytogenetic parameters studied.

Improved implantation rate after chemical removal of the zona pellucida

OBJECTIVE To evaluate the implantation rate achieved after chemical removal of the zona pellucida from day 5 human in vitro-derived embryos. DESIGN Prospective, randomized, controlled study. SETTING A tertiary care infertility clinic. PATIENT(S) Two hundred fifty-seven patients undergoing IVF with transfer of morulas or blastocysts on day 5 after oocyte retrieval. All patients had had at least two previous implantation failures. INTERVENTION(S) Chemical removal of zona pellucida by using acidic Tyrodes solution vs. no removal (controls). MAIN OUTCOME MEASURES Clinical pregnancy rate and implantation rate per transfer. RESULT(S) Embryos without zona pellucida implanted at nearly twice the rate of control embryos (15.7% vs. 27.5%). The pregnancy rate was also significantly higher in the zona pellucida-free group than the control group (31.0% vs. 46.1%). Removal of zona pellucida was most effective in embryos with delayed development, which reached the morula or early cavitating stage on day 5 of in vitro culture (implantation rate, 12.1% vs. 25.7%). CONCLUSION(S) Chemical removal of zona pellucida from day 5 in vitro cultured human embryos is an effective and safe method of significantly improving the implantation rate, especially of embryos with delayed development.

Recent advances in human sperm pathology

Electron microscopy is a valuable tool in understanding not only the presence but also the nature of sperm malformation causing human infertility. In the past, we have examined patients affected by severe teratospermia concomitant with andrological pathologies such as varicocele, cryptorchidism, and infection. In particular, we have demonstrated that, in the case of varicocele, a combination of different phenotypic defects typical of immature spermatozoa is present. This general study was carried out on 2000 infertile men who presented for sperm analysis at our laboratory over the course of 10 years. The ejaculate of all of them was examined by electron microscopy, statistically evaluated by a formula created by us (J of Andrology, 1995), and cytogenetically checked by fluorescence microscopy techniques. First of all, this study concerned the techniques of assisted reproduction, i.e. intracytoplasmic sperm injection (ICSI), partial zona disruption (PZD), and in vitro fertilization (IVF). The conclusion was that the evaluation of the sperm quality of males attempting artificial insemination must concern not only motility or staining characteristics but mainly submicroscopical and molecular properties. Moreover, the effect of follicle stimulating hormone (FSH) treatment on human sperm quality has been evaluated by our group testing the ultrastructure and the function of spermatozoa before and after the therapy. Using the sperm as an andrological monitor, it seems that the therapeutic effect of FSH depends on the type of sperm affections. In particular, phenotypic defects as apoptosis and immaturity can be corrected by FSH treatment. More recently, we approached the problem of genotypic sperm infertility. We demonstrated that some very peculiar defects, detected by electron microscopy, show a hereditary transmission having a genetic basis. In fact, they are much more frequent in consanguineous patients, and are clearly related to different degrees of consanguinity. Frequently, chromosomal translocations have sometimes been found correlated to these defects.A consequence of these demonstrations is that most of the present sperm defects are phenotypic and can be submitted to surgical or pharmaceutical cares, but others have genetic origin and cannot be corrected by surgical or pharmaceutical treatment. These malformations are transmitted to the offspring by techniques of assisted fertilization.

Lack of correlation between ultrasonography and histologic staging of the endometrium in in vitro fertilization (IVF) patients.

In 53 patients of an in vitro fertilization (IVF) program with unsuccessful fertilization of oocytes, an endometrial biopsy was carried out on the day of the intended embryo transfer. The results were compared with the thickness (assessed on the very same day by means of ultrasonography) and the echo pattern of the endometrium, which was classified into four grades (A to D). We found grade A in 16 cases (30%), grade B in 22 cases (41.5%) and grade C in 15 cases (28.5%); no endometrium was assessed as grade D. The distribution of histologic findings was not significantly skewed within the respective grading categories (only 37.5% of grade A endometria, 63.5% of grade B endometria and 66.5% of grade C endometria were in phase with the menses). The in-phase and out-of-phase endometria did not display significant differences in endometrial thickness (8.8 +/- 0.29 mm vs. 9.13 +/- 0.4mm). Neither the sonographically measured endometrial thickness nor the echo pattern correlated with the histologic findings, suggesting that ultrasonography is inadequate for drawing reliable conclusions about endometrial receptivity in an IVF program.

In-vitro culture of human embryos with mechanical micro-vibration increases implantation rates

The in-vitro culture of human embryos in a medium subjected to regular short intervals of mechanical agitation leads to increased development rates. This type of treatment tries to mimic conditions in nature whereby oviductal fluid is mechanically agitated by the epithelial cilia. This phenomenon can be explained by the fact that an embryo developing in vivo is naturally exposed to constant vibrations of around 6Hz with the periodically repeating increase to 20Hz. This review covers the history of this question and in this light offers an explanation through biological concept for one of the most recent developments in this area: in-vitro culture of human embryos with mechanical micro-vibration. The effect of mechanical micro-vibration on embryos during their in-vitro culture was examined. Pregnancy rates after the transfer of embryos in the group with in-vitro culture under mechanical vibration were increased.