H. Lee Higdon

Comparison of implantation and pregnancy rates in African American and white women in an assisted reproductive technology practice

OBJECTIVE To compare IVF outcomes between infertile African American and white women. DESIGN Retrospective cohort study. SETTING Hospital-based IVF practice. PATIENT(S) Women undergoing IVF procedures between November 1996 and June 2000. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Implantation and pregnancy rates. RESULT(S) There were 24 African American and 273 white women < or =40 years of age who underwent 25 and 333 IVF cycles, respectively. African American women were more likely to have had tubal factor as a primary diagnosis, to have had a child, and to have undergone fewer previous assisted reproductive technology (ART) cycles as compared to white women. No differences between the two groups for clinical variables were noted with the exception of body mass index (BMI [kg/m(2)], 27.1 in African Americans vs. 24.8 in whites). Implantation rates were higher in African American than in white women (35% vs. 23%, respectively). Pregnancy rates were 71% in African Americans and 48% in whites. After adjustment for tubal factor, BMI, and parity, the odds ratio for pregnancy in African American women versus white women increased from 2.6 to 3.3. CONCLUSION(S) This is the first study to demonstrate a significantly higher clinical pregnancy rate in African American women as compared to white women undergoing ART. These data strongly contradict a recent study comparing the same two groups of women undergoing ART. We urge other ART centers to report their data pertaining to race.

Endometrial receptivity defects during IVF cycles with and without letrozole

BACKGROUND Our aim was to study ways to improve IVF success rates in women with suspected endometrial receptivity defects. METHODS We conducted a retrospective cohort study examining the effect of letrozole (aromatase inhibitor) on integrin expression as a marker of endometrial receptivity. We compared IVF outcomes in 97 infertile women who had undergone ανβ3 integrin assessment by immunohistochemistry in mid-luteal endometrial biopsies. Of 79 women undergoing standard IVF, 29 (36.7%) lacked normal integrin expression. Eighteen other women with low integrin were studied after receiving letrozole during early IVF stimulation. An independent set of ανβ3 integrin-negative patients (n = 15) who had undergone repeat endometrial biopsy for integrin testing while taking letrozole were re-evaluated. RESULTS Clinical pregnancy and delivery rates were higher in women with normal ανβ3 integrin expression compared with those who were integrin negative [20/50 (40%) versus 4/29 (13.8%); P = 0.02 and 19/50 (38%) versus 2/29 (7%); P < 0.01, respectively]. In 18 women who received letrozole early in IVF, 11 conceived (61.1%; P < 0.001) compared with integrin-negative patients who did not receive letrozole. In integrin-negative women who were rebiopsied on letrozole, 66.7% reverted to normal integrin expression. Positive endometrial aromatase immunostaining using a polyclonal antibody was a common finding in infertile patients compared with controls. CONCLUSIONS Lack of endometrial ανβ3 integrin expression is associated with a poor prognosis for IVF that might be improved with letrozole co-treatment. Prospective studies are needed to confirm and extend these findings but the data suggest that aromatase expression may contribute to implantation failure in some women.

Intraoperative Detection of Subtle Endometriosis: A Novel Paradigm for Detection and Treatment of Pelvic Pain Associated with the Loss of Peritoneal Integrity

Endometriosis is a common disease affecting 40 to 70% of reproductive-aged women with chronic pelvic pain (CPP) and/or infertility. The purpose of this study was to demonstrate the use of a blue dye (methylene blue) to stain peritoneal surfaces during laparoscopy (L/S) to detect the loss of peritoneal integrity in patients with pelvic pain and suspected endometriosis. Forty women with CPP and 5 women without pain were evaluated in this pilot study. During L/S, concentrated dye was sprayed onto peritoneal surfaces, then aspirated and rinsed with Lactated Ringers solution. Areas of localized dye uptake were evaluated for the presence of visible endometriotic lesions. Areas of intense peritoneal staining were resected and some fixed in 2.5% buffered gluteraldehyde and examined by scanning (SEM) electron microscopy. Blue dye uptake was more common in women with endometriosis and chronic pelvic pain than controls (85% vs. 40%). Resection of the blue stained areas revealed endometriosis by SEM and loss of peritoneal cell-cell contact compared to normal, non-staining peritoneum. Affected peritoneum was associated with visible endometriotic implants in most but not all patients. Subjective pain relief was reported in 80% of subjects. Based on scanning electron microscopy, we conclude that endometrial cells extend well beyond visible implants of endometriosis and appear to disrupt the underlying mesothelium. Subtle lesions of endometriosis could therefore cause pelvic pain by disruption of peritoneal integrity, allowing menstrual or ovulatory blood and associated pain factors access to underlying sensory nerves. Complete resection of affected peritoneum may provide a better long-term treatment for endometriosis and CPP. This simple technique appears to improve detection of subtle or near invisible endometriosis in women with CPP and minimal visual findings at L/S and may serve to elevate diagnostic accuracy for endometriosis at laparoscopy.

Developing techniques for determining sperm morphology in today's andrology laboratory.

Purpose: To investigate three areas: the staining of spermatozoa; the Computer Assisted Semen Analysis (CASA); and the variability of technicians.Methods: Staining experiment: sperm from 15 beef bulls were randomized to one of three staining protocols. CASA experiment: slides were evaluated using the Integrated Visual Optical System and compared to technician results. Variability of technicians: five laboratorians analyzed the same set of 20 slides six different times.Results: Staining experiment: the size of the sperm increased in proportion to increased time and heat associated with each successive protocol. CASA experiment: coefficient of variation ranged from 18.3 to 101.7% (12 slides). Variability of technicians: the mean sperm morphology results ranged from 7.3 to 15% normal forms.Conclusions: Until laboratories adhere to the universal standard set by the World Health Organization to evaluate sperm morphology, a laboratory must rely on its own quality control to insure repeatable results.

Quality Management Issues in the Assisted Reproduction Laboratory

In the United States, the Clinical Laboratory Improvement Act (CLIA) of 1988 describes requirements and guidelines for implementing a quality control/quality assurance (QC/QA) program for moderate ...

Quality Control Management

The cornerstone of assisted reproductive technology (ART) is based upon quality control management. From instruments used to formulate media to methods to determine environmental properties such as temperature, relative humidity, and gas concentrations, all should be monitored and calibrated according to manufacturer’s specifications to insure their accuracy. In addition, attention to detail and the will to examine and improve our ART laboratory processes must be our main goals in our quest to provide a high quality, predictable product to the patients we serve. This review discusses quality control and quality assurance as they pertain to the ART laboratories.

Coexistence of polycystic ovary syndrome and endometriosis in women with infertility

Purpose The aim of this study was to investigate if there is a higher incidence of endometriosis in patients with polycystic ovary syndrome (PCOS), compared with normal fertile controls. Material and methods Women with PCOS according to Rotterdam criteria, with infertility and/or pelvic pain, were identified (n = 104), and together with fertile women seeking bilateral tubal ligation (n = 111), they were submitted to laparoscopy at the Greenville Hospital System or the University of North Carolina at Chapel Hill. A biopsy was performed in 40 patients with PCOS to confirm or not endometriosis. Results Age was similar in both groups (control: 29.7 ± 0.5 years; PCOS: 29.6 ± 0.4). The incidence of suspected endometriotic lesions in controls and PCOS patients was 12.6% (95% confidence interval [95% CI], 7.6%-20%) and 74% (95% CI, 64.8%-81.5%), respectively; with an odds ratio of 19.7 (95% CI, 9.6-40.2) of finding endometriosis in PCOS (p<0.0001). Our results were similar when endometriosis was confirmed by pathology report. Of the PCOS patients with endometriosis, 76% had endometriosis stage I or II, according to the revised American Society for Reproductive Medicine criteria. Conclusions In this case-control study, a significant association between endometriosis and women with PCOS with pelvic pain and/or infertility was found. The majority of endometriotic lesions (76%) were stage I or II.

Longevity of Donor Serum

AbstractPurpose: To determine the viability of long-term, stored serum, which is used in human in vitro production as a source of energy substrates, amino acids, vitamins, growth factors, and other nutrients. Method: Two-cell mouse embryos were used in this prospective, cohort study. Serum stored for 1-, 5-, 10-, and 12-year intervals was subjected to four replications of mouse-embryo testing. Result(s): There were no significant differences in blastocyst rates between any of the replicates by year (80–100% blastocyst rate; P > 00.1) or between pooled replicate means by time period. Conclusion(s): Serum may be frozen up to 12 years.