K. Bendikson

Characterizing the influence of vitamin D levels on IVF outcomes

BACKGROUND Vitamin D plays a role in reproductive capacity. Recently, several investigators have demonstrated higher IVF pregnancy rates in vitamin D replete women. The objective of this study was to validate these findings and to further elucidate the role of vitamin D in reproduction among a diverse group of women. METHODS This was a retrospective cohort study in an academic tertiary care center of 188 infertile women undergoing IVF. Serum levels of vitamin D (25OH-D) were measured in previously frozen serum samples. The main outcome measure was clinical pregnancy, defined as sonographic presence of a heartbeat following IVF. RESULTS The relationship between vitamin D status and pregnancy rates differed by race (P < 0.01). Among non-Hispanic whites, pregnancy rates declined with progressively lower levels of vitamin D, while in Asians, the reverse was true. Adjusting for age and number and quality of embryos transferred among non-Hispanic whites, the odds of pregnancy were four times higher in vitamin D replete versus deficient patients. Live birth rates mirrored pregnancy rates. Vitamin D status was not associated with ovarian stimulation parameters or with markers of embryo quality. CONCLUSIONS Vitamin D deficiency is associated with lower pregnancy rates in non-Hispanic whites, but not in Asians, possibly due to their lower IVF success rates. Vitamin D deficiency was not correlated with ovarian stimulation parameters or with markers of embryo quality, suggesting its effect may be mediated through the endometrium.

The status of oocyte cryopreservation in the United States

OBJECTIVE To determine the current status of oocyte cryopreservation across the United States, and the perceived indications for its use. DESIGN Cross-sectional survey of all IVF Centers in the United States. SETTING Telephone and fax based survey of all IVF practice or laboratory directors, conducted March to June of 2009. PATIENT(S) None. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Prevalence of oocyte cryopreservation, acceptable indications and age groups, number of oocyte cryopreservation cycles performed and thawed, fertilization and pregnancy rates, number of live births. RESULT(S) Of 442 centers contacted, 282 (64%) responded in 49 states. In these centers 143 (51%) programs currently offer oocyte cryopreservation, with a geographic trend toward the western-located clinics. Of all programs, 36% offer oocyte cryopreservation only for cancer patients or as an alternative to embryo cryopreservation after IVF, whereas 64% of programs offer it electively in women of advancing maternal age. For elective indications, 87% of programs accept patients aged 35-37 years, 49% consider age 38-40 years as acceptable, whereas only 26% of programs cryopreserve oocytes beyond age 40 years. Three hundred thirty-seven live births resulting from 857 thawed cycles (39.3% pregnancy rate [PR]) were reported across all centers. CONCLUSION(S) Oocyte cryopreservation is offered in more than 50% of ART clinics in the United States. Most programs that perform oocyte cryopreservation for cancer indications offer it for elective delay of childbearing as well. These data suggest a growing acceptance for this technology within our field.

Influence of vitamin D levels on in vitro fertilization outcomes in donor-recipient cycles.

OBJECTIVE To elucidate the role of vitamin D in reproduction by examining the relationship between recipient vitamin D levels and pregnancy rates in donor-recipient IVF cycles. DESIGN Retrospective cohort study. SETTING Academic tertiary care center. PATIENT(S) Ninety-nine recipients of egg donation at University of Southern California Fertility. INTERVENTION(S) Serum was collected from egg donor recipients before ET and was tested for vitamin D levels [25(OH)D]. MAIN OUTCOME MEASURE(S) Clinical pregnancy as defined by sonographic presence of a heartbeat at 7-8 weeks of gestation. RESULT(S) In a diverse population of 99 recipients (53% Caucasian, 20% Asian, 16% Hispanic, 7% African American), adjusted clinical pregnancy rates were lower among vitamin D-deficient recipients than among vitamin D-replete recipients (37% vs. 78%). Live-birth rates were 31% among vitamin D-deficient recipients, compared with 59% among vitamin D-replete recipients. There were no differences in adjusted clinical pregnancy and live-birth rates among recipients who were vitamin D deficient [25(OH)D<20 ng/mL] vs. among those who were vitamin D insufficient [20 ng/mL ≤ 25(OH)D<30 ng/mL]. CONCLUSION(S) Nonreplete vitamin D status [25(OH)D<30 ng/mL] was associated with lower pregnancy rates in recipients of egg donation. Since the oocyte donor-recipient model is able to separate the impact of vitamin D on oocyte vs. endometrium, these data suggest that the effects of vitamin D may be mediated through the endometrium.

The Outcome of Intracytoplasmic Sperm Injection Using Occasional Spermatozoa in the Ejaculate of Men With Spermatogenic Failure

PURPOSE Men with spermatogenic failure so profound that they are considered as having nonobstructive azoospermia occasionally have spermatozoa in the ejaculate. We compared intracytoplasmic sperm injection outcomes following the injection of ejaculated or surgically retrieved spermatozoa from these men. MATERIALS AND METHODS A study was performed of intracytoplasmic sperm injection cycles with no spermatozoa on initial semen analysis and 100 or fewer following centrifugation (cryptozoospermia). Only 16 couples that underwent intracytoplasmic sperm injection cycles with ejaculated spermatozoa and cycles with testicular spermatozoa were included. RESULTS Initial analysis was done to compare outcomes between the 2 semen origins. There was no difference in the rate of normal or abnormal fertilization between the 2 groups. The rate of clinical pregnancies seemed to favor testicular spermatozoa (47.4% vs 20.8%), although results were not significant. When a comparison was performed between the first testicular cycle and the ejaculated cycle closest in time to the cycle with testicular spermatozoa, a higher rate of normal fertilization with testicular spermatozoa was observed (60.9% vs 48.5%, p <0.05). Also, in this comparison a clear trend toward a higher percent of clinical pregnancies and deliveries in the testicular group was observed (50.0% vs 14.3%). CONCLUSIONS Transit through the male genital tract did not enhance the ability of ejaculated spermatozoa to achieve fertilization with intracytoplasmic sperm injection compared to that of testicular spermatozoa in men with severely impaired production. In ejaculated samples a lower number of spermatozoa available resulted in an impaired chance of achieving pregnancy. Using testicular spermatozoa may be a reasonable alternative for couples in whom multiple attempts at intracytoplasmic sperm injection have failed using ejaculated sperm from men with cryptozoospermia.

Fertility options for HIV patients.

Purpose of review This paper reviews the latest reproductive options for HIV infected couples. In light of the new treatment options and improved prognosis for HIV patients, policymakers have issued recent statements to guide physicians in the care of HIV patients desiring fertility. We will review the advances in reproductive technologies and ethical considerations that have led to these most recent statements. Recent findings Millions of young adults of reproductive age are afflicted with the HIV virus. With the improvement in treatment options for HIV patients and the increase in their life expectancy it is not surprising that many HIV patients desire children. Assisted reproductive technologies can assist serodiscordant couples in achieving pregnancy while at the same time minimizing risk of HIV transmission to the uninfected partner. Several European fertility clinics have a great deal of experience in providing both intrauterine inseminations and in-vitro fertilization to serodiscordant couples without seroconversion of the uninfected female partners. This is both a medical and an ethical issue. Guidelines from policymakers regarding this issue have changed over the years as a result of both changes in disease prognosis and the reproductive technologies. Summary Reproductive technologies provide a logical way to minimize HIV transmission for HIV couples desiring pregnancy. Although the most recent research is compelling, much more needs to be performed in order to establish the safety of these techniques. Protocols need to be put in place in order to assist physicians in better serving these patients. In addition, many ethical and legal issues need to be addressed before these treatments can become standard of care in the United States.

Smoking and infertility: a committee opinion

Approximately 21% of women of reproductive age and 22% of men of reproductive age in the United States smoke cigarettes. Substantial harmful effects of cigarette smoke on fecundity and reproduction have become apparent but are not generally appreciated. This committee opinion reviews the potential deleterious effects of smoking on conception, ovarian follicular dynamics, sperm parameters, gamete mutations, early pregnancy, and assisted reproductive technology (ART) outcomes. It also reviews the current status of smoking cessation strategies. This document replaces the 2012 ASRM Practice Committee document of the same name (Fertil Steril 2012;98:1400-6).

The use of preimplantation genetic testing for aneuploidy (PGT-A): a committee opinion

The value of preimplantation genetic testing for aneuploidy (PGT-A) as a screening test for in vitro fertilization (IVF) patients has yet to be determined. Several studies demonstrate higher birth rates after aneuploidy testing and elective single-embryo transfer (eSET), suggesting the potential for this testing to decrease the risk of multiple gestations, though these studies have important limitations.

Performing the embryo transfer: a guideline

A systematic review of the literature was conducted which examined each of the major steps of embryo transfer. Recommendations made for improving pregnancy rates are based on interventions demonstrated to be either beneficial or not beneficial.

Further evidence of the safety of assisted reproductive technologies.

Worldwide, it is estimated that more than 3 million babies have been born as a consequence of the application of some form of assisted reproductive technology (ART). Although the majority of children born after ART are healthy, some concerns remain regarding the safety of these novel procedures. Several studies have indicated that epigenetic programming may be disrupted after ART, because the incidence of genomic imprinting defects appears to be higher in ART offspring compared with the general population in some studies (1). Moreover, some animal studies and long-term follow-up studies of ART children have implied that there may be an increased incidence of genetic, physical, or developmental abnormalities, although several reports contradict these findings (2). Likewise, some investigators have suggested that intracytoplasmic sperm injection (ICSI), by virtue of its invasive nature, is more likely to result in genetic and/or developmental abnormalities. However, it is difficult to assess whether the purported abnormalities are a consequence of ICSI or rather result from the underlying defects responsible for the infertility. Moreover, many studies have not reported increased abnormalities after the application of ICSI (3). To clarify this issue, in a recent issue of PNAS, Caperton et al. (4) explored the influence of ART procedures on the creation of de novo point mutations in ART offspring. The incidence of point mutations in ART offspring has not been previously explored in either animals or humans. This important study provides much-needed insight on the impact of ART procedures on genomic alterations.

Removal of myomas in asymptomatic patients to improve fertility and/or reduce miscarriage rate: a guideline

The purpose of this systematic review is to evaluate if uterine myomas impact the likelihood of pregnancy and pregnancy loss, and if myomectomy influences pregnancy outcomes in asymptomatic women. There is insufficient evidence to conclude that the presence of myomas reduces the likelihood of achieving pregnancy. However, there is fair evidence that myomectomy (open or laparoscopic) for cavity-distorting myomas (intramural or intramural with a submucosal component) improves pregnancy rates and reduces the risk of early pregnancy loss. There is fair evidence that hysteroscopic myomectomy for cavity-distorting myomas improves clinical pregnancy rates but insufficient evidence regarding the impact of this procedure on the likelihood of live birth or early pregnancy loss. In women with asymptomatic cavity-distorting myomas, myomectomy may be considered to optimize pregnancy outcomes.