K. Paul Katayama

A Meta-Analysis of Controlled Studies Comparing Major Malformation Rates in IVF and ICSI Infants with Naturally Conceived Children

Purpose: To estimate the risk of major malformations in IVF and ICSI infants.Methods: Forty-four studies published in English since 1990 where the major malformation rate for IVF or ICSI cases was compared to an appropriate control group were reviewed. Nineteen studies met all selection criteria. In addition, a quality score was developed to assess each study based on sample size, timing of diagnosis, appropriateness of control group and other factors.Results: In 19 studies, the major malformation rates ranged from 0–9.5% for IVF; 1.1–9.7 for ICSI; and 0–6.9% in the control groups. When ICSI was compared to IVF, and multiple births compared to singleton, there were no statistically significant differences. When data from 16 studies involving 28,524 IVF infants and 2,520,988 spontaneously conceived controls and 7 studies involving 7234 ICSI infants and 978,078 controls were pooled, we found an overall odds ratio for the 19 studies of 1.29 (95% CI 1.01–1.67).Conclusions: The overall odds ratio of 1.29 was statistically significant at the 5% level. These results may be useful for counseling ART patients and properly designing the consent forms used for ART procedures. It is not clear whether this risk is due to the procedures used in ART. We found that some of these studies have design flaws. All of them lacked an appropriate control group, i.e. infertile patients conceiving spontaneously. These flaws may create biases that would in almost all instances increase the risk of major malformations in the study group. Further research with better designed studies will likely result in a better estimate of the risk of major malformations associated with IVF and ICSI.

Vitrification demonstrates significant improvement versus slow freezing of human blastocysts

Blastocyst culture has reduced the number of embryos transferred per cycle, whilst simultaneously creating new quandaries regarding supernumerary blastocyst cryopreservation. This retrospective study was undertaken to compare a slow freezing protocol to a vitrification protocol for cryopreservation of day 5 and day 6 human blastocysts. To demonstrate this, the survival, implantation rate and pregnancy rates were compared after thawing, assessment and embryo transfer of 86 consecutive day 5 and day 6 thawed blastocyst transfer cycles from January 1, 2002 to December 31, 2003. Seventy-one day 5 slow-frozen (SF) blastocysts were thawed and 59 embryos survived the thawing (83.1%). An average of 2.5 SF blastocysts was replaced per embryo transfer, resulting in a pregnancy rate of 16.7% (4/24). Concurrently, 41 vitrified (VIT) blastocysts were thawed and all 41 survived the thawing process (100%). An average of 2.0 VIT blastocysts was replaced per embryo transfer, resulting in a pregnancy rate of 50% (10/20). Survival, pregnancy and implantation rates of day 5 VIT blastocysts have significantly increased (P < 0.01, P < 0.02 and P < 0.01 respectively) over day 5 SF blastocysts. A similar trend was observed with day 6 blastocysts.

A meta-analysis of the impact of IVF and ICSI on major malformations after adjusting for the effect of subfertility.

ObjectiveTo estimate the effect of assisted reproductive technology (ART) on major malformation (MM) rate in ART offspring independent of the effect of subfertility on MM.DesignMeta-analysis.MethodsThis meta-analysis is based on our previously published meta-analysis of observational studies evaluating the relationship between ART treatment and MM rates, as well as recent research by Zhu et al. to estimate the impact of subfertility alone on MM in subfertile couples conceiving spontaneously.ResultsThe overall odds ratio for MM in our original meta-analysis, in which all studies used apparently inappropriate control groups of “normal” populations, was 1.29 (95% CI 1.01–1.67). Here we attempted to estimate the risk of subfertility and used this estimate to perform an adjusted meta-analysis. Zhu et al. found that about 40% of the odds of MM was due to subfertility. When we took Zhu’s finding into account, the adjusted odds ratio in the meta-analysis was 1.01 (95% CI 0.82–1.23).ConclusionsOur study suggests ART does not increase the risk of MM as much as previously reported. More research is needed to quantify the underlying risk of subfertility and separate it from the risk associated with ART. Physicians who counsel subfertile couples should recognize that previous studies of MM rates in ART patients probably overestimated the risk.

In vitro fertilization outcome: glass wool-filtered sperm versus swim-up sperm

At present, most in vitro fertilization (IVF) programs use a swim-up procedure for sperm preparation. This method mimics the in vivo selection of motile sperm by cervical mucus. Filtration through a column of glass wool, on the other hand, may result in recovery of more viable sperm from an ejaculate with relatively poor quality as compared with the swim-up procedure. Therefore, this study was designed to compare the sperm selected by these two methods, namely the swim-up procedure and the filtration procedure with a standardized glass wool column, with regard to the ability to fertilize human oocytes in our IVF program

Karyotype analysis of blighted ova in pregnancies achieved by in vitro fertilization

Pregnancies achieved by IVF and resulting in blighted ovum were karyotyped. The rate of aneuploidy was found to be 38% (5/13). In vitro fertilization does not appear to be a risk factor for chromosome anomaly in live births or miscarriages, and the data reported so far may suggest that aneuploid rates are actually lower for pregnancies achieved by IVF.

Preimplantation Diagnosis by Fluorescence In Situ Hybridization Using 13-, 16-, 18-, 21-, 22-, X-, and Y-Chromosome Probes

Purpose:Our purpose was to select the proper chromosomes for preimplantation diagnosis based on aneuploidy distribution in abortuses and to carry out a feasibility study of preimplantation diagnosis for embryos using multiple-probe fluorescence in situ hybridization (FISH) on the selected chromosomes of biopsied blastomeres.Methods:After determining the frequency distribution of aneuploidy found in abortuses, seven chromosomes were selected for FISH probes. Blastomeres were obtained from 33 abnormal or excess embryos. The chromosome complements of both the biopsied blastomeres and the remaining sibling blastomeres in each embryo were determined by FISH and compared to evaluate their preimplantation diagnostic potential.Results:Chromosomes (16, 22, X, Y) and (13, 18, 21) were selected on the basis of the high aneuploid prevalence in abortuses for the former group and the presence of trisomy in the newborn for the latter. Thirty-six (72%) of 50 blastomeres gave signals to permit a diagnosis. Diagnoses made from biopsied blasotmeres were consistent with the diagnoses made from the remaining sibling blastomeres in 18 embryos. In only 2 of 20 cases did the biopsied blastomere diagnosis and the embryo diagnosis not match.Conclusions:If FISH of biopsied blastomere was successful, a preimplantation diagnosis could be made with 10% error. When a combination of chromosome-13, -16, -18, -21, -22, -X, and -Y probes was used, up to 65% of the embryos destined to be aborted could be detected.

Sex determination by simultaneous application of polymerase chain reaction and fluorescent in situ hybridization on the same blastomere of a pre-embryo

OBJECTIVE To describe an investigation of the feasibility of carrying out polymerase chain reaction (PCR) and fluorescent in situ hybridization on the same single human cell for sex determination. DESIGN To develop protocol for a clinical diagnostic test in preclinical trials. SETTING Infertile human volunteers in a clinical environment. PATIENTS Polyploid embryos were obtained from patients treated by IVF at the Advanced Institute of Fertility. INTERVENTIONS Seventeen blastomeres biopsied from human polyploid embryos were analyzed for sex determination by simultaneous application of PCR and fluorescent in situ hybridization. MAIN OUTCOME MEASURE Presence of an X- or X and Y-chromosome band after agarose gel electrophoresis of PCR products and presence of an X- or X and Y-chromosome fluorescent probe signal after fluorescent in situ hybridization following PCR analysis. RESULTS By PCR, all 17 blastomeres were amplified and, by fluorescent in situ hybridization, 12 (70.6%) blastomeres produced signals that were consistent with PCR results. Two blastomeres showed only X signals, although by PCR they had both X and Y-chromosome bands. CONCLUSIONS The sequential use of PCR and fluorescent in situ hybridization on the same blastomere can be applied to improve the accuracy of sex determination before fresh ET.

Pregnancy with X-autosome translocation*

Pregnancy in a patient with premature ovarian failure because of a balanced X-chromosome and autosome translocation is rare. This paper presents a premature ovarian failure patient with X-autosome translocation t(X; 14) (q21.2; q32.3) who achieved pregnancy during estrogen (E)-progestin replacement therapy

ART and major structural birth defects in the United States

Sir, We read with interest the study by Reefhuis et al. (2009) showing that assisted reproductive technology (ART) treatment is a risk for structural birth defects. The authors recognize that this risk may be over-stated because underlying subfertility may in itself be an important risk factor for such defects. In our meta-analysis of 19 studies (Rimm et al., 2004), where we found an overall risk of 1.29, we noted the failure of each of those 19 studies to use the most appropriate control group, namely infertile couples conceiving spontaneously. Responding to the concern we raised, Zhu et al. (2006) attempted to design an analysis with a control group made up of subfertile couples. They compared three groups of children: those born of fertile couples (Group A), those born of infertile couples who conceived spontaneously after 12 months (Group B) and those born of infertile couples who conceived after ART treatment (Group C). They found that when compared with Group A, singletons in Group B and in Group C both had a higher incidence of congenital malformations. The adjusted hazard ratios were 1.20 [95% confidence interval (CI): 1.07 –1.35] and 1.39, respectively (95% CI: 1.23– 1.57). When the singletons in Group C were compared with those in Group B, the adjusted hazard ratio was 1.17 (95% CI: 1.00– 1.36). Zhu et al. suggested that some of the determinants of infertility might share a common causal pathway with mechanisms that cause congenital malformations. We were surprised that the Reefhuis study presents no overall rate of malformations in women aged 35 and over. Apparently there is a very large difference in the age distribution of the ART group and the non-ART group as shown in Table 1 for those without major birth defects. Only 13% of the non-ART mothers were 35 and older, whereas 55% of the ART mothers were 35 or older. The authors failed to show the age of the ART and non-ART mothers with a major defect. When there is such a large difference in the age distribution between the two groups, adjustment for age is not a sensitive method of analysis. Stratifying by age is more sensitive because it takes interaction into account.

Uterine sperm–egg transfer: a cost-effective alternative to IVF?

Direct transcervical transfer of spermatozoa and oocytes to the uterine cavity has been carried out in the past. This procedure could be a more appropriate approach than IVF for some anovulatory patients who require gonadotrophin stimulation, since the number of oocytes could be limited, thus reducing the occurrence of multiple gestations. However, most of the clinical pregnancy rates reported in the literature for gamete intrauterine transfer appear to be inferior to IVF pregnancy rates. This study attempted to improve the outcome of gamete intrauterine transfer by modifying some aspects of the procedure. This procedure is referred to as uterine sperm-egg transfer (U-SET) to imply that U (you the patient) set (determine) the number of oocytes to be transferred to the uterus. In this studys series of 16 anovulatory patients under the age of 36 years, the clinical pregnancy rate was 69% and the live birth rate was 50%.