Maria De Geyter

Prospective evaluation of the ultrasound appearance of the endometrium in a cohort of 1,186 infertile women

OBJECTIVE To investigate the effect of differences in endometrial thickness and pattern as visualized with present-day high-resolution transvaginal ultrasound equipment on the outcome of assisted reproductive treatment. DESIGN Prospective cohort study. SETTING Two large infertility units in university hospitals. PATIENT(S) The endometrial characteristics of 981 patients during 1,600 assisted reproductive treatment cycles were compared with those of 205 untreated women. In addition, abnormal echogenic patterns of the endometrium were characterized histologically in 44 patients. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Pregnancy rates. RESULT(S) The endometrium was significantly thinner in untreated women and women treated with IUI than in women treated with IVF or intracytoplasmic sperm injection. The exponential proliferation of the endometrium was similar in conception and nonconception cycles. The odds for a successful pregnancy were significantly lower in the presence of a thin endometrium in women treated with IUI but not in women treated with the long stimulation protocol for IVF or intracytoplasmic sperm injection. Singleton pregnancies were more common than multiple pregnancies in patients with thin endometria. CONCLUSION(S) The pregnancy rates of assisted reproductive procedures are influenced only marginally by the degree of endometrial proliferation, and treatment should not be canceled because of inadequate endometrial thickness.

Experience with transvaginal ultrasound-guided aspiration of supernumerary follicles for the prevention of multiple pregnancies after ovulation induction and intrauterine insemination * †

OBJECTIVE To avoid multiple pregnancies caused by ovulation induction. SETTING Infertile couples treated in the Womens Hospital and the Institute of Reproductive Medicine of the University of Münster, Münster, Germany. DESIGN The outcome of ovulation induction in patients in whom supernumerary ovarian follicles were aspirated transvaginally was compared with the outcome in patients in whom this intervention was not necessary. In a second randomized prospective study, the efficacy of a low dosage of gonadotropins was compared with a higher dosage. PATIENTS Two hundred twenty-seven couples suffering from male infertility, unexplained infertility, incipient ovarian failure, and polycystic ovaries. INTERVENTIONS Aspirations were performed if more than three follicles were sized > 14 mm. MAIN OUTCOME MEASURE Number of (multiple) pregnancies. RESULTS During 232 ovulation inductions, 127 aspirations of supernumerary follicles were performed (54.7%). The pregnancy rate (PR) in these cycles was similar to cycles in which aspirations were unnecessary (24.4% versus 21.9%). The efficacy of 75 units of FSH administered daily during the recruitment phase of follicular development was equivalent to 150 units of FSH (PR: 32.4% versus 31.6%), but supernumerary follicles were fewer (26.5% versus 76.3%). Six twins, two triplets (multiple PR: 10.4%), and no ovarian hyperstimulation syndrome occurred. CONCLUSIONS Transvaginal aspiration of supernumerary follicles does not reduce the PR in ovulation induction. Supernumerary follicles can be avoided by low-dose administration of gonadotropins without compromising the PR.

Low Multiple Pregnancy Rates and Reduced Frequency of Cancellation After Ovulation Induction with Gonadotropins, If Eventual Supernumerary Follicles Are Aspirated to Prevent Polyovulation

Purpose:Our purpose was to demonstrate the feasibility of the routine aspiration of supernumerary follicles in infertile patients with imminent polyovulation after ovulation induction with gonadotropins and to examine its effect on the frequency of cycle cancellation and on the (multiple) pregnancy rate.Methods:The data on 796 treatment cycles, performed between 1989 and 1996 on 410 infertile couples, were analyzed retrospectively. From October 1992, whenever necessary, supernumerary ovarian follicles were selectively aspirated transvaginally under ultrasound guidance to prevent the ovulation of more than three follicles. Thereafter, intrauterine insemination was performed.Results:After the adoption of transvaginal ultrasound-guided aspiration of supernumerary follicles into the treatment protocol in October 1992, the number of canceled cycles (P < 0.0001) and the multiple pregnancy rate (P < 0.01) were significantly reduced compared to those previously. The overall pregnancy rate remained stable. No ovarian hyperstimulation syndrome requiring hospitalization was noted, and no complications resulting from the follicle aspiration were registered.Conclusions:Transvaginal ultrasound-guided aspiration of supernumerary ovarian follicles increases both the efficacy and the safety of ovulation induction with gonadotropins. Because of the limited equipment required, this method represents an alternative for conversion of overstimulated cycles to more costly alternatives such as in vitro fertilization.

Production of reactive oxygen species by and hydrogen peroxide scavenging activity of spermatozoa in an IVF program

AbstractPurpose: Reactive oxygen species (ROS) including H2O2 produced by spermatozoa have been suggested, on one hand, to be associated with idiopathic male infertility and, on the other hand, to stimulate certain sperm function leading to fertilization. The influence of ROS on fertilization was investigated in 75 IVF patients by correlating fertilization rates with the production of ROS and the H2O2-scavenging activity of swim-up spermatozoa prepared in parallel with the IVF samples. Results: Low rates of ROS production by the swim-up sperm was detected by the luminol-dependent chemiluminescence assay. They were not correlated with fertilization rates. The hydrogen peroxide scavenging capacity of these spermatozoa, measured as the removal of exogenous H2O2 assayed spectrophotometrically, decreased stepwise in groups of patients achieving higher fertilization rates, suggesting a positive effect of this ROS on fertilization. An alternative explanation of this correlation is plausible in view of the association of both high scavenging activities and poor fertilization rates with poor sperm morphology. Conclusions: ROS produced by spermatozoa selected by swim-up plays no negative, if not a positive, role in fertilization.

Pattern of pineal melatonin concentrations during prolonged exposure to short photoperiods in photosensitive and photoinsensitive Djungarian hamsters

Abstract: In the Djungarian hamster (Phodopus sungorus) there is strong evidence that the nightly decompression or lengthening, respectively, of the pineal melatonin pattern is involved in conveying the inhibitory influence of short photoperiods. Some hamsters, however, are insensitive to photoinhibitory influences; other late‐responding hamsters show a delayed reaction of several months. The daily pattern of pineal melatonin proves that the mechanisms determining long‐ or short‐day patterns become effective in the morning and evening hours when melatonin concentrations of photoinhibited hamsters are clearly elevated, while those of long‐day hamsters are reduced to negligible low values. At two decisive time points in the morning and evening, male and female early‐responding photosensitive hamsters were killed after 5, 10, 15, and 20 weeks in short photoperiods, nonresponding hamsters after 10 and 20 weeks, and late‐responding after 20 weeks. In all early‐responding hamsters changes in gonadal stage, body weight, and pelage color corresponded to the decompression of the nightly melatonin pattern. During prolonged exposure to short photoperiods a decrease of mean melatonin concentrations in the morning and an increase of evening concentrations was observed in both sexes. The lengthening of nightly elevated melatonin concentrations was missing in photoinsensitive hamsters. In late‐responding hamsters this decompression seems to be delayed, as melatonin concentrations of female late responders indicate. In conclusion, the lengthening of the melatonin pattern seems to predict a photoperiodic reaction of the effector system. The lengthened pattern of photosensitive hamsters may not be unchangeable, as it may be subjected to modifications during prolonged exposure to short photoperiods.

First successful pregnancy in Switzerland after prospective sex determination of the embryo through the separation of X-chromosome bearing spermatozoa

QUESTION UNDER STUDY The feasibility and the potential advantages of separating X-chromosome bearing spermatozoa for the prevention of a severe X-chromosome linked disorder with the use of intracytoplasmic sperm injection are presented. METHOD A carrier of muscular dystrophy type Becker was treated with intracytoplasmic sperm injection, using spermatozoa previously stained with the Hoechst dye 33342 and sorted with flow cytometry. RESULTS After transfer of one single blastocyst, an intrauterine pregnancy arose. In the ninth week of gestation, the female sex of the embryo was confirmed with proof of absence of the SRY gene of the Y-chromosome. After normal pregnancy, the patient delivered a healthy daughter. CONCLUSIONS The staining of spermatozoa with specific markers and sorting with flow cytometry provides a means of preventing significant disease in the offspring and may help in reducing the number of surplus embryos needed for preimplantation genetic diagnosis.

Predictive parameters for ovarian response to hyperstimulation with exogenous gonadotropins after suppression of gonadotropin secretion of the pituitary using a long-acting GnRH agonist

Individually adapted gonadotropin dosage is more successful than standardized schemes for ovarian stimulation prior to in vitro fertilization and embryo transfer. Unfortunately, differences in ovarian response can not be predicted reliably. In order to develop predictive parameters for ovarian response the data from 99 cycles in 69 patients were analysed retrospectively. Before initiating ovarian stimulation for in vitro fertilization, an untreated menstrual cycle was examined using a commonly used endocrinological screening protocol. The ovaries were then stimulated with exogenous gonadotropins after previous suppression of endogenous gonadotropin secretion using a long-acting GnRH-analogue. The predictive value of this endocrinological screening protocol for ovarian response was evaluated. Ovarian response was defined as the logarithmically transformed ratio of the serum estradiol concentration at ovulation induction, divided by the number of ampoules of exogenous gonadotropins administered. Comparison of the various hormone characteristics with ovarian response led to identification of two distinct groups of patients showing reduced ovarian response: those with elevated serum levels of FSH on the third cycle day (> 9 units/l, P < 0.0001), and those with elevated serum levels of estradiol on the third cycle day (> 190 pmol/l, P < 0.02). Patients with high serum levels of TSH in the TRH test responded poorly to ovarian stimulation (P < 0.05), but also showed significantly higher serum concentrations of FSH (P < 0.01). No parameter correlated positively with ovarian response.

Die Reproduktionsmedizin heute und Chancen für die Zukunft

Despite the controversial discussions, which have accompanied it since its first introduction of into clinical medicine particularly in Switzerland, assisted reproductive medicine has come to acquire a firm standing in present-day society. This broad acceptance is the logical consequence of the availability of efficient methods of family planning which started with the introduction of oral contraception in the early sixties. Over time assisted reproductive medicine has grown with a considerable degree of efficacy due to improvements in the culture conditions in the embryology laboratory and due to sophisticated ovarian hyperstimulation. In conjunction with steadily rising treatment numbers the latter has contributed to a high incidence of multiple deliveries, which now is considered a complication of assisted reproduction and current opinion demands that multiple pregnancies must be avoided as much as possible. The experience in various countries has demonstrated that through the selection of one single embryo with high developmental capacity the incidence of multiple gestations can be lowered to virtually none. However, the restrictive legislations in vigour both in Switzerland and in Germany impede such an endeavour. Still, the significantly higher pregnancy rates achieved by extending the culture of embryos up to the blastocyst stage clearly demonstrate that embryology holds the clues to further considerable improvements of assisted reproductive technology. Through the rapid development of three-dimensional culture techniques, immature ovarian follicles e.g. primordial follicles may be cultured up to the mature Graafian stage thereby avoiding the need to stimulate the ovaries.Despite the controversial discussions, which have accompanied it since its first introduction of into clinical medicine particularly in Switzerland, assisted reproductive medicine has come to acquire a firm standing in present-day society. This broad acceptance is the logical consequence of the availability of efficient methods of family planning which started with the introduction of oral contraception in the early sixties. Over time assisted reproductive medicine has grown with a considerable degree of efficacy due to improvements in the culture conditions in the embryology laboratory and due to sophisticated ovarian hyperstimulation. In conjunction with steadily rising treatment numbers the latter has contributed to a high incidence of multiple deliveries, which now is considered a complication of assisted reproduction and current opinion demands that multiple pregnancies must be avoided as much as possible. The experience in various countries has demonstrated that through the selection of one single embryo with high developmental capacity the incidence of multiple gestations can be lowered to virtually none. However, the restrictive legislations in vigour both in Switzerland and in Germany impede such an endeavour. Still, the significantly higher pregnancy rates achieved by extending the culture of embryos up to the blastocyst stage clearly demonstrate that embryology holds the clues to further considerable improvements of assisted reproductive technology. Through the rapid development of three-dimensional culture techniques, immature ovarian follicles e.g. primordial follicles may be cultured up to the mature Graafian stage thereby avoiding the need to stimulate the ovaries.Trotz aller Kontroversen in der Vergangenheit erfullt die heutige Reproduktionsmedizin ein wichtiges Bedurfnis in unserer Gesellschaft. Sie ist die logische Folge der veranderten Bedurfnisse in der Familienplanung, die seit der Einfuhrung der oralen Kontrazeption in den sechziger Jahre moglich wurden. Die assistierte Reproduktionsmedizin hat durch die Optimierung der Bedingungen im reproduktionsbiologischen Labor sowie durch die hormonelle Stimulation der Ovarialfunktion ihre heutige Effizienz erreicht. Sowohl die Zunahme der Anzahl Behandlungen als auch die Effizienzsteigerung haben zu einer Vielzahl von Mehrlingsschwangerschaften gefuhrt. Eine Mehrlingsschwangerschaft nach assistierter Reproduktion stellt heute eine Komplikation dar und konnte durch die Ubertragung eines einzelnen Embryos nahezu verhindert werden. Letztere Vorgehensweise setzt jedoch die Selektion eines Embryos sowie die Kryokonservierung der anderen Embryonen voraus, beides Masnahmen, welche in Deutschland sowie in der Schweiz verboten...

TUNEL Labeling with BrdUTP/anti-BrdUTP greatly underestimates the level of sperm DNA fragmentation in semen evaluation.

Many studies have now confirmed that sperm DNA fragmentation (SDF) is associated with a poorer outcome of some forms of assisted reproduction technology. For this reason, SDF is an important parameter to evaluate in male fertility assessment. TUNEL (terminal deoxynucleotidyl transferase dUTP nick end labeling) assay coupled to flow cytometry is one of the most promising methods for SDF quantification. Several kits for the detection of DNA fragmentation are currently available on the market and all are recommended as equally appropriate to quantify SDF. In this work we compared for the first time the efficacy of two different types of TUNEL kits for SDF quantification: one using an indirect antibody-based labeling system (BrdUTP/fluorescein-anti-BrdUTP) and another using a direct labeling system (fluorescein-dUTP). We demonstrated that TUNEL indirect labeling system largely underestimates SDF when compared with the direct labeling, the differences ranging from 19.2% to 85.3% (p<0.05, n = 22). We observed that these differences were most pronounced among dead spermatozoa where indirect labeling stained 40.1% [23.6%, 58.2%] and the direct system 65.7% [36.5%, 90.9%] (n = 10, p<0.05). Interestingly, we found that both systems stained the living spermatozoa with the same efficiency. We showed that the differences are due to the steric hindrance of the antibody during its binding to the BrdUTP. Indeed, after sperm DNA decondensation, the percentages of TUNEL positivity increased significantly from 46.3% [31.8%, 61.7%] to 97.5% [96.1%, 98.8%] (p<0.05, n = 5). Our results are important for future use of TUNEL in clinical practice. Laboratories relying on the use of an antibody-based system heavily underestimate SDF, most particularly in infertile patients with reduced sperm motility. As a consequence, the kit using BrdUTP/fluorescein-anti-BrdUTP should not be recommended as a method to assay DNA damage in semen. This study represents one further step in the standardization of TUNEL among laboratories.