Shai E. Elizur

Searching for evidence of disease and malignant cell contamination in ovarian tissue stored from hematologic cancer patients

BACKGROUND Storing ovarian tissue for fertility preservation in cancer patients carries the risk of the presence of malignant cells that could lead to recurrence of cancer after reimplantation. Methods to exclude presence of cancer cells were used to improve the safety of cryopreservation-reimplantation procedures. METHODS Fifty-eight patients with hematological malignancies were referred for the storage of ovarian tissue for fertility preservation. Investigation included preoperative imaging and histological evaluation of fresh ovarian tissue. After thawing markers to detect minimal residual disease (MRD) were used and compared with patients disease used as positive control (five patients). RESULTS Preoperative imaging detected disease in the ovaries (two patients). Conventional histology post-tissue harvesting did not disclose malignant cells (56 patients). MRD results post-thawing were negative in Hodgkins disease (CD30 immunohistochemical staining), in T- and B-cell lymphoma (PCR for T-cell receptor and Ig clones, respectively) and in two chronic myelogenous leukemia patients (RT-PCR for BCR-ABL gene expression). However, highly sensitive real-time RT-PCR was positive in one CML patient and, this alarming result avoided tissue transplantation. CONCLUSIONS Preoperative imaging prevented operations and storage of tissue with cancer. Evaluation of stored ovarian tissue for MRD using sensitive markers is essential to increase safety and to prevent reimplantation of tissue with malignant cells.

Modified Natural Cycle Using GnRH Antagonist Can Be an Optional Treatment in Poor Responders Undergoing IVF

Purpose: To investigate the efficacy of gonadotrophin-releasing hormone (GnRH) antagonist supplementation during natural cycles in poor responders undergoing IVF-ET treatment.Methods: We retrospectively evaluated 540 cycles of 433 suitable patients who were divided by treatment protocol into modified natural, antagonist, and long agonist groups. There were 52 modified natural cycles with GnRH antagonist supplementation, 200 stimulated cycles with GnRH antagonist, and 288 long GnRH agonist cycles. Cycle characteristics and treatment outcomes were compared between the groups.Results: The mean number of oocytes retrieved in the modified natural group was significantly lower than in the stimulated antagonist and long agonist groups (1.4± 0.5 vs. 2.3± 1.1 and 2.5± 1.1, respectively, p < 0.05). The respective implantation and pregnancy rates were 10% and 14.3%, 6.75% and 10.2%, and 7.4% and 10.6%. Cycle outcome and cycle properties were similar.Conclusions: Modified natural IVF cycle with GnRH antagonist supplementation is a feasible alternative to ovarian stimulation protocols in poor responders.

FACTORS PREDICTING IVF TREATMENT OUTCOME: A MULTIVARIATE ANALYSIS OF 5310 CYCLES

The objective of this study was to analyse factors predicting live birth rate following IVF. A computerized database of 1928 women who underwent 5310 consecutive IVF cycles in a single IVF unit was evaluated. Data on the womens age, number of retrieved oocytes, performance of intracytoplasmic sperm injection (ICSI), aetiology of infertility, number of transferred embryos and option of choosing embryos for transfer were evaluated. There were 1126 pregnancies that resulted in 689 live births. Transferring two embryos doubled the chances of delivery compared with one embryo, but transferring three embryos was not significantly superior to two embryos. Moreover, following a three-embryo transfer, the multiple delivery rates were significantly higher (P < 0.01) compared with transferring two embryos. Optimal delivery rates were observed in women aged 26-30 years, with gradual decline with advanced age. The performance of ICSI resulted in higher delivery rates compared with conventional insemination. According to these data, the best live birth results following IVF treatment were achieved when the maternal age was 26-30 years, in couples with male factor infertility undergoing ICSI, and when two embryos were transferred.

Cumulative live birth rate following in vitro fertilization: Study of 5310 cycles

Most previous studies that calculated cumulative delivery rates following in vitro fertilization (IVF) treatments were limited in the number of cycles and the implementation of intracytoplasmic sperm injection (ICSI). Therefore, we assessed the yield of high-order consecutive IVF treatments (up to 14 consecutive cycles) with and without ICSI. Data from IVF cycles performed in a single center were retrieved from a computerized database. A total of 5310 cycles among 1928 patients were evaluated and cumulative delivery rates until the first delivery were calculated using life-table analyses. There were 1126 pregnancies resulting in 689 live births. Cumulative delivery rates reached 87% following 14 consecutive cycles. Cumulative delivery rates were higher following ICSI compared with cycles without (92.7% vs. 85.4%). In conclusion, each treatment cycle increased the cumulative delivery rate, resulting in a rate of 87% after 14 consecutive cycles. The introduction of ICSI resulted in the highest cumulative rates.

Role of embryo quality in predicting early pregnancy loss following assisted reproductive technology

Early pregnancy loss (EPL) significantly reduces the initial success rate of assisted reproduction treatments and increases the psychological burden on the patient. The aim of the current study was to investigate the association between embryo quality and EPL in IVF. A retrospective study of 1471 women undergoing IVF between July 2000 and October 2004 was performed. Multivariate logistic regression models evaluated the effect on EPL of the womans age, type and cause of infertility, endometrial thickness on the day of oocyte retrieval, performance of intracytoplasmic sperm injection, number of transferred embryos, embryo quality as assessed by the number of blastomeres in the leading transferred embryo at day 3, and the percentage of fragmentation. The 2902 oocyte retrieval-embryo transfer cycles resulted in 816 pregnancies (28.1%; 705 women) constituting the study cohort. Of these, 259 pregnancies (31.7%) ended in EPL and 557 (68.3%) in ongoing pregnancies. EPL risk was significantly associated with advanced (>35 years) maternal age (OR=1.53; 95% CI 1.12-2.09) and five or fewer blastomeres in the leading embryo transferred at day 3 (OR=1.82; 95% CI 1.16-2.85). In conclusion, the quality of transferred embryos, as assessed by the total number of blastomeres in the leading transferred embryo, and maternal age are predictors of EPL.

Safety of IVF under anticoagulant therapy in patients at risk for thrombo-embolic events

The objective of this study was to assess the safety of induction of ovulation and oocyte retrieval in patients at risk of thrombosis, necessitating treatment with anticoagulants. Twenty-four patients considered as high risk for a thromboembolic event underwent 73 IVF cycles and 68 oocyte retrieval procedures, and were treated concomitantly with anticoagulation therapy (low molecular weight heparin; LMWH). A subgroup of five patients considered at especially high risk for thrombosis was isolated. These patients were prepared for oocyte retrieval using a controlled spontaneous cycle. All these patients were programmed exclusively for surrogacy. Nineteen women underwent 49 cycles of ovulation induction with gonadotrophins. The average peak oestradiol concentration was 1791 +/- 1420 pg/ml with an average of 13.5 +/- 8.4 oocytes retrieved in each cycle. The five patients from the very high risk group underwent 24 cycles: the average peak oestradiol concentration was 163 +/- 98 pg/ml. In 18, an egg was retrieved and in 14, fertilization was achieved. No bleeding or thromboembolic complications were noted during treatment of both groups of patients. It is concluded that during induction of ovulation in patients at risk for thrombosis, the introduction of LMWH as a cycle protective treatment was not associated with any medical complication. The use of a controlled spontaneous cycle with LMWH is suggested in very high risk patients.

Elevated day 3 FSH/LH ratio due to low LH concentrations predicts reduced ovarian response.

Adequate ovarian response, essential for successful IVF, cannot be accurately predicted. This study retrospectively reviewed all patients undergoing IVF from 1998 to 2001. Inclusion criteria were age <41 years at treatment onset and a basal day 3 serum FSH concentration <12 IU/l. Women with FSH <or=8 IU/l underwent a secondary analysis. Two groups emerged according to basal day 3 serum FSH/LH ratio: >or=3 in group 1 and <3 in group 2 (controls). Age at treatment initiation, basal serum day 3 FSH and LH concentrations, peak serum oestradiol concentration, number of retrieved and fertilized oocytes and pregnancy rate were analysed. Groups 1 (n = 41, 111 IVF treatment cycles) and 2 (n = 596, 1,434 IVF treatment cycles) were similar in term of womans mean age. Group 1 had significantly higher mean basal day 3 FSH concentration (P < 0.01) and significantly lower oestradiol concentrations at oocyte retrieval (P < 0.01), mean number of oocytes retrieved and fertilized (P < 0.01) and pregnancy rate (P = 0.016). The same trend persisted after excluding 98 patients with basal FSH concentrations >8 IU/l. In conclusion, elevated day 3 FSH/LH ratio is associated with an inferior outcome in IVF treatment cycles and may be used as an additional predictor for decreased ovarian response.

Elevated Levels of FMR1 mRNA in Granulosa Cells Are Associated with Low Ovarian Reserve in FMR1 Premutation Carriers

Aim To assess the role of mRNA accumulation in granulosa cells as the cause of low ovarian response among FMR1 premutation carriers undergoing pre-implantation genetic diagnosis (PGD). Design Case control study in an academic IVF unit. Twenty-one consecutive FMR1 premutation carriers and 15 control women were included. After oocyte retrieval the granulosa cells mRNA levels of FMR1 was measured using RT-PCR. Results In FMR1 premutation carriers, there was a significant non-linear association between the number of CGG repeats and the number of retrieved oocytes (p<0.0001) and a trend to granulosa cells FMR1 mRNA levels (p = 0.07). The lowest number of retrieved oocytes and the highest level of mRNA were seen in women with mid-size CGG repeats (80–120). A significant negative linear correlation was observed between the granulosa cells FMR1 mRNA levels and the number of retrieved oocytes (R2 linear = 0.231, P = 0.02). Conclusion We suggest that there is a no-linear association between the number of CGG repeats and ovarian function, resulting from an increased granulosa cells FMR1 mRNA accumulation in FMR1 carriers in the mid-range (80–120 repeats).

Combination of ovarian tissue harvesting and immature oocyte collection for fertility preservation increases preservation yield

The aim of this study was to evaluate the safety and efficacy of combined ovarian tissue cryopreservation and oocyte aspiration just before ovarian tissue cryobanking. A retrospective cohort study of fertility preservation patients treated in 2007-2013 in one tertiary centre was performed. A total of 255 cancer patients were admitted for fertility preservation: 142 patients underwent ovarian tissue cryopreservation only (OTC), 56 underwent OTC plus oocyte retrieval from ovarian tissue (OTIVM), nine underwent oocyte aspiration and in-vitro maturation (AIVM) and 48 underwent all three procedures. The total number of oocytes, total number of metaphase II (MII) oocytes, maturation rate, fertilization rate and total number of cryopreserved oocytes between groups were compared. The study found significantly more oocytes (P < 0.001), more MII oocytes (P < 0.001), better maturation rate (P < 0.01) and more cryopreserved oocytes (P < 0.05) with all three compared with OTIVM or OTC. No adverse outcome was observed by performing oocyte retrieval before ovarian resection for cryopreservation. In conclusion, oocyte aspiration just before ovarian tissue cryobanking is safe and gains more oocytes with a better maturation rate than ovarian tissue oocyte cryobanking alone. Better results were obtained with 3 days of stimulation before oocyte retrieval.

Pelvic inflammatory disease in women with endometriosis is more severe than in those without

To determine the incidence and severity of acute pelvic inflammatory disease (PID) or tubo‐ovarian abscess (TOA) in hospitalised women with and without a history of endometriosis.