W. Rohini Edirisinghe

Ureaplasma parvum and Ureaplasma urealyticum are detected in semen after washing before assisted reproductive technology procedures

OBJECTIVE To investigate the prevalence of ureaplasmas in semen and washed semen and to explore their effect on semen andrology variables. DESIGN Prospective study. SETTING In vitro fertilization (IVF) unit of a private hospital. PATIENT(S) Three hundred forty-three men participating in an assisted reproductive technology (ART) treatment cycle. MAIN OUTCOME MEASURE(S) The prevalence of ureaplasmas in semen and washed semen tested by culture, polymerase chain reaction assays, and indirect immunofluorescent antibody assays. RESULT(S) Ureaplasmas were detected in 73 of 343 (22%) semen samples and 29 of 343 (8.5%) washed semen samples. Ureaplasmas adherent to the surface of spermatozoa were demonstrated by indirect immunofluorescent antibody testing. Ureplasma parvum serovar 6 (36.6%) and U. urealyticum (30%) were the most prevalent isolates in washed semen. A comparison of the semen andrology variables of washed semen ureaplasma positive and negative groups demonstrated a lower proportion of nonmotile sperm in men ureaplasma positive for washed semen. CONCLUSION(S) Ureaplasmas are not always removed from semen by a standard ART washing procedure and can remain adherent to the surface of spermatozoa.

Use of the acrosome reaction to ionophore challenge test in managing patients in an assisted reproduction program: a prospective, double-blind, randomized controlled study

OBJECTIVE To assess the utility of the acrosome reaction (AR) to ionophore challenge test in determining the sperm treatment protocols for patients undergoing assisted reproduction. DESIGN, SETTING, PATIENTS One hundred twenty-one couples undergoing an IVF-ET or GIFT procedure from January to July 1992 were included in this prospective study. All cases had a preliminary semen analysis within the previous 3 months and an AR to ionophore challenge test was carried out unless an acceptable fertilization rate occurred on previous IVF. For those patients whose AR to ionophore challenge score was below the accepted fertile range of > or = 10%, a second AR to ionophore challenge test was performed after exposure of sperm to the stimulant pentoxifylline. Couples then were managed by assisted reproduction with randomized allocation of oocytes for fertilization with a standard sperm preparation or with added sperm stimulants, either 3.6 mM pentoxifylline alone or combined with 3.0 mM 2-deoxyadenosine. The study was double-blind with neither the patients nor the embryologist knowing the AR to ionophore challenge result at the time of the IVF procedure. MAIN OUTCOME MEASURES Data from the preliminary semen analyses and AR to ionophore challenge scores were correlated with the fertilization rates achieved using control and treated sperm preparations. The rates of total fertilization failure and the numbers of clinical pregnancies occurring in each subgroup were also recorded. RESULTS All AR to ionophore challenge groups showed normal sperm counts except the groups with poor AR to ionophore challenge, which demonstrated reduced sperm counts. The group with normal AR to ionophore challenge scores or previous normal fertilization showed satisfactory fertilization rates with either control or treated sperm, although some individual cases showed reduced fertilization with treated sperm. The fertilization rate for the group with low AR to ionophore challenge scores improved significantly with pentoxifylline, and the benefit was greatest when this had been predicted from the AR to ionophore challenge studies. Cases with persisting poor AR to ionophore challenge despite pentoxifylline showed no significant improvement in fertilization rates with sperm exposed to either sperm stimulant regimens. Poor AR to ionophore challenge scores were also predictive of total fertilization failure, but this problem was reduced by sperm stimulation. The AR to ionophore challenge score at 10% cutoff level showed optimal levels of sensitivity (82.1%), highest negative predictive value (82.1%), and lowest false negative rate (17.9%). CONCLUSIONS The AR to ionophore challenge test is useful in the assessment and management of the male factor in assisted reproduction. It can be used to identify the majority of cases who will benefit from the use of sperm stimulants.

Pituitary down-regulation using leuprolide for the intensive ovulation management of poor prognosis patients having in vitro fertilization (IVF)-related treatments

A review of 118 treatment cycles in 115 women under prolonged GnRH analogue (GnRHa; leuprolide) treatment is presented. Patients were selected for treatment primarily on the grounds of poor previous response to stimulation (n=40). advanced age (>35 years; n=29), previous premature luteinizing hormone (LH) surge (n=30), polycystic ovarian disease (PCO; n=12), and elevaved androgens without evidence of PCO (n=5). An overall pregnancy rate of 28.8% per treatment cycle was attained, compared with a pregnancy rate of 6.2% (6/97, of which none went to term) in the previous completed treatment cycle for the same patients. Ovarian response, as measured by oocytes recovered and maximum estradiol levels observed, was significantly improved in all groups and this was associated with a prolonged follicular phase, significantly more human menopausal gonadotropin (hMG) stimulation and a relatively high incidence of ovarian hyperstimulation, particularly in pregnant patients Of specific techniques in the GnRHa cycle, GIFT produced a pregnancy rate per treatment of 50% (10/20); IVF-ET, 22% (8/36); PROST, 28% (13/46); and TEST 19% (3/16). No cyles were abandoned, compared with a cancellation rate of 24% in previous cycles without GnRHa. Patients with PCO performed paricularly well on GnRHa management, with a pregnancy rate per treatment of 58% (7/12). Pregnancy rates per treatment for the other groups were as follows: elevated age, 27% (9/33), high androgen, 40% (2/5); premature LH surges, 32% (9/28); and poor responders, 17.5% (7/40). A comparison using patients undertaking IVF-ET cycles in 1987 and 1988 shows that the use of GnRHa treatment in the poorprognosis groups lifts their performance into line with that seen in the “good”-prognosis groups. We conclude that pituitary down-regulation with GnRHa (long regimen) offers significant advantages for ovarian management in most groups of infertility patients and it is now being evaluated for routine use in the majority of cases in our practice.

The treatment of normospermic infertility by gamete intrafallopian transfer (GIFT)

Summary. Gamete intrafallopian transfer (GIFT) was applied in 207 treatment cycles in 73 couples. The pregnancy rate in cycles with only one (2/21, 9·5%) or two (2/29, 6·9%) oocytes transferred was significantly less than that in which four oocytes (36/116, 31·0%) were replaced. The collection of more than four oocytes did not influence the pregnancy rate in that treatment cycle. The overall pregnancy rate was 24·2% (50 of 207) and was similar in the four infertility groups studied (non‐occlusive tubal disorders, endometriosis, cervical factor and unexplained infertility) with 28 (56%) of the pregnancies delivered at 20 weeks. The pregnancy wastage included 4 (8%) ectopic pregnancies and 3 (6%) late pregnancy losses. The 12 multiple pregnancies occurred following the transfer of three and four oocytes.

Sperm stimulants can improve fertilization rates in male-factor cases undergoing IVF to the same extent as micromanipulation by partial zona dissection (PZD) or subzonal sperm insemination (SUZI): A randomized controlled study

PurposeOur purpose was to evaluate the efficacy of direct insemination (IVF), micromanipulation by partial zona dissection (PZD), and subzonal sperm insemination (SUZI) using spermtreated with pentoxifylline (PF) ± 2-deoxyadenosine (2DA).ResultsThe overall fertilization rate achieved was similar for all three fertilization techniques (33.1, 30.2, and 26.9% for IVF, SUZI, and PZD, respectively). Patients who had reduced fertilization in previous IVF attempts showed improved fertilization with sperm stimulants, either PF alone or PF in combination with 2DA in standard IVF. In certain cases, SUZI or PZD gave significantly improved fertilization rates in comparison to IVF.ConclusionSelective use of sperm stimulants in IVF can achieve fertilization for the majority of male-factor cases. However, PZD and SUZI techniques are useful, especially when sperm stimulants fail to achieve fertilization or achieve poor fertilization in direct insemination.

Trophoblast antigen levels in the first trimester of a trisomy 22 pregnancy

We report trophoblast antigen (pregnancy-associated plasma protein-A, PAPP-A; free beta-human chorionic gonadotrophin, F beta hCG) expression in a trimosy 22 pregnancy. Maternal concentrations of these antigens were depressed prior to detection of abnormalities by ultrasonography. Immunohistochemical findings were consistent with depressed marker expression.