The paradox of the Italian clinical embryologist in the national public health system: hints towards harmonization of a postgraduate educational curriculum.

Clinical embryologists are highly trained laboratory professionals with multiple roles, including laboratory, clinical, biobanking and quality system management. In most European countries, clinical embryologists are trained to work in Medically Assisted Reproduction (MAR) centres without a specifically dedicated educational path. The criteria required for employment vary according to the educational structure and the public or private nature of the centre. We have herein described the educational profile required by Italian clinical embryologists to work in MAR centres of the National Health System (NHS). Public centres currently represent 36% of all the Italian MAR clinics. According to the Italian law, a future clinical embryologist must achieve a 3-4 year unpaid post-graduate specialization in a different field, choosing from Genetics, Microbiology, Clinical Pathology or Nutrition. Accesses to the above-mentioned post-graduate courses are themselves very limited. Clinical embryologists are basically trained by senior colleagues. This situation makes inevitably difficult to recruit laboratory staff in NHS centres. Moreover, it represents an emblematic example of the need for an equal training curriculum, possibly ensuring a comparable education quality, mobility of trainees and dissemination of skills for clinical embryologists all over Europe.

Cryopreserved Gamete and Embryo Transport: Proposed Protocol and Form Templates-SIERR (Italian Society of Embryology, Reproduction, and Research).

Introduction: In Italy, the transport of cryopreserved biological material is controlled by several Decrees (Legislative Decree No. 191/2007 and No. 16/2010 and Health Ministry's Decree of October 10, 2012). Given the nature of their applications, the transport of reproductive cells has peculiar quality and safety requirements that must be applied universally, minimizing the chance of error. To standardize the cross-border shipping procedure to meet the quality, traceability, and safety criteria for cells and tissues, it is appropriate to establish a unified process using the same tools, forms, and communication channels. Methods: A working group has been created by SIERR. This "FOCUS Group" was constituted by representatives from Italian-assisted reproductive technology centers and sperm banks who worked together to define joint procedural steps and create specific forms to support the movement of cryopreserved samples. Results: The FOCUS Group identified the critical steps in the communication procedures between Italian centers and created the related forms: patient authorization, request from the recipient center, critical checks carried out by both sending and recipient centers, start of samples transfer, collection, transport and taking responsibility of the biological material, acknowledgment of samples arrival, and acknowledgement of any adverse event that occurred. Discussion: Indications on shipping between tissue institutions and legal responsibilities are important points and a working protocol with shared transport forms has been defined. Standard Operating Procedures are necessary in light of the increasingly widespread movement of biological samples between the various countries, and represent a valid means of support for the patients who could have a higher awareness of safety and traceability during each stage of gamete transport.

The α4ß1/EMILIN1 interaction discloses a novel and unique integrin-ligand type of engagement.

EMILIN1, a homo-trimeric adhesive ECM glycoprotein, interacts with the α4ß1 integrin through its gC1q domain. Uniquely among the C1q family members, the EMILIN1 gC1q presents only nine-stranded ß-sandwich fold and the missing strand is substituted by a disordered 19-residue long segment spanning from Y927 to G945 at the apex of the gC1q domain. This unstructured loop exposes to the solvent the acidic residue E933, which plays a key role in the α4ß1 integrin mediated interaction. Here, we experimentally determined that the three E933 residues (one from each monomer) are all required for ligand binding. By docking the NMR structure of the gC1q to a virtual α4ß1 crystal structure based on the known structures of α4ß7 and α5ß1 integrins we built a model of α4ß1-gC1q complex where three E933 residues are smoothly forced to coordinate the Mg2+ ion at the ßI MIDAS site of the integrin. By bringing the three E933 close in space, the trimeric supramolecular organization of gC1q allows the formation of a proper 3D geometry and suggests a quaternary-structure-dependent mode of interaction. Furthermore, we experimentally identified R904 as a synergistic residue for cell adhesion. Accordingly, the model showed that this residue is able to form potential stabilizing intra-chain salt bridges with residues E928 and E930. This mode of interaction likely accounts for a more stable and durable α4ß1-gC1q interaction in comparison with the prototypic CS1 ligand. To our knowledge, this is the first report describing the simultaneous involvement of all the three acidic residues of a trimeric ligand in the formation of a dimeric complex with the integrin ßI domain.

Different ART outcomes at increasing peak estradiol levels with long and antagonist protocols: retrospective insights from ten years experience.

PURPOSE: To evaluate the impact of high estradiol (E2) levels on assisted reproductive technologies outcomes in high responders (≥12 oocytes retrieved) according to the controlled ovarian stimulation protocol (COS) used. METHODS: Clinical retrospective evaluation of total, clinical pregnancy and implantation rates in ART cycles performed in high responders according to the COS protocol used (long or antagonist) at Pathophysiology Unit of Human Reproduction and Sperm Bank of Pordenone from June 2000 to December 2010. RESULTS: In high responders total, clinical and implantation rates were significantly higher in long if compared with antagonist protocol with peak estradiol level ≤3,000 pg/ml; on the contrary there was a significantly higher implantation rate with antagonist than long protocol with peak estradiol >3,000 pg/ml. However in this subgroup of patients total and clinical pregnancy rates showed only a trend favouring antagonist possibly due to a statistical ß error. CONCLUSIONS: In high responders long protocol seems to work better than antagonist when peak E2 is lower than 3,000 pg/ml but the opposite may be true for cycles with higher E2 levels.

Ultrastructural evaluation of human metaphase II oocytes after vitrification: closed versus open devices.

OBJECTIVE: To compare the ultrastructural appearance of oocytes after vitrification and warming with two different devices. DESIGN: Oocytes were examined by ultrastructural analysis after vitrification and warming with use of closed (CryoTip; Irvine Scientific, Santa Ana, CA) or open (Cryotop; Kitazato BioPharma Co., Ltd., Shizuoka, Japan) devices. SETTING: Pordenone Hospital IVF Unit and Medical Morphological Research Department, University of Udine. PATIENT(S): Surplus oocytes from 10 patients (aged 31-39 years) undergoing assisted reproductive technologies at the Pathophysiology Unit of Human Reproduction and Sperm Bank between 2006 and 2008. INTERVENTION(S): Oocytes with normal invertoscopic appearance underwent vitrification and warming with closed (CryoTip) or open (Cryotop) devices and were processed for transmission electron microscopy. MAIN OUTCOME MEASURE(S): Cryodamage extent and cell alterations in oocytes after open or closed vitrification and warming procedures and their rehydration rate. RESULT(S): A higher rate of complete oocyte rehydration and less-severe ultrastructural alterations were observed after vitrification and warming with the open Cryotop device. CONCLUSION(S): These preliminary data suggest that oocyte ultrastructure is better preserved with an open rather than closed vitrification and warming protocol.

Homologous in vitro fertilization in Turner syndrome: insights from a case report.

OBJECTIVE: To describe a bigeminal pregnancy obtained with a homologous intracytoplasmic sperm injection cycle in a patient with high-grade mosaic Turner syndrome (45,XO/47,XXX 97.5%/2.5%) with bicuspid aortic valve. DESIGN: Case report. SETTING: Unit of Pathophysiology of Human Reproduction in a general hospital. PATIENT(S): Patient with mosaic Turner syndrome with bicuspid aortic valve. INTERVENTION(S): Homologous intracytoplasmic sperm injection cycle after controlled ovarian hyperstimulation with a GnRH agonist flare-up depot protocol and menotropins. MAIN OUTCOME MEASURE(S): Pregnancy development, echocardiographic monitoring of aortic root, karyotypes of progeny. RESULT(S): Ongoing bigeminal pregnancy with the delivery of two healthy infants (46,XX and 46,XY, respectively) by cesarean section without any cardiovascular complication or aortic root echocardiographic modification in the mother. CONCLUSION(S): Even in patients with Turner syndrome with high-grade 45,XO mosaicism and reduced ovarian reserve, a trial of homologous reproduction should be offered after a thorough cardiologic evaluation to avoid pregnancy-related cardiovascular complications.

Comparison of protocols efficacy in poor responders: differences in oocytes/embryos competence with different protocols, a retrospective study.

At present, there is no agreement on poor ovarian response definition, and no definitive evidence that this prognosis can be changed by a specific protocol. Our data suggest that a flare-up protocol with a depot gonadotropin-releasing hormone (GnRH) agonist formulation gives higher total pregnancy and implantation rates than a GnRH antagonist, possibly by improving oocyte/embryo competence.

EMILIN1 represents a major stromal element determining human trophoblast invasion of the uterine wall.

The detection of EMILIN1, a connective tissue glycoprotein associated with elastic fibers, at the level of the ectoplacental cone and trophoblast giant cells of developing mouse embryos (Braghetta et al., 2002) favored the idea of a structural as well as a functional role for this protein in the process of placentation. During the establishment of human placenta, a highly migratory subpopulation of extravillous trophoblasts (EVT), originating from anchoring chorionic villi, penetrate and invade the uterine wall. In this study we show that EMILIN1, produced by decidual stromal and smooth muscle uterine cells, is expressed in the stroma and in some instances as a gradient of increasing concentration in the perivascular region of modified vessels. This distribution pattern is consistent with the haptotactic directional migration observed in in vitro functional studies of freshly isolated EVT and of the immortalized HTR-8/SVneo cell line of trophoblasts. Function-blocking monoclonal antibodies against alpha4-integrin chain and against EMILIN1 as well as the use of EMILIN1-specific short interfering RNA confirmed that trophoblasts interact with EMILIN1 and/or its functional gC1q1 domain via alpha4beta1 integrin. Finally, membrane type I-matrix metalloproteinase (MT1-MMP) and MMP-2 were upregulated in co-cultures of trophoblast cells and stromal cells, suggesting a contributing role in the haptotactic process towards EMILIN1.

beta 1 Integrin-dependent cell adhesion to EMILIN-1 is mediated by the gC1q domain.

EMILIN-1 (Elastin Microfibril Interface Located ProteIN), the prototype of the EMILIN family, consists of a cysteine-rich domain (EMI domain) at the N terminus, an extended region with a high potential coiled-coil structure, a short collagenous stalk, and a self-interacting globular gC1q-l domain. EMILIN-1 is an adhesive extracellular matrix constituent associated with elastic fibers, detected also in the proximity of cell surfaces. To localize the cell attachment site(s), monoclonal antibodies (mAbs) against EMILIN-1 or the gC1q-1 domain were used to inhibit cell attachment to EMILIN-1. Thus, one mAb mapping to the gC1q-1 domain caused complete inhibition of cell attachment. EMILIN-1 and gC1q-1 displayed a comparable dose-dependent ability to promote cell adhesion. Adhesion kinetics was similar to that of fibronectin (FN), reaching the maximum level of attachment at 20 min, but in the absence of cations adhesion was negligible. The relative adhesion strength to detach 50% of the cells was similar for EMILIN-1 and gC1q-1 (250-270 x g) but lower than that for FN (>>500). Cell adhesion to EMILIN-1 or gC1q-1 was completely blocked by a function-blocking beta(1) integrin subunit mAb. In contrast, adhesion to the complement C1q component was totally unaffected. Among the various function-blocking mAbs against the alpha integrin subunits only the anti-alpha(4) fully abrogated cell adhesion to gC1q-1 and up to 70% to EMILIN-1. Furthermore, only K562 cells transfected with the alpha(4) integrin chain, but not wild type K562, were able to adhere to EMILIN-1 and were specifically inhibited by anti-alpha(4) function-blocking mAb. Finally, cells attached to EMILIN-1 or gC1q-1, compared with cells plated on FN or vitronectin, which appeared well spread out on the substrate with prominent stress fibers and focal contacts, were much smaller with wide ruffles and a different organization status of the actin cytoskeleton along the cell periphery. This pattern was in accord with the ability of EMILIN-1 to promote cell movement.

Differential Expression of IRS-1 and IRS-2 in Uterine Leiomyosarcomas with Distinct Oncogenic Phenotypes: Lack of Correlation with Downstream Signaling Events.

PURPOSE: Insulin receptor substrates (IRSs) are essential for insulin-induced mitogenic effects on several cell types but they also are involved in cell transformation.We investigated whether the differential constitutive expression and potential distinct downstream signaling events of IRS-1 and IRS-2 might be related to discrete tumourigenic phenotypes of three human uterine leiomyosarcoma cell lines, one of which was specifically isolated for the present study. METHODS AND RESULTS: SK-UT-1B egressed effectively from a gellyfied Matrigel matrix and grew as did DMR cells in an anchorage-independent manner in agar and induced rapidly growing tumours in nude mice. On the contrary, SK-LMS-1 cells did not emigrate from Matrigel, neither grew in agar nor were they tumourigenic. IRS-2 was highly expressed in the more malignant cell lines, whereas IRS-1 was present only in SK-LMS-1 cells. However, upon insulin stimulation both IRS- 1 and IRS-2 were tyrosine phosphorylated with a similar kinetic in the respective cell lines; furthermore, after 1 min of insulin stimulation PI3-kinase associated with IRSs and after 2 min Shc was phosphorylated and associated with Grb2 with minor differences detectable among the various cell lines in the duration of phosphorylation and/or in their association irrespective of whether IRS-1 or IRS-2 were expressed. DISCUSSION: Our findings tend to exclude that the malignancy displayed by uterine leiomyosarcomas might be directly linked to the activation of distinct IRS-1- or IRS-2-dependent pathways.