Early pregnancy loss: how do men feel?

One in five pregnancies (20%) end in miscarriage. A specialized early pregnancy loss clinic to provide dedicated medical advice and support was established at the Rotunda Hospital in July 2002. A qualitative pilot study was conducted in July 2002 to assess the emotional response of male partners and also to establish if sufficient support services are provided for them. Ten consecutive couples attending the clinic 6-8 weeks following early pregnancy loss were included in the study. The partners were asked to complete a questionnaire with open and closed questions and return in the envelope provided. Nine questionnaires were returned. The average age of men attended was 28.6 years (range 20-39). The feelings described by men were typical of the grief and bereavement process. All wanted more time for discussion with doctors. They felt marginalized and although they felt support services for their partner were adequate, they felt that more support services for male partners should be provided. Based on these research findings, the specialized early pregnancy loss clinic is being developed to partner's needs and expectations. The appointment letter sent to the women now specifically states that the partner is welcome to attend. Partners are now included in the consultation.

Outcome from consecutive in-vitro fertilization/intracytoplasmic sperm injection attempts in the final group treated with urinary gonadotrophins and the first group treated with recombinant follicle stimulating hormone.

In the absence of specific dose equivalency data, the aim of this study was to compare the clinical results during the cross-over from menopausal urinary products (human menopausal gonadotrophin; HMG) to recombinant follicle stimulating hormone (FSH) follitrophin beta (FSHr) in order to determine whether the manufacturer's recommendation for equivalence of ampoule to ampoule (50 IU FSHr:75 IU HMG) would prove clinically correct. A total of 353 consecutive in-vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) treatment cycles was studied between 1st September 1996 and mid-February 1997. This included cycles in the last 191 women receiving HMG and the first 162 taking FSHr. All were down-regulated using a gonadotrophin releasing hormone (GnRH) agonist long protocol method from day 1 of the cycle. Greater efficacy was seen in the HMG group in terms of days of stimulation required, need to increase dosage, cycle discontinuation, number of follicles punctured, the numbers of oocytes retrieved and their quality. The hormonal response to stimulation assessed by oestradiol concentrations on days 5, 8 and day of human chorionic gonadotrophin (HCG) was significantly lower in the FSHr group. The ratio of oestradiol per follicle and per oocyte was significantly lower in the FSHr group. There was a highly significant increase in cost with FSHr therapy. Clinical pregnancy rates were 14% per cycle with FSHr and 20% per cycle with HMG.

Spermatozoal DNA flow cytometry and recurrent miscarriage.

Clinical investigations of the male partner of couples with recurrent miscarriage involves investigation of abnormalities in paternal chromosomes. This route of investigation does not include analysis of semen parameters. This investigation was conducted to evaluate DNA flow cytometry profiles of spermatozoa following staining with propidium iodide of couples attending the Pregnancy Loss Clinic for recurrent miscarriage. Ejaculates of 21 men were included in this study. DNA fluorescence was measured on the Becton Dickinson Fac Star Plus. Data were correlated with spermiogram parameters. The neat semen median minus peak channel values were negatively correlated with motility (p < .05). Therefore, DNA flow cytometry can provide confirmatory evidence for conventional semen analysis and is useful as a preliminary screening procedure for clinical management of the couple. It could also be used in association with programs for the assessment of possible reproductive toxicity and infertility in couples with recurrent miscarriage.

A randomized prospective study of early follicular or midluteal initiation of long protocol gonadotropin-releasing hormone in an in vitro fertilization program.

OBJECTIVE: To determine the optimum menstrual cycle time to initiate a long-protocol gonadotropin-releasing hormone agonist (GnRH-a) down-regulation regimen before hMG stimulation before IVF. DESIGN: Randomized, prospective, single, first cycle study. SETTING: University teaching hospital. PATIENTS: Eighty-six infertile couples undergoing IVF-ET attempt under rules for Ireland. INTERVENTION: Gonadotropin-releasing hormone agonist administered intranasally from day 1 or 21 of menstrual cycle. Human menopausal gonadotropin commenced when pituitary down-regulation was confirmed. MAIN OUTCOME MEASURES: Ovarian response, cancellation, fertilization, and pregnancy rates. RESULTS: No significant differences found between day 1 and day 21 initiation. But starting on day 1 is more easily recognizable by patients and avoids the possibility of administering GnRH-a in the presence of an unsuspected pregnancy. CONCLUSIONS: Both follicular and luteal phase initiation of GnRH-a long-protocol down-regulation are equally efficacious. In our clinical context, patients and management favor commencing on day 1.

Feulgen-DNA content of human sperm and outcome of in vitro fertilization.

Feulgen-DNA content of sperm was quantified in fresh semen samples of 20 consecutive couples during preparation for in vitro fertilization to measure the condensation state of sperm chromatin. Results were expressed as a percentage of expected haploid DNA value (1c). No significant differences were found between those who did not get pregnant, those who went full term, and those who aborted. Because fertilization can occur with a minority of normal sperm, it is concluded that the present findings do not provide useful clinical information about pregnancy outcome and in vitro fertilization.

The use of GDA-J/F3 monoclonal antibody for the detection of dead spermatozoa (necrosperm) during semen analysis.

The distinction between immotile necrosperm (dead spermatozoa) and those with immotility due to other causes is of the utmost clinical importance. The supravital dyes currently used for the identification of necrosperm are not highly reliable or accurate. In this study, GDA-J/F3 monoclonal antibody (MoAb) which reacts with the fibrous sheath (FS) was used as a specific probe for the detection of necrosperm using indirect immunofluorescence (IIF). Previously, several lines of evidence indicated the reaction of the antibody with necrosperm. This was confirmed in the current study where GDA-J/F3 MoAb failed to react with viable swim-up separated spermatozoa; such cells were only stained following sperm demembranation with 1% Triton X-100. Furthermore, by using immunogold electron microscopy of a normozoospermic sperm sample, all the spermatozoa which reacted with GDA-J/F3 MoAb showed damaged cytoplasmic membranes. Following these initial studies, sperm samples were obtained from 42 men attending infertility clinics and assessed by conventional semen analysis and GDA-J/F3 MoAb screening using IIF. The results showed a wide variation in sperm immotility and GDA-J/F3 reactivity; the ranges were 19-99 and 0-50% respectively. This novel immunological approach provides a simple and specific method of necrosperm enumeration for the investigation of male infertility.

The influence of peritoneal fluid from patients with minimal stage or treated endometriosis on sperm motility parameters using computer-assisted semen analysis.

The aim of this study was to determine the influence of peritoneal fluid from patients with minimal stage or treated endometriosis on sperm motility parameters. Peritoneal fluid aspirated at diagnostic laparoscopy for unexplained infertility from women during the luteal phase of the menstrual cycle (days 20-23) was incubated for 5 h with fresh semen samples obtained from men of recently proven fertility. Spermatozoa were prepared by a swim-up technique from unprocessed semen. Using computer-assisted semen analysis (Hamilton-Thorn Research, MA, USA), sperm motility and motion parameters were observed at 0, 120, 180 and 300 min. Compared with spermatozoa incubated in Earle's balanced salt solution/human serum albumin, the percentage motility, percentage progressive motility and progressive velocity of spermatozoa incubated in peritoneal fluid from patients without visible endometriosis were significantly higher (P < 0.05). Maximal effect was observed at 3 h and maintained until 5 h. We conclude that in an in-vitro study, in contrast to peritoneal fluid from patients with minimal stage endometriosis, peritoneal fluid from patients with unexplained infertility and no visible endometriosis can improve sperm motility when compared with culture medium.

Should gonadotropin-releasing hormone down-regulation therapy be routine in in vitro fertilization?

OBJECTIVE: To compare the classic clomiphene citrate (CC) and hMG regime for ovarian stimulation before IVF in women who received hMG post-long protocol down-regulation with either 3 mg triptorelin [INN] IM or 150 mg buserelin acetate four times daily intranasally. Furthermore, if possible, to determine the preferred method of down-regulation. DESIGN: A prospective study of 150 women randomized blind to the clinician to one of three alternative ovarian stimulation regimes when passing for the first time through an IVF program during 1992. RESULTS: Triptorelin [INN] down-regulated significantly more quickly than buserelin acetate. The non-down-regulated group CC and hMG used significantly less hMG in a shorter time. In these women LH levels at hCG administration were significantly higher. No other intergroup differences were found. Pregnancy and take-home baby rates for the overall study were, respectively, 32%:25% (per cycle) and 42%:33%; (per ET) for the triptorelin [INN] group 28%:22% and 39%:31%; the CC group 32%:24% and 46%:34%; and the buserelin acetate group 34%:28% and 42%:34%. CONCLUSIONS: Triptorelin [INN] and buserelin acetate were comparable in all parameters except down-regulation. The former was significantly quicker and more sure. In none of the clinical end points measured, however, was the classic CC and hMG non-down-regulation regime significantly less effective or troublesome than where down-regulation was used. These results therefore show that although indications for down-regulation before IVF exist, it should not be used on all patients.

Preparation of antibody free spermatozoa by in vitro immunodepletion using immunobeads.

In the present study ejaculates from six infertile men with antisperm antibodies were processed on a six step discontinuous percoll gradient. This treatment yielded a sperm fraction with a different percentage of sperm with antisperm antibodies. The resultant sperm preparation was incubated with immunobeads. Sperm were recovered following incubation by swim-up. Sperm recovered at the end of processing showed reduced populations of antisperm antibodies. Even though sufficient numbers of sperm were obtained to consider assisted reproduction, reduced motility was recorded in four of the ejaculates when compared with routine processing. Following trial preparations of semen samples this technique may play a role in sperm selection for assisted conception.

Does patient semen quality alter during an in vitro fertilization (IVF) program in a manner that is clinically significant when specific counseling is in operation?

PURPOSE: It has been shown that the stress of infertility may impair semen quality. Whether counseling can attenuate this affect is unproven. This study examines, in an IVF program setting, where specific counseling is in operation, whether semen collected on the day of oocyte recovery is significantly different from that obtained during the prior clinical suitability assessment of the couple. RESULTS: In the 125 consecutive couples examined, there were no significant overall differences in semen volume or sperm density. There was a significant increase in sperm motility on the day of oocyte retrieval (P < 0.001). Twenty-three patients (18.4%) showed an increase in quality, and 21 (16.8%) a decrease, on the day of oocyte recovery. The environment of production appeared to exert no influence. Fertilization failure occurred in seven couples, three (14%) of whom presented for the first time with decreased semen parameters on the day of IVF. This compares with 1 of 23 (4%) fertilization failure in those whose parameters increased. CONCLUSION: The semen quality of the vast majority of the patients studied in this highly counseled program does not appear to be significantly affected by the superstress of participation in the day of oocyte recovery.

Evaluation of bovine cervical mucus penetration as a test of human spermatozoal function for an in vitro fertilization programme.

Thirty-two couples participating in an in vitro fertilization (IVF) programme were evaluated as regards the prognostic value on fertilization of spermatozoal performance through flat capillary tubes filled with standardized midcycle bovine cervical mucus (Penetrak, Serono Diagnostics, Surrey, UK). A statistically significant correlation (P < 0.033) was observed between the distance travelled by the neat spermatozoa in the mucus and the % penetration of oocytes at IVF. There were also significant correlations between motility and progression (P < 0.004) and a borderline correlation between progression and the Penetrak results (P < 0.098). There was no significant difference between the Penetrak distances travelled between the 9 who conceived (33.4 mm) and the 23 who did not (29.9 mm). While the test does add to the knowledge of fertilization potential, the results extrapolated to a larger series would give false positive rates of 25% and false negative rates of 11%. The absence of a clear end point renders the Penetrak mucus penetration test insufficiently accurate to be used as a main measure of the male factor when advising for or against IVF therapy.

An Irish out-patient based in-vitro fertilisation service.

The first year's activity of a fully out-patient based, self financing, in vitro fertilisation service is reported. 98 couples had superovulation regimes tailored to need. 138 cycles were started. 109 retrievals were attempted using the vaginal ultrasound probe under Fentanyl and Midazolam sedation. In 106, oocytes were successfully retrieved (average seven per patient). In 80, embryos were transferred (average three). 13 patients achieved clinical pregnancies giving an overall pregnancy rate of 9.4% per cycle, 12% per oocyte retrieval, 16.5% per embryo transfer and 13% per patient who embarked on the programme. One pregnancy was ectopic, two aborted, and 10 are ongoing; this includes seven singleton foetuses and three sets of twins. All pregnant patients were referred back to their unit of origin for antenatal care and delivery.

The mast cell and histamine concentration of the human post-menopausal uterus.

Mast cells and histamine concentrations have been studied in uteri removed by hysterectomy from women in their post-menopausal years. Mast cell numbers were expressed as mean numbers/mm2 following fixation in 10% formalin and staining with Azure B. The majority of mast cells, in both the endometrium and myometrium, were very densely stained. Mast cells in the myometrium showed a significant negative correlation with years post-menopausal (rs = -0.52, P less than 0.05). Extracted histamine from uterine tissue was condensed with o-phthaldialdehyde to form a fluorophore and its fluorescence was measured at 450 microns using a spectrofluorometer. No significant correlation was found between histamine concentrations in the uterine wall and years post-menopausal.

Mast cells in the normal uterus and in dysfunctional uterine bleeding.

Mast cells in the human uterus were examined following fixation in 10% formalin and staining with Azure B. Mast cells were present in all parts of the corpus uteri. Cyclical changes were observed by light microscopy for mast cell numbers/mm2 in the functional endometrium, basal endometrium and the endometrial/myometrial border throughout the menstrual cycle. No significant differences were found for mast cell numbers in the menstrual, proliferative or secretory phases of the menstrual cycle in dysfunctional uterine bleeding (DUB). No correlation was found between mast cell numbers in the uterine wall in the secretory phase of the menstrual cycle and average menstrual blood loss for patients with DUB.

The ultrastructure of mast cells in the uterus throughout the normal menstrual cycle and the postmenopause.

During the menstrual cycle a gradation in mast cell granule ultrastructure was observed from the functional endometrium towards the myometrium of the uterus. Mast cells with particulate granules were present in the functional endometrium and those with granules containing identifiable scrolls in the basal layer of the endometrium and in the myometrium; mast cells containing very electron-dense granules were present in the deeper layers of the myometrium. The secretory activity of mast cells throughout the menstrual cycle is described. Mast cell secretion was observed to a lesser extent in the postmenopausal uterus. Mast cells with particulate granules were absent in the postmenopausal uterus and many very electron-dense granules were observed in mast cells in the myometrium.